In-School Care
Georgetown partners to nurture children’s mental health in Washington, D.C. schools
Childhood is supposed to be happy and secure, but there’s an increasing understanding that it isn’t always that way. It’s not just parents, teachers, and doctors who see this; the Centers for Disease Control and Prevention has documented that diagnoses of childhood depression and anxiety have steadily increased over the past 15 years to more than 10 percent of the population. And that’s just children who’ve been diagnosed.
“There’s a national crisis in children’s mental health in every city, state, sector, and demographic,” says Georgetown’s Matthew Biel, MD, MSc, whose expertise includes treating children and adolescents with anxiety, stress disorders, and trauma-related conditions. Biel sees these conditions every day as chief of the division of child and adolescent psychiatry at MedStar Georgetown University Hospital and associate professor of clinical psychiatry and pediatrics at Georgetown University School of Medicine.
Over the last 20 years, there’s been an increased acknowledgement that nurturing and safe homes, schools, and childcare in early childhood are the biggest predictors for mental and physical health and academic achievement into adulthood. This knowledge grows from the groundbreaking Adverse Childhood Experiences (ACE) study, published by CDC-Kaiser Permanente in 1998. The ten original ACEs are in three groups: abuse, neglect, and household dysfunction. Ongoing ACEs research has widened to study the impact of bullying, death of a loved one, deportation and migration, violence in the community, and racism.
Adversity is a common experience for many children growing up in D.C., where almost 25 percent of children have two or more ACEs; the most commonly occurring adverse experience is extreme economic hardship. In the last decade, Georgetown University Medical Center as a whole has elevated research, education, and outreach efforts to address health disparities. These efforts have focused on community-based activities, especially in the chronically underserved Wards 7 and 8, east of the Anacostia River. These predominantly African-American communities have long been passed over by D.C.’s overall economic prosperity. City health data indicate that residents of these wards experience poorer overall physical and mental health, witness more violence, have less household income, and have reduced life expectancy compared with residents in other parts of the city.
Georgetown’s Division of Child Psychiatry has been helping a wider population of children and young adults and their families by deepening its engagement with the city.
“There’s momentum around innovative mental health care strategies and integrating these approaches into schools, childcare, and primary care,” Biel says. He and others at Georgetown and other health care providers are bringing mental health programs into the community, including schools.
“The best way for us to reach kids and families is to design services that are accessible and effective, and to deliver these services in community settings,” Biel says.
A city in need
Biel co-directs the Early Childhood Innovation Network (ECIN), which was launched in 2016 with a $6 million, five-year commitment from the J. Willard and Alice S. Marriott Foundation. Biel’s co-director is Lee Beers, MD, at Children’s National Health System. The network is a citywide effort to improve developmental outcomes for children and families living in underserved D.C. communities with an aim of eliminating or decreasing the impacts of extreme, toxic stressors on young children from birth to age 5. These services include interventions and programs to promote parent and child mental health, deliver training for pediatricians and other primary providers to recognize and treat stress in children, and work with schools and community-based health clinics to build expertise and capacity.
“Integrating mental health services into primary care is a great potential vehicle for improving access to care,” Biel says, “but many pediatricians have very limited training in mental health.” One Georgetown Child Psychiatry innovation is to provide pediatricians real-time access to consultations from child psychiatrists during patient appointments. The phone consultations are provided in partnership with Children’s National Health System.
Biel is also part of WISE, the center for Wellbeing in School Environments, a cross- and multi-disciplinary team at MedStar Georgetown that brings evidence-based mental health interventions to D.C.’s public school students, from early childhood through high school, to improve mental health outcomes and enhance learning opportunities for youth. WISE’s innovations include consultations on student needs; evaluation and treatment of student mental health concerns on-site at schools; training for educators about development and mental health of students; increasing trauma sensitivity and mindfulness in classrooms; and helping prevent or reduce teacher burnout.
WISE’s focus is on prevention, early intervention, and support. Each school’s needs are different, and Georgetown tailors the formulation to the school. “Our intention is to say to each school, ‘How can we best partner with you?’” Biel says.
Trauma survivors
Karimah Ware, PsyD, assistant professor of clinical psychiatry and director of clinical training for the WISE Center, has
a traditional child psychiatry practice one day a week at Georgetown-MedStar Health. The rest of the week, under the aegis of the division of child psychiatry, you will find her doing school-based psychology in nine KIPP public charter schools in D.C.’s Wards 5, 7, and 8.
Ware’s role in the schools has two purposes. Most of her day is spent working with teachers and school administration teams—principals, guidance counselors, and social workers—to help identify students who need assistance and build sustainable capacity within the schools. As the school day winds down, Ware’s clinical work begins as she leads individual and group therapy with children, and other programs that offer social support and foster resilience.
“By and large, many students with whom I work have experienced some kind of stressor or trauma,” such as witnessing or being the victim of a violent crime, says Ware, whose expertise includes childhood depression and anxiety, grief, and trauma.
It’s tough to learn—and to teach—in many of D.C.’s public schools. “Schools are asked to do an awful lot,” says Katharine Landfield, who for more than 20 years was a social worker in high-need schools in D.C. and Virginia. “They are the container for child development for all of society.” Schools provide everything from education to meals and mental health support. Many of the students Landfield has seen are in families facing food, housing, and economic instability, underscoring the need for improved economic circumstances for parents to reduce stress overall, she adds.
“How can we help children with all that’s going on in their families’ lives?” Landfield asks.
In the past decade, after a rash of gun violence affecting children in the crossfire, the city has invested new resources to address kids’ mental health, like having an on-site dedicated social worker for every school. Schools either have a psychologist or share one with another school.
Community-focused research
Children don’t exist alone—and healthier adults and families mean healthier children. The Department of Psychiatry has a broad portfolio of research, much of it about trauma. “Georgetown’s research standout is focusing on the community,” says Mary Ann Dutton, professor and vice chair for research. The Department of Psychiatry is not a new player in the field; it has historically been focused on trauma, toxic stressors, and interventions research. More than 30 years ago, Georgetown was an early leader in the identification, study, and treatment of PTSD in veterans and populations affected by natural disasters.
Dutton’s own research is dedicated to interpersonal trauma and how to address it. “In many communities, accessing care for trauma is challenging,” she says.
Her colleague Elizabeth Hoge, MD, leads a population-based study which looks at mindfulness for reducing anxiety disorders. If mindfulness can be demonstrated to be as effective as medication, it could possibly become eligible for insurance coverage. Additional benefits include fewer negative side effects than medication, plus a wide range of health and wellness improvements.
Other research looks at interventions to depression in prenatal and postpartum care; preventing teen violence; the impact of mindfulness in parenting skills; and the efficacy of school-based interventions.
“We are trying to address the effects of chronically stressful environments,” Dutton says. “These are toxic environments. We’re dealing with everyday trauma of racism and poverty.”
Normalizing treatment
Dutton is concerned about identifying trauma, but not stigmatizing it. Dutton, Ware, and Biel agree that stigmas associated with seeking treatment for mental health and behavior issues still exists, “but it’s tremendously better than it used to be,” Ware says.
“Talking about seeking help is becoming part of the norm in kid-to-kid conversation,” Ware says. “By the time they are teenagers, many kids are very informed about therapy and are supportive of each other seeking therapy services.”
Providing and improving care in schools, and educating students dealing with extreme stress takes a high level of dedication. It’s a passion for Ware, who is a D.C. native.
“I love this work,” she says. “I want children who are underserved to have the same opportunities for social, spiritual, and economic growth as any other child in the city,” she says.
It’s a steep climb, but not impossible.
“The solutions involve energy and expertise,” Biel says. “Georgetown has both.”
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