Getting Pediatric Practices to Prevent Child Abuse and Neglect

1. Getting Pediatric Practices to Prevent Child Abuse and Neglect Steve Kairys, MD, MPH, FAAP, PI Tammy Piazza Hurley, Project Director

2. Session Objectives At the end of this session, participants will be able to: 1. To detail the epidemiology and long term effects of child abuse and neglect 2. To review the role of pediatrics in the primary prevention of child abuse and neglect 3. To learn specific office based strategies for the primary prevention of child abuse and neglect

3. The Importance of Prevention • 10-15% of young children are victims of serious physical trauma (Finkelhor and Straus) • Neglect is the leading cause of substantiated cases of abuse • Survey data demonstrate that 25% of females and 10% of males will be sexually abused by age 18 • Estimates of treatment costs are 24 billion dollars a year • Long term sequelae are enormous in terms of psychological and functional damage, substance abuse, delinquency, learned aggressiveness and abuse potential when a parent

4. The Adverse Childhood Experiences (ACE) Study The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences over the lifespan (18,000 participants)

5. Adverse Childhood Experiences Are Very Common Percent reporting types of ACEs: Household exposures: Alcohol abuse 23.5% Mental illness 18.8% Battered mother 12.5% Drug abuse 4.9% Criminal behavior 3.4% Childhood Abuse: Psychological 11.0% Physical 30.1% Sexual 19.9%

6. ACES determine the likelihood of the ten most common causes of death in the United States. Top 10 Risk Factors Are:

7. With an ACE Score of 0, the majority of adults have few, if any, risk factors for these diseases.However, with an ACE Score of 4 or more, the majority of adults have multiple risk factors for these diseases or the diseases themselves.

8. Many chronic diseasesin adults are determineddecades earlier in childhood.

9. The Role Primary Care Practice in Preventing Child Abuse and Neglect

10. Pediatric Primary Care: An Opportunity for Preventing Child Abuse & Neglect • Well accepted, institutionalized • Goal of prevention • Concern with child, family • Special relationship with family • No stigma • Multiple visits (1st few yrs.) • An opportunity, responsibility

11. Percent Of Children Who Saw A Pediatric Clinician In Past Year

12. Pediatrician Perspectives on Content of Health Supervision • Most pediatricians say they discuss traditional topics with less than 75%of parents of patients 0-9 months: • Immunizations (94%), nutrition (93%), sleeping positions (82%), breastfeeding (70%) • Less frequently discussed are topics related to cognitive development: • Reading to child (48%) & how child communicates (42%) • Least discussed are topics related to family & community needs: • Social support (28%), financial needs (16%), violence in the community (13%)

13. Parents’ Misconceptions Parents of young children… • 57% believe a baby younger than 6 months can be spoiled • Almost 40% believe a 12-month-old’s behavior can be based on revenge • 51% expect a 15-month-old to share What Grown-Ups Understand About Child Development, Civitas, 2000

14. Missed Opportunities • Parents concerns are often not elicited or addressed • 44-79% of parents report not discussing important child development topics with their pediatricians • About 57% of parents report receiving a developmental assessment of any kind • Only half of “exemplary” practices refer children to developmental programs

15. Dissemination Strategies • Continuing medical education • Evidence-based guidelines • Opinion leaders • Audit and feedback • Incentives & disincentives • Academic detailing • Patient and/or consumer activation • Office system innovations • Continuous quality improvement

16. A national health care promotion and disease prevention initiative that uses a developmentally based approach to address children’s health needs in the context of family and community.

17. Goals Bright Futures has four goals that will allow it to carry out its mission of improving the health of our nation’s children, families, and communities. These goals are to: • Work with states to make the Bright Futures approach the standard of care for infants, children, and adolescents; • Help health care providers shift their thinking to a prevention-based, family-focused, and developmentally-oriented direction; • Foster partnerships between families, providers, and communities; and • Empower families with the skills and knowledge to be active participants in their children’s healthy development.

18. Guidelines Comprehensive health supervision guidelines: • Developed by multidisciplinary child health experts—providers, researchers, parents, child advocates • Provide framework for well-child care from birth to age 21 • Present single standard of care based on health promotion and disease prevention model • Include recommendations on immunizations, routine health screening, and anticipatory guidance • Replace the former AAP Guidelines for Health Supervision

19. Features of 3rd Edition: Ten Themes Child development Family support Mental health and emotional well-being Nutritional health Physical activity Healthy weight Oral health Safety and injury prevention Healthy sexuality Community resources and relationships

20. Core Concepts • Prevention Works • Families Matter • Health Is Everyone’s Business

21. Official AAP Policy on Prevention The Pediatrician’s Role in Child Maltreatment Prevention – published October 2010 Pediatrics (http://pediatrics.aappublications.org/cgi/reprint/126/4/8330) • Factors and characteristics placing child at risk • Protective Factors • Review of Prevention and Intervention programs • Guidance for Pediatrician

22. Schmidt’s 7 Deadly Sins of Childhood* Normal developmental phases of childhood that may cause difficulty for some: • Colic • Awakening at night • Separation anxiety • Normal exploratory behavior • Normal negativism • Normal poor appetite • Toilet training resistance *Schmitt BA. Child Abuse and Neglect, 1987.

23. Guidance for Pediatrics • Obtain a thorough social history, initially and periodically, throughout a patient’s childhood. • Acknowledge the frustration and anger that often accompany parenting. • Talk with parents about their infant’s crying and how they are coping with it. • When caring for children with disabilities, be cognizant of their increased vulnerability and watch for signs of maltreatment.

24. Guidance • Be alert to signs and symptoms of parental intimate partner violence and postpartum depression. • Guide parents in providing effective discipline. • Talk to parents about normal sexual development and counsel them about how to prevent sexual abuse. • Encourage caregivers to use the pediatric office as a conduit to needed expertise. Become knowledgeable about resources in the community, and, when appropriate, refer families, especially stressed parents, to these resources.

25. Advocacy • Advocate for community programs and resources that will provide effective prevention, intervention, research, and treatment for child maltreatment and for programs that address the underlying problems that contribute to child maltreatment (eg, poverty, substance abuse, mental health issues, and poor parenting skills). • Advocate for positive behavioral interventions and supports in schools.

26. Practicing Safety: An Intervention to Prevent Child Abuse and Neglect Funded by the Doris Duke Charitable Foundation

27. Practicing Safety Overall Goal: Decrease child abuse and neglect by increasing screening and improving anticipatory guidance provided by pediatric practices to parents of children ages 0-3. • Funded by DDCF from 2003-3007 • 9 practices in NJ and PA • Used Complex Adaptive Theory • Toolkit consisting of 7 bundles

28. Toolkit Components Toolkit included 7 modules with: • Color coded Practice Guides: • Red: Coping with Crying/SBS Prevention • Purple: Parenting • Pink: Safety in Others’ Care • Blue: Family & The Environment • Orange: Effective Discipline • Green: Sleeping/Eating Issues • Aqua: Toilet Training • Parent Educational Materials • Office Marketing Tools • Staff tools • Moderate Interactives/Tangibles • Issues Management

29. Evaluation • Pre-Post staff survey • Pre-Post parent survey • Chart review • Toolkit evaluation • Physician interviews • Staff focus group interviews

30. Data Analysis • Staff and physician report of raised awareness about child abuse and neglect. • Staff and parent reports of a significant increase in maternal depression screening. • Toolkit data identified use of Infant crying, discipline and toilet training tools with families. • Staff report that maternal drug and alcohol issues were generally difficult for practices to address although those with established referral systems to social workers fared better. • Most practices noted that the intervention program contained too much information.

31. Lessons Learned • Some type of facilitation is needed to help the practices make change. • Efforts need to be made to spread intervention throughout practice. 3.AAP brochures, posters and screening tools were of most use to practices. • Need to get the materials into an electronic format as well culturally diverse for ease of building the materials into the core of the practice style. • Strong need for better connection to community resources.

32. Changes in practice Raised awareness about child abuse and neglect. Maternal depression screening was adopted by 4 of the 5 pediatric practices. . Infant crying, discipline and toilet training modules were also implemented by the practices. Maternal drug and alcohol issues were generally difficult for practices to address although those with established referral systems to social workers fared better. Most practices noted that the intervention program contained too much information.

33. Weaknesses Focus Groups Too much information (and cost of materials) Lack of feedback loop – from docs back to staff and from parents back to staff – staff discontent with not knowing impact of PS materials/efforts No change in roles; staff wanted to play a bigger role Physician Interviews Too many meetings Materials too wordy, language barriers

34. Practicing Safety: Phase II

35. Revised Toolkit • 3 Bundles • Infant: coping with crying • Mother/Caregiver: maternal depression, bonding/attachment • Toddler: effective discipline, toilet training • Each bundle includes a practice guide as well as tools for each topic

36. Infant Bundle • Introduce at 2 weeks to 4 weeks; Reinforce at 2 months • **Tools are identified by purple font

37. Mother/Caregiver Bundle • *Refers to the EPDS • Introduce at 2 weeks to 4 weeks; Reinforce at 2 and 3 months • **Tools are identified by purple font

38. Toddler Bundle: Discipline • Introduce at 6 months; Reinforce at 12, 15, 18, 24, 36 months • **Tools are identified by purple font

39. Toddler Bundle: Toilet Training • Introduce at 18 months; Reinforce at 2 and 3 years • **Tools are identified by purple font

40. Practicing Safety Project Aims • Improve assessment/screening and anticipatory guidance by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline (to 100% by November 2009). • Test use of the Practicing Safety tools for education by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline. • Test the usefulness of the Practicing Safety tools and ease of use of the tools; and determine strategies for use of the tools.

41. Practicing Safety Project Methods • Modified Learning Collaborative with 14 teams (lead physician plus 2 others from practice) • Model for Improvement; Plan, Do, Study, Act; small tests of change • Prework period (April 2009) • Baseline chart review • Pre-Inventory Survey • Learning Session 1(May 2009) • Action Period (June-November 2009) • Monthly Chart Review/Chart Documentation Forms • 10 charts of patients at the 2-month visit (infant and mother/caregiver bundles) • 10 charts of patients at the 18-month visit (toddler bundle) • Monthly Progress Reports • Monthly Team Calls • Review of Run Charts to guide improvements (posted to a Project Workspace Web site) • Follow-up (November 2009) • Post-Inventory Survey • Post Toolkit Evaluation Survey • Post-Telephone Interviews

42. Thank you to the 14 Practicing Safety Teams! Brooklyn, NY Maimonides Infants and Children’s Hospital-Newkirk Family Health Center Flushing, NY Flushing Hospital Medical Center Grand Rapids, MI Helen DeVos Children’s Hospital General Pediatrics Longview, WA Child and Adolescent Clinic Dayton, OH Children’s Health Clinic New Haven, CT Hospital of Saint Raphael Pediatric Primary Care Center Midlothian, VA Pediatric & Adolescent Health Partners West Reading, PA All About Children Pediatric Partners PC Charlotte, NC CMC-Myers Park Pediatrics Tuscaloosa, AL University Medical Center Greenville, SC Center for Pediatric Medicine Bluefield, WV Dr Frazer’s Office Houston, TX Lyndon B. Johnson Pediatric Clinic Brewton, AL Lower Alabama Pediatrics

43. Practicing Safety Results: Assessment/Screening and Anticipatory Guidance

44. Infant

45. Mother/Caregiver

46. Toddler: Discipline

47. Toddler: Toilet Training

48. Practicing Safety Results: Usefulness of Tools

49. Average Respondent Ratings of “Practicing Safety Tool Evaluation: Infant Bundle” Key: 1 = Poor 5 = Excellent

50. Average Respondent Ratings of “Practicing Safety Tool Evaluation: Mother/Caregiver Bundle” Key: 1 = Poor 5 = Excellent