Then, Now, and Next: The First 25 Years of CCFH

Celebrating 25 Years of Helping Children Heal and Thrive

There are few who carry as much of the history of the Center for Child & Family Health in their heads and hearts as Lisa Amaya-Jackson. Ask her to tell you how it all began, and, depending on the day, she may start the story at any of a dozen different pivotal moments, but this is the one most likely to evoke a glisten of tears as she talks:

“CCFH opened its doors in November 1996 at 3519 Westgate Drive in Durham after three years of soul-driven, intense planning. The carpets and fresh paint smelled and looked so good, and I can still picture the smiling face of Kay Hill [CCFH’s first administrator] as she greeted our first patients. I remember therapists and children talking animatedly as they saw the new space created especially for them. It was a miracle unfolding before my eyes!”

That opening day is the milestone we are celebrating as we mark CCFH’s 25th anniversary, but, to understand what made it so miraculous to Lisa and to those therapists and children who first came through CCFH’s doors, it is important to go back a few years.

An Audacious Idea

Throughout most of the 20th century, there was little acknowledgment of the reality and prevalence of child abuse, but a rising tide of research and awareness in the 1970s and 1980s brought the issue into public consciousness and discussion. Campaigns and organizations, like the North Carolina chapter of Prevent Child Abuse founded in 1979, were launched to pursue solutions. Here in Durham, a Child Advocacy Commission began in the mid-1980s. Muff Urbaniak, a longtime supporter of CCFH, was on the commission and remembers that a large part of their focus was how to respond better as a community to the problem of child abuse.

As a result of this ferment, many local community systems – especially, healthcare, social services, law enforcement, and the courts – had developed some means of responding to the needs of abused children. Duke and UNC, for example, both had dedicated teams to conduct forensic medical evaluations for children who had experienced sexual abuse. At Duke, there was also the Child Guidance Clinic, where ongoing care was available. The problem, though, was that these systems were fragmented with every agency interacting with families separately and without coordination. Also, while many recognized how badly children need mental healthcare in the wake of trauma, there were very few psychologists and therapists qualified to provide it.

Two pediatricians who specialized in public health approaches to child abuse – Desmond Runyan at UNC and Tom Frothingham at Duke – saw the flaws in the system, but they also firmly believed better outcomes were possible. They began a conversation with the Durham-Orange County Medical Society that led to sponsorship for a series of day-long retreats in 1993 and 1994 to imagine a more collaborative system. They asked Cheryl Amana-Burris from the law school at NC Central University to join them in leading the process, adding her expertise in the legal and social services aspects of the larger system. Together, these three brought together a broad array of stakeholders – county commissioners, judges, private citizens and professionals from law enforcement, medicine, mental health, social services, and a variety of other public and private agencies serving children and families. After reviewing many possibilities for a new and better system, the participants agreed on this vision: a free-standing and independent site where all of the institutions, agencies, and professionals involved in responding to child abuse could unify their efforts and achieve better outcomes for children.

A planning group was created with four representatives from each of the three universities, who, along with The Duke Endowment, provided seed money for the new endeavor. The success of this new enterprise, though, was not a foregone conclusion. Bringing together three universities, each with their own cultures and administrative structures, to create a community-based center that would embody a radically new approach to child abuse was a very heavy lift for everyone involved.

“What we were doing was truly audacious,” says Lisa Amaya-Jackson, “and there were some days I thought I was putting my career on the line before it had even gotten started!” Yet, she notes, there were also numerous university leaders who stepped forward at key moments to nudge the initiative past looming institutional obstacles. Julius Chambers, Chancellor of NC Central University at the time, made what was perhaps the most catalytic contribution to the fledgling effort: he was the first to sign the consortium agreement among the three universities that brought the center to life. Lisa also credits Matt Epstein, the organization’s first full-time executive director. With no institutional loyalties beyond the emerging center, he was able to be the fiercest advocate for making the vision a reality.

Despite the challenges, there was an undeniable momentum behind the effort. Mary Champagne, then Dean of the School of Nursing at Duke, was asked by Chancellor Ralph Snyderman to be one of the university’s three representatives on the founding Board of Directors for the center.

“What I remember most was the passion,” she says, “this deep sense we all shared that we had to do this.”

Pictured below: CCFH co-founder Lisa Amaya-Jackson. Legal Director Janis Ernst, Executive Director Matt Epstein, and co-founders Desmond Runyan and Tom Frothingham at a CCFH Operations Committee meeting in 1997. CCFH co-founder Cheryl Amana-Burris. CCFH staff gathered at the Westgate Drive office in 2004. 

Hustle & Bustle

From their new home on Westgate Drive, the multidisciplinary team of therapists, psychiatrists, doctors, nurses, and social workers dove head and heart first into their work. The extraordinary effort that had launched CCFH gave way to eagerness and excitement as the staff was now finally engaged in what they set out to do. Community members were also getting involved, making contributions such as painting clouds for children to look up at on the ceiling of exam rooms.

“It was a happy space and so child-friendly,” remembers Muff Urbaniak. “It just felt … right. I thought, if I were a parent bringing my child here, I would feel so comfortable.”
The atmosphere at the center was one of hustle and bustle in these early days. Staff were paged over the intercom throughout the day as their young clients arrived for treatment or evaluation. Colleagues gathered formally and informally to consult on complex cases. Research articles were passed around, reviewed, and discussed as teams learned how to conduct standardized assessments to measure things like PTSD symptoms in abused children. The office buzzed with the energy of being able to meet children’s needs with a comprehensive, wrap-around approach that had not been tried before.

“By bringing all these experts together, bringing these disciplines together – social work, psychology, psychiatry, pediatrics, law, training,” reflects Lisa Amaya-Jackson, “we were able to give these children and families the absolute state of the art from the minute they walked in until they left. That didn’t happen anywhere else.”

The mission of CCFH was big and audacious, but its footprint was still relatively small in those early years, as was the field of child traumatic stress. Nevertheless, the center was catching the attention of clinicians and researchers within and outside of North Carolina.

In 1998, Donna Potter was a therapist at a family services agency in Person County bringing children to CCFH for forensic medical examinations following suspected abuse. While searching for more effective ways to treat children who had experienced trauma, she connected with Lisa Amaya-Jackson and soon began attending CCFH’s didactic lecture series. She recognized right away that what CCFH offered was unique.

“The idea that there was this place where people were specially trained in how to talk with very young children about sexual abuse, that they had all of these wonderful services for treatment … I was completely enamored.” A year later, after completing an intensive training to conduct evaluations, Donna joined the CCFH staff. Today, she serves as Lead Clinical Faculty for CCFH’s NC Child Treatment Program, teaching those same evidence-based trauma treatment models she had sought to learn to clinicians across our state.

Around this time, a young researcher was being recruited to the small but strong and seasoned CCFH team. Ernestine Briggs-King was working as a community psychologist in South Carolina when her colleague Ben Saunders introduced her to Lisa Amaya-Jackson at a conference on child maltreatment in San Diego. Lisa launched a charm offensive to recruit Ernestine to CCFH and Duke, and she joined CCFH in August 2000. Today, Ernestine serves as the center’s Director of Research.

Ernestine recalls the conversations at that conference as an encounter with a who’s who of child traumatic stress experts at the time. In addition to Ben and Lisa, she connected with Judy Cohen and Anthony Mannarino, two lead developers of Trauma-Focused Cognitive Behavioral Therapy, still the gold standard in treating childhood trauma, and David Kolko, another nationally recognized expert in evidence-based treatments for childhood trauma.

“Those relationships were the start of a lot of different things for CCFH, one being our move toward evidence-based practices,” says Ernestine, explaining how knowing the developers and researchers in academia gave CCFH a head start in learning and practicing interventions that it now trains others to use. “Having the center be this connection between community and academic affiliation helped expedite our ability to bring some of what we knew as best practice to North Carolina.”

An Evolving Mission

The hustle and bustle of CCFH’s early years paved the way for a period of steady, varied growth through the following decade. Whenever the needs of children and families came into clearer focus, the center shifted and evolved to meet them.

As CCFH’s treatment and evaluation work became more established, efforts toward a more structured approach to preventing child maltreatment gained traction. Jan Williams had been working with a local organization called Child and Parent Support Services (CAPSS) in the mid-1990s when she realized just how difficult it was to help vulnerable, stressed families get back to a place of stability.

“There was so little hope in that work,” she remembers. “We were trying to do parent coaching without the [evidence-based] strategies.”

Jan convened a team to review prevention models that would better meet the needs of Durham families. With funding from Smart Start, they adopted the Healthy Families America model, an evidence-based home visiting program launched by Prevent Child Abuse America. The following year, in 1997, CCFH Executive Director Matt Epstein helped bring CAPSS under the umbrella of the center’s programs, embedding Healthy Families Durham (HFD) in CCFH and establishing its first intentional efforts at preventing child abuse and neglect.

“I think it was the best decision in the world to do that,” Jan says. Finding a home in an organization that understood child trauma and could provide clinical guidance meant that the HFD team could meet family needs more effectively than ever before. They could make referrals to evidence-based trauma treatment for both children and teen moms. They consulted with psychiatrists, attorneys, and physicians, and they always had someone to call in the clinic if an urgent safety matter arose for a family.

The energy around prevention work coalesced with the launch in 2002 of the Durham Family Initiative (DFI), a collaboration between CCFH and the Duke Center for Child & Family Policy. Over the course of twelve years, DFI developed and piloted new approaches to improve family well-being and reduce child maltreatment in Durham County, leading ultimately to the universal postpartum nurse home visiting program known today as Family Connects.

Turning to the Evidence

Both Jan and Healthy Families Durham had become well known in the area, and Tomeika Watson, who was finishing a position in school violence prevention at UNC School of Social Work, knew that CCFH was where she wanted to be next. A Smart Start grant expanded HFD’s capacity to serve families, opening up a new position for a family support worker in 2003, and Tomeika came on board. Eighteen years later, she leads Healthy Families Durham as its Program Manager.

“Over the course of the first couple months that I was here, even though people were from all different backgrounds – psychologists, psychiatrists, the medical team – everyone made you feel welcome,” Tomeika says, reflecting on her first impressions of CCFH. “Those relationships with people are part of why I continue today.”

Relationships within the center and across the field of child traumatic stress strengthened, as did CCFH’s drive to bring evidence-based treatment to children. The close connections to experts who were developing evidence-based treatments increased the understanding and motivation of the CCFH staff to put these treatments into practice here in Durham. That, in turn, strengthened the application for CCFH’s first grant from the National Child Traumatic Stress Network (NCTSN) in 2001. As Lisa Amaya-Jackson notes, this was the time when treatments were coalescing into manuals and being disseminated across the country.

“Getting an NCTSN grant meant that what was starting to happen nationally was coming to our own backyard,” she says. “The people that we were reading in the textbooks were now people we were talking to and thinking through what was the best [course for treatment].” For instance, Esther Deblinger, another co-developer of Trauma-Focused Cognitive Behavioral Therapy, was the first guest speaker in CCFH’s didactic lecture series.

The shift to following evidence-based trauma treatment models with fidelity would be a major turning point for the health of the children who came to CCFH, and later, for children throughout North Carolina. At the time, it was normal for children who had experienced trauma to stay in therapy for their entire childhood, but leaders in the field of child traumatic stress were beginning to demonstrate that evidence-based treatments, provided with fidelity to the model, resulted in a reduction of trauma symptoms that lasted. Children could get better and stay better.

This approach met some resistance from clinicians accustomed to weaving different treatment strategies together in their own way, but leaders at CCFH and in the field more broadly saw that using evidence-based treatment models with fidelity was the way to sustain healing in children. When CCFH was awarded NCTSN funding to become a Community Treatment and Services Center in 2003, its commitment to evidence-based treatment became official.

A Vision to Teach

That same year, George “Tripp” Ake joined the center staff on its first grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), working with Ernestine Briggs-King on research data and providing clinical services. He remembers how exciting a place it was to be, where professionals were constantly engaging with kids and there was so much to learn.

“I was so struck by this really difficult topic and how passionate and positive people were about being there and doing this work,” he says. “It introduced me to talking with families right after they learned about a disclosure [of abuse] and gave me a lot of skill in what it’s like being in the room with families that are struggling with something really difficult right then.”

In 2004, the center welcomed Robert Murphy as its new Executive Director. Coming from the Yale Child Study Center, he was drawn to the role because of how the community and university intersected at CCFH.

“That kind of mixture can be messy, but it’s creative and it’s fun – a never finished, never boring sort of place,” he reflects. He also recognized that, even eight years after its launch, there still was not anywhere else quite like CCFH.

Robert’s vision for CCFH’s growth centered on the expansion of training and disseminating evidence-based, trauma-informed practices. At the time, the center was primarily focused on providing direct services to the community through mental health treatment and family support programs, but Robert could see how the number of children receiving effective care could be exponentially increased by training other clinicians to use the evidence-based models the center was practicing and gaining real world experience in implementing. Tripp Ake remembers Robert applying for ten or more grants in his first year at CCFH in pursuit of this expansion.

“CCFH was doing amazing clinical work, amazing treatment,” Robert says. “It became pretty obvious that we had this tremendous opportunity to grow the workforce [and] the quality of the system serving kids. I thought that was the leading edge of where we could grow and expand our expertise.”

There was great energy throughout the center around this idea of training other clinicians to provide effective trauma treatment within their own communities, and in 2005, a group of CCFH staff embarked on their first project: teaching Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to clinicians in the Department of Behavioral Health for Washington, DC.

“I remember us all being incredibly excited about the opportunity,” says Robert, “both because we could put what we knew into action, but also because of how much it challenged us to recognize what we didn’t know.”

And so, the enthusiastic young CCFH staff piled together in a van and traveled to Washington every few months over the next year to transform how mental healthcare was provided to traumatized children. This first project was the beginning of today’s Training Services department at CCFH as well as the North Carolina Child Treatment Program (NC CTP), which Lisa Amaya-Jackson, Dana Hagele, and Rebecca Socolar would co-found in 2006.

With new grants making room for programs to launch or expand, CCFH moved in 2006 from its first home on Westgate Drive to a new location inside the NC Mutual Building in downtown Durham. The Clinic welcomed families on the ninth floor, with the rest of the staff on the floor above.

For Donna Newberne, who came on in 2005 with the Durham Family Initiative and now serves as the Mental Health Clinic Director and Clinical Faculty, the new space mirrored the high quality of the mental health treatment available at CCFH.

“Our clinical spaces [at the Mutual building] were more conducive to doing the work,” she says. “We had better facilities to deliver really good services, making our services that much more enhanced. I think it was more welcoming, too. It felt more like a clinic, which helped amplify what we were doing.”

Pictured below; Jan Williams in her NC Mutual Building office. Tomeika Watson (right) and a colleague meet among boxes of home visiting supplies making the move from Westgate Drive to downtown Durham. Donna Newberne from her office in the NC Mutual Building, where CCFH moved in 2006 as programs and staff grew.

Perfect Storms

Entering its second decade, CCFH had a new home that provided room to grow, and it was settling into a clearer sense of its identity and structure as an organization. It had well-established clinical services and a home-based prevention program, as well as the beginnings of strategic efforts to train other agencies in the models and practices that were proving so transformative here in Durham. These inter-related strategies – treatment, prevention, training – had brought to life the founding vision of a comprehensive approach to addressing child abuse and neglect. This work was far from complete, though, and the decade ahead would bring even more innovation and growth.

The year that CCFH moved into the NC Mutual Building, a pilot program began at UNC-Chapel Hill that would also be transformative both for CCFH and North Carolina as a whole. Dana Hagele had been part of the Duke and UNC teams doing forensic interviews and medical evaluations in the CCFH clinic in its early days. When those functions were absorbed back into the individual health systems, Dana left CCFH, but she took with her a deep sense of the great need throughout the state for mental healthcare for children who had experienced abuse. She also stayed in contact with Lisa Amaya-Jackson, and together – along with Rebecca Socolar, a child abuse pediatrician at UNC – they conceived of a plan that would improve referral and reimbursement pathways to increase access to trauma-informed care statewide. Early on, though, they discovered how few clinicians were trained to provide effective treatments like TF-CBT. So, they revised the strategy to focus on training the mental health workforce through statewide dissemination of evidence-based treatments.

With funding from The Duke Endowment, the Kate B. Reynolds Charitable Trust, the NC Division of Mental Health, Developmental Disabilities, and Substance Abuse, and the Governor’s Crime Commission, they piloted the NC Child Treatment Program in 28 counties in the northeastern part of the state, demonstrating that, with the right training, community clinicians could provide trauma-focused treatment with very good outcomes. In 2009, they expanded their scope to 90 counties, but the program was becoming less of a fit with its administrative home at UNC. It was, however, an excellent fit with CCFH’s emerging identity as a clinical provider with the capacity to train other clinicians. So, in 2010, CCFH became the new administrative home for NC CTP.

“It was a perfect storm of everything going right,” Dana says. “We had this small group of Duke faculty working at CCFH who were experts in the clinical models and training coming together with the statewide infrastructure we had built at UNC for dissemination and implementation at a time when people were realizing that evidence-based treatment models could be taught outside of graduate school. It was a huge wave.”

On the strength of its early accomplishments and its potential to transform mental healthcare for children who had experienced trauma, NC CTP secured an annual recurring appropriation from the NC General Assembly in 2013, expanding its reach to all 100 counties. Today, NC CTP enrolls 150 to 200 new clinicians each year, teaching five different evidence-based treatment models for child traumatic stress and related diagnoses, and its online roster of those who have successfully completed the rigorous training requirements shows qualified providers serving every county in North Carolina.

It was during this same period that the Durham Family Initiative – the partnership between CCFH and the Duke Center for Child & Family Policy (CCFP) that began in 2002 – also launched a pilot program that would become transformative for CCFH and in a much wider scope. The DFI research team, led by Kenneth Dodge and Karen O’Donnell (and later Robert Murphy when he joined CCFH in 2004), had examined home visiting programs from all over the world in search of a highly effective model for preventing child maltreatment in Durham. From this, they believed the best approach would be a universal model, an intervention that would support all families, regardless of their circumstances or risk factors. With funding from The Duke Endowment, they developed a plan to launch and evaluate a neonatal nurse home visiting program, initially called Durham Connects, that would reach 70 percent of Durham newborns each year once fully implemented.

A randomized controlled trial was built into the program model to generate strong evidence about the program’s impact, not only on child maltreatment, but on a full range of indicators for family and child well-being. From July 2009 through December 2010, all 4,777 residential births in Durham County at Duke Hospital and Duke Regional were randomly assigned according to birth date to receive either a nurse home visit or the usual neonatal services. The research team then compared the two groups at six-month milestones across a range of indicators of child and family well-being. The results were remarkable. At six months of infant age, mothers who had received home visits reported less anxiety and more positive parenting behaviors. Observers noted better parenting behaviors, safer home environments, higher quality child care choices, and more utilization of community services and resources. At twelve months of infant age, families with a nurse home visit had 50 percent fewer visits to the emergency room and hospitalizations than families who did not receive the service.

These findings were published in academic journals, which began to generate interest in reproducing Durham’s nurse home visiting model – rechristened Family Connects – in other communities. CCFH soon welcomed a team from Greensboro to shadow our nurses and learn the model for implementation in their community. Teams from other communities quickly followed, and interest grew to the point that CCFH and CCFP established a joint initiative called Family Connects International to promote and manage training and dissemination of the model.

Since that first pilot cohort, the CCFH program – now known as Family Connects Durham – has provided nurse home visits to nearly 20,000 families, and there are other sites offering the Family Connects program in 13 states.

EXPANDING HORIZONS

Family Connects and NC CTP were not the only significant expansions of CCFH’s work during its second decade. In 2005, the NC Child Response Initiative created what would become a very successful and much-loved partnership with the Durham Police Department. For eight years, CCFH worked with officers, teaching them to recognize and respond to the needs of traumatized children they encountered in the course of their work. In 2009, CCFH became the provider of home-based services for Durham Early Head Start, increasing the number of at-risk families it could serve through its prevention programs. That same year, CCFH began a project with the NC Division of Social Services and nine counties to design and implement trauma-informed practices for the unique challenges faced by child welfare workers. The cornerstone of this initiative – known as Project Broadcast – was a simple but effective assessment tool that enabled child welfare workers to identify signs of trauma in children entering foster care. Over 19,000 children were screened for trauma during the five-year pilot project. This work continues today in CCFH’s Trauma-Informed Communities Project, which supports counties in creating comprehensive trauma-informed systems of care for children, encompassing but not limited to child welfare services. And in 2011, CCFH became the provider of Post Adoption Support Services for a 20-county region in the center of the state, bringing trauma-informed services and support to families adopting children, especially those coming from adverse circumstances.

In 2015, on the doorstep of its 20th anniversary, CCFH moved to new offices at Kent Corner, a neighborhood revitalization effort by Duke University, Self-Help, and the City of Durham. CCFH was the first tenant to commit to the brand new 35,000 square foot office building, and it was able to design the layout of its first floor suite to match the needs of its many distinct programs. Once again, the whole CCFH team – now approaching 80 staff – were all in one suite, restoring the rich interaction that had been such an important part of its early years. And the clinic – now named the Martha S. Urbaniak Clinic for Children & Families – was placed at the very front of the suite, a reminder that providing the highest quality, compassionate care for traumatized children is where all of CCFH’s work and mission began.

Pictured below: A Durham family receives a Family Connects nurse home visit. The ribbon-cutting ceremony at CCFH’s current location at Kent Corner in 2015.

The Next 25 Years

Today, CCFH’s five treatment and prevention programs annually reach more than 2,000 children and families in Durham and surrounding communities. With training and dissemination efforts that span both the state and country, last year nearly 3,700 child-serving professionals learned trauma-informed practices with CCFH. On average, an estimated 8,000 children receive Trauma-Focused Cognitive Behavioral Therapy from a CCFH-trained clinician in North Carolina each year.

And CCFH continues striving to identify families’ needs and find opportunities to meet them. In the trauma treatment and training realms, this has meant adding new evidence-based treatment models for children and teens with problematic sexual behavior. In the prevention arena, a federally-funded initiative called the READY Project is fostering healthy development and wellness for Durham County children age 0 to 8. And across all of its work, CCFH is seeking to incorporate a racial equity lens to address the impact of systemic racism within our programs, our practices, and ourselves.

As the Center for Child & Family Health looks to the next 25 years, it strives to stay grounded in the spirit of exploration, learning, and transformation that infused its founding. Practices cannot be truly evidence-based unless they are informed by the complex and nuanced experiences of the children, families, and community partners they are meant to serve, and there is as much to learn from the communities where we work as there is from academic research.

Kelly Sullivan began at CCFH as a postdoctoral fellow in 2006, and today is the Director of Mental Health Services. She has been part of the organization’s remarkable growth and maturity. Still, she says, “I think the future is in humility.” She notes that CCFH cannot approach its work with a finished mindset. “I actually see us holding the hands of our community, our clients, and our co-workers. We’re trying to keep this link going and everybody in that link is really, really important.”

CCFH’s Director of Early Childhood Prevention Programs, Karen Appleyard Carmody, echoes this vision for the future.

“We learn how to be humble, share power, and take our lead from the families and communities with whom we work,” she says, “not assuming that we have all the answers and don’t need to modify our own work.”

The root of CCFH’s humility and its drive to keep learning is found in following the real-life needs of families who are vulnerable and of children who have experienced trauma. And with great passion, care, and openness to what others have to teach, CCFH’s team of therapists, social workers, home visitors, nurses, faculty, and staff will continue pursuing the vision that has compelled our work for the last 25 years: every child loved, nurtured, and safe.