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ONTARIO COLLEGE OF FAMILY PHYSICIANSHEALTHY CHILD DEVELOPMENT:IMPROVING THE ODDSInterpersonal Personal Violence Screening ...
The Early Years InterventionOpportunities to intervene                                               Early Years       Bio...
AAP Technical Report on the lifelong effects of early       childhood adversity and toxic stress                (Pediatric...
Hyper arousal       arousal                            Disrupts        Dysregulated CNSSympathetic                        ...
What is infant mental health?•   Infant mental health is the social, emotional & cognitive well being of infants and    to...
Developmental Consequences for            Trauma Exposure• Sleep problems                    • Anxiety• Eating problems “R...
Traumatic     events/experiences          Limited         Protective          Factors  Baby or Toddler unable to    recove...
Traumatic   events/experiencesProtective Factors that maymitigate or minimize impact  Baby or Toddler who has recovered fr...
Trauma                       Stress   Brain                                    Overalldevelopment      Overall    Relation...
Children need nurturing, loving environments         for healthy development…          Source: National Scientific Council...
We Need to Move Beyond Surveillance     and Beyond the PhysicalTypical Well Child Visit: Monitoring of physical growth and...
Early Action for Suspected    Infant Developmental / Mental Health Concerns                 when IPV is present•    Family...
Comprehensive Assessment• Consider screening for intimate partner violence at all  well woman visits and especially during...
The ALPHA Forms                 Antenatal Psychosocial Health Assessment  The ALPHA Forms are a reliable, valid, user-frie...
The ALPHA Forms / Antenatal Factors1) Family Factors -     Social Support (CA, WA, PD )                        Recent Stre...
FAMILY FACTORSSocial support (CA, WA, PD)   How does your partner/family feel about   your pregnancy?   Who will be helpin...
MATERNAL FACTORSPrenatal care (late onset) (WA)   First prenatal visit in third trimester?Prenatal education (refusal or q...
SUBSTANCE USEAlcohol/drug abuse (WA, CA)   How many drinks of alcohol do you have per week?   Are there times when you dri...
FAMILY VIOLENCEWoman/partner experienced or witnessed   abuse(physical, emotional, sexual) (CA, WA)   What was your parent...
Setting the Context within Primary Care                  Practice• You are the health care professionals who see many  wom...
Risk Factors               Normal Child                                  Child with                                       ...
The Role of Family Medicine in Screening for Domestic Violence
The Role of Family Medicine in Screening for Domestic Violence
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The Role of Family Medicine in Screening for Domestic Violence

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"Screening for Intimate Partner Violence in Health Care Settings" Presentation with the Waterloo Region Crime Prevention Council by Dr. Pat Mousmanis.

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The Role of Family Medicine in Screening for Domestic Violence

  1. 1. ONTARIO COLLEGE OF FAMILY PHYSICIANSHEALTHY CHILD DEVELOPMENT:IMPROVING THE ODDSInterpersonal Personal Violence Screening inPregnancy and Creating Opportunities In PrimaryCare: Impact on Infant Mental Health and OptimizingChild Developmental Outcomes
  2. 2. The Early Years InterventionOpportunities to intervene Early Years Biological Environment Birth Genetic Conception Social / Ecological Environment
  3. 3. AAP Technical Report on the lifelong effects of early childhood adversity and toxic stress (Pediatrics Vol. 129 No. 1 January 1, 2012 pp. e232 -e246 )
  4. 4. Hyper arousal arousal Disrupts Dysregulated CNSSympathetic HPA axis CatecholamineNervous system HPA system Pathway Hyper vigilant Suppressed Hyper-reactive immune system “survival mode”
  5. 5. What is infant mental health?• Infant mental health is the social, emotional & cognitive well being of infants and toddlers • An infant’s mental health begins at conception • An infant can have serious mental health and emotional problems • Poor mental health of an infant and/or toddler is sometimes about the absence of “normal experiences, interactions or reactions” • An infant who experiences poor mental health this early in life, will be vulnerable for poor mental health throughout life• Infant mental health = healthy social & emotional development that includes the infant’s capacity to: • Experience, regulate, & express emotions • Form close interpersonal relationships • Explore the environment & learn
  6. 6. Developmental Consequences for Trauma Exposure• Sleep problems • Anxiety• Eating problems “Re- • PTSD experiencing” or playing out • Relationship problems – memories of the event including poor attachment or• Toileting problems attachment disorders• Withdrawal • Depression• Increased • Dysregulation of stress system clinginess/separation • Low self-esteem• Unresponsive • Preoccupation with the• Verbal or language difficulties traumatic event such as• Developmental regression bringing up the episode• Onset of new fears repeatedly or uncontrollably• Aggressive outbursts or increased activity level
  7. 7. Traumatic events/experiences Limited Protective Factors Baby or Toddler unable to recover from traumaInfant or Toddler suffering from poor mental health
  8. 8. Traumatic events/experiencesProtective Factors that maymitigate or minimize impact Baby or Toddler who has recovered from traumatic experience/event
  9. 9. Trauma Stress Brain Overalldevelopment Overall Relationship/ health development attachment
  10. 10. Children need nurturing, loving environments for healthy development… Source: National Scientific Council on the Developing Child (2004)
  11. 11. We Need to Move Beyond Surveillance and Beyond the PhysicalTypical Well Child Visit: Monitoring of physical growth and development• Counseling about development, safety, nutrition and community resources• Providing immunization and other preventive care In IPV: Review safety concerns for the child• Think about, discuss, and together identify any risks/problems for action• Consider referral to consultants, and community resources to support the child’s needsConsider Child Protection Referral if required for supervised access visitsNEW: Assess parent-child interactions and look at the emotional needs of theinfant. Interpersonal violence can cause major impact to the mental health ofthe child. Providing community support for the mother can be a supportivefactor that can buffer risk factors. Provide early intervention by screening atwell child visits.
  12. 12. Early Action for Suspected Infant Developmental / Mental Health Concerns when IPV is present• Family assessment in depth- identify supports and strengths• Refer to Public Health for Home Visiting and for family support• Consider whether Child Protection Services ( CPS) are required• Provide information about shelters and emergency agencies• Further assessment / monitoring of child’s developmental status• e.g. Hearing assessment / vision assessment Speech, language, motor assessment Psychological assessment /evaluate attachment concerns Full socio-emotional assessment Parenting Capacity assessment – role of supervised access visits• Early infant / child intervention programs• Family centers, play groups, child care centers• Respite care if required – includes Shelters in IPV• Social work referral for financial or housing issues
  13. 13. Comprehensive Assessment• Consider screening for intimate partner violence at all well woman visits and especially during pregnancy and the post partum period when risks are higher – ALPHA (Antenatal Psychosocial Health Assessment) – Three key questions: • Have you ever experienced abuse? • Are you or have you ever been afraid of your partner? • Are you safe? ALPHA: http://dfcm19.med.utoronto.ca/research/alpha ALPHA Video illustrates interviewing techniques
  14. 14. The ALPHA Forms Antenatal Psychosocial Health Assessment The ALPHA Forms are a reliable, valid, user-friendly tools to be used byobstetrical care providers for the systematic assessment of the psychosocial health of pregnant women.Suggestions for Use•Complete after 20 weeks gestation•Can be completed in 1 visit (20 mins) or over several regular prenatal visits•Give the self-report out for completion in the office –avoid sending home ifworries about woman abuse•Can bill for counseling/psychotherapy when appropriate•Be sensitive to cultural issues; use non-family interpreters•Discuss with the woman before sharing information (ie CPS concerns) ;maintain confidentialityRemember that associations do not imply causality!
  15. 15. The ALPHA Forms / Antenatal Factors1) Family Factors - Social Support (CA, WA, PD ) Recent Stressful Life Events (CA, WA, PD, PI ) Couple’s Relationship ( CD, PD, WA, CA )2) Maternal Factors - Prenatal Care ( Late onset ) (WA) Prenatal education ( refusal or quit) ( CA) Feelings towards pregnancy after 20 weeks ( CA , WA ) Relationship with parents in childhood ( CA) Self-esteem (CA, WA ) History of psychiatric/emotional problems (CA , WA , PD) Depression in this pregnancy (PD)3) Substance Use - Alcohol and Drug Abuse ( WA, CA ) CAGE utilized ( Cut down, Annoyed, Guilty, Eye opener)4) Family Violence - Woman or partner experienced or witnessed abuse (physical, emotional, sexual ) ( CA, WA) Current or past woman abuse (WA, CA, PD) Previous child abuse by woman or partner (CA) Child discipline (CA) Critical Review of the Literature 15 antenatal factors associated with adverse postpartum outcomes of: woman abuse (WA) child abuse (CA) couple dysfunction ( CD) postpartum depression ( PD) increased childhood physical illness (PI)
  16. 16. FAMILY FACTORSSocial support (CA, WA, PD) How does your partner/family feel about your pregnancy? Who will be helping you when you go home with your baby?Recent stressful life events (CA, WA, PD, PI) What life changes have you experienced this year? What changes are you planning during this pregnancy?Couple’s relationship (CD, PD, WA, CA) How would you describe your relationship with your partner? What do you think your relationship will be like after the birth?
  17. 17. MATERNAL FACTORSPrenatal care (late onset) (WA) First prenatal visit in third trimester?Prenatal education (refusal or quit) (CA) What are your plans for prenatal classes?Feelings toward pregnancy after 20 weeks (CA, WA) How did you feel when you just found out you were pregnant? How do you feel about it now?Relationship with parents in childhood (CA) How did you get along with your parents? Did you feel loved by your parents?Self esteem (CA, WA) What concerns do you have about becoming/being a mother?History of psychiatric/emotional problems (CA, WA, PD) Have you ever had emotional problems? Have you ever seen a psychiatrist/therapist?Depression in this pregnancy (PD) How has your mood been this pregnancy?
  18. 18. SUBSTANCE USEAlcohol/drug abuse (WA, CA) How many drinks of alcohol do you have per week? Are there times when you drink more than that? Do you or your partner use recreational drugs? Do you or your partner have a problem with alcohol or drugs?CAGE:1. Have you tried to Cut down?2. Do you feel Annoyed if someone mentions your drinking?3. Do you feel Guilty for drinking?4. Do you ever need a drink in the morning to get going?, Eye-opener)OR T-ACE (Tolerance, Annoyed, Cut-down, Eye opener)
  19. 19. FAMILY VIOLENCEWoman/partner experienced or witnessed abuse(physical, emotional, sexual) (CA, WA) What was your parents’ relationship like? Did your father ever scare or hurt your mother? Did your parents ever scare or hurt you? Were you ever sexually abused as a child?Current or past woman abuse (WA, CA, PD) How do you and your partner solve arguments? Do you ever feel frightened by what your partner says or does? Have you ever been hit/pushed/slapped by a partner? Has your partner ever humiliated you or psychologically abused you in other ways? Have you ever been forced to have sex against your will?Child discipline (CA) How were you disciplined as a child? How do you think you will discipline your child? How do you deal with your kids when they misbehave?
  20. 20. Setting the Context within Primary Care Practice• You are the health care professionals who see many women and children at regular intervals• You can provide women exposed to Intimate Partner Violence with insight into the impact on her child• You can be the broker for her to obtain support• You are able to observe the family “in action” including moments of distress for the child (ie immunization, illness).• There are questions you can ask as a Family Health Team member (physician/nurse/ midwife/ social worker) about many of the determinants of health including risk factors
  21. 21. Risk Factors Normal Child Child with CNS insult Nurturant Dysfunctional Nurturant Caring dysfunctional Dysfunctional IPV Caring Environment IPV Environment At risk Opportunity High To thrive riskFor Child: Interactions & Relationships with Caregivers are the most crucial elements in the Environment EPIGENTICS Nature and Nurture continuously Interacting

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