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 TRAINING THE FUTURE
CHILD HEALTH CARE
WORKFORCE
to Improve the Behavioral Health of
Children, Youth, and Families

PROCEEDINGS OF A WORKSHOP

Steve Olson and Sarah M. Tracey, Rapporteurs

Forum on Promoting Children’s Cognitive,

Affective, and Behavioral Health

Board on Children, Youth, and Families

Division of Behavioral and Social Sciences and Education

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS

Washington, DC
www.nap.edu
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington,
DC 20001

This activity was supported by contracts between the National Academy of

Sciences and the American Academy of Pediatrics (unnumbered award); the
American Board of Pediatrics (unnumbered award); the Assistant Secretary for
Planning and Evaluation (HHSP23337021); Autism Speaks (unnumbered award);
the Centers for Disease Control and Prevention (200-2011-38807, TO #42); the
Conrad N. Hilton Foundation (20150118); the Robert Wood Johnson Foundation
(74234); the Substance Abuse and Mental Health Services Administration
(HHSP23337029); and the U.S. Department of Justice Office of Juvenile Justice
and Delinquency Prevention (2013-MU-MU-0002). Additional support came from
the American Psychological Association, the Community Anti-Drug Coalitions of
America, Global Alliance for Behavioral Health and Social Justice, the Hogg
Foundation for Mental Health, the Society for Child and Family Policy and Practice,
the Society of Clinical Child and Adolescent Psychology, and the Society of
Pediatric Psychology. Any opinions, findings, conclusions, or recommendations
expressed in this publication do not necessarily reflect the views of any
organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-46461-1

International Standard Book Number-10: 0-309-46461-7
Digital Object Identifier: https://doi.org/10.17226/24877
Epub ISBN: 978-0-309-46464-2

Additional copies of this publication are available for sale from the National
Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800)
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Copyright 2017 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine.

(2017). Training the Future Child Health Care Workforce to Improve Behavioral
Health Outcomes for Children, Youth, and Families: Proceedings of a Workshop.
Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/248
77.
The National Academy of Sciences was established in 1863 by
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Academies, please visit www.nationalacademies.org/about/whatwed
o.
 PLANNING COMMITTEE FOR THE WORKSHOP ON
TRAINING THE FUTURE CHILD HEALTH CARE
WORKFORCE TO IMPROVE BEHAVIORAL HEALTH
OUTCOMES FOR CHILDREN, YOUTH, AND FAMILIES

THOMAS F. BOAT (Cochair), University of Cincinnati College of

Medicine (dean emeritus) and Department of Pediatrics, Division
of Pulmonary Medicine, Cincinnati Children’s Hospital Medical
Center
LAUREL K. LESLIE (Cochair), American Board of Pediatrics and
Department of Medicine and Pediatrics, Tufts University School of
Medicine
HAROLYN M.E. BELCHER, Johns Hopkins University School of
Medicine and Kennedy Krieger Institute
GREGORY FRITZ, Bradley Hasbro Children’s Research Center
BIANCA K. FROGNER, University of Washington
ELIZABETH HAWKINS-WALSH, Catholic University of America
KIMBERLY EATON HOAGWOOD, Society of Clinical Child and
Adolescent Psychology; American Psychological Association;
Department of Child and Adolescent Psychiatry, New York
University School of Medicine
MARSHALL “BUZZ” LAND, JR., American Board of Pediatrics and
University of Vermont
MARY ANN McCABE, Society for Child and Family Policy and Practice;
Society of Pediatric Psychology; Department of Pediatrics, George
Washington University School of Medicine; Department of Applied
Developmental Psychology, George Mason University
 FORUM ON PROMOTING CHILDREN’S COGNITIVE,
AFFECTIVE, AND BEHAVIORAL HEALTH

WILLIAM R. BEARDSLEE (Cochair), Baer Prevention Initiatives;

Department of Psychiatry (chairman emeritus), Boston Children’s
Hospital; Department of Child Psychiatry, Harvard Medical School
C. HENDRICKS BROWN (Cochair), Departments of Psychiatry,
Behavioral Sciences, and Preventive Medicine, Feinberg School of
Medicine, Northwestern University
KAREEMAH ABDULLAH, National Community Anti-Drug Coalition
Institute and Community Anti-Drug Coalitions of America
DARA BLACHMAN-DEMNER, Crime, Violence, and Victimization
Research Division, National Institute of Justice
THOMAS F. BOAT, University of Cincinnati College of Medicine (dean
emeritus) and Department of Pediatrics, Division of Pulmonary
Medicine, Cincinnati Children’s Hospital Medical Center
FELESIA R. BOWEN, Center for Urban Youth School of Nursing,
Rutgers, The State University of New Jersey
DAVID A. BRENT, Department of Psychiatry, Pediatrics, and
Epidemiology, University of Pittsburgh School of Medicine
LAUREN CALDWELL, Children, Youth and Families Office, Public
Interest Directorate, American Psychological Association
ALEXA EGGLESTON, Conrad N. Hilton Foundation
COSTELLA GREEN, Division of Community Programs, Center for
Substance Abuse Prevention, Substance Abuse and Mental Health
Services Administration
RICK HARWOOD, National Association of State Alcohol and Drug
Abuse Directors
J. DAVID HAWKINS, School of Social Work, University of Washington
KIMBERLY EATON HOAGWOOD, Society of Clinical Child and
Adolescent Psychology; American Psychological Association;
Department of Child and Adolescent Psychiatry, New York
University School of Medicine
COLLEEN HORTON, Hogg Foundation for Mental Health, University of
Texas at Austin
JENNIFER KAMINSKI, Division of Human Development and Disability,
Centers for Disease Control and Prevention
KELLY J. KELLEHER, Center for Innovation in Pediatric Practice,
Health Services Research and Community Health and Services
Research, The Research Institute at Nationwide Children’s Hospital
UMA KOTAGAL, Department of Pediatrics, University of Cincinnati,
and James M. Anderson Center for Health Systems Excellence,
Cincinnati Children’s Hospital Medical Center
LAUREL K. LESLIE, American Board of Pediatrics; Department of
Medicine and Pediatrics, Tufts University School of Medicine
MARY ANN McCABE, Society for Child and Family Policy and Practice;
Society of Pediatric Psychology; Department of Pediatrics, George
Washington University School of Medicine; Department of Applied
Developmental Psychology, George Mason University
JENNIFER NG’ANDU, Robert Wood Johnson Foundation
LAWRENCE A. PALINKAS, Department of Social Policy and Health
and Behavior, Health and Society Research Cluster, University of
Southern California School of Social Work
MARY JANE ROTHERAM-BORUS, Child Psychiatry and Biobehavioral
Sciences, Global Center for Children and Families, Center for HIV
Identification, Prevention, and Treatment Services, Department of
Psychiatry, University of California, Los Angeles
JOYCE K. SEBIAN, Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration
PAT SHEA, Office of Technical Assistance, National Association of
State Mental Health Program Directors
ANDY SHIH, Scientific Affairs, Autism Speaks
JOSÉ SZAPOCZNIK, Department of Public Health Sciences, Miami
Clinical Translational Science Institute, Center for Family Studies,
University of Miami
VERA FRANCIS “FAN” TAIT, Department of Child Health and
Wellness, American Academy of Pediatrics
JENNIFER TYSON, Office of Juvenile Justice and Delinquency
Prevention, U.S. Department of Justice
DEBORAH KLEIN WALKER, Global Alliance for Behavioral Health and
Social Justice and Abt Associates

Forum Staff
WENDY KEENAN, Forum Director
SARAH M. TRACEY, Associate Program Officer
EMILY BACKES, Associate Program Officer (August 2016–February
2017)
ANTHONY JANIFER, Senior Program Assistant
SYLVIA NCHA, Intern, George Washington University (March–May
2017)

Board on Children, Youth, and Families Staff

NATACHA BLAIN, Director
LISA ALSTON, Financial Officer
PAMELLA ATAYI, Program Coordinator
 Reviewers

This Proceedings of a Workshop was reviewed in draft form by

individuals chosen for their diverse perspectives and technical
expertise. The purpose of this independent review is to provide
candid and critical comments that will assist the National Academies
of Sciences, Engineering, and Medicine in making each published
proceedings as sound as possible and to ensure that it meets the
institutional standards for quality, objectivity, evidence, and
responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the
process.
We thank the following individuals for their review of this
proceedings: Eric Holmboe, Milestone Development and Evaluation,
Accreditation Council for Graduate Medical Education; Christen
Johnson, Student National Medical Association, Dublin, Ohio;
Bernadette Melnyk, College of Nursing, Ohio State University; José
Szapocznik, Department of Public Health Sciences, University of
Miami Miller School of Medicine; and Lawrence Wissow, Bloomberg
School of Public Health, Johns Hopkins University.
Although the reviewers listed above provided many constructive
comments and suggestions, they were not asked to endorse the
content of the proceedings nor did they see the final draft before its
release. The review of this proceedings was overseen by Patrick H.
Deleon, F. Edward Hébert School of Medicine and the Graduate
School of Nursing, Uniformed Services University of the Health
Sciences. He was responsible for making certain that an independent
examination of this proceedings was carried out in accordance with
standards of the National Academies and that all review comments
were carefully considered. Responsibility for the final content rests
entirely with the rapporteurs and the National Academies.
 Contents

1 INTRODUCTION AND OVERVIEW

Levers for Change
Organization of the Workshop

2 PERSPECTIVES FROM PARENTS

Finding an Effective Program
Overcoming Stigma
Caring for the Entire Family
Making Connections with Patients and Families
Partnering with Behavioral Health Care Providers
Discussion

3 THE NATIONAL LANDSCAPE OF HEALTH CARE TRAINING

AND WORKFORCE PROCESSES
The Behavioral Health Workforce: Supply, Demand, Challenges,
and Opportunities
Nurses and Schools as Providers of Behavioral Health Services
Peer Providers
A Medical Student’s Perspective
Discussion
4 PROMISING MODELS
Improving Pediatric and Adolescent Behavioral Health Services and
Education at Ohio State University
Interprofessional Postdoctoral Fellowship Training on Integrated
Health Care at the University of Rochester
Interprofessional Training in Cleveland’s MetroHealth Medical
Center
Preparing Social Workers at the University of North Carolina
Integrated Primary Behavioral Care at Cherokee Health Systems
Training Models with Chronically Ill Children and Their Families

5 ACCREDITATION, CERTIFICATION, AND CREDENTIALING

An Overview of Physician Training, Licensure, and Certification
Certification of Pediatric Nurses
Certification and Maintenance of Certification
Curricular Change Driven by Accreditation
Accreditation and the Training of Clinical Psychologists
Training and Credentialing Family Peer Advocates
Accreditation of Patient-Centered Medical Homes
Discussion

6 OTHER CHILD-SERVING SETTINGS

The Education System
The Child Welfare System
The Juvenile Justice System
Residential Treatment
Individualized Service Plans for Children

7 COLLABORATIVE EFFORTS
Training Supported by the Maternal and Child Health Bureau
Evidence-Based Practices as Levers for Change
Foundation Support for Implementing Evidence-Based Practices
Integrating Care Through Payment and Policies
Financing and Reimbursement to Improve Training
8 POSSIBLE NEXT STEPS AND REFLECTIONS ON THE
WORKSHOP
Behavioral Health Promotion and Risk Prevention Through
Multigenerational Surveillance
Exposure to Evidence-Based Practices
Fostering Integrated Interprofessional Care
Meeting the Needs of Children with Disabilities and Complex Health
Conditions
Engaging Patients and Parents
Accreditation, Certification, and Credentialing
Other Child-Serving Systems
Reimbursement for Training and Clinical Care
Reflections on the Workshop

REFERENCES

APPENDIXES

A Workshop Statement of Task

B Workshop Agenda
C Poster Session Abstracts
D Biographical Sketches of Planning Committee Members, Workshop
Speakers, and Moderators
 Boxes, Figures, and Tables

BOXES
1-1 Forum Themes
1-2 Levers for Change

6-1 Possible Professionals in Multidisciplinary School Behavioral

Health Teams

FIGURES
3-1 Distribution of the behavioral health workforce
3-2 Maldistribution of the behavioral health workforce that limits
access to care
3-3 Overall staffing at school-based health centers
3-4 Mental health care staffing at school-based health centers
3-5 A continuum of helping relationships

5-1 Physician licensure and certification process in the United States

TABLES
3-1 National Projections of Supply and Demand for Selected
Behavioral Health Practitioners by 2025

7-1 The Maternal and Child Health Bureau’s Workforce Development

Programs
7-2 Centers for Medicare & Medicaid Services’ Categories of
Payments to Providers
 1

Introduction and Overview

“Between what is known and what is done is what is taught.”

Laurel K. Leslie, Tufts University School of Medicine, Workshop
Planning Committee Cochair

Childhood diagnoses of cognitive, affective, and behavioral

disorders are increasing in absolute numbers as well as in proportion
to the total childhood population in the United States (Institute of
Medicine, 2015). This documented increase is adding to the care and
cost burden for children and adolescents (hereafter referred to as
children in most cases in this publication) at alarming rates. An
estimated 13 to 20 percent of children ages 3 to 17 in the United
States experience a behavioral health disorder in any given year
(National Research Council and Institute of Medicine, 2009a), and
this rate does not include autism spectrum and cognitive disorders or
subthreshold cognitive, affective, and behavioral health symptoms.
Furthermore, behavioral disorders in children are very often a source
of disability in adulthood.
 Increasing numbers of evidence-based interventions have proven
effective in preventing and treating behavioral disorders in children
(Institute of Medicine and National Research Council, 2014).
However, the adoption of these interventions in the health care
system and other systems that affect the lives of children has been
slow. Moreover, with few exceptions, current training in many fields
that involve the behavioral health of children falls short of meeting
the needs that exist. In general, this training fails to recognize that
behavioral health disorders are among the largest challenges in child
health and that changing cognitive, affective, and behavioral health
outcomes for children will require new and more integrated forms of
care at a population level in the United States.
To examine the need for workforce development across the range
of health care professions working with children and families, as well
as to identify innovative training models and levers to enhance
training, the Forum on Promoting Children’s Cognitive, Affective, and
Behavioral Health held a workshop on November 29–30, 2016, titled
“Training the Future Child Health Care Workforce to Improve
Behavioral Health Outcomes for Children, Youth, and Families.”
(Appendix A provides the statement of task for the workshop.)
Established in 2014, the forum was created to bring together
patients and family members, health care providers, researchers,
government representatives, philanthropists, representatives of
professional associations, and others to connect prevention,
treatment, and the implementation sciences with the settings where
children receive care. Its primary aim is to inform a forward-looking
agenda for building a stronger research and practice base around
the development and implementation of programs, practices, and
policies to promote all children’s cognitive, affective, and behavioral
health. Box 1-1 summarizes some of the themes that have
characterized the past work of the forum.

BOX 1-1
Forum Themes
 In her opening remarks at the workshop, cochair of the
workshop planning committee Laurel K. Leslie pointed to three
themes that have run through the past workshops, papers, and
webcasts of the Forum on Promoting Children’s Cognitive,
Affective, and Behavioral Health. (More information about the
forum and its activities is available at http://www.nas.edu/ccab
[September 2017].)
The first theme, said Leslie, is that preventing, identifying,
and treating the cognitive, affective, and behavioral health
needs of children and their families must be prioritized. This
requires addressing the continuum of care from prevention to
treatment and from preconception to the transition to
adulthood. “If behavioral health concerns were a physical health
disorder, the entire nation would be mobilized around it,” Leslie
said. “Yet we have not mobilized around mental health.”
The second theme is that the systems within which families
seek help are fundamentally fragmented, even though the
systems have shared objectives. “We need to prioritize
continuity of care, integration of our efforts across sectors, and
interdisciplinary team-based care,” Leslie observed. This
requires that the family be recognized as integral to care, she
added, because “they are central partners with us as providers
in defining, implementing, and measuring the outcomes of
care.”
The third theme is that research, practice, and policy need to
reflect changes in the cognitive, affective, and behavioral
health-related needs of children, along with the diversity in the
backgrounds of children and their families. For example, a large
group of children have survived prematurity, cancer, and other
disorders that in the past would have caused death in
childhood, and many of these children and their parents have
continuing needs that are not being met. With regard to
diversity, Leslie pointed out that approximately 25 percent of
children in the United States currently are immigrants or the
children of immigrants, and over 40 percent of children live near
or below the poverty line. “That’s an enormous diversity that we
 have to be thinking about when we think about how we’re
going to move research to practice,” she said.

LEVERS FOR CHANGE

Obvious gaps, flaws, and shortfalls characterize the training of
professionals and others involved in delivering behavioral health care
to children and their families, said Laurel K. Leslie, vice president of
research at the American Board of Pediatrics, professor of medicine,
pediatrics, and community medicine and public health at Tufts
University School of Medicine, and cochair of the planning committee
for the workshop. For example, comparisons of survey data from
2004 and 2013 found that training continues to be a significant
barrier for pediatricians in the identification of behavioral health
problems and in the treatment of children and adolescents (Horwitz
et al., 2015). Many trainees in the behavioral health professions
(e.g., psychology, child and adolescent psychiatry) have relatively
little exposure to treatments that have proven effective (Weissman
et al., 2006). Whether within a specific discipline or across
disciplines, training is fragmented and lacks essential elements of
core knowledge about the promotion of child and family well-being
and the identification and treatment of behavioral problems. Training
models that yield continuous, integrated, team-based, and family-
focused behavioral health care exist but are rare and have limited
sustainability and spread, Leslie said.
Different disciplines bring unique competencies and contributions
to the prevention and treatment of behavioral problems, said Leslie.
Drawing on earlier work by Hugh Barr (1998), Leslie commented
that delineating them will be essential for an integrated, effective
workforce. Common competencies are shared by all disciplines that
deal with the cognitive, affective, and behavioral health of children.
Complementary competencies are specific to a professional role but
enhance the work of other professionals as well. Collaborative
competencies allow professionals to work together across roles and
across sectors. Building these competencies “has to be a priority for
us moving forward as we think about how to train a future
workforce,” Leslie said.
Leslie explained that the planning committee for the workshop
conceptualized levers for change in three primary areas: education
and training, governance and regulatory oversight, and alignment of
efforts.
Discussing the first, education and training, Leslie said, “We need
to think about how we develop new content and formats that take
into account changing the policy, practice, and science.” For
example, new modalities such as online and simulation tools can
increase educational efficiency and reduce challenges for
geographically isolated and smaller, less resourced training
programs. However, many faculty are not necessarily ready to use
innovations in education to provide information to their trainees, and
faculty development will be necessary. It may also be essential to
reconceptualize how curriculum is developed. One promising
approach, she said, is to flip the usual pathway of curriculum
development, which starts with the curriculum and then defines
educational objectives and assessments, to an approach that starts
with the health needs of children and in turn informs competencies
and objectives for training, curricular components, and assessment
(Frenk et al., 2010). “This approach is being put forward in several
disciplines as a way to change what we’re doing and align our
training with what families need,” Leslie stated.
The second lever for change identified by the planning committee
is governance and regulatory oversight by the wide range of
agencies that establish standards for training programs and set and
assess qualifications both for professions and for individuals. Training
programs are reviewed to make sure that they are meeting
established criteria; the settings in which people are trained also
undergo review. Individuals are certified, indicating that they have
completed training and have met standards of excellence established
for their discipline. They may also undergo licensure at the local,
state, or national level. The power of these accrediting,
credentialing, and licensing bodies has not been tapped. “This is a
very complex world but a potential lever for change,” said Leslie.
 The third lever identified is alignment with local, state, and
national efforts that are funded by the public and private sectors.
“Exciting change efforts” are under way, said Leslie, adding, “What if
we aligned all of these change efforts together and were able to
build on the strengths of those opportunities?”
To limit the potentially very wide scope of the discussion, the
workshop was focused on behavioral health and well-being, not on
physical, cognitive, or educational disabilities, even though, as Leslie
pointed out, they often coexist. The workshop also focused on the
future health professional workforce and the settings in which they
work, not on educators, child care providers, or other practitioners;
these topics are being addressed by other groups within the National
Academies of Sciences, Engineering, and Medicine.1 Finally, the
workshop did not consider clinical practice environments that
trainees enter after their classroom training. “This is an incredibly
important topic to be thinking about because those settings reinforce
trainees’ experiences, or they don’t, but we could not tackle that in
the course of these 2 days,” she explained.
During a breakout session on the first day of the workshop, the
participants divided into subgroups to further delineate potential
levers for change and barriers to change in preparing the future
health care workforce to deliver behavioral health care for children
and families. As an introduction to the broad range of issues
discussed at the workshop, Box 1-2 summarizes the subgroups’
discussions.

BOX 1-2
Levers for Change
On the first day of the workshop, the participants divided into
groups to further delineate and discuss levers and barriers in
making changes to prepare the future health care workforce to
provide optimal behavioral health care for children and families.
For this group activity, tables were organized around specific
topics. Results were summarized across the three levers for
change identified by the planning committee: education and
training, governance and regulatory oversight, and alignment of
local, state, and national efforts that are funded by the public
and private sectors. Chapter 8 lists possible next steps to
overcome barriers and take advantage of some of the levers for
change suggested by individual participants.

LEVERS FOR CHANGE GROUP ACTIVITY

Education and Training

Several workshop participants reported on areas around

education and training as a lever for change. Specifically, they
reported that education and training could (1) foster family-
centered, integrated, interprofessional, cross-sectoral care; (2)
engage parents and patients in the copromotion of behavioral
health outcomes; (3) expand content to address the behavioral
health needs of children with disabilities and chronic conditions;
(4) achieve competencies in taking multigenerational family
histories to identify areas of health promotion and risk
prevention; (5) achieve competencies in self-identifying as
members of interprofessional health teams early on in their
education and understanding their role and the roles of others;
(6) involve the use of objective structured clinical evaluations
with embedded competencies around working with
multigenerational families; (7) integrate the principles of
prevention, implementation science, and improvement science;
(8) achieve competencies in the use of evidence-based
practices to reduce unnecessary medical services and their
costs; (9) be restructured to incorporate new topics in already
full medical school curricula; (10) emphasize the value of
prevention, evidence-based practices, and integrated care in
high school and undergraduate programs; (11) incorporate
different levels of integration including practice, organizational,
and community-level integration to improve health outcomes;
(12) involve telemedicine and other forms of remote learning to
enhance training in areas that currently lack access or
resources; (13) prepare the workforce to meet the needs of
communities in which they serve; (14) incorporate cross-
sectoral training models to provide services across settings that
focus on competencies; and (15) strengthen career pathways
and hierarchies for parent/peer providers and residential
treatment providers.

Governance and Regulatory Oversight

Governance and regulatory oversight was addressed as a

second lever for change. Several workshop participants reported
back ideas from their groups’ discussions, including (1) creating
mechanisms for sharing successes, progress, and failures to
demonstrate which training models are effective; (2) creating
shared definitions, frameworks, and concepts of integration and
integrated care to avoid competing knowledge structures; (3)
integrating interdisciplinary training into existing frameworks
within each field; (4) developing models that offer time and
infrastructure for integrated, interdisciplinary, cross-sectoral
training and care through colocation, integration,
comanagement, and efficient and effective handoffs; (5)
promoting integrated, interdisciplinary, cross-sectoral training
and care through licensure, accreditation, and payment
mechanisms that reflect outcomes; (6) incorporating parent and
family voices and incentivizing parent and family participation;
(7) achieving agility and responsiveness to the changing needs,
environments, and demographics in the communities served;
(8) using an ecological framework to promote prevention in all
populations, including minority populations; (9) reducing stigma
and exclusion through fully inclusive systems for children with
disabilities or disorders, as has been done in some parts of the
education system; (10) developing metrics across fields needed
to achieve competencies that enable integrated care; and (11)
 incorporating prevention, evidence-based practices, and
implementation into licensing and accreditation standards.

Alignment of Local, State, and National Efforts Funded by the

Public and Private Sectors

The third lever for change discussed at the workshop was

alignment of local, state, and national efforts that are funded by
the public and private sectors. Ideas shared by several
workshop participants include (1) moving from a mindset of
spending to a mindset of investment, (2) creating opportunities
for value-based payment models (rather than fee-for-service
models) using metrics for wellness of families to accelerate
investment in community-focused behavioral health services,
(3) tying education and training money to quality and outcomes
based on community needs and offering equity in funding for
training in medical and behavioral health care, (4) creating
changes in training and accreditation to facilitate the growth of
value- and outcome-based models based on community needs,
(5) coordinating payment structures for services across sectors
and blending funding to provide integrated training, (6)
implementing new funding mechanisms that bring population-
based approaches and value-enhancing reimbursement to
primary care, (7) strengthening data sharing across disciplines
and systems around child and family care, and (8) coordinating
care that is oriented to the child and family rather than
bureaucracy.

ORGANIZATION OF THE WORKSHOP

This proceedings largely follows the workshop agenda (see
Appendix B). The first panel of the workshop featured the voices of
parents and patients (Chapter 2). They recounted their personal
stories as well as lessons they have learned in addressing the
physical, emotional, and behavioral health and well-being of
children.
The next panel outlined the national landscape of health care
training and workforce processes (Chapter 3). As part of this
discussion, Thomas Boat, cochair of the workshop planning
committee, introduced a paper released the day of the workshop
titled “Workforce Development to Enhance the Cognitive, Affective,
and Behavioral Health of Children and Youth: Opportunities and
Barriers in Child Health Care Training,” which compares the
competencies required across different disciplines to initiate a
discussion about developing a fundamental list of shared core
competencies.2
Promising training models that constructively take advantage of
levers of change under the area of education and training was the
next topic examined (Chapter 4). Six presenters described models
that have created improvements in such areas as incorporation of
evidence-based practices, interprofessional training and team-based
care, and the care of children with chronic medical conditions.
Workshop participants next investigated accreditation,
certification, and credentialing as levers for change in workforce
development (Chapter 5). Five presenters addressed the functions of
regulatory bodies that accredit programs and certify individuals as
part of a broader look at how regulatory oversight can influence the
workforce.
The agenda then turned to the third lever for change: alignment
with local, state, and national efforts that are funded by the public
and private sectors (Chapter 6). Presenters discussed other child-
serving systems and changes to enhance care in those settings.
They reported that training, reimbursement, and supervision can all
improve behavioral health care for children involved in these
systems.
The final panel examined current efforts involving financing,
training, and delivery models being fostered by federal agencies,
professional organizations, and foundations to highlight opportunities
for collaboration (Chapter 7).
 On the second day of the workshop, participants again broke into
subgroups to identify possible next steps that could be taken to
achieve the objectives identified earlier in the meeting. A list of
these possible steps and the reflections of workshop organizers and
presenters conclude this proceedings (Chapter 8).
In addition to the panel sessions, the workshop highlighted a
number of research programs related to integrated, interprofessional
care for children and their families in a poster session. Abstracts for
each poster are available in Appendix C. Appendix D provides
biographical sketches of planning committee members, workshop
speakers, and moderators.

__________________
1 In 2015, another committee at the National Academies published a consensus
report on training the workforce related to development and education for children
ages 0 to 8 (Institute of Medicine and National Research Council, 2015). See http
s://www.nap.edu/catalog/19401/transforming-the-workforce-for-children-birth-thr
ough-age-8-a [October 2017].
2 The paper is available at https://nam.edu/workforce-development-to-enhance-
the-cognitive-affective-and-behavioral-health-of-children-and-youth-opportunities-a
nd-barriers-in-child-health-care-training [September 2017].
 2

Perspectives from Parents

Points Highlighted by the Speakers

Costs are often a serious issue for families seeking
behavioral health care. (Mueller)
Stigmas associated with receiving behavioral health care
continue to inhibit many families from seeking care.
(Kinebrew)
When a child has a serious medical condition, the health
and well-being of her or his entire family can be put at
risk. (Gamel)
The ability to make human connections with patients and
families needs to be a priority in the training of the
behavioral health workforce. (Gargan)
 As partners with health care providers, parents are a
critical emerging workforce in behavioral health care.
(Sweeney)

The needs of children and families are the ultimate driving force
behind workforce training, said Deborah Klein Walker, president of
the Global Alliance for Behavioral Health and Social Justice and
senior fellow at Abt Associates, who moderated the workshop’s first
panel. How can training reflect the unique expertise and
perspectives of parents, she asked. What kinds of structures need to
be in place in health care delivery systems for this to happen? “We
have asked the experts to be the lead at this workshop,” said Walker.
“The experts are the parents, who really know day to day what is
needed for their child with a behavioral health issue and for their
families.”

FINDING AN EFFECTIVE PROGRAM

Rebecca Mueller and her husband adopted their son when he was
2 days old. “Being our first child, we kind of winged it. We’re still
winging it most days,” she said. At an appointment before he was 2
months old, her son’s pediatrician said, “Something’s going on here.
I’m not sure what, but let’s keep an eye on it.” Over the next year or
so, Mueller noticed that her son often played too roughly at play
groups. “He wasn’t mean or vicious. He just didn’t understand
boundaries,” she recounted. “And parents would scowl at me and
whisper to each other. It wasn’t very welcoming.”
When her son was 3, he entered a private preschool program, but
3 months later the family was asked to take him out of the program.
“He just didn’t fit in,” Mueller said. The family talked with their local
school district, and tests revealed issues with fine motor skills and
attention. Their pediatrician also sent the family to a local children’s
hospital for additional tests. Just after his 4th birthday, Mueller’s son
received a diagnosis of attention deficit hyperactivity disorder
(ADHD).
His physicians offered medication to treat the disorder, but Mueller
did not want to medicate a 4-year-old. Instead, she began to look
for programs that could meet their needs as a family. When her son
was 5, she learned about The Incredible Years Program and was
able to enroll her son in a subsidized study of the program.1 “We
won the lottery that day,” she said. Once a week the Muellers
traveled to a meeting and spent several hours learning how to meet
the needs of their son. He also went to classes that taught him how
to manage his emotions, stay calm, and be more aware. In addition,
the founder of the program persuaded the family to begin treating
their son with guanfacine, a blood pressure medicine that has been
effective with children diagnosed with ADHD.
“We had tremendous success,” said Mueller. “Today I get calls
probably every month from people in our area who’ve heard about
what I have experienced, and I always refer them to The Incredible
Years Program.” However, costs can be a serious issue, she noted. A
14-week program costs about $5,000, which is too much for many
families.
“My son is not cured,” said Mueller. “But if we hadn’t found The
Incredible Years Program, it would have been so incredibly hard.”

OVERCOMING STIGMA
Robyn Kinebrew’s twin sons were born prematurely, at 33½
weeks, and with sickle cell disease. They went through surgeries and
various other procedures and spent many days in the hospital.
Dealing with the medical aspects of their conditions was
straightforward, Kinebrew said. “The surgeons and hospital were
there to help. I felt that it represented our strength as a family, and
we had learned to navigate the system very well,” she recalled.
The emotional and behavioral aspects of their care were another
matter. The disease is very difficult to manage. When her sons had a
sickle cell crisis, they suffered from severe pain, which typically is
treated with strong narcotics. Moreover, the symptoms of the
disease have no obvious pattern. As she explained, “You might wake
up in the morning, you’re fine, and by that night you’re in so much
pain, you’re in the ER [emergency room] and you’re being admitted
and treated, and you never know how long the admission is going to
last. . . . There’s so much uncertainty.” Some days her sons went to
school in pain, which put a great deal of stress on the entire family.
They would text her from school to say that they were in pain and
ask to be picked up. She would reply, “I can come pick you up, but
can you just make it one more class? Can you make it one more
bell? Try to make it through to the end.”
As her sons got older, the emotional issues became more pressing,
and their hematologist recommended that the family see a therapist
and work on pain management techniques such as meditation or
coping mechanisms, separate from their primary clinician’s
treatment. “I wanted them to have other tools besides medicine,”
said Kinebrew. But when she took them to their first appointment
with a therapist, she felt embarrassed and ashamed. “I didn’t want
to run into anyone that I knew. I didn’t want people to think that
there was something mentally wrong with my children. As you got
on the elevator and you pushed the button, there was a certain floor
you go to, and I felt that everybody was staring at us. . . . In my
circle, you were considered a weak-minded person if you had to seek
out help.”
African American families have many reasons why they may not
seek treatment for an emotional or behavioral issue, said Kinebrew,
one of which is the stigma that continues to be associated with
behavioral health. Getting help for a physical condition is considered
normal, but taboos still surround getting help from a mental health
professional. She continued, “I’ve heard people say, ‘They’re just not
strong enough. They can’t handle anything. That’s why they need to
seek help.’ This is an issue in a lot of African American families. No
matter the problem, nobody wants to be seen like you can’t handle
it.”
Her sons were also skeptical. They had to miss school to see
therapists when they had already missed many previous days. But
they agreed, and since then they have gone to other self-
management programs to reinforce the coping skills they have
learned. Today her twins are sophomores in college and active in
many leadership roles, including serving as resident advisors. But
even as Kinebrew was speaking at the forum, one of her sons was
having a difficult pain crisis and using some of the coping
mechanisms he had learned. “I want to end on a positive note,”
Kinebrew said. “My feelings have evolved and changed, and I will
continue to encourage other families to use a mental health
therapist. It helps.”

CARING FOR THE ENTIRE FAMILY

When Breck Gamel was 38 weeks pregnant with her second son,
he stopped moving in the womb. When she went to the hospital, the
doctor urged an immediate delivery. Her son’s colon had burst in the
womb because he has cystic fibrosis, a life-shortening disease that
affects the lungs and gastrointestinal system. “It’s progressive,” said
Gamel, “and while we hope there will be a cure in his lifetime, cystic
fibrosis has a treatment burden that is intensive and requires
hospitalizations and a lot of medications every day. It’s very hard to
see my son suffer on a daily basis.”
At the time, Gamel’s older son was 2, and she had to be away
from her family for extended periods while her newborn was in the
neonatal intensive care unit. When she returned home, she began to
notice issues with her older son. “He wasn’t moving out of the
terrible twos. It was the terrible threes and the terrible fours. I
couldn’t leave him with a babysitter because of his anxiety. He
couldn’t leave my side, and I didn’t understand what was going on.
Finally I had no other choice but to say, ‘I need help,’” she said.
She contacted therapists but found talk therapy does not work
well with children who are barely talking. When she learned about
play therapy as an option, she registered her son for a program,
even though he was one of the youngest children in the program. At
age 6, he began to take medications to treat his anxiety. He also
received psycho-educational assessments when he began to have
trouble in the first grade, which revealed that he was both gifted and
dyslexic.
Gamel drew several lessons from her experience, the first being
“don’t forget the siblings.” When a child has a disorder, the entire
family suffers, not just that child and his or her parents.
Second, said Gamel, “don’t forget the caregivers.” Realizing that
the families of children with cystic fibrosis often have to deal with
anxiety and depression, the Cystic Fibrosis Foundation did a study
that found siblings have even higher anxiety and depression than
people with cystic fibrosis (Quittner et al., 2014). However, the study
found the greatest anxiety and depression among caregivers, and
especially among mothers, “because they’re the ones who are
oftentimes the primary caregivers.” Yet resources are lacking to help
caregivers deal with these issues, she noted.
Finally, Gamel reemphasized the point that caring for a child with
special needs is burdensome. “It’s hard to find support. It’s hard to
figure out how you’re going to pay for support. Families who live
with chronic diseases like mine are already bogged down by having
to do breathing treatments and putting on a vest to shake his lungs,
and we’re missing school because we’re at the doctor regularly,
every couple of weeks or every couple of months. And then to have
a doctor say to us, ‘Just go to this appointment, or go fill up this
prescription.’ It is not as easy as that. It is just one more thing. It
begins to add to the anxiety and depression that already exists,” she
said. Families and caregivers need to find a way of gaining a sense
of control and advocacy, she continued, so they can deal with their
own behavioral health challenges. They also need to know where to
go to get information and find people who can help them.
The parent is not the problem, she emphasized. Once, when a
physician told her, “You need to be the mother,” she was shocked.
The comment she should have made, she said, is, “Exactly—that’s
why I want to make sure that you do your job.”

MAKING CONNECTIONS WITH PATIENTS AND FAMILIES

 When Lynda Gargan’s son was 2, she began to notice “red flags
that he might be walking a bit of a different path than some of his
classmates.” When he was 4, his well-meaning preschool teacher
was “at the end of her rope” with him. Gargan began to look more
intensively for answers when he was in the third grade, though
teachers still had a tendency to say, “he’s just a boy,” “he’s an
athlete,” “give him time,” or “it’s a phase.” As Gargan said, “No one
would listen to me.”
Gargan lived in secrecy about the issues her son was having until
a public event finally brought them into the open. “I learned what
happens when something like this goes public. I learned that it was
my fault, the kid had too much money, his parents weren’t paying
any attention,” she said. Gargan’s family had enough resources to
seek help for her son. But “imagine what happens for
disenfranchised families, fragile families, that are trying to piece
together their lives day to day and are having these issues,” she
said.
Gargan pointed out that crises are extremely unpredictable, as are
physical health challenges. Policies and procedures are needed to
support parents in these crises. “When I suddenly get a call saying,
‘Your son has just been arrested. We think you probably want to get
down to the courthouse right now,’ there needs to be a way for me
to do that without blame and embarrassment. I need to have
everyone’s support, just as if I had gotten a call saying, ‘Your son
just broke his leg, and you need to get to the hospital,’” she said.
Gargan urged teaching the behavioral health workforce to
prioritize making human connections with the patients and families
they serve. “If we talked with a health care worker who did not
make eye contact, I wrote them off. They weren’t going to be
helpful,” she said. She also emphasized that parents are a child’s
only constants, noting health care workers “come and go, but we
will always be there.” Finally, she emphasized the need to bring
parent and family peers into the workforce as respected partners.
When Gargan’s son graduated from college, he wanted to enter
the military. But he was turned down because of the medication he
had been taking since he was a teenager. “This is our first
generation of highly medicated children,” she pointed out. “The
military has no idea what that’s going to result in.”
Today her son is 28, works for an international company in sales,
and is an “incredible, successful young man.” But the experience
taught her about the prejudices still associated with behavioral
health challenges. Physical health challenges tend to generate
compassion, Gargan observed, but behavioral health challenges tend
to make people back away. “We put our heads down,” she said. “We
thank God it wasn’t our child. We have some work to do on
normalizing behavioral health experiences.”

PARTNERING WITH BEHAVIORAL HEALTH CARE

PROVIDERS
When her daughter began to suffer from severe anxiety, Millie
Sweeney downplayed the problem and attributed it to a phase. But
as her daughter approached her teen years, her anxiety was
affecting everyone in the family. “If the wind blew, there was a
tornado coming, . . . and she wants everybody to get into the closet.
If it’s raining and we’re driving, she’s absolutely positive that we’re
going to have a wreck, that someone’s going to slide into us. If it’s
snowing, we’re not going to make it home,” Sweeney described. Her
daughter began to have meltdowns at school during thunderstorms,
sometimes resulting in calls saying that she was inconsolable. Her
psychosomatic symptoms worsened, including stomachaches and
headaches.
Neither her daughter nor Sweeney wanted to begin anti-anxiety
medicine, but the situation continued to deteriorate. “Homework was
a meltdown every night. It was about perfectionism. If she wrote
something wrong, she would tear it up because the teacher would
definitely give her an F if it wasn’t absolutely perfect,” Sweeney
recalled. After trying to handle her daughter’s anxiety on her own,
Sweeney found a therapist, and things slowly started to improve.
“But the key to that change—and this is what I want to emphasize
today—is that the therapist partnered with me as the parent. We
were partners. We worked together toward the same goal with my
daughter. She listened, she respected my role and my knowledge,
and she did the same thing for my daughter,” Sweeney stated.
A critical breakthrough was discovering her daughter could
channel her anxious energy into dance. “She could express her
emotions in a way that was acceptable. She was winning
competitions. I saw her confidence and her competence go up, her
coping skills, to the point that now she is a junior in one of the top
100 high schools in the nation,” Sweeney said. Her daughter is still
anxious and has stomachaches before every test, “but she’s learning
how to deal with that. She’s learned coping skills through therapy,
because the therapist partnered with us,” Sweeney explained.
Parents and behavioral health care providers are partners, said
Sweeney. Parents can teach providers, educators, therapists, or
probation officers how to manage care for their children. “As we go
into the next couple of days, talking about workforce development,
consider the fact that parents are a critical emerging workforce in
behavioral health,” she said. For example, Sweeney urged the
creation of curricula for providers that focus on family-driven care,
suggesting, “Have parents come and present. Have youth come and
present. Starting there is the best way to train the new and
upcoming workforce.” Such training can help build systems of care
that foster cooperation among providers and families, she said.
The Family-Run Executive Director Leadership Association, where
Sweeney is deputy director, works with family-run organizations on
data collection, research partnerships, quality indicators for
parent/peer support providers, and other workforce issues.
“Parent/peer support providers can enhance any other service that’s
going on,” she said. Such organizations also can act to institute
policies and procedures that help normalize being a parent of a child
with a behavioral disorder, she said.

DISCUSSION

Terms that Can Reduce Stigma

 In response to a question about whether a term other than
“mental health” or “behavioral health” might produce less stigma for
parents and their children, Gamel responded that “calling it what it is
has been the most empowering.” When she attended a previous
conference to speak about her successes dealing with behavioral
health issues, she said she had not realized that mental health care
was what she had been doing. “I thought it was coping, I thought it
was surviving. I didn’t know I was going to therapy,” she said, but
added that referring to what she was dealing with as mental health
was empowering for her. “The more [the term] gets used, the more
embraced it can be. That would be my suggestion: calling it what it
is,” Gamel said.
Gargan, in contrast, expressed a preference for the term
“behavioral health.” That is the term that she uses clinically and
personally, and it is more expansive than other terms. “The
terminology is important,” she added, “because words matter. But it’s
the picture that comes to mind with the terminology that we have to
work on.”
Kinebrew, too, favored the term “behavioral health” over “mental
health.” For her, the latter still has negative connotations. When “I
think ‘mental,’ I think something is wrong with me,” she said.
Sweeney agreed that “behavioral health” is a more expansive and
accepted term. But she also urged asking families about the terms
they prefer: “Some may be very comfortable with calling it what it is.
I am. But others like to term it ‘coping skills’ or ‘emotional issues’. . .
. It all depends, but ask.”
Mueller said that when she is asked, she says that she is seeing a
therapist. “I don’t have a negative image of therapist,” she said. She
added that when she uses the term with confidence, it does not
have a negative implication.

Parents as Professionals and as Advocates

Another topic raised in the discussion period was whether parents
acting as professionals or partners with professionals may
undermine their ability to advocate for their children. Gargan
observed that everyone in the health care workforce should be an
advocate working on behalf of families. But while parents are
advocating, they can also be providing support, “which is a very
different thing.” Working with such parents may require cultural
training within the workforce, but that should not be an
insurmountable obstacle, she said.
Sweeney made the same point: parent/peer support has advocacy
as one of its core competencies at the individual level and at the
system level. Parents may need training in how to be assertive and
not aggressive and how to be solution focused, but peer supervision
can help parents balance their roles. Parents “need to have
supervision from someone who helps them maintain their identity as
a parent, who helps them when something that they are working
through with another family triggers something about their own
journey,” she said.

The Transition to Adulthood

A final topic of discussion during this session involved the
transition from adolescence to adulthood at 18, when young people
gain certain rights of confidentiality and autonomy. Gargan said that
she and her son’s father talked with their son several years before
he turned 18 about the upcoming change. They worked with health
care professionals, filled out forms, and prepared for the transition.
That way, she explained, “we have continued to have great family
relationships with his professionals.”
Kinebrew, too, started at an early age to teach her sons how to
speak up for themselves. “At 14, 15, 16, they answered questions
for the doctors while I was in the room just to back them up. Even
now, I’m still at the appointments for the most part, but they are the
ones interacting with the doctors. . . . As they get older they’ll be
able [and] confident.”
At the same time, Sweeney observed that health care providers
need to help parents understand their evolving role. While young
people are learning about their new responsibilities upon turning 18,
parents need to get that information as well, she said.
__________________
1 Information about the program is available at http://www.incredibleyears.com
[September 2017].
 3

The National Landscape of Health Care

Training and Workforce Processes

Points Highlighted by the Speakers

The field of behavioral health is in the midst of a workforce
crisis because of increased demand, too few workers, a poorly
distributed workforce, the need for training focused on
behavioral health, and the increased emphasis on team-based
care. (Beck)
Nurses and schools are particularly valuable providers of child
and family behavioral health services. (Chapman)
Peer providers who use their lived experiences and have
received training to work with others represent another
segment of the behavioral health care workforce. (Bergan)
Medical students need to learn about the situations they are
likely to encounter in delivering behavioral health to children
and families. (Johnson)
 The workforce involved in promoting children’s cognitive, affective, and
behavioral health is broad and varied. It includes pediatricians, adult and
child psychiatrists, family medicine physicians, obstetricians and
gynecologists, nurses, community and public health professionals, social
workers, teachers and other school staff, and parents who have been
trained to fill professional roles. Physicians may work in the fields of
pediatrics, family medicine, psychiatry, obstetrics and gynecology, or a
combined field. Pediatric psychologists may work in primary care or
subspecialty care. Nurses include registered nurses, nurse practitioners
(including pediatric, family, and psychiatric nurse practitioners), and
primary care mental health nurses. Social workers with bachelor’s or
master’s degrees may work in the fields of behavioral health, substance
use and addiction, or youth and families. Parent and peer support
providers, parent coaches, and community health workers may all work
on behalf of children’s behavioral health.
As Thomas Boat, dean emeritus of the College of Medicine at the
University of Cincinnati, professor of pediatrics in the Division of
Pulmonary Medicine at Cincinnati Children’s Hospital Medical Center, and
cochair of the workshop planning committee, pointed out during a panel
discussion of health care training and workforce processes, all of these
groups are the products of workforce training and, to some extent, all are
involved in that training. As a specific example, Boat observed that “some
residents are now training both in pediatrics or family medicine and in
psychiatry or child and adolescent psychiatry. If we had more of those
people, they would be a major asset to what we’re trying to do.”
Boat was the lead author of a discussion paper released the day of the
workshop titled “Workforce Development to Enhance the Cognitive,
Affective, and Behavioral Health of Children and Youth: Opportunities and
Barriers in Child Health Care Training.”1 The paper points to shortfalls in
all disciplines in the numbers of individuals who are positioned to promote
children’s cognitive, affective, and behavioral health. The number of
physicians, for example, who are trained to address the behavioral health
needs of children and families “falls woefully short of what we should
have in place,” said Boat. Model programs and pathways exist for training
of the workforce (as described in the next chapter), but none of them has
been disseminated or systematically vetted in health care settings, “and
they need to be,” Boat observed. Nor is competence in this area a stated
expectation of licensing, certification, or program accreditation bodies,
which is an opportunity that should be exploited, Boat said.
The discussion paper lays out training pathways for eight different
disciplines. For pediatrics, for example, it describes 3-year programs for
both core pediatrics and subspecialty pediatrics. It then cites curriculum
guidelines and defined competencies for cognitive, affective, and
behavioral health. It also provides the numbers of training programs and
a general sense of workforce numbers. “Hopefully these data are helpful
in terms of being able to focus our attention and our efforts going
forward,” Boat said.
The paper describes models of highly integrated care in an effort to
understand what works and how successful models can be transported to
other health care areas. It also discusses the need to train the workforce
of the future to conduct program evaluation and outcomes research,
which Boat called “an important consideration as we go forward.” In
addition, more cross-disciplinary training will be an important future
objective. Overall, the paper is a platform for thinking about what is being
done now and what can be done in the future, said Boat. “As we go
through this workshop, hopefully we can extend these considerations. . . .
I hope that this paper will catalyze your thinking about what you can do
individually and at your programs at home to further the cause of
promoting children’s cognitive, affective, and behavioral health.”
After Boat’s introduction of the background paper, panelists looked at
different sectors to provide an overview of the current and projected
workforce and the status of training across multiple disciplines that serve
children and families.

THE BEHAVIORAL HEALTH WORKFORCE: SUPPLY, DEMAND,

CHALLENGES, AND OPPORTUNITIES
The field of behavioral health, which encompasses people who are
involved in the prevention or treatment of behavioral health and
substance use disorders, is in the midst of a workforce crisis, observed
Angela Beck, director of the Behavioral Health Workforce Research Center
at the University of Michigan School of Public Health. According to a
report by the Annapolis Coalition on the Behavioral Health Workforce
(2007), the crisis has several interconnected elements:

an increased demand for behavioral health services,

 too few workers to meet the demand,
a poorly distributed workforce,
a need for additional training,
an increased emphasis on integrated team-based care and
treatment of co-occurring disorders, and
a lack of systematic workforce data collection in behavioral health.

The core licensed professionals in the behavioral health workforce are

psychiatrists, psychologists, marriage and family therapists, social
workers, licensed professional counselors, and psychiatric nurse
practitioners, Beck explained. Certified professionals include addiction
counselors, peer providers, psychiatric rehabilitation specialists,
psychiatric aides/technicians, and case managers. Not all people working
in behavioral health are licensed or certified, said Beck, “but there are
opportunities for licensure and certification for many behavioral health
occupations.” Primary care providers also serve as frontline behavioral
health providers, regardless of whether they have specialized training in
this area. She noted that behavioral health workforce capacity covers a
very diverse set of occupations.
More than 900,000 core licensed professionals work in behavioral health
(see Figure 3-1), though the numbers vary depending on the data source.
This workforce is maldistributed across the United States, she added (see
Figure 3-2). About 4,000 behavioral health Health Profession Shortage
Areas (HPSAs), as designated by the Health Resources and Services
Administration, currently exist, with an increase of about 300 HPSAs since
2012. Approximately 2,800 psychiatrists are needed to address the
shortage, said Beck. More than one-half (55%) of U.S. counties, mostly in
rural areas, have no practicing psychiatrists or social workers.
Calculating how many more behavioral health workers are needed is a
difficult problem. It depends on the extent of unmet needs, the
distribution of future workers, and other factors. It also is an important
question, Beck said, “because we know that mental, emotional, and
behavioral disorders in youth are costly in the health care system [and]
that youth behavioral health concerns have reportedly increased over
time.”
According to recent projections from the Health Resources and Services
Administration (2016), shortages will continue to be substantial among
core licensed professionals in 2025, with the exception of behavioral
health nurse practitioners and physician assistants (see Table 3-1). The
total shortage in the selected behavioral health occupations is projected
to be about 250,000 workers. This list does not include peer providers or
other nonlicensed workers, and it is not specific to children and families,
but she said she did not think the numbers would improve by including
these types of workers.

FIGURE 3-1 Distribution of the behavioral health workforce.

SOURCE: Beck (2016).
 FIGURE 3-2 Maldistribution of the behavioral health workforce that limits
access to care.
SOURCE: Beck (2016).

Beck concluded by listing some of the challenges and opportunities for

behavioral health workforce development. The recruitment and retention
of workers is a challenge, particularly given the high turnover in the field.
The workforce is aging, more workers are needed in rural areas, the
workforce needs to become more diverse, and people serving specialized
populations need more specialized training, she observed. She also
pointed out that scopes of practice both enhance and limit the capabilities
of the workforce. “Recommendations or priorities around scopes of
practice may be important to keep in mind,” she suggested.

NURSES AND SCHOOLS AS PROVIDERS OF BEHAVIORAL HEALTH

SERVICES
Susan Chapman, professor in the Department of Social and Behavioral
Sciences at the University of California, San Francisco School of Nursing,
spoke about two valuable providers of behavioral health services in
communities: nurses and schools.
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future as they have been in the past, if you so will it. The reverse may
bring disaster on every portion of the country; and if you will have it
thus, we will invoke the God of our fathers, who delivered them from
the power of the lion, to protect us from the ravages of the bear, and
thus, putting our trust in God, and to our firm hearts and strong
arms we will vindicate the right as best we may.
In the course of my service here, associated at different times with
a great variety of Senators, I see now around me some with whom I
have served long; there have been points of collision, but whatever of
offense there has been to me I leave here; I carry with me no hostile
remembrance. Whatever offense I have given which has not been
redressed, or for which satisfaction has not been demanded, I have,
Senators, in this hour of our parting, to offer you an apology for any
harm which, in the heat of discussion, I have inflicted. I go hence
unencumbered of any injury received, and having discharged the
duty of making the only reparation in my power for any injury
offered.
Mr. President and Senators, having made the announcement
which the occasion seemed to me to require, it only remains for me
to bid you a final adieu.
 Speech of the Hon. Henry Wilson of
Massachusetts

In the canvass against Horace Greeley at Richmond, Ind., August 3,

1872.

AN ABSTRACT.

Gentlemen, standing here to-day, in this presence, among these

liberty-loving, patriotic men and women of Wayne county, I want to
call your attention for a few moments to what we have struggled for
in the past.
Nearly forty years ago, when the slave power dominated the
country—when the dark shadow of human slavery fell upon us all
here in the North—there arose a body of conscientious men and
women who proclaimed the doctrine that emancipation was the duty
of the master and the right of the slave; they proclaimed it to be a
duty to let the oppressed go free. Rewards were offered—they were
denounced, mobbed—violence pervaded the land. Yet these faithful
ones maintained with fidelity, against all odds, the sublime creed of
human liberty. The struggle, commencing forty years ago against the
assumptions and dominations of the slave power, went on from one
step to another—the slave power went right on to the conquest of the
country—promises were broken, without regard to constitutions or
laws of the human race. The work went on till the people, in their
majesty, in 1860, went to the ballot-box and made Abraham Lincoln
President of the United States. [Cheers.] Then came a great trial; that
trial was whether we should do battle for the principles of eternal
right, and maintain the cause of liberty, or surrender; whether we
would be true to our principles or false. We stood firm—stood by the
sacred cause—and then the slave power plunged the country into a
godless rebellion.
Then came another trial, testing the manhood, the courage, the
sublime fidelity of the lovers of liberty in the country. We met that
test as we had met every other test—trusting in God, trusting in the
people—willing to stand or fall by our principles. Through four years
of blood we maintained those principles; we broke down the
rebellion, restored a broken Union, and vindicated the authority and
power of the nation. In that struggle Indiana played a glorious part in
the field, and her voice in the councils of the nation had great and
deserved influence. [Cheers.]
Now, gentlemen, measured by the high standard of fidelity to
country, of patriotism, the great political party to which we belong
to-day was as true to the country in war as it had been in peace—true
to the country every time, and on all occasions.
Not only true to the country, but the Republican party was true to
liberty. It struck the fetters from the bondman, and elevated four and
a half millions of men from chattel-hood to manhood; gave them
civil rights, gave them political rights, and gave them part and parcel
of the power of the country. [Applause.]
Now, gentlemen, here to-day, I point to this record—this great
record—and say to you, that, measured by the standard of patriotism
—one of the greatest and grandest standards by which to measure
public men, political organizations or nations—measured by that
standard which the whole world recognizes, the Republican party of
the United States stands before the world with none, to accuse it of
want of fidelity to country. [Cheers.] Measured by the standard of
liberty, equal, universal, impartial liberty—liberty to all races, all
colors and all nationalities—the Republican party stands to-day
before the country pre-eminently the party of universal liberty.
[Loud cheers.] Measured by the standard of humanity—that
humanity that stoops down and lifts up the poor and lowly, the
oppressed and the castaways, the poor, struggling sons and
daughters of toil and misfortune—measured by that standard, the
Republican party stands before this country to-day without a peer in
our history, or in the history of any other people. [Renewed and
general applause.] We have gone further, embraced more, lifted up
lowlier men, carried them to a higher elevation, labored amid
obloquy and reproach to lift up the despised and lowly nations of the
earth than any political organization that the sun ever shone upon.
And then, gentlemen, tested by the support of all the great ideas
that tend to lift up humanity, to pull none down, to lift all up, to carry
the country upward and forward, ever toward God, the Republican
party of the country has been, and now is, to-day, in advance of any
political organization the world knows.
Gentlemen, I am not here to maintain that this great party, with its
three and a half millions of voters, tested and tried as it has been
during twelve years—I am not here to say that it has made no
mistakes. We have committed errors; we could not always see what
the right was; we failed sometimes; but, gentlemen, take our record—
take it as it stands—it is a bright and glorious record, that any man,
or set of men, may be proud of. We have stood, and we stand to-day,
on the side of man, and on the side of the ideas God has given us in
His Holy Word. [Applause.] There has not been a day since by the
labors, the prayers and the sacrifices of the old anti-slavery men and
women of the country, from 1830 to 1855—during twenty-five years
—I say to you, gentlemen, here, to-day, that this party, the product of
these prayers, and these sacrifices, and these efforts—with all its
faults—has been true to patriotism, true to liberty, true to justice,
true to humanity, true to Christian civilization. [Cheers.]
I say to you here to-day, that all along during this time, the
Democratic party carried the banners of slavery. Whenever the slave
power desired anything they got it. They wielded the entire power of
the nation, until, in their arrogance, when we elected Abraham
Lincoln, they plunged the country into the fire and blood of the
greatest civil war recorded in history. After the war all the measures
inaugurated for emancipation—to make the country free—to lift an
emancipated race up—to give them instruction and make them
citizens—to give them civil rights and make them voters—to put
them on an equality with the rest of the people—to every one of that
series of thirty or forty measures the Democratic party gave their
President unqualified and united opposition. Well, now, we have
been accustomed to say that they were mistaken, misinformed, that
they were honest—that they believed what they did; but, gentlemen,
if they have believed what they have said, that they have acted
according to their convictions from 1832 to 1872—a period of forty
years—can they be honest, to-day, in indorsing the Cincinnati
platform—in supporting Horace Greeley? [“No, no!”]
Why, we have read of sudden and miraculous conversions. We
read of St. Paul’s conversion, of the light that shone around him, but
I ask you, in the history of the human family have you ever known
three millions of men—three millions of great sinners for forty years
—[laughter]—three millions of men, all convicted, all converted, and
all changed in the twinkling of an eye. [Renewed laughter.] Why,
gentlemen, if it is so, for one I will lift up my eyes and my heart to
God, that those sinners, that this great political party that has been
for forty years, every time and all the time, on every question and on
all questions pertaining to the human race and the rights of the
colored race, on the wrong side—on the side of injustice, oppression
and inhumanity—on the side that has been against man, and against
God’s holy word; I say, gentlemen, that I will lift up my heart in
gratitude to God that these men have suddenly repented.
Why, I have been accustomed to think that the greatest victory the
Republican party would ever be called upon to win—and I knew it
would win it, because the Republican party, as Napoleon said of his
armies, are accustomed to sleep on the field of victory. The
Republican party—that always won—always ought to win, because it
is on the right side; and when it is defeated, it only falls back to
gather strength to advance again. [Applause.] I did suppose that the
greatest task it would ever have, greater than putting down the
rebellion, greater than emancipating four millions of men, greater
than lifting them up to civil rights—greater than all its grand deeds—
would be the conviction and conversion of the Democratic party of
the United States. [Laughter and cheers.] Just as we are going into a
Presidential election—when it was certain that if the Republican
party said and affirmed, said by its members, said altogether, that its
ideas, its principles, its policy, its measures, were stronger than were
the political organization of the Democrats. I say, just as we are going
into the contest, when it was certain that we would break down and
crush out its ideas, and take its flags and disband it, and out of the
wreck we would gather hundreds of thousands of changed and
converted men, the best part of the body—just at that time some of
our men are so anxious to embrace somebody that has always been
wrong that they start out at once in a wild hunt to clasp hands with
our enemies and to save the Democratic party from absolute
annihilation. [Laughter.] To do what they want us is to disband.
Well, gentlemen, I suppose there are some here to-day that belonged
to the grand old Army of the Potomac. If when Lee had retreated on
Richmond, and Phil. Sheridan sent back to Grant that if he pushed
things he would capture the army—if, instead of sending back to
Sheridan, as Grant did, “Push things,” he had said to him, “Let us
disband the Army of the Potomac; don’t hurt the feelings of these
retreating men; let us clasp hands with them,” what would have been
the result? I suppose there are some of you here to-day that followed
Sherman—that were with him in his terrible march from
Chattanooga to Atlanta—with him in that great march from Atlanta
to the sea—what would you have thought of him if, when you came in
sight of the Atlantic ocean, you had had orders to disband before the
banners of the rebellion had disappeared from the Southern
heavens?
I tell you, to-day, this movement of a portion of our forces is this
and nothing more. I would as soon have disbanded that Army of the
Potomac after Sheridan’s ride through the valley of the Shenandoah,
or when Sherman had reached the sea, as to disband the Republican
party to-day. The time has not come. [Loud and continued applause.]
I am not making a mere partisan appeal to you. I believe in this
Republican party, and, if I know myself, rather than see it defeated
to-day—rather than see the government pass out of its hands—I
would sacrifice anything on earth in my possession, even life itself.
[Loud applause] I have seen brave and good men—patriotic, liberty-
loving, God-fearing men—I have seen them die for the cause of the
country—for the ideas we profess, and I tell you to-day, with all the
faults of the Republican party—and it has had faults and has made
some mistakes—I say to you that I believe upon my conscience its
defeat would be a disaster to the country, and would be a stain upon
our record. It would bring upon us—we might say what we pleased,
our enemies would claim it, and the world would record it—that this
great, patriotic, liberty-loving Republican party of the United States,
after all its great labors and great history, had been weighed in the
balances and found wanting, and condemned by the American
people.
 Well, gentlemen, I choose, if it is to fall, to fall with it. I became an
anti-slavery man in 1835. In 1836 I tied myself, pledged myself, to do
all I could to overthrow the slave power of my country. During all
these years I have never given a vote, uttered a word, or written a line
that I did not suppose tended to this result. I invoke you old anti-
slavery men here to-day—and I know I am speaking to men who have
been engaged in the cause—I implore you men who have been true in
the past, no matter what the men or their natures are, to stand with
the grand organization of the Republican party—be true to its cause
and fight its battles—if we are defeated, let us accept the defeat as
best we may; if we are victorious, let us make our future more
glorious than the past. If we fail, let us have the proud consciousness
that we have been faithful to our principles, true to our convictions;
that we go down with our flag flying—that we go down trusting in
God that our country may become, what we have striven to make it,
the foremost nation on the globe. [Immense applause.]
 Speech of Senator Oliver P. Morton, of
Indiana,

On the National Idea, at Providence, R. I.

The distinguished orator was introduced by Senator Anthony, and
made an extended speech, from which we take the more pertinent
paragraphs:
From this proposition two corollaries have been adduced from
time to time, and I must say with great force of logic. The first is that
this Union is composed of sovereign and independent States who
have simply entered into a compact for particular purposes, and the
government is merely their agent; that any State has the right to
withdraw from the Union at pleasure, or whenever in its judgment
the terms of the compact have been violated, or the interests of the
State require its withdrawal. The second is that each State has the
right to nullify any law of Congress which, in the judgment of the
State, is in violation of the compact by which the government was
formed. This doctrine has been the evil genius of the country from
the foundation of our government. It may be said to be the devil in
our political system. It has been our danger from the first. It is the
rock in the straits, and we fear that the end is not yet. Now what can
we oppose to this doctrine? We oppose what we call “the national
idea.” We assume that this government was formed by the
governments of the United States in their aggregate and in their
primary capacity. We assume that, instead of there being thirty-
seven nations, there is but one; instead of there being thirty-seven
sovereignties, there is but one sovereignty. We assume that the
States are not sovereign, but that they are integral and subordinate
parts of one great country. I may be asked the question here, “Are
there no State rights? Would you override the States? Would you
obliterate State lines?” I answer, “No.” I answer that this doctrine is
the only doctrine that can preserve the peace of this nation and
preserve the rights of the States. I answer that there is a vast body of
State rights guaranteed and secured by the Constitution of the
United States, by the same Constitution that created and upholds the
government of the United States; that these State rights have the
same guarantee that the rights of the National Government have,
equally entitled to the protection of the Supreme Court, springing
out of the same instrument, and that one set of rights are just as
sacred as the other. Some confound the idea of State sovereignty and
State rights as being one and the same thing. Others seem to suppose
that State rights are only consistent with State sovereignty, and
cannot exist except upon the theory of State sovereignty; while I
assume that State rights are consistent with National sovereignty,
and are safest under the protection of the nation. The Constitution
gives one class of rights to the government of the United States. They
are specified, and they carry with them all the rights that are
indispensable and necessary to their full execution and enjoyment.
The rest are to be held and enjoyed by the States, or reserved to the
people. The States have their rights by the agreement of the nation.
That seems to be the important truth that is so often overlooked, that
the rights of the States, sacred and unapproachable, are sacred by the
agreement of the nation, as much so as are the powers that are
conferred upon the government of the United States, that the States
derive their powers from the same source, viz: The Constitution of
the United States. That Constitution says that the government shall
have one class of powers, and that other powers shall be gained by
the States, to be enjoyed by them or reserved to the people. In the
consideration of this question, we must reflect that the nation had
assembled in convention in 1787, and there formed a government,
there declared what rights should be given to the National
Government, and what rights should be reserved to the States, and
that, in either case, the grant and guarantee is an act of national
sovereignty by the people in convention assembled. When we shall
embrace this idea fully, all the danger of centralization will pass
away, though we discard the idea of State sovereignty.
I do not differ so much with many gentlemen in regard to what the
rights of the States are. I differ with them in regard to the titles by
which they hold them. I say that so far as State rights are concerned,
and the rights of the government, that we are not to go back beyond
the period of 1787, when the Constitution was formed. The rights of
the elder States, and of Rhode Island as she has them now, are to be
dated from the formation of the Constitution. Then they came into
convention. They had the right to make any sort of government they
pleased, and they did. And in that government they guarantied and
secured to the States the great body of rights in regard to local and
domestic government, but it was the agreement of the nation at that
time. So far as the new States are concerned, they are to come in on
an equality. They are to have the same rights with the old; and this
theory would be impossible of execution except upon the idea that
the rights of the States and of the National Government are to be
determined from the action that was taken at that time. The difficulty
had been in regard to this theory of State sovereignty, and the
assumed right of secession and of nullification was the result. They
assumed that these States existed as nations separate and distinct
before that time, and that they only loaned a portion of their rights
for a particular purpose. This is the base of that theory; while we
assume that the people were acting together at that time in their
aggregate capacity, raising a system of government, giving the United
States certain powers, and providing that the States should hold and
enjoy the rest, excepting those that were reserved to the people. The
preservation of local self-government is essential to the liberties of
this nation. Nobody endorses that sentiment more strongly than I
do. Nobody will stand by the rights of the States more firmly than I
will. I hold that their rights are consistent with national sovereignty,
and that national sovereignty is consistent with the rights of the
States, and I deny that these rights are the result of inherent original
State sovereignty. In other words, we differ in regard to the title.
What the States should have, and what the government should have,
was settled by the act of the nation in convention in 1787, changed to
some extent by the adoption of amendments since that time. It is not
enough for a party to deny the right of secession. It is not enough for
a party to deny the right of nullification. They must go further. They
must deny the doctrine of State sovereignty; for as long as that
doctrine is admitted, these other things will spring up spontaneously
from it, and whenever the occasion allows it. If we were to admit that
the States were sovereign, then we would be bound to say that
Webster did not answer Hayne, and that Webster and Hayne never
answered Calhoun. If once it is admitted that the States are
sovereign, it is hard to resist the corollaries to which I have referred,
that they have the right to secede, and that they have the right to
nullify.
The doctrine of nationality planted deep in the hearts of the
American people is our only sheet-anchor of safety for the future.
Our country is greatly extended, from the tropical to the arctic
regions, with every variety of climate, soil, and productions, with
different commercial and manufacturing interests. The States on the
Pacific slopes are separated from those on this side of the Rocky
Mountains by fifteen hundred miles of mountain and desert. They
have a different commerce from what you have, almost an
independent commerce. Their commerce will be with China, Japan,
Australia, the western countries of South America, and the islands of
the Southern Pacific. It is now but in its infancy, but it bids fair to
develop into colossal proportions, and may change the commercial
aspect of the world. We know not what feelings of independence may
arise in those States in time to come. It is difficult to deny the effect
that may be produced by the separation of vast States with a different
commerce acting in conjunction with forced theories of the origin
and laws of our government. In saying this I will cast no imputation
upon the loyalty of those States. They are now as loyal as any, and
were during the war. But we can imagine that what has been may be
again. And we can understand what may be the danger of this
doctrine, if it should still maintain its hold in the minds of the
American people, when conflicting interests arise, and conflicting
notions arise as to what may be the interests of the people; as in 1812
a war was brought about which was regarded as being fatal to the
interests of the New England States, they took their position upon it.
We have had a law which was regarded in South Carolina as being
fatal to her interests, and she took her position upon it. This doctrine
was again seized by slavery in 1861, and the rebellion was brought
on. And what may happen in the far future upon the eastern and
western coasts, upon the northern and southern extremities of our
nation, we cannot tell.
The idea that we are a nation, that we are one people, undivided
and indivisible, should be a plank in the platform of every party. It
should be printed on the banner of every party. It should be taught in
every school, academy, and college. It should be the political North
Star by which every political manager should steer his bark. It should
be the central idea of American politics, and every child, so to speak,
should be vaccinated with this idea, so that he may be protected
against this political distemper that has brought such calamity upon
our country. Were the mind of the nation, so to speak, fully saturated
with this sentiment of nationality, that we are but one people,
undivided and indivisible, there would be no danger though our
boundaries came to embrace the entire continent. It is therefore of
the utmost importance that it should be taught and inculcated upon
all occasions. What the sun is in the heavens, diffusing light, and life,
and warmth, and by its subtle influence holding the planets in their
orbits and preserving the harmony of the universe—such is the
sentiment of nationality in a nation, diffusing light and protection in
every part, holding the faces of Americans always toward their home,
protecting the States in the exercise of their just powers, and
preserving the harmony and prosperity of all.
We must have a nation. It is a necessity of our political existence,
and we find the countries of the Old World now aspiring for
nationality. Italy, after a long absence, has returned. Rome has again
become the centre and the capital of a great nation. The bleeding
fragments of the beautiful land have been bound up together, and
Italy again resumes her place among the nations. And we find the
great Germanic family has been sighing for a nationality. That race,
whose overmastering civilization is acknowledged by all the world,
has hitherto been divided into petty Principalities and States, such as
Virginia and South Carolina aspire to be, but now are coming
together and asserting their unity, their national existence, and are
now able to dominate all the nations of Europe. We should then
cherish this idea, that while the States have their rights sacred and
unapproachable, which we should guard with untiring vigilance,
never permitting an encroachment, and remembering that such
encroachment is as much a violation of the Constitution of the
United States as to encroach upon the rights of the general
Government, still bearing in mind that the States are but subordinate
parts of one great nation, and that the nation is over, all even as God
is over the universe. Without entering into any of the consequences
that flow from this doctrine, allow me for to-night to refer to that
great national attribute, that great national duty—the duty and the
power to protect the citizen in the enjoyment of life, liberty, and
property. If the Government of the United States has not the power
to protect the citizens of the United States in the enjoyment of life,
liberty, and property in cases where the States fail, or refuse, or are
unable to grant protection, then that Government should be
amended, or should give place to a better. Great Britain sent forth a
costly and powerful expedition to Abyssinia to rescue four British
subjects who had been captured and imprisoned by the government
of that country. She has recently threatened Greece with war, if she
did not use all her power to bring to justice two brigands who had
lately murdered two British subjects. These things are greatly to the
honor of Great Britain. And our Government threatened Austria with
war if she did not release Martin Kosta, who had declared his
intention to become a citizen of the United States, and was therefore
protected by the Government of the United States. More recently we
have made war upon Corea, a province in Asia, and slaughtered her
people, and battered down her forts, because Americans shipwrecked
upon her coast were murdered and the government had refused to
give satisfaction for it. And if a mob in London should murder half a
dozen American citizens, we would call upon that government to use
all its power to bring the murderers to punishment, and if Great
Britain did not do so, it would be regarded as a cause of war. And yet
some people entertain the idea that our Government has the power
to protect its citizens everywhere except upon its own soil. The idea
that I would advocate, the doctrine that I would urge as being the
only true and national one, flowing inevitably from national
sovereignty, is that our Government has the right to protect her
citizens in the enjoyment of life, liberty, and property wherever the
flag floats, whether at home or abroad.
Speech of Hon. J. Proctor Knott, of Kentucky,

Delivered in the House of Representatives on the St. Croix and

Superior Land Grant, January 21, 1871.
The house having under consideration the joint resolution (S. R.
No. 11) extending the time to construct a railroad from St. Croix river
or lake to the west end of Lake Superior and to Bayfield—
Mr. Knott said: Mr. Speaker—If I could be actuated by any
conceivable inducement to betray the sacred trust in me by those to
whose generous confidence I am indebted for the honor of a seat on
this floor; if I could be influenced by any possible consideration to
become instrumental in giving away, in violation of their known
wishes any portion of their interest in the public domain for the mere
promotion of any railroad enterprise whatever, I should certainly feel
a strong inclination to give this measure my most earnest and hearty
support; for I am assured that its success would materially enhance
the pecuniary prosperity of some of the most valued friends I have on
earth; friends for whose accommodation I would be willing to make
almost any sacrifice not involving my personal honor or my fidelity
as the trustee of an express trust. And that act of itself would be
sufficient to countervail almost any objection I might entertain to the
passage of this bill not inspired by any imperative and inexorable
sense of public duty.
But, independent of the seductive influences of private friendship,
to which I admit I am, perhaps, as susceptible as any of the
gentlemen I see around me, the intrinsic merits of the measure itself
are of such an extraordinary character as to commend it most
strongly to the favorable consideration of every member of this
house, myself not excepted, notwithstanding my constituents, in
whose behalf alone I am acting here, would not be benefited by its
passage one particle more than they would be by a project to
cultivate an orange grove on the bleakest summit of Greenland’s icy
mountains.
Now, sir, as to those great trunk lines of railways, spanning the
continent from ocean to ocean, I confess my mind has never been
fully made up. It is true they may afford some trifling advantages to
local traffic, and they may even in time become the channels of a
more extended commerce. Yet I have never been thoroughly satisfied
either of the necessity or expediency of projects promising such
meagre results to the great body of our people. But with regard to the
transcendent merits of the gigantic enterprise contemplated in this
bill, I have never entertained the shadow of a doubt.
Years ago, when I first heard that there was somewhere in the vast
terra incognita, somewhere in the bleak regions of the great
northwest, a stream of water known to the nomadic inhabitants of
the neighborhood as the river St. Croix, I became satisfied that the
construction of a railroad from that raging torrent to some point in
the civilized world was essential to the happiness and prosperity of
the American people if not absolutely indispensable to the perpetuity
of republican institutions on this continent. I felt instinctively that
the boundless resources of that prolific region of sand and pine
shrubbery would never be fully developed without a railroad
constructed and equipped at the expense of the government, and
perhaps not then. I had an abiding presentiment that, some day or
other, the people of this whole country, irrespective of party
affiliations, regardless of sectional prejudices, and “without
distinction of race, color, or previous condition of servitude,” would
rise in their majesty and demand an outlet for the enormous
agricultural productions of those vast and fertile pine barrens,
drained in the rainy season by the surging waters of the turbid St.
Croix.
These impressions, derived simply and solely from the “eternal
fitness of things,” were not only strengthened by the interesting and
eloquent debate on this bill, to which I listened with so much
pleasure the other day, but intensified, if possible, as I read over this
morning, the lively colloquy which took place on that occasion, as I
find it reported in last Friday’s Globe. I will ask the indulgence of the
house while I read a few short passages, which are sufficient, in my
judgment, to place the merits of the great enterprise, contemplated
in the measure now under discussion, beyond all possible
controversy.
The honorable gentleman from Minnesota (Mr. Wilson), who, I
believe, is managing this bill, in speaking of the character of the
country through which this railroad is to pass, says this:
“We want to have the timber brought to us as cheaply as possible.
Now, if you tie up the lands, in this way, so that no title can be
obtained to them—for no settler will go on these lands, for he cannot
make a living—you deprive us of the benefit of that timber.”
Now, sir, I would not have it by any means inferred from this that
the gentleman from Minnesota would insinuate that the people out
in this section desire this timber merely for the purpose of fencing up
their farms so that their stock may not wander off and die of
starvation among the bleak hills of St. Croix. I read it for no such
purpose, sir, and make no comment on it myself. In corroboration of
this statement of the gentleman from Minnesota, I find this
testimony given by the honorable gentleman from Wisconsin (Mr.
Washburn). Speaking of these same lands, he says:
“Under the bill, as amended by my friend from Minnesota, nine-
tenths of the land is open to actual settlers at $2.50 per acre; the
remaining one tenth is pine-timbered land, that is not fit for
settlement, and never will be settled upon; but the timber will be cut
off. I admit that it is the most valuable portion of the grant, for most
of the grant is not valuable. It is quite valueless; and if you put in this
amendment of the gentleman from Indiana you may as well just kill
the bill, for no man and no company will take the grant and build the
road.”
I simply pause here to ask some gentleman better versed in the
science of mathematics than I am, to tell me if the timbered lands are
in fact the most valuable portion of that section of country, and they
would be entirely valueless without the timber that is in them, what
the remainder of the land is worth which has no timber on it at all?
But, further on, I find a most entertaining and instructive
interchange of views between the gentleman from Arkansas (Mr.
Rogers), the gentleman from Wisconsin (Mr. Washburn), and the
gentleman from Maine (Mr. Peters), upon the subject of pine lands
generally, which I will tax the patience of the house to read:
 “Mr. Rogers—Will the gentleman allow me to ask him a question?
“Mr. Washburn, of Wisconsin—Certainly.
“Mr. Rogers—Are these pine lands entirely worthless except for
timber?
“Mr. Washburn, of Wisconsin—They are generally worthless for
any other purpose. I am personally familiar with that subject. These
lands are not valuable for purposes of settlement.
“Mr. Farnsworth—They will be after the timber is taken off.
“Mr. Washburn, of Wisconsin—No, sir.
“Mr. Rogers—I want to know the character of these pine lands.
“Mr. Washburn, of Wisconsin—They are generally sandy, barren
lands. My friend from the Green Bay district (Mr. Sawyer) is himself
perfectly familiar with this question, and he will bear me out in what
I say, that these timber lands are not adapted to settlement.
“Mr. Rogers—The pine lands to which I am accustomed are
generally very good. What I want to know is, what is the difference
between our pine lands and your pine lands?
“Mr. Washburn, of Wisconsin—The pine timber of Wisconsin
generally grows upon barren, sandy land. The gentleman from Maine
(Mr. Peters) who is familiar with pine lands, will, I have no doubt,
say that pine timber grows generally upon the most barren lands.”
“Mr. Peters—As a general thing pine lands are not worth much for
cultivation.”
And further on I find this pregnant question the joint production
of the two gentlemen from Wisconsin.
“Mr. Paine—Does my friend from Indiana suppose that in any
event settlers will occupy and cultivate these pine lands?
“Mr. Washburn, of Wisconsin—Particularly without a railroad.”
Yes, sir, “particularly without a railroad.” It will be asked after
awhile, I am afraid, if settlers will go anywhere unless the
government builds a railroad for them to go on.
I desire to call attention to only one more statement, which I think
sufficient to settle the question. It is one made by the gentleman
from Wisconsin (Mr. Paine), who says:
 “These lands will be abandoned for the present. It may be that at
some remote period there will spring up in that region a new kind of
agriculture, which will cause a demand for these particular lands;
and they may then come into use and be valuable for agricultural
purposes. But I know, and I cannot help thinking that my friend
from Indiana understands that, for the present, and for many years
to come, these pine lands can have no possible value other than that
arising from the pine timber which stands on them.”
Now, sir, who, after listening to this emphatic and unequivocal
testimony of these intelligent, competent and able-bodied witnesses,
who that is not as incredulous as St. Thomas himself, will doubt for a
moment that the Goshen of America is to be found in the sandy
valleys and upon the pine-clad hills of the St. Croix? Who will have
the hardihood to rise in his seat on this floor and assert that,
excepting the pine bushes, the entire region would not produce
vegetation enough in ten years to fatten a grasshopper? Where is the
patriot who is willing that his country shall incur the peril of
remaining another day without the amplest railroad connection with
such an inexhaustible mine of agricultural wealth? Who will answer
for the consequences of abandoning a great and warlike people, in
the possession of a country like that, to brood over the indifference
and neglect of their government? How long would it be before they
would take to studying the Declaration of Independence and
hatching out the damnable heresy of secession? How long before the
grim demon of civil discord would rear again his horrid head in our
midst, “gnash loud his iron fangs and shake his crest of bristling
bayonets?”
Then, sir, think of the long and painful process of reconstruction
that must follow with its concomitant amendments to the
constitution, the seventeenth, eighteenth and nineteenth articles.
The sixteenth, it is of course understood, is to be appropriated to
those blushing damsels who are, day after day, beseeching us to let
them vote, hold office, drink cocktails, ride a-straddle, and do
everything else the men do. But above all, sir, let me implore you to
reflect for a single moment on the deplorable condition of our
country in case of a foreign war, with all our ports blockaded, all our
cities in a state or siege, the gaunt specter of famine brooding like a
hungry vulture over our starving land; our commissary stores all
exhausted, and our famishing armies withering away in the field, a
helpless prey to the insatiate demon of hunger; our navy rotting in
the docks for want of provisions for our gallant seamen, and we
without any railroad communication whatever with the prolific pine
thickets of the St. Croix.
Ah, sir, I could very well understand why my amiable friends from
Pennsylvania (Mr. Myers, Mr. Kelley and Mr. O’Neill) should be so
earnest in their support of this bill the other day; and if their
honorable colleague, my friend, Mr. Randall, will pardon the remark,
I will say I consider his criticism of their action on that occasion as
not only unjust, but ungenerous. I knew they were looking forward
with a far-reaching ken of enlightened statesmanship to the pitiable
condition in which Philadelphia will be left unless speedily supplied
with railroad connection in some way or other with this garden spot
of the universe. And beside, sir, this discussion has relieved my mind
of a mystery that has weighed upon it like an incubus for years. I
could never understand before why there was so much excitement
during the last Congress over the acquisition of Alta Vela. I could
never understand why it was that some of our ablest statesmen and
most disinterested patriots should entertain such dark forebodings of
the untold calamities that were to befall our beloved country unless
we should take immediate possession of that desirable island. But I
see now that they were laboring under the mistaken impression that
the government would need the guano to manure the public lands on
the St. Croix.
Now, sir, I repeat, I have been satisfied for years that if there was
any portion of the inhabited globe absolutely in a suffering condition
for want of a railroad it was these teeming pine barrens of the St.
Croix. At what particular point on that noble stream such a road
should be commenced I knew was immaterial, and it seems so to
have been considered by the draughtsman of this bill. It might be up
at the spring or down at the foot-log, or the water-gate, or the fish-
dam, or anywhere along the bank, no matter where. But in what
direction should it run, or where it should terminate, were always to
my mind questions of the most painful perplexity. I could conceive of
no place on “God’s green earth” in such straitened circumstances for
railroad facilities as to be likely to desire or willing to accept such a
connection. I knew that neither Bayfield nor Superior city would
have it, for they both indignantly spurned the munificence of the
government when coupled with such ignominious conditions, and let
this very same land grant die on their hands years and years ago
rather than submit to the degradation of a direct communication by
railroad with the piny woods of the St. Croix; and I knew that what
the enterprising inhabitants of those giant young cities would refuse
to take would have few charms for others, whatever their necessities
or cupidity might be.
Hence as I have said, sir, I was utterly at a loss to determine where
the terminus of this great and indispensable road should be, until I
accidentally overheard some gentleman the other day mention the
name of “Duluth.”
Duluth! The word fell upon my ear with a peculiar and
indescribable charm, like the gentle murmur of a low fountain
stealing forth in the midst of roses; or the soft, sweet accents of an
angel’s whisper in the bright, joyous dream of sleeping innocence.
“Duluth!” ’Twas the name for which my soul had panted for years,
as the hart panteth for the water-brooks. But where was Duluth?
Never in all my limited reading, had my vision been gladdened by
seeing the celestial word in print. And I felt a profound humiliation
in my ignorance that its dulcet syllables had never before ravished
my delighted ear. I was certain the draughtsman in this bill had
never heard of it or it would have been designated as one of the
termini of this road. I asked my friends about it, but they knew
nothing of it. I rushed to the library, and examined all the maps I
could find. I discovered in one of them a delicate hairlike line,
diverging from the Mississippi near a place marked Prescott, which, I
supposed, was intended to represent the river St. Croix, but, could
nowhere find Duluth. Nevertheless, I was confident it existed
somewhere, and that its discovery would constitute the crowning
glory of the present century, if not of all modern times. I knew it was
bound to exist in the very nature of things; that the symmetry and
perfection of our planetary system would be incomplete without it.
That the elements of maternal nature would since have resolved
themselves back into original chaos if there had been such a hiatus in
creation as would have resulted from leaving out Duluth! In fact, sir,
I was overwhelmed with the conviction that Duluth not only existed
somewhere, but that wherever it was, it was a great and glorious