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Institute for Public Service Reporting – Memphis

Brains vs. Trauma

When children are rushed to the hospital in Memphis, trauma counselors are there waiting for them

Since January 2021, the University of Memphis BRAIN Center has provided free mental health services for trauma patients at Le Bonheur Children's Hospital. The trauma care team includes (from right) Dr. Kiersten Hawes, Dr. Eraina Schauss, Dr. Regan Williams, graduate students Caitlynn Frazier and Sydnie Roberts. (Lisa Buser/Courtesy Le Bonheur Children's Hospital)
Since January 2021, the University of Memphis BRAIN Center has provided free mental health services for trauma patients at Le Bonheur Children’s Hospital. The trauma care team includes (from right) Dr. Kiersten Hawes, Dr. Eraina Schauss, Dr. Regan Williams, graduate students Caitlynn Frazier and Sydnie Roberts. (Lisa Buser/Courtesy Le Bonheur Children’s Hospital)

An errant bullet fired from a street in South Memphis last year hit 16-year-old Evan sitting inside his home watching TV. The bullet tore a hole through his arm and leg.

Instantly, before anyone could call 911 — even before the teenager was fully aware of what had happened — first responders in his brain and body rushed into action.

Powerful stress hormones mobilized his muscles, heart, and lungs to fight or flee the peril. They also, at least temporarily, blocked the ability of his brain and nervous system to calm his body.

The trauma and its physiological impact intensified as the teenager was rushed to the emergency room at Le Bonheur Children’s Hospital, where surgeons and nurses treated and stabilized his physical wounds.

Several hours later, after Evan was admitted to the hospital, two mental health counselors did something that rarely happens at pediatric hospitals: They began assessing and treating the young patient’s hidden mental wounds.

Using a form of mental health triage, they quickly determined that Evan — like two-thirds of the children brought to Le Bonheur with traumatic injuries over the past three years — was experiencing acute stress disorder.

In reaction to trauma, a hypervigilant brain and body can get stuck in fight, flight or freeze mode. The sympathetic and parasympathetic nervous systems become dysregulated. Acute trauma disorder, left undiagnosed and untreated, often leads to post-traumatic stress disorder and long-term, life-changing consequences.

Those consequences can include impaired brain development and academic performance, and increased risk for chronic physical and mental health problems, behavior issues including criminal actions, and addictions.

“Trauma reorganizes the brain,” said Dr. Eraina Schauss, a licensed professional counselor and founding director of the BRAIN Center at the University of Memphis. “And no single person experiences trauma in the same way. We do all we can to heal the body. We have to do all we can to heal the brain, to teach the brain to self-regulate and become more resilient to trauma. That work has to start when a trauma patient arrives at the hospital.”

That work doesn’t happen in most U.S. hospitals, but it does at Le Bonheur, a Level 1 Pediatric Trauma Center.

For more on Le Bonheur’s trauma-informed mental health services, read “Healing a Child’s Hidden Wounds a Breath at a Time”

Since January 2021, Le Bonheur has been providing free, trauma-informed mental and behavioral health services to more than 3,000 children admitted to the hospital for gunshot wounds, burns, injuries from motor vehicle crashes, falls, and other unintentional traumatic injuries.

The Le Bonheur program, Hurt-2-Healing, is the nation’s first integrated behavioral health model specifically designed for pediatric trauma patients. It’s a response to a fractured health care system that prevents or doesn’t provide timely access to mental health services, especially when trauma is most acute.

“Most children and adolescents with traumatic exposure or trauma-related psychological symptoms are not identified and consequently do not receive any help,” according to the American Psychiatric Association. “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.”

The lack of access to mental health care is especially acute in Memphis, a majority minority city with high rates of poverty, violent crime, and childhood trauma.

Memphis has been designated one of the nation’s 6,822 mental health professional shortage areas. Eight of the nine mental health centers in Memphis have “high” unmet needs, according to the federal government.

Hurt-2-Healing (H2H) addresses the shortage, and related insurance complications, by training interns — graduate students from the clinical mental health counseling program at the University of Memphis — to provide the free bedside counseling at Le Bonheur.

So far, results are promising and significant. H2H counselors have triaged more than 3,000 pediatric trauma patients admitted to Le Bonheur since January 2021. Two-thirds of them showed symptoms of acute stress disorder. More than eight in 10 had never received mental health counseling before.

The counselors have provided more than 4,000 mental health counseling sessions. But they don’t have funding to follow and assess the program’s longer-term impact. “Without funding for a thorough follow-up evaluation, we can’t really know,” Schauss said.

Schauss hopes more funding is on the way. She is working with state health officials and others to expand H2H to pediatric hospitals in Nashville, Knoxville, Chattanooga, and Johnson City. She believes the program can become a model for pediatric hospitals across the country. Others agree.

“This is exactly the program want to set up in Nashville,” said Dr. Harold ‘Bo’ Lovvorn, medical director of the Pediatric Trauma Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt University. Carell is the third busiest Level 1 pediatric trauma center in the country. Medical staff there has more than 2,500 trauma encounters every year.

“For children who survive trauma, we need to find ways to address their mental health needs before we send them home,” Lovvorn said. “We can’t just keep sending kids back into the same environments without support.”

INJURIES AND MEMORIES

Any injury can be traumatic for a child. But injuries sustained by gunshots, physical abuse, and car crashes tend to be the most traumatizing.

“With those injuries, children are often dealing with a lot of fear and grief, especially is someone else died,” said Dr. Trey Eubanks, a pediatric surgeon and former trauma medical director who was named Le Bonheur’s president last year. “They also tend to have a lot of flashbacks. They are replaying the event over and over in their heads.”

Traumatic memories are stored differently in the brain. They can be readily accessed, intentionally or unintentionally, and experienced as if they are happening in the present moment.

These “flashbacks” are often triggered by a sight, sound, or smell that reactivates the amygdala, putting the brain and body back on full alert. The original traumatic event has a beginning and end, but flashbacks cause the brain and body to relive the trauma over and over.

Unless and until trauma is resolved, the slightest perception of threat — a frown, a stare, a shove, a loud noise, someone yelling — can send the brain and body back into fight or flight mode days, months, years later.

Dr. Trey Eubanks
Dr. Trey Eubanks

“I can look at someone who’s got a broken leg or a busted-up face and say he’s got problem,” Eubanks said. “It’s hard to do that with someone suffering from the psychiatric impact, the mental stress of a trauma. We screen every child now.”

Last year, a 17-year-old girl was brought to Le Bonheur with multiple broken bones and a collapsed lung. The patient was one of 347 car-crash victims brought to the hospital in 2023.

In the ICU, the teenager told nurses she was having flashbacks, nightmares, and enormous feelings of survivor guilt. After the child was admitted to the hospital, mental health counselors began treating her psychological wounds.

They triaged the girl with the Child Stress Disorders Checklist-Short Form. It is used to assess traumatic stress symptoms in the immediate aftermath of a trauma. Caregivers can respond for children too young to understand the questions.

  • Do you feel any physical sensations when you are reminded of the accident, such as headaches, stomachaches, nausea, or difficulty breathing?
  • Do you avoid doing things that remind you of the accident, like talking about what happened?
  • Do you startle easily when you hear a sudden or loud noise?
  • Do you feel upset or angry when you are reminded of what happened?

The girl answered yes to 3 of the 4 questions. The average score for Le Bonheur’s vehicle-crash victims is 2.18. Only victims of weapons-related injuries score higher, averaging 2.40. Any score above 1 is concerning.

H2H mental health counselors saw the girl every day she was in the hospital. After she was discharged, she continued the therapy as an out-patient.

“If you don’t address a child’s physical wounds, they will get worse and they won’t heal,” said Dr. Kiersten Hawes, clinical director of the BRAIN Center Trauma Counseling Services at Le Bonheur. “The same is true for mental wounds. There’s a mind-body connection. Treating one doesn’t treat the other. Physical wounds can heal pretty quickly. Mental wounds can last forever.”

MENTAL HEALTH EMERGENCY

The Memphis program reflects the growing national interest in integrated mental and physical health services, especially for children.

Mental health challenges are 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.

“There is a behavioral health crisis in the United States,” Reginald Williams, vice president of health policy for the Commonwealth Fund, told Congress in testimony delivered last March. “Medical and behavioral health services in the U.S. are delivered in separate, poorly coordinated systems. As a result, people can sometimes experience years-long delays between the onset of symptoms and treatment.”

National health leaders began issuing warnings about a mental health crisis among youth during the pandemic.

In October 2021, the Children’s Hospital Association, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry jointly declared a national state of emergency in child and adolescent mental health.

U.S. Surgeon General Vivek Murthy
U.S. Surgeon General Vivek Murthy

Two months later, U.S. Surgeon General Dr. Vivek H. Murthy issued a rare public health care advisory on an “emerging mental health crisis among youth.” Said Murthy: “It would be a tragedy if we beat back one public health crisis only to allow another to grow in its place. Mental health challenges in children, adolescents, and young adults are real, and they are widespread, but most importantly, they are treatable, and often preventable.”

Most of the focus has been on children and youth brought to emergency rooms who already are experiencing mental health issues, many from previous traumas.

For example, a study published in 2022 showed that during the pandemic, ER visits for suicide or self-injury increased 7 percent, and visits for disruptive, impulse control, or conduct disorders increased 2 percent. Visits by children with existing mental health diagnoses also increased 2 percent.

A study published in 2023 showed that almost half of children who go to the ER with mental health crisis don’t get the follow-up care they need.

“This crisis has only grown since the COVID-19 pandemic and requires increased investment from policymakers,” Matthew Cook, CEO of the children’s Hospital Association, told Congress last fall.

Other than the work being done at Le Bonheur, there are no studies that focus on the mental health needs of children and youth brought to hospitals with traumatic injuries. Injury is the leading cause of death in pediatrics. It’s also the leading cause of acute trauma disorder in children.

Every year, approximately 4.5 million children under age 18 sustain an injury that requires treatment at a hospital emergency department. Nearly 200,000 of those children suffer injuries serious enough to require hospital admission. At least two-thirds of them show symptoms of acute stress disorder, based on the experience of the H2H program.

“We have needed this sort of mental health trauma screening 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.”

INTEGRATED CARE

The U.S. surgeon general’s recommendations for addressing the youth mental health 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.”

Several states have established statewide mental health screenings in schools. The new More for Memphis initiative would establish 50 school-based health centers that would include mental health screenings.

But mental health screenings are done rarely if ever in hospital emergency departments when physical trauma is most acute. “That requires resources and expertise and those are expensive and generally unavailable in regular hospitals,” said Vanderbilt’s Lovvorn.

At Vanderbilt’s pediatric hospital, patients and their caregivers can meet with social workers or chaplains to discuss their mental health challenges, but mental health counseling is not part of the hospital’s standard of care.

Children enrolled in TennCare (the state’s Medicaid program) or the Children’s Health Insurance Program (CHIP) are eligible for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) to identify possible delays in growth and development, including behavioral assessments. But EPSDT coverage applies to primary care, not to hospitals.

Murthy, Cook and others have called on Congress to pass the Helping Kids Cope Act and additional investments to increase pediatric behavioral health services at children’s hospitals.

Federal and state governments could have a major impact on the problem. Medicaid is the largest payer of mental health services for both adults and children. Nearly half of U.S. children receive their health insurance through Medicaid, which covers children living in low-income families, in foster care or with disabilities.

Dr. Bo Lovvorn
Dr. Bo Lovvorn

Children insured by Medicaid are more likely to have a mental health condition than their peers. Unfortunately, guaranteed coverage of mental health services under Medicaid does not translate to guaranteed access. On average, Medicaid reimburses children’s hospitals only 80 percent of the cost of care provided.

“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 Allied Behavioral Health Solutions in Nashville.

Peak said private insurance typically only covers the first 60 minutes of mental health services provided at hospitals. Most often, it covers the intake by a social worker who does not provide long-term care. Insurance also 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.

None of those programs help the more than five percent of children who remain uninsured in Tennessee, one of 10 states that have rejected Medicaid expansion funds. In 2021, state lawmakers did approve a $217 million increase in funding to serve uninsured children in need of mental health care. But much of that funding is focused on schools, mobile clinics, and psychiatric hospitals, not ERs in pediatric hospitals.

“We’re seeing mental health symptoms in the emergency department,” Lovvorn said. “That’s where and when they need to be addressed. We have to retool the system to provide full physical and mental health care to kids experiencing traumatic injuries.”

RETOOLING THE SYSTEM

On her first day as a mental health counseling intern at Le Bonheur, Sydnie Roberts saw a doctor holding a mother’s hand.

They were keeping watch over the mother’s 9-year-old child, a victim of domestic abuse. The boy had suffered a severe blow to his head. Machines were keeping his body alive.

“I remember thinking, ‘Oh, my God. This is real. This is trauma. And this is happening every single day here,” Roberts said.

Last year, Le Bonheur’s emergency department treated 112 child abuse victims last year, up from 81 in the year before the pandemic. The hospital also treated 178 children with gunshot wounds. That compares to 150 the year before and 68 five years ago.

“I know people are going through traumatic situations every day whether I’m here or not,” Roberts said. I want to be here. I want to be their safe space.”

Dr. Kiersten Hawes
Dr. Kiersten Hawes

Roberts is one of half a dozen interns who provide free, unlimited mental health counseling to injured children at Le Bonheur. The interns are graduate students at the Clinical Mental Health Counseling program at the University of Memphis.

By using medically supervised interns as counselors, Hurt2Healing solves several challenges in providing mental health care.

Like many states, Tennessee doesn’t have enough mental health counselors. Nearly half the U.S. population lives in a mental health workforce shortage area. That includes Memphis and all of Tennessee, according to data from the Kaiser Family Foundation. Tennessee needs 300 more practitioners to fill the growing need.

H2H has trained 40 interns to provide mental health counseling at Le Bonheur. The program provides those graduate students with the internship they need to be licensed by the state.

Hawes, who supervises the interns, is a Le Bonheur staff member. That allows the hospital to seek reimbursement for the interns’ services from TennCare — a policy that was established only last summer.

The H2H mental health counseling is now part of the hospital’s standard of care. Hawes makes daily rounds with other medical professionals at Le Bonheur. She huddles with her team every morning to discuss each patient’s needs and progress. Each intern treats no more than five patients at a time.

The counseling sessions take place in the hospital, often at bedside. But the counselors also continue to see some discharged patients for weeks or months at the hospital’s outpatient clinic.

“It’s really disheartening that there’s only one program like this in the entire state,” said Katie Van Landingham, vice president of governmental and community affairs at the University of Memphis.

Van Landingham is working with Schauss and state health officials to expand Hurt2Healing to four other pediatric hospitals in Tennessee. Medical chiefs at those hospitals have signed letters of endorsement for the program. The hospitals would partner with nearby graduate or medical schools to enlist interns. The BRAIN Center Memphis would train the interns.

RE-REGULATING BRAIN AND BODY

Vanderbilt’s Lovvorn said he is eager to bring Hurt2Healing to his hospital, and to see it established at all the state’s pediatric hospitals. Still, he has some questions.

“We do a lot of stuff to a child who is brought here with a traumatic injury, and that can include surgery,” he said. “How do we differentiate the stress and trauma of being in the hospital from the stress and trauma of the actual injury itself? We’re going to have to figure that out.”

Figuring that out, and sustaining and expanding Hurt2Healing statewide, will require more time and more funds.

The state recently raised reimbursement rates for mental health service providers in fiscal years 2023 and 2024. Higher rates can encourage providers to accept insurance as payment. But higher reimbursement rates won’t begin to cover the costs of the novel program.

Schauss and the BRAIN Center Memphis are seeking $2 million in recurring state funds to cover operations costs.

“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.

Dr. Eraina Schauss
Dr. Eraina Schauss

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.

“I can’t stop thinking about it,” Evan, the 16-year-old gunshot victim, told the counselor one day last year. “It feels like it’s happening to me again.”

Evan was jumpy. He couldn’t focus. He couldn’t sleep. He was sitting safely in his hospital bed, but he looked scared.

The counselor explained to the teen that he was experiencing flashbacks.

“After a traumatic event such as having a gunshot wound, it is normal to experience flashbacks, anxiety, feeling on edge, and other emotions,” the counselor said.

The teen nodded. The counselor told him that he was going to show him a breathing exercise that would help him feel better.

“Your mind and body are still trying to protect you from harm, even though you’re no longer in danger,” the counselor explained. “Breathing has a way of telling our mind and body that we are safe.”

Trauma can knock the nervous system out of sync.

Shallow or rapid breathing activates the sympathetic nervous system, the “fight or flight” system that controls the release of stress hormones. Trauma can send this system into overdrive.

Deep, regulated breathing stimulates the vagus nerve thta runs from the brain to the abdomen. It’s in charge of turning off the “fight or flight” system and turning on the parasympathetic nervous system, the “calm and control” system.

The simple breathing exercise literally calmed her nerves, reducing her stress, anxiety, and pain. Deep breathing, play therapy, and other therapeutic interventions can help to re-regulate the nervous system.

The teenager followed the counselor’s instructions, breathing in deeply through his nose for four seconds, then holding his breath for four seconds, then exhaling through his mouth for four seconds.

“How do you feel?” the counselor asked Evan.

“I feel better,” Evan said. “I feel like I can breathe.”


David Waters is associate director of the Institute for Public Service Reporting at the University of Memphis. The Institute receives grant funding from the Urban Child Institute in Memphis. The BRAIN Center’s work is supported by a grant from the Urban Child Institute.

The Institute is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in select states across the country.

Written By

David Waters is Distinguished Journalist in Residence and assistant director of the Institute for Public Service Reporting at the University of Memphis.

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