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:  Smoking  Severe Obesity  Physical inactivity  Depression  Suicide attempt  Alcoholism  Illicit drug use  Injected drug use  50+ sexual partners  h/o STDs

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 diseases in adults are determined decades 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.  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

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. 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 Guidelines

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)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: 1.Colic 2.Awakening at night 3.Separation anxiety 4.Normal exploratory behavior 5.Normal negativism 6.Normal poor appetite 7.Toilet training resistance *Schmitt BA. Child Abuse and Neglect, 1987.

23. Guidance for Pediatrics 1.Obtain a thorough social history, initially and periodically, throughout a patient’s childhood. 2.Acknowledge the frustration and anger that often accompany parenting. 3.Talk with parents about their infant’s crying and how they are coping with it. 4.When caring for children with disabilities, be cognizant of their increased vulnerability and watch for signs of maltreatment.

24. Guidance 5.Be alert to signs and symptoms of parental intimate partner violence and postpartum depression. 6.Guide parents in providing effective discipline. 7.Talk to parents about normal sexual development and counsel them about how to prevent sexual abuse. 8.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 9.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). 10.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 1.Some type of facilitation is needed to help the practices make change. 2.Efforts need to be made to spread intervention throughout practice. 3.AAP brochures, posters and screening tools were of most use to practices. 4.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. 5.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 Infant Bundle: Coping with Crying Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light:Assessment/ Screening Anticipatory Guidance -Example: How often does your baby cry and how do you handle it? -Provide anticipatory guidance -Welcome to the World of Parenting brochure -Guide for parents: Swaddling 101 -Crying poster Yellow light:Parent concerns-Example: Who can you call to help when you need a break? -Provide anticipatory guidance -Refer to family strengthening organization Red light:Possible safety concerns for infant Referral to Child Protective Services for evaluation and care management Introduce at 2 weeks to 4 weeks; Reinforce at 2 months **Tools are identified by purple font

37. Mother/Caregiver Bundle Mother/Caregiver Bundle: Maternal Depression/Bonding/Attachment Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light: Assessment/Screening Anticipatory Guidance -Edinburgh Postnatal Depression Scale (EPDS) -Example: Is the mom’s partner available for support? -Example: What do you enjoy doing with your baby? -Provide anticipatory guidance -Postpartum Depression Brochure -Refresh. Renew. Recharge Poster -Have you Read to Your Baby today button Yellow light: At risk for depression/<9* but have concerns/early signs Referral to support system, including PCP, OB, Behavioral health agency, home visiting program Red light: Depression/≥9* or ≥1 on Q#10*/potential risk to self and/or infant Referral to Child Protective Services and/or Behavioral Health agency *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 Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light:Assessment/ Screening Anticipatory Guidance -Example: What makes you lose it with your baby/child? How do you handle it? -How were you disciplined as a child? -Provide anticipatory guidance -Teaching Good Behavior-Tips on Discipline -Play is How Toddlers Learn -Reading. Routine. Relationships. Rewards poster Yellow light:Evidence help is needed/parental frustration/unrealis tic expectations -Example: How do you handle temper tantrums? -Provide anticipatory guidance -Temper Tantrum brochure -Refer to family strengthening organization Red light:Possible safety concerns for child Referral to Child Protective Services for evaluation and care management Introduce at 6 months; Reinforce at 12, 15, 18, 24, 36 months **Tools are identified by purple font

39. Toddler Bundle: Toilet Training Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light:Assessment/ Screening Anticipatory Guidance -Example: Have you thouhgt about or started toilet training? How is it going? -Provide anticipatory guidance -AAP Toilet Training brochure Yellow light:Evidence help is needed/parental frustration/unrealis tic expectations -Provide anticipatory guidance -Potty Chart -Bedwetting Brochure -Refer to family strengthening organization Red light:Possible safety concerns for child Referral to Child Protective Services for evaluation and care management 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. Tuscaloosa, AL University Medical Center Dayton, OH Children’s Health Clinic Houston, TX Lyndon B. Johnson Pediatric Clinic Grand Rapids, MI Helen DeVos Children’s Hospital General Pediatrics Greenville, SC Center for Pediatric Medicine Brooklyn, NY Maimonides Infants and Children’s Hospital- Newkirk Family Health Center Flushing, NY Flushing Hospital Medical Center New Haven, CT Hospital of Saint Raphael Pediatric Primary Care Center West Reading, PA All About Children Pediatric Partners PC Longview, WA Child and Adolescent Clinic Bluefield, WV Dr Frazer’s Office Brewton, AL Lower Alabama Pediatrics Thank you to the 14 Practicing Safety Teams! Charlotte, NC CMC-Myers Park Pediatrics Midlothian, VA Pediatric & Adolescent Health Partners

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” Swaddling 101World of Parenting Coping with Crying Hug, Hold, Comfort, Cuddle Information/ Content Appropriate Information3.94.64.34.2 Adequately Comprehensive/ Thorough4.04.44.34.1 Aids in Patient Care3.94.54.34.2 Cultural Sensitivity Literacy Level is Appropriate3.53.94.54.4 Culturally Appropriate3.84.24.4 Free of Bias4.5 4.6 Usefulness Readability3.54.14.64.5 Relevant Information3.94.24.4 Purpose is Clear3.94.34.4 Effective3.94.24.3 Total (average)3.94.34.44.3 Key: 1 = Poor 5 = Excellent

50. Average Respondent Ratings of “Practicing Safety Tool Evaluation: Mother/Caregiver Bundle” Post Partum DepressionRefresh, Renew, Recharge Edinburgh Postnatal ScaleRead to Baby Button Information/ Content Appropriate Information4.54.14.43.4 Adequately Comprehensive/ Thorough4.34.14.23.4 Aids in Patient Care4.54.14.53.4 Cultural Sensitivity Literacy Level is Appropriate3.74.23.64.3 Culturally Appropriate4.14.44.14.2 Free of Bias4.54.64.34.6 Usefulness Readability4.14.23.94.1 Relevant Information4.2 Purpose is Clear4.64.24.44.3 Effective4.1 4.43.9 Total (average)4.34.2 4.0 Key: 1 = Poor 5 = Excellent

51. Average Respondent Ratings of “Practicing Safety Tool Evaluation: Toddler Bundle” Toilet Training Potty Chart Bed- Wetting Teaching Good Behavior Temper Tantrum Playing is Learning Reading, Routine, etc. Information/ Content Appropriate Information4.74.64.24.84.94.74.5 Adequately Comprehen-sive/ Thorough4.64.34.24.7 4.64.5 Aids in Patient Care4.74.54.14.74.84.54.4 Cultural Sensitivity Literacy Level Appropriate4.14.64.3 4.24.44.3 Culturally Appropriate4.44.54.44.54.6 4.3 Free of Bias4.7 4.64.8 4.74.5 Usefulness Readability4.54.74.14.6 4.5 Relevant Information4.74.54.14.74.8 4.4 Purpose is Clear4.8 4.34.8 4.6 Effective4.54.64.04.64.74.64.2 Total (average)4.6 4.24.64.74.64.4 Key: 1 = Poor 5 = Excellent

52. Practicing Safety Results: Office Systems Inventory

55. Average Time spent at 2- and 18-month well child visits from pre to post intervention Pre-test Average (n=13 practices) Post-test Average (n=13 practices) Change in minutes (average) On average, how much time is spent at a 2-month well child visit (in minutes) 19.2 minutes20.6 minutes+1.4 minutes On average, how much time is spent at a 18-month well child visit (in minutes) 21.7 minutes22.3 minutes+0.6 minutes

56. Practicing Safety Results: Qualitative Themes

57. Qualitative Themes  Consistent use of PS toolkit  Systemization of risk  Changes to chart documentation  Community resource linkages  Initiation of meetings  Improved medical education  Implementation of QI methodology  Increased awareness  Challenges  Unanticipated positive outcomes

58. Practicing Safety Lessons Learned  Practices need guidance in order to incorporate practice- based protocols that address child abuse and neglect prevention as part of well-child care  Pediatricians, once supported and mentored, are excited to offer families more concrete and systematic guidance in these areas  Practicing Safety can inform more successful implementation of enhanced care and assists practices in establishing a medical home  Parents are receptive to guidance on these topics and believe these issues are of significant concern  Practicing Safety provided an opportunity for enhanced clinical education for physicians, nurses, residents, etc

59. Practicing Safety Lessons Learned (con’t.)  Practices tailored tools to fit their patient population. Some practices incorporated tools for more than the project prescribed well-child visit based on age. Some practices collapsed the suggested “green” and “yellow” assessment questions and anticipatory guidance and used both levels routinely as primary prevention topics at well-visits for all of their families with children in the targeted age ranges  Some practices found a need for multi-lingual, low literacy and more graphic materials for parents  Just participating in PS raised awareness of child abuse and neglect issues for all roles in the pediatric office  Chart documentation is key to determining improvements in care

60. Practicing Safety Lessons Learned (con’t.)  It is important to have an engaged practice champion to succeed & leadership support, teams enhance practice change  Some practices found it challenging to promote the bigger picture of their work to the rest of the practice physicians and staff – the importance of testing and measuring prior to full-on implementation  Administrative and clinical priorities compete with making change (H1N1, EMR implementation, staff turnover)  Coding and reimbursement remain a challenge  The project motivated practices to link with community.  Lastly, practices would like more info on diffision.

61. Additional Resources  Practicing Safety QuIIN Web Page: http://www.aap.org/qualityimprovement/quiin/ PracticingSafety.html http://www.aap.org/qualityimprovement/quiin/ PracticingSafety.html  Project Staff Jill Healy, QuIIN Project Manager jhealy@aap.orgjhealy@aap.org Tammy Hurley, Manager, Child Abuse and Neglect Prevention Activities thurley@aap.org thurley@aap.org

62. The Safe Environment for Every Kid (SEEK) Model: Pediatricians Preventing Child Maltreatment Preventing Child Maltreatment Howard Dubowitz, MD, MS Wendy Lane, MD, MPH Cindy Weisbart, PsyD University of Maryland School of Medicine University of Maryland School of Medicine

63. The SEEK Model  Specially trained physicians  Parent Screening Questionnaire (PSQ)  Brief assessment of problems  Initial management  Physician - social worker team  Referral to community agencies

64. Introduction to the PSQ  Provides context: “We want to help families have a safe environment for kids”  Builds on what’s accepted: injury prevention  Universal: “We’re asking everyone …”  Empathic: “Being a parent is not easy”

65. Parent Screening Questionnaire (PSQ)  brief  easy to read  answer yes/no  convenient, time to complete  voluntary

66. PSQ

67. Examples of PSQ Questions  Intimate partner violence: In the past year, have you been afraid of a partner?  Substance abuse: In the past year, have you felt the need to cut back on drinking or drug use?  Depression: Lately, do you often feel down, depressed, or hopeless?

68. If screen +  PSQ : 1-2 questions per problem  Brief assessment  Initial management, refer  A positive screen is not a diagnosis

69. SEEK Study Design Subset of mothers recruited Model Care (Intervention) Trained pediatricians, Parent Screening Questionnaire, + social worker. All patients receive Model Care Initial Survey 6 Mo. Survey Medical Chart & CPS Record Review Standard Care (Control) All patients receive standard pediatric primary care Randomly assign practices 12 Mo. Survey

70. SEEK HPs SEEK I: Residents’ continuity clinics SEEK II: Private practices in central Maryland Agreed for practice to be randomized to intervention or control group If in intervention group, agreed to attend training and implement SEEK

71. SEEK Study Samples SEEK I  558 families  Low income, urban  Mostly African American  Pediatric resident clinic  92 residents SEEK II  1121 families  Middle class, mostly suburban  Mostly white  18 pediatric private practices  101 pediatricians &pediatric nurse practitioners

72. Hypothesis 1 Training physicians to address risk factors for CM will significantly improve their:  Attitudes  Knowledge  Comfort level  Perceived competence  Practice

73. SEEK I: Practice Behavior Intervention vs. Control Residents Range: 0 - 5 p =.03 (pretest - 18 months) α =.72

74. SEEK I: Rates that Problems were Screened for During Regular Checkups based on chart review % DepressionPartner Violence

75. SEEK I & II PSQ: Conclusions  Very good test - retest reliability  High sensitivity – depression, stress  Low sensitivity – acceptable?  High specificity - all risk factors except food insecurity

76. In Summary  Improved physician sense of competence and screening for risk factors, based on: Self-report Medical chart review Direct observation  In SEEK I and II  Sustained 18 months after initial training

77. The SEEK model will help prevent child maltreatment Hypothesis 2

78. Parent-Child Conflict Tactics Scale (CTS – PC)  Parent’s report of psychological and physical aggression in disciplining a child  Starts with positive approaches, escalates with increasingly violent behaviors  Adequate reliability, validity Straus et al, Child Abuse & Neglect. 1998;22:249-70

79. Medical Neglect: Non-compliance † based on chart review (SEEK I) * P = 0.05 † MD documented “non-compliance”

80. Medical Neglect: Delayed Immunizations † based on chart review (SEEK I) † MD documented * P = 0.002

81. Child Protective Services Reports for Abuse or Neglect (SEEK I) * P = 0.03

82. SEEK II CPS Results Group No CPS Reports Pre-SEEK CPS Reports Only During SEEK CPS Reports Only Pre and During SEEK CPS Reports n (row %) Interven- tion 579 (95)15 (3)8 (1)7 (1) Control 519 (98)6 (1) 3 (0.6)2 (0.4) P = 1.0 using Fisher’s exact test

83. Closing thoughts  Practices can incorporate screening and guidance into their practices  Focused engagement in child abuse prevention shows promise  Reimbursement issues need to be addressed  It appears that more than one model on practice improvement can be effective

84. The Road Ahead ……….  Further replication, evaluation, refinement  Prioritize resident continuity clinics  Begin pre-natally  SEEKING SAFETY- combine the elements of the two models  Broad outcomes based study of at least 100 practices

85. Thank you! Questions