UCLA

Trauma exposure is prevalent among children and adolescents and is associated with broad and lasting consequences for mental health, development, and functioning. Despite the critical importance of early identification and treatment, many trauma-exposed youth do not receive timely or appropriate care. This dissertation examined the pathways through which trauma-exposed youth move from documentation and assessment to engagement in trauma-focused treatment, with particular attention to the provider factors that shape access and equity across the care continuum. Study 1 used medical record data from a large healthcare system to examine how provider characteristics were associated with mental health documentation, screening, and referrals among trauma-exposed youth. Administration of the Patient Health Questionnaire was associated with greater odds of documenting trauma exposure and psychosocial adversity but was not associated with the documentation of a formal trauma- and stressor-related diagnosis. Among youth with documented trauma, mental health needs, screening, and referral practices varied by provider gender, provider type, caseload composition, and departmental context, indicating that access to trauma-informed care within a single healthcare system is not uniformly distributed. These patterns may also reflect structural factors, including differences in insurance coverage, authorization requirements, and access to available behavioral health services. Study 2 extended these findings through in-depth qualitative interviews with providers delivering trauma-focused treatment to Latiné youth and Spanish-speaking families. Providers described a complex, non-linear care pathway involving four stages: trauma recognition and referral routing, evaluation of trauma and contextual factors, treatment selection and planning, and treatment delivery and closure. Three major bottlenecks repeatedly disrupted progress. The first occurred at the point of referral, where language barriers, limited bilingual provider availability, and immigration- and insurance-related constraints often prevented families from reaching intake. The second occurred during mandated reporting, which represented an acute risk for family disengagement following disclosure. The third involved sustaining caregiver engagement during treatment, where logistical barriers, unresolved caregiver trauma, and doubts about treatment effectiveness repeatedly interrupted trauma-focused work. Together, these studies demonstrate that disparities in trauma-focused care emerge through cumulative provider- and system-level barriers across the care continuum, from documentation and assessment through referral, intake, and sustained treatment engagement. Building more equitable, culturally responsive, and trauma-informed pathways to care for historically underserved youth and families will require strengthening each stage of this pathway rather than relying on any single point of intervention.