It specialized in type of trauma care gaining praise
Children are voiceless - this does not help
The University of Iowa Stead Family Children's Hospital is seen in April 2017 from Kinnick Stadium in Iowa City. With UI's Child Assessment Center closed, suspected child abuse cases are no longer referred to an on-site clinic. (Stephen Mally/The Gazette)
By Maria Curi, IowaWatch
As child abuse cases in Iowa spiked dramatically, the University of Iowa Hospitals and Clinics closed a specialized outpatient clinic that provided comprehensive services for 15 years to Eastern Iowa.
The closure means hundreds of child abuse victims and their families will not be able to access a method of trauma care that experts praise.
The facility, the Child Assessment Clinic, was run by Dr. Resmiye Oral, a pediatrician, and was closed last summer. Its clients now are sent 32 miles away to the UnityPoint Health-St. Luke’s Child Protection Center in Hiawatha, one of six such centers in the state.
The shutdown came as the number of child abuse findings sharply increased in Iowa. Abuse findings increased 26 percent to more than 2,000 cases from 2016 to 2017, including increases in sexual abuse, physical abuse, neglect and cases of infants having illegal drugs in their system, according to a report in the Des Moines Register.
Yet the state Department of Human Services, which oversees child protection services, suffered a $4.3 million cutback in state funding amid the growing burden.
Tom Moore, the University of Iowa Health Care spokesman, said the UIHC clinic was closed in part because the hospital considered its clinic and the St. Luke center duplicative in that both are “outpatient settings.”
However, the services of the two clinics were not entirely duplicative, according to an IowaWatch review involving interviews, research and a study of their respective programs.
The UIHC clinic provided markedly different services in a hospital setting than the St. Luke center does, including critical elements of the highly-touted “trauma-informed care” for dealing with child abuse victims and their families.
St. Luke’s — the state’s oldest child protection center — and other child protection centers like it play an important role in protecting children against child abuse in Iowa. It sees a far greater number of cases than the UI clinic.
But Oral said the UIHC Child Assessment Clinic was the only medical setting in Iowa that practiced trauma-informed care with both the children and their parents. Now, trauma-informed care is practiced only on children in mental health clinics such as Orchard Place in Des Moines.
“Sometimes an agency will say they’re practicing trauma-informed care and what they’re really doing is they’re practicing trauma-specific services."
- Gladys Noll Alvarez
Trauma-informed care project coordinator at Orchard Place
Trauma-informed care is a growing movement nationwide, said Gladys Noll Alvarez, trauma-informed care project coordinator at Orchard Place, where she has worked for 33 years.
“We’re one of the only places that … has chosen an organizational model that is a trauma-informed care model to implement and get certified,” Alvarez said.
Alvarez holds a UI master’s degree in social work and has worked with sexual abuse victims in individual, family and group therapy.
She said trauma-informed care is important in treating child abuse “because it understands that trauma is not something that happens to a select group of people, that trauma is universal, and that traumatic things happen to a majority of people and it impacts how we view our relationships with each other, with our clients, with our organization.”
Unlike other child protection centers, the UIHC assessment clinic accepted all abuse and neglect allegations regardless of whether they were reported to Human Services or law enforcement. It also accepted referrals of suspected child abuse victims from emergency rooms and lay people, including parents.
Dr. Charles Jennissen, a UIHC emergency room pediatrician, said Oral’s clinic provided a vital service to the families and children who rely on the UIHC. Although a hospital emergency room is ideal for identifying trauma in patients, it is not a good place for assessing and connecting them with behavioral health specialists. Jennissen said Oral’s clinic was an on-site setting to which he would refer these patients.
Oral, who provides inpatient consultation for children and families admitted to UIHC with concerns about child abuse or neglect, has more than 20 years of experience in child abuse pediatrics. She received training in identifying the cumulative impact on abuse victims from adverse childhood experiences through the ACE Interface Master Training Program.
“Our society has become such a stressful society that all of us are being traumatized,” Oral said. She said effective treatment requires understanding the trauma and family history and other child abuse assessments included in trauma-informed care.
Trauma-informed care can be applied to any system like health care or education. It consists of realizing the widespread impact of trauma, according to the Substance Abuse and Mental Health Services Administration, an agency of the U.S. Department of Health and Human Services. The agency says trauma-informed care specialists understand the potential paths for recovery; and recognize the signs and symptoms of trauma in clients, families, staff and others involved with the system. They respond by integrating that knowledge into procedures and practices that avoid re-traumatization.
HOW IT WORKED AT UIHC
Oral used her clinic as a tool for practicing trauma-informed care by providing in-depth trauma screenings for children and their parents. Screenings identify emotional abuse and other trauma experts categorize as adverse childhood experiences. After those adverse experiences are identified, professionals use that information to resolve issues of abuse and neglect.
Oral said more research is needed to show administrators in charge of allocating hospital funds that trauma-informed care leads to better health outcomes.
In the fiscal 2019 budget, the state’s House Health and Human Services Appropriations Subcommittee allocated $40,511 for the study and collection of data on adverse childhood experiences. Subcommittee Chairman David Heaton, R-Mount Pleasant, said he understands the impact of adverse childhood experiences on someone’s behavior.
“It opens them up to all kinds of problems whether it be physical, mental — it can do everything,” he said.
Professionals measure trauma by the number of adverse experiences a child has confronted.
In 2012, a study from the Central Iowa ACEs Committee found that more than half of the state’s adult population experienced at least one adverse childhood experience. The most common was emotional abuse, which accounted for 28 percent of the total.
Nationwide, nearly 35 million or half of America’s children have experienced one or more types of childhood trauma, according to a 2012 study by the National Center for Health Statistics at the Centers for Disease Control and Prevention.
When the UI Stead Family Children’s Hospital received a patient whom medical personnel suspected was a child abuse victim, the child was sent to the on-site assessment clinic.
At the clinic, Oral conducted a two-to-four-hour psychosocial assessment to identify adverse childhood experiences involving the child and the parents.
If the assessment indicated that families needed supplemental attention, Oral would connect them with therapists, psychologists and integrated pediatric health homes where care for adults with a serious mental illness and children with serious emotional disturbances are treated.
But, with the clinic now closed, a suspected child-abuse victim instead is sent from the Children’s Hospital to St. Luke’s Child Protection Center in Hiawatha.
The instances that have not been reported to Human Services or law enforcement but are at risk for abuse have one less clinic to go to where trauma-informed care is available, and they have no clinic available where these services are provided to both the children and parents.
HELP AT ST. LUKE’S
St. Luke’s is one of six child protection centers in Iowa and concentrates on child abuse cases.
The full process at St. Luke’s includes a forensic interview to determine facts about the suspected abuse, medical examination and a session involving the parents and a family advocate to assess parents’ attitudes and teach them about child abuse.
Julie Kelly, manager of St. Luke’s Child Protection Center, said in an interview that “we are not providing in-depth screenings for trauma, but I’m not sure what it is that she (Oral) was providing, just to be quite honest.”
When asked in a follow-up email whether it would be accurate to say St. Luke’s center does not practice trauma-informed care, Kelly wrote back: “That statement is absolutely not true or accurate. St. Luke’s CPC practices trauma-informed care.”
The center declined to supply IowaWatch with a list of its providers, or say whether its staff has received trauma-informed care training.
The staff, in addition to Kelly, includes a forensic interviewer trained and certified by the National Children’s Alliance, a medical director who is a family practice physician trained in child abuse, a registered nurse certified in sexual assault examinations and a family advocate certified in victim services. Kelly is a licensed master social worker and has worked at the St. Luke’s Child Protection Center for 23 years. She became manager of the center in December 2011.
“Sometimes an agency will say they’re practicing trauma-informed care and what they’re really doing is they’re practicing trauma-specific services,” said Alvarez.
Trauma-specific services recognize trauma and include collaborating with other human services agencies, which St. Luke’s does. In contrast, trauma-informed care, which Oral’s clinic practiced, requires that the entire organization be trained, and screenings have to be done not just on patients and but also on the agency’s staff.
Those screenings are required for everyone — from receptionists to administrators, according to the Substance Abuse and Mental Health Services Administration — so they understand their own trauma because that “greatly” influences the individual’s receptivity and engagement with the services they provide.
“Whenever I’m speaking to people I really talk about the difference between just practicing trauma-informed interventions — which is very good, (and) I’m not downgrading that at all — but when an agency is practicing trauma-informed care it’s looking at trauma from both sides of that lens,” Alvarez said.
WHY CLINIC CLOSED
Oral said she thinks the UIHC closed the clinic because the Iowa Legislature cut Medicaid in fiscal 2018.
“It comes down to money,” Oral said. “And I don’t blame our administrators, because it is the Legislature’s responsibility. They cut down the budgetary support to the UIHC to such an extent administrators are left with no option but cutting costs.”
But Moore, the spokesman, said the UIHC’s decision to shut down Oral’s clinic had nothing to do with cost-cutting. In addition to eliminating what he calls duplication, Moore said UIHC wanted to increase collaboration with St. Luke’s center.
“The primary reason that the Child Assessment Clinic closed was to enable the UI to focus on its duty to provide inpatient care and ensure that outpatient services were provided by Child Protection Centers to patients and families affected by either a suspicion of, or evidence of, child abuse or neglect,” he wrote in an email.
At St. Luke’s Child Protection Center, a child believed to be victim of abuse meets with a forensic interviewer who seeks information about the abuse allegation that may be used in a criminal investigation and for determining the appropriate services for the child and family.
Authorities from Human Services and law enforcement observe the interview so the child does not have to repeat the experience to different agencies.
At the same time, family advocate Nancy Scheumann meets with the parents or guardians of the child in a referral and education session to discuss an information packet. That session reviews child abuse dynamics and behaviors the parents may expect from their child.
Scheumann also assesses the parents’ attitudes and feelings about the child abuse allegations, the investigation and the process used to assess the safety of the child’s living arrangements. She makes written referrals to follow-up sources when needed.
In fiscal 2017, the St. Luke’s Child Protection Center reported to the Iowa Department of Public Health that it saw 849 children and their families. Scheumann sees and follows up on an average of 12 families per week.
Oral’s clinic saw between 80 to 100 patients per year.
Both the Child Assessment Clinic and St. Luke’s center have provided evidence against child abusers to law enforcement. And both follow-up with the families until they indicate it is no longer needed.
Since closure of the Child Assessment Clinic at the UIHC, St. Luke’s Child Protection Center has seen an increase in consultations with medical staff and in medical referrals from the hospital, Kelly said.
But St. Luke’s doesn’t get any funding from UIHC. It’s funded through grants from St. Luke’s Hospital and private donations received through St. Luke’s Healthcare Foundation.
Kelly said the center used to have a full-time and a part-time family advocate, but the part-time family advocate was let go because there wasn’t enough work.
Now that the center is accepting referrals from the UIHC and its workload has increased, Kelly and Scheumann said they need another advocate.
“I think our center and all the other centers are doing a great job for families,” Kelly said.
This article was produced by the Iowa Center for Public Affairs Journalism-IowaWatch.org, a nonprofit news website that collaborates with Iowa news organizations to produce explanatory and investigative reporting.
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