Improving Trauma-Informed Care for Children

TMA Written Testimony

House Human Services Committee 

Testimony Submitted on Behalf of :

  • Texas Pediatric Society
  • Texas Medical Association
  •  Federation of Texas Psychiatry

In Opposition of House Bill 2368 and House Bill 1536 

March 26, 2019

Chair Frank, Vice Chair Hinojosa, and Committee Members,

The Texas Pediatric Society, Texas Medical Association, and Federation of Texas Psychiatry appreciate the opportunity to submit written testimony regarding House Bill 1536 and House Bill 2368. We thank Representative Miller for his efforts to promote trauma-informed care for children in foster care. Childhood trauma can have lifetime consequences if left unaddressed. It is imperative that Texas find constructive approaches to reducing the incidence of trauma among children while also ensuring the state’s health care delivery system has the expertise to respond appropriately when trauma has occurred. As such there are provisions of each bill that we support. At the same time, our organizations also have voiced serious concerns about the bills and cannot support them as filed. We ask you to consider the following as you deliberate on both bills.

Childhood trauma often results in a lifetime of negative consequences. Research shows that many of the most common life-threatening health conditions among adults, including obesity, heart disease, alcoholism, and drug use, are directly related to childhood adversity. While a single event like a natural disaster or even assault may traumatize a child, the effects multiply when the trauma continues, whether by repetition of similar stresses (as in an environment of domestic violence or parental drug abuse) or accumulation of disparate ones. The effect may be particularly severe when trauma involves the child’s parents or primary caregivers. Early toxic stress and trauma are nearly universal in children who have been adopted or placed in foster care.

Our organizations actively engage in efforts to promote a more trauma-informed and trauma-responsive service system for children and young adults in foster care – whether it be through the development of educational opportunities for physicians such as continuing medical education or the Central Texas Pediatric Trauma Learning Collaborative, the promotion of training such as Texas Health Steps Online Provider Education or American Academy of Pediatrics Trauma-Informed Pediatric Provider Course, or participation in activities such as the Statewide Collaborative on Trauma-Informed Care.

Physicians and health care providers play an important role in identifying and addressing trauma and traumatic stress, especially in children. While we have learned a great deal about the impact of trauma on the developing brain, the research continues to evolve.

House Bill 1536

Areas of Support: We support the appointment of regional coordinators to assist the Department of Family and Protective Services (DFPS) in creating a trauma-informed system of care. We also support the creation of a trauma-informed care taskforce, though we recommend the composition of the task force ensure inclusion of primary care and specialty physicians with expertise in trauma-informed care as well as social workers, psychologists, child advocates, and others with appropriate expertise. Moreover, we caution against being too prescriptive in outlining the responsibilities and goals of the taskforce. 

Areas of Concern: The bill defines trauma and trauma-informed care (trauma-informed program or trauma- informed service), codifying definitions and practices in statute that will continue to change as the science progresses. Further, the language does not mirror any nationally recognized definition, such as the Substance Abuse and Mental Health Services Administration definition of trauma. HB 1536 also outlines a “trauma- informed system of care” that is overly prescriptive and may create standards of care that are inconsistent with evolving best practices.

Any definitions of trauma-informed care and practices would be better addressed via agency rulemaking.

House Bill 2368

Areas of Support: We appreciate the provisions of HB 2368 that would enhance existing outcome-based performance measures and incentives to promote trauma-informed care for children in foster care, especially given the shortage of physicians and health care providers who accept Medicaid.

Areas of Concern: The bill goes further to require trauma-informed care training for certain physicians and health care providers who provide behavioral health care to children in foster care. A 2016 TMA physician survey found that only 45 percent of physicians accept and treat patients with Medicaid (and many of those only take a small number of patients). The administrative burdens and low payments already serve to de-incentivize physicians and health care providers from accepting patients with Medicaid. According to the Kaiser Family Foundation, Texas only meets 34.5 percent of the need for behavioral health care providers. Imposing mandatory training on physicians and health care providers who participate in STAR Health would further strain the Medicaid behavioral health workforce, restricting access to health care for children in foster care.

Addressing the Relationship Between Trauma, Mental Health, and Psychotropic Medications

Finally, our organizations want to address the language in both bills surrounding the use of psychotropic medications and the overlap between trauma and mental health. The proposed trauma-informed care taskforce in HB 1536 is tasked with reducing the use of psychotropic medications for children in foster care. Since 2004, DFPS and the Texas Health and Human Services Commission (HHSC) have collaborated with the medical community to ensure appropriate prescribing of psychotropic medications to children in foster care, resulting in the creation of a statewide monitoring system and evidence-based clinical parameters for use by practicing physicians. In the most recent “Update on the Use of Psychotropic Medications for Children in Texas Foster Care,” HHSC and DFPS reported that despite the substantial increase of children in the Texas foster care system, psychotropic prescribing has steadily and significantly decreased since the release of the prescribing parameters in 2005.

HB 2368 specifies the need for training regarding the “overlap between symptoms of trauma and mental health disorders” and the “risk of using psychotropic medications for children with exposure to trauma.” We know that trauma’s influence on the brain may result in behaviors that potentially can be misidentified as common mental health or developmental diagnoses, but we also know that these issues may be comorbid.v Interventions must be tailored individually to meet the needs of each child. Therapy, family, and caregiver supports, and medications when needed all can play a role in healing. The American Academy of Pediatrics likens the use of medications to the use of a cast for children with a fracture. Appropriately used medications can help to stabilize a child so that healing can take place through the use of therapy as well as fostering family and caregiver supports.


We share the goal of Representative Miller, the committee, and our partners in advocacy to create a trauma- informed environment for children in foster care, whose exposure to trauma is nearly universal. However, we must proceed judiciously toward this goal, ensuring we establish policies and practices nimble enough to progress with the evolving management and treatment of children exposed to trauma. Additionally, we must avoid inadvertently exacerbating the shortage of physicians and health care professionals willing to take care of children in foster care.

Thank you for the opportunity to comment. We stand ready to work with Representative Miller and the committee to improve the lives of children in foster care.

86th Texas Legislature Letters and Testimonies

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Last Updated On

March 26, 2019

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