10

All the King’s Horses

Bittersweet memories of time that’s slipped away
And new found words for everything I always meant to say,
Concrete walls all about, cold bars made of steel,
Guards with iron shackles, to strap them on my heel.
A scream of pain rings aloud, I hear it from my bed.
I listen closer to the voice and find it mine instead.
The pain is not so physical like the one before you’re dead,
This pain comes from deep within the center of my head.
It hurts to think I’m sitting here waiting just to die,
If I could only understand all the reasons why.
I don’t know what tomorrow brings, the truth is I don’t care,
So I’ll sit inside this hell and at these walls I’ll stare.
Dying now bit by bit, a little more each day
I write down these last words—the ones you’ll ask I say.
So now you’ve read this poem and today’s my execution date.
They’ll say it’s time to die and I’ll tell them it’s too late.

—JEFFREY, “LAST WORDS”

NAME		SEX		DATE OF BIRTH
Mother				Jan. 30, 1960
John		M		July 6, 1975
Jeffrey		M		Nov. 21 1976
Julie		F		Feb. 6 1979

11-23-78 Request from mother to child welfare agency for housing and for child care while in hospital to have third child. Mother and her boyfriend live with her mother and three boyfriends. No transportation. Referred to child care referral service. Housing grant not available from this agency. Referred to employment division.

1-9-79 Public health nurse requested child welfare contact for [mother] for assistance with parenting, budgeting and supporting services offered; [mother] declined services.

10-22-70 “Accidental” call by mother for ambulance; mother confused; declined ambulance.

10-23-79 Neglect report received and investigated. Mother depressed and unable to care for children though reluctant to have children removed; father contacted but encouraged shelter care. Mother committed self to state mental hospital; children removed to shelter care.

10-25-79 Neglect report was filed; after investigation the report was found to be valid.

11-23-79 Mother returned home. Children returned home. Several follow-up contacts made. Family wants no further services. Case closed by child welfare.

11-23-79 Request made for physical abuse—after investigation the report was found to be valid.

11-23-79 Referral made for physical abuse, after investigation, report was found to be valid (the record is unclear on nature of abuse and on agency action taken).

1-10-80 Police department investigating an abuse complaint reported to child welfare that the state of the house was such that the children were susceptible to neglect if left in that environment.

4-2-80 Report similar to January’s was repeated from the police department. The home conditions reported and described were much worse, however.

7-7-80 Referral was made for neglect. Mother found walking down the middle of highway, suicidal. Report was found to be valid. Children placed in shelter care.

9-17-80 Case referred to permanent planning due to the “inability of both parents to meet the children’s emotional and physical needs.” Recommended that “other resources be considered including termination of parental rights and adoption.” (Children in foster care.)

—A SAMPLING OF THE EARLY RECORDS FROM JEFFREY’S CHILD
PROTECTIVE SERVICES FILE DURING HIS FIRST THREE YEARS

I wish [Protective Services] could have been more specialized. They were there when we were in big trouble. But they weren’t there any other time. They weren’t there when we needed a person to talk to. Somebody to put our arm around and be our friend and somebody that we could trust. If I could have just trusted Mark [caseworker], I would have told him everything. I couldn’t. I mean, he can take me out to have an ice cream cone if he wants, that’s fine. I’m more than willing to accept that when I’m a little kid. That didn’t make him my friend. If he’d been around me more, if he’d made more attempts to show me that he cared about what was going on with me, maybe not even so much asking me a bunch of questions about my grandma and grandpa or whatever. But taking us to the park and a lot of times when I was a little kid, I wouldn’t even want to go to the park. Mostly, I’d just want somebody to talk to. . . . If he would have come up with me when we lived at the mountain. If he would’ve walked out in the woods with me like I did every single day because I wanted to get away from my house. I wanted to get away from the things that were going on there. Those buttes, I have been all over those buttes. There is not one part of those buttes I don’t know. Not one part. I mean, I know every single animal that lives out there. Every single type of an animal. Everything. Every single type of bug. Everything. And if he’d have come up and I could’ve shown him what I knew, and, you know, if he’d shown me a little of what he knew and we could have just been friends, I would’ve trusted him with anything. . . .

—JOHN, AUGUST 1996

If somebody says, “Hey, I see you going somewhere, I see a spark of something in you, I know you’re going to do something great when you grow up,” and, you know, just keep on encouraging instead of discouraging, I think that’s where it’s going to make the difference. . . . My grandma, she was there always from the beginning [for me]. She was steady. But she didn’t see it in Jeffrey. She wanted to see it in Jeffrey. She always told him that, but you can tell. You can tell by the way that people talk, you know, it wasn’t as firm a belief. I don’t know. It’s hard to explain. See, kids are sensitive. They can sense every single thing about a person. . . . You can be telling a kid one thing, you could be saying, “You’re going to be great. You’re going to be the president of the United States. You’re going to be doing this and this.” But if they don’t really, if that adult doesn’t really believe it down in their heart that they can really do that, the kid knows. It doesn’t matter. Jeffrey didn’t get that.

—JOHN, AUGUST 1996

I thought it was ordinary for so long, that every kid lived the same kind of life I did. I didn’t think it was anything unusual to see a kid get beat up or to see him come to school with black eyes or bruises, maybe a broken arm or something like that. I didn’t think that was ever—every kid went through it. I look back on it now, and I realize how sad that is.

—JEFFREY, AUGUST 1996

On October 14, 1994, a boy sat next to his lawyer in a Multnomah County courtroom in Portland, Oregon. His shackled feet, clad in Nike hightops, dangled several inches above the floor. As the frustrated judge wrestled with what to do about a ten-year-old child who had “a rap sheet half as long as the boy is tall” and who had been arrested for eleven felonies in the previous five months, his mother made an impassioned plea for a “second chance.”1 Among the felonies James was charged with were car theft, robbery, arson, and assault—nicking a classmate in the neck with a piece of glass, for which he had been expelled from grade school. James was characterized by his juvenile court counselor as “beyond out of control.”

The week before the court hearing, the judge had granted a special sanction that allowed James to be placed in a detention home at an age under the legal limit of twelve. The authorities interviewed by Oregonian reporters agreed that there were increasing problems with what to do about violent children under twelve. “There’s a big hole in the system,” said Bill Morris, program supervisor for the County Juvenile Department. “The trouble is, we’re seeing more and more kids doing bigger things at younger ages.” Karen Lee, a spokesperson for the Oregon Children’s Services Division, told the reporters, “This is the quintessential case of where there is nothing in the system for a kid who’s got such severe problems at such a young age. There are only a handful of treatment beds and there is a two-year waiting list for every one of them.”

At the time of the hearing, the court had amassed a thick file of nearly thirty referrals on a mixture of custody issues and delinquencies during James’s young life. They documented a common continuum: born into an impoverished environment, including a period of homelessness; evidence of early physical and sexual abuse; a mother with a history of alcohol and substance abuse; a father who spent his teen years in a detention home and had been in and out of prison since; placement in at least three foster homes; and a fourteen-year-old brother then in foster care. James had been in Oregon’s child welfare system since he was seven months old.

Had James begun life as a puppy entrusted to the local Oregon Humane Society, he might have had a better chance. Thanks to the work of the American Humane Association, puppies in Portland are not placed with families until they have met with a “counselor” who explains puppy needs in depth. If a family plans to take home a very young puppy, they have to testify that someone will be at home to nurture it during the day—at least half time—until the puppy is housebroken. Payment must be made up front for the puppy’s shots and worming, and a deposit is required toward the neutering of the animal. This deposit will be refunded when proof is sent to the humane society that the surgery has taken place. Finally, a fenced backyard or a contained area outside must be provided for the puppy. There will be a home visit by humane society staff to check these safeguards.

None of this thinking follows most human babies, with the possible exception of children adopted through licensed agencies. The vast majority of babies in our nation receive no assurances that their basic needs for shelter, safety, and nurturing will be met. And we pay a big price in our society for this disconnection between what we know children need and what we allow to happen to a growing percentage.

The result—especially for children abused or neglected, and then turning violent in our communities—is an amazing web of expensive and often ineffective bureaucracies, which comes into play once children who are submerged in predictably destructive circumstances rise to the surface of the child welfare system. Just one confirmed case of child abuse or neglect is likely to trigger the involvement of at least five separate bureaucracies, not including special education or medical services. The police, the court, child welfare, and an average of two private treatment agencies are typically involved—and the results, for our most difficult children, are abysmal. For families, the experience usually confirms a sense of failure. And their odyssey has just begun.

GHOSTS AT THE POLICY TABLE

One-third of the new homes being built in America are being built behind bars. Yet we continue to produce more criminality than we’re reducing, in spite of our desperate efforts to contain the problem.2 Our nation’s approach to the problem of violence mirrors our approach to children generally. We operate within an ambulance mentality. It’s as if young battered bodies continue to fall before our eyes from a known precipice. Where once a few fell each year, now they come every hour, faster and faster. Our response to this tragedy is to position ambulances at the bottom of the cliff. As the bodies fall, we hasten to make better ambulances and schedule them to arrive at the bottom of the cliff more frequently. In response to increased gang shootings and delinquency, drug abuse, and child abuse, we hasten to build better headlights, better sirens, better motors, or wider doors on the ambulances. We are so busy responding to the immediate crisis and trying to repair the damage that we never consider how poorly the ambulance system itself is working and what we might do to keep children from the edge of the cliff.

The criminal justice system is another example of this ambulance mentality. We view violence as the problem, rather than seeing it as a late-stage symptom. If we trace the cycle of violence backward, we will see that most of the people now in prison were arrested as adolescents (62 percent). In high school, they were likely to have been involved in alcohol, drugs, and gangs. Typically, these kids weren’t doing well in school. They were truant, often delinquent, sometimes runaways, other times pregnant. People knew they were in trouble.

If we look a little earlier, most of these troubled adolescents were known in grade school as children who had learning, behavioral, or emotional problems; a frightening number were delayed, had physical handicaps or developmental disabilities. If we look back still earlier to the neighborhood, a high percentage of these children were children known to be left alone, inadequately dressed and fed, without adequate supervision—children with parents too absorbed in drugs, mental illness, poverty, or the criminal justice system to parent in an adequate way. Many of these children were neglected or abused. And the neighbors knew; they just didn’t know what to do.

Finally, if we look back to the beginning, these are the babies born in hospitals in every community who go home with parents too overwhelmed to show the first signs of cherishing their babies. Some mothers are clearly depressed, or are teenagers without support, or have bruised faces or backs. Many of these mothers had little or no prenatal care, and some brought their babies into the world hooked on or affected by the same drugs they ingested to mask despair.

While none of these factors automatically kicks off the cycle of violence, the correlations are far too great to overlook. But we wait. We wait for the babies of overwhelmed families to be abused or neglected and for these abused and neglected children to fall behind in school and for children failing in school to become delinquent or pregnant. While clearly recognizing the warning signals—parental substance abuse, family violence, teenage pregnancy, to name but a few—we wait. We wait for parents to fail and for children to appear in the system. By that time, for many children, it’s too late. And we pay dearly. The educational system, the child protective services system, the juvenile justice system, the prison system, and the welfare system are stretched beyond capacity, and they can’t fix the problems. We pay for children growing up damaged and angry. When we talk about crime, bigger jails, expanded police, more drug enforcement, we are talking mostly about the same kids—later.

Educational and social supports are rapidly growing industries. Communities across the country struggle with outdated responses and systems that can’t begin to deal with the growing numbers of children and families requiring services. From our ambulance perspective, we marshal tremendous resources to deal with the symptoms. But what we are paying for is often ineffective, not enough, or too late to alter the course.

The current service continuum is designed to treat child and family dysfunction once full-blown symptoms are detected. Multiple agencies respond to late-stage symptoms of pathology or dysfunction, assess and label these symptoms, and try to help families and children overcome the problems. But it is not a system designed to identify, let alone support, child or family health. Overwhelmed by the quantity and intensity of need, these systems can hardly afford to do anything for children who have not already fallen from the cliff or are precariously close to the edge. During infancy and toddlerhood, when we still have the opportunity to preserve full potential and when human learning and relating are at their most vulnerable—and also at their most opportune—our society is not paying attention. Our educational and social service systems ignore the earliest stages of life, an oversight that undermines the effectiveness of the education system and the entire continuum of child welfare, which begins too late.

Dr. Ronald David, of the Wiener Center for Social Policy at Harvard’s Kennedy School of Government, when talking about the health care system in our nation, could as well be speaking of the system of services for children when he says:

What we currently have in place is not a health care system but a disease care system. We have created a medical complex that is pretty darn good at diagnosing disease, managing disease, and sometimes curing disease, but not nearly so good at preventing disease—and sometimes it’s only too good at creating disease.3

AMERICA THE BEAUTIFUL

The number of Americans who have been victimized by violent crime remains a staggering reflection of life in our nation. Although crime has dropped significantly, the numbers are still appalling. According to FBI statistics, from 2002 through 2009 an estimated 740,000 youths ages ten to seventeen were arrested for a violent crime, including 9,980 murders/nonnegligent manslaughters. During that same period of time, nearly 5 million total arrests were made for violent crime—over 1 million more than the population of Los Angeles, the second-largest city in the United States. Of those violent crimes, 107,180 were murders/nonneglient manslaughters. In 2009, juveniles were responsible for 13.9 percent of all arrests, 14.8 percent of arrests for violent crime, and 24.2 percent of all property crimes (including 43.7 percent of all arsons).4

Concerning violent crime, the reality may be far worse than the official crime data reflect. When looking at the crime data, a serious discrepancy is found between the number of crimes reported by law enforcement and those reported by victims, and the latter is significantly higher than the official crime data. The National Crime Victimization Survey (NCVS) is administered by the U.S. Census Bureau on behalf of the Bureau of Justice Statistics. In 2011, NCVS findings showed that only 49 percent of violent crime and 37 percent of property crimes were reported to the police. That year 5.8 million Americans age twelve or older reported being the victims of a violent crime and 17.1 million were the victims of property crimes. In 2011, despite the official crime data showing a decrease in violent crime that year, according to NCVS data, there was a 17 percent increase in victimization from nonfatal violent crime per 1,000 people age twelve or older. In spite of these disparities in data, in 2011, overall crime victimization declined 72 percent from data reported in 1993.5

The good news is that violent crime among juveniles has decreased by 50 percent from 1994 to 2009, the last year reports were issued by the Office of Juvenile Justice, bringing it to the lowest level since the late 1970s.6 Additionally, the overall rate of serious violent crime against youth ages twelve to seventeen (including rape and other sexual assault, robbery, and aggressive assault) has declined 77 percent from 1994 to 2010.7 The National Conference of State Legislatures puts it this way:

A rise in serious juvenile crime in the late 1980s and early 1990s led to state laws that moved away from the traditional emphasis on rehabilitation in the juvenile justice system toward tougher, more punitive treatment of youth, including adult handling. During the past decade, juvenile crime rates have declined, and state legislatures are rebalancing approaches to juvenile crime and delinquency in order to identify methods that produce better results for kids at lower cost.

Today, there is more and better information available to policymakers on the causes of juvenile crime and what can be done to prevent it. This includes important information about neurobiological and psychosocial factors and the effects these factors have on development and competency of adolescents. The research has contributed to recent legislative trends to distinguish juvenile from adult offenders, restore the jurisdiction of the juvenile court, and adopt scientific screening and assessment tools to structure decision-making and identify needs of juvenile offenders. Competency statutes and policies have become more research-based, and youth interventions are evidence-based across a range of programs and services. Other legislative actions have increased due process protections for juveniles, reformed detention and addressed racial disparities in juvenile justice systems.8

While the overall crime rate has declined—and while juvenile crime has steadily declined, especially during the first decade of this century (see chapter 1)—some troubling trends remain in the crime statistics, including the following.

Racial Disparity: According to the National Council on Crime and Delinquency, African Americans make up 13 percent of the general U.S. population, yet they constitute 28 percent of all arrests, 40 percent of all inmates held in prisons and jails, and 42 percent of the population on death row. In contrast, Caucasians make up 67 percent of the total U.S. population and 70 percent of all arrests, yet only 40 percent of all inmates held in state prisons or local jails and 56 percent of the population on death row. Hispanics and Native Americans are also alarmingly overrepresented in the criminal justice system.

African Americans are arrested at a rate 2.5 times higher than the rate of arrest for Caucasians. For violent offenses and for drug-related offenses, the arrest rate for African Americans is 3.5 times higher than the arrest rate for whites and 6 times the rate for murder, robbery, and gambling. Native Americans are arrested at 1.5 times the rate for Caucasians.9

Black youth, who constitute only 16 percent of the U.S. juvenile population, account for 58 percent of juveniles arrested for murder and 67 percent of arrests for robbery. Black juveniles, similar to black adults, are arrested at five times the rate of white juveniles for violent crimes.10 While the overall rate of serious violent crime against twelve- to seventeen-year-olds declined since 1994, the rate of serious violent crime against black youth was more than twice the rate affecting white and Hispanic youth.11 Half of all black men without a high school diploma will go to prison at some point in their lives. More black men are currently under the control of the criminal justice system—in prison, on probation or on parole—than the number of black men in slavery in 1850.

Gangs: According to the FBI, in 2011, 33,000 violent street gangs, motorcycle gangs, and prison gangs with about 1.4 million members were criminally active in the United States. This represents a 40 percent increase from an estimated 1 million gang members in 2009. A “threat assessment” done by the National Gang Intelligence Center found that gangs are responsible for 48 percent of violent crime in most jurisdictions and up to 90 percent in several others. Law enforcement officials attribute this sharp increase in gang membership and criminal activity to improved reporting, more aggressive gang member recruitment, the formation of new gangs, new opportunities for drug trafficking, and collaboration among rival gangs and drug-trafficking organizations. Analysts also recognize that the gangster rap culture, the use of the Internet and social media (for recruitment and communication), the proliferation of generational gang members, and a shortage of law enforcement resources have contributed to the influx. Gangs are evolving and many are becoming increasingly sophisticated, advancing beyond their traditional role as local retail drug distributors into a variety of illegal moneymaking activities, including robbery, drug and gun trafficking, fraud, extortion, and prostitution. Gangs are also involved in highly profitable white-collar crime that is much harder to detect including counterfeiting, identity theft, and mortgage fraud. U.S.-based gangs have established strong working relationships with Central America and Mexico as well as several organized crime groups in the United States.

The rise in gang membership is occurring in communities across the nation, with gang members migrating from cities to suburban and rural communities in order to recruit new members, expand their drug distribution territories, and enlarge their profits and influence. Local neighborhood gangs and female gang membership are also rising in many communities. Prison gangs—with members who may continue to exert control over street gangs—are of particular concern to law enforcement. Gang infiltration of the military also poses a significant threat. Members of at least fifty-three gangs have been identified on U.S. military bases both at home and abroad, where they may be learning to operate advanced weaponry and combat techniques that could then be deployed on the streets of their communities when they return home after discharge. Also of grave concern are gang members acquiring and arming themselves with high-powered, military-style weapons and equipment through a combination of illegal purchases, straw purchases via intermediaries, and thefts from individuals, vehicles, residences, and commercial establishments.12

Girls: While females commit a smaller proportion of crimes than males, the number of girls and women committing crimes continues to trend upward. Although the majority of their crimes may be less ­serious—running away from home, truancy, and other status ­offenses—girls may be fleeing from serious problems and victimization that make them vulnerable to behaviors such as prostitution and drug use. FBI data indicate that in 2011, 25.9 percent of all arrests in 2011 were female (more than 1 in 4, a leap from the 1 in 7 reported when Ghosts from the Nursery was first published in 1997). Approximately 12.7 percent of those arrested females were under the age of eighteen.

According to the Office of Juvenile Justice and Delinquency Prevention court statistics for 2009, young women are increasing in the delinquency caseload; the number of girls has grown at an average rate of 3 percent per year compared with 1 percent per year for males since 1985. In 2009, females accounted for 28 percent of the total delinquency caseload, up from 19 percent in 1985.13

The rates are also increasing for adult women. Bureau of Justice Statistics indicate that between 1995 and midyear 2004, the total number of females in state and federal prison grew 5 percent per year, compared with 3.3 percent growth for males.

Approximately 1 of every 8 adults on parole (94,000), and almost 1 of every 4 adults on probation (957,600), is female.14

Bullying: At least 20 percent of children ages two through seventeen were the victims of bullying during the year 2007–2008. According to children age twelve to eighteen who reported being bullied, 79 percent of the incidents occurred within the school, 23 percent on school grounds, 8 percent on the school bus, and 4 percent elsewhere. It is very likely that bullying is a much more pervasive problem than the official data reflect. A 2009 survey found that only 36 percent of kids who were bullied at school had reported it to a teacher or another adult.15

Children’s Exposure to Violence: Children are more likely than adults to witness or to be the victims of violence. In 2011, more than 60 percent of children ages seventeen and younger were directly or indirectly exposed to violence. In addition, community violence that children don’t directly witness has been shown to have a negative impact on children’s attention and cognitive performance. In 2008, the U.S. Department of Justice conducted a national survey of children exposed to violence, interviewing children age ten and older and the adult caregivers of children younger than ten. The survey found that nearly half the children (46 percent) had been physically assaulted in the previous year and that more than half (57 percent) had been assaulted sometime during their life. In the prior year, 25 percent of the children had witnessed violence in their homes, schools, and communities. Thirty-eight percent had witnessed violence against another person sometime during their life. Nearly 1 in 10 (9.8 percent) had seen one family member assault another in the past year and more than 1 in 5 (20.3 percent) witnessed one family member assault another at some point in their lifetime.16

Overlooking Mental Health: A majority of juvenile offenders in residential facilities have at least one mental illness. Two-thirds have symptoms associated with aggression, depression, and anxiety. The rate of severe mental illness among incarcerated youth is conservatively estimated at 27 percent—two to four times higher than the national rate of all youth. Thirty percent of these juveniles were physically or sexually abused.17 Data indicate that up to 93 percent of justice system youths have experienced trauma, the majority of which stems from child abuse and neglect.18

While estimates of children’s exposure to violence range from 14 percent to 34 percent of all children in the United States, we know from the abuse and neglect data that children are twice as likely as adults to be victims of serious violent crime and three times as likely to experience simple assault. More than 13 percent of all female adolescents report having been sexually assaulted, while 35 percent to 45 percent of adolescents report witnessing violence.19

INCARCERATION NATION

In addition to the high-dollar costs of using incarceration as a primary strategy for cutting crime, we are already paying high social costs. Families are further undermined when young fathers are put in jail. As we have seen, children growing up without fathers—or worse yet, with criminal fathers—are more likely to feed the same cycle, particularly if they are boys. Prisoners rarely emerge from jail better educated, with prosocial skills or improved job eligibility. The reverse is usually true. This cycle feeds itself in widening circles with each generation, creating a swelling tide of abused, neglected, and antisocial children.

BRIDGE INTO TROUBLED WATER

The juvenile justice system has too often been a stopping-off point for offenders between the experiences of childhood and the adult criminal justice system. Besieged by the rising tide of young offenders and contradictory theories and policies on how to respond, the juvenile justice system is in transition. “The juvenile justice system is not working well for anyone—not for violence-prone juveniles, not for their victims, not for communities,” says Andrew Stein, chair of New York State’s Commission for the Study of Youth Crime and Violence.20 On one side of the argument are conservative voters and politicians who push for longer sentences and remanding younger criminals to adult courts. On the other side are liberal voters and politicians who advocate treatment, education, and separate environments for young offenders so that they can be rehabilitated rather than become habitual offenders. Most states have vacillated between countervailing “reforms” passed by politicians anxious to target short-term gains.

Where the opposing forces in this ongoing debate tend to agree is on the notion that juvenile offenders need firmly structured environments. Where they disagree is on the most effective ways to accomplish this. The options range from tougher sentences in detention centers to boot camps to structured one-on-one mentoring by community recreational or religious organizations (e.g., Big Brother and Big Sister). There is strong evidence that grouping antisocial young people into detention centers, let alone adult prisons, only intensifies antisocial behavior. The skills to earn a living for a decent wage, to relate prosocially within the community, to parent, to build constructive relationships in general, are lost in prison settings. Since we are all creatures of habit, young people released from such settings tend to drift back to what they know. Generally, the longer the time served in prison, the more dangerous kids become.21 For the majority who have been grouped from early childhood with children who also have behavioral problems, jail or detention only reinforces their identification with antisocial peers. Most of these children have come from households where parents were too busy or too troubled to focus on raising children. Prison may be their first exposure to the structured learning of everyday skills.

Not only is the incarceration of juveniles expensive—up to $250,000 per year per juvenile—but it is often ineffective at deterring further criminal behavior. In 2007, states spent more than $5.7 billion to lock up 64,558 juveniles in residential facilities. The costs varied widely by state from $24 per day ($8,760 annually) in Wyoming to $726 per day ($265,000 annually) in Connecticut. According to the American Correctional Association, the price to incarcerate one child averages $240.99 per day ($88,000 per year) in the United States.22

Three-quarters of the teenagers released from juvenile institutions are soon arrested again.23 About half wind up continuing the cycle at an annual cost that is often high enough to pay for three children to attend Harvard. Until the turn of the century, the available recidivism data from New York State (based on a study of juvenile delinquents and offenders discharged from custody between 1991 and 1995) showed that 75 percent were rearrested within three years. Given extensive reforms undertaken by the Office of Children and Families, this statistic has significantly improved but still remains very high. In 2008, 49 percent of incarcerated youth were rearrested within one year of release and 66 percent were rearrested within two years of their release. Boys were significantly more likely to get rearrested than girls. Data from 2004–2005 show that in California, 62 percent of juveniles released from custody were rearrested within one year and 76 percent within two years. And in 2006, 43 percent of juveniles incarcerated in Texas were rearrested with one year of release and 63 percent within two years.24

Many studies have confirmed a grim picture of delinquent recidivism. One study by Dorothy Lewis of a group of ninety-seven formerly incarcerated delinquent boys showed that all but six had adult criminal records, most for violent crimes.25 While easier for adolescents than for adults, it’s hard to change one’s sense of self-image, peer identification, and basic living skills and habits from an antisocial to a prosocial orientation. And society doesn’t make it easy, even for very young felons. The New York Times profiled a boy it called Tony in a series entitled “When Trouble Starts Young.”26 When Tony, age thirteen, tried to return to a junior high school as a condition of his release from detention after a grocery store robbery, he had simply missed too much. Earning a living at minimum wage also had no appeal. In telling the story of Tony, reporter Joseph Treaster wrote:

Halsey Junior High, where he had last attended class in the eighth grade, did not want to take him back. Gershwin Junior High, nearby, did not seem eager to have him, either. But Mr. Gattuso [school staff] made some calls and, after about six weeks, Tony was admitted to Gershwin.

“I went like two or three days,” Tony said, “and that was it. Every time I went there, they weren’t doing anything in class. They were practicing for graduation and I said, ‘Why am I practicing for graduation?’ I wasn’t even in school.”

Tony said Mr. Gattuso had offered to help him find a job. But he wasn’t interested. “I figured you work all these hours and just get a little bit of money,” he said. “You can rob somebody in five minutes and get more money than you’d make in like a week of working.”

A major barrier to the success of the juvenile justice system has been the lack of a bridge back into the community—to schools, jobs, and nondelinquent friendships. Even when juvenile systems have succeeded with their goals, because of a lack of resources, few juveniles exiting juvenile justice will successfully be reabsorbed into the community, beginning with school. There are several hurdles, including a dearth of special schools, the need to maintain safety in regular schools, the lack of a system to maintain partial credits for formerly truant students, and the embarrassment of learning disabled and formerly truant students. Many need extra help. Alternative schools designed for delinquent youth typically reexpose returning youth to more “bad kids.”

One promising alternative that is receiving increasing attention is “after care” for juveniles who have served time in detention or jail and are now ready to return to their communities. These programs, which vary greatly in their intensity and costs (from $3,000 to $8,000 per youth), assign young people to individual advocates who provide mentoring, regular telephone contact, and weekly meetings with youths and their families to keep them on track. They help children go back to school, to find jobs, and to integrate into gatherings of prosocial peers. New friendships are built through athletics and recreational activities, in contrast to probation and parole, in which officers rely on weekly or monthly office visits and periodic drug testing to keep tabs on potential recidivists. Case managers in after care programs ideally work with a dozen or fewer youngsters, in contrast to the one hundred or more of the typical parole officer’s workload. The effectiveness of the after care program appears to improve when the mentor-to-youth ratio is low. Michael Corriero, a former New York State Supreme Court judge who dealt with the most serious juvenile offenders in Manhattan, says, “We need almost a one-on-one with these kids. We try to have it, but it’s not properly funded or supported.”27

Desperate to place responsibility for children as close as possible to the source of the problem, some communities have tried to hold parents responsible for their children’s delinquency. For example, beginning in 1995, when kids act out in Silverton, Oregon, parents may be brought to court and charged with bad parenting. Ordering parents to attend classes on parenting or drug abuse is an alternative to fines of up to $1,000. But typically parents of delinquent children, many of whom are as young as seven, feel they have little ability to control their children. Skills may help, but the problems are often deeper. With many of the offending children coming from homes in which the parents are also offenders, or mentally ill, or drug abusing, this approach has little hope of measurable impact on the growth of delinquency, unless the concept of parenting is expanded to include not only skills, but also the broader supports essential to constructive parenting, including treatment for the parents’ own mental illnesses and drug abuse.

By the teen years, these children are often repeating the cycle of their parents, including early pregnancies, alcohol addiction, and drug use. These are the beginnings of the undoing of yet another generation. The good news is that the use of illicit drugs by adolescents has been declining, from 55 percent of students in 1999 to 49 percent in 2012. The students who had used an illicit drug “other than marijuana” was also down, from a high of 31 percent in 2001 to 24 percent in 2012.28

But adolescents are increasingly turning to their family medicine cabinets for sources of getting high. Particularly among boys, a growing problem is the abuse of prescription medications and over-the-counter drugs like cold medications. Common products like Robitussin, NyQuil, Dimetapp, and Vicks contain dextromethorphan (DXM), which acts as a painkiller and (in large doses) a hallucinogen, leading to a state of artificially induced euphoria. Seemingly innocuous over-the-counter medications are increasing the rates of poisonings, seizures, and addiction. A study from the University of Cincinnati reported that out of a sample of 54,000 high school students, 10 percent reported abusing OTC drugs.29

Prescription painkillers, and the medications increasingly being prescribed for ADHD such as Ritalin and Adderall, are also increasingly abused among teens. Their widespread availability in medicine cabinets across America, along with online information found via YouTube and Google, provides easy access combined with instructions on the many ways these drugs can be used and abused.30

But of all drugs available, alcohol remains the most commonly used and abused drug among American teens. Alcohol abuse is the cause of more than 4,700 deaths in underage youth each year.31 According to CDC data, children and young adults ages twelve to twenty drink 11 percent of all alcohol consumed is in the United States and more than 90 percent of alcohol consumed is in the form of binge drinking. In 2010, approximately 189,000 hospital emergency room visits were for patients under twenty-one who had injuries and other conditions linked to alcohol.

The 2011 Youth Risk Behavior Survey found that among high school students, over the course of thirty days:

• 39 percent drank some amount of alcohol;

• 22 percent binge drank;

• 8 percent drove after drinking alcohol;

• 24 percent rode with a driver who had been drinking.32

In 2011, the National Survey on Drug Use and Health reported that 25 percent of youth aged twelve to twenty drank alcohol, and 16 percent reported binge drinking. Also in 2011, the Monitoring the Future Survey reported that 33 percent of eighth graders and 70 percent of twelfth graders had tried alcohol, and 13 percent of eighth graders and 40 percent of twelfth graders drank during the previous month.33

Given the connections between early neurological damage and the use of drugs or alcohol during pregnancy and the potential impact of these substances on sperm, especially during adolescence, we may see a much larger wave of attention and learning disorders in the next generation.

In response to the serious rise in juvenile crime reported in the original printing of Ghosts from the Nursery, states moved away from the traditional emphasis on rehabilitation to a punitive “get tough on crime” approach. But soaring costs of juvenile incarceration and truly dismal recidivism outcomes have led to a serious rethinking of juvenile justice. Legislatures and social service agencies across the nation are now seeking to implement more effective approaches to juvenile crime. This new wave of thought is also being driven by emerging research into the long-term impact of the neurobiological and psychosocial factors at play in a child’s environment and the plasticity of the adolescent brain, as well as the rigorous evaluation of programs and services that effectively put troubled kids on a positive track.

Although things appear to be moving in the right direction for juvenile justice policy and practices, relatively little attention has been paid to the factors at the core of aggressive and violent behavior among juveniles—specifically, the impact of early trauma. Trauma-informed treatment and practices is an emerging field fueled by the findings of the Adverse Child Experiences study, first published by Kaiser Permanente San Diego and the Centers for Disease Control in 1999, shortly after Ghosts from the Nursery was first released. The ACE research quietly transformed medical practice—and is recognized as having huge implications for emotional and behavioral as well as physical health and disease.

First formulated by Dr. Vincent Felitti, a visionary physician and founder of the California Institutes of Preventive Medicine in San Diego, the ACE research began as an effort to understand why many morbidly obese Kaiser patients—who were being successfully treated in the clinic—were dropping out of a foolproof program to lose weight. A strong proponent for including in-depth patient histories along with physical examinations and lab work in medical diagnoses, Felitti, in his effort to understand the reticence of successful weight loss patients to continue the program, began to interview this group. It became clear that childhood events were a significant influence on patients’ weight, and on adult behavior and health in general. During a subsequent presentation on this experience to the Centers for Disease Control, Felitti met a CDC epidemiologist, Dr. Robert Anda, who soon became his collaborator in designing the study. The ACE questionnaire was gradually refined to include a very specific list of adverse childhood experiences including child abuse, domestic violence, addiction, mental illness or incarceration of a family member, and parental loss due to separation, divorce, or death. Each category, regardless of frequency of occurrence, was scored as one point. The questionnaire was mailed to Kaiser patients in San Diego—a predominantly white, middle-class, educated, and middle-aged group that provided a high rate of return on the questionnaire. The researchers cross-referenced the health status of more than seventeen thousand Kaiser patients with their responses to the ACE questions. The results were astounding—even to the researchers.

Most surprising was the sheer prevalence of adverse childhood experiences even in this population. Two-thirds of respondents reported experiences in one or more categories. More than a quarter of them had grown up in a household where there was an alcoholic or drug abuser; the same percentage had been beaten as children.

While the study has made medical history in showing high correlations between ACE scores and leading types of physical disease including heart disease, type 2 diabetes, and susceptibility to several forms of cancer, the correlations with behavioral health, especially addiction, are equally riveting. Compared with a person having no history of adverse childhood experiences, an individual with an ACE score of 4 or higher is seven times more likely to be alcoholic, six times more likely to have had sex before age fifteen, forty-six times more likely to be depressed, and twelve times more likely to commit suicide. The research is strong testimony to the role of emotional trauma in our bodies and in our lives. The chemistry of strong negative emotions—especially fear-inducing situations experienced early and chronically in life—can take a child off course in ways we are only beginning to connect.

As emotional trauma is further recognized as lying at the root of violent and aggressive behavior and addiction—and behavioral health in general—the field of treatment for individuals requiring such systems as child welfare, juvenile justice, and adult corrections is beginning to focus not just on the “what” of treatment (the techniques and skills addressed) but rather on the “how” (the way that services are delivered and the nature of the relationships involved). Historically, most of what has been available in the way of treatment for troubled kids focuses little attention on how those services are delivered. As a result, many of the institutions and services that are intended to help in fact may, even with the best of intentions, repeatedly retraumatize a child or adolescent. Some efforts are under way to try to shift the social service culture toward trauma-informed practice. For example the Sanctuary Model—developed beginning in 1992 by Dr. Sandra Bloom at the Andrus Children’s Center in Yonkers, New York—­focuses on organizational change. Its goal is to work with people instead of doing things to or for them. The model is designed to provide an understanding of the impact of trauma on learning and behavior, and to enhance the ability of staff working in the human services field to communicate with one another and to collaborate when providing treatment. “Social workers, psychiatrists and nurses don’t share a common way of working with clients,” says Dr. Bloom. “The Sanctuary Model gets everybody on the same trauma-informed page. . . . Most clients who present to human service delivery organizations have been exposed to significant adversity, chronic stress, and frequently overwhelming trauma. . . . [But] they cannot heal within the context of traumatizing—or traumatized—organizations that may actually create more, not less pathology.”34

LAST STOP: SCHOOL

Children appearing in the juvenile justice system are typically students who are well-known to school administrators for truancy, skipping classes, poor grades, and learning and emotional disabilities. A surprising number—estimated at 20 percent—have low intelligence and impulsive behavioral problems from detectable developmental problems such as fetal alcohol syndrome. Many are also traumatized children whose lack of emotional self-regulation resulted in diagnoses like ADD or ADHD, identified earlier at the grade school level long before delinquent behavior came to light.

Schools—like the juvenile justice system—are caught by changing social factors in a catch-22. At the center of the dilemma is special education, the federally mandated stream of dollars that exists to make sure that all children, regardless of their handicaps, have access to an education that will meet their needs. Special education is a huge expense to school districts, consuming an estimated 21 percent of all education spending in 2005. The cost to school districts is rapidly escalating, with 41 percent of the total increases in education spending from 1996 to 2005 funding special education services.

Most of the children receiving federal dollars for special education are not deaf, blind, or classified as having an obvious physical disability. The vast majority have specific learning disabilities, such as reading and information processing problems, or behavioral problems resulting from early trauma. From 1976 to 1994, the number of children with specific learning disabilities requiring special services went from just under 800,000 served annually to nearly 2.4 million, an increase of 1.6 million or 45 percent.35 In 1993 through 1994, approximately 7.7 percent of all children enrolled in school received special education services compared with 4.5 percent in 1976–1977, an increase of about 70 percent.36 Students with specific learning disabilities (SLD) accounted for the majority of that increase, comprising more than half of all disabled children served.37

For decades after the enactment of the Individuals with Disabilities Education Act (IDEA), the number of students with disabilities steadily increased until it peaked in 2004 and 2005 with 13.8 percent of all students (6.72 million) in special education programs. The following year, the numbers began to decline, and by 2010, more than 13 percent of students nationwide (6.48 million) received special education services.

But inside of this overall decline, there were differing trajectories for individual categories of disabilities: specific learning disabilities, consistently the largest category of all, fell from 6.1 percent to 4.9 percent (2.86 million to 2.43 million). Mental retardation fell 1.3 percent to 0.9 percent (480,000 to 407,000). Autism and “other health impairment” (OHI) quadrupled from 93,000 to 378,000, while OHI numbers doubled from 303,000 to 689,000, increasing from 0.8 percent to 1.4 percent of students.

However, much disparity exists between states, so the accuracy of the data can be difficult to judge. Budgets in many districts may influence spending. For example, Rhode Island reported more than 18 percent of its students were receiving special education services in 2009–2010, while Texas reported 9.1 percent.38

When Ghosts was originally published, Ritalin was being prescribed for 3 percent to 5 percent of all children in the United States to control attention disorders. Because most of these children were males, 10 percent to 12 percent of boys in the United States between the ages of six and fourteen were taking this medication.39 A report published in April 2013 by the Centers for Disease Control reported that about 11 percent of school-age children in the United States—more than 1 in 10—and 19 percent of high school–aged boys had been diagnosed with ADHD. In 2013, 6.4 million American children between the ages of four and seventeen have been diagnosed with ADHD, representing a 16 percent rise since 2007 and a 53 percent rise over the past decade. It’s hard to believe that 15 percent of grade school–aged boys and 7 percent of girls have an ADHD diagnosis. And for teens (age fourteen to seventeen) this statistic increases to almost 20 percent of boys and 10 percent of girls.40

About two-thirds of the children with a current diagnosis of ADHD take prescription drugs such as Adderall or Ritalin. These drugs, while enormously effective when the diagnosis is correct, can also lead to addiction, anxiety, and psychosis.41 As of 2012, American children have become the new frontier for the sale of prescription drugs. One-quarter of the children insured by Medco, a large manager of prescription benefits, took prescription medicine to treat a chronic condition, including asthma, ADHD, obesity, heartburn, and diabetes—representing a spending increase for drug costs of 10.8 percent, more than triple the amount for seniors.42

Once students are identified with special needs—physical, emotional, or cognitive—they are entitled to special services. The federal government requires each school district to match federal dollars in providing for such children. Meeting this requirement may consume up to a quarter of the total operating budget for a district. In addition, when children enter kindergarten unprepared to learn—with limited vocabularies, poor emotional regulation, poor social skills, hunger, chronic illness, or other health problems—schools find themselves responsible not only for formal education, but also for the roles of social workers, nurses, mental health counselors, confidants, babysitters, meal providers, drug and alcohol preventionists, and parents. Teachers may be called upon to teach such diverse skills as manners, sex education, AIDS prevention, and bowel control, all formerly the jurisdiction of parents. And they must be knowledgeable about the signs of child abuse and neglect.

While social services in the schools are crucial, at the same time schools are struggling to teach reading, writing, and math. Among fifteen industrialized nations, thirteen-year-olds in the United States rank seventh in science achievement and twelfth in mathematics achievement—well below competitor nations.43 Public schools have almost no funding to serve their brightest students, and gifted students from financially impoverished backgrounds are particularly bereft. Public schools in the United States are not functioning effectively as either social service agencies or educational institutions. For children en route to the criminal justice system, public education currently affords few ameliorating opportunities.

SCHOOL DAYS, SCHOOL DAYS,
GOOD OLD GOLDEN RULE DAYS

Contrary to what we might want to believe, school is not a particularly safe place for many children. In 2011, the CDC culled a nationally representative sample of children in grades nine through twelve on youth violence: 

• 32.8 percent reported being in a physical fight in the twelve months preceding the survey;

• 16.6 percent reported carrying a weapon to school on one or more days in the thirty days preceding the survey;

• 5.1 percent reported carrying a gun on one or more days;

• 7.4 percent reported being threatened or injured with a weapon on school property one or more times in the twelve months preceding the survey;

• 5.9 percent reported that they did not go to school in the thirty days preceding the survey because they were afraid either at school or on their way to or from school;

• 20.1 percent reported being bullied on school property in the twelve months preceding the survey;

• 16.2 percent reported being bullied electronically (via e-mail, chat room, texting, website)—22.1 percent of girls experience this type of bullying compared with 10.8 percent of boys.44

THE EYE OF THE STORM

While children are perpetrating crime,45 they are also likely to be the victims of crime. Mike Green, formerly the district attorney for Monroe County (Rochester, New York) and currently the executive director of the New York State Division of Criminal Justice Services, says that in all his years as district attorney he never prosecuted a capital case where the defendant didn’t have a serious history of child abuse. More than 740,000 children are treated in hospital emergency departments as a result of violence every year—more than eighty-four every hour. The total cost of this travesty is $124 billion every year.

In our nation, the wealthiest in the world, 3.3 million reports of child abuse or neglect occur every year, involving 6 million children. Among all industrialized nations, the United States has the worst rate of child abuse: Five children per day are lost to abuse-related deaths. Eighty percent of these deaths involve children under the age of four. Every ten seconds a report of child abuse is made in America—an intolerable reality.46

Along with the juvenile justice and education systems, the child welfare system is caught with an impossible task between opposing social and political forces: to protect children from their own families. The stories of violent outcomes for children living in chaotic and abusive families become grimly redundant. Stories such as that of the ten-year-old fifth-grade boy in Englewood, Colorado, who sexually abused eighteen-month-old Jazmine Hean in May 1996 and then beat her with a dog chain and stomped on her. With shoe marks on her head and hand, he left her to die in a bed with a dead cat. The boy’s family had a long history of both child neglect and family violence. The family had been involved with the county social services since they moved to Englewood in 1977. In 1978 neighbors were reporting that the children were not being fed and that their mother was beating them with her fists. In a report on the mother written five years before the ten-year-old killer was born, the chief domestic relations counselor wrote, “The accounts from a variety of sources regarding her habitual neglect boggle the mind.” The report cited several episodes of serious neglect including hospitalization of a son for “failure to thrive,” or lack of normal weight gain often associated with child neglect. The report also described the father, Mickey Horton, as a man who “had difficulty controlling his anger.” Both parents had been charged with abuse and neglect in the past and had received twenty-three citations for code violations on the family home, mostly for trash, litter, and derelict vehicles. Police were called to the residence forty times in the two years preceding Jazmine’s killing, fifteen times at the family’s request.

When the police arrived on the scene after Jazmine’s murder, they found the house filthy and overcrowded. Much the same, in fact, as it had been in 1982, when an inspection revealed “an accumulation of food and trash in the dining and kitchen areas, clean and soiled clothing scattered throughout the residence, severely soiled carpets, heavy accumulation of debris throughout the residence, heavy accumulation of paper, open cans, rags, and other items in the bedroom . . . cooking facilities were covered with grease and crusted food.”47 Two days after Jazmine’s death, Horton was served with a summons detailing 135 code violations, and city workers constructed a chain-link fence around the house and served notice that it would be demolished in sixty days unless he came up with an acceptable plan for its rehabilitation.

The child welfare file on Jeffrey and his siblings, John and Julie, lists regular reports of abuse and neglect, more than half of which were validated. Neighbors called the agency responsible for helping those children, and in some cases services were briefly made available. Jeffrey’s mother requested the agency’s help voluntarily on more than one occasion prior to Julie’s birth when she was overwhelmed by two small children, pregnancy, and her own chronic bouts of depression.

But the children fell through the cracks. In spite of short periods of assistance, no concerted effort was ever in place to deal with the complex combination of factors at play: drugs, mental illness, abuse, neglect, multiple moves, multiple boyfriends, to name only a few. The most frequent response of the agency was to remove the children to foster care, a consequence that deterred Jeffrey’s mother from honest disclosure of the help she needed. In the existing system of child protective services, treatment programs carry not only stigma but also the risk of providing agency workers with information that can be used against parents in a battle to retain or regain custody of their children. For Jeffrey and his family, the child welfare system was simply not equipped to assist beyond emergency services or crisis intervention. Had services been offered during Jeffrey’s mother’s first pregnancy and the months after birth by supportive outreach from the health department or from an early education program to help with mental health problems, substance abuse treatment, employment, housing, and so forth, chronic patterns could have been precluded or interrupted at natural points of access to the family.48

Like juvenile officers and teachers, caseworkers in child protective services are beleaguered by caseloads they can’t begin to handle; most are carrying 30 percent to 50 percent more cases than are recommended by national standards. Litigation against child welfare agencies has become a routine form of child advocacy; lawsuits have been filed or threatened in almost every state.49 Foster care systems are overrun and underfunded. Infants under the age of one account for a quarter of all children in foster care. An estimated three in five foster children have serious health problems, and a similar proportion are at risk of problems from prenatal drug exposure. Fifty percent of young children in foster care have unidentified or unmet needs for health care. One in eight of those children receives no routine health care; one in three has not received immunizations.50

Countless media reports on juvenile justice, on public schools, and on child welfare systems in the United States confirm major problems with all three systems. All of these systems were created to serve fewer children with less intense needs. The explosion of children in dire circumstances and with increasingly serious problems exceeds the bureaucracies’ capacities to keep up with either the quantity or intensity of services required. All of these systems fail for the same reason: They are overwhelmed by complexities they cannot possibly handle thoroughly.

In order for child welfare to have successfully intervened with Jeffrey and his family, three factors would have had to be in place. First, the child welfare system would have had to be able to develop an integrated treatment plan together with other agencies (e.g., alcohol or drug treatment, employment, and mental health). Staff and bureaucracies would have had to work together, preferably under one roof, with common goals and incentives. Second, the agencies would have had to make their services available and accessible so that the family could work and still attend treatment sessions with the help of child care and transportation assistance. And most important, services would have had to be provided early enough in the developmental cycle of the children, and in a manner considering and supportive of the trauma-affected parents, to nurture and stimulate the babies’ basic potential and to prevent obvious risks from taking their toll.

The violent children of the future are now babies. If we want to reduce the predictable tide of traumatized children that will continue to overwhelm existing bureaucracies, we can. But achieving this will require us to create a very different continuum of services, which begins with addressing the needs of parents around us who are now pregnant or parenting babies.

Strong efforts to intervene from the point of conception, gestation, and birth, particularly for children at high risk, are beginning to receive attention. Promising prevention programs such as home visitation of all new babies by a trained public health nurse or trained paraprofessional are increasingly being researched, refined, and implemented on a small scale in several states. Head Start has moved from focusing only on children three to five to create centers for and in-home outreach to families with children from birth to three (Early Head Start).

However, it is still an all but impossible task for parents to find substantive help and intervention for their infants and toddlers in most communities. Witness the story of Karen and Michael. Karen, a fifth-grade teacher, was excited about and well prepared for the birth of her first child, Michael. She had participated in Lamaze classes with her husband and chose to have a midwife assist her in delivering her baby in a local hospital. Her labor was less than four hours; she used no drugs or anesthesia. While she had worried that Michael was not more active during the last few weeks of pregnancy, he was born easily and seemed healthy. Soon after birth, however, problems began to appear. He had difficulty sucking and didn’t take to the breast, even after weeks of assistance from a lactation specialist. He appeared to be irritable and developed reflux, a condition that caused him to spit up frequently and to cry with digestive discomfort. He trembled when he cried, and his movements were jerky. He was extraordinarily stiff, would not mold to his mother’s body, and was highly sensitive to light and sound. Michael would waken from sleep right into screaming. He had trouble sleeping and woke up for long periods around the clock. At three and four months of age, he still would not look at a human face but generally preferred inanimate patterned objects such as wallpaper or vertical blinds.

At each well-baby visit, Karen mentioned her growing concerns to her pediatrician, who minimized all of them and told her not to worry. As the weeks passed, Karen became isolated by Michael’s tendency to become overstimulated when she ventured out with him. As her loss of sleep and the effects of Michael’s irritability mounted, she became more desperate. In tears at a doctor visit scheduled to treat an ear infection when Michael was three months old, she poured out her fear to the pediatrician that something was seriously “wrong” with her baby. The doctor again discounted Michael’s symptoms and recommended to Karen that she see a therapist for antidepressants. Fortunately, a family friend of Karen’s who was a child therapist corroborated Karen’s observations. She knew that Michael’s shakiness, refusal of eye contact, stiffness, and poor regulation of states of arousal were clear signals that all was not right. The friend began calling various specialists she knew to decide how to connect Karen with the help she needed for her baby. A call to the local health science center’s child development and rehabilitation center referred her to a pediatric neurologist. The neurologist’s nurse scolded the friend for inquiring about these symptoms in a three-month-old baby—“too young” was her brusque conclusion. She recommended that Karen or her pediatrician should call the neurologist back if Michael had not outgrown these signs of “immaturity” by six to eight months of age.

Refusing to give up, Karen’s friend called a personal friend at the medical school who was a specialist in treating attention deficits. This specialist made a personal call to a friend of his, a developmental pediatrician, who agreed to see Michael. Two weeks after this call and months after Karen first began expressing concerns to her doctor, the developmental pediatrician examined Michael and noted a strong left-sided dominance in motor functions, as well as the stiffness and the trembling. She prescribed a course of physical therapy.

By nine months of age, as Karen worked with Michael under the direction of the physical therapist, many of his symptoms had begun to abate. He outgrew the reflux, began sucking normally, established good eye contact and reciprocal vocalizing. But, although he crawled and was active, Michael could not sit up. He also remained very stiff, and his shakiness continued, intensifying as he grew tired. At ten months, the developmental pediatrician recommended an MRI scan of Michael’s brain to acquire further diagnostic information. The results of the MRI showed an old hemorrhage in the temporal occipital region, which the neurologist believed occurred immediately before or just after birth. While the neurologist immediately eliminated trauma or an external blow as the cause of the problem, it took several months to determine the reason for the hemorrhage. Michael had a rare blood disease, which caused internal bleeding around the time he was born. As the result, Michael experienced chronic head pain during his first months of life, lowering his ability to tolerate additional frustration or excitement. By the time Michael was almost two years old, his symptoms had mostly disappeared and he appeared to be a very normal little boy who had overcome his early losses. He was active, energetic and very well coordinated.

But accessing a diagnosis and treatment during the critical time of his early brain development was extraordinarily difficult. Karen was educated, aggressive, and able to pay for Michael’s care outside of her managed-care policy, which was being well guarded by a pediatrician who could not discern Michael’s symptoms even when Karen pointed them out. In addition, Karen had personal connections to a route of influence and inside help that would normally only be made available by more “blatant” or “urgent” symptoms of impairment.

Karen’s experience is unfortunately typical. Passed off as signs of immature nervous, motoric, or emotional development—or blamed on the mother—early signs of neurological abnormalities in infants are often overlooked. The opportunity for rerouting the damaged neurological circuits during the time Michael’s brain was still highly plastic could have been missed, resulting in more profound effects and cumulative damage. The subtleties of early infant physical and emotional behavior, and the hesitant messages from frightened parents, are frequently passed over until preschool or kindergarten, when more obvious symptoms may be caught in federally funded early intervention screenings. Few communities have the trained staff or outreach programs, even in private clinics, to do a good job of screening for early emotional and behavioral problems affecting infants.

No one has been more aware of this lack or more knowledgeable about how to meet it than Dr. T. Berry Brazelton. Dr. Brazelton’s developed, in partnership with his colleague Dr. Ed Tronick, a program called Touchpoints designed to train child-focused professionals in the first three years of emotional and behavioral development.51 Based on his book by the same title, Touchpoints training prepares professionals to work with parents in a sensitive and strength-based context so that parents are knowledgeable and prepared for the surges and regressions of normal development, including recognition of signs of pathology. By offering parents anticipatory guidance just ahead of their child’s behavioral changes, when both parents and child are vulnerable and relationships are challenged, many problems can be prevented.

Another extraordinarily promising training program that is gradually penetrating the public health system is NCAST, Nursing Child Assessment Satellite Training, developed by Dr. Kathryn Barnard at the University of Washington. Like Touchpoints, NCAST focuses on outreach to parents of children zero to three. It primarily trains nurses who are meeting with pregnant and new mothers in public and private settings. Its tools include a feeding and a teaching scale, each of which identifies in clear language the specific behaviors that characterize a healthy interaction between a parent and a child engaged in feeding or teaching and learning. Tiny units of behavior: reciprocal eye contact, vocalizations for babies and for mothers, a variety of touches and voice tones—dozens of minute behaviors—are listed on a binary scale. The magic of the NCAST scales lies in their usefulness with young or first-time parents or with parents who themselves were abused or neglected as babies.

Complex positive interactions like emotional regulation are broken down into a series of individual behaviors that can be modeled and taught. The baby’s ability to communicate his or her needs clearly and the baby’s responsiveness to the parents’ behaviors are also scored. NCAST training for parents and the professionals who work with them can help demystify the complexities of healthy early relationships so that positive interactions can be supported or taught in a nonstigmatizing way at the time the interactive patterns between parents and babies are forming. One of its greatest strengths lies in its ability to allow parents to, first of all, see what they are doing right and then to work with them to strengthen that base.52 NCAST and Touchpoints can both most effectively be embedded in programs that serve young or first-time parents from pregnancy through the child’s third year of life. Several promising programs are emerging in many states. These programs share the goal of supporting parents from the earliest possible point in their relationships with their babies rather than allowing those relationships to erode to the point of lost potential and trigger the need for later-stage services. Early Head Start and Healthy Start (each of which provides home visitors), and the Nurse-Family Partnership, pioneered by Dr. David Olds, are three examples.

When we think of crime prevention programs, we may think of boot camps, midnight basketball, drug education classes in schools, or organized neighborhood watches. However, an April 1997 report to Congress by a team of criminologists found none of those to be particularly effective.53 By contrast, the study reported that infant home-visitation programs appear to have lasting effects because problems are dealt with early.

MOTHER HUBBARD’S CUPBOARD

Violent behavior is often linked to poverty or the underclass to the point that some policy analysts cite poverty as the primary cause of violence in our culture. There is no question that poverty is an indirect contributor to violent behavior. Children growing up in significant poverty are measurably more fearful and often more antisocial than children of more affluent families and often show signs of depression by age five. Impoverished parents are more likely to be depressed, show less warmth, and have a more authoritarian discipline style, including yelling and hitting. This style is often attributed to an ongoing fear for their children’s safety and the need to maintain immediate physical control in the face of external threats such as drive-by shootings.54

But while financial poverty is often cited as the root of violence, one has to ask: If we were to eliminate poverty, would we still have violence? The answer is clearly yes. Material poverty certainly contributes to familial stress, to the erosion of health and safety, and to the subsequent depletion of confidence and competence parents need to raise their children. But the problem of crime and violent behavior won’t be solved through the ancient argument that all we really need to do is eliminate poverty. Even if a good case could be made for this argument, voters are unwilling to approach the problem of violence through that door. From both a substantive and a financial perspective, we have to look more deeply and more specifically.

Impoverishment in the families producing violent children often exists at a deeper than material level. When we look closely at the families of violent children across classes and racial differences, we find an impoverishment of human connectedness, trust, support, and emotional nurturing. People feel angry and alienated—often for several generations. There is a sense of separateness; a chronic irritability; an absence of optimism, joy, and knowing how to laugh; and a need to numb against hopelessness. When children are born into such settings, child abuse and neglect are palpable potentials. Nurses in hospitals often say they can identify at birth which babies will soon become known to child welfare agents. The problem isn’t so much that we can’t see these children coming as that we aren’t sure what to do or how much to get involved.

While several promising paths are available to us, there is no single prescription, no silver bullet. Solutions—like the problems—are complex. We have a growing body of scientific research on the human brain and a growing number of programs that have been thoroughly enough evaluated to show strong results for both parents and children. In order for these approaches to have any major impact on violence, however, we will have to radically change our nation’s operant view of babies. If American child care practices reflect our beliefs about children, then it is clear that most of us view infancy as only a prelude to the really important period of development. We see babyhood as an innocuous time for learning basic muscle control, which we expect to automatically occur as long as basic needs are met. The truth is, in fact, the reverse. Far from a benign state of perpetual malleability, infancy is the period of our most complex and formative learning and of laying the foundation for how we connect with other people, the effects of which can last for a lifetime.

WE KNOW THAT IN AMERICA TODAY:

• The United States has less than 5 percent of the world’s population but more than 23 percent of the world’s incarcerated people.55

• Some individual U.S. states imprison up to six times as many people as nations of comparable population.56

• The United States imprisons the most women in the world.57

• One in 31 Americans currently lives under the jurisdiction of the criminal justice system—in prison, on parole, or on probation.58

WE ALSO KNOW THAT:

• In 2010, 828,000 children ages 12 to 18 were victims of nonfatal crimes.59

• In 2011, 20 percent of school children reported being bullied on school property and 16 percent reported being cyber-bullied during the prior twelve months.60

• In 2008, more than 60 percent of children ages 17 and younger were exposed directly or indirectly to violence; 46 percent had been physically assaulted in the previous year and 57 percent had been assaulted sometime during their life. More than 1 in 5 (20.3 percent) witnessed one family member assault another at some point in their lifetime.61

• Every three hours a child is killed by a firearm.

• In 2010, 4,828 young people ages 10 to 24 were murdered.62

• Nearly 1 in 5 high school–aged boys and 11 percent (6.4 million) of school-age children overall have received a medical diagnosis of ADHD—an increase of 16 percent since 2007 and 53 percent in the last decade.63

BUT DO WE CONNECT THIS DATA WITH THESE FACTS?
IN THE UNITED STATES:

• A child is abused or neglected every forty-seven seconds.

• Infants and toddlers are the most likely group to be victims of maltreatment.

• Children under four make up 40 percent of the total.

• Every two minutes a child enters foster care and remains there an average of more than two years.

• A child is born into poverty every five seconds; 25.9 percent of children live below the poverty level.64

• An estimated 26 percent of all children in the United States experience or witness a traumatic event prior to age four.65

• The United States ranks 131 out of 184 countries in premature births.66

• The annual cost of center-based child care for a four-year-old is more than the annual in-state tuition at a public four-year college in twenty-six states and the District of Columbia.67

• Less than 30 percent of three- and four-year-olds in poverty were enrolled in Head Start in 2009, and only 2 percent of eligible children under age three were enrolled in Early Head Start.68

OF THE NATIONS CONSIDERED “INDUSTRIALIZED” OR “DEVELOPED,”69 THE UNITED STATES IS NUMBER ONE IN:

• Percentage of population incarcerated

• Number of billionaires

• Military weapons exports

• Defense expenditures

• Gross domestic product

• Per capita health expenditures

AMONG INDUSTRIALIZED NATIONS,
THE UNITED STATES ALSO RANKS:

#29 in infant mortality

#22 in low birth weight rates

#31 in the gap between the rich and the poor

#23 in science scores

#17 in reading scores70

POSTSCRIPT

Since Ghosts was first published, strong growth has occurred in the quantity as well as the quality of home-visitation programs across the nation. Nurse-Family Partnership, the earlier referenced program created by Dr. David Olds, is available in many states although it typically serves a fraction of eligible families. This program has been extensively evaluated with longitudinal controlled studies in three states. The following outcomes have been documented among participants in at least one of the three trial sites—Elmira, New York; Memphis, Tennessee; and Denver, Colorado.71

Improved Pregnancy Outcomes:

• A 79 percent reduction in preterm delivery for women who smoke.

• Reductions in high-risk pregnancies as a result of greater intervals between first and subsequent births.

Improved Child Health and Development:

• A 59 percent reduction in child arrests at age fifteen.

• A 39 percent reduction in injuries among children.

• A 56 percent reduction in emergency room visits for accidents and poisonings.

• A 48 percent reduction in child abuse and neglect.

• A 50 percent reduction in language delays of children at twenty-one months.

• A 67 percent reduction in behavioral and intellectual problems at age six.

Increased Economic Self-Sufficiency:

• 32 percent fewer unintended subsequent pregnancies.

• An 82 percent increase in the mother’s labor force participation by the child’s fourth birthday.

• A 46 percent increase in the father’s presence in the household.

• 60 percent fewer arrests of the mother.

• 72 percent fewer convictions of the mother.

Savings to Taxpayers: A study conducted in 2009 by the Pacific Institute for Research and Evaluation (PIRE) showed that the federal government saves more than it spends on program costs, netting a 54 percent return, including:

• A 20 percent reduction in months on welfare.

• A 9 percent reduction in Medicaid costs.

• An 11 percent reduction in food stamp costs in the ten years following the birth of the child.

Inspired by Healthy Start in Hawaii, Healthy Families America (HFA) is also active in most states and has been supported by the national organization Prevent Child Abuse America, which also provides technical assistance, training, and accreditation for the programs.

The following facts are documented outcomes from HFA sites:

• Birth Outcomes and Birth Weight: Two rigorous studies show improvement in birth outcomes of 55 percent or higher, including more babies born at a healthy weights and fewer babies with birth complications.

• Breast-Feeding: For parents enrolled prenatally HFA boosted rates of breast-feeding by 25 percent or more in two studies; breast-feeding has demonstrated significant positive impacts on child and maternal health.

• Parenting Attitudes: Attitudes improved faster for those enrolled in HFA compared with those in a control group in the majority of studies; the research literature shows a clear relationship between parenting attitudes and child maltreatment.

• Attachment and Home Environment: The vast majority of studies at all levels of rigor show significant improvements in home environment, including parent-child interactions and developmental stimulation.

• Interpersonal Violence: HFA mothers showed significant decreases in perpetration of and victimization from physical assault—34 percent and 21 percent, respectively.

• Child Abuse and Neglect: A large study found less physical and psychological abuse for HFA parents than for control parents at one year; results at two years showed the greatest impacts for first-time mothers and psychologically vulnerable mothers.72

Our nation is finally beginning to make real progress on the implementation of home visiting across the country. The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant program, which was authorized by Congress in 2010, provided $1.5 billion over five years in new guaranteed funding for grants to states to support the establishment and expansion of voluntary, evidence-based home-visiting programs to assist at-risk families with young children. It remains to be seen whether this funding will be extended and perhaps increased past 2016.