The Perkins Perspective | Features | Winter 2014
Breaking Down the Barriers to Health Care
By Thomas “T.K.” Brasted, PsyD
When you think of a child from a broken home where he and his mother were beaten and emotionally abused by his father ― a child who now bounces from one homeless shelter to another with his mother in search of safety and stability ― you can easily imagine that this child might suffer from some sort of psychological disorder.
Indeed, research has shown that family discord, physical abuse, maternal depression, poverty, and homelessness significantly increase the risk of emotional and behavioral problems in children. Yet in my clinical practice, I often encounter children who have endured such horrific hardships and display incredible resiliency. This was certainly the case for Joseph, a 6-year-old boy with bright eyes and a beaming smile.
I met Joseph while volunteering as a behavioral health consultant for a free medical clinic that HopeCentral provided to the shelter for women and children where Joseph lived. His mother had brought him to the clinic because she was concerned about his recent regression to bedwetting. Our pediatrician assessed him for a possible urinary tract infection and various other medical conditions, but ultimately concluded that the most likely cause of Joseph’s bedwetting was stress-related. My colleague, therefore, requested my support in screening for psychiatric disorders and providing behavioral health care to the family as needed.
Joseph had been through an awful lot in his short life, but you would never know it by looking at this energetic, happy-go-lucky kiddo. It was clear from their interactions that he had a healthy bond with his mother, and he seemed to feel comfortable in his own skin, as evidenced by the Wiggles’ song that he sang to himself while playing with the toys in the exam room.
This is a child who has endured cruel maltreatment by the hands of a father who was supposed to love and protect him. He and his mother left behind all their worldly possessions to seek refuge from the abuse, and they spent nearly a month sleeping in a cold car while his mother searched for vacancies at a shelter. Nevertheless, with the exception of bedwetting, Joseph had thus far managed to evade the emotional and behavioral problems associated with childhood trauma.
Interventions at the Right Time and Place
At the point when I met with Joseph, he did not need lengthy, in-depth psychotherapy. However, he would clearly benefit from some relaxation skills training to help him manage his reactions to stress and tools to address his bedwetting. Providing these types of interventions to children and families in the pediatric primary care clinics where they first go for help not only is a convenience, but also reduces a number of barriers to accessing care.
Stigma is one obstacle that keeps children from receiving the behavioral health care they need. Joseph’s mother admitted that if I had not been a member of the primary-care team, she would never have considered taking Joseph to a mental health professional for fear that the other women at the shelter would assume that she was a bad parent or that her child was “screwed up.”
Another barrier to behavioral health care, particularly for low-income families, is the lack of a diagnosable psychiatric disorder. Despite the fact that a child may be suffering from functional impairments stemming from emotional distress, and regardless of the fact that the early treatment of such problems can prevent their progression, most insurance companies and Medicaid will not cover services that do not meet the criteria for a full-fledged psychiatric disorder. While more affluent families have the disposal income to pay for needed care out of pocket, that is not an option for low-income families, making this not only a health concern but also an issue of social justice.
By incorporating behavioral health providers onto the primary care team, clinics like HopeCentral are able to bridge this gap. Joseph’s mother has not brought him back in for an appointment recently, but I heard he is doing well now. He has apparently had “dry nights” pretty consistently for the past several months. He continues to be well-behaved, smile brightly, and sing Wiggles’ songs.
Thomas “T.K.” Brasted, PsyD, is a clinical psychologist and behavioral health director at HopeCentral, a community health center in King County, Washington. He graduated from the Coast Guard Academy, served as a Coast Guard officer for five years, and then earned his doctorate at Argosy University in Seattle, Washington. He completed internship training in behavioral health consultation at HealthPoint.
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