2018-19 TOW #38: Child abuse recognition

April is child abuse prevention month, an important reminder to discuss this always challenging but critical topic. Our role in primary care encompasses strategies to build resilience, promote strong relationships, link families to resources, and screen and refer for concerns as mandated reporters. SCH’s Protection, Advocacy and Outreach team has 3 prevention programs: Period of PURPLE crying, Medical-Legal Partnership, and Positive Parenting (which funds our Promoting First Relationships (PFR) training).

Materials for this week:

Take-home points for child abuse recognition:

  1. How many children are affected by maltreatment? We are likely to encounter child maltreatment in our practices: 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. How are “neglect” and “verbal abuse” defined? Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child; it includes lack of adequate nutrition, hygiene, shelter, and safety. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. “Verbal abuse” refers to nonphysical forms of punishment intended to cause shame and humiliation.
  3. What is the AAP stance on corporal punishment and why? As of fall 2018, the AAP opposes any form of corporal punishment, including spanking, as it is not effective for changing long-term behavior and is associated with many adverse outcomes, including aggressive behavior and mental health problems. Here’s a very informative infographic on the psychology of spanking. Dr. Sege, who co-authored the AAP statement, discusses how you can talk to parents who were spanked themselves in this podcast (here’s the interview transcript).
  4. Which children are at highest risk for child abuse? Children in all SES levels are at risk, and in ~80% of cases, parents are perpetrators. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired or multiple gestation pregnancy. Parent-level risk factors include poverty, multiple children under 5, substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for development.
  5. What is the most overlooked form of abuse? Bruising is the most frequently missed form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and referral to CPS. Before being diagnosed with child abuse, 25% to 30% of abused infants have “sentinel” injuries, such as facial bruising, which can be a harbinger of worse injury.

2018-19 TOW #36: Learning disabilities

Our role in addressing child development extends into the school years as we help children when there are concerns about school performance. I had a long discussion with a school psychologist this week who helped identify important needs for one of my patients. This is a really important topic for us to be knowledgeable about to support families and partner effectively with schools.

Materials for this week:

Take-home points:

  1. How many children are affected by learning disabilities? The lifetime prevalence of learning disabilities in US children is 5-10%, so should be considered when children are having school difficulties. Learning disabilities are heritable, but specific genes are still being identified. fMRI studies show children’s brains with learning disabilities differ in structure and  function.
  2. How do we define a learning disability and what are the types? A learning disability is a disorder that affects a child’s ability to read, use and understand language, write, or do mathematical calculations. Learning disabilities have been described as a significant discrepancy between academic achievement and intellectual potential, despite receiving appropriate instruction. Two main types are verbal/language (affecting ~80% of those with learning disabilities including dyslexia, i.e., difficulty reading and dysgraphia, i.e., difficulty writing) and non-verbal (dyscalculia, including problems with visual-spatial relations, math, and problem solving). There is a lot of overlap, and children often have both types.
  3. What’s the pediatrician’s role in diagnosis? Usually, behavior problems are the first presenting symptoms. Children may act out or withdraw because they cannot meet the demands or may have difficulty paying attention to material they don’t understand. We should first identify or exclude other causes that impact academic performance such as psychosocial (e.g., abuse, neglect), medical (e.g., prematurity, drug exposure, hearing/vision problems) and developmental issues (e.g., ADHD). Formal testing required to confirm a specific diagnosis is typically the school’s role. We can refer the child to the school’s committee on special education for evaluation. The request should be in made in writing by the parent, and we can often be helpful by including a note outlining specific concerns. We can also refer for advanced evaluation by a psychologist or developmental-behavioral pediatrician.
  4. What’s our role in monitoring? Our role includes being an advocate for the child in interfacing with school personnel, assisting the family in understanding the diagnosis, and monitoring progress. We should routinely screen for associated problems that can arise such as new behavioral difficulties, anxiety, and depression.
  5. How should we interface with schools? First, we have to obtain permission with a signed Release of Information form from the parents. An important law to be aware of is the Individuals with Disabilities Education Improvement Act (IDEA) part B, a federal law ensuring that all students ages 3-21 receive a free and appropriate public education under the least restrictive environment, regardless of disability. If a child is found to qualify for special education services under IDEA laws, an individualized education program (IEP) is created, outlining the plan for special education service. We can access the Medical-Legal Partnership if we feel that children are not receiving services for which they qualify under the law.

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 #21: Firearm injury prevention

This week’s topic seems particularly timely given the overwhelming physician response to the NRA’s “stay in your lane” tweet last week. We have many resources locally including the incredible Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention. The Seattle Children’s community benefit team and REACH pathway residents have worked to develop local resources and events.

Materials for this week:

Take-home points for firearm safety:

  1. Statistics: 1 in 3 homes in the US with children have firearms, many of which are not locked. 80% of unintentional firearm deaths of kids under 15 occur in a home. 64,000 adults in King County with a firearm in or around their homes reported storing their gun(s) loaded and unlocked. The safest thing is not to have a firearm in your home, as it is 43 times more likely to be used to kill a family member or friend rather than be used in self-defense. In a case-control study done by Grossman et al., storing firearms locked, unloaded, or separate from the ammunition was associated with significantly lower risk of unintentional and self-inflicted firearm injuries and deaths among adolescents and children.
  2. Many depressed teens die from suicide by firearms. If you are tight for time and cannot screen for firearms in every clinic wellness visit, be sure to include specific counseling in visits with depressed teenagers. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline.
  3. What to offer for gun safety? There are 5 main types of locking devices: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Generally, we should avoid devices that use keys. Visit www.lokitup.org for information about how to store firearms. We need to help advise that the safest way to store guns is unloaded, locked, and out of reach of young children and teenagers! Consider using a statement like: “Having a loaded or unlocked gun in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store your unloaded guns in a locked drawer or cabinet, out of reach of children.”
  4. How do we advise parents and firearm safety? We can counsel parents to ASK other parents about guns in their home before sending over their child to play: http://askingsaveskids.org/ Suggested wording includes:  “Knowing how curious my child can be, I hope you don’t mind me asking if you have a firearm in your home and if it is properly stored…” For family members, this might include: “[Mom, Dad] this is awkward for me and I mean no disrespect. I am concerned Susie will find one of the firearms in your home when we visit. Do you keep them locked up with the ammunition stored separately?”
  5. Does counseling work? Several studies have found counseling in office visits to be associated with improved safe storage of firearms. A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Likewise, Barkin et al. found that brief office-based counseling increased the use of safe storage.

2018-19 TOW #17: Community Pediatrics

Some of the R2 are on the REACH Pathway month 1 this block, and it’s a great time to be inspired by many pediatricians in our midst taking leadership roles in advocacy. I’m honored to know some of them as friends from my own residency class (go R’06’s!), including Rupin Thakkar MD who is our current WCAAP president. Rupin recently gave a shout out to our Harborview pediatricians, Drs. Vai Pidaparti R2 and Beth Dawson-Hahn for their immigrant health toolkit. Beth will be giving noon conference this week on her outstanding work advocating for immigrant children. I could highlight hundreds (likely thousands) of examples of pediatricians in our area who have made significant contributions through advocacy.

Materials for this week:

Take-home points for this week:

  1. What are some of the social and environmental needs our patients face that can affect their care? Many children being cared for in community-based pediatric settings, including our residency clinics, face numerous social needs that affect their health: food insecurity, poor housing, parent substance use or mental illness, family violence, and unsafe neighborhoods. Most of these have now been characterized as Adverse Childhood Experiences (ACEs) and are associated with developing toxic levels of stress that can impact long-term health. There is evidence that when we address these needs by helping parents and families, children fare far better over the lifetime.
  2. How do we prioritize addressing these needs? Henize et al. propose that one way to prioritize these is using the Maslow Hierarchy of Needs, i.e., addressing the most basic needs should be the focus before ones higher up on the pyramid. First are Physiologic needs for food and housing, then Safety from violence and mental health problems, then Love/Belonging, with children supported by loving parents who have community support, then Esteem and Respect, with education and employment, and finally, as these other needs met can come Self-Actualization or Achieving One’s Potential. Another helpful way to think about needs is the IHELLP mnemonic: Income, Housing, Education, Legal, Literacy and Personal Safety.
  3. Where do we find the community resources? Bright Futures divides potential community resources among 4 major categories that we should access for our patients: health, development, family support, and adult assistance. In our area two key ways to find needed assistance is through Within Reach and Washington State 2-1-1. Dr. Abby Grant, one of the former REACH residents and now REACH faculty and pediatrician at Harborview prepared this amazing list of community resources for our area.
  4. What are some of the recommended skills for engaging as pediatricians serving the community? The AAP policy statement defines some key skills: 1) working effectively in interdisciplinary settings, 2) partnering with public health, community organizations, and child welfare agencies, 3) recognizing root sources of health and pathology from children’s social, economic, physical, and educational environments, and 4) advocating on multiple levels including at the local, state, and national levels.
  5. If collaboration and partnerships are key to addressing social determinants of health, how do we do this? Henize and colleagues outlined a set of steps: 1) build a case through family-centered needs assessment, 2) organize and prioritize appropriate interventions, 3) work with key community partners to build and sustain interventions, and 4) operationalize interventions in the clinical setting. If you want to learn more about becoming an advocate, the AAP Committee on Community Pediatrics has advocacy training modules available.

Borrowing a line from Hamilton… Look around, look around, at how lucky we are to be alive right now… in our field of pediatrics and surrounded by these inspiring colleagues doing amazing work. I’m glad we have each other for the work that’s still ahead.

2018-19 TOW #10: Road traffic safety

This is always an important topic, even more so as kids return to school and will be on the road, and also because newly released guidelines for car seat safety were just published by the AAP. A big thank you to Dr. Beth Ebel MD MPH who provided key review points. Beth is a national expert on this topic and a former member of the national AAP committee who developed policy recommendations. Dr. Brian Johnston MD MPH, our Chief of Pediatrics at Harborview serves on the current committee that released the updated recommendations, below. (Fun fact: 3 former graduates of our program serve on the current committee (Brian, Sarah Denny, and Ben Hoffman!)

Materials for this week:

Take-home points for this week:

  1. As pediatricians, we must advocate for car seat and seatbelt use EVERY TRIP EVERY TIME. Most crashes occur on the day-to-day driving routes.
  2. We should know recommended car seat types for children of different ages and sizes. (See the AAP report). Basic summary:
    • Rear-facing 5-point harness carseat until reach weight limits (up to about age 4, previous recommendation was at least age 2).
    • Once forward facing, use a car safety seat to that seat’s weight and length limits (typically about 60 pounds).
    • When they exceed the seat’s limits, use a convertible belt-positioning booster seat (high back is preferred) until they have reached at least 4’9″, typically between ages 8-12.
    • Until age 13, always sit in rear seats in full lap and shoulder belt.
  3. Teen driving is the most dangerous time for teens in terms of risk of injury and death. Motor vehicle crashes are the number one cause of teen death. We can make it safer through driving contracts and graduated driver’s licenses (see the teen driving contract and state Graduated Driver’s Licences GDL laws).
  4. Distracted driving for teens and adults is a major issue and has increased with ubiquitous texting. It is now the law in our state to not use a phone or text while driving, and parents must be role models. Parents should use “chauffeur” time as catch up/phone down time for parent AND child.
  5. Review safe and active travel options. Encourage families to use the bus to navigate around the city for a weekend expedition. Use resources like One Bus Away, Metro transit route guide, and Google maps. Walking and biking to school are great and allow kids to be active, but kids must be visible and be safe. Check out Walking School Bus resources for local schools. When crossing the street, stay alert and put phones down!

2018-19 TOW #8: Early learning

This topic is one that makes me hopeful for the world when we see the progress made in recognizing the importance of early learning for children and local and nationally advocacy to improve it. There’s a long way to go for universal access, but Harborview Pediatric Clinic has done a great job with Dr. Abby Grant’s leadership to strengthen an integrated referral approach to early learning. I am so excited to share the newer resources that social work students put together to help us identify where to refer our patients.

Take-home points about early learning:

  1. Our role: We as pediatricians have an opportunity to advocate for our patients through early learning settings: referrals to quality child care, preschool and Head Start programs, and also supporting work on policies and funding for these programs.
  2. Why preschool matters: Robust research shows that children who participate in high-quality preschool programs have better health, social-emotional, and cognitive outcomes than those who do not participate. Participating in quality early learning can boost educational attainment and income later in life – some studies have followed up participants into their 40s and 50s. A key factor in the most successful programs is very high-quality offered by well-trained staff.
  3. Preschool helps address disparities: Children from low-income families on average start kindergarten 12 to 14 months behind their peers in pre-literacy and language skills – they have the most to gain from preschool programs.
  4. We can do better: Only 41% of children from low-income families are enrolled in preschool compared to 61% of more affluent peers.
  5. Next steps: While most pediatricians inquire about early education, only a small proportion assist families in completing Head Start applications. Read the attached to learn more about options for publicly funded programs for your patients. Please remember to advocate for quality early learning settings for your patients and in our local and state policy decisions.

2018-19 TOW #5: Water Safety and Drowning Prevention

Summer is a great time to review water safety, especially in Seattle where we have access to so much beautiful open water and sunshine to enjoy it. Safety around water is critical, as drowning is actually a leading cause of injury death for children. Seattle Children’s has partnered with community organizations through programs like Everyone Swims to develop materials and advocate for policy changes to prevent drowning, including contributions from our own residents.

Check out this week’s teaching resources here:

Take-home points for understanding drowning and promoting water safety:

  1. Epidemiology of drowning: Death from drowning is a top 3 cause of injury death in childhood. It is the leading cause of injury death for 1-4 year olds and the 2nd leading cause for 5-14 year olds. Unfortunately, it disproportionately affects minority children. Children can drown in only 1-2 inches of water. Adolescent males have a 10-fold increased risk of drowning compared to females. They have higher risk exposure, more risky behaviors (e.g., swimming alone and at night), and are more likely to drink alcohol in aquatic settings.
  2. Drowning definition: Drowning is no longer defined as death from submersion. The WHO defines it as “a process of experiencing respiratory impairment from submersion/immersion in liquid” and outcomes are classified as death, morbidity, or no morbidity.
  3. Risk reduction: Drowning can be prevented by many strategies including 1) adult supervision within arm’s reach, 2) life jackets, 3) pool fencing that encloses the pool and is at least 4 feet high, 4) swimming at lifeguarded areas, and 5) swimming lessons. The American Academy of Pediatrics (AAP) recommends children begin to learn to swim by age 4. In one study, taking formal swimming lessons was associated with an 88% reduction in drowning risk (Brenner et al. Arch Ped Adol Med 2009).
  4. Drowning prevention: Pediatricians have a role in helping prevent drowning. Screen for swimming ability at age 4-5 and refer to swim lessons (see pool info handouts on Everyone Swims tab on the SCH drowning prevention page). Discuss water safety with families and provide information, including handouts here: http://www.safekids.org/watersafety

TOW #49: Adverse Childhood Experiences (ACEs)

We are fortunate to be in a time in pediatrics when the neuroscience is catching up with what we have long known about social determinants of health affecting children’s development. The original study on Adverse Child Experiences (ACEs) was published 20 years ago in a collaboration between the CDC and Kaiser. Growing understanding of the science behind toxic stress outcomes is generating renewed interest and investment in early childhood programming, such as here in King Co with the Best Starts for Kids program, and nationally in programs like the AAP Resilience Project, among others.

A big thanks to the fantastic advocacy of Drs. Colleen Gutman (Chief ’17) and Abby Grant who helped prepare these resources to inform your clinic practices. These materials also build on and relate to the approaches we have discussed in Promoting First Relationships (PFR).

Resources for this week:

Take-home points on ACEs/Trauma-informed care:

  1. Ecobiodevelopmental framework (EBD) – As reviewed in the AAP Technical Report, “an emerging, multidisciplinary science of development supports an EBD framework for understanding the evolution of human health and disease across the life span.” Science has shown significant associations between the “ecology of childhood” and many developmental outcomes and life course trajectories.
  2. ACEs definition: Adverse childhood experiences (ACEs) are experiences in early life that have detrimental effects on child development and adult health outcomes including abuse, neglect, being exposed to intimate partner violence, mental illness, and drug addiction. In addition, poverty and racism can exacerbate the effects of other ACEs.
  3. Toxic stress definition: Adversity and maltreatment in childhood are thought to affect development and health through chronic exposure to stress. This repeated and ongoing activation of stress response pathways is termed “toxic stress”, in contrast with normal, healthy, physiologic stress response mechanisms. Children experiencing adversity and maltreatment have been shown to have elevations in inflammatory cytokines and dysregulation of their HPA axis, and their brains may develop differently.
  4. Protective factors: Thankfully, the presence of a positive, nurturing adult is powerful in protecting against the negative effects of toxic stress. While there is great variability in genetic susceptibility to stress reactivity, nurturance mediates and protects against the negative effects of toxic stress and adversity (not just in humans, but across animal species, too).
  5. Pediatricians’ role in addressing ACEs/toxic stress: we are being called upon to take more active roles in developing and implementing science-based strategies to reduce toxic stress in early childhood, and hopefully thereby tackle some of the pressing disparities in learning, behavior, and health. We can become knowledgeable about the concepts and resources on trauma-informed care (as above). We can take a “universal precautions” approach and treat everyone with respect and humility. We can be aware of somatic symptoms that may be signals of untreated stress/trauma. We can also give special attention to care provided to those who are affected by trauma to help build nurturing and resilience, and avoid retraumatizing children and/or caregivers.

TOW #48: Fatherhood

In honor of Father’s Day next weekend, we are going to review the role of dads and how to expand beyond our traditionally mother-centric perspective of child-raising to be intentional about engaging fathers (and other support parents) in the care of children. Many more children are being raised in families where parents are not married, where mothers are working, and/or where the father is the primary parent, so supporting fathers to be actively involved as parents is increasingly important. Indeed, we have some great father role models in our program!

Materials for this week:

Take-home points on fathers’ role in parenting:

  1. Definition of father has expanded: a father can be any male adult who is most committed to, caring for, and supportive of the child including a stepfather, grandfather, adolescent father, father figure, or a co-parent in a gay relationship, regardless of living situation, marital status, or biological relation.
  2. Barriers to fathers’ involvement in child’s health care: 4 major barriers include employment (lack of flexibility, etc), interpersonal (cultural barriers, mother not wanting father to be involved, or not living in home), personal (lack of knowledge, comfort), and health care system (lack of access to records, appt times, etc).
  3. Fathers’ involvement matters: The presence of fathers positively impacts health, mental health, and educational achievement of children. We can encourage single mothers to increase the involvement of dedicated male role models in a child’s life. Additionally, we can discuss the importance of an involved father figure and parenting tips directly with fathers whenever possible. We can help dads know what a difference they make.
  4. Dads may need coaching and encouragement: Men are less likely to have babysat or helped care for siblings when growing up compared to women. We need to address dad, learn his name, make eye contact with him, and include him when providing information about parenting. We also need to ask him direct questions and remind mom of the importance of involving dad. We can help foster the mentality of teamwork as the best way to support the child. Doing this at the nursery and newborn visits is especially helpful to set the tone from the start, like handing the baby to the dad or asking dad to help change the diaper. Specific ways for us to encourage dads to be part of care include doing the bedtime routine (the sleep expert Dr. Craig Canapari emphasizes a simple sleep routine that one parent can do solo), and doing night-time feedings.
  5. Advocate for parent-leave policies: Data from countries like Denmark that have generous paternity leave policies show impressive outcomes: dads become involved from the beginning, and it’s better for the country’s overall productivity, as it supports more moms to return to work when both parents engage and share in child-rearing. We can all advocate through the AAP and other pediatric organizations to have more family-friendly leave policies in the US; encouragingly, our local tech employers seem to be setting the stage for adopting them, and we can hope the trend finally spreads!