Almost 700,000 U.S. children are abused each year. Many more children are traumatized by bullying, crime, domestic violence, food insecurity or a family member with untreated mental health or substance use issues.
Traumatic experiences in childhood can have long-term consequences for mental and physical health. Adults with a history of trauma exposure are more likely to develop depression, PTSD, substance abuse and antisocial behaviors. They are also more likely to smoke and attempt suicide, among the leading causes of death.
Good evidence-based treatment is available for trauma. However, only about a third of traumatized children ever come into contact with a mental health provider.
"So if we could figure out how to meet the [mental health] needs of families in pediatric primary care, we might be tapping into a very underserved population.” -- Dr. Rochelle Hanson
In contrast, pediatricians see 90% of all kids in well-child visits, but as few as one in 10 screens for post-traumatic stress. That’s a huge missed opportunity, according to MUSC clinical psychologist Rochelle F. Hanson, Ph.D., of the National Crime Victims Research and Treatment Center at MUSC.
“What we know from research is that families are much more likely to see a primary care provider than a mental health professional,” said Hanson. “They're unlikely to seek mental health services because of stigma and other issues. So if we could figure out how to meet the needs of families in pediatric primary care, we might be tapping into a very underserved population.”
With team science pilot project funding from the South Carolina Clinical & Translational Research (SCTR) Institute, Hanson teamed up with pediatrician Elizabeth M. Wallis, M.D., to study whether trauma training and a simplified screening process would improve pediatric residents’ ability to recognize children with trauma and refer them for specialty care.
“There’s a national push for primary care clinicians to better assess and treat mental health conditions in children, but many pediatricians aren’t trained to do so,” said Wallis. “We have such a resource in the National Crime Victims Center; it’s a real opportunity for us to improve care for children and families, as well as the training of our resident physicians.”
Thirty-three residents received two hours of training, including instruction on how to perform a simplified three-question trauma screening. Residents who received training were more open to implementing trauma-informed care and did in fact complete significantly more screens (8% versus zero). However, they did not increase their referral of children who screened positive for psychiatric services. These results were published in the October issue of Clinical Pediatrics.
“Our data showed that some of the barriers they still faced after the training were time constraints and still feeling a little bit unsure if it was in the scope of their practice as a pediatrician,” said Aubrey R. Dueweke, Ph.D., first author of the study. Dueweke had significant training and experience in integrating behavioral health into primary care at the University of Arkansas at Fayetteville before coming to MUSC.
“But probably the biggest issue was that they didn't know what to do if they found out a child had been a victim of a crime or abuse because you can't just ignore it,” said Hanson. “And so they were frustrated because then they wouldn't know what kind of resources were available and how to do a good referral.”
To address those barriers, Hanson and Wallis received Victims of Crime Act (VOCA) funding that enabled them to hire personnel to provide services directly to traumatized children in the pediatric primary care setting. With case manager Emily Fanguy and therapist Carla Newman now on board, pediatricians can easily refer children who screen positive for trauma for a brief consultation. Fanguy assesses the mental and physical needs of the children and helps to connect them to services when needed. Newman provides evidence-based mental health treatment either in clinic or out in the community.
“Because of that VOCA grant, we're also able to provide services in the community so the therapist can go to schools, homes, churches, restaurants, libraries or wherever she needs to meet them,” said Hanson.
“We care for many vulnerable patients and families and, for many of them, accessing mental health care in a traditional sense is nearly impossible,” said Wallis. “That has multiple ramifications down the line when a child or family has an untreated mental health problem. With the VOCA funding, we’re able to make it a little easier for some families to access the care they need, and our primary care clinicians are able to see the benefit of mental health care on their patients.”
To integrate behavioral health further into the pediatric clinic, Wallis and Daniel W. Smith, Ph.D., co-director of the Charleston Consortium Psychology Internship program and professor at the NCVC, Department of Psychiatry and Behavioral Sciences, created a new pediatrics rotation for psychology interns with funds awarded from a Health Resources and Services Administration grant.
Hanson and Wallis supervise two half-time interns each semester to provide integrated behavioral health care. If a child screens positive for trauma, the interns are available to provide an immediate behavioral health consult.
“And I think that that addresses one of the huge barriers the pediatric primary care residents had – that it was outside their realm of practice,” said Hanson. “The residents just love having someone that they can ask ‘Hey, can you tag in?’”
“This is exciting because these are relatively new providers in the medical field,” said Dueweke. “The hope would be that we can grow practitioners that are comfortable working within this integrated system.”
“My hope is that eventually the idea of behavioral health care not being integrated and coordinated sounds foreign to us rather than the opposite.” -- Dr. Elizabeth Wallis
With funding from the SCTR discovery pilot project program, Hanson and Wallis want to go even one step further in identifying children who have been exposed to trauma. They are partnering with Chief Research Information Officer Leslie Lenert, M.D., MS; bioinformatician Vivienne Zhu, M.D., MS; and pediatric radiologist and bioinformatician Morgan Mcbee, M.D. Zhu and Lenert recently received funding to develop and evaluate a natural language processing tool to help to identify emergency room patients who are victims of intimate partner violence. The tool does so by summarizing clues in the clinical notes in the electronic health record. Those artificial intelligence strategies can now be applied to identify children who are or have been victims of abuse. They could one day help pediatricians identify which patients to refer for trauma-informed care.
“My dream would be that one day when a child came in for just his or her well-check visit, an alert would pop up that this is a kid at risk,” said Hanson. “Pediatricians would then be sure that they’re safe or have referrals to access care. So there really is a big picture to me where all of these efforts come together.”
Wallis agreed. “The more support we can provide to primary care in assessing and treating mental health concerns and accessing care, the easier we make it for families to get the support they need,” she said. “My hope is that eventually the idea of behavioral health care not being integrated and coordinated sounds foreign to us rather than the opposite.”