Reverse the Trend of Irreversible Actions: Ohio AAP Store it Safe - - PowerPoint PPT Presentation

Reverse the Trend of Irreversible Actions: Ohio AAP Store it Safe Program

September 28, 2019 Ohio AAP Annual Meeting

Panelists

• Jeremy Hardjono – Student Advocate
• Michael Gittelman, MD, FAAP – Cincinnati Children’s Hospital
• Michele Dritz, MD, FAAP – Cornerstone Pediatrics
• Sarah Denny, MD, FAAP – Nationwide Children’s Hospital
• Denise Meine-Graham – Franklin County LOSS
• Discussion and Questions

1HELPS

Jeremy Hardjono

Jacob Bice

Remembering Jacob

Becoming Something More...

# 1 H E L P S

Hello Empathy Learn Parents & Professional Save

Hello

• Be a friend
• Greet them whenever you see them
• The little things matter

Photo by Eliott Reyna on Unsplash

Empathy

• Actions rather than words
• Care, and show it
• Take them seriously

Learn

• Signs
• Get to know them… but be subtle
• Have a conversation with them about what is bothering them specifically

Photo by nikko macaspac on Unsplash

Parents/Professional

• Better chance getting them to talk to professionals
• Parents play a vital role in treatment
• Parents can take important steps to prevent
• Monitor closely- every teen responds different to medication

My story...

We have, as documented, no financial relationships to disclose or Conflicts of Interest (COIs) to resolve

Think about why you Wanted to be a Pediatrician????

Leading Causes of Death Among US Children Ages 1-19, 2016- 2018

0% 5% 10% 15% 20% 25% 30% 35% 40% Unintentional Injury Suicide Homicide Malignant Neoplasms Congenital Anomalies Heart Disease Influenza & Pneumonia Cerebrovascular

59.3%

• CDC, 2017

Leading Causes of Injury Death, 1-19 year olds

Cause Annual Fatality % Total Unintentional MV Traffic 3780 27% Suicide 2669 19% Homicide 2682 19% Unintentional Suffocation 1310 9% Unintentional Drowning 913 7% Unintentional Poisoning 797 6% Unintentional Pedestrian 539 4% Unintentional Fire/Burn 281 2% Unintentional Firearm 114 1% Other Injury 772 6% Total Annual Fatalities 13,857 100%

28 Children Die Every Day!!!!

Firearm Safety is a Public Health Issue

• Child Protection: Daily, 7 children or teens are killed with guns
• Domestic Violence: Monthly, 51 women are shot to death by intimate

partners

• Mental Health: More than 60% of deaths by firearm are suicides
• Racial Justice: Guns are the leading cause of death for black males ages 15-

34

Compared to other countries, American Children (< 15) are:

• 12 times more likely to be killed by a gun
• 17 times more likely to be a gun homicide victim
• 9 times more likely to die of an accidental gun injury
• 10 times more likely to die of a gun suicide

15-19 year olds: Suicide on the Rise

• 2nd leading cause of death
• 30% increase since 2000
• Ratio of attempted to

completed suicide 50-100:1

• Males 3x greater completion,

Females 2x more attempts

• A death every 3 hours
• 28% increase ED visits past 5

years

• Miron, JAMA 2019
• Shane, Pediatrics 2016

Suicide Completion by Mechanism

• Over 1/2 of all US homes have a firearm

– > 200 million guns – Majority are handguns

• Ohio

– 37% of households report a firearm – 46% reported gun was in unlocked location

• Teens are impulsive

– 91% fatal if attempt by gun vs. 23% by ingestion

Firearm 42% Poisoning 6% Falls 3% Other 6% Behavioral Risk Factor Surveillance System

Time Elapse Between Decision and Attempt

• Interviews with survivors of near-lethal suicide attempts

– 25% made attempt within 5 minutes of decision – 50% within 20 minutes – 71% within 1 hour

• Most made decision within 1 hour of a crisis (eg. break-up or fight)

Many Families Have a Misconception about the Risk of Firearms

• 6 in 10 Americans believe that guns in the home make people safer
• However, a gun with an impulsive teen makes them less safe

– Homicide of a household member is 3x more likely – Suicide: 5x more likely – Intimate partner homicide: 7x more likely for women

• 2/3 of unintentional gun-related deaths could be prevented if guns are

stored locked and unloaded.

Storing Firearms Safely/Lack of Firearm Reduces Suicide

• Facts

– Suicide risk present for all family members in a house with a firearm; especially impulsive teens – Higher risk no explained by mental illness or history of suicidality – If a gun is not present or available, it is rarely used as a method for suicide

Miller M, Annual Review Public Health 2012

Link Between State Gun Ownership and Suicide Rates

State Suicide Rate (per 100K) % Household gun prevalence AK 15.2 59.8 SD 14.9 59.9 WY 11.9 65.5 RI 3.1 12.4 MA 3.0 11.5 NJ 2.6 11.4 Knopov, AJPH 2019 Each 10% increase gun ownership, 27% increase youth suicide rate

Types of Interventions to Prevent Injuries (4 E’s)

• Engineering/Technology

– Airbags, smoke alarms, booster seats

• Environmental Modification

– Bike lanes, traffic signals, window guards

• Enforcement/Legislation

– Child safety seat laws, speed limit enforcement, GDL

• Education

– Screen for modifiable risk and educate families and patients about prevention

Why Talk to Patients About Guns?

• Primary care providers interact with teens prior to suicide

– 45% saw PCP within 1 month, 77% within 1 year

• Physicians are supposed to inquire and counsel patients about health-

related behaviors, conditions and risks

• Physicians have opportunity to educate patients about:

– household risk factors – how to mitigate risk

• This education is particularly important where increased risk factors apply

Missed Opportunities

Injury Topic Weighted % (95% Confidence Interval) Pa ICARIS-2 ICARIS-1994 Any topic – Overall 0-1 2-6 7-12 13-14 42.4 (39.9–44.9) 62.8 44.6 39.0 27.3 39.3 (36.2–42.3) .12 Smoke detectors, 0–14 y 14.9 (13.0–16.8) 8.8 (7.2–10.5) <.01 Poison control number, 0–6 y 25.7 (22.5–28.9) 24.9 (21.1–28.6) .75 Firearm storage, 2–14 y 10.0 (8.3–11.8) 6.3 (4.8–7.8) <.01 Bicycle helmets, 5–14 y 30.4 (27.5–33.3) 18.6 (15.5–21.7) <.01 Car seats/seat belts, y 0–14 28.7 (26.4–31.0) 25.4 (22.7–28.1) .07 0–6 38.5 (34.9–42.0) 30.7 (26.8–34.6) <.01 7–14 19.0 (16.2–21.9) 20.5 (16.9–24.2) .52

Chen, Pediatrics 2007

Psychiatric patients PED

• 5% screen for firearms

by resident

• 20% screened by all

parties

Naureckas, Arch Peds 2019

Barriers to Discussing Guns with Patients

• Ketabchi 2019
• Ohio AAP Members

– Time constraints – Lack of training/information about guns and gun safety – Fear of negative reaction – Don’t feel part of routine practice

Education vs Behavior Change

• Screening tools help assess current behaviors
• If family is unfamiliar - may just need education

– Likely change will be made if simple request

• Example - poison center number by phone
• If information was heard before

– What would encourage the change in behavior? – What are some approaches to having action occur?

Body of Evidence for Injury Prevention Counseling in the Office Setting

• 7 reviewers from the AAP (former) Section on Injury, Violence, and Poison

Prevention

• Reviewed articles from 1964-1991
• Inclusion

– Original report – IP counseling in a primary care setting

• Rated strength of study design and outcomes

Bass et al. Pediatrics. 1993

Bass et al. Pediatrics. 1993

MV Restraint Non-MV Restraint

• 10,330 citations
• 103 randomized clinical trials
• 22 studies evaluated
• Most assessed effect on a safety behavior not injury rate
• No studies on pedestrian, drowning, motorcycle or firearm injuries

DiGuiseppi and Roberts. Future Child. 2000

Counseling About Firearms Works

• Pediatric practices, 8% gun ownership
• 1 month follow-up surveys
• Counseling by pediatrician

– No significant difference in gun removal – 62% improved storage in home vs 27% controls

• Pediatric ED setting
• Prospective follow-up of adults

presenting with child for psych

• Counseling at-risk groups by

physician vs. control

– 63% locked up or disposed firearm – 0% controls made any change Carbone, Arch Peds Adol Med 2005 Kruesi, J Am Acad Adoles Psych 1999

Summary of Findings for Office-based Firearm Counseling

• Suicidal ideation and attempts are on the rise
• Firearm access increases suicidal completion
• Teens are impulsive
• All parties on both sides of firearm discussion agree guns should be

stored safely in the home

• Counseling about firearm storage by pediatricians

– Is the same as other prevention discussions – Changes behavior in the home setting

Questions?

Th The Teen e Teen Bra Brain in: Development, Impulsivity & Keeping Teens Safe

Michele Dritz, MD, FAAP Adolescent Medicine

Teen Brain, Harvard Magazine, 2008

Teenage Brain, National Geographic, 2011

Adolescence

Time of heightened exploration and novelty seeking which aids in gaining experiences needed for more complex adult decision making Rapid growth can increase risks AND resiliency Developmental needs trigger anticipatory guidance and resources Skill development includes effective decision-making, emotional regulation, emerging independence and healthy coping strategies Habits formed lay the foundation for adult health Education plays a big role

Domains of Adolescent Development

• Physical
• Psychological & Cognitive
• Social

Frontal Lobe

• Responsible for:

– Personality, judgment, reasoning, problem solving, rational decision making, – Logic and understanding of consequences – Governs impulsivity & aggression – Organizing thoughts, planning for the future – Undergoes significant changes during adolescence

• Not fully developed until mid-20s

Prefrontal Cortex

• Part of the frontal lobe:

– Helps with impulse control, judgments, reasoning – One of the last areas of the brain to develop fully. – During this time, there is an increased need for:

• Structure, mentoring, and guidance from adults

Temporal Lobes

• Controls hearing,

understanding speech, sorting new information, short- term memory and emotional regulation

• Contains:

– Amygdala and hippocampus

• Matures around 18-19

years of age

Brain Maturation

The prefrontal cortex (CEO) of the adolescent becomes pruned, sloughing off up to 40% of its neural branches, as it grows new neural connections for more sophisticated functioning. Changing neural connectivity and rising dopamine levels creates a heightened responsiveness to incentives and socioemotional contexts during this time, when impulse control is still relatively immature

Greater refinements in neural connectivity and extensive myelination continues through adolescence. The brain does not fully mature until the early/mid 20s

“The Teenage Brain”

• Slower Development of the frontal cortex compared to limbic region can

lead to:

– More “gut” reactions than reasoning

• More likely to use amygdala (emotions) than prefrontal cortex (reasoning) for information processing
• But this stage also requires balance with developmentally-appropriate

exploration and experience-gaining that is needed to acquire independence skills, cognitive task complexity and successful transition into adulthood

It takes experience to train the brain AND It takes supports to help keep youth safe during the learning process

Impulsivity and Risks Unique During Adolescence

• In emotionally-heightened situations, the more

mature limbic system will win over the prefrontal control system.

• Teens may know better, but the intensity of the

emotional context biases the behavior in the opposite direction despite the recognized risks

• The combo of heightened response to rewards

AND immaturity in behavioral control areas may bias adolescents to seek immediate rather than long-term gains

• Potentially explaining the increase in risky decision

making and emotional reactivity

Adolescence and Suicide

• Suicide is unfortunately not just an “adolescent problem”:

– Highest rate: Adults 45-54yo then 85+yo – Faster rise in rates in 15-24yo

• Proposed theories for increasing rates in adolescents:

– More stress → More depression & mood disorders (1°diagnosis when suicidal behavior) – More awareness of suicidal and self-harming behaviors → More teens referred for events – Fewer ways to escape negative communication and bullying through seamless connectivity → fewer “safe spaces” to practice emotional wellness and learn self- care

Youth th Most At Risk:

• Family or personal history of

suicide/attempts

• Male gender
• LGBTQ+
• History of Abuse
• Parental Mental Health Problems
• Personal Mental Health Problems

including:

• Sleep Disturbances
• Depression, Bipolar,

Psychosis, PTSD

• NSSI behaviors
• Behaviors including:
• Impulsivity
• Aggression/Severe Anger
• Pathologic Internet Use
• Substance Use Disorders
• Recent Life Stressors

Risk Factors and Protective Factors

• Underlying conditions or context that can exacerbate the emotional versus

behavioral control imbalance:

– ADHD – Mood disorders – Personality Disorders (especially Cluster B) – Adverse Childhood Events (ACEs) – Substance Abuse

• Many opportunities to reduce negative outcomes through Protecti

ective ve Factors ctors:

– Community & Caring Adult Connectedness – Healthy Coping Tools & Modeling – Effective Parenting Styles: Authoritative vs others – Physical & Emotional Supports:

• Parental monitoring, clear limits and predictability
• Locking up guns & medicines
• Graduated drivers license programs
• Opportunities to build social and emotional competence

“Problem-free is not fully prepared”

• Karen Pittman,

Forum for Youth Investment

Recognizing developmentally-appropriate “push-and-pull” of adolescent maturation Differentiating between being at-risk and experiencing risk Identifying and supporting protective factors Shifting from a paradigm of “fixing behavior deficits” to building and nurturing skills and strengths

References and Resources

• Casey BJ, Jones RM, Hare TA. “The adolescent brain”. Ann N Y Acad Sci. 2008;1124:111–126.
• Romer D, Reyna VF, Satterthwaite TD. “Beyond stereotypes of adolescent risk taking: Placing the adolescent

brain in developmental context”. Developmental Cognitive Neuroscience. 2017; Vol 27:19-34.

• Shain B, COMMITTEE ON ADOLESCENCE. “Suicide and Suicide Attempts in Adolescents”. Pediatrics. Jul

2016, 138 (1) e20161420

• American Academy of Child & Adolescent Psychiatry, “Teen Brain: Behavior, Problem Solving, and Decision

Making”, No. 95; September 2016.

• Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. “Childhood Abuse, Household Dysfunction,

and the Risk of Attempted Suicide Throughout the Life Span: Findings From the Adverse Childhood Experiences Study”. JAMA. 2001;286(24):3089–3096.

• Terzian MA, Andrews KM, Moore KA. “Preventing Multiple Risky Behaviors among Adolescents: Seven

Strategies”. Child Trends Research-to-Results Brief. Publication #2011-24. September 2011.

• Kenard, B. “Talking about teen suicide: Why it’s increasing and what parents and doctors can do”. University of

Texas Southwestern Medical Center. Medblog. May 31, 2018. https://utswmed.org/medblog/teen-suicide-risk/

• SAMHSA Suicide and Prevention Resource Center. http://www.sprc.org/
• American Foundation for Suicide Prevention. “Suicide Statistics”. https://afsp.org/about-suicide/suicide-

statistics/.

Partnership for the Safety of Children Around Firearms

Sarah A. Denny, MD, FAAP

Goals

• Come together and discuss in a non-devisive way about gun safety
• Determine messaging to be used throughout the state to promote safety

“Store It Safe”

To Be Addressed

• Unintentional firearm related injuries/deaths to children
• Suicide of teens due to firearms

Not to Be Addressed

• Removal of guns
• A gun registry
• Gang violence
• Mental health issues

Lessons Learned in Phase 1

• Distrust of medical community
• Feel judged
• Fear of registry
• Open to conversation
• It’s all in the approach

Phase 1 Materials

• Talking points/discussion guide for physicians
• Family Handout
• Article in Ohio Pediatrics
• Social media push
• Columbus Dispatch Editorial Board
• Gun Box Pilot
• NCE presentation

Pilot Project

• 1. Give handout for families on gun/barrier safety at every 2-3 year-old visit
• 2. Offer a gun box to families during this visit
• 3. Provide a survey to ALL families at sites participating in gun box

distribution at the end of their 2-3 year old visit

Gun Boxes

Uses for gun boxes

Declining gun boxes

Phase 2

• Adolescents and Suicide Prevention

Phase 2 Goals

• Determine our message/objectives for providers
• Marketing materials specific for adolescent well child visits
• Parents
• Teens
• Healthcare providers
• Social media marketing suicide/injury
• Parents
• Teens
• Healthcare providers

Main Message

• For adolescents
• For healthcare providers of adolescents
• For families with adolescents

For Parents of Teens:

For Providers:

For Teens:

Next Steps

• Focus Groups
• Store it Safe QI Learning Collaborative
• Social Media Campaign
• Potential Legislation
• Expanded Partnerships
• Fundraising

• Sarah.denny@nationwidechildrens.org

Questions?

Questions?