Welcome to the training on Addressing Adverse Childhood Experiences through Trauma-Informed Care provided by Texas Health and Human Services (HHS) and the Texas Department of State Health Services (DSHS).
The goal of this module is to equip Texas Health Steps providers and other health-care professionals to recognize adverse childhood experiences (ACEs), the resulting trauma and toxic stress, screen for health consequences, and provide culturally sensitive trauma-informed care for children and adolescents.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Specify the nature of adverse childhood experiences (ACEs), their impact on short- and long-term health, and the providers’ role in addressing them.
- Apply ethical guidelines for reporting suspected abuse and neglect.
- Assess the steps required to provide culturally sensitive trauma-informed care to children, adolescents, and caregivers affected by ACEs.
Please note this module expires on 3/9/2021.
This module was released on 3/9/2018.
Continuing Medical Education
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Texas Medical Association (TMA) through the joint providership of The Texas Department of State Health Services, Continuing Education Service and Texas Council of Community Centers. The Texas Department of State Health Services, Continuing Education Service is accreditated by TMA to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Nursing Education.
The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Social Work Education.
Licensed Professional Counselors
The Texas Department of State Health Services (DSHS), Continuing Education Service is an approved provider (#690) by the Texas State Board of Examiners of Professional Counselors to offer continuing education contact hours to Licensed Professional Counselors. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) for Licensed Professional Counselors.
Licensed Marriage and Family Therapists
The Texas Department of State Health Services, Continuing Education Service is an approved provider (#466) by the Texas State Board of Examiners of Marriage and Family Therapists to offer continuing education contact hours to Licensed Marriage and Family Therapists. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) for Licensed Marriage and Family Therapists.
Certified Community Health Worker
The Texas Department of State Health Services, Promotor(a)/Community Health Worker Training and Certification Program has certified this course for 1.50 contact hour(s) of continuing education for Certified Community Health Workers and Community Health Worker Instructors.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated 1.50 hour(s) for attendance.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
- American Academy of Pediatrics (AAP) Policy Statement: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health
Presents the AAP’s endorsement of a developing leadership role for the entire pediatric community to bring about fundamental change in early childhood policy and services.
- Texas Health Steps Anticipatory Guidance Resource List
Comprehensive list, includes AAP’s Bright Futures, a resource for a variety of screening tools and forms; Connected Kids: Safe, Strong, Secure, a resource for anticipatory guidance; and the United Way’s Ages and Stages website. Also includes patient education resources.
Acutely Traumatized Children: Identifying and Managing Posttraumatic Stress
Provides practical suggestions and resources to enable providers to apply the surveillance, trauma-informed anticipatory guidance, and evaluation (STAGE) approach to caring for traumatized children and their parents within the constraints of real-world pediatric practice.
- The 12 Core Concepts: Concepts for Understanding Traumatic Stress Responses in Children and Families
Developed by the National Child Traumatic Stress Network (NCTSN), the concepts cover a broad range of points that practitioners and agencies should consider as they strive to assess, understand, and assist trauma-exposed children, families, and communities in trauma-informed ways.
- Adverse Childhood Experiences (ACE) Study
Major findings, statistics, and other tools housed on the Centers for Disease Control and Prevention (CDC) website.
- AAP’s Trauma Toolbox for Primary Care
A six-article series for health-care providers from the AAP. Available in English and Spanish.
- Child Welfare Information Gateway website
Clearinghouse of information promoting child and family well-being; public awareness and creative, supportive communities; prevention programs; and evidence-based practice.
- National Child Traumatic Stress Network
Features a robust clearinghouse of materials on child traumatic stress arranged by audience, topics, and online research.
- Safe, Stable, and Nurturing Relationships May Shield Children Against Poor Health Later in Life
A CDC web page with information about promoting healthy, safe, stable, and nurturing surroundings to counter adverse experiences in childhood, promote optimal development, and reduce disparities in health.
- Texas Department of Family and Protective Services (DFPS) Data Book
The Annual Report and Data Book is an overview of DFPS programs, services, performance, and accomplishments, and a comprehensive statistical resource of DFPS services.
- AAP’s The Resilience Project
Includes symptom-specific video vignettes demonstrating how to approach children and their parents in a clinical setting.
- Through Our Eyes: Children, Violence, and Trauma
A series of videos addressing public awareness about violence and abuse, treatment, advocacy, community-based approaches, school interventions, and more. Also offers an online resource guide from the U.S. Department of Justice Office for Victims of Crime.
- Trauma-Informed Care Consortium of Central Texas
Provides Central Texas with information about trauma through online resources, quarterly newsletter, online access to trauma-informed services, and centralized calendar for trauma trainings (these trainings are available for professionals, parents, and others).
Practice Resources for Identifying, Screening, and Referral
- Ages and Stages
Parent-completed developmental and social-emotional screening tools designed to help pinpoint delays as early as possible.
- AAP’s Bright Futures Tool and Resource Kit
Includes forms to streamline preventive medical checkups; documentation forms to reflect the richness of a Bright Futures checkup and to document work; practice management tools; and additional tools designed to aid in screening and developing community linkages, such as the Pediatric Symptom Checklists.
- Child and Adolescent Needs and Strengths Trauma Exposure and Adaptation Version (CANS-TEA)
An information integration tool for children and adolescents exposed to traumatic events.
- Child Sexual Behavior Inventory (CSBI) (Version 2)
Evaluates children ages 2 through 12 years who have been or may have been sexually abused.
- Co-Occurring Joint Action Council (COJAC) Screening tool (CST)
A short and simple tool to screen individuals for co-occurring disorders.
- Texas Department of State Health Services: Child Abuse Screening, Documenting, and Reporting Policy for Contractors and Providers
State of Texas requirements for screening, documenting, and reporting child abuse are described in detail.
- Disorder Specific Severity Measures
From the DSM-5, this may be administered to individuals who have received a diagnosis or who have a clinically significant syndrome that falls short of meeting full criteria. Some of the assessments are self-completed while others require a clinician to complete. For children ages 11 through 17 years, includes measures for anxiety, depression, panic disorder, and PTSD, among others.
- Identifying, Treating, and Referring Traumatized Children: The Role of Pediatric Providers
Features a short version of the UCLA Post-Traumatic Stress Disorder-Reaction Index (PTSD-RI).
- The National Child Traumatic Stress Network. Types of Traumatic Stress.
A list of the common types of traumatic stress that can be experienced by children.
- Parents' Evaluation of Developmental Status (PEDS)
Evidence-based screen that elicits and addresses parental concerns about a child's language, motor, self-help, early academic skills, behavior, and social-emotional/mental health; indicates when parental concerns suggest problems requiring referral and which concerns are best responded to with advice or reassurance.
- Texas Child and Adolescent Needs and Strengths (CANS)
Used to assess needs, strengths, and level of care.
- Texas Health Steps Checkup Components web page
A summary of the federal- and state-mandated components of a Texas Health Steps medical checkup, which must be documented in the medical record as a condition for provider reimbursement by Medicaid.
- Texas Local Mental Health Authorities (LMHAs)
List and locations of 38 Local Mental Health Authorities overseen by the Texas Department of State Health Services (DSHS).
- Trauma Symptom Checklists for Children (TSC-C) and Young Children (TSCYC)
Evaluates acute and chronic post-traumatic symptoms in children and adolescents ages 8 through 16 years, and young children ages 3 through 12 years, respectively.
- Traumatic Events Screening Inventory (TESI-C)
A 15-item physician-administered interview that assesses a child's experience of a variety of potential traumatic events.
- Visit Discharge and Referral Summary for Family
Part of the AAP’s Helping Foster and Adoptive Families Cope with Trauma guide, this form is designed to be completed by the provider and given to family members to guide them in following up on referrals, and having the correct information to provide to the receiving/referred professional. It may also be useful for the provider when communicating with a mental health professional. This form is not intended to provide a complete history, nor is it for the referred professional to complete. The form can be completed electronically, printed, and provided to the family, and saved to your files.
- ACES Too High website
Go-to website for background, news, and information about the ACE Study, developmental neurobiology — how severe stress and trauma affect a child’s developing brain and nervous system, and epigenetics, specifically, how our genes turn off and on in response to our experiences and social environment.
- National Child Traumatic Stress Network (NCTSN) Resources for School Personnel web page
Effective resources for educators and school personnel that include information on bullying and cyber bullying, psychological first aid, speaker series, and the Child Trauma Toolkit for Educators. Some materials available in English and Spanish.
- The Trauma Informed Care Project resources web page
Publications, links, videos, and books from an organizational structure and treatment framework focused on understanding, recognizing, and responding to the effects of all types of trauma. In addition, the project emphasizes physical, psychological, and emotional safety for both consumers and providers, and helps survivors rebuild a sense of control and empowerment.
Children and Youth with Special Health-Care Needs
- Association of Maternal and Child Health Programs web page
Resources for the care of children and youth with special health-care needs.
- Culturally-Sensitive Trauma-Informed Care web page
Part of the Children’s Hospital of Philadelphia Health Care Toolbox website; features key component explanations and provider materials that include questions to ask patients and care delivery tips.
Foster and Adoptive Families
- Healthy Foster and Adoptive Families Cope with Trauma: A guide for pediatricians
A webinar and downloadable guide from the AAP to support adoptive and foster families by strengthening the abilities of pediatricians to identify traumatized children and educate families and empower them to respond to a child’s behavior in a manner that acknowledges past trauma but promotes the learning of new, more adaptive reactions to stress. Includes a Coding Tips sheet and Visit Discharge Form for evaluations involving screening and anticipatory guidance related to trauma and other mental health/developmental concerns.
- Cenpatico U
Provides extensive trauma training to caseworkers, foster families, child-placing agencies, residential treatment centers, and others within the child welfare system, using the National Child Traumatic Stress Network (NCTSN) Child Welfare Trauma Training Toolkit.
- Historical Trauma Among the Native American Population: What Service Providers Need to Know
Created for the Indian Country Child Trauma Center, whose mission is to develop culturally appropriate interventions and improve treatment and services for all children and adolescents in Indian Country who have experienced traumatic events.
Maternal PTSD and Depression
- Maternal Posttraumatic Stress Disorder and Depression in Pediatric Primary Care Association With Child Maltreatment and Frequency of Child Exposure to Traumatic Events
Discusses potential for screening and intervention for maternal PTSD and maternal depression, to increase a provider’s ability to reduce children's exposure to traumatic stress and maltreatment.
- Edinburgh Postnatal Depression Scale
Developed for screening postpartum women in outpatient, home visit settings, or at the 6- to 8-week postpartum examination.
- Patient Health Questionnaire-9 (PHQ-9)
A depression assessment measure from the DSM-5 developed to be administered at the initial patient interview and to monitor treatment progress.
- Medical Events and Traumatic Stress in Children and Families
A slide presentation on medical trauma by The Center for Pediatric Traumatic Stress at the Children’s Hospital of Philadelphia and available on the NCTSN web site.
- Pediatric Medical Traumatic Stress Toolkit for Health Care Providers
Offers a compendium of tools to guide medical professionals in effectively assessing and treating medical traumatic stress in children and families, from the NCTSN.
- Psychosocial Assessment Tool
A brief screening tool used for assessing psychosocial risk in families of children newly diagnosed with cancer.
- Center for the Study of Traumatic Stress
Study, research, and intervention on the impact of war, including deployment stress, parenting and family function, and the impact of war injuries on military children and families.
- 2-1-1 Texas
A free, confidential information and referral phone line answered 24/7 by nationally certified specialists with access to a comprehensive database of community organizations, government agencies, and nonprofits in Texas.
- AAP’s Mental Health Initiatives website
Dedicated to transforming systems and practices, building clinician skills, disseminating tools, and enhancing community resources for mental health/substance abuse care.
- Behavioral Health Treatment Services Locator
Sponsored by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to assist in finding alcohol and drug abuse treatment or mental health treatment facilities and programs around the country.
- California Evidence-Based Clearinghouse for Child Welfare (CEBC)
Provides a searchable database of programs for professionals serving children and families involved with the child welfare system. Program descriptions include a CEBC Scientific Rating, citations and summaries of relevant peer-reviewed research on the program, program description, and training and contact information.
- Evidence-Based Child and Adolescent Psychosocial Interventions
Outlines evidence-based child and adolescent psychosocial interventions and includes traumatic stress as one of the presenting problems. Published by and updated twice a year by AAP’s Pediatrics journal.
- National Registry of Evidence-based Programs and Practices (NREPP)
SAMHSA’s searchable online database of mental health and substance abuse interventions. NREPP is one way that SAMHSA is working to improve access to information on evaluated interventions and reduce lag time between the creation of scientific knowledge and its practical application in the field.
- Psychological First Aid Field Operations Guide (PFA)
Developed by the NCTSN and the National Center for PTSD, PFA is an evidence-informed approach for assisting children, adolescents, adults, and families in the aftermath of disaster and terrorism. The website offers free online training and downloadable first aid manuals in English, Spanish, Japanese, and Chinese.
- Seeking Safety
A model of counseling to help improve coping skills, originally developed for trauma, substance abuse, and/or post-traumatic stress disorder (PTSD). It is also applied broadly to increase coping and stabilization.
- Trauma-Focused Cognitive Behavioral Therapy for Children Affected by Sexual Abuse or Trauma (TF-CBT)
An issue brief from the Child Welfare Information Gateway that explores research and practice on trauma-focused cognitive-behavioral therapy (TF-CBT), an evidence-based treatment approach shown to help children, adolescents, and their parents overcome trauma-related difficulties.
- Trauma-Informed Treatment: Best Practices
A downloadable PowerPoint presentation by James A. Peck, PsyD at the 2009 Los Angeles County Annual Drug Court Conference.
- American Academy of Pediatrics, Council on Community Pediatrics, Linton, J. M., Griffin, M., & Shapiro, A. J. (2017). Policy Statement: Detention of Immigrant Children.
- American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics. (2012, reaffirmed 2016). Policy Statement: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics, (129)1, 224-231.
- American Academy of Pediatrics and Dave Thomas Foundation for Adoption. (2015). Helping Foster and Adoptive Families Cope with Trauma.
- American Academy of Pediatrics, Council on Foster Care, Adoption, and Kinship Care, Committee on Adolescence, & Council on Early Childhood. (2015). Policy Statement: Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics, (136)4: e1131-40.
- American Academy of Pediatrics. (2014). Trauma Toolbox for Primary Care.
- American Academy of Pediatrics, Committee on Pediatric Workforce. (2013). Policy Statement: Enhancing Pediatric Workforce Diversity and Providing Culturally Effective Pediatric Care: Implications for Practice, Education, and Policy Making. Pediatrics, 132(4), e1105-e1116.
- American Academy of Pediatrics, Committee on Child Abuse and Neglect. (2010). Child Abuse, Confidentiality, and the Health Insurance Portability and Accountability Act. Pediatrics, 125(1), 197-201.
- Attorney General of Texas. (2013). When You Suspect Child Abuse or Neglect: A General Guide.
- Bethell, C. D., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse Childhood Experiences: Assessing The Impact On Health And School Engagement And The Mitigating Role Of Resilience. Health Affairs, (33)12.
- Briggs-Gowan, M. J., Ford, J. D., Fraleigh, L., McCarthy, K., & Carter, A. S. (2010). Prevalence of exposure to potentially traumatic events in a healthy birth cohort of very young children in the northeastern United States. Journal of Trauma Stress, 23(6): 725-733.
- Centers for Disease Control and Prevention. (2012). Child abuse and neglect cost United States $124 billion. [Press release].
- Centers for Disease Control and Prevention, Injury Prevention & Control: Division of Violence Prevention. (n.d.). Adverse Childhood Experiences, looking at how ACEs affect our lives & society.
- Children’s Hospital of Philadelphia. (2013). Recognizing Burnout and Compassion Fatigue.
- Center on the Developing Child at Harvard University. (n.d.). The Impact of Early Adversity on Children's Development Video.
- Dierkhising, C. B., Ko, S. J., Woods-Jaeger, B., Briggs, E. C., Lee, R., & Pynoos, R. S. (2013). Trauma histories among justice-involved youth: findings from the National Child Traumatic Stress Network. European Journal Psychotraumatology, (2013)4.
- Ellis, W.R. & Dietz, W.H. (2017). A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model. Academic Pediatrics, 17(7S).
- Felitti, V., & Anda, R. (2010). The relationship of adverse childhood experiences to adult health, well being, social function and health care (Chapter 8). The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease, Cambridge University Press.
- Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2015). Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results From the National Survey of Children's Exposure to Violence. JAMA Pediatrics, 169(8):746-54.
- Gerson, R., & Rappaport, N. (2013). Traumatic stress and posttraumatic stress disorder in youth: Recent research findings on clinical impact, assessment, and treatment. Journal of Adolescent Health, 52(2), 137-143.
- Harvard University, Center on the Developing Child. (2017). Toxic Stress.
- Horner, G. (2016). Resilience. Journal of Pediatric Health Care, 31(3): 384-390.
- Jones, R., Flaherty, E. G., Binns, H. J., Price, L. L., Slora, E., Abney, D., … Sege, R. D. (2008). Clinicians’ Description of Factors Influencing Their Reporting of Suspected Child Abuse: Report of the Child Abuse Reporting Experience Study Research Group. [Abstract]. Pediatrics, 122(2), 259-266.
- Luthar, S. S., & Eisenberg, N. (2017). Resilient Adaptation Among At-Risk Children: Harnessing Science Toward Maximizing Salutary Environments. Child Development, 88(2):337-49.
- Pfifferling, J-H., & Gilley, K. (2000). Overcoming Compassion Fatigue. Family Practice Management, 7(4).
- Sege, R. D., & Amaya-Jackson, L., American Academy of Pediatrics Committee on Child Abuse and Neglect, Council on Foster Care, Adoption, and Kinship Care; American Academy on Child and Adolescent Psychiatry Committee on Child Maltreatment and Violence; National Center for Child Traumatic Stress. (2017). Clinical Report: Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment. Pediatrics, 139(4): e1-13
- Shanley, J. R., Shropshire, D., & Bonner, B. L. (2009). To Report or Not Report: A Physician’s Dilemma. Virtual Mentor, 11(2), 141-145.
- Shonkoff, J. P., Garner, A. S., AAP Committee on Psychological Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics. (2012). The Lifelong Effects of Early Childhood Adversity and Toxic Stress, Pediatrics, 129(1), 232-246.
- Southammakosane, C., & Schmitz, K. (2015). Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety. Pediatrics, 136(2): 351-9.
- Szilagyi, M., Kerker, B. D., Storfer-Isser, A., Stein, R. E., Garner, A., O’Connor, K. G, . . . McCue Horwitz, S. (2016). Factors Associated With Whether Pediatricians Inquire About Parents' Adverse Childhood Experiences. Academic Pediatrics. 16(7):668-75.
- Substance Abuse and Mental Health Services Administration, Trauma and Justice Strategic Initiative. (2014). Concept of Trauma and Guidance for a Trauma-Informed Approach.
- Substance Abuse and Mental Health Services Administration, GAINS Center. (n.d.). How Being Trauma Informed Improves Criminal Justice System Responses. Fact Sheet: Historical Trauma.
- Texas Department of Family and Protective Services. (2013). Department of Family and Protective Services 2016 Data Book.
- Texas Department of State Health Services. (2010). DSHS Child Abuse Screening, Documenting, and Reporting Policy For Contractors Providers.
- Texas Department of State Health Services. (2017). Texas Health Steps Checkup Components.
- Texas Department of State Health Services. (2017). Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents.
- Texas Medicaid & Healthcare Partnership. (2017). Texas Medicaid Provider Procedures Manual (TMPPM).
- Texas State Legislature. (2011). Texas Family Code.
- Texas State Legislature. (1975-2011). Texas Penal Code § 21.11.
- The Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health. (2012). Adverse Family Experiences. National Survey of Children's Health (NSCH), 2011-2012.
- The Child and Adolescent Health Measurement Initiative. (n.d.). ACEs Project.
- The National Child Traumatic Stress Network. (n.d.). Types of Traumatic Stress.
- Turney, K., & Wildeman, C. (2016). Mental and Physical Health of Children in Foster Care. Pediatrics, 138(5): e20161118.
- U.S. Department of Health and Human Services, Children’s Bureau. (2015). Child Maltreatment 2015.
- U.S. Department of Justice, Office for Victims of Crime. (2013). Through Our Eyes: Children, Violence, and Trauma—Introduction video.
- American Academy of Pediatrics. (n.d.). AAP Mental Health Initiatives.
- American Psychological Association. (2008). Children and Trauma: Update for Mental Health Professionals.
- Center for Pediatric Traumatic Stress. (2010). Culturally-Sensitive Trauma-Informed Care.
- Center on the Developing Child at Harvard University. (n.d.). Toxic Stress.
- Centers for Disease Control and Prevention. (2017). Adverse Childhood Experiences (ACE) Study.
- Johnson, S. B., Riley, A. W., Granger, D. A., & Riis, J. (2013). The Science of Early Life Toxic Stress for Pediatric Practice and Advocacy. Pediatrics, 131(2), 319-327.
- Texas Department of Family and Protective Services. (2013). Trauma-Informed Care Training.
- The National Child Traumatic Stress Network. (n.d.). Military and Veteran Families and Children.
- U.S. Department of Justice Attorney General’s National Task Force on Children Exposed to Violence. (2012). Defending Childhood: Protect, Heal, Thrive: Report of the Attorney General's National Task Force on Children Exposed to Violence final report.
The medical definitions provided in this module were obtained from the American Psychiatric Association, the Centers for Disease Control and Prevention, the U.S. National Library of Medicine, and WebMD.
National Child Traumatic Stress Network. Resources for Parents and Caregivers.
U.S. Department of Health and Human Services, Child Welfare Information Gateway. Resources on Trauma for Caregivers and Families.
U.S. Substance Abuse and Mental Health Services Administration. Resources for Parents and Caregivers.
- Early Childhood Materials focused on trauma and justice
Links to multiple resources, including-audience specific resources such as military deployment and homelessness, from the federal Substance Abuse and Mental Health Services Administration (SAMHSA).
- Partnering with Parents: Apps for Raising Happy Healthy Children, a colorful, parent-friendly booklet designed to look like a smartphone app.
- NCTSN Resources for Parents and Parents web page
A wealth of resources for birth parents, adoptive parents, resource or foster parents, grandparents, caregivers, and all others who care for children and teens.
- Parenting After Trauma: Understanding Your Child’s Needs
Part of the AAP’s Helping Foster and Adoptive Families Cope with Trauma guide, explains how trauma can impact children and provides tips for making them feel safe in their new home. Pediatricians can copy and provide this handout to foster and adoptive parents. An AAP clearinghouse of topic-specific resources and articles for parents, including information on emotional wellness, resilience, and coping with trauma.
- Triple P - Positive Parenting Program
Multi-level system of family intervention developed through more than 30 years of clinical research trials. It aims to prevent severe emotional and behavioral disturbances in children by promoting positive and nurturing relationships between parent and child. It also offers training for organizations and practitioners as well as self-help and parent resources.
- Sesame Street in Communities
- Videos for children and other resources aimed at educating and helping children deal with ACEs like divorce and incarceration of a loved one.
Recognizing, Reporting, and Preventing Child Abuse
Implement best practices to effectively screen for child abuse, comply with legal reporting requirements, and promote protective factors that prevent child abuse.
Preventing Unintentional Injury
Equip Texas Health Steps providers and others to identify risk factors for unintentional injury from birth through 20 years, provide age-appropriate anticipatory guidance, and apply state law and best practices to prevent unintentional injury and death.
Texas Health Steps Guidance
Texas Health Steps Guidance
Anticipatory guidance—age-appropriate education and counseling—is a required component of every Texas Health Steps preventive medical and dental checkup. Texas Health Steps offers age-appropriate education and counseling topics so providers can assist patients, families, and caregivers to understand growth, development, and healthy practices. Texas Health Steps recommends that health-care providers personalize anticipatory guidance depending on the needs of their patients. Anticipatory guidance topics should be individualized and prioritized based on questions and concerns of the child or adolescent and their parent or guardian. Specific guidance should also be based on findings obtained during the health history and physical exam.
Texas Health Steps offers Anticipatory Guidance-A Guide for Providers, which includes guidance topics for every age group birth through 20 years. It mirrors anticipatory guidance topics included on the Texas Health Steps Child Health Clinical Record Forms.
Families and caregivers of children with chronic medical conditions face complex challenges and extended stress. Providing long-term care for a child with a disability or chronic illness can take a physical, emotional, and financial toll. It also requires a time commitment that can be difficult to achieve.
As a pediatric health-care provider, you “have a responsibility to recognize caregiver burden (Adelman, Tmanova, Delgado, Dion & Lachs, 2014). Research has shown that caregivers are at increased risk for depression, anxiety, and other negative health effects of what can be a crushing responsibility. At each pediatric checkup, make it part of your routine to inquire whether family or caregivers have questions or concerns about their roles, their own health, or navigating the health-care system.
The health of your young patients and the health of their caregivers are interwoven.
Caregivers who feel overwhelmed may not be able to provide appropriate care for a child in need. You must be alert to outcries for help or signs of health problems related to caregiving, including loss of sleep and diet imbalance. Open communication allows you to be a sounding board for caregivers who are struggling with their duties. At the same time, be on the watch for signs of fatigue or stress in caregivers who try to project an “all’s well” attitude even when they are having problems.
Your role includes providing practical counseling about stress and offering resources designed to help families and caregivers cope.
Top 10 Caregiver Coping Skills
Sharing this Top Ten list of coping skills can help caregivers learn strategies that may reduce stress:
- Understand your feelings.
- Express your emotions.
- Educate yourself about your child’s illness or condition.
- Keep communications open.
- Talk to other parents.
- Focus on the strengths and goals that are achievable.
- Believe in your child.
- Establish routines.
- Maintain your sense of humor! There is no co-pay for laughter!!
- Remember that taking care of yourself is caring for your family.
Source: Parent to Parent of New York State
Resources to share with families and caregivers
Aging and Disability Resource Centers (ADRCs) operated by Texas Health and Human Services (Texas HHS). The centers are welcoming and offer information about state and federal health benefits as well as local programs and services. The trained staff can connect caregivers with services such as home care, meals, transportation, legal help, attendant care, respite support, and housing. Visit the ADRC website for a list of resource center locations in Texas.
Family Support Services, a program to help families care for children with special health-care needs at home. Services are provided by the Children with Special Health Care Needs (CSHCN) Services Program, a branch of the Texas Department of State Health Services.
Navigate Life Texas, a multilingual website created by parents for parents of children with disabilities and special health-care needs. This unique site offers comprehensive, relevant, and reliable information for families, professionals, advocates, and anyone working with children who have disabilities and their families. Sponsored by the Texas Interagency Task Force on Children with Special Needs.
Take Time Texas, a website offered by Texas HHS that includes a state inventory of respite services.
Texas Parent to Parent offers peer support for parents of children with special health-care needs.
All Medicaid managed care organizations (MCOs) provide case management services (called service management for STAR members with special health-care needs). In the other Medicaid managed care programs, everyone gets some level of case management. Patients should first be referred to the plan’s service coordinator and then referred to Case Management for Children and Pregnant Women if patient needs cannot be met by the plan’s services. Health plans are also required to make appropriate referrals to case management services.
For patients enrolled in STAR Medicaid, STAR Health, or Fee-For-Service (FFS) Medicaid, providers can make a referral by one of these methods:
- Calling 877-847-8377 (877-THSteps).
- Contacting a case manager (“Find a Case Manager” web page accessed from the Resources for this module).
- Submitting the Case Management Referral Form (the form is also accessed from Resources).
For patients enrolled in STAR Kids:
- Health Plan service coordinators and others can refer by submitting the STAR Kids Case Management Request Form (the form is also accessed from Resources).
Early Childhood Intervention (ECI) is a statewide program for families with children birth through 35 months who have disabilities and developmental delays. All health-care providers are required by federal and state regulations to refer children 35 months and younger to the local ECI program as soon as possible but no later than seven days after the suspicion or identification of a developmental delay.
To qualify for ECI services, a child must have:
- A qualifying medically diagnosed condition that has a high probability of resulting in a developmental delay. For more information, visit the ECI Qualifying Diagnosis Search web page.
- An auditory or visual impairment as defined by the Texas Education Agency (TEA) rule at 10 TAC Section 89.1040.
- A documented delay of at least 25 percent in one or more of the following areas of skills and development: gross motor, communication, cognition, fine motor, social, emotional, or self-help. Or, a documented delay of at least 33 percent when the delay occurs only in expressive language.
- A qualitative determination of delay, as indicated by responses or patterns that are disordered or qualitatively different from what is expected for the child’s age.
To refer a child, providers should use the ECI Provider Referral and Feedback form. The form, which requires a parent or guardian signature, helps ensure that ECI’s evaluation results and service plan are shared with the referring provider.
To refer families for services, providers can call the local ECI program.
Texas Health Steps requires that all federal- and state-mandated checkup components be documented in the medical record in order for the checkup to be considered complete and to qualify for provider reimbursement. Any checkup component that is not completed must be noted in the medical record, along with the reason it was not completed and a plan to complete it. The medical record must also contain documentation of all screening tools used, screening results, and referrals. Texas Health Steps child health clinical record forms are optional but are recommended to assist providers with documentation of all required checkup components. Providers should be aware that Texas Health Steps checkups are subject to retrospective review and recoupment if the medical record does not include all required documentation.
A medical home is the patient’s primary point of contact when accessing health care. The medical home concept was developed by the American Academy of Pediatrics (AAP) and is promoted by Texas Health Steps. A medical home is defined as one in which care is accessible, family-centered, continuous, comprehensive, compassionate, coordinated, and culturally effective. It is a partnership between a child, the family or caregiver, and the child’s primary health-care setting. The primary health-care setting can be a physician’s office, a hospital outpatient clinic, a school health center, a community health center, or a health department clinic.
Providers who need assistance finding a specialist or subspecialist who accepts patients enrolled in Medicaid can find a specialist or subspecialist by using the Texas Medicaid & Healthcare Partnership (TMHP) Online Provider Lookup or by calling the Texas Health Steps toll-free help line for providers at 800-964-2777 Monday through Friday from 8 a.m. to 6 p.m. Central Time. Select option 3 to speak with a representative.
Providers can access a set of child health clinical record forms to document Texas Health Steps preventive medical checkups. The set includes a form for each checkup under the Texas Health Steps Periodicity Schedule, for patients from up to 5 days old through 20 years. Providers can save or print the forms.
Each form includes the required components for that age’s checkup, along with space for documenting routine, non-required components of a medical checkup. The backside of the form includes a helpful list of suggested anticipatory guidance topics and checklists such as the Hearing Checklist for Parents and Lead Risk Factors.
Texas Health Steps is the preventive care services program for children birth through 20 years who are enrolled in Medicaid. Texas Health Steps provides regular checkups and screenings as part of the Early and Periodic Screening, Diagnosis, and Treatment program, also known as EPSDT.
In Texas, EPSDT is known as Texas Health Steps, which includes the preventive care components—or Early and Periodic Screening (EPS)—of the total EPSDT service. Required medical checkups and preventive care services are provided in accordance with the latest Texas Health Steps Periodicity Schedule, which is modeled after the one developed by the American Academy of Pediatrics (AAP). Additional checkup components are required in Texas to meet federal and state guidelines, and checkups are encouraged as part of the medical home. The Periodicity Schedule specifies when each of the checkup components is due. Providers should always refer to the latest schedule available. To download a PDF of the Periodicity Schedule online, visit the Texas Health Steps Provider Information web page.
The Texas Medicaid & Healthcare Partnership (TMHP) updates the TMPPM monthly. The policy updates are published on the TMHP website and in banner messages, which appear weekly on a provider’s Remittance and Status Report as well as on the website. Providers can find updates on the web page in two ways:
Release Notes—Changes to the TMPPM arranged by date, with most recent at the top of the list.
Change History—Changes to the TMPPM arranged by chapter. (If a chapter has not changed, it will not appear on the list).
NOTE: Providers should always check the TMHP website for the current TMPPM, banner messages, and policy and procedures updates. Archived versions of the TMPPM will remain online for reference purposes.