2019-20 TOW #8: Promoting First Relationships in Pediatric Primary Care (PFR-PPC)

We’ve been fortunate to offer training to residents in a relationship-based parenting approach called Promoting First Relationships (PFR). PFR was developed at UW and has been shown to improve caregiver responsiveness and child outcomes, especially for children in foster care. Huge thanks to the team who helped adapt PFR for our residency training.

Materials for this week:

Take-home points:

  1. Why are early relationships so important to children’s development? Research in neurodevelopment, toxic stress, adverse childhood experiences, early child and brain development, and infant mental health continues to demonstrate the critical nature of the early caregiver-child relationships as a driver of physical, social, and emotional wellbeing.
  2. What are the fundamental infant and early childhood mental health concepts that inform the PFR approach? 1) Importance of early attachment and parental attunement and reciprocity, 2) responsive caregiving including noticing and understanding child cues and how they help children regulate, 3) need for caregivers to provide co-regulation for children’s big emotions, especially those emerging at 9-24 months of life, 4) reframing challenging behavior as stemming from unmet physical, social or emotional needs
  3. How can we as pediatricians help with developing children’s primary caregiver relationships? We are uniquely positioned to influence early relationships from our knowledge of child development, our trusted relationship with families, and the frequency of wellness visits during early childhood. Pediatric care providers are often the only service provider that sees new families in the first year of life. We can observe attachment and relationships in the office and provide positive feedback to parents about how they are helping their children through attunement, response, understanding, and co-regulation.
  4. What are the PFR strategies and why are they used? PFR strategies include Joining, Positive Feedback, Positive Instructive Feedback, and Supportive Reflective Capacity. These strategies are designed to help medical providers increase parent or caregiver’s feelings of competence, confidence and joy, so they are better able to support their child’s social emotional development. One of the reasons I really appreciate this program is the focus on developing parents’ strengths and joy in their parenting. I have noticed I enjoy visits more when I am attuned to the relationships and “catching them doing well” in modeling effective approaches with their children.

2018-19 TOW #45: Substance use

As pediatricians in primary care, our roles include universal screening, brief intervention, and referral to treatment (SBIRT) for adolescent substance use. After Washington state legalized adult use of marijuana in 2012, we entered a new era of adolescent substance use. One patient I saw under age 13 described in detail why marijuana was a “natural drug” that had medicinal properties to justify why she used it. The societal messages are confusing and often erroneous for teens, so it’s important for us to help provide accurate information and support.

Materials for this week:

Take-home points for substance use problems:

  1. What’s the epidemiology of youth substance use? Among US teens, average first use of alcohol is 13.1 years, ~50% have tried alcohol by 8th grade, and almost 80% have tried it by high school graduation. >50% have tried other drugs by the end of high school, most often marijuana, and ~20% have used prescription drugs non-medically (a BIG increase).
  2. What are the risk factors for substance abuse? Parents with substance abuse, history of abuse, depression or learning disabilities (especially ADHD), family conflict, friend use, and  living in a rural area. Data have shown that those who drink prior to age 15 years are 4 times more likely to develop alcohol use disorder than those who start at age 21. Protective factors include a stable, supportive home environment with clear parental expectation and rules, friends not involved with substances, and personal, academic and social success.
  3. What are the associated problems with substance use? There are many including school drop-out, violence, motor vehicle accidents, pregnancy, and permanent decrease in IQ with prolonged use. Youth getting Ds and Fs in school are 3x more likely to be using alcohol than those getting As.
  4. How should we screen? Use the HEADSSS assessment to screen all youth. It’s helpful to frame this as a “we care about you, teenage years can be hard, and we want to help.” It is also recommended to ask parents and teens together what they have talked about and their attitudes. If concerned, follow-up with the CRAFFT assessment: 2 or more positive responses are predictive of problem use.
  5. Where can we refer? Options to address problem use include mental health counseling and specific substance use treatment. Local resources: Adolescent medicine at SCH, and community programs such asRyther Center for Children and Youth and Therapeutic Health Services

2018-19 TOW #31: Promoting wellness & self-care

As we head into the Valentine’s week, we will discuss some ways to teach how to love and care for ourselves and how to promote wellness among our patients. While teens may be notorious narcissists, they need to be given support in how to actually care for themselves.

Materials/Resources for this week:

Take-home points for promoting wellness and self-care among our patients:

  1. Rising concerns about teen stress and mental health: As rates of depression and anxiety have risen for kids and teens, pediatricians are called upon to become more comfortable discussing these conditions, and what we can do to prevent and treat them. Many teens may take some time to warm up to the idea of seeing a therapist or another provider, so we will be their first stop, and sometimes the only one.
  2. Priorities for wellness promotion: Most importantly, we can focus on basics: sleep, nutrition, and physical activity. Increasingly tools like mindfulnessrelaxation skills (e.g. breathing techniques, stretching), biofeedback, mindful eating, and positive psychology practices like offering gratitude have shown success among youth.
  3. Wellness skills can be learned and practiced: long before the frontal lobe is fully developed, youth can learn and practice self-care and wellness. These skills are not necessarily innate, so we get better with practice: think of them like exercises for the mind. I often remind patients that even professional athletes get a lot of help to manage stress and build skills to perform at the top levels.
  4. Offer resources for parents to support their children/teens: Parents offer guidance, resources, and role modeling and may need help themselves in navigating challenges. We can support parents’ self care and offer resources, like those here.
  5. Walk the talk: “Doctor, heal thyself” is a well known expression in medicine. As we become familiar with self-care approaches and resources, we can use this to help patients. Teens appreciate knowing that the adults around them are human and have to keep learning too. We can be deliberate about acknowledging the need for and benefit of self-care/wellness amidst the daily stressors of life.

2018-19 TOW #30: Race and Medicine

Happy February! As we celebrate Black History Month in February, we are covering a critical topic affecting all children: bias and racism.* A big thank you to the input of many people on this topic and the efforts happening at SCH/UW, including our amazing residents and faculty in D-Comm, INCLUDE curriculum team, and the Center for Diversity and Health Equity (CDHE). Given the national dialogue and health disparities, it’s more important than ever that we use our roles as physicians to address bias and racism. While we honor the significant work that has come before us, we acknowledge there’s much more work yet to do. I’m grateful our children in Seattle Public Schools are also getting specific education this week with a national Black Lives Matter at school week.

*Note: This is a really big topic – try to review at least one article. In clinic, I suggest you watch Dr. Jones’ or Dr. Roberts’ TED talks and discuss how you have observed racism affecting health and personal ways we can try to make a difference.

Materials for this week:

Take-home points for this week – structured as a charge to each of us, as outlined from the article by Hardeman et al. in the NEJM

  1. Learn about, understand and accept racism – in ourselves and in our institutions. As Hardeman et al, describe “Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals. If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.” Those who have had white privilege must be able to understand and recognize what that means to see the effects of racism in our society. Watch Dr. Camara Jones’ TED talk on the gardener story and effect of differential preference over time.
  2. Understand how racism has shaped our narrative and the rhetoric we have used in medicine to erroneously relate race to biologic differences. Medical schools are now recognizing the need to address the curriculum to better deconstruct race as a social rather than biologic construct, and we need more change (see Rebekah’s article above and R3 Paul Homer’s RCP this year). We must continue to educate ourselves about our societal and institutional structural racism and approaches to address this through writers such as Ta-Nehesi Coates, local writer Ijeoma Oluo, and UW-trained sociologist Robin DiAngelo. PBS’ Black Culture Connection features writers, community influencers, and movies/documentaries.
  3. Define and name racism – develop consistent definitions and use accurate vocabulary – Dr. Jones describes race as “the societal box into which others put you based on your physical features.” Racism is a “system that encompasses economic, political, social and cultural structures, actions and beliefs that institutionalize and perpetuate an unequal distribution of privileges, resources and power between White people and people of Color.” (Hilliard, 1992). We should shift our focus in medicine and health research from identifying race to identifying racism and its effects on health. We also need to name and discuss the concepts of race and racism with our children, especially white children. Great article about this in the Washington Post by a child development professor who also is in a mixed-race family. Most children by the ages of 5-6 have developed some sense of racial identity. We have found children’s books to be a great way to broach the conversations at our house. There’s also Teaching children about race – Modules 13 and 14 from the UW I-LABS (includes many fantastic video training resources about child development).
  4. Provide clinical care and conduct research that contributes to equity – As physicians we have opportunities to be change-makers and it starts with therapeutic alliances with patients and becoming aware of the resources available to us as pediatricians. Our residents are now shaping our own INCLUDE curriculum with talks from local experts like Roberto Montenegro MD PhD and Tumaini Coker MD MPH. As part of INCLUDE, this spring interns will receive a day-long Equity, Diversity and Inclusion training from the CDHE.
  5. Be aware of and join local efforts. UW President Ana Marie Cauce launched a Race and Equity Initiative in 2015 for the UW community to acknowledge and confront bias and racism at all levels. The Department of Pediatrics continues active efforts to address diversity and equity, thanks to the leadership and vision of many, including our residency’s Diversity Committee and CDHE. There are so many ways to continue to inform ourselves, and here are a few more:

2018-19 TOW #25: Media guidelines

As we hit the frenzy of holiday shopping for media devices, now is a great time to revisit media screening and counseling! Dr. Pooja Tandon MD MPH lent her great expertise in reviewing and updating this topic for us. Another national media expert among our faculty, Dimitri Christakis, served on the committee that updated the most recent national AAP media policy.

Materials to review:

Take-home points to review on media for youth:

  1. Media exposure for youth is significant with quantity and quality important for us to address. We now have a plethora of devices that contribute to media exposure for youth, and most babies are exposed to TV by 4 months old!
  2. The 2 most important questions to ask our families in clinic are: 1) How much screen media is your child exposed to every day? 2) Does your child have a TV or internet-connected device in the bedroom? I also like to ask “what guidelines have you set for media use at home?”
  3. Parents should be encouraged to set limits on screen time – this is less often done among low income families. Children whose parents make an effort to limit media use (through the home media environment and rules about screen time) spend less time with media than their peers. Parents should be “media mentors” and teach children and teens how to use media appropriately. I’ve heard experts talk about thinking of media use like having a driver’s license, where you demonstrate effective, safe use.
  4. Based on guidance from the AAP, we recommend no screen time for children under 2. As of 2016, apps are acceptable starting 18 months, and videochatting with family did not count toward screen time. We should limit recreational screen time to an hour per day. For older children screen time does not include school use or homework. If parents do allow more (a reality!), at least help them select more educational/prosocial media (like PBS, or shows recommended by Commonsense Media: www.commonsensemedia.org (which we rely on all of the time at our house for movie selection!)
  5. TVs in the bedroom are (and other media that are connected to the internet) are associated with many concerning negative effects on health. Counsel early about media to help prevent the placement of TV’s in the bedroom (which is over 50% by age 2-4 among low-income families). Parents should limit media time 1 hour before bed.

2018-19 TOW #12: Autism Spectrum Disorder

Autism spectrum disorder (ASD) has emerged as one of the most important pediatric issues in recent decades. Fortunately, advocacy and investment has helped our understanding of the many facets of autism including risk factors, diagnosis and treatment. We have much yet to learn to better address ASD and support those affected by it.


Take-home points:

  1. What are the criteria for diagnosing autism? The DSM criteria were revised for DSM-5 and include 2 major categories of symptoms: 1) persistent deficits in social communication and social interaction across multiple contexts, and 2) restricted, repetitive patterns of behavior, interests, or activities. These symptoms must be present in the early developmental periodcause clinically significant impairment, and not be better explained by intellectual disability or global developmental delay. Symptoms are also classified for severity and accompanying intellectual impairment(s).
  2. How prevalent is ASD? Prevalence has increased in recent decades with a 2012 CDC prevalence study reporting it to be as high as 1 in 88 in certain areas, and as many as 1 in 54 among boys. The increase in prevalence is due to multiple factors including greater awareness, earlier diagnosis, diagnostic substitution due to the ability to qualify for more services with autism, and broader diagnostic criteria. Certain genetic diseases have a higher prevalence of autism and should be considered in the diagnosis including Neurofibromatosis, Tuberous-Sclerosis, Fragile X, and Angelman.
  3. When should we screen? The AAP recommends formally screening for autism using a tool such as the M-CHAT at 18 and 24 month visits. We can also begin to screen prior to that, through developmental surveillance. Reimbursement for screening can be obtained using CPT codes 96110 (Developmental Testing, Limited).
  4. How should we screen? The M-CHAT-R/F was a revision with a 2-stage screening process to decrease false positives. Low-risk is a score 0-2. Medium risk is 3-7, and high risk is >=8 among the first set of 20 questions. Refer high risk children, and use the follow-ups questions for the medium risk group. If children continue to be >=2 after follow-up questions, they should be referred – they are likely to have ASD (~50%) or a developmental disorder (95%). Using the follow-up questions, the screener is 85% sensitive and 99% specific for ASD.
  5. What resources are available locally? Children under 3 should be referred to the Birth-to-Three resources while awaiting formal diagnostic evaluation through UW or SCH. We have an impressive local (and very busy) Autism Center at Seattle Children’s. In addition to the clinical resources, the Center hosts a series of free lectures for families and caregivers and a blog. Nationally, the Autism Speaks website has many great resources for families as well.

2018-19 TOW #11: Bullying

With return to school and National Bullying Prevention Month coming up, this is an opportune time to discuss bullying. Bullying has received increasing attention and concern for children’s health in recent years. The effects of bullying can be devastating, and our role in identifying, discussing, and addressing bullying is really important. Our esteemed and internationally known child health and injury prevention expert at Harborview, Dr. Fred Rivara MD MPH, chaired a panel for the Institute of Medicine to report on bullying and how to prevent it.

Materials for this week:

Take-home points:

  1. How do we define bullying, and what are the forms? Bullying is an intentional, aggressive and repeated behavior that involves an imbalance of power or strength. The power difference can be in size, age, political, economic, or social advantage. Bullying includes physical, verbal, social (trying to hurt a person’s reputation within a group or organization), cyberbullying, and cyber harassment (bullying by an adult online).
  2. How frequent is bullying? Estimates are that ~20-30% of youth in the US report being bullied, and 1 in 3 youth is affected either as a victim or perpetrator or both. Cyberbullying is estimated for 7-15% of youth. While “bully” conjures up certain images, most kids who are bullying are typically developing boys and girls who are learning to navigate their social world.
  3. What are the effects of bullying? All forms of bullying can lead to physical illness, low self-esteem, anxiety and depression, including becoming suicidal. Some victims may also become bullies themselves.
  4. What are risk factors and how do we identify it? Risk factors for aggressive behavior include depression, school problems, living in violent communities, and having parents who are absent, abusive, or disengaged. Risk factors for being a victim include developmental or physical differences, such as intellectual disability or obesity and LGBT status. Red flags include somatic complaints, decreased motivation/school performance, avoiding school, frequently losing items or asking for money, unexplained injuries, and threatening to hurt self or others.
  5. What can we do to help prevent bullying? Ask questions to help screen. “Do you ever see kids picking on other kids?” “Do kids ever pick on you?” “Do you ever pick on kids? (And tell the truth; you’re not in trouble.)” The motto often shared is “Telling is not tattling. It is getting someone help” (not just to get someone in trouble). When we identify bullying, we should take concerns seriously. We should talk to children and their parents and provide counseling about the importance of getting help from an adult. We should contact school personnel directly if we are concerned they are not adequately addressing it. We should also refer the child to a therapist or counselor for help.

TOW #34: Sibling rivalry

Sibling rivalry is an issue near and dear to my heart as we often meet the criteria for intense sibling rivalry at our house! Seriously, how many times do I have to say that it’s not okay to hit your sister?! I vow to remember to call out the sweet hugs more often. 🙂

I love Maya Angelou’s writing, and her quote certainly resonates for this topic: “I don’t believe an accident of birth makes people sisters or brothers. It makes them siblings, gives them mutuality of parentage. Sisterhood and brotherhood is a condition people have to work at.”  ~Maya Angelou

Sibling rivalry materials are provided thanks to our beloved Dr. McPhillips who developed teaching for this topic. Materials for this week:

Take-home points for sibling rivalry:

  1. Frequency: Sibling rivalry is a predictable, normal and healthy response to the birth of a new brother or sister. Check out this pretty hilarious ad about what it feels like to have a new sibling!
  2. Why it’s normal: Sibling rivalry demonstrates that an older child is appropriately attached to his/her parents and that he/she is able to respond to a perceived threat to this relationship. Absence of sibling rivalry is worrisome!
  3. Risk factors: More common in same sex siblings. More common in girls than boys. The smaller the age difference—the greater the rivalry (and the closer the friendship). There is no “ideal” spacing of children, although experts suggest that 3 or more years between kids may decrease some rivalry.
  4. Natural history: Less common as children become older, especially after about 8 years old (friends, school and outside interests more important to sense of place in world).
  5. How to address: Involve older children in age-appropriate care for their younger child/infant so they feel included, provide special time for the older child, acknowledge feelings, point out all the wonderful things the older child can do that they younger one will want to emulate. Based on her research, Brené Brown recommends setting clear limits about zero tolerance for name calling and hurtful physical aggression between siblings.

TOW #33: Eating disorders

This week’s topic is Eating Disorders, in recognition of National Eating Disorders Awareness week. This is a tough diagnosis for multiple reasons. Thankfully we have our wonderful adolescent medicine colleagues locally to provide expert guidance on this topic, so help is close by.

Materials for this week:

Take home points to review about Eating Disorders:

  1. Epidemiology: Once thought of as primarily a problem for white upper middle class females, unfortunately, the number of males and minority tweens/teens of both genders with disordered eating has increased in recent years, with up to 14% meeting criteria for disordered eating NOS. About 0.5% of female adolescents are diagnosed with anorexia and 1.5% with bulimia. Teens are particularly high risk during times of transition, and also in highly competitive athletics.
  2. Clinical definition: Eating disorders involve dysfunctional eating habits (may include restrictive eating and binge/purging), weight changes, and body image distortion with intense fear of gaining wt. Suspect in patients who fail to maintain weight in adolescence (especially concerning if <85% of ideal body wt, IBW), or who have amenorrhea, cold intolerance, constipation, headaches, fainting or dizziness. Ask about satisfaction with weight, efforts to control weight, exercise, and changes in diet. The female athlete triad is defined by low energy with or without eating disorder, hypothalamic amenorrhea, and osteoporosis. (DSM-5 criteria are in Tables 1 & 6 in the Peds in Review article).
  3. Physical exam: Some patients have normal exams, and patients with bulimia may have normal weight. Vital sign changes are important including bradycardia, hypothermia, and orthostatic changes. Skin findings may include acrocyanosis, lanugo, peripheral edema, and muscle atrophy. “Russell sign” is callus/abrasion over the MCP/PIP joints from tooth scraping while inducing vomiting. Also look for worn tooth enamel and salivary gland enlargement from purging.
  4. Work-up: Review wt trajectories/changes, and compare weight to median BMI (50th percentile BMI for age on growth chart, which is the ideal body wt). The current weight is divided by the IBW. In primary care it is more important to diagnose medical complications of eating disorders and refer for psychological management. Labs to consider initially are BMP (electrolyte, BUN, glucose abnormalities), ESR (to rule out systemic inflammation), and CBC (assess for malignancy/anemia).
  5. Management: Eating disorders represent complex physical and mental health disorders with high mortality rates. Refer to adolescent medicine for multidisciplinary care. If acutely ill/worsening, determine if patient meets criteria for inpatient admission in consultation with adolescent specialists (see AAP guidelines for hospitalization in Table 4 of this review). Provide regular follow-up as PCP for overall health/support and encouragement to engage in treatment. SSRIs may be considered for concurrent depression/anxiety, especially with bulimia.

TOW #28: Depression

As I sit here with a lightbox trying to get some relief from mood-dampening darkness this time of year(!), it seems quite an appropriate time to review how we identify and treat depression. In the movie Inside Out, I loved how the character Sadness demonstrated that we all need a little to appreciate the fullness in life. But, of course, too much is a bad thing, and recognizing and diagnosing when the usual ups and downs becomes depression is an important part of our pediatric practice. Addressing mental health, or “brain health,” as some suggest we refer to it, is a growing part of pediatrics. Dr. Laura Richardson, division chief in adolescent medicine, is a wonderful renowned expert on addressing adolescents with depression and included below are pearls that she shared. It can be a particularly S.A.D. time of year. Fortunately, there are ways we can support our patients and each other (plug for Resident Appreciation Days coming up Jan 29-Feb 2!).

Materials for this week:

Take-home points for depression:

  1. Epidemiology: Cumulatively, an estimated 14–25% of youths have at least one episode of major depressive disorder before adulthood, and 40% of these will have a recurrent episode within 2 years. Before puberty, girls and boys have equal rates of depression, but after puberty, it’s double for girls compared to boys.
  2. Screening: PHQ-9 is a useful and validated screening tool that is becoming the default tool for adolescent depression screening, and can help to follow persistence of symptoms. Irritability is often thought of as interchangeable with depressed mood as a key criteria of depression in teens.
  3. Diagnosis: You cannot rely on a single screening test to diagnose depression – more is needed. When unsure of the diagnosis in primary care, schedule a follow-up and perform a second screening. Dr. Richardson et al. found the strongest predictors of persistent symptoms are severity of depression symptoms at the time of presentation, and continued symptoms when re-screened 6 weeks later. This speaks to the importance of assessing symptom severity and following up with repeated screening.
  4. Treatment: Pediatricians need to play an “active monitoring” role to meet with, track, and support patients to make sure that they are getting better. We can make a difference by caring, tracking symptoms, helping people get to treatment, and actively coaching them to take steps to try to feel better (through better sleep, sharing what they are feeling with family members, spending time doing something enjoyable, decreasing their stresses at school, etc). Not everyone will engage in therapy, so we may be the only treatment source. Dr. Richardson and team also found we do even better when we do collaborative care management, such as using care coordination to support ongoing check-ins.
  5. Utilize resources available: Thanks to Dr. Sheryl Morelli who helped develop a local gen peds clinical guideline to review important resources, which includes PAL guidelines/resources and the AAP Guidelines for Adolescent Depression in primary care GLAD-PC materials.