Kimberly Burkhart, Ph.D.
Assistant Professor of Pediatrics & Psychiatry at the University of Toledo
College of Medicine;
Pediatric/Clinical Child Psychologist;
Michele Knox, Ph.D.
Professor of Psychiatry at the University of Toledo College of Medicine;
Clinical Psychologist
Prevalence rates
◦  Internalizing Disorders
◦  Externalizing Disorders
◦  Neurodevelopmental Disorders
◦  Feeding and Eating Disorders
◦  Elimination Disorders
Family violence and child abuse are serious public
health problems.
Corporal punishment is one of the most common
forms of discipline in the United States.
At least 3 million children are abused each year.
There are serious negative short-term and long-term
Aggressive behavior and delinquency
Posttraumatic stress disorder
Heart disease
Drug use
Overview of mental health initiatives
}  Mental Health Leadership Work Group
}  Building Mental Wellness Learning
The Liaison Committee on Medical Education indicated that
curriculum of a medical education program must prepare
medical students for their role in addressing the medical
consequences of common societal problems.
The level, degree, and type of medical school curricula in
child maltreatment varies widely.
The Council on Medical Student Education in Pediatrics
indicated that medical students should be able to list the
characteristics of the history and physical examination that
should trigger concern for possible physical, sexual, and
psychological abuse and neglect. Medical students should
also understand the occurrence of domestic violence and
child abuse, as well as be able to identify markers. They
should also be able to summarize the responsibilities of a
“mandatory reporter”.
}  ACT Raising Safe Kids Program
}  Play Nicely Program
}  Obesity prevention/intervention
}  Community outreach initiatives
}  Developmental/behavioral lecture series
}  Developmental/behavioral rotation and
psychology rotation offered to residents
}  Incorporating behavioral health assessment
into pediatric research (IRB protocols and
scholarly research projects)
First medical school in the country to implement the CAST
Credit/no credit Child Advocacy Elective for medical students
20 hours of didactics, 2- to 4-hours of time on the inpatient
unit, 2-hour meetings every month in which faculty and related
professionals present on relevant topics, 1- to 2-hours in small
group case discussion, observation of one patient on the child
and adolescent psychiatry inpatient unit, and studying one deidentified case involving suspected child abuse
Topics include definition of child maltreatment (CM), prevalence,
risk and protective factors, role of professionals in addressing
CM, suspected child maltreatment, physical and mental health
indicators of child maltreatment, medical perspectives on CM,
cycles of family violence, promoting social change, corporal
punishment and physical abuse, sexual abuse, domestic
Results indicate that “medical students’ selfreported preparedness to identify signs of
child maltreatment, to report a case of
suspected child maltreatment, to recommend
or secure needed services for a maltreated
child, and likelihood to report suspected child
maltreatment if they suspected but were not
sure significantly improved after completing
University of Toledo College of Medicine is the
regional center for the Great Lakes (Dr. Michele
2-hour sessions for 8 sessions
Key components of the program include
expectations for development, understanding the
impact of violence, how to control/manage
parent and child anger, teaching children how to
resolve conflict without aggression, using
positive discipline strategies, and reducing the
impact of violent media
Settings for program implementation include
pediatric clinics, schools, child care centers,
community health centers, and drug court…
500 professionals are trained each year.
}  Approximately 1,500 to 2,000 parents
complete ACT per year.
}  Average cost of $266.65 per ACT participant
}  Facilitator training costs between $0-$200.
Improved nurturing and positive parenting
}  Improved social support
}  Improved anger management
}  Lower rates of psychologically and physically
aggressive behavior toward children
}  Reduced harsh discipline
}  Decreased externalizing behavior in children
Developed and implemented at Vanderbilt
University Medical Center
}  The program teaches aggressionmanagement strategies to parents, teachers,
and healthcare professionals.
}  Presented in the form of multimedia viewing
and vignettes
◦  Parental viewing takes approximately 15 minutes.
◦  Healthcare professional viewing takes
approximately 40 minutes.
◦  Childcare professional viewing takes approximately
30 minutes.
There was a significant increase in the proportion of
medical students and residents who felt that their
ability to counsel parents about hurtful behavior was
high or very high.
Two months later, there was a higher proportion of
medical students and pediatric residents who
recommended redirecting, promoting empathy, and
not using physical punishment.
Parents in the intervention group had an Attitudes
Toward Spanking (ATS) score that was significantly
lower than the ATS score of parents in the control
group. Parents in the control group were two times
more likely to report that they would spank a child
who was misbehaving compared with parents in the
intervention group.
CAST – Multidisciplinary student enrollment and
faculty involvement
ACT Raising Safe Kids – Medical students and
pediatric/psychiatry residents are implementing
the program at a local elementary school that is
in the same catchment area as the pediatric clinic
Play Nicely – Being implemented at well care
visits for children ages 2 to 4. Will be
implemented to medical students at their first
week of medical school (orientation week) and to
pediatric/psychiatry residents
Hospital consultation-liaison services
}  Lifestyle, Eating, Activities and Attitudes
Program (LEAP)
}  Prevention/Intervention of bullying and its
}  Educating first-time mothers on child care
}  School-based pediatric clinic referrals
}  Obesity prevention and intervention
◦  Nutrition guidance
◦  Motivational interviewing/behavioral modification
◦  Physical activity
Monthly lectures
Psychology rotation
◦  Diagnostic assessments
◦  Psychological evaluations
◦  Therapy
Developmental-behavioral rotation
◦  Autism spectrum disorder evaluation
◦  Developmental evaluation
◦  Prenatal alcohol and/or drug exposure evaluation
In-house presence in the pediatric clinic
◦  Screening instruments
School-based pediatric clinics
A cross temporal meta-analysis on 72
samples of American college students
(1979-2009) indicated that empathic concern
has dropped most sharply followed by
perspective taking.
}  There is a significant decline in empathy
scores at the end of the third year, which
persisted until graduation.
}  Research suggests that the decline in
empathy occurs when patient contact
Lack of knowledge of how to identify mental
health concerns and of evidence-based
assessment and intervention treatment options
Access to child advocacy knowledge
Lack of comfort in communicating with parents
Cultural/language barriers
Reimbursement barriers
Lack of time
Planning and organizational challenges
Staffing challenges
Engagement of patients
Emerging professionals into the community
Community-based liaisons
Systemic intervention
Assisting and securing transportation
Multidisciplinary treatment teams
Presence at community mental health centers
Unified case conceptualization
Increase access to healthcare
Shift the concept of mental illness from an
individual patient approach to a public health,
population-based approach
What interventions have you been
implementing in your settings?
}  How can we continue to work together to
engage underserved, marginalized
UTMC’s approach to engaging underserved,
largely marginalized populations…
Anticipate that the Play Nicely program will result
in decreased positive attitudes toward spanking,
increased nurturing, and a decrease in
externalizing behavioral problems
Anticipate that medical students and residents
will have an increased awareness regarding
behavior management parenting strategies and
increased comfort in discussing violence
prevention and intervention strategies
Increase in comprehensive care (i.e. increase in
behavioral health referrals).
Future directions for UTMC
Burkhart, K., Knox, M., & Brockmyer, J. (2013). Pilot evaluation of the ACT Raising
Safe Kids Program on children’s bullying behavior. Journal of Child and
Family Studies, 22(7), 942-951.
Compton, M.T., & Shim, R.S. (Eds.) (2015). The social determinants of mental health.
Arlington, VA: American Psychiatric Publishing.
Knox, M., & Brouwer, J. (2008). Early childhood professionals’ recommendations for
spanking young children. Journal of Child & Adolescent Trauma,1, 341348.
Knox, M., Burkhart, K., & Cromly, A. (2013). Supporting positive parenting in
community health centers: The ACT Raising Safe Kids Program. Journal of
Community Psychology, 41(4), 395-407.
Knox, M., Burkhart, K., & Howe, T. (2011). Effects of the ACT Raising Safe Kids
parenting program on children’s externalizing problems. Family Relations,
60, 491-503.
Knox, M., Burkhart, K, & Hunter, K. (2010). ACT Against Violence Parents Raising Safe
Kids Program: Effects on maltreatment-related parenting behaviors and
beliefs. Journal of Family Issues, 32(1), 55-74.
Knox, M.S., Pelletier, H., & Vieth, V. (2014). Effects of medical student training in
child advocacy and child abuse prevention and intervention. Psychological
Trauma: Theory, Research, Practice, and Policy, 6(2), 129-133.
Portwood, S.G., Lambert, R.G., Abrams, L.P., & Nelson, E.B. (2011).
An evaluation of the Adults and Children Together (ACT)
Against Violence Parents Raising Safe Kids Program. Journal
of Primary Prevention, 32, 147-160.
Scholer, S.J., Brokish, P.A., Mukherjee, A.B., & Gigante, J. (2008). A
violence-prevention program helps teach medical students
and pediatric residents about childhood aggression. Clinical
Pediatrics, 47(9), 891-900.
Scholer, S.J., Hamilton, E.C., & Johnson, M.C., & Scott, T.A. (2010).
A brief intervention may affect parents’ attitudes toward
using less physical punishment. Family Community Health,
33(2), 106-116.
Scholer, S.J., Hudnut-Beumler, J., & Dietrich, M.S. (2010). A brief
primary care intervention helps parents develop plans to
discipline. Pediatrics, 125, 242-249.
Weymouth, L.A., & Howe, T.R. (2011). A multi-site evaluation of
Parents Raising Safe Kids Violence Prevention Program.
Children and Youth Services Review, 33, 1960-1967.