The high cost of childhood trauma

You might not think that jail is a typical topic of conversation for a 4-year-old. But for many children in Tulare County, the topic is a central part of their young lives.

As a therapist in Cutler with Family Services, a nonprofit organization contracted with the county health department to provide mental health services, Zenaida Cruz is faced daily with the challenge of helping young children process adult-level problems. Most of Cruz's patients are referred by Child Welfare Services.

For some kids, their fathers are in jail. For others, both parents may be incarcerated. And even if they're not the direct victim, many of Cruz's clients have witnessed the traumas that brought the police to their home — domestic violence, gang activity, sexual abuse or alcohol and drug abuse.

Cruz's office is stocked with children's picture books with titles like "Mommy, what is jail?" and "The Cryin' House" that are supposed to help little ones — some of whom are diagnosed with post-traumatic stress disorder — to understand and cope with their fractured homes.

Mental health officials say such trauma is not without consequence. It sows the seeds of mental illness that costs the community taxpayer dollars for treatment, in lost productivity and in a perpetual cycle of family instability that often leads to crime.

"For developing brains, there's a neurobiological response," said Caity Meader, executive director of Family Services. "Repeated exposure to traumas — domestic violence, sexual abuse, poverty, homelessness — has an impact on development."

The impact, Meader says, is that these children develop survival skills — namely the fight or flight response — at a time when they should be developing problem-solving and relationship-building skills. Without the ability to solve problems or build relationships, the child heads into their teenage and adult years at a considerable disadvantage.

Trauma-related disadvantages

The first place this trauma-related disadvantage becomes apparent is at school. Teachers are trained to spot shifts in children's behavior that may be tied to trauma.

Two of the most common of which are aggression and a general withdrawal from activities.

"We don't see a kid with a new diagnosis written across their forehead," said Eileen Whelan, administrator for behavior services with the Tulare County Office of Education. "We don't have all the information, we just see the school behavior."

Kids exhibiting aggression are connected to services immediately, but children who simply withdraw might take longer to notice. Sometimes, though, there are obvious cases of trauma the agency handles.

About a month ago in May there was a mother in Farmersville who was shot and killed. We knew those kids would need help, she said, but think of all that happens that isn't out in the open.

In addition to behavior issues, children with traumatic home situations often suffer academically.

"Kids can get so far behind in school they start looking like special education kids," Whelan said. "[But] if you're worried about someone shooting your mother, you're not paying attention to math."

Nature vs. Nurture

Mental health professionals agree that mental illness is generally a combination of biology and environment. And biological predispositions are indeed prevalent.

Between one in four and one in five people are going to possess some form of mental illness, County Mental Health Director Dr. Timothy Durick said.

"Any couple has a shot of having a child that's predisposed for something in the spectrum of mental disorders," he said.

Mental health officials say environment can determine how or if a disorder will present itself. The environment can either mask or exacerbate the illness.

The environment many Tulare County children grow up in exacerbate the problem, Family Services officials say.

While more severe mental disorders requiring medication and/or hospitalization are referred to other agencies, Family Services officials say that about 95 percent of their active case load of 150 to 300 youth patients are in therapy to treat mental illnesses that are a direct result of early childhood trauma. (Note: an exposure to trauma does not necessarily mean there is not also biological issues present.)

Officials say many of the kids they're seeing now might never have become mental health patients had they not suffered early traumatic experiences.

Stark numbers

Crime statistics from the California Attorney General's Statistic Center tell the story of a community where children are subjected to considerable trauma.

Violence, drug abuse and sex offenses occur in Tulare County at a rate that is 25 to 50 percent higher than in the state's major urban areas, Meader said.

Drug and alcohol abuse is by far the most common denominator when Child Welfare Services is called to a home, CWS Deputy Director John Mauro said.

Drug and alcohol abuse can involve physical harm or simply neglect. An addict often can't hold down a job or put food on the table. Both varieties of abuse have profound effects on a child and their sphere of relationships.

When a child's parents are continually in crisis mode, the burden of teaching important life skills falls to other adults — grandparents, extended family members, teachers and coaches, said Mary Alice Boylan, a licensed marriage and family therapist, who serves as the clinical manager for Family Services.

A lack of healthy parent-child attachment has long-ranging consequences, even into subsequent generations, Cruz said. "This starts a cycle that continues," she added.

Systemic problems

Family Services officials say that children often receive chemical treatments for problems originating from environmental stress. But therapy, they say, addresses the root of the problem.

"Our medical and insurance system lends itself to quick cheap pills," Meader said. "A long term commitment to therapy is better, but it doesn't fit the model."

Another factor — insurance doesn't cover nurture issues the way it does nature issues, Boylan said.

The American Psychiatric Association produces a diagnostic and statistical manual of mental disorders — referred to as "Psychiatry's Bible" — that contains codes physicians provide to insurance companies to determine how treatment is covered.

"Realizing the importance of environment — it humanizes us," Boylan said. "Instead of labeling children, we're looking at the whole picture of the way a child came to be."

But without a clear diagnostic label, billing insurance is complicated, if not impossible, she added. There's no billing code for bad parenting like there is for major depressive disorder.

For all the above reasons, Family Services officials say mental health care should follow the general shift occurring in other medical disciplines that emphasizes prevention, in hopes of avoiding expensive interventions.

"We've reached critical mass," Meader said. "Our society as a whole will be challenged to step back and not look for the quick fix. We need to invest in projects that address the root cause of the issues and not just treat the behavior that comes after the fact."

Follow the reporter on Twitter @KyleHarvey001.

150-300

The average number of active cases Family Services has involving children.

95

The percentage of cases that involve a mental illness that can be tied directly to trauma. *Note, the existence of trauma does not eliminate the possibility of a biological component to the illness.

Editor's note

This story is the second in a series about mental health care in Tulare County. It was produced as a project for The California Endowment Health Journalism Fellowship, a program of USC's Annenberg School of Journalism.

Report Child Abuse

To report suspected child abuse, call 1-800-331-1585.

This story was originally published in the Visalia Times-Delta

Photo Credit: Steve R. Fujimoto