TOW #22: ACEs/Trauma-informed care

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 almost 20 years ago in a collaboration between the CDC and Kaiser. But recently, growing understanding of the science behind toxic stress outcomes is generating renewed interest and investment, such as here in King Co with the recent passing of the Best Starts for Kids levy-the first of its kind! Best Starts for Kids - King County

There has been much interest recently in this topic both nationally at the AAP and locally in our program. Colleen Gutman did a wonderful RCP, residents and Dr. Ivor Horn hosted a terrific journal club, and Dr. Abby Grant gave a great talk to the REACH residents, all in the past month. So, naturally, we need to do a TOW, too. A big thanks to the fantastic advocacy of Colleen and Abby to help prepare these great resources to disseminate to everyone for informing their clinic practices.

Resources for this week:

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

  1. Ecobiodevelopmental framework (EBD) – As reviewed in the 2012 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." That is, 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, drug addiction, poverty and racism.
  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: 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.
  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. Inform yourselves about the resources on trauma-informed care (as above). Take a "universal precautions" approach and treat everyone with respect. 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 #21: Adolescent sexuality

One of the great aspects of being a pediatrician is the opportunity to see children across the lifespan and to be part of their transition into adolescence. We have the privilege to help them and their parents navigate through an incredibly important (albeit challenging) phase in life as they emerge into expressing their sexuality. So, here are some materials to get us more comfortable with the sex talks.

Materials for this week:

Key take-away points on adolescent sexuality:

  1. Importance of discussing conditional confidentiality: When meeting with adolescents, we need to review that our discussions are confidential EXCEPT for situations of abuse or self-harm (when we are mandated reporters). Some helpful wording: "When we talk about topics like sex, drugs, and your feelings, our conversation is confidential. This means that what we talk about is between you and me and I won’t tell other people, such as your parents, unless you want them to know. One exception to this is if I am concerned someone has abused or hurt you. Another exception is if I am concerned you are at risk of hurting yourself or someone else."
  2. How to broach the subject of sexuality/sexual orientation: we want to normalize the conversation as much as possible and put our patients at ease. “Many teens your age have romantic interests. Have you been attracted to anyone? Do you find yourself attracted to guys, girls, both?” This can be followed by more specific questions about sexual activity. Remember, sexual attractions can be evolving throughout adolescence so you should continue to ask as this may not be a fixed preference.
  3. Asking about sexuality activity: Some prefer to start by asking what questions the teen may have: “What questions do you have about sex that you’ve never really had the chance to ask?" Others prefer to start by asking directly about types of sexual activity. “There are different ways people have sex–anal, oral, and vaginal. Have you ever had any of these types of sex?” or “Now or in the past have you had sexual relations with males, females, or both?"
  4. Screen for unwanted sexual activity: As mandated reporters, we need to ask about a history of sexual abuse with a question like: "Has anyone touched you in a way you didn't want to be touched?"
    “Have you ever felt forced or pressured into having sex with anyone?”
  5. Counsel on contraception: Discussing contraception and pregnancy prevention is so important for us to do: in one US study, 46% of males and 33% of females did not receive formal education about contraception before their sexual debuts. Contraception should be discussed with both males and females regardless of whether they have started having sex. Helpful wording includes “What are you doing to protect yourself from pregnancy?” or “What are you doing to protect yourself from sexually transmitted infections?"

Bring on the hormones – we will be ready!

TOW #20: Depression

It’s common for all of us to get a touch SAD this time of year. As we were reminded by the character Sadness in Inside Out, 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 advocate we refer to it, is a growing part of pediatrics. The recent national AAP conference provided many reminders that mental health diagnoses are not adequately covered by pediatricians, and this in part because they are not addressed enough in pediatric training. Dr. Laura Richardson in adolescent medicine is our wonderful renowned expert on addressing adolescents with depression and included below are pearls that she shared.

Materials for this week:

Take-home points for depression:

  • 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.
  • 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.
  • 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.
  • 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.
  • Utilize resources available: PAL guidelines/resources and the AAP Guidelines for Adolescent Depression in primary care GLAD-PC materials and teen-specific resources:
  • Advocacy opportunity: Our state AAP chapter, WCAAP, is participating in a large project, Transforming Pediatric Practice, which seeks to improve pediatric access and better integrate behavioral health into pediatric settings. For more info, contact Sarah Rafton, Executive Director WCAAP at