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Reach Grenada • Founded in 2008, REACH Grenada's mission is to improve the emotional and social wellbeing of abused and abandoned children by providing training, support and wellness programs for these children and their caregivers, thus securing a brighter future. REACH Grenada works with children residing in Grenada's care homes where many were previously victims of physical, sexual and/or emotional abuse, neglect and abandonment. Our multi-dimensional programs promote children's long-term healthy development, thus alleviating the effects of early childhood adversity. • www.reachgrenada.org
New York StateCHILD AND ADOLESCENT PSYCHIATRY FOR PRIMARY CARECAP-PC • CAP PC has partnered with the REACH Institute to provide primary care physicians with a premier education program, the Mini Fellowship in Child and Adolescent Mental Health. This is a CME training program developed by the REACH Institute in recognizing, assessing, and managing mild-moderate mental health problems in children and adolescents. This intensive training is lead by Peter Jensen, M.D. and a group of internationally renowned medical teachers. The program is at no cost to participating PCPs and consists of a three day dynamic workshop, involving interactive learning methods. The program also includes twice monthly case-based phone conferences for 6 months. For more information please visit http://www.thereachinstitute.org or contact Melanie Louis at melanie@thereachinstitute.org • CAP PC is a collaboration between the Departments of Psychiatry at the University at Buffalo, University of Rochester, Columbia University/New York State Psychiatric Institute, SUNY Upstate, and North Shore/Long Island Jewish, along with the REACH Institute. • http://www.cappcny.org/home/
University of Massachusetts, Boston Infant-Parent Mental Health Fellowship/Postgraduate Certificate Program • The Fellowship is a part-time post-graduate program consisting of 12 intensive, interactive three-day weekends, meeting every other month (Jan, Mar, May, July, Sept, Nov.) over the course of two years. • Fellows have the opportunity to learn directly from world luminaries, including Chief Faculty, Ed Tronick, T. Berry Brazelton, Dan Siegel, Bruce Perry, Charles Zeanah, Joy Osofsky, Kevin Nugent, Beatrice Beebe, George Downing, Peter Fonagy, and many more. • http://www.umb.edu/academics/cla/psychology/professional_development/infant-parent-mental-health
•Prevalence of diagnosable mental health problem in children: 20.9%* •Anxiety disorders 13.0% •Mood disorders 6.2% •Disruptive disorders 10.3% •Substance use disorders 2% *Surgeon General’s Report, 1999, children and adolescents *Costello and Pantino, 1987: 13-20%
Children’s Mental Health, why Primary Care Involvement? • •Many children and adolescents with emotional/behavioral problems could be identified in primary care settings • •Primary Care is the ideal context because it is accessible and less stigmatizing for most families than specialty care • •Among children and adolescents referred to a mental health specialist, less than ½ reach a mental health professional and are treated • •There are existing tools for identifying children with psychosocial problems in the primary care setting
Children’s Mental Health cont’d • •Lengthy delays can occur between onset on MH problems and initiation of adequate Rx • •Delays in Rx are associated with poorer outcomes, more distress, compromise Rx success, increase contact with law enforcement
Pediatric Symptom Checklist (PSC) Scoring – quick, easy • •Total score • •3 subscale scores • –Attention • –Externalizing • –Internalizing • 17 item or 35 item formats (PSC 17 or PSC 35) • 12% middle income children “screen-in” or have positive scores; higher for lower income children[2]
Pediatric Symptom Checklist (PSC) • Emotional and physical health go together in children. Because parents are often the first to notice a problem with their • child’s behavior, emotions, or learning, you may help your child get the best care possible by answering these questions. • Please indicate which statement best describes your child. • Please mark under the heading that best describes your child: • Never Sometimes Often • 1. Complains of aches and pains 1 _______ _______ _______ • 2. Spends more time alone 2 _______ _______ _______ • 3. Tires easily, has little energy 3 _______ _______ _______ • 4. Fidgety, unable to sit still 4 _______ _______ _______ • 5. Has trouble with teacher 5 _______ _______ _______ • 6. Less interested in school 6 _______ _______ _______ • 7. Acts as if driven by a motor 7 _______ _______ _______ • 8. Daydreams too much 8 _______ _______ _______ • 9. Distracted easily 9 _______ _______ _______ • 10. Is afraid of new situations 10 _______ _______ _______ 11. Feels sad, unhappy 11 _______ _______ _______ • 12. Is irritable, angry 12 _______ _______ _______ • 13. Feels hopeless 13 _______ _______ _______ • 14. Has trouble concentrating 14 _______ _______ _______ • 15. Less interested in friends 15 _______ _______ _______ • 16. Fights with other children 16 _______ _______ _______
17. Absent from school 17 _______ _______ _______ • 18. School grades dropping 18 _______ _______ _______ • 19. Is down on him or herself 19 _______ _______ _______ • 20. Visits the doctor with doctor finding nothing wrong 20 _______ _______ _______ • 21. Has trouble sleeping 21 _______ _______ _______ • 22. Worries a lot 22 _______ _______ _______ • 23. Wants to be with you more than before 23 _______ _______ _______ • 24. Feels he or she is bad 24 _______ _______ _______ • 25. Takes unnecessary risks 25 _______ _______ _______ • 26. Gets hurt frequently 26 _______ _______ _______ • 27. Seems to be having less fun 27 _______ _______ _______ • 28. Acts younger than children his or her age 28 _______ _______ _______ • 29. Does not listen to rules 29 _______ _______ _______ • 30. Does not show feelings 30 _______ _______ _______ • 31. Does not understand other people’s feelings 31 _______ _______ _______ • 32. Teases others 32 _______ _______ _______ • 33. Blames others for his or her troubles 33 _______ _______ _______ • 34. Takes things that do not belong to him or her 34 _______ _______ _______ • 35. Refuses to share 35 _______ _______ _______ • Total score ______________ • Does your child have any emotional or behavioral problems for which she or he needs help? ( ) N ( ) Y • Are there any services that you would like your child to receive for these problems? ( ) N ( ) Y • If yes, what services?______________________________________________________________________________________________
HOW TO INTERPRET THEPSC OR Y-PSC • The PSC consists of 35 items that are rated as “Never,” “Sometimes,” or • “Often” present and scored 0, 1, and 2, respectively. The total score is calculated • by adding together the score for each of the 35 items. For children and • adolescents ages 6 through 16, a cutoff score of 28 or higher indicates psychological • impairment. For children ages 4 and 5, the PSC cutoff score is 24 or • higher (Little et al., 1994; Pagano et al., 1996). The cutoff score for the Y-PSC • is 30 or higher. Items that are left blank are simply ignored (i.e., score equals • 0). If four or more items are left blank, the questionnaire is considered invalid. • A positive score on the PSC or Y-PSC suggests the need for further evaluation • www.brightfutures.org
Other Tools • •CRAFFT –screening for drug use and alcohol • •PHQ-9 – depression screening for adolescents
The majority of adolescents have used alcohol or another drug by the time they have reached 12th grade. Alcohol is the most commonly used drug among adolescents and is responsible for more mortality and morbidity in this age group than all other drugs combined. Use typically begins during early adolescence, with peak initiation during grades 7 through 9. By the 12th grade, 80% of high school seniors report having used alcohol, 62% report having gotten drunk, and 31% report heavy episodic use. • Among adolescents who drink alcohol, 38% to 62% report having had problems related to their drinking,6 such as interference with work, emotional and psychological health problems, the development of tolerance, and the inability to reduce the frequency and quantity of use. • Massachusetts Department of Public Health Bureau of Substance Abuse Services • March 2009
CRAFFT is a mnemonic acronym of first letters of key words in the 6 screening questions. The questions should be asked exactly as written. • Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? • Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? • Do you ever use alcohol or drugs while you are by yourself, or ALONE? • Do you ever FORGET things you did while using alcohol or drugs? • Do your family or FRIENDS ever tell you that you should cut down • on your drinking or drug use? • Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CRAFFT Screening Tool for Adolescent Substance Abuse • Scoring and Interpretation: • Part A: If “yes” to any questions in Part A, ask all 6 CRAFFT questions. If “no” ask CAR question then stop. • Part B: Score 1 point for each “YES” answer. • CRAFFT Score Degree of problem related to alcohol or other substance abuse Suggested Action • 0-1 No problems reported None at this time. • 2+ Potential of a significant problem. Assessment required.
Probability of Substance Abuse/Dependence Diagnosis Based on CRAFFT Score 1. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153(6):591-6. 2. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156(6):607-14.
What is the Adverse Childhood Experiences (ACE) Study? • CDC and Kaiser Permanente Collaboration • Over decade long. 17,000 people involved. • Looked at effects of adverse childhood experiences over the lifespan. • Largest study ever done on this subject.
What Are ACEs?Adverse Childhood Experiences • Sometimes referred to as toxic stress or childhood trauma. Regional Child Abuse Prevention Councils 2011 ACEs are experiences in childhood that are unhappy, unpleasant, hurtful.
HMO Members in ACE Study • 80% White, including Hispanic • 10% Black • 10% Asian • About 50% men, 50% women • 74% had attended college • 62% age 50 or older
Severe and persistent emotional problems Health risk behaviors Serious social problems Adult disease and disability High health, behavioral health, correctional and social service costs Poor life expectancy The higher the ACE Score, the greater the likelihood of :
Finding Your ACE Score • While you were growing up, during your first 18 years of life: • 1. Did a parent or other adult in the household often or very often… • Swear at you, insult you, put you down, or humiliate you? • or • Act in a way that made you afraid that you might be physically hurt? • Yes No If yes enter 1 ________ • 2. Did a parent or other adult in the household often or very often… • Push, grab, slap, or throw something at you? • or • Ever hit you so hard that you had marks or were injured? • Yes No If yes enter 1 ________ • 3. Did an adult or person at least 5 years older than you ever… • Touch or fondle you or have you touch their body in a sexual way? • or • Attempt or actually have oral, anal, or vaginal intercourse with you? • Yes No If yes enter 1 ________ • 4. Did you often or very often feel that … • No one in your family loved you or thought you were important or special? • or • Your family didn’t look out for each other, feel close to each other, or support each other? • Yes No If yes enter 1 ________ • 5. Did you often or very often feel that … • You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? • or • Your parents were too drunk or high to take care of you or take you to the doctor if you needed • it? • Yes No If yes enter 1 ________
6. Were your parents ever separated or divorced? • Yes No If yes enter 1 ________ • 7. Was your mother or stepmother: • Often or very often pushed, grabbed, slapped, or had something thrown at her? • or • Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? • or • Ever repeatedly hit at least a few minutes or threatened with a gun or knife? • Yes No If yes enter 1 ________ • 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? • Yes No If yes enter 1 ________ • 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? • Yes No If yes enter 1 ________ • 10. Did a household member go to prison? • Yes No If yes enter 1 _______ • Now add up your “Yes” answers: _______ This is your ACE Score.
Abuse of Child Emotional abuse, 11% Physical abuse, 28% Contact sexual abuse, 22% Neglect of Child Emotional neglect, 19% Physical neglect, 15% Trauma in Child’s Household Alcohol or drug use, 2% Depressed, emotionally disturbed, or suicidal household member, 17% Mother treated violently, 13% Imprisoned household member, 6% Loss of parent, 23% Types of Adverse Childhood Experiences (Birth to 18)
Neurobiological Impacts Disrupted development Anger–rage Hallucinations Depression/other mental health challenges Panic reactions Anxiety Somatic problems Impaired memory Flashbacks Dissociation Health Risks Smoking Severe obesity Physical inactivity Suicide attempts Alcohol and/or drug abuse 50+ sex partners Repetition of trauma Self injury Eating disorders Violent, aggressive behavior Impacts of Childhood Trauma and Adoption of Health Risks to Ease Pain
Life in a Tough World If trauma/toxic stress occurs early in life, the brain becomes wired to survive it. Regional Child Abuse Prevention Councils 2011
By adolescence, children seek relief through: Drinking alcohol Smoking tobacco Sexual promiscuity Using drugs Overeating/eating disorders Delinquent behavior Regional Child Abuse Prevention Councils 2011
High Risk Teen Behaviors • May not be the core problem • They may be the coping devices • A way to feel safe or just feel better Regional Child Abuse Prevention Councils 2011
Adverse Childhood Experiences vs. Smoking as an Adult Regional Child Abuse Prevention Councils 2011
Adverse Childhood Experiences vs. Adult Alcoholism Regional Child Abuse Prevention Councils 2011
ACE Score vs. Intravenous Drug Use Regional Child Abuse Prevention Councils 2011
Caring Communities Can Help Reduce ACEs Regional Child Abuse Prevention Councils 2011
Protective Factors • Are conditions that increase health and well being • Are critical for everyone regardless of age, sex, ethnicity or racial heritage, economic status, special needs, or the dynamics of the family unit • Are buffers that provide support and coping strategies Regional Child Abuse Prevention Councils 2011
Protective Factors that Strengthen Families and Communities • Nurturing and Positive Relationships • Knowledge of Parenting and Child Development • Parental Resilience • Social Connections • Concrete Support in Time of Need Regional Child Abuse Prevention Councils 2011
