Kimberly Burkhart, Ph.D. Assistant Professor of Pediatrics & Psychiatry at the University of Toledo College of Medicine; Pediatric/Clinical Child Psychologist; MEDTAPP Scholar 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 effects: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Depression Anxiety Suicide Aggressive behavior and delinquency Posttraumatic stress disorder Smoking Heart disease Drug use Overview of mental health initiatives } Mental Health Leadership Work Group } Building Mental Wellness Learning Collaborative } } } } 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”. CAST } 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 program 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 violence… } 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 CAST.” } } } } University of Toledo College of Medicine is the regional center for the Great Lakes (Dr. Michele Knox). 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 behaviors } 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 implications } 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 increases. } } } } } } } } } } 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 populations? } } 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.
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