Issue Brief 66 - Engaging Pediatric Primary Care to Address Childhood Trauma: Part of a Comprehensive Public Health Approach

November 19, 2018

Engaging Pediatric Primary Care to Address Childhood Trauma

Part of a Comprehensive Public Health Approach

Early identification of trauma exposure and treatment of traumatic stress is critical to a child’s lifelong health and well-being. Exposure to trauma is common, with approximately 71% of all children exposed to violence, abuse, or other forms of trauma by 17 years of age.¹   Trauma exposure places children at increased risk for a host of developmental, behavioral health, and health problems. For example, childhood trauma exposure is associated with traumatic stress (including post-traumatic stress disorder) as well as chronic health and mental health problems through adulthood, including heart disease, obesity, substance abuse, diabetes, suicide, emphysema, and premature death.² However, many children suffering from trauma exposure are not identified or do not receive effective treatment services. Pediatric primary care can play an important role in identifying and treating children exposed to trauma as one part of a comprehensive, state-level, public health approach to prevention, early identification, and access to evidence-based treatment.

Primary Care Plays a Critical Role in Identifying and Supporting Children Exposed to Trauma

Recognizing the public health impact of childhood trauma exposure, a goal of the Connecticut State Health Improvement Plan (SHIP), led by the Department of Public Health (DPH), is to increase the number of children and adults screened for trauma by primary care and behavioral health providers.³ Pediatric primary care is well positioned to identify child trauma exposure and related symptoms given that more than 90% of children attend an annual well-child visit and many visit the pediatrician’s office several times per year.⁴ Screening for trauma in pediatric primary care also affords the opportunity for pediatricians to evaluate and provide more holistic treatment for the physical health conditions that can be associated with trauma exposure. 

Pediatric primary care plays a critical role in:

• Proper and early identification of trauma exposure and related symptoms, and talking with families about the effects of trauma
• Identifying and supporting family strengths and resilience that help prevent or mitigate the psychological and physical effects of trauma exposure
• Connecting children and families to appropriate, evidence-based, trauma-focused treatments and services.

Challenges Related to Trauma Care in Primary Care

Despite the high prevalence of trauma exposure, screening is not yet routine in pediatric primary care. Trauma exposure and traumatic stress reactions are often undetected or misdiagnosed until serious health or behavior problems develop. Pediatricians face several challenges related to identifying children suffering from traumatic stress:

• Although pediatricians can be reimbursed for developmental and behavioral health screening through Medicaid, the currently approved list of reimbursable measures does not include a validated trauma screening instrument.
• Training aimed at educating pediatricians about the impact of child traumatic stress on health, and on how to talk with children and families about trauma, is limited. Among a list of various behavioral health conditions, pediatricians have reported being least comfortable talking about trauma.⁵
• Most validated child trauma screening measures are lengthy and impractical for routine use in the pediatric primary care setting.
• In the event of a positive trauma screen, pediatricians have limited information about local referral sources to trauma-focused behavioral health treatment providers.

Resources for Primary Care Providers to Identify and Support Children Exposed to Trauma

A Brief, 10-Question Child Trauma Screen for Use in Pediatric Settings:  Recognizing the need for brief trauma screening measures, CHDI led the development of the Child Trauma Screen (CTS) in partnership with the Connecticut Department of Children and Families (DCF) and Dr. Christian Connell (formerly of Yale University, currently at Penn State University). The CTS is a 10-item measure of trauma exposure and traumatic stress in children 6 to 17 years old (a version for children 3 to 6 years old is also available) that was empirically developed and is supported by two independent studies conducted in outpatient children’s behavioral health clinics.^{6, 7} The CTS is currently used to screen children in Connecticut’s child welfare and juvenile justice systems. CHDI recently tested the CTS in a large primary care setting in Connecticut and found that the CTS performed well compared to a validated but longer measure of PTSD symptoms. The study also found that 51% of all children attending well-child visits reported at least one trauma exposure and 19% reported clinically significant levels of traumatic stress symptoms. Despite the high levels of trauma among children they serve, pediatricians reported concerns about how they could routinely conduct trauma screening in primary care with current resources and reimbursement policies. As new reimbursement approaches are developed to better support trauma screening in pediatric primary care, the CTS is available to providers at no cost (available at www.chdi.org/cts).

Trauma Training and Referral Resources for Primary Care:  Pediatric primary care practices can participate in education developed and delivered through CHDI’s Educating Practices training program, which supports pediatric practices with timely, evidence-based information and materials about a variety of pediatric health topics. The Educating Practices trauma training includes introductory information about trauma in children and how to conduct trauma screening using the CTS. The presentation includes referral information to local community providers who have been trained in child trauma treatments. Connecticut, primarily through funding from DCF, has built an impressive network of child behavioral health providers trained in evidence-based treatments for children suffering from trauma (directory available at www.kidsmentalhealthinfo.com).

Policies and Practices to Support Trauma Screening in Primary Care

While Connecticut has made great strides in addressing childhood trauma, more support is needed to engage child health providers in early identification of children suffering from trauma, provide support and information to families about trauma, and ensure linkages to trauma-informed behavioral health services. The following recommendations can ensure that Connecticut uses its entire continuum of resources to support early trauma identification and services:

• The Department of Social Services and commercial insurers should reimburse pediatric primary care providers to screen children annually for trauma exposure and traumatic stress beginning at three years of age. For children younger than three, DSS and commercial insurers should reimburse pediatricians to screen children for trauma exposure only, and to screen caregivers for exposure and traumatic stress symptoms.
• Programs and providers that maintain directories and referral sources for children’s trauma and behavioral health treatment (e.g., Access Mental Health, United Way/211, commercial insurers) should include the most current list of providers of evidence-based trauma treatments found at https://ebp.dcf.ct.gov/ebpsearch/.
• The state should consider expanding training and quality improvement activities to increase the number of behavioral health providers who provide evidence-based trauma treatment to children. 
• DPH, as part of SHIP, should provide pediatric primary care sites with training in workflow strategies that support: discussing trauma with all families at least annually, child trauma screening, referrals for trauma-focused services, and coordinating patient care with other service providers.
• To document the State’s progress toward addressing childhood trauma and improving public health, state child-serving state agencies (e.g., DPH, DCF, Department of Social Services, Office of Early Childhood) and workgroups (e.g., SHIP, Multi-System Trauma Informed Collaborative) should establish and implement integrated cross-system strategies (e.g., billing codes, chart audits, and physician surveys) to measure the implementation of trauma screening, referrals for and utilization of treatment services, and ongoing needs.

This Issue Brief was prepared by Susan Macary, Jason Lang, Lisa Honigfeld, and Kyle Barrette.  For more information, contact Jason Lang