Identifying and Addressing Traumatic Stress and Suicidality in Youth Served by Children’s Advocacy Centers

Summary

Children who experience maltreatment are at high risk for posttraumatic stress disorder (PTSD). Sexual abuse is associated with more than twice the risk of PTSD and three times the risk of suicide attempts.^1,2 Children’s Advocacy Centers (CAC) are “one-stop shops” for children and families after allegations of sexual abuse and other severe maltreatment. There are over 950 CACs in the US, and they serve hundreds of thousands of children annually. CACs use multidisciplinary, cross-system teams of professionals to investigate allegations of sexual abuse and other severe maltreatment and connect families to services.^3–5 Team members are well-positioned to identify at-risk youth and connect them to evidence-based mental health treatments. However, implementing mental health screening and referral practices is challenging.⁶ There is an urgent need to strengthen mental health screening/referral efforts in CACs and identify effective implementation strategies for team-based settings. 

This case study describes efforts to improve the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS). The Care Process Model for Pediatric Traumatic Stress (CPM-PTS) is a brief screening and response protocol to guide the identification of and response to trauma, suicidality, and traumatic stress in children ages 5 to 18 years old.⁷ It was developed at the University of Utah with a grant from the Substance Abuse and Mental Health Services Administration (Principal Investigator: Brooks Keeshin, MD). The CPM-PTS includes two parts: 1) evidence- based screening tools for posttraumatic stress (UCLA PTSD Reaction Index Brief Form⁸) and suicide risk (Columbia-Suicide Severity Rating Scale⁹) completed by youth or their caregivers and 2) technology-guided decision support to support frontline CAC staff in responding. 

Researchers at the University of Utah and the University of Pittsburgh studied how the CPM-PTS was implemented in CACs and found that implementation was challenging for many.⁶ Common barriers were staff self-efficacy and comfort with suicidality, competing workflows, and limited time; facilitators included training and support in responding to suicidality, external funding, workflow integration, and leadership support.⁶ Teamwork was also important for implementation.¹⁰ Together, the researchers are developing new ways to better implement the CPM-PTS in team-based settings like CACs.¹¹ 

Significance

More than 30 CACs across the country have implemented the CPM-PTS, delivering it to thousands of youth.^6,12,13 Using the CPM-PTS, CAC staff have screened youth for traumatic stress symptoms and suicidality, delivered brief interventions, and connected youth to evidence-based mental health treatments. Use of the CPM-PTS improves early identification and treatment access for youth experiencing PTSD symptoms. Strategies that improve implementation of the CPM-PTS will further improve outcomes for youth served by CACs. These strategies may also improve use of evidence-based interventions in similar team-based settings. 

The CPM-PTS provides a structured approach that reduces variability and potential biases in referral decisions, improving equity in responses to suicidality and mental health needs across groups. In addition, CACs have wide reach into rural areas, where youth have high suicide rates¹⁴ and are less likely to receive mental health care.¹⁵ The CPM-PTS has been implemented in more than 20 CACs serving rural and frontier youth. 

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Developed care process model for systematically identifying and responding to post-traumatic stress in youth.  demonstrated.

Clinical

Guidelines

Created electronic infrastructure for administering screening tools and providing decision support for frontline providers. demonstrated.

Clinical

Software technologies

Screened thousands of youth for traumatic stress, and connected hundreds of youth to evidence-based mental health treatments.  demonstrated.

Community

Community health services

Expanded access to evidence-based treatments for post-traumatic stress.  demonstrated.

Community

Health care accessibility

Provided brief interventions to two-thirds of youth served by CACs via frontline staff.  demonstrated.

Community

Health care delivery

Developed training and psychoeducational resources for child abuse professionals working with CACs.  demonstrated.

Community

Health education resources

Improved the quality of services provided to youth by Children’s Advocacy Centers (CACs).  demonstrated.

Community

Health care quality

Provided psychoeducation to caregivers about supporting youth after trauma via frontline staff.  demonstrated.

Community

Disease prevention & reduction

Improve youth mental health and reduced post-traumatic stress symptoms through engagement in evidence-based treatment.  potential.

Community

Life expectancy & quality of life

Reduce suicide risk.  potential.

Community

Life expectancy & quality of life

Reduce social and economic costs related to youth post-traumatic stress and suicide.  potential.

Economic

Societal & financial cost of illness

Published statewide data to provide information on the prevalence of trauma exposure, traumatic stress symptoms, and thoughts of suicide/self-harm among youth served by Children’s Advocacy Centers (CACs).  demonstrated.

Policy

Scientific research reports

Published papers describing associations between teamwork and implementation outcomes.  demonstrated.

Policy

Scientific research reports

The state of Utah added a Mental Health Services Specialist position to provide ongoing training and support for the Care Process Model for Pediatric Traumatic Stress (CPM-PTS).  demonstrated.

Policy

Policies

Screening for traumatic stress and suicidality is incorporated into standard procedures at over 20 Children’s Advocacy Centers (CACs). demonstrated.

Policy

Policies

This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹⁶

Clinical

The CPM-PTS provides frontline staff at CACs with clear guidelines for systematically identifying and responding to post-traumatic stress and suicidality in youth. We developed electronic infrastructure that allows easy administration of screening tools and facilitates consistent decision-making in accordance with best practice recommendations. 

Community

The CPM-PTS has been implemented by more than 30 CACs so far. We provided resources, training, and ongoing support to support its implementation, using lessons learned from our ongoing research. Effective implementation of the CPM-PTS has improved the quality of services provided by CACs and directly impacted the youth they serve. 

Thousands of youth have been screened for post-traumatic stress and received brief interventions to reduce symptoms. Hundreds have been connected to evidence-based treatments that may reduce post-traumatic stress and suicide risk over time. 

Economic

Improving identification of youth at risk for PTSD and suicide and connecting these youth to effective treatments has the potential to reduce the social and economic costs of PTSD and suicide. 

Policy

Our published research on the implementation of the CPM-PTS has informed efforts to implement the CPM-PTS in CACs across the country. This work has also led to policy changes at the local, state, and national levels through the policies of individual CACs, state chapters of CACs, and the national organization for CACs, the National Childrenʼs Alliance. 

Lessons Learned

Our work was conducted in close collaboration with community partners, including professionals working in and with CACs, CAC leadership, and state and national organizations. The active involvement of our partners shaped our path through the different phases of this project and magnified its impact on practice.