Early stressors like trauma can lead to developmental changes that have life-long negative health consequences (Merikangas et al., 2010; Anda et al., 2006). Approximately 1 in 4 youth experience substantial trauma during their developmental years (Merikangas et al., 2010; Duke, Pettingell, McMorris, and Borowsky, 2010). Such findings suggest the need for early intervention and treatment for adolescents exposed to traumatic events and adversity. Ideally, adolescents could be treated within primary care settings where parents overwhelmingly seek services for their children. Primary care settings are sought out at a 94% to 97% rate of services as compared to only a 4% to 33% rate of parents seeking out mental health services (Guevara et al., 2001). Unfortunately, no adolescent trauma-informed interventions have yet been adapted for use in primary care (Glowa, Olson, and Johnson, 2016). This study aimed to fill this critical gap between adolescent mental health issues associated with trauma and adverse childhood experiences and the lack of treatment in integrated primary care settings. The need for trauma-informed treatment for adolescents who have experienced trauma and adverse experiences is especially salient as evidence-based treatment for adolescents in this setting is limited. A modified Delphi approach was employed to address this gap in the research. Two rounds of questionnaires and focus groups were utilized with a panel of experts and youth stakeholders to gain consensus on treatment recommendations. Ultimately, expert panelists and youth stakeholders identified 59 recommendations for adolescent trauma treatment to be delivered in integrated primary care settings. / Doctor of Philosophy / Childhood trauma can have negative health, social, and educational outcomes that extend into adulthood and over one’s lifespan (Black, Woodworth, Tremblay, & Carpenter, 2012; Merikangas et al., 2010). Approximately 1 in 4 youth today experience trauma (Duke et al., 2010). Trauma can include a variety of things such as physical, sexual, or emotional abuse; being the victim of a crime; witnessing violence in the home; living through a natural disaster or experiencing an accident (Anda et al., 2006; APA, 2017). The frequency of trauma in adolescence suggests the need for early intervention and treatment. Ideally, adolescents could be treated within primary care settings where parents and adolescents frequently seek care services. Unfortunately, no adolescent trauma interventions have been created for this setting (Glowa, Olson, & Johnson, 2016). This study was designed to improve the treatment of adolescent trauma in primary care settings. For this research study a modified Delphi technique was used. Two rounds of questionnaires and focus groups were utilized with participants that consisted of a panel of experts from the field and youth aged 14-18 years old. Ultimately, the study participants made 59 recommendations for adolescent trauma treatment to be delivered in primary care settings.

Collaborative efforts between medical and behavioral health professionals is required to simultaneously treat individuals with medical and mental health disorders. However, there is lack of focus on the competencies and trainings needed by behavioral health clinicians (BHCs) transitioning to integrated primary care (IPC) settings. The purpose of this qualitative interpretive phenomenological study was to describe the lived experiences of BHCs who have transitioned from specialty outpatient behavioral healthcare settings to IPC settings. Semi-structured interview questions were used to collect data. Using interpretive phenomenological data analysis approach, themes and the shared meanings and experiences of 8 licensed BHCs were explored. Seven participants had graduate degrees and 1 participant had post-graduate degree. All participants had at least a year of experience working in IPC settings, worked full-time in North Carolina, and had over a year of experience in traditional behavioral healthcare settings. Results indicated that participants shared experiences in 5 themes: (a) clinical experience, (b) effective communication, (c) collaboration with primary care providers(PCPs), (d) continued education and trainings, and (e) care coordination. The outcome of this research will inform institutions, administrators, and credentialing boards to consider implementation of defined competencies for BHCs in community health centers that operate on IPC principles to ensure collaborative efforts between BHCs and PCPs in order to help provide effective holistic and affordable health care in a systems-based approach.

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Although less than half of all patients with mental disorders seek mental health treatment per se, approximately 80% of all people will visit their primary care physician (PCPs) within a year (Strosahl, 1998). However, it is not well understood how to best handle patients presenting with mental health issues in primary care practices. The purpose of this project was to implement an intervention involving a screening measure for anxiety and mood disorders in a primary care setting to increase the volume of anxiety and mood disorder screening, to increase the accuracy of disorder detection, and to also enhance PCPs patterns of referral to mental health professionals (MHPs). Though starting with a quantitative design, difficulties encountered throughout the project eventually led to a largely qualitative analysis, which did yield useful information. A pilot project demonstrated anxiety and mood disorders were commonly noted in patients’ medical charts (46%), but also found referrals were rarely made for mental health services (7%), despite colocation of a licensed psychologist and licensed clinical social worker within the practice. This indicated that services available to provide comprehensive integrated total health care may not be have been used to their full potential. In the main project, 59 participants from a family medicine clinic and 20 PCPs from that clinic participated. The My Mood Monitor (M3) was administered to the patients and became part of their Electronic Medical Records (EMR). The M3 screens for anxiety, depression, and bipolar disorders within primary care settings. In 2 separate noon conferences, PCPs were trained on diagnostic criteria for anxiety disorders and mood disorders, interpretation of M3 results, and the internal Mental Health Professional referral process. The project was hampered by a full-scale switch from paper-based medical records to an EMR and accompanying lack of user experience with EMR functions, lack of efficient transfer of M3 results into the EMR, and an unforeseen switch of psychologists mid-way through the study. However, results were obtained that showed relatively low levels of PCP review of M3 results, potentially high rates of anxiety disorders and mood disorders within the setting, relatively high levels of PCP knowledge of diagnostic criteria for anxiety and mood disorders, and that patients may not prefer a ‘warm handoff’ model of mental health referral. These findings are couched within a number of important caveats, but future directions for research were clearly implied.