Children’s Advocacy Center Successfully Delivers Evidence-Based Treatment Virtually
After receiving a grant, the Children Advocacy Centers of North Dakota, including Red River Children’s Advocacy Center (RRCAC) and Dakota Children’s Advocacy Center (DCAC) had the opportunity to receive telehealth training and consultation from the Medical University of South Carolina (MUSC). MUSC had created a successful pilot program focused on delivering evidence-based treatment called Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) for children and teenagers experiencing trauma.
“We started this program in July 2019,” said Heidi Tupa, a mental health clinician at RRCAC. “It took us a little bit to get it up and running and work out the kinks. We had some initial resistance from some of the schools who didn’t quite understand their role.” However, once the program was established, it has generated significant benefits for the patients and community.
Photo description: RRCAC’s main entrance
CACs are community-based, child-focused organizations that work alongside a multidisciplinary team to coordinate communities’ responses to incidents of child abuse with the goal of promoting healing and justice for victims and their families.
The RRCAC in Fargo had five clinicians and the DCAC in Bismarck had an additional six clinicians participating in the telehealth pilot program. “Most of our referrals come from social services, law enforcement, or a sex trafficking program who work with at risk-youth called YouthWorks,” Tupa said. “Our CAC is part of a multidisciplinary team that includes county workers, the police, a human trafficking task force, and domestic violence and sexual assault centers across the state. The state’s attorney’s office is often involved, and rural cases come to us through the Sheriff’s Department.”
Photo description: Heidi Tupa, mental health clinician at RRCAC (left); Nicola Herting, PhD, mental health director at RRCAC (middle), and Anna Schimmelpfennig, PhD, assistant mental health director at RRCAC (right)
Assessment and Treatment
During the initial interview, the referral source meets with the CAC forensic team, which usually includes a family advocate, program coordinator, medical representatives, and non-offending caregiver. “We discuss whether the child needs a medical exam and/or trauma assessment,” Tupa explained. “Perhaps the family needs to be connected with services. We talk about what is needed to keep that child safe and address his or her well-being and mental health.”
Those children who require a trauma assessment are then connected with the RRCAC where an initial telehealth screening takes place.
“We want to assess that child’s particular situation, including caregivers and environment, to ensure that it is conducive to telehealth,” Tupa said. “Does that child have a private space? Can discussions be confidential? If they have 10 people in a one-bedroom home, they may not be a good candidate for telehealth.” Tupa explained that children or teens who are actively suicidal or have issues with aggressive behavior toward property may also need to be seen in person.
Clinicians then perform a trauma assessment, which usually includes an interview with the child or teen, as well as the parent or parents, to assess symptoms. Patients may be evaluated for post-traumatic stress disorder, anxiety, or depression, and then clinicians determine whether further sessions or a community referral would best meet the needs of each patient.
For those that qualify for the telehealth program, RRCAC sends loaner equipment such as a tablet that’s locked down with a loaded data package so patients do not need to have internet service at their homes.
“We also send out supplies for the Trauma Focused-Cognitive Behavioral Therapy,” Tupa said. “The packages are based on the patient’s age and contain materials that are used throughout the course of treatment.” Materials may include books, relaxation tools, educational cards, and other projects.
“We use a lot of worksheets, games, and books,” Tupa said. “Many of the tools are the same as when we do in-person therapy. For instance, for young children, we read a story about Brave Bart who is a cat with trauma to deliver psycho education. There’s a stress ball activity that we can do together for relaxation, and we use bubbles to teach deep breathing exercises.”
Photo description: Teletherapy session at RRCAC
Depending on the level of trauma and caregiver support, treatment length varies for each child. “If a patient is experiencing complex trauma or a situation that’s more recurrent or chronic, treatment can take longer,” Tupa said. “However, we know that research shows that a strong supportive caregiver actually increases a child’s ability to heal more quickly.”
Since much of North Dakota is rural, the RRCAC telehealth program has helped reach many patients successfully. “We serve some counties that are quite far away, even a few in Minnesota,” Tupa said. “We have only a few CACs in the state, so some families are more than two hours away. They obviously drive here for forensic interviews, but when we can offer the trauma assessment and therapy through telehealth, that saves our families time off work and money for gas. With North Dakota winters, travel can also be difficult and a significant barrier to care. It’s helped a lot of rural families.”
The RRCAC has experienced fewer no-shows as a result of its telehealth program. “If a patient hasn’t connected in the first 10 minutes of a telehealth appointment, we’ll call them,” Tupa said. “Usually, they’ll jump right on. When they were being seen in-person, that kind of delay in combination with travel time would cut the session time in half, and often resulted in a cancellation.”
In addition, telehealth has provided families with a great deal of flexibility. “I work with one family that owns their own business,” Tupa said. “For the session, the mom takes the child into a car and does the session in the parking lot. It’s private and convenient for them.”
Another advantage is being able to see the children in their own environments. “I really like that kids can show me things in their room,” Tupa said. “They love to show you their pets since they can’t bring them to the office. One child had a pet bunny in the virtual session just sitting on their lap, creating that extra comfort. I may see something in their room like a bottle of lotion that I can then encourage them to use for relaxation exercises. I wouldn’t see those things during an office visit. It just gives us more insight into their home environment.”
Photo description: RRCAC’s technology equipment and therapy box supplies