A student arrives late to school each morning, downtrodden and listless. A girl can’t concentrate in class. Teachers deal with a boy’s daily emotional outbursts. A pediatrician is puzzled by a young patient’s dwindling appetite.…
A student arrives late to school each morning, downtrodden and listless. A girl can’t concentrate in class. Teachers deal with a boy’s daily emotional outbursts. A pediatrician is puzzled by a young patient’s dwindling appetite. Another child is tormented by anxiety and nightmares. The common denominator for all these kids could be trauma.
Poverty, violence, natural disasters or insecure housing may affect a child’s mental health. Growing evidence highlights the effects of toxic stress and long-lasting harm to kids exposed to abuse, neglect and dysfunctional households.
In response, trauma-informed clinics and schools, and other culturally aware programs, take a different approach to supporting kids. These are just some examples:
Baltimore Mental-Health Hub
The staff at the Harriet Lane Clinic strives to set a welcoming tone for families in the East Baltimore community. Clinicians enter the waiting room to invite kids back into the treatment area and ease the way for parents who may be apprehensive about seeking out mental health care.
For about a decade, Dr. Barry Solomon, interim chief of the division of general pediatrics and adolescent medicine at Johns Hopkins Children’s Center, has worked to incorporate mental health services into pediatric primary health care at the Harriet Lane Clinic, which serves a largely African-American population.
The effort to co-locate mental and primary health care is growing nationwide, says Solomon, an associate professor of pediatrics at the Johns Hopkins University School of Medicine. Access to mental health care also reaches children when they come in for routine medical care such as wellness visits or asthma checkups.
With pediatricians and mental health professionals working side by side, kids with mental health concerns are more likely to be identified and referred for treatment. That’s crucial because only a fraction of U.S. children — 20 percent or less — get treatment for common mental health and behavioral issues, Solomon says.
About one-quarter of Baltimore City residents live below the poverty line, encompassing nearly 35 percent of the city’s children. Within the core of the Harriet Lane Clinic, a dedicated team directly addresses social determinants of health affecting individual families.
Parents or patients fill out a simple brief form, asking if they need help in finding food, housing, health insurance, job resources or adult education; paying utility bills or applying for public benefits; locating child care, childproofing supplies like cabinet locks, clothing and diapers; or accessing legal resources or transportation to clinic appointments.
“There’s really no wrong-door approach to refer to us,” says Sarah Hill, program associate for Health Leads at the Harriet Lane Clinic. Health Leads is a national health care group that connects families to basic resources they need to get and stay healthy. At their convenience, families can visit the help desk, where volunteers such as Johns Hopkins premed students work with them to jump-start the process of locating essential resources. Advocating might mean reaching out to utilities and asking them to restore power in households where kids use nebulizers for asthma. By addressing concerns like these, Hill says, families can redirect their focus where it’s needed — on their children’s well-being.
Open-ended discussions with children and teens can uncover traumatic causes of behavioral and emotional problems. “It’s not necessarily asking, ‘Would you like access to mental health services? ‘” explains La Toya Mobley, a pediatric clinical social worker at the Harriet Lane Clinic. Rather, it’s posing questions like, “What is your experience at home?” to get at the heart of the matter.
“Trauma and ADHD mirror each other,” Mobley says. “So we’re asking more questions about trauma, especially with the increase in shootings and things like that.” Apparent symptoms of attention deficit hyperactivity disorder could actually stem from trauma. “Many times we find that a family member has been killed, or children don’t have enough to eat or they’re homeless,” she says. “Maybe that’s why they can’t sit still in school versus truly having a diagnosis of hyperactivity.”
Kids provide conversational cues. “I just hate school,” prompts Mobley to probe: “Are people picking on you? Are they being mean?” Eventually, she says, it comes out: “My cousin was killed and I don’t like walking down this specific street because I have to go down it to get to my school. When I get to school, I don’t like being there because I keep thinking about my cousin.”
Mobile mental health care is available for some patients, with providers traveling to the home when families agree and kids feel ready for treatment.
“I normally make a deal,” Mobley says. “How about we get mobile treatment to come out three times? You can call me and say, ‘Toya, I hate it,’ and they never have to come back again.” Most often, she says, kids meet the therapist and it works out well.
Mobley describes a long-time, adolescent patient who at different points experienced depression, issues with substance use and physical abuse. A mobile mental health unit went out to this patient while she was pregnant, and she was connected to services including the TurnAround program for victims of intimate partner violence and a work-study program at a community college. She has since graduated and left her abusive partner. She continues with therapy and feels confident taking care of her 2-year-old son.
The Harriet Lane clinic also offers a maternal mental health clinic, where mothers are screened and followed for depression on site. This convenient, holistic care alleviates unwarranted stigma adults may feel when coming to a mental health facility, Solomon says. Parents and children benefit alike, he adds: “If the mom’s not well, she’s going to have a hard time caring for that child.”
Empowering North Carolina Parents
An intervention to counteract “low activation,” or a low level of patient or family engagement or self-assertiveness in health care, has boosted involvement among parents with kids getting care at El Futuro, a bilingual mental health clinic serving Latino immigrant families in Durham, North Carolina.
“There was evidence that — out of deference for clinicians’ training — families were apt to be passive in discussions, taking suggestions [but] providing little feedback to clinicians about any concerns or questions,” says Kathleen Thomas, a senior research fellow in mental health services research at the University of North Carolina–Chapel Hill. “Also, the clinic experienced a lot of no-shows for appointments.”
In a study led by Thomas on the program to increase parental activation, nearly half of the children had been diagnosed with an adjustment disorder. According to the National Library of Medicine, adjustment disorders involve “a group of symptoms, such as stress, feeling sad or hopeless and physical symptoms that can occur after you go through a stressful life event.”
Key program components include emphasizing the important role of the parent acting as a partner in a child’s mental health care and practicing the skills to do so. Unfortunately, the current political climate could overshadow gains parents have made, says Thomas, who is also an adjunct associate professor in health policy and management.
“One example from our parent advisers is that, while they may feel engaged and self-confident at El Futuro, they have not followed up on suggested referrals to the larger health system out of concerns about payment and documentation requests,” Thomas says.
Schools with trauma-informed staff members — from teachers to cafeteria workers — may serve as places of learning and healing.
A Colorado-based consulting program called Resilient Futures expands on the work of the Healthy Environments and Response to Trauma in Schools program developed at the University of California–San Francisco. HEARTS grew out of the need to better serve the growing number of students with trauma.
In trauma-informed schools, every adult in the building who interacts with kids and families receives a basic level of training, says Laura McArthur, a clinical psychologist and executive director of Resilient Futures. More intensive training is geared to teachers and certain classrooms, making sure systems are in place to help struggling kids who are most impacted by trauma.
Students considered as behavioral challenges could be reacting to trauma. A student may talk about wanting to hurt him or herself, or others, McArthur says. It might be a kid who is becoming physically aggressive, or one who has just lost a family member and shows signs of depression.
Trauma outside the school affects the children within. It could be kids in immigrant families feeling pushed out of their communities, or a gun tragedy or death by suicide nearby, McArthur says. “Domestic violence, physical abuse or neglect, really extreme poverty — this kind of stuff is happening all the time to our kids.”
Behavior plans created from a trauma-informed perspective seek to promote healing, McArthur says. For instance, rolling out “peace corners” in classrooms gives kids a space where they can go to self-regulate. Stocked with supplies like Play-Doh and coloring books, these welcoming spaces help kids calm down if they’re angry, or feel better if they’re sad.
Students tend not to talk about issues troubling them outside school, McArthur says. Even so, having a safe place to be during the day can help them feel safe enough to focus and learn.
Clinic patients and families are reluctant to reveal their deep-rooted traumas, as well, Solomon says. First, he says, trust has to build: “These are hard issues to tackle. It’s not something that you meet them for the first time and you’re going to get them to open up. So they have to make sure that this is a safe place.”