RALEIGH — Dana Hagele’s pediatric practice has always extended beyond the examining room. Specializing in child abuse, she was used to working with police, social workers and others on behalf of her patients.
But when she realized how many troubled North Carolina children weren’t getting much-needed counseling, Hagele took on a much broader challenge – bringing effective mental health treatment to children across the state who have suffered abuse, neglect or other types of trauma.
The stakes are high. Studies show untreated trauma actually disrupts the growth of a child’s brain and often leads to substance abuse, poor performance in school, early pregnancy and other problems.
For nine years, Hagele has pushed to get a program up and running to train practitioners in helping children get past traumatic experiences, touting a results-oriented counseling approach to the nonprofit groups, government agencies and legislators that have funded it.
The program she co-founded, the N.C. Child Treatment Program, got its first state funding last year after a 3-year pilot program. Last week, she updated legislators on its progress in hopes of getting continued funding this year.
So far, the group has trained nearly 200 clinicians in 90 counties. More than 90 percent of its patients have shown improvement in symptoms such as behavior issues and depression, most after only a few months of treatment.
Child advocate Michelle Hughes says Hagele’s dogged promotion of the effort was crucial in getting legislation passed to fund it. She recalls one winter when Hagele pitched her program to legislators before Christmas when she was nine months pregnant, and returned in January after giving birth to do it again.
“She is so admirably committed to building a mental health system that helps children recover from maltreatment and violence,” says Hughes, an officer on the board of The Covenant, a policy group that advocates for children.
Karen McLeod, co-chair of the state Child Fatality Task Force, which sponsored the legislation, says the program has been a forerunner in state and national efforts to focus on preventive care and measurable outcomes – a shift that’s been slow to occur in mental health treatment.
“She’s cares deeply about this issue, but she also understands the science and she’s able to message it from a financial perspective,” McLeod says.
Helping more children
Hagele grew up in a suburb of Chicago, where she decided as a fifth grader that she would be a doctor.
She went on to study at Boston University, but chose to stay in Scotland after spending her sophomore year abroad there. She says the focus on academics suited her seriousness toward her studies.
“At an American university, people would joke about not studying,” Hagele says. “I was maybe a little nerdier.”
She returned to the United States for medical school, where she took an elective class on child abuse, what was then an emerging specialty within pediatrics. She also trained in a county hospital for her pediatric residency, where she saw many abuse cases.
“It just caught my attention and ignited my professional passion,” she says. “I think pediatrics in general is about prevention, and most kids have the luxury of parents advocating for them. But there are a lot of kids who don’t live that way, and often when they come to your attention, it’s through child abuse.”
She came to Chapel Hill to study public health; learning to look at patterns of abuse spurred her career toward tackling systemic problems.
“Working for the well-being of a population instead of one kid in a room is a more satisfactory way to deal with the horror of child abuse,” she says. “You see a lot of horror, and without having tools to address that, it would be very demoralizing.”
Hagele, 45, still sees patients at UNC Hospitals and has a joint appointment with the department of social medicine. It was in that capacity that she conceived the idea for the treatment program.
She was reviewing the files of children who had been identified as abused by social service agencies when she noticed that these children were rarely referred for mental health treatment. It was a major gap in the system, and she resolved to fix it.
“I just started rolling up my sleeves and doing it,” she says.
‘Buying an outcome’
She and fellow co-founder Lisa Amaya-Jackson decided to focus on a treatment program developed at Duke University; Amaya-Jackson focuses on the clinical side of the operation, while Hagele worked to promote the program and secure funding.
Hagele’s pitch, honed over the years for different audiences, is largely practical. Traumatized children who go untreated are more likely to end up burdening the state through Medicaid, foster care, special education classes, and other expensive services later in life.
The treatment had been shown to improve a child’s mental health measurably in 12 to 18 weeks, rather than relying on ongoing counseling. And the expertise was at Duke, which joined in the partnership.
“If you’re investing something, you should be buying an outcome,” she says.
The program initially was aimed specifically for children who were victims of sexual abuse, but eventually widened to include all kinds of trauma: losing a parent, witnessing domestic violence, living with a serious medical condition, and so on.
The program employs checklists to screen for a variety of causes of trauma. A lot of children reach social services for a specific reason, but have a host of other mental health issues.
“Kids are referred for sex abuse, but when you start scratching the surface, there are a lot of other risk factors,” she says. “A lot of times we find the reason they get attention from social services is not really the problem.”
Children and parents are taught to manage stress, work through negative thoughts about the trauma and control their behavior. Their symptoms are recorded throughout the process.
In 2006, the group started a pilot project in northeastern North Carolina with funding from the state Division of Mental Health, the Duke Endowment and several nonprofit groups. The General Assembly appropriated $2 million for the program last year.
Three-fourths of children who have gone through the program so far have their treatment covered through Medicaid. The organization’s role is to train mental health workers and track their progress. Clinicians train for a year in which they handle two cases with the help of a trainer.
Hagele is seeking both to expand the program and to continue refining its training, particularly to make sure that they maintain their skills after the intense training is over.
“We should have the same standard for clinicians dealing with sex abuse as we do for those doing surgery,” she says.
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