Pediatric Psychology Partnership for Abuse Prevention

1. Pediatric Psychology Partnership for Abuse Prevention Terri L. Weaver, Ph.D., Patrice L. Pye, Ph.D., Heidi M. Sallee, M.D., Phyllis Terry Friedman, Ph.D., Melissa L. Maglione, Desarie Holmes, Ebonee Lyle, and Sharonda C. Ayers Saint Louis University Research and Training funded in part by USPHS 1-D40 HP00051-01

2. Statement of the Problem • Intimate partner violence (IPV): A Public Health Problem with Health Disparities • Disparities are seen in the incidence, prevalence, and burden of IPV among specific population groups; • African American women and their children experience disproportionate risk for IPV • Social and environmental risk factors include being young, divorced or separated, earning lower incomes, and living in an urban area

3. Statement of the Problem contd. • Intimate partner violence (IPV): A Public Health Problem with Health Disparities • In spite of the magnitude of the problem, IPV is underreported, underidentified and at risk populations are underserved; • The current project focuses on reducing issues of health disparity in IPV by eliminating barriers to care for underserved African American women and their children

4. Medicine Psychology Transdisciplinary Approach Public Health

5. Increase the Diversity of Health Service Psychologists Reduce health disparities in IPV Objectives Develop a partnership with an ambulatory pediatric setting Develop a dual degree Ph.D./MPH

6. Interdisciplinary Collaboration Medicine Domestic Violence Advocates Strategic Planning Interdisciplinary Steering Committee Clinical Experiences Clinical Experiences Nursing Public Health Psychology Products (Publications, Presentations)

7. Objectives 1 and 2 • Reduce issues of health disparity in intimate partner violence by eliminating care for underserved African American Women and their children; • Increase the number of health service psychologists from diverse backgrounds who are culturally competent and aware of health disparities.

10. Objective 2: Increase Diversity of Health Service Psychologists • Three female African American clinical psychology trainees were recruited to work on the project.

11. Objective 3 and 4 • Develop a partnership with an ambulatory pediatric setting to increase the number of health service psychologists trained regarding the impact of IPV, the relationship with health care issues, within an integrated health care model. • Develop a dual degree Ph.D./MPH to scaffold current and future integration of knowledge.

12. Objective 1: Curricular Enhancements • Broad-based exposure to IPV implemented within the clinical core courses by developing a standardized didactic curriculum(i.e. Psychopathology, Clinical Assessment, Clinical Interventions, Ethics and Professional Issues, and Human Diversity). • Curricula informed by psychological (American Psychological Association) and medical based curricula (Massachusetts Medical Society).

13. Objective 2: Increase Diversity of Health Service Psychologists • Three female African American clinical psychology trainees were recruited to work on the project.

14. Objective 3: Pediatric Psychology Partnership • The clinical training site is at University Pediatrics, Cardinal Glennon Hospital. • University Pediatrics is an ambulatory primary care setting training physicians, medical students, interns, and pediatric residents at Saint Louis University School of Medicine. • University Pediatrics is located in St. Louis City, a medically underserved community.

15. Description of Clinical Populations University Pediatrics serves: • Average of 6000 patients per year. • 80% African American. • Hispanic, Vietnamese, Bosnian, African, Chinese and other minorities are also represented. • Generally low SES (80% Medicaid). • Primarily from inner city St. Louis and the surrounding North County.

16. Clinical Populations contd. • University Pediatrics serves a large percentage of single and teenage mothers. • Typical clinic presentations include poor nutrition, failure to thrive, prematurity, asthma and behavioral and school-related problems.

17. Pediatric Psychology Partnership: Educational Modalities • Enhanced an integrated clinical team (ICT), modeled after similar existing clinical teams in the training program. • Didactic and experiential learning modalities regarding the dynamics of IPV were provided. • Students read empirical, theoretical, and clinical case literature related to IPV and its impact, as well as literaturerelated to working within an interdisciplinary setting.

18. Pediatric Psychology Partnership: Educational Modalitiescontd. • Guest lecturers from Nursing, Pediatric Psychology, and Battered Women’s advocacy agencies educated students on issues concerning child development and the impact of IPV on children, empowerment of women experiencing IPV, and working within a health care setting. • Clinical psychology trainees role-played situations, such as conducting screenings for IPV during well and sick pediatric visits, assessing for risk, and conducting a safety plan.

19. Pediatric Psychology Partnership: Developing a Culture of Relevance • Faculty obtained hospital privileges • “Child and Family Safety Project” name tags worn by project staff (Safety more “pediatric friendly “) • IPV-related posters placed throughout the clinic • Resource and safety planning cards were placed in the women’s restroom facilities • Educational presentations to nursing staff, medical attendings. Pediatric Grand Rounds focused on IPV and implications for ambulatory pediatric settings. Grand Rounds conducted during National Domestic Violence Awareness Month.

20. Pediatric Psychology Partnership: Clinical Integration • Initially, clinical psychology trainees only accompanied pediatric residents into clinic visits for the screening and for index visits (mothers with children two and under who are unaccompanied) • Subsequently, clinical psychology trainees were fully integrated into the health care visit: • Paired with a pediatric resident for all cases • Resident present during the screening

21. Development of Integrated Clinical Team (ICT): Quantitative Outcomes • Knowledge based evaluation pre and post team. Median pre-intervention score : 34 (75%) with a low score of 34 (71%) and a high score of 43 (90%). Median post intervention score : 39 (81%) with a low score of 36 (75%) and a high score of 43 (90%).

22. Focus Groups: Qualitative Findings • Attitudes regarding the integration of intimate partner violence (IPV) into integrated vertical team: • Expectations were met but less than optimal time spent at the practicum site; • Recommendations for a specialized ICT; • Wanted more time to implement what they learned;

23. Focus Group Results contd. Post-integration awareness of IPV issues and comfort with assessing IPV and relevant sequelae in all cases. • Clinical psychology trainees felt they obtained a beginning level of competence to ask assessment questions; • Regarding the ambulatory pediatric placement trainees would like more integration with residents and other faculty.

24. Focus Group Results contd. Post-integration awareness and comfort with conducting a risk assessment, and safety planning with IPV-related cases; • Mock interviews were helpful; • Trainees expressed surprise at how open patients were to the assessment and may need additional strategies to contain patient reactions.

25. Student Growth: Journal Reflections • Enhanced team increases knowledge but would like even more exposure; • Further integration suggested for ambulatory pediatric setting; • Greater understanding gained for “why women stay”; • Greater understanding of the complexities of IPV.

26. University Pediatrics: Patient Quantitative Outcomes • 42 screenings conducted to date; • Formal Feedback on the Screening Process is Available on 20 participants; • Safety Assessment Data is available on 19 participants; • 4/19 (21% ) endorsed safety concerns within the past year;

27. University Pediatrics: Patient Characteristics • 75% of Visits were a “well child” visit; • Age of the Child • Younger than 6 months 5/20 (25%) • 6 months – 1.5 Years 7/20 (35%) • 1.5 years – 2 years 6/20 (30%) • > 2 years of age 2/20 (10%)

28. Screening Feedback • 20 participants have provided feedback • Asking about personal safety should be done as part of the pediatric visit; • 75% (15/20) very much or completely agree • Mother’s safety significantly affects the well being of the child; • 95% (19/20) very much or completely agree

29. Screening Feedback contd. • I learned information that was helpful during safety planning; • 55% (11/20) very much or completely agree; • 4 patients who endorsed current safety concerns “very much” or “completely agreed”

30. Resource Card Data: Quantitative Outcomes • Card Data tracked from 9/19 – 11/14/03 • 129 total cards placed in the women’s restrooms • 30 cards placed in the bathrooms each week • 1st three weeks 0 cards remained at the end of the week; • Weeks 4 and 5 averaged 9.5 cards taken

31. Lessons Learned • Inform all interdisciplinary staff about the project and seek input prior to project implementation; • Develop language consistent with the culture you are seeking to enter (i.e. use of anticipatory guidance, problem based assessment); • Learn implicit and explicit goals of other parties (i.e., could assist with particularly complex cases, assist with interpreting psychological case findings); • Identify an advocate (s) on the inside;

32. Lessons Learned contd. • Develop informal opportunities for trainees from different disciplines to get to know one another; • Train clinical psychology trainees to be active (rather than reflective) problem solvers; • Acculturate clinical psychology trainees to engage in time efficient problem identification and remediation;

33. Future Directions • Develop Exportable Curricula; • Develop resident training in IPV; • Expand services to include a broader range of patients; • Develop an IPV health intensive team; • Increase diversity of faculty supervisors; • Develop an area of concentration within the clinical psychology training program.