There are decades of empirical work that establish the link between mood, cognitions, sensory perception, and the experience of physiological suffering (Tang, Salkovskis, Hodges, Wright, Hanna & Hester, 2008; Stroud, Thorn, Jensen, & Boothby, 2002). Furthermore, perceived threats to the physical or psychological integrity of self or others can produce physiological dysregulation and alterations in neurophysiology and neurofunctioning (Schore, 2001; DeBellis, Keshavan, Clark, Casey, Giedd, Boring, et al. 1999; Perry, 2001). However, 21st century healthcare is still largely characterized by a siloed approach to service delivery, where physiological and psychological treatments are provided by disparate groups of professionals, in separate settings, with little coordination of care (Hogan, 2003). In contrast, integrated models provide behavioral health services within primary care settings and emphasize collaboration between primary care professionals and mental health providers. In 2003, the President’s New Freedom Commission on Mental Health recognized this gap and issued a challenge, “Understanding that mental health is essential to overall health is fundamental for establishing a health system that treats mental illnesses with the same urgency as it treats physical illnesses.” (p. 15). A meta-review of behavioral outcome studies for several disease categories (i.e., cardiovascular disease, diabetes, chronic back pain, depression, asthma) noted positive changes in physiological and service utilization outcomes as a result of psychosocial intervention delivered in healthcare settings (Center for the Advancement of Health, 2000). However, to some, the most persuasive argument for an integrated healthcare model is embedded in the medical offset research that documents significant healthcare savings in venues where psychosocial treatments are used in conjunction with physical care. In fact, Cummings, O’Donohue, & Ferguson (2003) report a 20% to 30% reduction in medical cost above and beyond expenditures associated with psychosocial or behavioral care provision in an integrated model, findings that have been replicated across settings and sectors (Levant, House, May, & Smith 2006; Chiles, Lambert, & Hatch, 1999).
The promise and utility of integrated healthcare is particularly salient in the pediatric arena. Childhood can be a vulnerable period for the onset of emotional and behavioral problems, often brought about by child maltreatment, violence exposure and other adverse childhood experiences (Shonkoff & Phillips, 2000). If untreated, these problems may persist into adolescence and adulthood and are associated with a compromised health trajectory, and increased healthcare cost (See Adverse Childhood Experiences Study by Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, et al. 1998).
The University of Kentucky Center on Trauma and Children provides a pathway to integrated care for trauma-exposed children by providing training on traumatic stress detection for pediatric healthcare providers, conducting biopsychosocial assessments of at-risk children, and through the provision of integrated behavioral healthcare. The center uses a framework that supports integration of psychosocial and physical care through:
Coordinated design and implementation of services: Building a cooperative culture by involving all partners in the development and implementation of the care model.
Structured coordination: Operationalizing roles and responsibilities so that boundaries and points of interface are clearly defined, communication pathways are established, and accountability is appropriately sited.
Maintenance of reciprocal feedback loops that keep the partners informed of client outcomes, feedback, areas for quality improvement, and the effectiveness of small tests of change.
This integrated framework allows for the expeditious delivery of psychosocial and healthcare interventions to families in all areas of the state, where access to services may be limited. The center also strives to create community capacity to provide integrated trauma-informed care to children throughout the state, through its training and education programs. For more information about the UK Center on Trauma and Children and integrated trauma-informed care for children, please visit our website at ctac.uky.edu.
Chiles Ja, Lambert MJ, Hatch AL. (1999). The impact of psychological interventions on medical cost offset: a metaanalytic review. Clinical Psychological Science and Practice. 6:204–20.
Cummings, N.A., O’Donohue, W.T., & Ferguson, K.E. (Eds.). (2003). Behavioral health in primary care: Beyond efficacy to effectiveness. Cummings Foundation for Behavioral Health: Health utilization and cost series (Vol. 6). Reno, NV: Context Press.
DeBellis, M., Keshavan, M., Clark, D., Casey, B., Giedd, J., Boring, A. et al. (1999). Developmental traumatology part II: Brain Development. Biologic Psychiatry, 45, 10, 1271– 1284.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. American Journal of Preventive Medicine,14: 245–258.
Hogan, M. (2003). New Freedom Commission Report: The President’s New Freedom Commission recommendations to transform mental health care in America, Psychiatric Services, 54,11,1467–1474.
Levant, R., House, A., May, S., & Smith, R. (2006). Cost offset: Past, Present, and Future, Psychological Services, 3, 3 195–207).
Perry, B.D. (2001). The neurodevelopmental impact of violence in childhood. In Textbook of Child and Adolescent Forensic Psychiatry, (Eds., D. Schetky and E.P.Benedek) American Psychiatric Press, Inc., Washington, D.C. pp. 221–238.
Schore, A., (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health, Infant Mental Health Journal, 22, 201–269.
Shonkoff, J. P. & Phillips, D.A. (2000). From Neurons to Neighborhoods: The science of Early Childhood Development. Washington, DC: National Academies Press
Stroud, M., Thorn, B., Jensen, M., & Boothby, J. (2000). The relation between pain, beliefs, negative thoughts, and psychosocial functioning in chronic pain patients, Pain, 84, 347–352.
Tang N. Salkovskis, P., Hodges, A, Wright, K., Hanna, M., Hester, J. (2008). Effects of mood on pain responses and pain tolerance: An experimental study in chronic back pain patients, Pain, 138, 392–401.
Ginny Sprang, PhD, is the Buckhorn endowed professor of Child Welfare and Children’s Mental health at the University of Kentucky and executive director of the Center on Trauma and Children. She can be reached at (859) 543-0078.