A 14-year-old boy was playing basketball in a park near his home last year when a bullet fired from a passing car tore through his abdomen and knocked him down.
The teenager was taken by ambulance to the emergency room at Le Bonheur Children’s Hospital where doctors and nurses treated his physical wounds.
Then, in the ICU, two mental health counselors did something that rarely happens at pediatric hospitals: They began assessing and treating the young patient’s hidden wounds.
Using a form of mental health triage, they quickly determined the boy — like two-thirds of the children brought to Le Bonheur with traumatic injuries over the past year — was experiencing acute stress disorder.
Often undiagnosed and untreated, acute stress disorder often leads to post-traumatic stress disorder and long-term, life-changing consequences. Those include impaired brain development and academic performance, increased risk for chronic physical and mental health problems, behavior issues and addictions.
Since January 2021, the opens in a new windowBRAIN Center at the University of Memphis has been providing free, trauma-informed mental and behavioral health services to all children (and their caregivers) treated at Le Bonheur for gunshot wounds, burns, injuries from motor vehicle accidents and other unintentional traumatic injuries.
So far, the results are significant. Of the 617 trauma patients ages 2-18 admitted to Le Bonheur in the first eight months of the program, 64% showed symptoms of acute stress disorder, and 100% of them accepted the mental health care services.
Flawed system
“We have needed this for so long,” said Dr. Regan Williams, medical director of Trauma Services at Le Bonheur. “So many of our young trauma patients have mental health needs, and their families have struggled to find it. There are so many barriers.”
Millions of Americans with mental illness struggle to find mental health care in a fragmented, limited, complex and costly system full of obstacles.
Nearly half of the 60 million adults and children living with mental health conditions in the United States go without any treatment, according to the opens in a new windowNational Alliance on Mental Illness.
The problem is especially acute in hospitals, where trauma-informed mental health services are poorly covered by insurance and rarely provided.
The BRAIN Center’s program at Le Bonheur is an unprecedented effort to create a new standard of care for how hospitals here and everywhere address traumatic injuries in children.
“This is extremely progressive and pioneering on Le Bonheur’s part,” said Dr. Eraina Schauss, founding director of the BRAIN Center at the University of Memphis. “Le Bonheur is the first hospital in the country to create a new trauma mental health division specifically to address the enormous needs of young trauma patients in our community.”
Emerging crisis
Last December, U.S. Surgeon General Dr. Vivek H. Murthy issued a rare opens in a new windowpublic health advisory on what he called an “emerging” mental health crisis among youth, exacerbated by the pandemic.
“It would be a tragedy if we beat back one public health crisis only to allow another to grow in its place,” Murthy wrote in his advisory. “Mental health challenges in children, adolescents, and young adults are real, and they are widespread, but most importantly, they are treatable, and often preventable.”
Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor life outcomes in young people. One in five children ages 3-17 in the U.S. has a mental, emotional, developmental or behavioral disorder, according to the CDC.
Murthy’s recommendations for addressing the crisis included “routinely screening children for mental health challenges and risk factors, including adverse childhood experiences (ACEs). Screenings can be done in primary care, schools, emergency departments, and other settings.”
Mental health screenings for children are done in primary care clinics, and sometimes in schools. A proposed new state funding formula for public education is expected to increase the number of counselors, social workers, and nurses in schools.
But mental health screenings rarely if ever are done in hospital emergency departments when the trauma is most acute.
As a result, “most children and adolescents with traumatic exposure or trauma-related psychological symptoms are not identified and consequently do not receive any help,” the American Psychiatric Association (APA) opens in a new windowreports. “Even those who are identified as in need of help frequently do not obtain any services. This is especially true for children from ethnic and racial minority groups and for recent immigrants, who have less access to mental health services.”
Memphis underserved
That is especially true in Memphis, which has been designated as one of the nation’s 5,833 opens in a new windowmental health professional shortage areas. Eight of the nine mental health centers in Memphis have “high” unmet needs, according to the federal government.
“There’s been an exponential increase in the level of trauma children are experiencing,” said Dr. Susan Elswick, director of the School Mental Health Access to Resources through Telehealth ( opens in a new windowSMART) Center at the University of Memphis. “Mental and behavioral health needs are at an all-time high.”
Dr. Altha Stewart of Memphis, past president of the APA, says the COVID-19 pandemic has heightened the need for more mental health professionals for children and adolescents.
“It’s not just a pandemic, it’s a syndemic,” said Stewart, founding director of the opens in a new windowCenter for Youth Advocacy and Well-Being at the University of Tennessee Health Science Center. “The impact of the pandemic has been horrific on children. When you combine the physical, emotional and social traumas so many children are experiencing, you have a syndemic.”
Last year, a 17-year-old girl was brought to Le Bonheur with a rib fracture and collapsed lung. The patient was a passenger in a car, and the driver was killed on impact.
In the ICU, the teenager told mental health counselors that she was having flashbacks, nightmares and enormous feelings of survivor guilt.
Counselors triaged the child with the Child Stress Disorders Checklist-Short Form ( opens in a new windowCSDC-SF), used to assess traumatic stress symptoms in the immediate aftermath of a trauma.
The girl scored 3 (out of 4). The average score for Le Bonheur’s vehicle-crash victims last year was 2.18. Only victims of weapons-related injuries scored higher, averaging 2.40. Any score above a 1 is concerning.
‘Walking wounded’
Over the next several days, counselors treated the girl with Mindfulness-Based Stress Reduction (MBSR), Acceptance and Commitment Therapy, grief therapy and coping skills. After she was discharged, she continued the therapy as an out-patient.
Those and other cognitive-behavioral therapy (CBT) techniques are effective in treating children and adolescents who have persistent trauma reactions, the APA reports.
Le Bonheur’s bedside mental health care is provided by eight student interns from the U of M’s Clinical Mental Health Counseling graduate programs. They are supervised by Dr. Kiersten Hawes, the BRAIN Center’s clinical director who makes daily rounds with other medical professionals at Le Bonheur.
“It’s crazy we haven’t had these services from the beginning,” Hawes said. “So many children in our community, in our society, are among the walking wounded. We can’t see their wounds, but we can treat them. We shouldn’t just discharge them and let them go back to their lives untreated.”
Children can develop acute stress disorder after being exposed, directly or indirectly, to a traumatic or terrifying event — a serious injury, violence or the threat of death.
Children who have been exposed to multiple traumas are more vulnerable.
Children are resilient, and many can recover from traumatic events without mental health intervention, especially those with strong, stable and supportive home environments.
But many cannot.
“Recovery can be impeded by individual and family factors, the severity of ongoing life stressors, community stress, prior trauma exposure, psychiatric comorbidities and ongoing safety concerns,” the APA reports.
Symptoms
Children who develop opens in a new windowacute stress disorder show several symptoms for three to 30 days after a traumatic event. Among them:
- Recurring, uncontrollable and intrusive distressing memories of the event
- Recurring distressing dreams of the event
- Feelings that the traumatic event is recurring — for example, in flashbacks
- Intense psychological or physical distress when reminded of the event (for example, by entering a similar location or by sounds similar to those heard during the event)
- A persistent inability to experience positive emotions (such as happiness, satisfaction or loving feelings)
- An altered sense of reality (for example, feeling in a daze or as if time has slowed)
- Memory loss for an important part of the traumatic event
- Efforts to avoid distressing memories, thoughts or feelings associated with the event
- Efforts to avoid external reminders (people, places, conversations, activities, objects and situations) associated with the event
- Disturbed sleep
- Irritability or angry outbursts
- Excessive attention to the possibility of danger (hypervigilance)
- Difficulty concentrating
- An exaggerated response to loud noises, sudden movements or other stimuli (startle response)
The symptoms must cause significant distress or significantly impair functioning.
“Because children who have experienced traumatic stress may seem restless, fidgety, or have trouble paying attention and staying organized, the symptoms of traumatic stress can be confused with symptoms of attention-deficit/hyperactivity disorder (ADHD),” the APA reports.
Last year, a five-year-old girl accidently spilled boiling-hot noodles into her lap. She was rushed to Le Bonheur and treated for severe burns.
In the ICU, she told mental health counselors she was afraid to go back home and afraid of loud sounds.
Counselors triaged the child with CSDC-SF. She scored 2 out of 4, which is high for burn victims. The average score for Le Bonheur’s burn victims last year was 1.40.
While the girl was recovering in the hospital, counselors treated her with play therapy and mindfulness-based stress reduction (MBSR), a therapeutic intervention that can reduce stress, anxiety and pain.
Care not sustainable
Counselors also treated the girl’s caregiver, who was experiencing anxiety and guilt.
Significant depressive and/or PTSD symptoms have been found in 20-40% of caregivers of children with traumatic injuries, the APA reports.
“Our approach is two-generational,” Hawes said. “We also attend to the mental health needs of the caregiver, so that they are capable of being present and providing support to their child who is recovering from a traumatic injury.”
The free mental health counseling at Le Bonheur is meeting a need. It’s also unsustainable.
The BRAIN Center’s program is funded by a grant from the Urban Child Institute, which is set to expire June 30. The Center has applied for another year of funding. (The Institute for Public Service Reporting also receives grant funding from the Urban Child Institute.)
Whenever the grant funding ends, the program will have to rely on regular billing for private insurance or TennCare, the state’s Medicaid program.
“The maze that is funding for behavioral health services is often very complex and generally does not cover every activity that a behavioral health program likely delivers,” said Alison D. Peak, executive director of opens in a new windowAllied Behavioral Health Solutions in Nashville.
For example, insurance typically only covers the first 60 minutes of mental health services provided at hospitals, Peak said. Most often, it covers the intake by a social worker who does not provide long-term care.
Insurance doesn’t cover paperwork time, collaboration with other providers and community resources, or efforts to engage in case management for a family or youth and other similar services.
Reimbursement for mental health services at hospitals gets more complicated.
Children enrolled in TennCare or the Children’s Health Insurance Program (CHIP) are eligible for Early and Periodic Screening, Diagnostic and Treatment ( opens in a new windowEPSDT) to identify possible delays in growth and development, including behavioral assessments.
But EPSDT coverage applies to primary care, not to hospitals.
Many state Medicaid programs do not allow multiple providers to bill for services on the same date of service.
TennCare does, but the billable services often result in reimbursements that don’t offset the cost of the billing staff and time required to bill for the services rendered.
Also, the BRAIN Center uses graduate students to provide the mental health care at Le Bonheur, which also hasn’t been reimbursable.
That will change July 1. A new TennCare policy will allow for reimbursement of qualified behavioral health graduate students who are properly supervised.
More changes needed
“There has been discussion within the workforce for needing reimbursement rates that better reflect the broader work that is required within behavioral health,” she said. “It’s never just an hour of talk therapy.”
The 14-year-old gunshot victim was in the hospital 12 days.
The boy was jumpy and easily startled. He was experiencing flashbacks, nightmares, numbness. He found it difficult to go to sleep and go back to sleep. He was afraid to go home and back to school. His caregiver was afraid for him.
Over the course of more than 20 therapy sessions, each lasting about an hour, the counselor talked to the patient and his caregiver about their shock, fears and anxieties, their hidden wounds.
The counselor explained how the body and brain react to trauma and stress, and the possible short-term and long-term consequences.
The counselor treated both with two forms of trauma-informed therapy: Mindfulness-Based Stress Reduction and Interpersonal and Social Rhythm Therapy (IPSRT), a form of psychotherapy often used to treat bipolar and other mood disorders.
IPSRT emphasizes techniques to manage stressful life events, regulate emotions, reduce disruptions in social rhythms and adjust to change.
“It was a major adjustment, but the patient is recovering well,” Hawes said. “He and his caregiver are following up for outpatient counseling. The child has returned to school and some of his normal activities.”
In 2021, mental health counselors at Le Bonheur have provided more than 1,900 sessions and treated more than 850 families.
“It is my hope that our research and findings will find its way to the right individuals who can make legislative and policy changes to fund these critical services for patients who are most in need, and not after months or years of suffering,” Schauss said.
This story first appeared at dailymemphian.com under an exclusive use agreement with The Institute.
