Why Minds Matter

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When she was 8 years old, Princess Carr began to throw herself down the stairs at school. She wanted someone to notice her. Some people did. Classmates called her crazy. Teachers put their arms around her and soothed her. But for years, no one did much more than that.

At home, Princess’ mother abused her. She’d beat her until her nose bled, then lock her in a closet for hours, blood pooling in her hand. If Princess tried to come out, her mother would beat her again. Other times, Princess’ mother beat her with a baseball bat, breaking her thumbs once. On their way to the hospital emergency room, her mother coached her to say that she’d been playing with the bat with her brother and he’d hit her. Princess lied every time.

“I wanted them to take me,” says Princess, now 22, a chatty and thoughtful young woman, with a broad, bemused smile and rolling laugh. (For three years, she has been a writer for the magazine Foster Care Youth United, where I am an editor.) “But I was my brothers’ protector. If they took them away, I couldn’t protect them, and I couldn’t deal with that.”

Some nights, Princess protected her mother. Her mother’s boyfriend would beat her, and Princess would find her mother curled on the floor. Her mom would lean her head against Princess’ shoulder and ask, “Why? Why is this happening to me?” Even as a child, Princess could never understand how her mother could be beat so bad and still do the same thing to her.

Princess loved school. She loved to read and write, loved her teachers, and signed up for every after-school activity because she was afraid to go home. Princess was a teacher’s pet. She was smart and docile. “I was the little girl, skinny, with pigtails and the shabby clothes and big glasses, the one always with her head faced to the floor, and who didn’t talk until you spoke to her.”

But she began to crack as she got older, banging her head on the floor, running up and down the halls so she could spend all day with her “friends,” the dean and the principal, instead of boring classes where she got beat down by other kids. By junior high, she’d started fighting back when people picked on her. She began cutting school to go to the library, where she could read to rest her mind. And she’d started to fear she could not handle the beatings much longer. “I honestly felt that eventually she would wind up killing me, or I would end up killing her,” Princess says.

By the time she was 13, Princess had learned the lesson that no adult was going to listen or help. So she began running away for weeks and months at a time, sleeping on the street and in train cars, prostituting in Coney Island for money.

Often, she dropped by The Door, a youth center in Soho, for therapy and for every program the place offered. Oddly enough, it was her mother who’d read about The Door and sent her there, saying Princess needed to stop cutting school and do something with her life. By then, Princess already knew she was gay, and her first impression of The Door was that her counselor was gorgeous and there was a bunch of gay people there. “I thought, ‘Oh, yes. Mommy doesn’t even know what she has done,'” she says, laughing.

One night in winter, when Princess was about 14, she was riding the train alone, asleep. A man came over, took her hand, peeled off her glove, and put her hand in his pants without saying a word. No one else was in the car but a drunk man. When the train pulled into a station, the man said to Princess, “Come on, we’re getting off the train.” She was so scared, she went. He took her to a building somewhere, in some borough, and raped her in the stairwell. Then he fell asleep. She tried to pull her coat from under him, then ran down the stairs as he chased her.

At the train station, Princess was standing in front of the turnstiles, crying, when the first of two angels appeared. A man walked up and said, “Don’t,” then handed her a token. On the train, a young woman came and sat down next to her. “Do you want to come home with me?” she asked. She brought Princess to an apartment filled with children, laid her down in a bunk bed, rubbed her back and let her fall asleep. In the morning she asked, “Where do you want to go?” “The Door,” Princess said. The woman dropped her off at 9, and Princess got a medical exam, spoke to her counselor, then walked around the corner to Laight Street, the first stop for kids placed in foster care. She asked the Administration for Children’s Services (ACS) to find her a home.

In foster care, Princess finally got help. She spent more than a year in psychiatric hospitals, mostly because she asked to be hospitalized and then refused to leave. She got sent to a therapist, her thick file growing with each new visit. But though she’d been trying her whole life to get someone to listen, Princess stonewalled almost every psychiatrist she was sent to.

On her own, though, she kept going to The Door. There, her counselor was very different. She asked questions; she listened; she spoke to Princess like a friend. She gave her coloring books and cigarettes, even though she did not approve of cigarettes–anything that helped Princess to feel like she wasn’t crazy. She did not sit in silence, expecting Princess to talk. She did not read a case file first, forming her impressions before she’d heard even a word from Princess herself, or insist on medicating her, even though the medication gave Princess a heavy feeling that scared her. “I’m very animated, and the medication stifled that,” Princess says. “I’ve learned that it’s one thing to be loud and afraid, it’s another thing to not be able to speak and be afraid. I was like that for a very long time as a child. And I can’t go back to that.”

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When the World Trade Center came crashing down, New Yorkers learned how it feels to cower in fear, to lose in a flash their sense of safety, or to mourn a sudden, unpredictable loss.

New Yorkers, and Americans across the country, also knew that these fears and losses demanded an outpouring of support. Cadres of counselors made their way into schools, hospitals, churches–anywhere that people gathered in grief. Beyond treating the distressed, they also trained parents and teachers to recognize and respond to trauma. These are admirable responses to a disaster.

But September 11 also exposed just how traumatized many teenagers, in particular, really are, and the woeful inadequacy of the systems they’re supposed to turn to for support.

Last year, in an effort to assess the impact of 9/11, the New York City Department of Education surveyed 4th- through 12th-graders. It found that 75,000 kids were suffering symptoms of post-traumatic stress disorder because of the attack. More disturbingly, however, the study concluded that 190,000 students have mental health problems that require treatment. A majority of students in the public schools had experienced traumatic events prior to September 11. Nearly two-thirds of all students reported being exposed to violence in their communities or families. Of all students, 39 percent had seen someone killed or seriously injured, 29 percent had seen the violent or accidental death of a close friend, and 27 percent had witnessed the violent or accidental death of a family member.

Experiencing intense or repeated violence can give young people the feeling that life is precarious, unpredictable, violent and chaotic. Growing up with that view–and little control over what happens to you–is a recipe for anxiety and depression. “9/11 has given people who had never been traumatized a glimmering of an understanding of what it feels like to feel unsafe all the time,” says Marylene Cloitre, director of the Child Trauma Project at the New York University Child Study Center.

Teens are particularly at risk of viewing themselves and the world more darkly after experiencing trauma, Cloitre says. Depressed teens are disinclined to talk about their feelings, and prone to act on them. And so they’re viewed as troublemakers, not kids in trouble.

Parents and teachers see kids every day, and they’re the most likely people to recognize that a teen acting out of control or deeply withdrawn needs help. But teachers with more than 30 students in each class and counselors juggling hundreds of kids usually have little time to provide even the most basic referrals to services.

Poor parents, meanwhile, overwhelmed by their teens’ behavior and stressed by the burdens of poverty, often respond harshly when their kids begin to act out. That exacerbates the problem, says Susan Saegert, Director of the Center for Human Environments at CUNY, who has studied the relationship between harsh parenting and community violence. Says Saegert, “Many of the families we visited were severely overburdened, and they would ask the grad students, ‘Can you be my child’s psychologist?'”

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People who elect to pay for private therapy know just how valuable it can be. Though it can easily cost thousands of dollars, wealthy Americans shell out the money because they believe the treatment is worth it. Adults making more than $61,000 a year get mental health treatment more than three times as often as those making less than $15,000.

The treatment gulf between rich and poor hasn’t gone unnoticed. Nor have its consequences. In the last decade, federal and state governments have begun to act on a growing body of research showing that kids who grow up with violence are much more likely to become perpetrators–and that certain therapeutic interventions do temper the effects of trauma. “If you can, imagine growing up in an environment where the people who care about you are also threatening and abusive, where in order to survive you need to be aggressive, fight back,” says Robert Franks, director of operations at the National Center for Children Exposed to Violence at the Yale Child Study Center. “Children see that violent people are the ones in power and in control, so over time they take on those qualities and those ways of functioning.”

Effective programs help adolescents recognize that what’s adaptive in a violent neighborhood is not healthy in the outside world. Techniques like cognitive-behavioral therapy help teens understand how trauma has affected them, and it also teaches them behaviors that help them cope.

But if there’s one reason government officials across the country have begun to pay serious attention to trauma and its consequences, it’s because of their own worst nightmare: deep budget deficits. When kids don’t get mental health services, they’re finding, states are paying the price. A June 2002 report to the National Conference of State Legislatures documents the low number of kids getting early intervention, and links it to the incredibly high cost of hospitalizations, intensive case management services and foster care placements that states end up paying for.

New York is typical: Most kids only get help once they’re in crisis. Fewer than half of youth who end up in residential treatment centers–at a cost to the state of nearly $150 each day–had ever been seen in a public mental health clinic. The same is true for kids in state psychiatric hospitals.

But one elected official who seems to understand that treating trauma is an essential investment is New York mayor Michael Bloomberg. As part of his school reform plan, Mayor Bloomberg has unveiled a $60 million initiative to forge partnerships between the Department of Education and the city’s Department of Health and Mental Hygiene, with the goal of making sure that students who need help get treated in their schools and communities. Chancellor Joel Klein calls the effort “critical to ensuring student success in the classroom.”

But what Bloomberg can’t do is increase the capacity of publicly funded clinics to adequately serve poor kids. Since 1995, the Pataki administration has put strict limits on Medicaid spending on mental health. [See “The Clinic Crunch,” below.] One result is that most mental health clinics in New York City that treat children and adolescents insured by Medicaid are seriously underfunded and do not provide the treatments that have been proven effective. The clinics, run by private nonprofits licensed by the State Office of Mental Health, have waiting lists up to six months long. They are typically staffed by inexperienced and overwhelmed therapists. They have staff turnover rates of up to 50 percent a year, according to the Coalition of Voluntary Mental Health Agencies.

And with the exception of a few programs that specialize in treating teens, the clinics usually provide therapy that’s designed for adults. Their results are not good. According to a 2001 report for ACS, only 20 percent of case reviews showed that youth in foster care improved under the care of clinics.

Treatment of trauma is a relatively new field. It sprang out of work with combat veterans after the Vietnam War and with rape victims who came forward in the 1970s because of feminism. But effective, research-tested forms of therapy, typically lasting just 10 to 12 weeks and far more structured and focused than traditional psychodynamic therapy, are still cutting-edge. Few therapists at publicly funded clinics have had extensive training in techniques like cognitive-behavioral therapy, even though clinics are the mainstay of treatment for kids in foster care, who tend to have experienced severe traumas like physical or sexual abuse.

In the moments after 9/11, New York’s mental health providers found creative ways of dealing with trauma. Foundations funded innovative programs like an oral history project that helps kids in Chinatown talk about how 9/11 affected their community. Massive federal grants–the Project Liberty mental health outreach program alone cost $154.7 million–paid for social workers to provide crisis counseling in schools and at clinics. Safe Horizon taught teens how to conduct short workshops about the effects of trauma for other teens at their high schools.

But the money did not go toward creating lasting improvements in school or clinic mental health services. In fact, the program put together by the September 11 Fund and the Red Cross relies wholly on services purchased from private practitioners. Clients are free to choose any licensed therapist, to go for as long as needed, and to be reimbursed generously enough so they can afford to go. By any measure, it’s an ideal scenario for successful mental health treatment.

But for poor New Yorkers who did not lose a family member or a job on 9/11, or who live far from Ground Zero and work far from downtown, if they work at all, mental health care remains in the dark ages. A treatment that has proven power to help people achieve control over their lives remains out of reach of those who arguably have the most to gain from it. Even when poor people can get care, it is vastly inferior to the therapy wealthier New Yorkers choose every day to pay for themselves.

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The grace and heft of each piece of furniture in Elizabeth Kandall’s spare office, the milky white walls and the gray sunlight reaching through the windows project stability and calm. Kandall believes the ambience of a therapist’s office is important. Patients appreciate an office, and by extension a therapist, that seems under control. Kandall is the New York director of the Children’s Psychotherapy Project. It’s a program that matches private practice therapists with foster youth, whom they agree to treat, for free, for as long as it takes. Like Princess, kids in foster care tend to suffer the most extreme trauma. Even so, foster youth usually are treated at publicly funded clinics, by the most inexperienced of therapists.

After graduate school, Kandall took a year-long internship at a well-run but somewhat chaotic community clinic. Almost every child in her caseload was in foster care. Despite caring supervision, she felt unprepared to handle what the children told her. The office space itself did not help. One day, a patient’s favorite chair would be gone, and no one could find it. Toys for play therapy inevitably had missing parts. “It was, ‘We have these pieces, but not the board,’ just a mishmash of parts without much attention paid to them, which is such an awful replica of the disjuncture in their lives,” says Kandall, sitting in a wide, floral-patterned chair with her feet drawn up under her, her small hands still in her lap, a single gold chain looping across the neckline of her white sweater.

The unpredictability of the clinic mirrored Kandall’s own insecure status there. Even as she tried to form trustworthy relationships with her patients, she felt that the relationship she was offering was a lie. At the end of the year, her internship would end, and the pay would be too low to tempt her to stay. At best, her young charges would see a string of caring but unseasoned clinicians. Older and more skilled therapists tend to make their way into private practice, where they can double their salaries while seeing less challenging patients.

Because clinics pay so poorly, and demand so much of their staffs, it’s easy for even the most determined clinicians to become desensitized to the experiences their clients describe–experiences too horrific and alien for a therapist to let herself imagine. Private therapists usually take a range of cases; a tolerable load might consist of one high-conflict divorce, several people who feel stuck in their lives, and one patient suffering intense depression. Clinic workers see a lot of that last category. For them, doing effective work in treating patients is “not a matter of becoming clinically better,” explains Kandall. “Even experienced people need to be reminded of things they can’t imagine. It’s too much to take in.”

That frozenness can reveal itself in many ways. Mel Schneiderman, director of psychiatry at New York Foundling, a private foster care agency, recalls interviewing candidates for the position of a social work supervisor. One woman came from a major clinic and had been assigned to the special foster care division there. Schneiderman asked her to describe a case and her treatment goals. The woman described a kid who had been physically and sexually abused, and said her primary treatment goal was improving the child’s hygiene. “Why hygiene?” Schneiderman asked. “Because that’s affecting her relationships,” the woman told him. “What are your goals for most kids?” he asked. She said, “Hygiene.”

“Does this reflect the clinicians out there?” Schneiderman asks rhetorically. Still, he understands the impulse–find one small, attainable goal and focus on it. “These kids have profound separation and loss issues,” he says. “It’s difficult.”

When they flee the clinics, therapists usually leave the neediest cases behind, too. But when she moved into private practice, Elizabeth Kandall wanted to find a way to keep working with poor young people. So when she heard about the Children’s Psychotherapy Project in San Francisco, started by Toni Heinemann in 1995, she believed she’d found an answer. In New York, Kandall set up a branch of the project three years ago. Seventeen volunteer private therapists work with one patient each, and gather weekly in consultation groups to discuss their cases, because even for experienced professionals, the tremendous pain and need and posturing of foster youth can be too much to bear alone.

“We’re trying to provide something really different–we’re trying to give kids in foster care the really good stuff, the really senior therapists, the kind of therapists my friends or I would like to go to, and a relationship that’s available as long as they want it, in spaces where things are cared for, continuous and harmonious,” Kandall says. She thinks often about the chronic strangeness of life for foster youth. So much of most children’s experience is sameness–same bed every night, same bed every morning, same person who says similar things to you every day. She’s tried to imagine herself as a little person, wondering: Who is this person? Where’s my mom? It smells really weird here. Where’s my bed? They don’t make eggs the same way. “A child usually incorporates strange things into a fabric that’s known,” Kandall says. If nothing else in a child’s life can stay the same, she hopes therapy, at least, can provide that constant.

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The physical boundaries enclosing Red Hook–water on three sides, and the Brooklyn-Queens Expressway cutting overhead along the other–can seem impenetrable. Manhattan pulses in clear view across the river, but the ties of family and poverty have held teenagers within this neighborhood for generations. Along the river, factories and empty lots blot out the shore. In winter, the dim streets stay nearly empty all day. The quiet can feel by turns calm and discomfiting.

Millie Henriquez-McArdle, of the South Brooklyn Community High School on Conover Street, grew up here and has been working with young people in Red Hook for long enough to sense its currents. The peak of Red Hook’s violence has passed, but teens in the neighborhood have not forgotten years of dropping to the floor at the sound of gunshots. Drug dealing, domestic violence and deep poverty are still rampant in the projects.

The Community High School serves troubled youth–it’s a “second chance” school for kids who’ve dropped out elsewhere–and teachers there believe that anxiety and depression are at the root of many students’ difficulties in school. At one point, three students were suffering from alopecia, a condition in which high levels of stress cause bald patches on the body. “That’s pretty serious,” Henriquez-McArdle says. “All the things happening in their lives they have no control over. The financial situation in the home, being raised by themselves or grandparents, their parents are HIV-positive or have substance- or alcohol-abuse problems–you name it, these kids are out there dealing with it. They’re young and they do not have the experience, insight or the real understanding that it’s not their fault.”

Unfortunately, there’s nowhere good for seriously distressed teens to get help. The school shares the same building with the preventive services program of Good Shepherd, a foster care agency, but older youth, ages 16 to 20, are not eligible for preventive services. There are no mental health clinics in Red Hook; places nearby have long waiting lists.

And Henriquez-McArdle does not believe adult-oriented community clinics are appropriate for teens, anyway. “We have sent kids to clinics and a lot of times kids come back and say, ‘I’ll sit there and they ask me a question, they don’t say anything, but want me to talk.’ It’s very hard for them,” Henriquez-McArdle says. “They walk out of there and they’ve stirred up a lot of stuff but they’re not feeling empowered in any way.”

The Community High School uses a very different approach. School counselors talk to young people about what’s causing their anxiety or depression. They also help the teens to identify their own strengths. Then they talk about how teens can use their strengths to take control of their own lives. The strategy helps them cope with things they can’t change, like a parent’s illness or violence in the streets, and to find ways to change the things they can. This kind of counseling cuts down on the despair and defeatism that turn so many kids toward using drugs, getting involved with gangs, or just hanging out at home watching television, avoiding reality.

Over the last five years, poor teenagers in Red Hook have had many new reasons to be stressed. Mothers leaving welfare for work often rely on their older children to take on the responsibilities of caring for younger kids. One study from the poverty policy research group MDRC found that welfare reform has improved life for working moms and their young children, but made life tougher on older youth. School performance among teens suffers, and those with younger siblings have the most problematic outcomes, because they typically have more caretaking responsibilities and less parental supervision than teens whose parents were on welfare but not working. Having a parent in a work program increased the rates of suspensions, expulsions and dropping out of school among teens with younger siblings.

As reform efforts have shown, many women on the rolls–as many as 50 percent in some studies–were suffering from depression, often stemming from untreated traumas like sexual abuse and domestic violence. When parents are depressed, the effect on children and teens can be disastrous. Children of depressed mothers are much more likely to have trouble functioning socially and academically. These kids tend to be either socially withdrawn and passive, or to be aggressive and act out, often switching between extremes because they can’t keep their emotions under control.

Susan McDonald is a guidance counselor at P.S. 15 in Red Hook. She oversees more than 400 kids. “We have a lot of students who are dealing with incredible sadness and shyness, or they’re acting out and running out of class,” she says. The school cannot afford to hire more guidance counselors. “So ‘guidance’ is the operative word–you have to guide them to services, to people who have the time and training to figure out what’s causing so much anxiety.”

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Luz Hernandez brought her daughter, Amanda, to therapy at Good Shepherd because she was desperate. In 5th grade at the time, Amanda was “a little terror.” It seemed like Amanda had been born angry. She fought with other kids, got suspended from school, refused to listen. Luz has raised eight kids–including two of her brothers after her mother died when Luz was 22, and the children of friends and cousins and neighbors who could not care for their own. One afternoon Amanda’s mother, who was addicted to drugs, brought 11-month-old Amanda to Luz’ Laundromat in Red Hook. “Can you watch Amanda?” her mother asked. Luz, who is 62 but looks to be in her forties, is a small, strong Puerto Rican woman with short black hair and tough demeanor. “Three hours,” Luz told her, pointing her finger sharply. “Three hours,” Amanda’s mother replied, but Amanda is now 18 and has been with Luz ever since.

Luz is fiercely protective of all the children she has cared for. But Luz did not feel she had the strength to keep fighting the battles Amanda waged against her and everyone else each day. So when a teacher at P.S. 15 suggested that Luz go to family counseling, she decided to go.

She ran into problems right away. First Luz tried Neighborhood Counseling in downtown Brooklyn, but she felt the therapist acted perfunctory and unenthusiastic. Luz did not trust talking to someone who saw her only as one case in a long line. Next she tried Heartshare. The therapist she met there seemed young and unsure of herself. Luz leaned forward and asked, “Are you new at this?” “Yes, I just started,” the woman told her. “No offense, but I want somebody who’s been already doing this a long time,” Luz replied. Then Luz tried Good Shepherd and spoke to a man named Rob. He seemed caring and thoughtful from the start. “It’s very hard for me to trust and open up,” says Luz, “but I told Rob, ‘I need someone like you.'”

In part it felt easier to trust Rob because he came recommended. Good Shepherd has built a reputation in Red Hook for supporting families in ways that go far beyond the reach of traditional therapy. Counselors act as advocates for the families they treat. They visit the children’s schools and talk with their teachers and guidance counselors. Rob helped Luz find a new school for her son who has a learning disability, tracked down a lawyer for her once and visited her family at home. That’s important to Luz. She works two jobs, cooking dinner between her shifts. “These people give the kids the attention we can’t,” she says.

Funded by ACS preventive services funds and private grants, Good Shepherd has a record that makes fragile families feel safe coming forward with their troubles: about 99 percent of the 423 children treated in 2000 remained with their families. Good Shepherd’s aggressive private fundraising also enables the agency to pay its social workers relatively high salaries. Their high-quality work has changed the shape of preventive services here. Nearly all of the 90 families receiving therapy at any given time have chosen to ask for help. That’s unusual. It happens because of the program’s close ties to families through the local elementary school, P.S. 15, where a Good Shepherd-run after-school Beacon program provides activities for kids and teens, too. Good Shepherd social workers on-site at the Beacon funnel families to the counseling program just three blocks away.

At first, Luz and Amanda went together. For about nine months, Amanda refused to say a word. “Do you want to say anything?” Rob would ask her. She’d sit with her arms folded across her chest and shake her head no. But Luz talked. She spoke about how much it scared her to feel so angry with Amanda that she’d hit her or yell at her or tell her harsh truths. She’d say to Amanda, “I don’t see nothing good for you. You gotta calm down that terror, or life won’t give you nothing.” She told Rob that she did not want to hurt Amanda, but she did not know how to get through to her in any other way.

Luz began to recognize that she had her own troubles, too. Luz had been raised hard by her mother and older brothers. She believed it was a sign of weakness to display emotion. But one day Luz told Rob, “I’ve got so many things inside me. I’ve had a lot of issues myself since I was a little girl. I’ve been afraid to bring them out, but I don’t want to take it out on the children. I don’t want to hit her.” Then Luz began to cry. “You want to talk about it?” Rob asked. Luz began to tell secrets she’d kept inside for years. Says Luz, “In my life, he’s the only person I’ve told the truth about my life.”

Eventually, Amanda began to open up, and she began individual counseling, because there were things she did not want to say in front of Luz. In therapy, Amanda learned to calm her temper. She began to improve in school. Most importantly, she and Luz learned a new way to speak to each other. Before, Luz says, “it was, ‘What the mother says is what you do.'” Luz had chafed at her mother’s authority growing up–she quit school on the sly, when it became too much to work nights at a factory and watch her brothers and go to school by day. And she rebelled against her brother’s advice to get a city job, though if she’d followed it, she could be close to retirement now.

Still, she knew no other way to raise a child. “Before, everything I had inside of me, I threw it at my kids,” Luz says. Now, things are different. “Now, we talk. And if I get angry, I say, ‘Forget it, I’ll talk to them later.’ My daughter will say, ‘Ma, I think you did this wrong.’ And I think about it, and I come back and apologize.”

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At a moment when spiraling Medicaid costs are helping send New York City and State into multibillion-dollar debt, it’s become likely that mental health services for the poor will receive not more funding, but brutal blows. The public has become more aware that people who suffer traumas can better cope with life if they get help. Public officials have acknowledged that better mental health intervention for children and teens can improve kid