ACOG and Adult Manifestations of Childhood Sexual Abuse

1. ACOG and Adult Manifestations of Childhood Sexual Abuse IT IS IMPORTANT TO ASK PERMISSION TO TOUCH THE PATIENT!!!!! • NOTE: Pelvic exams may be associated with terror or pain for survivors. • Pelvic exams are associated with feelings of vulnerability and being examined by relative strangers may cause the survivor to re-experience past feelings of powerlessness, violation, and fear. • Many patients will not express openly their discomfort but will silently experience distress. • All procedures should be explained in advance and whenever possible the patient should be allowed to suggest ways to lesser her fear. • The patient has the right to stop the exam at any time. • Techniques to help her through include: talking through the steps, maintaining eye contact, allowing her to control the pace, allowing her to see more (mirror), or having her assist during her exam.

2. ACOG: Opioid Abuse, Dependence,and Addiction in Pregnancy Committee Opinion May 2012; The American College of Obstetricians and Gynecologists (Committee on Health Care for Underserved Woman and the American Society of Addiction Medicine).

3. ACOG: Opioid Abuse, Dependence, and Addiction in Pregnancy Summary: Opioid Use in Pregnancy is Common. Current Standard of Care for Pregnant Woman during pregnancy is Referral for Opioid Assisted therapy with Methadone and Buprenorphine can be considered. Medically supervised tapered doses of opioids during pregnancy often result in relapse to former use. Abrupt discontinuation of opioids in an opioid-dependent pregnant woman can result in preterm labor, fetal distress, or fetal demise.

4. ACOG: Opioid Abuse, Dependence, and Addiction in Pregnancy (Questions to Ask) 4 P’s • Parents: Did any of your parents a problem with alcohol or other drug use? • Partner: Does your partner have a problem with alcohol or drug use? • Past: In the past, have you had difficulties in your life because of alcohol or other drugs; including prescription medications? • Present: In the past month have you drunk any alcohol or used other drugs? Scoring: Any “Yes” should trigger further questions.

5. ACOG: Opioid Abuse, Dependence, and Addiction in Pregnancy (Questions to Ask) CRAFFT – Substance Abuse Screen for Adolescents and Young Adults • C: Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? • R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? • A: Do you ever use alcohol or drugs while you are ALONE? • F: Do you ever FORGET things you did while using drugs or alcohol? • F: Do your FAMILY or FRIENDS ever tell you to cut down? • T: Have you gotten in TROUBLE using? Scoring: Two or more positive items indicated the need for further assessment.

6. ACOG: Opioid Abuse, Dependence, and Addiction in Pregnancy The rationale for opioid-assisted therapy during pregnancy is to prevent complications of illicit opioid use and narcotic withdrawal, encourage prenatal care and drug treatment, reduce criminal activity, and avoid the risks to the pregnant mother of associating with a drug culture (rape, attack, death, etc). Also comprehensive opioid assisted therapy with prenatal care reduces the risk of all obstetric complications.

7. ACOG: Opioid Abuse, Dependence, and Addiction in Pregnancy REMEMBER MEDICALLY SUPERVISED WITHDRAWL IN OPIOID DEPENDENT PATIENTS IS NOT RECOMMENDED DURING PREGNANCY BECAUSE OF ALL OF THE POTENTIAL SERIOUS MATERNAL AND FETAL COMPLICATIONS INCLUDING FETAL DEATH

8. “If you think you’re too small to make a difference, try sleeping in a room with a mosquito.” African Proverb

10. WHAT IS ONE PUBLIC HEALTH DEPARTMENT DOING? PUBLIC HEALTH NURSES IN PORT TOWNSEND, WA AT THE JEFFERSON COUNTY HEALTH DEPARTENT INCLUDE CHILDHOOD TRAUMA SCREENING IN THEIR REGULAR SCREENINGS FOR PREGNANT WOMAN AND FAMILIES WHY? BECAUSE THE RESEARCH IS CLEAR! “TOXIC STRESS FROM ADVERSE CHILDHOOD EXPERIENCES CAUSES ADULT ONSET OF CHRONIC DISEASES SUCH AS HEART DISEASE AND DIABETES. IT CAUSES SUICIDE AND DEPRESSION. IT ALSO LEADS TO COMMITTING VIOLENCE AND BECOMING A VICTIM OF VIOLENCE. IT CAUSES CHILDREN AND FAMILIES IMMENSE SUFFERING. OUR PURPOSE IS TO HELP CHILDREN GROW UP TO BE HEALTHIER AND HAPPIER”

11. GOING OVER OUR OWN ACES • ONE OF THE FIRST STEPS WAS GETTING TOGETHER AND GOING OVER THERE OWN ACES. • WE WILL DO THIS TODAY PRIVATELY. • THINK ABOUT BEING A PREGNANT MOTHER WHO HAS EXPERIENCED SOME OR ALL OF THESE 10 CATEGORIES OF ADVERSITY AS A CHILD. • HOW DO YOU THINK THIS WOULD HAVE AFFECTED OR HAS AFFECTED YOU? • HOW WOULD YOU FEEL? OR WHAT DO YOU WISH HEALTH CARE PROVIDERS COULD HAVE DONE FOR YOU WHEN YOU WERE A CHILD?

12. JEFFERSON COUNTY PUBLIC HEALTHPRENATAL HEALTH SCREENING QUESTIONNAIRE • VOLUNTARY NOT MANDATORY • COMPASSIONATE “Our goal is to help you understand your own health needs as a parent. When parents have health problems such as substance use, depression, or experienced abuse, the whole family is likely to have more challenges.” • PRIVACY IS RESPECTED “Your answers to these questions are confidential. You can skip any question that you do not want to answer.”

13. Starting the Conversation about a Person’s ACE Score Requires Sensitivity • “Becoming pregnant often brings up thoughts about one’s own childhood, thoughts of wanting to make life better for your child, making healthy changes.” • “These questions help us understand your health risk.” • “Science has proven what we knew—the bad things that happen to kids can cause problems for their whole life but they don’t have to.” • “People who have childhood trauma often have more health problems and have a harder time getting through life.”

14. Starting the Conversation about a Person’s ACE Score Requires Sensitivity • The mothers are told that the science is NEW because “we don’t want them to feel guilt or shame about what their parents did or what they did as parents.” • The mothers are told that most people have a score of 1 or 2 and that responses to higher ACE Scores --- such as alcoholism, drug use, obesity, depression --- ARE NORMAL. • For somebody who is an ACE survivor, a sense of shame is going to be one of the fundamental feelings. • By normalizing this, explaining ACEs as science based, it helps mothers reframe to move away from shame.

15. Typical Patient Responses • “Well duh!” • “No wonder I’m so messed up.” “No wonder I’m sick all the time.” “No wonder I can’t quit using ……. alcohol, drugs, cigarettes.” • “These are very good questions. Nobody has asked me about this before.” • “Now my life makes sense.”

16. Also • It is important acknowledge how difficult life is with a high ACE score. • The nurses say “How have you managed to get through your life with such an ACE score?” or “People with a high ACE score like yours usually have to work harder at just about everything.” • This acknowledgement really helps people feel understood – sometimes for the first time. • The ultimate goal is to help people find their own motivation to change by giving them an understanding of their own life story and health risks, to encourage them to make things different for their children.

17. Those Who Are Not Ready • Generally will say then their ACE score is Zero or that a High ACE score has not affected their life. Don’t press. • However, it is still an opportunity to discuss how ACES affect brain development which by itself can be powerful and thought provoking education for the patient.

18. A Great Future A time when asking about childhood trauma will be a normal part of any healthcare visit. A time when everyone understands that a difficult childhood can contribute to a lifetime of health problems and personal suffering. A time when everyone realizes that we are all vested in reducing the impact of adverse childhood experiences.

22. ` “The Solution of All Adult Problems Tomorrow Depends in Large Measure Upon the Way Our Children Grow Up Today” Margaret Mead

23. ACEs Often Last a Lifetime . . . But They Don’t Have To • Healing can occur • The cycle can be broken • Safe, stable, nurturing relationships heal parent and child. Regional Child Abuse Prevention Councils 2011

24. It Starts With All of Us! • Identify and understand the importance of protective factors • Utilizing protective factors in your own life • Empower others by educating and encouraging them to use protective factors Regional Child Abuse Prevention Councils 2011

25. Caring Communities Can Help Reduce ACEs Regional Child Abuse Prevention Councils 2011

26. Protective Factors • Are conditions that increase health and well being • Are critical for everyone regardless of age, sex, ethnicity or racial heritage, economic status, special needs, or the dynamics of the family unit • Are buffers that provide support and coping strategies Regional Child Abuse Prevention Councils 2011

27. #1 = Nurturing and Positive Relationships…… are the key to mentally healthy children and adolescents Regional Child Abuse Prevention Councils 2011

28. Safe, Stable, Nurturing Relationships SAFE = free from harm STABLE = a high degree of consistency NURTURING = compassionate, responsive caregiver(s) Regional Child Abuse Prevention Councils 2011

29. Building Supportive Relationships It Starts with Modeling • Asking questions and wondering • Becoming an active listener • Pointing out the positive • Being empathetic Regional Child Abuse Prevention Councils 2011

30. Building Nurturing and Attachment Observe, attend and listen to children Provide safe and stable home life Model caring behavior Respond to child’s needs Use positive discipline Notice and reinforce child’s strengths Regional Child Abuse Prevention Councils 2011

31. Set up activities that promote bonding and attachment • Acknowledge nurturing behavior • Provide information on related topics: • early secure attachments • responding to cries • shaken baby • how father’s nurture, etc. • Be a caring adult or mentor a child Regional Child Abuse Prevention Councils 2011

32. #2 - Knowledge of Parenting and Child Development Why Important? Parenting is not static Behavior that is not understood tends to be interpreted negatively Normal challenges can lead to frustrations and harsh discipline Regional Child Abuse Prevention Councils 2011

33. Increasing Knowledge ………… Begin where parents are at: • discuss hopes and dreams for their children • identify strengths and build on them • set up a time or place where parents can discuss and get information • provide educational materials, websites Regional Child Abuse Prevention Councils 2011

34. Educate parents on what to expect next • Model and teach positive ways to manage challenging behaviors: routines, limits, redirection, logical consequences • Attend or set up parenting classes • Learn about or educate others on the signs and symptoms of child abuse • Provide education on ACE’s Regional Child Abuse Prevention Councils 2011

35. #3 – Parental Resilience Good outcomes in spite of serious threats, toxic stress Resilient people: • are prepared to be effective in the world • can adapt to challenges • are mentally healthy

36. Resilience is … Feeling connected to a caring family and community Self-regulation skills Positive view of self Motivation to be effective in the environment Regional Child Abuse Prevention Councils 2011

37. Begin with yourself • Take care of our own mental health • Develop healthy coping skills (regular exercise, reading, listening to music, etc.) • Seek out healthy family/friends for support • Use community supports (counseling, substance abuse tx, self-help programs, etc.) Regional Child Abuse Prevention Councils 2011

38. Building Resilience • Recognize early signs of stress and connect people to resources • Develop a trusting relationship and provide support • Be a good neighbor • Look for and point out inner strengths Regional Child Abuse Prevention Councils 2011

39. Teach skills to youth • Plan activities that focuses on nutrition, exercising and relaxation techniques • Help children develop healthy relationships Regional Child Abuse Prevention Councils 2011

40. #4 - Social Connections Network of emotionally supportive friends, family and neighbors Important because: Ease burden of parenting Decrease isolation Children have a broader access to supportive adults and positive role modeling Provide opportunities to help Regional Child Abuse Prevention Councils 2011

41. Building Social Connections • Identify what parents already have in place and build upon it • Provide opportunities for parents to get together – use parents skills, abilities and interest • Look for community opportunities – faith based, schools, community centers, support groups • Provide encouragement and support to try new things • Teach social skills Regional Child Abuse Prevention Councils 2011

42. #5 Concrete Supports in Time of Need Food, shelter, basic services critical to child and family well-being Link caregivers to community resources and extended family Work on sustainability Regional Child Abuse Prevention Councils 2011

43. If our society is to prosper in the future, we will need to make sure that all children have the opportunity to develop intellectually, socially and emotionally. Regional Child Abuse Prevention Councils 2011