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Assessing, Intervening, and Preventing Children’s Exposure to Violence

Posted By ccaviness On February 29, 2012 @ 12:25 pm In Issue 12,Right Column | Comments Disabled

            ”There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their rights are respected, that their welfare is protected, that their lives are free from fear and want and that they can grow up in peace.”

Kofi Annan, 7th Secretary-General of the United Nations

Martha Davis, MSS and Sandy Dempsey, MSS, MLSP

Co-Directors, Institute for Safe Families

www.instituteforsafefamilies.org

 

The Institute for Safe Families (ISF) is a Philadelphia-based, non-profit organization whose mission is to strengthen families by creating healthy, nurturing environments that promote the positive development of children and prevent family violence.  In the last five years, ISF has been working steadily to develop programs and materials that identify how early trauma affects the full development of children.  Resources developed by ISF have been disseminated worldwide and incorporated into nationally distributed curricula.

More Information about ISF Resources
RADAR stands for R=Routine inquiry A=Are you being hurt? D=Document findings A=Assess Readiness R=Respond. ISF has developed a number of protocols for use in the identification and management of interpersonal violence (IPV) in the health care setting. These protocols are modeled on the RADAR mnemonic originally developed by the Massachusetts Medical Society.RADAR for Women: The original RADAR protocol was designed for use in screening female patients in traditional primary care or emergency medical settings. Our most updated version incorporates much that has been learned through research over the last 10 years, including an assessment of the patient’s readiness to make changes to improve safety.RADAR for Men: This protocol offers providers language to use in asking and counseling male patients about their involvement in IPV both as perpetrators and as victims.RADAR for Pediatrics: This modification offers justification and explanation for IPV inquiry in the pediatric setting and scripts for providers willing to incorporate this behavior into their practice.

C.H.A.N.C.E. Training Curriculum: Caregivers Helping to Affect and Nurture Children Early. These materials are designed to provide those working in early care and education (ECE) programs with an opportunity to learn about the impact of domestic violence on young children and their families and to learn and practice skills for responding effectively.

Parenting After Violence: A Guide for Practitioners: Parenting After Violence (PAV) has been designed to assist service providers and practitioners in working with families in which domestic violence has occurred. While many of the principles and activities may be applicable to work with families that have experienced other kinds of trauma (community violence, child abuse, death, substance abuse, or divorce, to name a few), PAV addresses domestic violence specifically in order to accentuate the unique dynamics of violence that occurs between intimate partners. The PAV Guide aims to assist parent educators, domestic violence advocates, abuser treatment providers, child treatment providers, and those who work in supervised visitation programs to facilitate healing in the individuals they work with and in their relationships affected by domestic violence.

ISF developed trainings and curricula for early care and education providers (CHANCE), child welfare providers (Parenting After Violence), and health care providers (RADAR).  What underlies these efforts and unifies our approach among all of our programs is that childhood stressors—family violence, abuse and neglect, substance abuse, etc.—are interrelated and often occur within the same families.  As research has shown, a critical factor that makes stressful events tolerable as opposed to toxic, is the presence of supportive adults who create safe environments, while helping children learn to cope and recover from violence and adversity.  The focus then becomes finding practical ways in multiple settings and systems that assess, intervene, and prevent frequent stressors encountered by children.

The ISF Process 

For each program initiative, ISF partners with organizations such as the Philadelphia Department of Public Health (PDPH), local children’s hospitals, universities, domestic violence and child trauma service providers, the Pennsylvania Chapter of Prevent Child Abuse, the Pennsylvania Chapter of the American Academy of Pediatrics and the Center for Non Violence and Social Justice at Drexel University.

For over two decades, ISF has used a four-step process to address systemic change.  This process has been essential in getting the systems involved to focus on family violence and adverse childhood experiences.  These may not be the primary issues for the system, but likely are significant secondary issues affecting their practice.

  1. Experts in the field and key stakeholders within relevant systems are brought together to form a Think Tank or Network, facilitated by ISF staff.  These teams of clinicians, advocates, and service providers explore issues regarding family safety and the positive development of children that are relevant to that system, looking for innovative interventions for complex problems.
  2. Current research is collected and evaluated, and innovative ideas are explored.  Services are devised and with ISF leadership, training curricula is often developed by these groups.  Collaborating organizations implement the direct services provided.  Through its Think Tanks and Networks, ISF most often assists in the development of policies and procedures, while delivering training and education to staff that are responsible for service delivery.
  3. As part of service implementation, ISF facilitates forums that bring together multi-disciplinary providers in order to further examine the problem area.  These groups discuss specific cases, while planning and reviewing integrated services. These forums offer service providers opportunities for peer support, skill enhancement, and discussion of policy implications for the systems serving the population.
  4. ISF conducts or facilitates evaluations of the effectiveness of the training, intervention, and service delivery.  Participating organizations act upon information from the evaluation and the information is disseminated as widely as possible to promote replication and inform future directions in programming and policy development.

Six ISF programs that focus on children exposed to violence are described below.  Each of these programs has been developed using this four-step process.

CAMP (Children and Mom’s Project/Pediatric Champions)

CAMP is a citywide collaboration led by ISF.  CAMP was piloted at St. Christopher’s Hospital for Children and the Children’s Hospital of Philadelphia primary care clinics, and is now being expanded throughout Philadelphia.  Lutheran Settlement House’s Bi-lingual Domestic Violence Program provided additional leadership in developing this work.  Through CAMP, families are screened for domestic violence using our Pediatric RADAR tool; services are provided to prevent further violence; and professionals help mothers and children recover and heal.  Since 2005, the St. Christopher’s Hospital for Children’s on-site domestic violence counselor has seen over 650 survivors of domestic violence and their families; the need continues to grow.  As of October, 2010, the counselor has received 230 referrals for services.  Upon referral from the hospital staff, the onsite domestic violence counselors are able to respond immediately in person.  The services most often provided to domestic violence victims are supportive counseling, housing support, safety planning, and legal advice.  The program started in the St. Chris Ambulatory clinics and now referrals come from all over the hospital.

When CAMP began, medical residents were surveyed regarding their knowledge and attitudes toward the screening for domestic violence. Following that survey and prior to training, a chart audit determined how many families were already being screened for domestic violence. Less than 1% of charts had any documentation of screening.  After just three months of intervention and training, screening rates in the Ambulatory Clinic rose to 36% and has been sustained since. Due to the success of increased screening rates and referrals, CAMP—which began in the outpatient ambulatory clinics—is now a fully funded and institutionally valued hospital-wide effort.  There is a hospital policy on domestic violence for patients and staff. New staff is trained in the policy and protocol of CAMP.

CAMP demonstrates that the “Pediatric Champions” model is key to instituting sustainable change, due to the emphasis on leadership and teamwork.  In a recently published study on what sets hospitals apart in terms of low acute myocardial infarction mortality, researchers looked at what distinguished top-performing and low-preforming hospitals (Curry, et.al. 2011).  They found no specific process or protocol helped the top hospitals; the success translated into teamwork and collaboration.  The most successful hospitals had a positive culture.  This culture is characterized by shared organizational values and goals, consistent involvement of senior management, broad staff presence and expertise, effective communication and coordination among interdependent groups, and an approach to problem solving that involves collective learning and growth.  These hospitals had an approach similar to the models used by ISF.  This includes CAMP, which employs a multidisciplinary team and intervention with a shared vision, values and goals, buy-in from senior administration, clear communication, and coordinated effort.

CAMP is now set up in two phases.  Phase One consists of ISF identifying, training, and mentoring “Pediatric Champions” within new pediatric health care settings.  These “Champions” facilitate Phase Two: actual establishment of CAMP services.  ISF currently supports six pediatric settings with the CAMP/Pediatric Champions model.  These sites evaluate our work to ensure goal completion.

Partnering with Parents  

This past year, ISF worked in partnership with national experts to develop an innovative and multi-purpose toolkit—Partnering with Parents (PwP).  PwP promotes healthy brain development through family violence assessment and teaching positive parenting strategies.  The PwP Toolkit helps pediatricians and other child-serving providers address these issues by bridging the gap between highly correlated risk factors and pathways for more streamlined assessment, intervention, and prevention.  The toolkit helps providers facilitate counseling for parents, while also providing additional resources for parents.  These resources are important steps in PwP that are aimed to increase positive parenting, while mitigating the effects of childhood exposure to violence and adversity.

Family Safe Zone

In 2012, ISF will develop and pilot The Family Safe Zone, a comprehensive educational and intervention program.  The goals are to assess for, intervene in and prevent child abuse, while focusing on preventing exposure to violence and adversity.  Our vision is that the Family Safe Zone pilot project will operationalize the information within the PwP Toolkit.  The program will be piloted and evaluated at St. Christopher’s Hospital for Children (SCHC) and its ambulatory pediatric clinics.  Components of the program include:

  • Engaging the pediatric health care community at SCHC in child abuse prevention by raising awareness about child abuse and encouraging active roles in preventing it
  • Educating professionals, hospital staff, and community members on methods to positively intervene in situations that may become unhealthy for children
  • Encouraging positive parenting practices by having a PwP Counselor work with parents to improve their knowledge about the negative effects of corporal punishment, family violence, and the effects of trauma on early brain development
  • Evaluating the utility and effectiveness of this project

Spare the Rod

Spare the Rod is an ISF initiative used to replace physical punishment with other more effective discipline measures.  The goal is to promote Philadelphia as a “no-hitting, no-spanking” city, while helping parents employ positive alternatives to physical discipline.  The association between physical punishment and increased aggression over time is irrefutable (Grogan-Kaylor, 2005).  This includes an elevated risk of future violence toward family members and intimate partners (Cast et.al. 2006; Douglas, 2006; Straus, et.al., 1997).  Evidence indicates that frequent and harsh physical punishment—characterized as discipline rather than child maltreatment—can also alter the structure and function of a child’s brain and the internal balance of stress hormones (Bugental et.al. 2003; Watts-English et.al. 2006).

The Philadelphia Adverse Childhood Experiences (ACE) Study Task Force

In 2012, ISF will convene and facilitate the Philadelphia ACE Study Task Force.  The goal is to examine ways to operationalize the ACE Study information in child-serving organizations, such as pediatrics, child welfare, and early care and education.  The ACE Study began in 1995 and is ongoing.  The study examined childhood origins of many of our Nation’s leading health and social problems.  Findings from the ACE Study indicate that childhood adverse experiences increase the risk for the ten most common causes of adult death in the United States.  This study underscores the relationship of childhood abuse, neglect, domestic violence, and other related experiences on health throughout the lifespan.  The findings are consistent with recent discoveries about the neurobiology of stress and the effect of stress on the developing central nervous system.

ISF will conduct a national survey to assess “who, what, where, when and how” the ACE Study information is being used.  Our goal is to translate the science and findings of the ACE Study into regional pediatric practice.  ISF, in collaboration with Prevent Child Abuse PA, the PA Chapter of the American Academy of Pediatrics, and the Philadelphia Public Health Department, will hold a major conference for state and regional pediatric clinicians on “How to Use the ACE Study in a Pediatric Setting.”

ISF is motivated by the new and emerging science on toxic stress, trauma, and early child development.  Part of the challenge in the coming decade, will be to find practical ways to translate this science into meaningful action among providers and communities, while improving the safety and health of all families and children.  For more information about ISF and resources, go to www.instituteforsafefamilies.org [1].

 

References

Anda, RF, Felitti, VJ, & Bremner, JD. (2006). The Enduring Effects of Abuse and Related Adverse Experiences in Childhood:  A convergence of evidence from neurobiology and epidemiology, Eur Arch Psychiatry Clin Neuroscience, 256, 174-186.

Anda, RF. (2005). The Health and Social Impact of Growing Up With Adverse Childhood Experiences:  The Human and Economic Costs of the Status Quo.  Paper downloaded from ACEstudy.org

Anda, RF.  Adverse Childhood Experiences and Population Health in Washington:  The Face of a Chronic Public Health Disaster.  Results from the 2009 Behavioral Risk Factor Surveillance System, July, 2, 2010.

Bugental DB, Martorel GA, Barraza V. (2003). The hormonal costs of subtle forms of infant maltreatment. Hormones and Behavior,43,237-244.

Cast, A. D., Schweingruber, D., & Berns, N. (2006). Childhood Physical Punishment and Problem Solving in Marriage. Journal of Interpersonal Violence, 21(2), 244-261.

Congressional Briefing. Anda, RF and Felittii, VJ. Adverse Childhood Experiences as a National Public Health Problem. Sponsored by the American Academy of Pediatrics and The Family Violence Prevention Fund. Capitol Hill, Washington, DC. April 18, 2006.

Curry, LA; Spatz, E; Cherlin, E; Thompson, JW; Berq, D;Ting, HH; Decker, C; Krumholz, HM; & Bradley, EH. (2011). What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study.  Annals of Internal Medicine, 154,384-390.

Douglas, E. (2006). Familial violence socialization in childhood and later life approval of corporal punishment: a cross-cultural perspective. The American Journal of Orthopsychiatry, 76(1), 23-30.

Grogan-Kaylor A. Corporal punishment and the growth trajectory of children’s antisocial behavior. (2005). Child Maltreatment,10,283-292.

McColgan, M.D., Cruz, M; McKee, J; Dempsey, S; Davis, M; Barry, P; Yoder, A.L.; Giardino, A. Results of a multifaceted Intimate Partner Violence training program for pediatric residents. Child Abuse & Neglect (2010), doi:10.1016/j.chiabu.2009.07.008

Straus MA, Sugarman DB, Giles-Sims J. (1997). Spanking by parents and subsequent antisocial behavior of children. Archives of Pediatric Medicine, 151(8),761-767.

Straus MA. (1996). Spanking and the making of a violent society. Pediatrics,98(24),837-842.

Watts-English, T, Forston, B, Gibler, N, Hooper, S, & De Bellis, M. (2006). The Psychobiology of Maltreatment in Childhood. Journal of Social Issues, 62(4), 717-736.


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