1. The identification and treatment of physical and sexual violence among adolescents in a healthcare setting: The Mount Sinai Adolescent Health Center By Angela Diaz, MD, MPH Physical and Sexual Violence Among Youth: Intervention Policies and Programs March 1, 2005

2. Mount Sinai Adolescent Health Center (AHC) AHC uses a holistic, multidisciplinary, integrated approach to physical health, reproductive health, mental health and health education for adolescents

3. AHC Vision To help adolescents grow up happy, healthy, and well-educated, with hopes and opportunities

4. A Bio-Psycho-Sociocultural-Spiritual Approach Physical Psychological  Cognitive  Emotional  Interpersonal  Behavioral Social Cultural Spiritual

5. Adolescent-Friendly Health Care Bio-psycho-sociocultural-spiritual approach  Comprehensive and integrated services Accessibility  Geographic  Financial: services regardless of ability to pay Confidentiality  Involvement of parents and family is encouraged, but confidential services are provided when necessary Trained staff  Experts in adolescent health Innovative  Adapting to changing needs of adolescents

6. Building Competencies Comprehensive and integrated services Health education  Prevention  Risk reduction support Nutrition education and counseling Physical health care  Routine care, acute and chronic illness Reproductive health care Mental health services  Individual, family, group therapy  Crisis intervention and case management

7. AHC Adolescents and Services Ages 10-21 All genders Services free of charge

8. Origin of Patients Visiting the AHC, 1997-2000

9. AHC Sexual Victimization Experience 1985  anonymously surveyed 60 female patients - 35 (58%) reported sexual assault with 25% being incest 1989  interviewed 141 female patients - 32 (23%) reported sexual assault with 66% being incest 2001  68 (15%) of 450 consecutive female patients presenting for mental health services self-report coerced sex

10. Promoting Disclosure All staff, including support staff, trained and supported to feel comfortable to assess signs of abuse and to respond appropriate to their role Posters and other visible messages that this is a safe place to disclose Educational materials Screening Measures Direct Inquiry

11. Adolescents seeking mental health services: Adquest They are experiencing violence:  74% have witnessed violence  43% worry about safety  37% worry they do dangerous things  37% have been victims of violence  24% have been sexually abused  24% have been threatened or assaulted with weapon  10% have been raped  7% are in violent dating relationship They want to talk:  82% want to talk about school  80% want to talk about family and home life  76% want to talk about friends  71% want to talk about safety and violence  65% want to talk about work  62% want to talk about substance use

12. Direct Inquiry Disclosure rates of abuse increase if clients are asked directly by their providers Of a study group at AHC (1997), 22.7% disclosed sexual abuse when asked directly by their physician during their routine medical screening 81% of these patients accepted referrals to counseling as a result of this disclosure Diaz, A. & Manigat, N. (1999). The health care provider’s role in the disclosure of sexual abuse: the medical interview as a gateway to disclosure. Children’s Health Care Journal, 28(2), 141-149.

13. Direct Inquiry - Questions Has anyone ever touched your body in a way that made you feel uncomfortable or when you did not want them to? Has anyone ever forced you to perform any sexual act on your body or on theirs? Has anyone ever touched your breast when you did not want them to? Your vagina? Penis? Buttocks? Anus? Or any other part of your body?  If yes, who was it? Was it your father? Mother? Brother? Sister? Uncle? Aunt? Grandparent? Neighbor? Teacher? Stranger?

14. Age of Victim at First Episode* Age (years)N 3-412 5-619 7-816 9-1022 11-1213 13-1411 15-17 7 *mean age at first episodes was 8.8 year

15. Age of Perpetrator at First Episode* Age (years)N 10-1920 20-2919 30-3928 40-4920 50-595 60-697 70-793 unknown4 *mean age of perpetrator was 32.0 year

16. Perpetrators First Episode All Episodes NN (%) Father3134 (21) Father surrogate2232 (19) Mother or surrogate2 3 (2) Siblings7 13 (8) Other relatives2336 (22) Nonrelatives1547 (28) Total100165

17. Case Control Examination Controls selected with no history of sexual abuse Similar  age, education, race/ethnicity, and SES

18. Comparison of Perceived Relationship with Mother

19. History of Running Away

20. Comparison of Coopersmith Self-Esteem Scores

21. Comparison of Depressive Symptoms

22. Comparison of Suicidality

23. Interventions & Therapy Modalities Support upon disclosure Crisis Interventions Therapy Modalities  Individual  Family  Group  Psychoeducational  Psychotherapy  Trauma-specific therapy  Art therapy