TMA Testimony by Marjan Linnell, MD
Submitted on behalf of:
- Texas Pediatric Society
- Texas Medical Association
Nov. 13, 2018
Chair Raymond, Vice Chair Frank, and Committee Members,
My name is Marjan Linnell, MD, FAAP, and I am a pediatrician at Austin Regional Clinic in Kyle. I am testifying on behalf of more than 51,000 combined members of the Texas Pediatric Society (TPS) and the Texas Medical Association (TMA). Our organizations appreciate the opportunity to testify, and we look forward to working with the legislature during the 86th session on the following strategies to prevent and address childhood trauma and preserve families.
Increase funding for Prevention and Early Intervention (PEI) programs and maximize opportunities made available through the Family First Prevention Services Act to promote resilience and preserve families.
We were happy to see a request for increased funding for PEI programs in the Department of Family and Protective Services (DFPS) Legislative Appropriations Request. The American Academy of Pediatrics (AAP) states that the presence of protective factors such as parental knowledge, social connections, socioemotional competence, and concrete and tangible support in times of need are paramount in determining how children and families fare in times of stress. Voluntary, community-based PEI programs aim to promote resilience in families and prevent interface with the child welfare system, which can be not only traumatic for families, but also costly to the state. For example, in fiscal year 2017, the Nurse-Family Partnership (NFP) demonstrated not only fewer childhood injuries and instances of abuse and neglect in families served, but also a return on investment of more than 500 percent for dollars spent on high-risk populations and a nearly 300-percent return for dollars spent on all individuals served. NFP pairs young expectant women and new moms with home visiting nurses who provide guidance and support on the safe care of newborns and young children. We urge the legislature to increase funding for PEI so these critical and cost-saving programs can serve more children and families in need of support. We also encourage the legislature to invest in the creation and implementation of a strategic plan to maximize the opportunities made available through the federal Family First Prevention Services Act, which provides an opportunity for states to draw down a federal match for trauma-informed mental health, substance use, and in-home parenting support services for children at imminent risk of entering foster care and their families. This spectrum of prevention, both before and when children and families present with imminent risk, helps families build the protective factors needed to mitigate the impact of stress and trauma, build resilience, and remain safely together.
Improve access to mental health interventions, integrated models of care, and information sharing regarding the child’s trauma history to mitigate the impact of trauma on children in Texas foster care.
According to AAP, adverse childhood events (ACEs) often contribute to common life-threatening health conditions, including obesity, heart disease, alcoholism, and drug use.
Children with multiple ACEs are at even greater risk for negative outcomes. Yet, early identification and intervention for children who experiences ACEs can mitigate poor health and social outcomes.
To help physicians better recognize and respond to ACEs, Texas Medicaid provides physician and provider education via webinars developed by the Texas Health Steps program, which promotes well-baby/well-child care for children enrolled in Medicaid, including children in foster care. Moreover, national and state medical societies have provided numerous training opportunities and resources. The AAP Resilience Project, PATTeR Project, and Healthy Foster Care America Trauma Guide help physicians and medical providers implement trauma and ACE-informed approaches. AAP also held a live course, The Trauma-Informed Pediatric Provider, in Houston last spring and will host another this spring in San Antonio.
Last year, TPS and TMA each had educational tracks dedicated to ACEs at their respective annual meetings. TMA has since hosted similar opportunities for the Concho Valley Medical Society and the Austin Psychiatric Society. I am also participating in the TPS Central Texas Pediatric Trauma Learning Collaborative, where my colleagues and I have been working to identify and address ACEs and related factors in the primary care setting. The variety of opportunities available allow us to seek education that fits the needs of our unique specialties, patient populations, and practice schedules.
We know that trauma’s influence on the brain may result in behaviors that potentially can be misidentified as common mental health or developmental diagnoses, but we also know that these issues may be comorbid. Interventions must be tailored individually to meet the needs of each child. Therapy, family and caregiver supports, and medications when needed all can play a role in healing. According to AAP, “it is important to help the child and family understand that medications can alleviate symptoms while the real work of healing is done through therapy. One can think of these medications as serving the same function as a cast does for children with a fracture. They help to stabilize the child so healing can take place. ”
Since 2004, DFPS and the Texas Health and Human Services Commission have collaborated to ensure appropriate prescribing of psychotropic medications to children in foster care, resulting in the creation of a statewide monitoring system and clinical support tool developed with input from practicing physicians. The recent Update on the Use of Psychotropic Medications for Children in Texas Foster Care shows that despite the substantial increase of children in the Texas foster care system, psychotropic prescribing has steadily and significantly decreased since the release of the prescribing parameters in 2005.
Despite gains, we must pair education and system-improvement efforts with better access to mental health care. Difficulty connecting patients, especially Medicaid patients, with quality mental health services remains a huge barrier in our efforts to identify and address childhood trauma. The following recommendations will help ensure we have supports in place that promote healing in children with exposure to trauma:
- Ensure the Medicaid managed care organizations assist primary care physicians with identifying physicians and mental health providers who offer evidence-based treatment modalities such as cognitive behavioral therapy (including trauma-focused cognitive behavioral therapy). Provider directories should indicate clearly which physicians and providers offer evidenced-based treatment. Further, the health plan should help physicians identify these professionals when they are unable to find an in-network physician or provider on their own. Ready access to such information will improve primary care physicians’ ability to refer children to appropriate mental health services.
- Improve access to mental health supports by promoting innovative and integrated models of care such as the Texas Child Psychiatry Access Program (CPAP). The CPAP program would create a statewide network of regional hubs staffed by child and adolescent psychiatrists, licensed mental health clinicians, and resource specialists that assist pediatric primary care physicians in meeting the mental health needs of children. Not only would this assistance to primary care physicians free up psychiatrists and other mental health professionals to serve children with higher needs, but also these hubs can also serve as integrated behavioral health training environments that bolster the mental health workforce.
- Ensure primary care and treating physicians caring for children in foster care have ready access to a child’s trauma history. Without this information, physicians who care for these children cannot establish a baseline understanding of the child’s exposure to trauma. Currently, this information is being shared inconsistently across the state. Because caseworkers and caregivers are tasked with the coordination of so many different services and activities for children in foster care, finding a way to facilitate this sharing of information would be helpful to ensure the physician has a foundational understanding of the child’s trauma.
Thank you again for the opportunity to testify today and for your dedication to the health and well-being of children who have experienced trauma, especially children in the Texas foster care system. We look forward to working with the legislature and other stakeholders to improve access to prevention programs and promote opportunities to better serve the needs of children and families.
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