families we serve are latino. 35% are african-american. 13% caucasian. 6% asian. about 35% our modeling will spanish-speaking. these children come from all of san francisco's neighborhoods, but the majority live in the mission, the excelsior district, and bayview hunters point. in addition to the forensic medical services, which provide comprehensive mental health services such as active outreach, case management, school and home visits, trauma focused individual psychotherapy, family therapy, and parenting classes. unfortunately, many of the children we serve our victims of holly-victimization -- poly- victimization. they are often victims of sexual abuse, child abuse, -- physical abuse, sexual abuse, and witnesses to domestic violence. a recent study demonstrates that

children exposed to even one type of violence are at greater risk for experiencing other types of violence. a child who is physically assault in the past year is five times as likely to be sexually victimized and more than four times as likely to be maltreated during the same time. these children should be a priority for our strategic intervention. will work closely with the trauma recovery center. the trauma recovery center is an award-winning nationally recognized program that treats the adult victims of violence -- rape, domestic violence, victims of shootings, assault, family members of homicide victims, and most recently, we have begun to see refugees who are victims of torture. our clinicians work in a collaborative fashion in providing family-centered treatment. treatment models with children must and should focus on the child with parents receiving

services to help support the child. all too often, however, this model fails because it does not go far enough. parents, in addition to receiving a parenting class is and consultation a round child rearing, are themselves in need of trauma-focused treatment. many of these parents have their own history of cumulative trauma, including their own history of child abuse. at the trauma recovery center, our research shows that more than one half of the adult victims we serve have a history of experiencing more than four different types of trauma and 47% report a history of childhood abuse. one of the unfortunate aspects of untreated cumulative trauma is that it is associated with poor outcomes, and it often produces chronic posttraumatic stress. chronic ptsd may exert itself by perpetuating the circle of violence, leading people to have problems if emotional control,

substance abuse, difficulty maintaining relationships, and it certainly affects how people parent. trauma and violence begets, and violence. a joint collaborative effort appears to be an effective model for treating traumatized families and attempting to prevent further re- victimization. outcome today demonstrates that family, children, and adult victims treated have been -- have seen a level of improved functioning. but our best efforts and despite enormous support from the department public health, there are significant needs that remain unmet. over the last four years, due to the economic downturn, our annual mental health budget was reduced by $100,000, leaving us with the mental health team made up of only 3.5 mental health providers to provide treatment

to sexually abuse children in san francisco. this has resulted in a long waiting list of children who are waiting to be seen. the trauma recovery center has been cut back $500,000. we are facing another budget cut of $240,000. should this go through in july, many of these traumatized individuals will not have access to our, services, and this will not only affect our traumatized adults but their children as well. i am appreciative for you holding this hearing, and i appreciate the board of supervisors for their ongoing concern for the very vulnerable families reserve. thank you. supervisor olague: thank you.

>> thank you for the opportunity -- to talk about the work we are doing at san francisco general hospital and the child trauma research program. [inaudible] and if we could have the overhead please. the title of my presentation is "babies remember: early violence last a lifetime." the reason i call it that way is to echo supervisor olague's comments about the long-term repercussions of early violence and the science of brain development and epidemiology has shown us that when we are faced with the violent adolescents and adults, the likelihood is that person has been abused for has

witnessed domestic violence as a young child. supervisor avalos: you can actually use the other microphone. can we switch to the microphone closer to the computers, and you can make all those pages -- page advances in the same spot. >> thank you. all our children need help, but young children, particularly, need help, and the figures show nationally and in the bay area as well that children in the first five years of life are disproportionately exposed to domestic violence and to child abuse, and the first year of life is the most dangerous year in the entire spectrum from birth through 18 years of age with more children dying from of use in the first year of life

than at any other age. we also know that incidences of fatalities and severe child abuse have doubled in the first year of life and in the first three years of life, it seems the economic downturn, as a result of the increased stresses that families are exposed to. children exposed to violence can come from many different ports of entry, but once a child experiences one type of violence, the likelihood that he or she will experience other types of violence as well increases exponentially. for example, there is a 47% overlap between exposure to domestic violence and being sexually abused or physically abused. and we know that our returning veterans from iraq and

afghanistan are suffering from increased violence against themselves in the form of suicide but also from increased perpetrating of violence against their most loved ones in their homes. the conclusion is that violence is a lethal virus. the american academy of child and adolescent psychiatry recently submitted a report saying that violence is to mental health what tobacco is to physical health and the children's exposure to violence is the single most preventable cause of mental illness. we know that there is an association between the number of dramatic stressors that children are exposed to, and the likelihood that the child will develop two or more psychiatric

disorders, and the more types of violence and chronic exposure to violence, the more complicated these psychiatric pictures are, and the more difficult it is to treat these children, and the less equipped we are because often, these children are seen in different systems, and across the nation, the system still needs work in preschools, in substance abuse, in juvenile dependency, in the pediatrics system. the reason that violence is a virus is that it causes,, and, lives in the body, and it is a biological stamp that the child carries.

we talk about the body remembering. this is a slide that has been disseminated by the center for disease control in atlanta showing a 3-year-old. these are two slides side-by- side. the slide on the right shows the brain of a three year-old who has been exposed to severe and repeated cumulative trauma. we find that the key aspects of the brain that created the architecture of brain structure that have to do with planning, with learning, with regulation of assets, with social behavior's do not develop. and there is more fluid in the brain that actual brain matter. on the left side, we have the grain of a normally developing

3-year-old where the structures that promote learning, that promote intimacy, that promotes social commitments are developed well, so this child, unless there really is comprehensive intervention in schools, in family, and mental health treatment, will continue to develop into and out of control adolescent and possibly into a parent who is repeating the cycle of abuse by inflicting on his or her child what happened to him. there is help. at the national child traumatic stress that or, we are developing and disseminating evidence-based forms of treatment, and what we find again and again is that working

with traumatized children involves working with traumatized parents, but to work with traumatized parents and traumatized children, we need to support the providers. just because of violence is a virus and trauma is a virus, it affects the providers of, services, who often decide they cannot do this work without the necessary system support, our program is designed for providing mental health consultation to community-based programs and to the department of social services to help providers understand the manifestations of trauma in the form of aggression, withdrawal, not showing up for services so

that those services become trauma-informed. what we find is that using the parent as a protective shield is the most effective way of protecting the child. the program, the treatment we developed this call child/parent psychotherapy, and we meet together with the parent and child to help them talk to each other about what happened to them because we know that the first response to trauma is, "i don't want to remember. i don't want to think. i don't want to talk, and i don't want to hear you talk about it." we find that 3-year-olds remember things that happened to them when they were 1 year old, two years old that the mother or father never thought the child saw or understood, and when the

child through his play shows that he remembers what happened, the parents realize the impact that their trauma is having on the child, and then we can have a collaboration to interrupt the injured generational cycle up from a transmission, and what we -- the injured generational cycle -- the intergenerational cycle. one of the children in the study continued to show symptoms, and this was a child in a very dangerous neighborhood where drive-by shootings get triggering the experience of the trauma, and this is a reminder of how we need safe neighborhoods for safe families and for well-functioning children. one of the most unexpected and

satisfying parts of the research was that not only the children improved in their traumatic stress, the mothers improved as well, even though the focus was on helping the mother's help their children. they have lower ptsd, lower depression, lower sentence of post-psychiatric stress. the way we understand this is that mothers develop a great deal of their self esteem as individuals from how well their children are doing, and when they find themselves understanding the child's behavior, responding adaptive lee, helpfully to the children's behavior and having the child respond by a loving ways as opposed to repeating with the mother of the aggression that they experienced as children, the mothers feel they are doing well, and their depression and ptsd decreases.

so what we need is to support rather than punish parents, and we know that nationally, much more money is being devoted to the punitive parts of the system rather than the support of parts of the system, and -- supported parts of the system, and we need to prioritize the funding stream that provides help for the parents so that the parents can help the child. economic interventions have a great deal of importance in this area. for example, in milwaukee in minnesota, programs that provide increased income for families result in decreased domestic violence and overall well-being. so we need to continue more services, and i have the honor of being on the attorney general's task force with children exposed to violence and

the report we are planning to present in july talks about the importance of early identification. right now, many, many children are referred for mental health services, and the clinicians do not do an assessment of, exposure and violence exposure. so that by now, that should be considered clinical malpractice. we need to have trauma-informed systems so that early identification of trauma becomes part and parcel of the training of clinicians and service providers. we also know that preschoolers expelled from child care at three times the rate as children from kindergarten through 12th grade, and we know that black boys are expelled at four times

the rate of white boys. so, attention to a conscious bias, building in cultural competence, and starting in the earlier system were children and families are receiving services is imperative. thank you very much. supervisor olague: thank you. [applause] we will hear from the speaker's first. then we can hear from members of the public, and then we will have questions. if any of you have to leave after you speak, please let us know. supervisor avalos: that was actually very informative. thank you very much. supervisor olague: thank you very much, yes. i wanted to thank mr. alvarez for being here, for listening to this, as we speak about creating healthy neighborhoods and healthy living places. i just want to thank you for being present and listening to

the testimony. we will hear next from child crisis services. >> [inaudible] i am the director of comprehensive crisis services. >> i am the medical director of comprehensive child crisis services and foster care mental health. >> comprehensive price of services provide youth, adults, and care givers with crisis response services all over san francisco. we are comprised of three components. our first component is our child crisis unit, which is a 24-hour seven-days a week mobile crisis service which serves clients

every year. our second team is our adult mobile crisis unit, which is a six-day-a-week unit with 60% of our clients having prior, exposure. our third team is our crisis response service, which is also a 24-hour seven-day week mobile response to scenes of homicides, suicides, stabbings, shootings, and domestic violence. it serves approximately 280 clients a year with 53 of those being children who are exposed to trauma. our team is built up of a multidisciplinary staff, including social workers, psychologists, marriage and family therapist, psychologists, and health workers who have multiple experience with diverse populations. we also are a multi-link listed unit, which include spanish, cantonese, mandarin, vietnamese, tagalog, and russian.

we also have other languages available with telephone interpreter services. >> to give you a little bit of information, the child crisis services provides crisis assessment intervention and stabilization for san francisco children under age 18 or publicly-funded youth, a privately-funded, and uninsured clients. we are a 24-hour a day service seven days a week with clinical staff available at all times. we are a mobile service that response to schools, emergency rooms, foster homes, group homes, residential treatment centers, and we also provide services in our office, which is located in the baby. in addition to that, we provide phone tree not for many more cases. in the thousands. i did not have the actual number of what it was last year. we have a flexible service model so we are able to help lead people to what would be the right service provider for them

if it is not us. some of our crisis assessments are assessments for youth who might be experiencing suicidal ideation or homicidal ideation, out of control behavior's, or psychosis. violence is a major risk factor for mental health problems in youth, and we see probably about 70% of our youth that you have prior, exposure, oftentimes in their communities are experiencing ongoing trauma. in addition to there being post- traumatic stress disorder, we also see the present on going dramatic stress, which complicates any attempts at treatment. additionally, we provide, focus groups and the poorman group's in the school setting. we provide short-term case management and linkage to outpatient mental health services for youth that come

through our agency, and this requires a close coordination with the schools, with their primary care providers, and with mental health services. a lot of times, in addition to whatever the mental health problem is that they are entering our services for, they are having behavioral problems in the school setting, may be problems with truancy. they may also be having physical sentence, which may be related to anxiety sentence -- headaches, stomachaches, but maybe other things that are also not getting treated, whether it is asthma, allergies, or other complex medical issues. we utilize a family systems approach, dealing not just with the youth, but with the entire family and their entire support system, whether that is biological, family, or community family. in addition, we are able to provide psychiatric medication and evaluation and short-term medication management in which we are using similar medications to treat youth as are used to

treat combat veterans. what we often see is that similar to combat veterans, they have some of the same symptoms, but in contrast, where our combat veterans coming back are coming back here and are not in the same war zone, many of our youth are living in areas where there's ongoing exposure to whether it is family violence or community violence, which always makes things more complicated. quite a few of our clients are involved with the foster care juvenile justice system. a number of the crisis cases we see with kids that are involved with probation, that we see actually at the juvenile justice center at times as well, so those are really important pieces of what we are looking at. also in working with the schools, i think one of the things we see in addition to the behavior problems is there is

absolutely an increased incidence in learning problems for kids that have been exposed to trauma. if you are constantly focused on when the next best thing is going to happen, it is hard to focus on what the teacher in front of your class is saying and it is hard to dance to the next level. >> our other team, our crisis response team provide short-term and long-term individual support to families and community members exposed to violence. this is our team that response to homicide scenes were homicide victims are taking and helping the family to victim services, sometimes helping fill out applications or also helping the family with funeral arrangements, finding locations of where to bury their loved ones as well.

the services are offered to families as well as to children. they provide critical services as well as juvenile hall, people's homes, at our office, and at other programs as well. supervisor avalos: i have a question. occasionally, when there is a homicide or very traumatic event, my office -- we tried to help the victims in some way or another. is the best access point for us through crisis response network? sometimes, we actually help with arranging services for the funeral or fund raising. what is the best way to access to the family, would you say, for families experiencing extreme trauma? >> you can access our office, and we could help link you. the crisis response -- they use

an evidence-based treatment model, which is cognitive behavioral therapy. many of the clients they see -- most of -- 100% of the clients they see have been exposed to numerous traumas, which are similar to the struggles as the combat veterans. they continually are traumatized. it is chronic, ongoing exposure in their community. the challenges that we hear that our clients their fear of crossing different barriers to access, treatments to go to school, to go to work, in neighborhood communities. the way to access -- how we are accessed is for when there is a homicide, shooting, were critical incident, the police department calls us. we have a relationship with them where they notify us of the incident. we also get calls from san

francisco general as well to access our debriefing services and our ongoing treatment. you can call our number at 415- 970-3800. supervisor olague: you will be around later, right? i can ask you questions then? all right, i have a couple of questions. our final two speakers. thank you again. then we will go to public comment. among supervisors, i am kevin, and i am program manager in eastern and family community support department, working with the 15 wellness programs we have in our high school. as well, i am the point person for crisis response and coordinate support services 4 lgbt q -- for lgbtq youth.

first, we have to know the students who have experience, need a clear set of boundaries and a safe place to learn. we have clear commitments to safety and policies and procedures to keep our students safe in school. the second is we are employing a district-wide restored practices approach to addressing the areas of discipline. the third is we have research- based curriculum in elementary, middle, and high schools. the board is we provide direct services to our students on- site as well as professional development to support clinical intervention as well as consultation around students who are affected by trauma. regarding the direct service, we have 65 social workers at 80 of our elementary and middle schools. we have 17