Brief Primary Care-Based Intervention Can Combat Stress in Teens, UH Rainbow Studies Find

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Approach being used to counter toxic stress among patients at the new UH Rainbow Center for Women & Children

Innovations in Pediatrics – Winter 2019

A one-time, 30-minute stress management intervention can be easily integrated into a primary care appointment and can make a significant difference for teens coping with day-to-day stressors, as well as toxic stress caused by abuse, neglect, community violence and poverty. That’s the conclusion of two recent studies from University Hospitals Rainbow Babies & Children’s Hospital and the new UH Rainbow Center for Women & Children – the first studies to show such an effect in an adolescent primary care clinic.

Kimberly Burkhart, MD Kimberly Burkhart, PhD

A direct response to community health needs, the UH Rainbow Center for Women & Children is a new $26 million, 40,000-square-foot health center. It is designed to provide community-centered care that addresses medical, social and environmental factors influencing health. The Center takes an integrated and collaborative approach with patients and community stakeholders to address health disparities.

“Our goal was to create an integrated/collaborative care model within the new UH Rainbow Center for Women and Children,” says UH Rainbow pediatric psychologist Kimberly Burkhart, PhD, lead author of the studies. “Within this model, behavioral health intervention can be offered in the primary care setting.”

With funding provided by Ohio’s Medicaid Technical Assistance and Policy Program (MEDTAPP), Dr. Burkhart and colleagues designed a stress management intervention that included education on how stress affects the body, the positive benefits of exercise, as well as instructions in diaphragmatic breathing and progressive muscle relaxation. This intervention also included a biofeedback game to aid in relaxation. This intervention was incorporated within the context of well-care visits and upon physician request.

The pilot study included 30 patients between the ages of 11 and 21 who completed questionnaires before and after receiving the intervention. Factors such as social determinants of health, anxiety level, depression, perceived stress and subjective feelings of distress were assessed. Participants were also asked about their experience with the stress management intervention and whether they found it helpful and would practice the techniques at home.

Results show that there was a significant decrease in subjective distress after participants completed the intervention. In addition, 93 percent reported that the intervention was helpful and that they had the skills to practice relaxation at home. These results were published in the journal Clinical Pediatrics.

In a second study, Dr. Burkhart and colleagues compared responses between a group of adolescents who received the intervention and a control group. They also included an objective measure of heart rate variability.

“The intervention group had significantly lower subjective units of distress scores than did the control group at post-intervention,” Dr. Burkhart says. “The majority found that it was helpful in learning stress management strategies, they felt more relaxed and felt that they had the requisite knowledge to practice at home. We also found that there was a change in heart rate variability.” The results of this follow-up study are in press in the Journal of Pediatric Health Care.

Dr. Burkhart says that this integrated care model has been incorporated into the care provided at the UH Rainbow Center for Women & Children. At the same time, she encourages pediatricians and other adolescent care providers to add brief training in stress management to the services they provide.

“The American Academy of Pediatrics encourages more extensive anticipatory guidance, particularly around toxic stress, so this is certainly a very effective way of doing that,” she says. “It’s time-effective, cost-effective and needed. Additionally, CPT codes are allowing for more options with billing to cover these integrated services.”

If widely adopted, the effects of better stress management in adolescents could be enormous.

“Our goal is to provide prevention and intervention for the social determinants of health,” she says. “We want to provide stress management strategies as early as possible to prevent and treat depression and anxiety. We know that internalizing symptoms and mental health problems are highly correlated with physical health outcomes, such as obesity and cardiovascular disease.”

Stress Management Intervention: A Pilot Evaluation in an Urban Adolescent Medicine Clinic, Clin Pediatr (Phila). 2018 Jun;57(6):700-705.

For more information about this research or the new UH Rainbow Center for Women & Children, please email

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