adverse childhood experiences and practice: informing services in pediatric medical settings

Adverse Childhood Experiences and

Practice: Informing Services In Pediatric

Medical SettingsDeandra Clark, MDKim Conant, LPN

Kristine Hobbs, LMSWRamkumar Jayagopalan, MD

SC Children’s Trust Conference, September 18, 2015

Who are We? Where Did We Come From?

Why are We Here Today?

Agenda

• Why SEEK?• Dr. Ramkumar Jayagopalan, Carolina Pediatrics, Columbia

• How to SEEK?• Kristine Hobbs, Mental Health Integration Coordinator, QTIP

• What if ‘they’ don’t want to SEEK?• Dr. Deandra Clark, AnMed health Children’s Healthcare Center

• What if you SEEK and FIND?• Kim Conant, Special Care Needs Coordinator, Palmetto Pediatric

and Adolescent Clinic

• Discussion

Why SEEK?Dr. Ramkumar Jayagopalan

TRAUMA INFORMED

CARE Ramkumar Jayagopalan

WHAT IS TRAUMA ?

TOXIC STRESS

Emotional stress.• Positive stress- helps guide growth

• Tolerable stress- not helpful but no permanent damage

• Traumatic stress / Toxic stress

TOXIC STRESS

• Extreme, frequent, extended activation of the stress response, without the buffering presence of a supportive adult.

• Neglect, abuse, extreme poverty, family violence, substance abuse, and parental health problems.

• These are examples of Adverse Childhood Events ( ACEs).

WHY ADDRESS TOXIC STRESS?

Adverse Childhood Experiences ( ACE ) study• Attention problems, oppositional behavior,

emotional dysregulation, sleep problems, toileting problems, anger, anxiety and depression- directly related to childhood adversity.

• High risk for adverse health outcomes as an adult- cardiovascular, cancers, asthma, depression and autoimmune diseases.

• High risk behaviors like alcohol and drug addiction.• Enormous financial and personal cost.

ACE PYRAMID

WHAT TOXIC STRESS DOES ?

TOXIC STRESS

EPIGENETIC CHANGES

BRAIN DEVELOPME

NTMALADAPTIVE BEHAVIOR

ADVERSE HEALTH

OUTCOMES

TRAUMA EPIDEMIC

• 68% of all kids have had at least one PTE (potentially traumatizing event).

• More than half of these kids have had more than two PTEs.

• Strong link between exposure to PTEs in childhood and long term somatic and emotional health outcomes.

WHAT CAN PEDIATRICIANS DO?

• Identify traumatized children.

• Screening for consequences of trauma.

• Effective interventions for treatment.

• Create a trauma sensitive office culture.

How to screen for trauma?

• Open ended or direct questioningSince the last time I saw your child ( you), has anything really

scary or upsetting happened to your child or anyone in the family?

• Standardized screening tools SWYC- Survey of Wellbeing of Young Children One screen for developmental, emotional , mental health and family risk factors ( Age 0-5). SEEK PTSD- RI TSC- C Ideally should be done at all well child visits.

How to identify trauma symptoms ?

• Change in bodily functions- sleep, eating and toileting.

• Change in behavior- detachment, aggression, anxiety, fantasy.

• Impaired development and learning.

TRAUMA SCREENING PROTOCOL

SCREEN FOR TRAUMA

POSITIVE

SCREEN FOR PTSD SYMPTOMS

NEGATIVE

KEEP SCREENING

FOR SYMPTOMS

POSITIVE- MILD10-20

COUNSELING/

EDUCATION

POSITIVE- SEVERE

PTSD> 20

REFER EBTs

NEGATIVE

RESCREEN EVERY WELL CHECK OR IF

INDICATED

PTSD REACTION

INDEX

How to respond?

Affirmation• HELP – Hope, Empathy, Language,

Patience.• Provide education materials.

Anticipatory guidance

In-office treatments:• Self care- good sleep, exercise…• Focused breathing and relaxation

techniques- pin wheel ?

Refer for treatment.• PCIT• TF- CBT• Know what are the evidence based

treatments available.• Know your community trauma resources.

SO WHY DO IT ?

• That is what pediatricians do!

And……..

You would look cool !

RESOURCES

AAP Healthy Foster Care America

www.aap.org/fostercare

National Child Traumatic Stress Network

www.nctsn.org

Child Trauma Academy

www.childtrauma.org

Project BEST ( Bringing Evidence Supported mental health Treatments. )

www.musc.edu/ncvc

How to SEEK?Kristine Hobbs

• Trauma Informed Care• Why pediatricians?• Why SC?

• Tools available• Resources for Pediatricians• Resources for Families• Next Steps…

“From the time of its inception as a recognized specialty of medicine, the field of pediatrics has attached great significance to both the process of child development and the social/ environmental context in which it unfolds.”

http://www.pediatricsdigest.mobi/content/129/1/e224.full

Why Pediatricians…

http://childlaw.sc.edu/JointCommittee/2013%20Annual%20Report%20JCLCC.pdf

Why South Carolina?

Last year (2012)… • 1,087,000 children living in South Carolina• SC ranked 43rd in the nation by the Annie E. Casey

Foundation in overall child well-being• 490,000 children lived in some officially measured

degree of poverty • 583,000 children were on Medicaid• 25,400 children were the subject of a child

maltreatment investigation• 3,800 children lived in foster care• 17,000 cases of delinquency were referred to the

family courts• 93,000 children received special education services• 57% of students received subsidized school meals to

access adequate nutrition• 25% of students who start school will not graduate

with peers

http://childlaw.sc.edu/JointCommittee/2013%20Annual%20Report%20JCLCC.pdf

“The Safe Environment for Every Kid (SEEK) model …address prevalent psychosocial problems:• parental

depression• substance abuse• major stress• intimate partner

violence• food insecurity• discipline

challenges”

http://theinstitute.umaryland.edu/seek/

One Tool….

http://t

heinstitute.umaryl

and.edu/seek/

Resources for You and Your Families

http://theinstitute.umaryland.edu/seek/seek_parenthandouts.cfm

Next Steps…Poison Control #Smoke Detector – Fire DepartmentQUIT LineDSS – SNAP; local food banks; free & reduced lunchParent supports; churches, community, child care center; First Steps; Home visitors; social support networks; Military resourcesPersonal support network, DMH, private therapist EAP at workDepression – same as above; include doctorDomestic violence – manned across stateSubstance – fast track through DAODAS using their SBIRT contacts….

SEEK CHEAT SHEET – Lexington County SEEK Topic

Resource Ideas

 Phone Number Website

Poison Control

National Hotline Number

1-800-222-1222  

Smoke Detector

Local Fire Department

803-785-8343  http://www.lex-co.sc.gov/departments/DeptAH/emergencymanagement/Pages/index.aspx

Tobacco Smoke

SC DHEC QUITLine

1-800-QUIT NOW https://www.scdhec.gov/health/chcdp/tobacco/quit-for-keeps/

Food Needs

SC DSSLocal Food Bank

DSS - 1-(800)-616-1309We Care Center – Chapin--(803) 345-3244Sharing God’s Love, Irmo--(803) 732-3188Harvest Hope Food Bank, Cayce--(803) 794-1627LICS – Lexington Interfaith Community Services, Lexington (803) 957-6656

https://dss.sc.gov/content/customers/food/foodstamp/foodstampcalc.aspxhttps://dss.sc.gov/Scmapp/default.aspxhttp://chapin_sc.suntopia.org/food_pantries.php

Parenting Support

First StepsHome VisitorsChurchesParenting Groups

Saxe Gotha Presbyterian Church - Respite Care for children with special needs and their siblings - 3rd Saturday of each month – 4:30- 7:30Ginny Aldinger 803.629.5212

http://www.acswebnetworks.com/saxegotha/article229636.htm

Extreme StressDown, Depressed or Hopeless

Hotline NumberLocal DMHTherapists EAP programs Church/Community affiliated groups

Lexington County Mental Health Center – 803-359-7206Suicide & Crisis Hotline1-800-999-9999Family Service Center (803) 733-5450

http://www.state.sc.us/dmh/lccmhc/ www.fsconline.org 

Interpersonal Violence

Domestic Violence HotlineLocal Resources

National Domestic Violence Hotline800-799-7233Sistercare, IncPhone: 803-926-0505; Hotline: 1-800-637-7606

http://sistercare.com/

Drugs or Alcohol

Local DAODAS Center

LRADAC(803) 726-9400;

http://www.lradac.org/

What if they don’t want to SEEK?

Dr. Deandra Clark

Parent Cover Sheet - AnMed

Dear Parents, The American Academy of Pediatrics recommends the use of screening tools at every Well Child Check/physical for your child. These screening tools include screens for post-partum depression, developmental delays, Autism, depression and mental health issues, and economic hardships. Today’s questionnaire is the “Safe Environment for every Kid.” It asks some personal questions. It’s aim is to strengthen families, support parents, and improve children’s health, development, and safety. The reason we use these screens in this office is to identify issues where we can offer assistance and referrals if needed. To that aim, attached is a list of resources in Anderson that help with issues addressed in this questionnaire. Our goal is always to provide you the best care possible. We thank you for your willingness to help us provide that care. 

Thank you,Your Care Team

AnMed’s Food

Pantry Resource

List

ANDERSON Family ResourcesTopic Phone Number Website

 Poison Control

 1-800-222-1222

Need a Smoke Detector?

 210 McGee Road(864) 260-4016

 www.acfire.org 

Ready to Quit Smoking?

 1-800-QUIT-NOW  www.scdhec.gov/health/chcdp/tobacco/quit-for-keeps/ 

  Food Needs?

DSS- 1-800-616-1309Salvation Army --(864) 225-7381New Life Philadelphia Center -- (864) 224-4052Good Neighbor Cupboard -- (864) 224-1701Anderson Interfaith Ministries -- (864) 226-2273

https://dss.sc.gov/content/customers/food/foodstamp/index.aspxhttps://dss.sc.gov/Scmapp/default.aspxhttp://anderson_sc.suntopia.org/food_pantries.php

   Supports for parenting?

National Parent Helpline1-855-427-2736 (M-F 7a-4p)Family Connections1104 Ella St. -- (864)231-8100Email: sfields@FamilyConnectionSC.orgNational Alliance on Mental Health (NAMI)1 (800) 950-NAMI (6264)

 http://scfirststeps.org/anderson/http://www.familyconnectionsc.orghttp://www.nami.org 

 Feeling Down, Depressed or Stressed?

Anderson-Oconee-Pickens County Mental Health Center200 McGee Road -- (864) 260-2220 Suicide &Crisis Hotline1-800-999-9999

  www.aopmentalhealth.org   

  Interpersonal Violence?

National Domestic Violence Hotline 1-800-799-7233National Child Abuse Hotline1-800-4-a-Child (1-800-422-4453Safe Harbor --(864) 467-1177hotline- 1-800-291-2139

 WomensHealth.gov www.safeharborsc.org

 Ready to cut down on substance use?

Anderson/Oconee Behavioral Health Services226 McGee Road(864) 260-4168

  http://www.aobhs.org

For more ideas contact the United WayPhone #211 or www.211.org

Anderson Family

Resource List

What if you SEEK and Find?

Kim Conant, LPN

Sumter County Family’

s Resourc

e List

Kershaw County Family

Resource List

H HopeE EmpathyL2 Language

LoyaltyP3 Permission

PartnershipPlan

HELP

SEEK Log – Little River

Discussion Question:

How can we work together in our

communities to address toxic stressors for kids

and families?