Practicing Safety Steve Kairys, MD, MPH, FAAP Diane Abatemarco, PhD, MSW Practicing Safety Learning Session May 30, 2009

Disclosures Steven Kairys:I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Diane Abatemarco:I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

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 (over 60%)  Children < age 3 account for nearly 30 percent of victims.  Estimates of treatment costs are 24 billion dollars a year.  Long term sequelae are enormous in terms of psycho- logical and functional damage, substance abuse, delinquency, learned aggressiveness and abuse potential when a parent.

The Relationship of Adverse Childhood Experiences to Adult Health Status A collaborative effort of Kaiser Permanente and The Centers for Disease Control and Prevention Vincent J. Felitti, M.D. Robert F. Anda, M.D.

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)

What do we mean by Adverse Childhood Experiences? Experiences that represent medical and social problems of national importance. -Childhood abuse and neglect -Growing up with domestic violence, substance abuse or mental illness in the home - Parental loss - Crime

ACE Study Design Survey Wave 1 -- complete 71% response (9,508/13,454) n=15,000 71% response Survey Wave II n=15,000 All medical evaluations abstracted Present Health Status Mortality National Death Index Morbidity Hospital Discharge Outpatient Visits Emergency Room Visits Pharmacy Utilization All medical evaluations abstracted vs. &

The Adverse Childhood Experiences (ACE) Study Summary of Findings: Adverse Childhood Experiences (ACEs) are very common ACEs are strong predictors of later health risks and disease This combination makes ACEs the leading determinant of the health and social well-being of our nation

Categories of Adverse Childhood Experiences Category Prevalence (%) Abuse, by Category Psychological (by parents)11% Physical (by parents)11% Sexual (anyone)22% Household Dysfunction, by Category Substance Abuse26% Mental Illness19% Mother Treated Violently13% Imprisoned Household Member 3%

What is conventionally viewed as a problem is actually a solution to an unrecognized prior adversity.

Adverse Childhood Experiences determine the likelihood of the ten most common causes of death in the United States. Top 10 Risk Factors: smoking, severe obesity, physical inactivity, depression, suicide attempt, alcoholism, illicit drug use, injected drug use, 50+ sexual partners, h/o STD.

Evidence from ACE Study Suggests: Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs.

Adverse Childhood Experiences Social, Emotional, & Cognitive Impairment Adoption of Health-risk Behaviors Disease, Disability Early Death The Influence of Adverse Childhood Experiences Throughout Life Death Birth

The Role Primary Care Practice in Preventing Child Abuse and Neglect

Percent Of Children Who Saw A Pediatric Clinician In Past Year

Periodic Survey of Fellows of the American Academy of Pediatrics  Periodic Survey: National, random sample, mailed survey of 1600 US members of AAP  Fielded: March August 2000  Return rate = 67%  Data reported on 811 pediatricians who provide health supervision to children under 36 months of age

 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%) Pediatrician Perspectives on Content of Health Supervision

 Common topics not discussed over 50% even though 86% of pediatricians think those topics are important:  discipline  child development  behavior  Only 33% discuss guidance/discipline with parents of toddlers What Doctors Talk About With Their Families

Percent of Pediatricians Screening Young Children for Developmental Problems AAP Periodic Survey #53, 2002

Parents With Concerns About Their Children Ages 4-35 Months National Survey of Early Childhood Health, 2000

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

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

What Child Health Professionals Should Do  Screening: Identify risk factors that could lead to a problem, and initiate treatment to reduce or remove the risk  Educate: Anticipate potential problems, and initiate treatment to promote resilience in the child and family  Treat and Refer: Newly identify a problem, diagnose, initiate treatment or referral and provide care coordination

PRACTICING SAFETY PHASE I

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.

TOOLKIT 7 Color coded Modules: 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

Practice Guides with:  Background information about each topic  Assessment Questions  Anticipatory Guidance  Parent Educational Materials  Office Marketing Tools  Staff tools  Moderate Interactives/Tangibles  Issues Management Practicing Safety Modules include…

Practice Guide A tool for the clinician  Explanation of topic  Stages to introduce and reinforce information  Assessment Questions  Anticipatory Guidance  Materials for the office, parents, and staff  Issues Management

Practice Guide - Utilization A tool for the clinician  Assessment Questions  Anticipatory Guidance

Incorporate the materials into your routine patterns of practice

Create and use a Community Resource Guide

Data Analysis: Phase 1

Pre-Post Test Significance: Staff Responses Difficulty making changes in practice

Pre-Post Test Significance: Staff Responses Use of screening tool for depressionCounseling for maternal depression

Pre-Post Test Significance: Parent Responses Asked about depression

Pre-Post Test Significance: Parent Responses Reading to your child

Tool Evaluation Summary Overall usefulness of modules (Percentage of respondents who rated module as 3 or 4) Module 1: Coping with Crying Module 2: Parenting Module 3: Safety in Others’ Care Module 4: Family & the Environment Module 5: Effective Discipline Module 6: Sleeping and Feeding Module 7: Toilet Training

Tool Evaluation by Module Tools Rated most useful Coping with Crying Module  “Coping with Crying” posters (95% rated 3 or 4)  “World of Parenting” brochure (83% rated 3 or 4) Parenting Module  “Post-partum Depression” brochure (89% rated 3 or 4)  “Bonding With Your Child” booklet (88% rated 3 or 4) Safety in Others’ Care Module Support telephone numbers magnet (82% rated 3 or 4)  “Choosing Child Care: What’s Best for Your Family” (59% rated 3 or 4) Family and the Environment Module Support phone #s magnet (88% rated 3-4)  Domestic violence shoe card (74% rated 3- 4) Effective Discipline Module  “Teaching Good Behavior—Tips on Discipline” brochure (88% rated 3 or 4)  “Temper Tantrums: A Normal Part of Growing Up” brochure (87% rated 3 or 4) Sleeping and Feeding Module  “Sleep Problems in Children” brochure (75% rated 3 or 4)  “Feeding Kids Isn’t Always Easy” brochure (75% rated 3 or 4) Toilet Training Module  “Toilet Training” brochure (95% rated 3 or 4)  “Bed-wetting” brochure (89% rated 3 or 4)

Further Assessment  Focus group discussion sessions were conducted with 5-8 members of the practice staff, including members and non-members of the Reflective Adaptive Process (RAP) team.  In-depth telephone interviews were conducted with a physician in each of the practices.  Qualitative data collected were reflexively coded by 3 members of the research team separately. Inter-rater reliability was checked.

Changes in practice  Raised awareness about child abuse and neglect.  Maternal depression screening was adopted by 4 of the 5 pediatric practices. The practice that did not adopt screening identified lack of a referral source for depressed mothers within the community.  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.

Strengths of Practicing Safety Staff focus groups  Raised staff and MD awareness of issues and approach to patients/parents.  Helped institute depression screening and discussion of toilet training.  Provided opportunity for practice to reflect  Materials and helping identify parents at risk Physician interviews  Increased awareness of problems leading to child abuse & neglect  Developed more systematic ways of sharing information

Weaknesses Focus Groups  Too much information (and cost of materials)  Not targeted to varied audience  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  Staff complained of too much work

Revisions 5 Points to Practicing Safety 1. Reflective Practice Change 2. Infant 3. Mother 4. Toddler 5. Community

Toolkit Revision InfantMotherToddler BUNDLES

Team Expectations  Submit 20 Monthly Chart Documentation Forms on 30 th of every month (June-November)  Submit Monthly Progress Report on 30 th of every month  Share lessons learned and problem-solve with other participating practices through monthly conference calls and .  Complete a post-Inventory survey in November  Complete a Tool Evaluation survey in November  A selected number of practices will be asked to participate in telephone interviews at the conclusion of the project  Work with other members of your practice’s clinical team to improve care processes related to maternal depression screening, counseling about crying, counseling about toilet training, and counseling about effective discipline.  Test innovations in care delivery to prevent child abuse and neglect.

Agenda For Day  Baseline Data Results  Toolkit Bundles (Infant, Mother/Caregiver, Toddler)  Model for Improvement  Data Collection and Measurement  Team Planning Time  Team Sharing  Wrap Up and Next Steps Ask Questions! Share Experiences! Plan for Testing!