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Vital Signs

Banishing childhood trauma with telemedicine

By Matthew C. Wiencke

Post-traumatic stress disorder (PTSD) is often associated with veterans of military service. But it hits children, too—children who have been victims of sexual abuse, physical or emotional abuse, or neglect. Or of a catastrophic illness, a house fire, or the death of a parent.

"We know that children who have been sexually abused have a higher rate of developing post-traumatic stress disorder, which may range as high as 40 or 50 percent," says Dr. Robert Racusin, a DMS child psychiatrist. And according to national studies, adolescents are victims of violence at a higher rate than any other age group.

To help New Hampshire children who suffer from trauma, Dr. Stanley Rosenberg began to offer training for mental-health clinicians in an evidence-based treatment called trauma-focused cognitive behavioral therapy (TF-CBT). But many therapists who would have liked to take advantage of the training found the long drive to Dartmouth a problem.

Distant: The head of a center in one of those distant locations asked if DHMC could set up a network so the 10 mental-health centers spread across the state could videoconference with each other, allowing distant clinicians to be trained over the network. The Dartmouth Trauma Interventions Research Center (DTIRC), which Rosenberg heads, thought the possibility had promise, as did several funding sources.

Now, nine of the 10 centers have all the technology for videoconferencing in place

Dartmouth got funding to establish a telemedicine network that links New Hampshire's 10 mental-health centers.

"At least in theory . . . geography would no longer be a barrier."

(and the 10th is nearly there), and the clinicians at two of the centers are fully trained in TF-CBT.

Aspects: The technique has two aspects: exposure therapy—using personal trauma narratives to overcome the pain of traumatic events; and cognitive restructuring—understanding how thoughts about an event influence behavior. About 100 New Hampshire children are now receiving TF-CBT treatment for PTSD. (For more on the technique, see this article.)

The 10 centers are independent organizations, so putting the network together required coordination on many levels—with the centers' CEOs, child

directors, frontline clinicians, and information technology specialists, explains Rosenberg. And maintaining it will be an ongoing process. "We're going through a long process of negotiation and relationship building and trust building," Rosenberg adds.

The outlook is good, though, says training coordinator Dr. Kay Jankowski: "Everybody's in it together . . . . [The agencies] are taking a leap here by trying out this technology, and Stan has put in a huge amount of resources in terms of helping the agencies buy equipment and . . . steer this whole thing." And the actual training, says Racusin "goes extraordinarily well. . . . [it feels] almost the same as face-toface conversation."

The telemedicine approach also makes more efficient use of families' time, since they don't have to travel long distances to DHMC when a child needs care if treatment is available from trained clinicians at their local mental health center.

Goal: Rosenberg's team is also planning to use telemedicine to train clinicians in other therapies for treating severe depression and disruptive behavior disorders. And the ultimate goal is to use telemedicine to consult with pediatricians around the state and to treat patients directly. So if a child in Berlin, N.H., had autistic spectrum disorder, Racusin explains, and that child "needed to be followed by someone who had a certain skill set, but that person happened to be in Nashua, then at least in theory it wouldn't matter where [the child was]—geography would no longer be a barrier."

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