Well Child & Teen Assessment Tools

February and March 2014 Well Child & Teen Assessment Tools

Review current recommendations for well child & teen care • Discuss feedback obtained from HFHT Nurses, Mental Health Counsellors, Dietitians and Physicians • Explore HFHT version of well child & teen assessments using the HFHT well child & teen resource guides highlighting “hot topics” • Break • Small group tool exploration PSS or P&P Agenda

“Preventive health care visits are recommended every one to two years”…we know that this is not currently routine practice in Hamilton • College of Family Physicians of Canada as well as the Canadian Pediatric Society currently support use of the Greig Health Record (2010) • “Given the evolving nature of evidence and changing recommendations the Grieg Health Record is meant to be used as a guide only” Current Recommendations http://www.cps.ca/tools-outils/greig-health-record

Many of the items on the Greig Health Record have already been discussed repeatedly in the Rourke (examples: water and sun safety, dental care, second hand smoke and smoke detectors) • There are many more “pressing issues” or “hot topics” affecting our youth and their families which are not found/highlighted in the Greig (examples: child mental health (age 6-9), sexual orientation, gender identity, finances, energy drinks, and teen specific- future goals, cell phone, other addictions Feedback from HFHT

Given the large amount of feedback from HFHT staff we have revised the Grieg and created two templates (instead of 3) one for children 6-12 and one for teens 13-17 • Like the Greig, these templates are to be used as a guide only, you may use them as often as you need and as thoroughly as you need • Also like the Greig, there are resource guides available to provide you with background information for each of the template questions • Currently 5 practices are piloting the templates, looking at when they could/should be used and how HFHT Tools

Guide Content

According to the Childhood Obesity Foundation: • There has “been a dramatic increase in unhealthy weights in children. In 1978, only 15% of children were overweight or obese. By 2007, Statistics Canada found that 29% of adolescents had unhealthy weights.” • “Most adolescents do not outgrow this problem and in fact, many continue to gain excess weight.” • “If current trends continue, by 2040, up to 70% of adults aged 40 years will be either overweight or obese.” Ht, Wt, BMI, BMI % http://www.childhoodobesityfoundation.ca/statistics

“Of 51 922 Canadian youth in grades 6 to 12, 50.9% spent more than 2 hours per day in screen-based behaviours. The average daily screen time was 7.8 (± 2.3) hours” http://www.phac-aspc.gc.ca/publicat/cdic-mcbc/31-4/assets/pdf/cdic-mcbc-31-4-ar-01-eng.pdf “Just under 7% of Canadian children and youth achieve the guideline of 60 minutes of moderate-to-vigorous physical activity (MVPA) per day at least 6 days a week.” http://www.statcan.gc.ca/pub/82-625-x/2011001/article/11553-eng.htm FYI Screen Time vs Physical Activity

So what can we do about increasing BMIs and rates of child obesity? • Take Weights AND Lengths/Heights (both) routinely at baby, child and teen visits. This include well baby/child/teen visits as well as visits for other appointments (e.g. ear infection visits we do weights for medication calculation but not lengths) • Utilize WHO Growth Charts for 0-2 looking at Weights-for-Lengths and how the child is trending, and WHO Growth Charts 2-19 for BMIs and how the child is trending • Refer the family to office Dietitian if the Weight-for-Length or BMI is over the 85th% or when growth is significantly trending away from their usual curve • Utilize the Nutrition and Healthy Lifestyle section of the Well Child and Well Teen guides. 5,4,3,2,1,0

EQAO testing results for 2012-2013 http://eqaoweb.eqao.com/eqaoweborgprofile/ResultsPage.aspx?Lang=E&mySearch=Hamilton Hamilton Wentworth District School Board (120 schools) School

Ontario trends over the past year: • 68% of grade 3 students are meeting the provincial standards (B- to B+) for reading; up 7% from 5 years ago • 77% of grade 6 students are meeting the provincial standards for reading; up 8% from 5 years ago • The ability for grade 3 & 6 students to communicate well has improved by 9% over the past 5yrs. • Math scores have decreased over the past 5yrs – 67% of grade 3 students and 57% of grade 6 students are meeting the provincial standards compared to 70% & 63% respectively from 2008 • More students continue to not meet the grade 6 math standards despite meeting the standards in grade 3. • 71% of grade 9 students are enrolled in Academic math and 84% of those students are able maintain provincial standards • 29% of grade 9 students are enrolled in Applied math, 44% are meeting provincial standards School

Provincial high school drop out rates Data produced by Statistics Canada. Labour Force Survey 2012. Ottawa: Statistics Canada, 2012 School

Unemployment rate (in %) for 25- to 29-year-olds, by educational attainment; Statistics Canada, Labour Force Survey. Updated May 1, 2013. School

As per the Ontario Ministry of Education “Bullying is typically a form of repeated and aggressive behaviour directed at an individual or individuals that is intended to cause (or should be known to cause) fear and distress and/or harm to another person's body, feelings, self-esteem, or reputation. Bullying occurs in a context where there is a real or perceived power imbalance. Bullying can take many forms. It can be: • physical – hitting, shoving, stealing, or damaging property • verbal – name calling, mocking, or making sexist, racist, or homophobic comments • social – excluding others from a group or spreading gossip or rumours about them • written – writing notes or signs that are hurtful or insulting • electronic (commonly known as cyber-bullying) – spreading rumours and hurtful comments through the use of e-mail, cell phones (e.g., text messaging) and on social media sites. Peers- Hot Topic: Bullying http://www.edu.gov.on.ca/eng/safeschools/bullying.html

As per Prevnet: Emotional & Behavioural Signs of Being Bullied Afraid to go to school or other activities -Appears anxious or fearful Low self-esteem and makes negative comments -Appears unhappy, irritable Injuries, bruising, damaged clothing or articles -Trouble sleeping, nightmares May appear isolated from the peer group -Threats to hurt themselves or others Complains of feeling unwell (headaches and stomach aches) Lower interest in activities and lower performance at school Loses things, needs money, reports being hungry after school Relationship Signs of Being Bullied -Parents may be overprotective, restrictive -Siblings may bully child at home -Few friends at school or in neighbourhood-Lonely and isolated at school -Teachers may be unaware of child's strengths and challenges and therefore unresponsive to needs -Few opportunities to shine and show talents at home, school or in the community (positive power) *Prevnet also includes signs of bullying others* Peers- Hot Topic: Bullying http://www.prevnet.ca/bullying/signs

Hamilton – Presence of children within couple families • Among couples (married and common-law) in the census metropolitan area of Hamilton, 48.3% were couples with children aged 24 and under at home. In comparison, 46.9% of couples in Canada had children aged 24 and under at home. • Among couples with children aged 24 and under at home in the census metropolitan area of Hamilton, 88.6% were intact families, in which all children were the biological or adopted children of both parents; while 11.4% were stepfamilies, where at least one child was the biological or adopted child of only one married spouse or common-law partner. For Canada as a whole in 2011, 12.6% of couples with children aged 24 and under were stepfamilies. http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-cma-eng.cfm?LANG=Eng&GC=537 FamilyRelationships

Single parent families • In Hamilton, 71.7% of census families were married couples in 2011, while 10.8% were common-law-couples and 17.5% were lone-parent families. Family Relationships http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-cma-eng.cfm?LANG=Eng&GC=537

Family Finances http://www.sprc.hamilton.on.ca/wp-content/uploads/2009/04/Incomes-and-Poverty-in-Hamilton-Full-Report-April-2009.pdf http://www.hamilton.ca/CultureandRecreation/Recreation/Information/RecreationFeeAssistanceProgram.htm

Temper Tamers- Lynwood Charlton Centre - Does your child (7 - 12 years old) have problems with temper or anger? This 10 week program includes a parent orientation and parent-child sessions to help with child anger management issues. COPEing with Impulsive and Forgetful Children: Visual Strategies for Improving Self-Control McMaster Children’s Hospital, Chedoke - This single session workshop will help caregivers understand how they can use visual strategies to help their child (including children with ADHD) gain better self control. Parenting Your Anxious Child McMaster Children’s Hospital, Chedoke- This workshop will provide examples and strategies for parents/caregivers that may be useful in parenting their “anxious” child. COPEing with 3 to 12 year olds Behaviour McMaster Children’s Hospital – Chedoke - Using problem solving discussions, video tapes and homework projects, this 8-week evidence based program teaches parents skills to strengthen relationships and increase cooperation with their children. Parenting/Discipline http://www.communityed.ca/docs/Parent/Course%20Flyers/hamilton/growing-together-guide-2014-jan-aug.pdf

COPEingwith 3 to 12 year olds with ADHD McMaster Children’s Hospital – Chedoke - Caregivers meet once weekly for 2 hours for 8 weeks. Using problem solving discussions, videos and homework projects, caregivers learn evidence based skills to strengthen relationships, reduce oppositional behaviours and increase cooperation. Parent Support Workshops John Howard Society - This is a four session workshop designed to offer parents and caregivers with youth aged 12-17yrs the opportunity to: share their concerns and to meet other parents/caregivers facing similar issues, learn realistic and practical approaches for addressing challenges faced in raising adolescents today and to increase their knowledge of relevant resources. ** No Cost** COPEing with Teens McMaster Children’s Hospital – Chedoke - Caregivers meet once weekly for 2 hours for 8 weeks. Using problem solving discussions, and videos, caregivers learn evidence based skills to strengthen relationships, reduce conflict, increase cooperation and restore communication. Parenting/Discipline http://www.communityed.ca/docs/Parent/Course%20Flyers/hamilton/growing-together-guide-2014-jan-aug.pdf

Managing Meltdowns McMaster Children’s Hospital – Chedoke- Meeting weekly for six weeks, this is an educational group for caregivers of children/teens 4 to 18 years with difficult and explosive behaviours. This group focuses on spirited temperments, coping strategies and collaborative problem solving. Positive Discipline McMaster Children’s Hospital – Chedoke- Participants will learn evidence-based positive parenting strategies in this one session workshop. Incredible Years for Parents of Children ages 5-12 – City of Hamilton, Public Health Services. Call (905) 540-5018 for information or to register. The Incredible Years is a free parenting program for parents and caregivers of children 3-12 years of age. During this 12-week program, you will learn how to build a positive relationship with your child and how to deal with challenging behaviours. To learn more about the Incredible Years program, visit http://www.incredibleyears.com/ Topics include: Play, Praise & Rewards, Limit Setting , Handling Misbehaviour Parenting/Discipline http://www.communityed.ca/docs/Parent/Course%20Flyers/hamilton/growing-together-guide-2014-jan-aug.pdf

As per the Canadian Sleep Society -”As children grow and develop, the amount of sleep needed changes. The time spent in sleep decreases from 10-11 hours for school-aged children to approximately 9 hours of sleep for teenagers. -Poor sleep can affect a child’s mood, behaviour and ability to learn. -Children are not always like adults when they are tired. Sometimes children who do not get enough sleep do not look tired. Children may show their fatigue in different ways. Children who do not sleep well may have poor behaviour, be aggressive or show short attention spans. Children who are difficult to awaken in the morning and slow to become alert may not be getting enough sleep. There are of course other reasons that children have these same problems, but poor sleep should be considered. Some other symptoms of sleep disorders include, but are not limited to: - nighttime bedwetting - snoring - extreme restlessness at night - frequent nightmares - other problems with falling asleep, staying asleep, waking too early or unusual nighttime behaviours” Sleep Issues/Snoring http://www.canadiansleepsociety.ca/Map/www/pdf/brochure/sleep_children.pdf

Informal questions for child template • PHQ2 and GAD2 for teen template Mental Health

As per Child and Youth Mental Health Anxiety Tool Kit: • “Taken together, anxiety disorders are the most common mental illness in children and youth. Prevalence for having at least one childhood anxiety disorder varies from 6 to 20% over several large epidemiological studies (Costello et al., 2005).” • “Often co-occurs with other medical and psychiatric conditions” • “Girls more likely than boys to report anxiety disorder especially specific phobia, panic disorder, agoraphobia and SAD” • “Common presentations in anxious children: Prominent somatic symptoms (e.g., stomach aches, headaches), Catastrophic misinterpretation (e.g., “Let’s go see the doctor” interpreted as “They are going to lock me in hospital”), Escape and avoidance behaviours (e.g., school refusal), “Fight” (i.e., oppositional/ aggressive) response to avoid anxiety-provoking situation“ Mental Health- Anxiety http://www.shared-care.ca/files/Anxiety_Overview_Revised_2013_April.pdf

As per Child and Youth Mental Health Anxiety Tool Kit: “Different anxiety disordersinclude: Selective Mutism, Separation Anxiety, Generalized Anxiety Disorder, Specific Phobias, Social Phobia, Obsessive Compulsive Disorder, and Panic Attacks and Panic Disorder” “Important to differentiate normal developmental fears from pathological anxiety Common fears at various ages: 0-1: Loss of support, strangers, loud noise 1-3: Parental separation, toilet, animals, dark 3-5: Separation, darkness, “bad people” 5-7: Being alone, supernatural, harm, dark 7-9: School, injury, appearance, death Adolescence: Personal relations, appearance, school, future, safety, world events, animals Mental Health- Anxiety http://www.shared-care.ca/files/Anxiety_Overview_Revised_2013_April.pdf

As per Child and Youth Mental Health Anxiety Tool Kit: Depression (Mood Disorders) • “Rare in children, Common in adolescents: 4-8% • Male to female ratio 1:1 in childhood and 1:2 in adolescence • Youth depression is different than adult depression: Reactive or irritable mood, Increased appetite more common, Cutting/self-harm, Ask about school, peers and home (Cheung) • How depression differs from normal teen moods: Persistent changes in mood, Mood changes not precipitated by environment, Drastic changes in academics, friendships, temper, and involvement in activities (Cheung)” Mental Health- Depression http://www.shared-care.ca/files/Anxiety_Overview_Revised_201_April.pdf

As per Child and Youth Mental Health Anxiety Tool Kit: “Bipolar Disorder: • Bipolar disorder is rare in children. Even in youth it is rare compared to depression. Regardless, it is always important to screen for mania by asking about less need for sleep, grandiosity, etc. when meeting a child or youth with depression • When teens present with manic episodes, there is often a history of previous depressive episodes. • Children who are later diagnosed with bipolar disorder often have a history of ADHD Suicide: • 15-20% of teenagers report suicidal ideation, 5% attempt suicide - More attempts in females and more completions in males • Asking about suicidal ideation does not increase suicidal ideation or suicides Mental Health- FAQs http://www.shared-care.ca/files/Anxiety_Overview_Revised_201_April.pdf

Both the Child and Teen tool ask about Body Changes/Puberty, Body Image/Dieting and Gender Identity, Sexual Orientation Development/Sexuality

Body changes and puberty can begin to be discussed in the Child Assessement. • SOGC states children (even as early as 6-8) should receive basic, age appropriate, information related to puberty. • Some changes may include; Female- Menstrual Issues (starting usually 10.8-14.5 years old), breast changes, pubic/underarm hair, acne; Male- Penile enlargement, testicular volume increase, scrotal changes, pubic/underarm hair, acne • Precocious puberty- The appearance of physical signs of puberty before the age of 7 or 8 in females and 9 in boys. • Sexual Maturity Rating scale included in the Tanner/Greig Health Record Resource • The term “Puberty” refers to a stage of biological maturation where a boy or girl becomes capable of reproduction • Median age for first experience with sexual intercourse is 17, although 5% of boys and 1% of girls will have had intercourse by their 12th birthday http://www.sexualityandu.ca/health-care-professionals/sexuality-and-child-development BODY CHANGES & PUBERTY

Body Image and Dieting can also be affected by body changes and puberty. • As they go through puberty, it is typical for young people to develop a heightened, at times seemingly obsessive, preoccupation with their physical appearance. Anxiety over physical appearance can lead to feelings of inadequacy (SOGC). • Parents play an important role in promoting a positive body image in their children (SOGC). • Canadian data, from 2001, states that nearly one-half of Ontario teenagers (12 to 18 years) attending public school feel unhappy about their weight; additionally, Canadian cross-sectional data suggests that more than one in five teenage girls are ‘on a diet’ at any given time. http://www.cps.ca/documents/position/dieting-adolescence Body Image & Dieting

Risk Factors http://www.cps.ca/documents/position/dieting-adolescence Body Image & Dieting

Gender Identity is linked to a persons’ sense of self, and the sense of being male or female. Gender dysphoria refers to the unhappiness that some people feel with their physical sex &/or gender role. People’s gender identity may be different from their birth-assigned sex, and may include: • Transgender: People whose life experience includes existing in more than one gender. This may include people who identify as transsexual, and people who describe themselves as being on a “gender spectrum” or as living outside the categories of “man” or “woman.” • Transsexual: People who were identified at birth as one sex, but who identify themselves differently. They may seek or undergo one or more medical treatments to align their bodies with their internally felt identity, such as hormone therapy, sex-reassignment surgery or other procedures. • Intersex: People who are not easily classified as “male” or “female,” based on their physical characteristics at birth or after puberty. This word replaces the inappropriate term “hermaphrodite.” • Crossdresser: A person who, for emotional and psychological well-being, dresses in clothing usually associated with the “opposite” sex. • Trans: An umbrella term used to describe individuals who, to varying degrees, do not conform to what society usually defines as a man or a woman. Gender Identity http://www.ohrc.on.ca/en/gender-identity-and-gender-expression-brochure

Approximately 1 in 11,000 men (0.009%) and 1 in 30,000 women (0.003%) seek treatment for gender dysphoriaat specialized clinics • It is important to note that many gender-variant people are comfortable with their gender identity • Gender dysphoria in adolescence may be accompanied by depressed mood, anxiety, and behaviourproblems • The Standards of Care as outlined by the World Professional Association for Transgender Health clearly recommends against physical interventions before the age of 16. They recommend that surgery only be performed after the age of 18 and after the individual has lived in their desired gender role for at least two years http://www.cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFactSheet_GenderDysphoriaInAdolescentsAndAdults.pdf Gender Identity

Basic Categories of Sexual Orientation (refers to romantic and/or sexual attraction to men, women or both sexes) • HeterosexualA male who is romantically and/or sexually attracted to femalesA female who is romantically and/or sexually attracted to males • GayA male who is romantically and/or sexually attracted to males • LesbianA female who is romantically and/or sexually attracted to females • BisexualA male or female who is romantically and/or sexually attracted to both males and females • Queer and QuestioningSome people do not think of their own sexual orientation in terms of the categories of heterosexual, gay, lesbian or bisexual. Some people will find that none of these categories seem to fit for them. http://www.sexualityandu.ca/sexual-health/sexual-orientation-and-coming-out Sexual Orientation

Sexual orientation is not a diagnosis, and it is not the practitioner’s job to discover what the adolescent’s orientation is. The practitioner, rather, should create an environment in which the adolescent feel they can discuss any questions or worries they may have • The best available Canadian statistics are from a2003 British Columbia Adolescent Health Survey • 1.5% of all boys identified themselves as bisexual, mostly homosexual or 100% homosexual • 3.5% of sexually active boys said that they have had sex with someone of the same gender in the past year • 3% of girls identified as bisexual, mostly homosexual or 100% homosexual • 6.4% of sexually active girls reported having had sex with someone of the same gender in the past year • American data is similar • 1.1% of teens identified as gay or bisexual, but 4.5% stated that their main sexual attraction was to individuals of the same sex • A Massachusetts study found that 2.5% of youth self-identified as gay, lesbian or bisexual http://www.cps.ca/en/documents/position/sexual-orientation Sexual Orientation

Trampoline injuries are most common among children 5 to 14 years of age and include: cuts and bruises, sprains and strains, broken bones, head injuries, and though rare, injuries to the back and neck that have caused paralysis or death. Is there a safe way to use a trampoline at home? No. Using a trampoline at home is not a safe way for children and youth to play. Injuries can happen even when adults are supervising. And safety enclosures (nets) around the trampoline do not prevent all injuries. Many injuries happen when: there is more than one child on the trampoline at the same time, doing “tricks” such as flips or somersaults, landing hard or the wrong way when jumping, or children are pushed or fall off the trampoline. For these reasons, the Canadian Paediatric Society recommends: Parents should not buy trampolines for their children or teens to use at home. Trampolines should not be considered play equipment. Education & Advice- Trampolines

Some things about helmets you may not know: -Different sports require different helmets (e.g. a bicycle helmet cannot be used for skateboarding or hockey) -Helmets come in different sizes (Have the child shake her head from side to side and from front to back. The helmet should not move around when she/he shakes her/his head) -Bike helmets should be replaced after 5 years or after a crash where the cyclist has hit their head -Do not use second hand helmets where you do not know the helmet’s crash history -Do not wear baseball hats/hats/hair clips etc under your helmet as may change the way the helmet fits -Do not put stickers on your helmet as they could make the plastic weak Education & Advice- Helmet Safety http://www.parachutecanada.org/injury-topics/topic/C8

Concussions: • A concussion is a brain injury. Any blow to the head, face, neck or to the body that causes a sudden shaking or jarring of the brain inside the skull may cause a concussion. • A concussion can result from any number of activities including receiving a check in hockey, falling from a jungle gym, being in a motor vehicle collision or slipping on an icy sidewalk. • You do not need to lose consciousness to have had a concussion. Education & Advice- FAQ http://www.parachutecanada.org/injury-topics/topic/C8

What are the signs and symptoms of a concussion? • Symptoms usually last for seven to 10 days but may last for several weeks to several months in some people. • Physical: headache, nausea or vomiting, dizziness, blurred vision, fatigue or low energy, sensitivity to light or noise, loss of consciousness • Cognitive (thinking): general confusion or fogginess, difficulty concentrating, difficulty remembering • Emotional: .more emotional, irritability, sadness, nervousness or anxiety THE SIX STEPS TO RETURN TO PLAY INCLUDE: (Min 1 day per step) 1. No activity, mental and physical rest until symptom-free 2. Light aerobic activity like walking or stationary cycling 3. Sport-specific activity like skating or running 4. Training drills without body contact 5. Training drills with body contact — only once cleared by a physician 6. Game play Education & Advice- FAQ http://www.parachutecanada.org/downloads/resources/Concussion_supplement_e06-handout.pdf

Greig Health Record • HFHT 6-12 Well Child Resource Guide • HFHT 13-17 Well Teen Resource Guide • Canadian Physical Activity and Sedentary Behaviour Guidelines ages 5-11 and 12-17 Handouts

Well Child & Teen Assessment Tools