SBHCs offer crucial mental health services to underserved children

The Adverse Childhood Experiences Study, one of the largest investigations ever conducted to assess the effects of trauma on children, found that almost two-thirds of children are at risk for at least one adverse childhood experience, which could cause a multitude of mental and physical health issues across their lifetime.

Recent data released from the 20-year Adverse Childhood Experiences (ACE) Study, conducted by Kaiser Permanente’s Health Appraisal Clinic in San Diego and the CDC, have shed new light on the long-term impact of childhood trauma and how it can affect physical and psychological health well into adulthood.

The researchers have studied more than 17,000 children since 1995 and determined that increased exposure to traumas such as child abuse, substance abuse, incarceration of a parent, neglect, divorce and suicide can lead to an early death. Recent data indicate that more than 20% of children will experience three or more adverse experiences during their childhood.

“It is important to be aware of adverse experiences that students have gone through and address those early on so students are less likely to experience long-term challenges,” Kimani Norrington-Sands, PhD, organization facilitator for the school mental health unit, at the Los Angeles Unified School District, said during an interview with Infectious Diseases in Children.

ACE study researchers developed the ACE questionnaire, a 10-question survey that measures a child’s exposure to trauma. Respondents are asked questions related to domestic child abuse, substance abuse and neglect, and the survey assigns one point for each affirmative response. Higher scores indicate a greater exposure to trauma and consequently a higher risk for negative impacts throughout the respondent’s lifetime.

Photo courtesy of Irwin L

To illustrate the negative effects of trauma on children, the ACE researchers developed the ACE Pyramid, a conceptual framework of the progression of adverse childhood experiences throughout a child’s entire lifespan. The scale begins with adverse childhood experiences; leading to social, emotional and cognitive impairment; adoption of health-risk behaviors; disease, disability and social problems; and ultimately an early death.

Adverse childhood experiences have the potential to severely impact the mental health, development and well-being of children, making mental health services within school-based health centers a crucial element for addressing the psychosocial issues among the pediatric population.

According to the 2010-2011 census regarding school-based health centers (SBHCs), in a survey of almost 1,500 SBHCs compiled by the School-Based Health Alliance, approximately 71% reported offering some type of mental health services. SBHCs usually follow one of two models: a primary care and mental health plus model, which provides a primary care physician as well as a staff of mental health professionals, health educators, social services liaisons and nutritionists; or a primary care and mental health model, which provides only a PCP and a mental health professional such as a psychologist or substance abuse counselor.

Infectious Diseases in Children spoke with several mental health experts working inside SBHCs nationwide about how trauma related to child abuse, substance abuse and homelessness can be screened for and ultimately treated. SBHCs are uniquely positioned to identify and mitigate the symptoms of adverse childhood events, in an effort to improve future quality of life for this vulnerable population.

Lingering trauma of child abuse

Physical and emotional child abuse make up a majority of the traumatic experiences covered in the ACE questionnaire. The ACE Study specifically acknowledges violence against children, or the threat of violence against children, as an adverse experience. Based on the ACE Pyramid, victims of child abuse are at a significantly higher risk for early death.

“Many of our kids experience complex trauma, or they might experience situations in which they have concurrent symptoms of abuse: they might have one experience of abuse at one point in their lives and then later experience another different type of abuse,” Norrington-Sands said. “It is important to recognize in the assessment and treatment of students with a history of complex trauma that they may have ongoing direct and/or vicarious experiences of traumatic events, such as witnessing community violence.”

The process of identifying an undiagnosed condition related to trauma is known as screening. Screening for trauma can be difficult because narrowing down the at-risk population of students requires the involvement of teachers, counselors, and medical SBHC staff, according to Jane Ripperger-Suhler, MD, program director of child and adolescent psychiatry at the University of Texas. Broader screening of entire schools, or entire grade levels produces the best results, but requires more logistical resources.

“For the 2014-2015 school year, the Los Angeles Unified School District screened 1,535 students, after obtaining parent/guardian consent, at 53 of our elementary, middle and high schools,” Norrington-Sands said. “We identified students in various ways, dependent upon the schools’ needs, as well as staffing considerations. Because we wanted to be responsible in our work, we screened based upon if we had the resources to screen and provide treatment if we made the referrals.”

Students’ screenings for trauma in some schools were based on whether they have been referred for services to the school-based psychiatric social worker, while some high schools screened entire grade levels, such as sixth or ninth graders

“What we found was that among those screened students, 98% reported having exposure to one or more adverse events in their lifetime,” Norrington-Sands said. “On average, they reported experiencing six adverse childhood experiences.”

Children also are sometimes identified as victims of child abuse through one-on-one counseling sessions.

“I treated a child with a developmental disability who was having a lot of conflict with their parent, and revealed to me that both parent and the child were hitting each other,” Ripperger-Suhler told Infectious Diseases in Children. “The first thing we did was try to talk to the parent and the child together to get an idea of what was happening. Ultimately, we made the decision to involve child protective service, because the parent was really struggling, and we were hoping that child protective services would provide some support.”

In situations like these, children and parents can benefit from the continuum of care provided by SBHCs. Throughout the school year, mental health workers are provided ample opportunities to monitor the progress of an intervention.

“The ongoing process actually involved the therapist at the SBHC who continues to see both the child and the parent weekly to provide support and help the parent identify the issues that are keeping them from parenting effectively, all while letting the child know we are on their side,” Ripperger-Suhler said.

Onsite treatment of trauma within SBHCs is often done through one of two programs, Cognitive Behavioral Intervention for Trauma in Schools (CBITS) or Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

CBITS is a 10-week group modality program for youth with a history of trauma, which includes one to three individual sessions and trauma education for parents as well as teachers. TF-CBT is a 12- to 16-session psychotherapeutic treatment that focuses on behavioral and mental challenges related to trauma, such as PTSD, depression and anxiety for students, Norrington-Sands said.

According to an AAP policy statement, adverse childhood experiences can have lifelong and intergenerational effects, which require pediatricians to identify and address these issues as early as possible, and ultimately ensure a healthier population and workforce.

“There is research that SBHCs are effective at getting kids into services, because the access problems are reduced,” Ripperger-Suhler said. “If we want kids to have better mental health, and therefore grow up to be more productive adults, then we should provide their mental health in the best way possible, which I think is through the schools.”

Addressing adolescent substance abuse

Another major issue with adolescents is the mitigation of trauma associated with substance abuse behaviors. SBHCs play a crucial role in exposing adolescents, a difficult-to-reach population, to programs that discourage the use of drugs and alcohol.

SBHCs provide children who normally would not have access to mental health and counseling services with resources in friendly and familiar environments. These services can provide a dialogue about certain substance abuse behaviors, according to Gina Silva, MSW, CSWA, a mental health therapist at Merlo High School SBHC, in Beaverton, Oregon.

“The children have access to a medical provider to discuss things that may seem unimportant in a bigger sense, but are significant when you see them happening every other day. In certain situations, it is crucial to diagnose and catch issues before they get worse,” Silva told Infectious Diseases in Children.

According to the 2010-2011 SBHC census, 53.2% of SBHCs reported that they provide some type of substance abuse counseling, while another 9.6% reported having a fully trained alcohol and drug counselor on staff.

Approximately 77% of surveyed schools reported that they offer alcohol and drug use prevention programs that target individual students, while about 30% reported programs targeting small groups. Another 33% reported schoolwide programs.

“The incidence of substance use in adolescents is alarming,” Mandy McKimmy, DNP, clinical assistant professor at the Oregon Health & Science University School of Nursing, told Infectious Diseases in Children. “The literature has shown a strong relation to age at first use of substance abuse and risk for addiction as an adult.”

According to the ACE Study, exposure to someone who abuses alcohol or drugs is considered a traumatic experience. Furthermore, trauma exposure in this form may lead to what the ACE Study calls, “adoption of health risk behaviors.”

“I have noted children with significant substance use tend to have multifactorial problems in school with attendance, social interactions and poorer grades,” McKimmy said. “I am continually surprised by adolescents’ willingness to openly and honestly discuss their substance use and abuse.”

A primary concern within SBHCs located in low socioeconomic areas is the danger of trauma-vulnerable children being exposed to drugs or being supplied with drugs by their parents or guardians.

“We have stories with our students where the kid gets up in the morning and the first thing mom and the kid do together is get high,” Leisa Irwin, executive director of the Paladin Career and Technical High School, in Blaine, Minnesota, said in an interview. “While you might expect an older brother or an older sister to share drugs with a younger sibling, the cases we see are moms, dads, aunts or uncles [supplying substances, and] it seems far more prevalent than I ever would have imagined.”

Identifying students who are abusing substances or suffering from substance abuse exposure is often done through observational analysis of their behavior during school hours.

“The best way to screen young children is to look for typical [attention-deficit/hyperactivity disorder] behaviors — kids who are very unable to settle, irritable, have a lack of concentration,” Silva said. “With adolescents, unfortunately, screening is not very different. They are very distracted in school, irritable, and experience challenges in retaining information.”

Screening children for substance abuse issues is most commonly done through the use of two screening programs: the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) survey, and the Screening, Brief Interventions, and Referral to Treatment (SBIRT) program.

“[CRAFFT] can be completed by the student prior to their visit or during the visit with the provider,” McKimmy said. “I prefer to use it in the clinic with the student, as that affords a great opportunity for brief advice or brief intervention at the same time as the screening. If time is a constraint, then at least you’ve addressed that there is a problem and assessed the patient’s willingness to change and can set up follow-up appointments.”

The most common intervention program used for adolescents is Teen Intervene, according to multiple SBHC experts.

“Teen Intervene is a combination of cognitive behavioral therapy and motivational interviewing,” Silva said. “It is three sessions, with one of the sessions done with a parent.”

Motivational interviewing functions by identifying and engaging the intrinsic motivations for a given behavior, then working with the patient to alter the behavior by promoting change.

“Motivational interviewing is a key component when working with adolescents and substance abuse,” McKimmy said. “I believe there is a need to establish rapport with the patient prior to any big change; however, utilizing these methods, I’ve even had successes with patients on a first visit. To me, just addressing the fact that adolescents do use substances, and being able to offer advice and education to an adolescent, whether or not they are currently using any substance, is a success.”

Identifying children in homeless situations

Homeless children are considerably more likely than their stably homed peers to have an adverse childhood experience, score lower on standard achievement tests and perform poorly in elementary school, according to literature on homelessness from the National Association for the Education of Homeless Children and Youth.

The burden of homelessness is primarily isolated to low-socioeconomic and urban areas. About 54% of SBHCs are concentrated in urban areas, 28% are located in rural areas and the remainder are in suburban areas. This geographic make-up allows for SBHCs to provide treatment services to the most medically vulnerable populations.

According to a study by Nicole L. Hair, PhD, of the department of health management and policy at the School of Public Health, of the University of Michigan, and colleagues, exposure to low socioeconomic status had negative impacts on development and learning, which are facilitated by a lack of structural brain development.

“Homelessness impacts every area of a child’s health and development — physical, cognitive, emotional and social,” Barbara Duffield, director of policy and programs for the National Association for the Education of Homeless Children and Youth, told Infectious Diseases in Children.

Homelessness usually exists within schools as a vague and hidden form of trauma. Oftentimes, a student will live with multiple family members, friends of family or peers, throughout the school year. This makes screening for homelessness a difficult task for SBHC staff, often only making itself apparent through breakdowns in communication with a child’s parents.

“We often find out that students are homeless during conference time when we are trying to contact a parent and their phone numbers are no longer active,” Irwin said. “We track the student down in the school and ask them, ‘How do we get ahold of your mom?’ And the student replies, ‘Well, she’s living with my aunt right now.’ You go through this whole process to determine where the student is living and eventually find out that they are staying with a friend of a friend — and that this is only temporary until their parents get their apartment back. Suddenly, you are flooded with a lot of information that you didn’t know.”

Educational services provide a constant point of contact between children and supportive adult figures. Because of this, SBHCs are opportunely positioned to address the issues of trauma caused by exposure to homelessness.

“School-based health centers are an essential part of the response to child and youth homelessness,” Duffield said. “School is the only universal safety net for homeless children. There is not a shelter bed for every child who needs one, but there is a federally mandated seat in the classroom for every homeless child and youth.”

Homelessness oftentimes presents itself to SBHC staff as merely a component of multiple compounded forms of trauma. Substance abuse is often a contributing factor in both child-abuse trauma and homelessness.

“Sometimes, we wonder what type of trauma comes first,” Irwin said. “Substance abuse plays a significant role in many homelessness situations. The families that end up displaced, usually one of the core support people, whether it be mom or dad, often has a substance-abuse issue.”

Homelessness is treated by activating government assistance services, which are a mandatory component of every school district nationwide.

“Being able to recognize signs, such as discussion of mobility, sleep disorders, inability to obtain proper nutrition or basic medication, will help health professionals identify homelessness, and make appropriate referrals to the school district homeless liaison, a position required for every school district under federal law,” Duffield said.

In service to the community

Mental health services within SBHCs not only help the individual students, but also contribute to making the school function as a better community service.

According to an AAP policy statement on SBHCs, the combination of mental health and medical health services within a school setting benefits overall school performance. By giving students the access to mental health services, communication between students, parents and staff improves. Other schoolwide positive outcomes include a decrease in tardiness, absences and discipline referrals.

Students who utilized SBHC mental health services also were more likely to be promoted to the next grade level and graduate than students who did not.

“In order for our students to be successful in an educational environment, with all of the other issues that they are dealing with, they absolutely need access to health care,” Irwin said. “The fact that the school is the one constant in their life makes it the best opportunity we are going to have to get them the services.”

Routine screenings for issues related to homelessness, substance abuse, and child abuse are only useful if collaborative relationships exist with local services, according to an AAP policy statement.

“SBHCs play an invaluable role to students, families, communities, and society as a whole, by increasing the access to quality, culturally appropriate mental health services,” Norrington-Sands said. “SBHCs work to address health disparities as well as issues that negatively impact an individual, familial and community functioning. The effectiveness of SBHCs will continue to grow through the expansion of services, reputation establishment and integration within the school and community.”

The evidence-based effectiveness of SBHCs makes them paramount to making significant positive impacts on the lives of students struggling with trauma.

“I cannot imagine not providing these services — it would be a huge disservice to our community,” Irwin said. – by David Costill

• References:
• CDC. Adverse Childhood Experiences (ACE) Study. www.cdc.gov/violenceprevention/acestudy. Accessed July 30, 2015.
• Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2012;doi:10.1542/peds.2011-2662.Council on School Health. Pediatrics. 2012;doi:10.1542/peds.2011-3443.
• Data Resource Center for Child & Adolescent Health. www.childhealthdata.org. Accessed Aug. 7, 2015.
• Hair NL, et al. JAMA Pediatr. 2015;doi:10.1001/jamapediatrics.2015.1475.
• Lofink H, et al. 2010-2011 Census Report of School-based Health Centers. School-Based Health Alliance; 2013. www.sbh4all.org. Accessed July 30, 2015.
• National Association for the Education of Homeless Children and Youth Fact Sheet: Homeless Children and Early Learning. www.naehcy.org. 2015. Accessed August 7, 2015.

• For more information:
• Barbara Duffield, can be reached at bduffield@naehcy.org.
• Leisa Irwin, can be reached at leisa.irwin@paladincareertech.com.
• Mandy McKimmy, DNP, can be reached at mckimmy@ohsu.edu.
• Kimani Norrington-Sands, PhD, can be reached at k.norrington-sands@lausd.net.
• Jane Ripperger-Suhler, MD, can be reached at jarippergersuhler@seton.org.
• Gina Silva, MSW, CSWA, can be reached at gina.silva@lifeworksnw.org.

Disclosures: Duffield, Irwin, McKimmy, Norrington-Sands, Ripperger-Suhler and Silva report no relevant financial disclosures.

Should contraceptive services be included in the range of medical care available through SBHCs?

Students are entitled to the full range of services through SBHCs, rather than a double standard for contraceptives.

The reason SBHCs were created, the original idea, was that teens were largely underserved, particularly low income teens, by the mainstream health system. In addition, they are not terribly great users of preventive care. In order for communities to more effectively deliver preventive services to potentially at-risk teens, we need to bring those services to where they are – in this instance, the schools.

That theory has been well tested for over 40 years now, and we know unequivocally that SBHCs provide improved, increased access to primary care, mental health, oral health and reproductive health services.  

However, if SBHCs aren’t providing reproductive health services, then how are they insuring that adolescents are getting access to this aspect of their care that they can’t follow through on? Granted, it is a small sliver of what adolescents need from their health care provider, but in this instance, especially if you are a sexually active teen, it is an important sliver.

The frequent barrier to implementation is the idea of ‘community values’, often a vocal minority of parents or community leaders who give voice to the idea that “the community doesn’t want adolescents to have access to birth control in schools.” Honestly, this is an issue that was more of a problem 15-20 years ago than it is today. The last census we have from 2010 found that more than 50% of SBHCs reported that they were unable to provide contraception on-site, which is a significant change from 10-15 years ago when approximately 75% of SBHCs reported that they were prohibited from dispensing contraceptives. So, the trend is moving in the right direction.

I would not advocate for a legislative mandate to implement contraceptive services because then we may be ‘throwing the baby out with the bath water’. Communities may choose not to provide this model in their schools if they felt contraceptive services were mandatory; in some instances, these are school policies, so we may have to go school district by school district to take this on.

John Schlitt is the president of the School-Based Health Alliance in Washington DC. He can be reached at 1010 Vermont Ave NW, Suite 600, Washington, DC 20005. Disclosure: Schlitt reports no relevant financial disclosures.

Contraceptive services can be gradually implemented into SBHCs through community engagement.

The offering of reproductive health services in SBHCs has certainly been an area of controversy, in particular the provision of contraceptive services on-site. I believe this stems largely from a certain discomfort among many parents in America about the idea that adolescents could be sexually active and may actually need that protection.

SBHCs quite often have to face this debate and, in doing so, have to address teen sexuality and work within their communities to educate parents and ensure that they are comfortable with the provision of these services. Furthermore, this controversy can even have a ‘ripple effect’ on whether these clinics exist, and I think SBHCs are quite sensitive to the fact that offering sexual and reproductive health services across the board can be controversial.

Unfortunately, a majority of SBHCs do not offer contraceptive services on-site, largely due to the fact that they are prohibited from doing so by either state or local school district laws or policies; it is only in very few cases that schools have adopted their own policy voluntarily prohibiting contraceptive services.

To counter this, many of the SBHCs I have reviewed have had to start off by offering general health services, and gradually begin to offer family planning services, allowing the community to become accustomed to the clinic and the important role that it plays. What we have found is that older clinics are more likely to offer contraceptive services rather than newer clinics, after they have become more established and better able to advocate for these services.

SBHCs serve as a vital source in order to ensure that adolescents have the knowledge they need to wait and delay sex, but also be prepared when they do become sexually active. When young people are surveyed about where they want to receive information regarding sex and prevention from, health care providers are right up there at the top. Adolescents want to hear from doctors and health professionals, and what better place than on school grounds, where access is easy for them and it is easier for providers to link them to the health care they need.

Heather Boonstra, MA, is the director of Public Policy in the Guttmacher Institute in Washington DC. She can be reached at 1301 Connecticut Ave. NW, Ste. 700, Washington DC 20036. Disclosure: Boonstra reports no relevant financial disclosures.