New Jersey

New Jersey

Pediatrics

www.aapnj.org | The Annual Child Abuse & Neglect Prevention Special Edition

PREVENTION MATTERS Using a Strength-Based Approach to Allison Blake, PhD, LSW Steven Kairys, MD. MPH, FAAP Build Resilience in Adolescents Stacy Doumas, MD Page 6 Page 4 Commissioner’s Letter Conflict in the Family

Pooja Shah, MD Ramon Solhkhah, MD Page 8

Understanding Intimate Partner Violence and Sexual Violence Among Adolescents Monica Weiner, MD, FAAP Romelia Freydel, MSN, RN,CPNP-PC Page 12

New Jersey

Pediatrics www.aapnj.org | Special Edition

ISSN 2375-477X

4 Commissioner Blake’s Letter

COLUMNS & RESOURCES

By Allison Blake, PhD, LSW Commission of Department of Children and Families

6 Conflict in the Family By Steven Kairys, MD, MPH, FAAP

8 Using a Strength-Based

Approach to Build Resilience in Adolescents By Stacy Doumas, MD

Pooja Shah, MD Ramon Solhkhah, MD

10 Finding Your Words: Building Trust

By Marita Lind, MD, FAAP

12 Understanding Intimate Partner Violence and Sexual Violence Among Adolescents

Allison Blake, PhD, LSW

Commission of the Department of Children and Families

24 Childhood Physical

Abuse: A Predictor of Adolescent Behavior By Paulette Diah MD, MPH, FAAP

26 Cyberbullying: What

is it and hat can we do about it? By Susan R. Brill, MD Samit Patel, MD, Pediatric Resident

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Regional Diagnostic and Treatment Centers

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PerformCare

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CDC - Understanding Sexual Violence

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Autism Speaks

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Delta Dental - P.A.N.D.A.

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Family Success Centers Listing

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Physician Champions

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DCF Publications Order Form

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Human Trafficking: What to Look for During a Medical Exam/Consultation

41 CRAFFT Screening

By The Center for Adolescent Substance Abuse Research

By MonicaWeiner, MD, FAAP Romelia Freydel, MSN, RN, CPNP-PC

18 Child Abuse and Children with Special Health Care Needs By Janice Prontnicki, MD, MPH, FAAP

New Jersey

Pediatrics

www.aapnj.org | The Annual Child Abuse & Neglect Prevention Special Edition

PREVENTION MATTERS Conflict in the Family Allison Blake, PhD, LSW Page 4

Steven Kairys, MD. MPH, FAA Page 6

Using a Strength-Based Approach to Build Resilience in Adolescents Stacey Doumas, MD Pooja Shah, MD Ramon Solhkhah, MD Page 8

Understanding Intimate Partner Violence and Sexual Violence Among Adolescents Monica Weiner, MD, FAAP Page 12

In Recognition of Child Abuse and Neglect Prevention Month

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New Jersey Pediatrics

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New Jersey Pediatrics and Special Edition is published by NJAAP. For information about the publication including article submissions and advertising opportunities, please contact Michael Weinstein at mweinstein@aapnj. org or by phone at (609) 842-0014, ext. 116. Advertisements in New Jersey Pediatrics do not imply or imply NJAAP endorsement of the product, services, or claims made for any product by a manufacturer. Advertisers in New Jersey Pediatrics do not influence articles, their content or the opinions expressed in this publication.

www.aapnj.org

Fran Gallagher, MEd Executive Director, NJAAP

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elcome to the 2016 New Jersey Pediatrics Special Edition, Prevention Matters, in recognition of April as Child Abuse and Neglect Prevention Month. This year’s edition emphasizes topics confronting adolescents. Preventing and reducing the occurrences of child maltreatment at every age is crucial to all of us and this issue will serve as an important resource for the pediatric health care teams caring for youths and adolescents. In the 2013 Child Protection and Permanency Abuse and Neglect Findings Report, the most current comprehensive report, the data revealed that all 21 counties in New Jersey contributed to a combined 94,486 number of maltreatment reports. Over 11,970 of these reports resulted in findings that were either Established or Substantiated, concluding that according to statute, a preponderance of evidence found that a child had been abused or neglected. Nineteen percent of these finding were specific to teens between the ages of 13-171. NJ offers a wealth of resources for supporting and strengthening families as well as information to link caregivers to assistance, skill building and support. Too often, many professionals and families alike are unaware that these vital services are available right in their community! One example is the Family Success Center (FSC). An up-to-date directory of the 50+ Centers can be found on pages 30-40. Perhaps a member of your health care team could reach out to the FSC in your area to learn more about them and what they have to offer, or even invite their director to come to your next staff meeting to share the information with your staff/team. Is Child Abuse & Neglect Prevention a subject that you feel would benefit your practice team?

See page 44 to meet our dedicated Pediatric Champions who work with us on educational outreach and learn about each of the NJAAP training options available to you and to colleagues in your community. Trainings include both CME and MOC Part 4 options. These opportunities are made possible through a grant from the NJ Department of Children & Families (NJ DCF), as part of our ongoing partnership to keep children safe and healthy. Interested and passionate about child abuse and neglect prevention? NJAAP is always seeking to expand the training team. We offer peer to peer, train-the-trainer preparation and you choose the number of trainings in which you participate. Commissioner Allison Blake, PhD publishes a regularly updated dashboard with data on the NJ DCF website as part of continuous quality improvement efforts (www.state.nj.us/dcf/childdata/ continuous/Demo.2015_Q4.pdf). NJ DCF is a leader in quality improvements based on data driven decisions that demonstrate improved outcomes such as: fewer placement changes for children in foster care, stronger infrastructure for community support for families, and more. We continue to work in partnership to address child abuse and neglect concerns including human sex and labor trafficking also known as “modern day slavery”. Please think about where you are in terms of your knowledge and comfort level in relation to identifying red flags for child abuse and neglect; and, how you can incorporate improvements as part of your routine protocol to help prevent abuse. Reading this resource may be a review or a starting point. Either way, NJAAP has resources and support to help you as you continue to care for NJ’s children and adolescents. Warm Regards,

1. www.state.nj.us/dcf/childdata/continuous/2013_ AnnualAbuseNeglectReport.pdf)

New Jersey Pediatrics Volume 42 • Issue 2 • Spring 2016 Editorial and Advertising Offices 3836 Quakerbridge Road Suite 106 Hamilton, NJ 08619 Office: (609) 842 0014 Fax: (609) 842 0015 www.aapnj.org Editors Indira Amato, MD, FAAP Michael Weinstein President Elliot Rubin, MD, FAAP Vice President Jeffrey Bienstock, MD, FAAP Vice President-Elect Alan Weller, MD, FAAP Treasurer Jeanne Craft, MD, FAAP Secretary/Journal Editor Indira Amato, MD, FAAP Immediate Past President Margaret (Meg) Fisher, MD, FAAP Medical Director Steven Kairys, MD, MPH, FAAP Executive Director Fran Gallagher, MEd

Editorial Board Indira Amato, MD

Chuck Geneslaw, MD

Srividya Naganathan, MD

Alan Meltzer, MD

Jeanne Craft, MD

Mike Spedick, MD

Ernie Leva, MD

Sonia Varma, MD

L. Nandini Moorthy MD

Kaitlyn Storey, DO

Fran Gallagher, MEd

Michael Weinstein

New Jersey Pediatrics Spring 2016

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Conflict in the family Steven Kairys, MD, MPH, FAAP Chair, Pediatrics, Jersey Shore University Medical Center Medical Director, NJAAP/PCORE

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onflict is a regular part of every family. There are daily minor and major disagreements and child behaviors that lead to corrective efforts by the caregiver, usually mother and/or father. This article will describe the consequences of corrective actions that are counterproductive and that lead to short and long term untoward effects. The article will also describe methods of more positive parenting and the important role that pediatricians can play in teaching and modeling effective parenting and in including oversight of discipline and parenting as a regular part of well child care. In the United States the majority of parents, as high as 80% in many studies, believe that corporal punishment is effective and useful to change behavior. Some of this is because the parents were raised themselves that way. There are still strong ties between corporal punishment and religion, especially parts of Christianity. This is also closely tied to the American struggle between the rights of the child, the rights of the parents, and the role of government in protecting children from harm. And as the US continues to waiver on this dichotomy, over 30 nations, including a number of third world countries, have bans on the use of corporal punishment by families or institutions. The UN Convention on the Rights of Children is the treaty mainly cited as providing protection for children from violence. Only two countries in the UN have failed to ratify the treaty; the United States and Somalia. The result of numerous studies is that corporal punishment does not work any better in the short term than other methods and has a number of short and long term negative consequences. Perhaps the major short term consequence is that the punishment was done out of anger and the child is bruised and injured. When a child is injured with bruises, that automatically becomes child abuse, requiring State intervention, whether the bruising was intentional or not. The long term consequences are even more concerning. Child victims of corporal punishment tend to be more aggressive and more anti-social and to have less long term compliance. Often, these children are fearful of their parents, exhibit trauma effects and have increased aggression and antisocial behaviors as adults.

Although all of this research is correlational (there are no randomized control studies), the effect is seen in all of the studies, including studies from 10 to 12 other cultures and societies. Talking to families about parenting and discipline should start long before the toddler era. Waiting until conflict has already occurred means a lost opportunity for anticipatory guidance. The discussions can elicit parental understanding of discipline, especially if both parents have similar ideas about management. Teen years are a major period for giving rise to conflict in the home. Teen rebellion in this time manifests as various behaviors including testing house rules, demanding independence, insisting no one “trespasses” in their private space and riling against being treated as a young child. Many pediatricians limit discussion around discipline to a few tools, such as ignoring tantrums, or use of time out or redirecting a child. These tools can be effective but they should be based on an overarching vision of what constitutes effective, positive parenting. The first concept is to be able to explain the difference between discipline and punishment. Effective discipline teaches children over time how to control their behaviors and take responsibility for their actions. Punishment is a response to an unwanted behavior and the aim is to stop the child by using a painful or unpleasant method that may have no connection to the behavior itself; e.g. verbal punishment or corporal punishment or withholding something the child likes to do or giving penalties such as grounding or stopping allowances. Punishment may curtail a behavior in the short term, but the message is fear and not retraining. Punishment emphasizes power of authority; “Do what I say because I say it”, and often leads to rebellion, sneakiness or desire for revenge. The punishment is often arbitrary and can imply a moral judgement, the sense that the child is bad. It demands compliance and elicits disrespect and sometimes the fear of a loss of love. Sometimes,with verbal punishment, it is demeaning, belittling and sometimes it is all talk and backed with little or no action. Positive parenting respects the child but not the behavior. The parent tries to understand the underlying issues leading to the poor behavior and who actually ‘owns’ the problem.

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Parents listen to their child and accept them as they are. Parents encourage independence and use natural and logical consequences that are linked to the behaviors rather than arbitrary punishment. Parents use humor, stay calm and show good will and respect for the child. They make sure the child is safe first and then deal with the issues when emotions are calmer. Parents try not to give mixed messages or have widely different responses to the conflicts. Parents thus learn to act, not reflexively react. Natural and logical consequences aim to teach the child to take responsibility for his or her poor behaviors. Natural consequences allow the child to learn the results of their actions from the natural order of the world. Logical consequences allow the child to learn from the reality of the social order- the children must see these as logical responses that make sense to them. The goal is to motivate the child to learn alternative approaches rather than to force their submission. The child hopefully learns strategies and approaches that can be building blocks to a lifetime of more social responsiveness and personal ego building. Often the parent can provide several choices, all of which are acceptable to the parent. Allow the child some choice at times. Assure the child that after the consequence he or she may try again. Be patient, it may take a number of interventions to be effective. For example, a teen who always gets up late on weekdays should have the natural consequence of dealing with schoolissued penalties for being tardy rather than the parent enabling the behavior by rushing out the door to drive the teen to school in an effort to avoid the consequences.

A logical consequence of not doing the chores, such as not feeding the animals, is that animals get fed before the teen is fed or permitted to leave the house. A teen who doesn’t put gas in the car doesn’t use the car the next time. Providing choices when possible presents the teen with some sense of ownership and respect. Again the parent needs to be comfortable with all of the choices. Positive parenting works only if the relationship between the parents and child is one of mutual respect. Parents have to be firm and stick to the consequences, but as stated should be kind and calm and show respect. Value the teen and look to encourage strengths and assets; spend more time encouraging rather than correcting. Try at least one positive statement a day. Parents need to learn to talk less and act more. Avoid enabling the teen, avoid performing tasks they can and should do. Ask more rather than demand. Try no matter the conflicts to have fun being a parent. A simple and great screening question for the pediatrician is just that: “Are you having fun being a parent?” Poor behaviors will elicit parental emotion and anger at times. Don’t neglect the emotion but don’t allow them to produce inappropriate responses. Teach parents that being proactive and preventing conflict works wonders. Stay positive. A weekly family meeting where everyone gets listened to with respect and where teenagers can bring up their issues and needs can be very helpful.

A logical response to a teen misbehaving in the car is to pull over and let them know the behavior is a driving distraction. Perhaps, return home and cancel the excursion if the behavior continues. Or do not drive or allow the teen to drive the next time he or she asks for permission. This is a logical consequence. Similar response for the child who acts out in the store and makes shopping a real chore. Threats and taking things away or corporal punishment are reactions and there is no effective teaching taking place. Avoidance is a logical consequence of many behaviors. Whining and tantrums are best responded to by walking away. However, be sure to compliment the teen for positive actions and behaviors.


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Using a Strength-Based Approach to Build Resilience in Adolescents

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Stacy Doumas, MD Department of Psychiatry Jersey Shore University Medical Center Pooja Shah, MD Department of Psychiatry, Jersey Shore University Medical Center Ramon Solhkhah, MD Department of Psychiatry, Jersey Shore University Medical Center

ith the advent of ground breaking discoveries in modern science, medical studies have been successful in identifying the complex correlation between a person’s physical and emotional health; deterioration in either can exponentially affect the other. The first point of identification of mental illness is often during adolescence with approximately 1 in 5 having a diagnosable mental illness.1 Social and academic pressure, low self-esteem, hormonal fluctuations, brain development and risky behavior such as drug and alcohol use are among the stressors that predispose adolescents to mental adversity.2 Childhood adversity can have significant negative impacts on mental health that last into adulthood. 1,3 Research in the field of mental health often focuses on risk identification, pathologizing some of the variants of behavior and strategizing treatment options which can alleviate the negatives. Little has been done to focus on the positive promotive factors in an adolescent’s life. Using a resiliency paradigm we can formulate a strength-based intervention which incorporates these factors and focuses on a positive outlook towards life. We can view these adolescents as “having potential” as opposed to “being at risk”.3 Resilience Resilience is defined as “an individual’s ability to properly adapt to stress and adversity”.4 For adolescents, adversity may include trauma, tragedy, loss, threats or significant stress such as relationship problems (family, peer, or partner), serious health problems, academic difficulties or financial stressors. Resiliency refers to “bouncing back” from difficult experiences. It involves thoughts and behaviors and can be learned and developed in anyone. Resiliency theory helps us understand why some youth grow up to be healthy adults in spite of risks exposure.5 Many studies have tried to identify factors that render youth resilient. Among the factors that have been most articulately pointed out by research are interpersonal factors (gender, intelligence, aspects of temperament, and genes), factors within the family (stable and positive relation to an adult), and factors of the broader environment (being integrated into the community)4. Internal resilience factors (assets) include personal strengths, problem solving skills and self-efficacy.

External factors (resources) include societal influence in the form of school, home, community participation and peers. 8,9,10 Resilience in the context of adolescent mental health is described as the process in which risks are encountered and assets and resources are used to avoid a negative outcome13. Strength-Based Approach to Developing Resilience Using a strength-based approach with teens focuses on analyzing and identifying an individual’s strengths and their resources in addition to developing appropriate coping mechanisms to be used during times of adversity. As opposed to more traditional approaches, a strength-based paradigm describes how the promotive factors within the individual compensate and counteract negative factors during crisis, formulating positive youth development and fighting risks, rather than focusing on problems .7 Youth development programs that aim to surround youth with protective factors in their environment may achieve greater benefits in outcomes than those that aim to minimize risk.1 Strength-based interventions work on the foundation of principles of self-reliance and developing a positive mindset. Practitioners who use this approach intentionally assess and reinforce an adolescent’s strengths, abilities, passions and talents. They also work with others to strengthen their support network.11 Additionally, adolescents learn to cope with stress using strategies called coping skills. These may include deep breathing, journaling, listening to music, exercising, meditation or whatever healthy skill helps them cope with stress. Although the teens we treat can’t avoid all adversity, using a strength-based model we can help them be prepared for challenges and avoid seeing crises as insurmountable problems. What Does Resiliency Look Like? The following describe many aspects of resiliency that can be developed and enhanced in adolescents using a strengthbased approach 3: • Strong sense of optimism and hope • View of life as a dynamic journey where they are an active participant • Positive and meaningful relationships • Capacity to make realistic plans and take steps to carry them out • Positive view of themselves and confidence in strengths and abilities continued on next page

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• Skills in communication and problem solving • Capacity to manage strong feelings and impulses • View of obstacles as challenges • Awareness of weaknesses, but building on strengths

Pediatricians can serve as partners with families, schools, and community agencies to foster healthy youth development by balancing the goals of preventing problems, promoting development and encouraging engagement among all of their adolescent patients.11

• Knowledge of what they can and cannot control in their lives

For some health care providers, training may be helpful that incorporates interactive sessions to apply skills and having tools available for use in their practice.11

• Understanding of the need to give back and support others

Tips for Using a Strength-Based Approach with Adolescents

Using a Strength-Based Approach in Clinical Encounters

• Approach them with the belief that they possess strengths and talents.

Physician-patient interactions during clinical encounters cultivate meaningful connections with adolescents, whether that interaction is with a mental health provider or a primary care provider. It is imperative for the clinician to practice active listening and have a nonjudgmental approach to be able to identify and enhance the strengths in an adolescent.9 Motivational interviewing, a collaborative, person centered style of eliciting and strengthening motivation for change, is recommended.11 Physicians should be able to highlight and elicit the strengths and protective factors in the patients, both internal and external. Interviewing should start with open ended questions and aim to identify friends at school, love interests, future aspirations, and family and friend support systems. Questionnaires for teens that address strengths may be helpful to gather information if there are time constraints.11 Collaborating with family, teachers, and guidance counselors promotes connectedness and resilience.10 It is important to educate the parents about highlighting their child’s strength and participating in their life. Physician visits should be appropriately spaced in order to be able to assess the progression. Each follow-up session should aim to reinforce the strengths of the patient and add external resources as needed.11 In addition to improving mental health, strength-based approaches, including motivational interviewing, hold potential for clinical efficacy in chronic disease applications.14 The American Academy of Pediatrics supports the use of strength-based approaches in clinical encounters with teens.11 With chronic disease management becoming an increasingly important aspect of adolescent primary care, implementing a strength-based approach to treat teens with medical conditions in pediatric offices may be very useful approach.14

• Use active listening, motivational interviewing and remain nonjudgmental. • Elicit strengths, protective factors and indicators of healthy development. • Questions for teens may include: o What do you love to do? o What are you good at? o What are you good at in school? o Who do you get along with best (at home and in school)? o What adults are supportive of you? o What do you do to help others? o What do you want for yourself now and in the future? • Educate parents about their teen’s strengths, being supportive and involved, avoiding or handling difficulties, fostering problem solving skills and encouraging supportive social networks. • Collaborate with others (families, teachers, counselors, community organizations, mental health providers) to support the adolescent and promote healthy development.11

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Finding Your Words: Building Trust Marita Lind, MD, FAAP General Pediatrics

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s a pediatrician who regularly cares for children who have been abused, I am often asked how and when physicians should begin talking to teenagers about sexual abuse. Often, pediatricians ask if there are certain behaviors that should prompt this conversation, such as cutting or refusing to undress for a physical. These questions remind me of how challenging physicians can find addressing sexual abuse, and how awkward it may feel discussing it with their teenage patients. Since there are no standard screening tools regarding sexual abuse, this article presents some practical approaches to initiating a conversation with teens about sexual abuse. Six strategies for initiating a sexual abuse conversation with teens: 1. Sexual abuse, in its various forms, affects one in 4 girls and one in 5 boys in the United States by their 18th birthday. This means that if you have 1500 children on your panel, 20 % of whom are teens, you are, on average, the primary physician to approximately 66 teens who have experienced some degree of sexual abuse. By that measure, fulltime pediatricians reading this article, collectively, are providing care to hundreds of teens who will, or have already experienced sexual abuse. This is the basis for the argument that pediatricians should routinely provide anticipatory guidance regarding personal space and privacy to children and their caregivers. The key to success? Begin at an early age and repeat it often at each well visit. 2. Following the above calculation, it is plausible that many conversations between pediatricians and teens, revolving around puberty and sexual behavior, have occurred after the teen experienced sexual abuse. Adding a few questions to this routine conversation not only conveys the message that your practice is a safe environment in which to discuss all concerns and questions, but equally important, to help reveal instances of sexual abuse. Even the simplest questions can open the door to a meaningful dialogue. One suggested question might be “Have you ever been touched sexually without your permission?” 3. Teens know about sexual abuse. What they are often uncertain about is to whom they can turn to for non-judgmental support and answers.

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So, a critically important message to convey with your teenage patients is - If you ever worry that something unsafe is happening to you, you can always come here for help. Incorporating this type of messaging into your body-safety anticipatory guidance, will go a long way toward building trust. 4. Teens instinctively observe their pediatricians to determine if they can be trusted to help in times of uncertainty. If the pediatrician avoids the “private parts” during the yearly physical, and chooses not talk about puberty or menstrual periods, the child concludes that the doctor cannot handle or does not want to discuss topics related to genitalia and overall sexual health and behaviors. Make sure your patients know you are comfortable with and open to discussing questions and concerns related to sex. Demonstrate your comfort by sitting down in the exam room and avoid rushing through your discussion pertaining to these critical topics. 5. Teens often don’t understand how an encounter with sexual abuse impacts their behavior and mental and physical health. They are grateful to learn about how the brain responds to stress and how such stress can impact their future wellbeing. It is enormously beneficial for teens to hear from you that the difficulties they are confronting - or have experienced - are recognized and can be treated. Teens need to hear and know there is always hope. 6. Be direct when discussing topics about sex and safety with your teen patients. Pediatricians have learned to ask about consensual sexual behavior, but are often uneasy with asking about coerced sexual behavior, including human trafficking. While law enforcement and other governmental agencies are already addressing human trafficking and have been for some time, healthcare providers have only recently begun tackling the issue at the practice level. While the reality of limited time make addressing such a complex issue a formidable challenge, there are ways to bring light to potential red flag concerns. Two simple but effective questions you can ask your teen patients are; “Has anyone ever asked you to have sex with someone else?” and Have you ever had sex with someone in exchange for food, shelter, drugs or money?” continued on next page www.aapnj.org

Using a Strength-Based Approach to Build Resilience in Adolescents from page 9 Conclusion C.S. Lewis said, “Hardships often prepare ordinary people for an extraordinary destiny”. Each of us will experience adversity. When working with adolescents it is important to help them stay healthy, develop resiliency, use positive coping skills and know when to seek help from their support network. Whether a pediatrician, a counselor or a psychiatrist, we can use a strength-based resiliency model with adolescents to help them triumph over adversity and become their best self. References: 1. Schwarz, S. W. (2009). Adolescent mental health in the United States: Facts for Policymakers Retrieved November 9, 2012, from http://nccp.org/publications/pdf/text_878.pdf 2. McDougall, T., & Brophy, M. (2006). Truth hurts: young people and self-harm. Mental Health Practice, 9(9), 14-16 3p. 3. Hammond, W. (2010) Principles of Strength Based Practice. Resiliency Initiatives. 4. Skala, K. Bruckner, T. Beating the odds: an approach to the topic of resilience in children and adolescents. Neurosychiartr. 2014;28(4):208-17. 5. Zimmerman, M. A. (2013). Resiliency theory: a strengthsbased approach to research and practice for adolescent health. Health Education & Behavior:The Official Publication Of The Society For Public Health Education, 40(4), 381-383. 6. Masten, A. S., Herbers, J. E., Cutuli, J. J., & Lafavor, T. L. (2008). Promoting Competence and Resilience in the School Context. Professional School Counseling, 12(2), 76-84.

7. Masten, A. S. (2007). Resilience in developing systems: Progress and promise as the 4th wave rises. Development and Psychopathology, 19, 921-930. 8. Bernard, B. (1993). Fostering resiliency in kids. Educational Leadership, 51(3), 44. 9. Bernard, B. (1991). Fostering resiliency in kids: protective factors in the family, school, and community. 10. Hanson, T. L., & Kim, J. (2007). Measuring Resilience and Youth Development: The Psychometric Properties of the Healthy Kids Survey. Issues & Answers. REL 2007-No. 34. Regional Educational LaboratoryWest, 11. Taliaferro, L. A., & Borowsky, I. W. (2012). Integrating clinical practice: Beyond Prevention. Promoting Healthy Youth Development in Primary Care. American Journal Of Preventive Medicine, 42(Supplement 2), S117-S121. doi:10.1016/j. amepre.2012.03.017 12. Donnon, T. ). ( 1 ), & Hammond, W. ). ( 2,3 ). (2011). Resiliency: Embracing a strength-based model of evaluation and care provision. Wilfrid Laurier University Press. 13. Dray, J., Bowman, J. Wolfenden, L. Campbell, E. Freund, M. Hodder, R. Wiggers, J. Systematic review of universal resilience interventions targeting child and adolescent mental health in the school setting: review protocol. Systematic Reviews. (2015) 4:186. 14. Chung, RJ. Burke, PJ. Goodman, E. Firm Foundations: strength-based approaches to adolescent chronic disease. Curr Opin Pediatr. 2010 Aug; 22(4):389-97.

Finding Words continued from page 10

As stated in the beginning of this article, we don’t yet have a validated screening tool in our tool bag. But, it is clear that we need to ask important questions at each visit. Similarly to domestic violence screening, we should be providing our teen patients with multiple opportunities to react before they feel comfortable disclosing such experiences.

Hopefully, the suggestions contained in this article will help you tailor your own conversation, one that empowers teens to voice their concerns and disclose their traumatic experiences. To accomplish this, Pediatricians first need to find their words so that their teen patients can use theirs.

As our understanding of the long-term health impact of childhood trauma grows, pediatricians will undoubtedly continue providing their patients with the anticipatory guidance, resources and referrals needed to ensure their optimal health. Since sexual abuse is a trauma that most often occurs secretly, treatment cannot commence until the abuse has been disclosed. New Jersey Pediatrics Spring 2016

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Understanding Intimate Partner Violence and Sexual Violence Among Adolescents Monica Weiner, MD, FAAP Medical Director Metro Regional Diagnostic Treatment Center Romelia Freydel, MSN, RN, CPNP-PC Pediatric Nurse Practitioner Metro Regional Diagnostic Treatment Center

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ntimate partner violence (IPV) and sexual violence (SV) are major public health problems which can directly impact an adolescent’s physical and psychological health. IPV occurs between two people in a close relationship and can be physical, emotional, or sexual. It can occur among heterosexual or same-sex couples of any orientation and does not require sexual intimacy. SV can be perpetrated by intimate partners, but also by family members, teachers, acquaintances, strangers or others.

IPV can include physical force such as scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, hairpulling, slapping, punching, hitting, burning, use of weapon (gun, knife, or other object), or restraining.1 IPV can also include psychological abuse such as degrading, harassing, name calling, blaming, threats, stalking or isolating. Abusive partners may also monitor or control an adolescent’s cell phone usage, clothing choices, school attendance or use of contraceptives. The adolescent may be threatened using digital media such as by posting or threatening to post nude pictures of the victim, stalking the victim through social media, or humiliating the victim through social networks.2 SV involves unwanted sexual contact, which may include verbally or physically coerced touching or kissing, or forced vaginal, oral, or anal penetration. SV can occur when a victim is alert and rational, irrational, semiconscious, or unable to respond due to violence or alcohol or other drug ingestion. Medications used for drug-facilitated sexual assault include flunitrazepam (“roofies”), ketamine (“special K”), gamma hydroxybutyrate (GHB) or other prescription sedatives, illegal sedatives, or over the counter medications.3 These drugs alone or in combination with alcohol can leave the victim incapacitated and unable to protect themselves from SV. It is also important to remember that alcohol by itself is frequently used to incapacitate a victim or undermine their judgment. IPV frequently begins in junior high school and peaks during the high school years, with approximately 35% of male and female high school students reporting having engaged in IPV.4

Results from the 2013 Youth Risk Behavior Surveillance survey revealed that approximately 10% of high school students who went on dates during the past year reported being deliberately hit, slammed, or injured by an object or weapon by someone they were dating. Approximately 10% of the same group reported being forced to kiss, touch, or have sexual intercourse with someone they were dating. 7.3% of high school students reported that they were forced to have sexual intercourse at some time in the past.5 Although adolescents experience high rates of IPV and SV, they are often partially blamed by society for their victimization, especially if underage drinking or other illegal or other offenses are involved (e.g., truancy, running away, “behavior problems”). Some adolescents may be vulnerable to SV and IPV due to homelessness, disabilities, substance abuse, bullying, or a family history of domestic violence.6 Adolescents with a history of being victimized in the past are also at increased risk for being victimized again in the future. Among adult victims of rape, physical violence, and/or stalking by an intimate partner, 22% of women and 15% of men first experienced some form of IPV between 11 and 17 years of age. Almost 80% of adult female victims of rape experienced their first rape before they were 25 years old. 42% experienced their first rape before they were 18. Among adult male victims of rape, 27.8% experienced their first rape when they were age 10 or younger.7 Although these statistics are alarming, they likely represent only part of the full picture. Sexual abuse and assault are under-reported and all adolescents regardless of their race, gender identity, sexual preference, or socioeconomic status should be screened for SV or IPV. In cases of possible IPV or SV, an adolescent may need treatment for physical injuries that are unexplained or for which the mechanism of injury does not match the explanation provided by the adolescent. He or she may have self-inflicted injuries or have signs or symptoms of depression. The patient may be reluctant to undress or have a genital or anal examination. There may be a delay in seeking medical care or frequent emergency room visits. He or she may be accompanied by an overly attentive or controlling partner. In cases of SV, an adolescent may also present repeatedly for treatment of sexually transmitted diseases, pregnancy testing, or seeking pregnancy treatment and/or termination. continued on next page

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When IPV or SV is suspected, the healthcare provider should discuss the possibility of IPV or SV in a manner that is supportive and not accusatory. Explaining that screening for IPV and SV is routinely done on all the adolescent patients will reduce the patient’s anxiety during the screening process.2 Adolescents may not report IPV or SV due to fear or confusion. Some of the challenges faced by teenagers following a sexual assault or IPV include: seeing the perpetrator at school; apprehension or uncertainty about what happened (e.g., unwanted sex vs. rape); lack of money or transportation to get medical or legal help; distrust of authority figures and/or the legal system; and fearing public knowledge about the assault.8 Adolescents may be uncertain about a physician’s obligation to inform or not inform parents about sensitive information, which may lead to reluctance to disclose abuse or assault.9 They may also be hesitant to tell a parent or guardian because they fear losing access to activities, friends, or privileges. Additionally, adolescents are egocentric. They focus largely on themselves and believe their peers are equally interested in them. This can affect an adolescent’s decision to report or not report IPV or SV because they do not want to be looked down upon by their friends or others.10 Lastly, adolescents are new to “dating” and may not have an understanding of what a healthy relationship should be like and also may think that the abusive relationship is the only one they can have. If a patient discloses SV to a healthcare provider, there are several factors that can impact the type of medical care a victim may need based on the timing of the sexual assault and whether physical injuries are present.11 If the sexual assault occurred within the past 5 days, it is important to have the patient go to an emergency department where a complete medical evaluation can be performed. This includes a complete examination, offering prophylaxis for sexually transmitted diseases, a discussion of emergency contraception and HIV prophylaxis if needed, and evidence collection. If the assault occurred more than 5 days prior to the adolescent’s disclosure, a visit to the emergency department is not necessary. However, the healthcare provider should offer sexually transmitted disease and pregnancy screening and treatment if needed, as well as emotional support and referral to mental health services.

Although laws vary from state to state, generally, if an adolescent reports SV to their healthcare provider, then the provider is mandated to report the abuse/assault to the police. If the perpetrator is a parent, teacher, coach, religious leader, or someone who is in a “caretaking role” towards the patient, the SV must also be reported to child protective services (in NJ, the Division of Children Protection and Permanency). Prior to reporting, the adolescent should be informed and it should be explained that by law the provider is mandated to report the sexual abuse/assault. This can open a discussion about the patient’s safety and why it is important for the provider to protect them from future harm. The provider can also inform the adolescent that while the provider is mandated to report, the adolescent has a right to either pursue or not purse the allegations. Pediatricians should be proactive in having an open dialogue with all their adolescent patients about IPV and SV. Creating a sincere and candid line of communication will allow adolescent patients to feel more comfortable asking questions in a private environment. Pediatricians can provide one-to-one education about SV and IPV to adolescents as part of anticipatory guidance. For adolescents with questions or concerns who are not yet ready to speak with their medical provider, it can be helpful to make pamphlets and other information obvious and available in the waiting room or other parts of the clinic. For further guidance for medical providers on how to address violence prevention in your practice, see the AAP program “Connected Kids: Safe, Strong, Secure,” a clinical guide with handouts for parents and teens. Adolescents in New Jersey seeking assistance can call or text the 2NDFLOOR youth helpline (1-888-222-2228) any time to receive confidential advice for problems including dating violence. Essex County area teens can visit the AREAS 4 YOU website at www.areaskeepgirlssafe.com for advice about violent relationships and to sign up for a support group. Loveisrespect is a national organization which provides multiple ways for an adolescent to contact a trained peer advocate 24 hours per day, including a hotline at 1-866331-9474. Additional information is available at www.loveisrespect.org.

references on page 14 New Jersey Pediatrics Spring 2016

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Suspect Sexual Abuse? Uncertain of Your Next Step? Contact the Nearest Regional Diagnostic and Treatment Centers for Child Abuse and Neglect Audrey Hepburn Children’s House Hackensack University Medical Center 30 Prospect Avenue Hackensack, New Jersey 07601 (201) 996-2271 Metropolitan Regional Child Abuse Diagnostic and Treatment Center Children’s Hospital of New Jersey at Newark Beth Israel Medical Center 201 Lyons Avenue Newark, New Jersey 07112 (973) 926-4500 Dorothy B. Hersh Child Protection Center The Children’s Hospital at St. Peter’s University Hospital, 123 How Lane New Brunswick, New Jersey 08901 (732) 448-1000

IPV and SV References 1. Breiding MJ, Basile KC, Smith SG, et al. Intimate Partner Violence Surveillance Uniform Definitions and Recommended Data Elements. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA: 2015. 2. Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 119: 12-7. 3. Du Mont J, Macdonald S, Rotbard N, et al. Factors Associated with Suspected Drug-Facilitated Sexual Assault. Canadian Medical Association Journal 2009, 180: 513-519. 4. O’Leary KD, Smith Slep AM. Prevention of Partner Violence by Focusing on Behaviors of Both Young Males and Females. Prev Sci 2012; 13: 329-339. 5. Centers for Disease Control and Prevention.Youth risk behavior surveillance—United States, 2013. MMWR, Surveillance Summaries 2014; 63, vol. 4. 14


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NJ Child Abuse Research Education & Service CARES Institute Rowan School of Osteopathic Medicine 42 East Laurel Road, Suite 1100 Stratford, New Jersey 08084 856-566-7036 Jersey Shore University Medical Center 1945 Route33 Neptune City, New Jersey 07753 (732) 775-5500 St. Josephs Children’s Hospital 703 Main Street Paterson, NJ 07503 (973) 754-2500

6. Lundgren R, Amin A. Addressing Intimate Partner Violence and Sexual Violence among Adolescents: Emerging Evidence of Effectiveness. Journal of Adolescent Health 2014; 56: S42-S50. 7. Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2011. 8. O’Connell, K. Challenges Facing Teen Survivors Seeking Protection Orders in Washington. Connections-Washington Coalition of Sexual Assaults Programs 2009; 11: 7-10. 9. Klostermann B, Slap B, Nebrig D, et al. Earning Trust and Losing it: Adolescents’ Views on Trusting Physicians. The Journal of Family Practice 2005; 54:679-687. 10. Pastorino E, Doyle-Portillo S. What Is Psychology?: Essentials. 2nd ed. Australia: Wadsworth Cengage, 2010: 325-375. 11. Kaufman, M. Care of the Adolescent Sexual Assault Victim. Pediatrics 2008; 122:462-470.

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Child Abuse and Children with Special Health Care Needs Janice Prontnicki, MD, MPH, FAAP Director of Developmental and Behavioral Pediatrics Department of Pediatrics, Rutgers New Jersey Medical School

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hildren with special health-care needs (CSHCN) are defined as “those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally”.1 Within this group are children with developmental disabilities. As defined by the Centers for Disease Control and Prevention, developmental disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas. About one in six children in the U.S. have one or more developmental disabilities or other developmental delays. 2 Developmental disabilities include conditions such as Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), intellectual disabilities, motor and communication disorders, learning disabilities and emotional/behavioral disorders. CSHCN and increased risk of maltreatment

Numerous studies have documented an increased risk of child abuse among children with special health care needs and children with developmental disabilities in particular. 3-9 The generally cited figure is that children with developmental disabilities are at least twice as likely to be abused. In addition, studies have shown these children are more at risk for the entire spectrum of maltreatment (neglect, physical, emotional and sexual abuse) and repeated episodes of abuse. 5 Because of this, the American Academy of Pediatrics (AAP) has noted that the “maltreatment of children, including those with disabilities, is a critical public health issue”. 10 A study by the Boys Town National Research Hospital found that children with disabilities are 2.2 times more likely to be sexually abused, 1.6 times more likely to be physically abused, and 1.8 times more likely to be a victim of neglect than children without disabilities3. More recent studies have looked at individual disabling conditions rather than group all children under the “disability” umbrella. When analyzed by condition, it has been found that children with behavioral and mental health conditions are more at risk for abuse and neglect than children with physical or intellectual disabilities. Specifically, children with behavioral disorders were found to be 7 times more likely to be abused/neglected than neurotypical children.6

In data collected from 1997-2000 through federally funded mental health programs, 18.5% of children with ASD have been reported to have suffered from physical abuse and 16.6% have been sexually abused. 11 In a sobering study from China, 88% of parents whose child had a diagnosis of Autism, self-reported that they had physically maltreated their child. This study found that the more severe the child’s degree of ASD symptoms, the more common and more severe the reported maltreatment. 12 The difference in percentages between these two studies may be attributed to numerous factors, but the under-reporting of abuse, especially among this communication-challenged population, remains a major concern. The reasons for increased risk The reasons hypothesized for these increased risks are numerous. Unfortunately, in many ways, a family dealing with a child‘s special health-care needs creates the “perfect storm” for abuse or neglect. An often cited (and sometimes debated) factor is the additional family/caregiver stress a chronic health condition or developmental disability can trigger. Such stressors may include caregiver burnout, increased financial demands, parental guilt regarding the child’s condition, unrealistic expectations regarding the child’s abilities and social isolation. There are various child or condition-specific characteristics that can also put the child at greater risk. The child may have limited communication and social skills so that self-reporting is hindered. The increased dependence on caregivers for personal hygiene issues may blur the lines of appropriate physical and sexual contact. In addition to parent and child influences, there are community and systems factors which may further increase the risk. For example, a child with special health care needs may spend significant time away from home in a special school with numerous caregivers. Again the lines of appropriate touch can be blurred. Overuse of aversive techniques and restraints can become abusive. There may be disincentives for reporting of suspected abuse. Institutions including special schools and child care programs may be reluctant to report suspected abuse by its workers fearing loss of licensure or financial harm. In turn, a desperate family may be less likely to report concerns about possible institutional abuse because of the limited opportunities to move the child into another situation. continued on next page

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Conversely, if the school or daycare provider suspects abuse by a parent, they may be less likely to report due to financial disincentives (fear of losing the client) or misplaced concern over alienating the family or increasing the parental stress level. Studies have shown that even child protection caseworkers tend to minimize the suspicion of abuse in hypothetical case vignettes where the child was identified as disabled. 13 In this study, children with disabilities were more likely than other children to be viewed as having characteristics that “contributed” to the abuse. The caseworkers demonstrated increased empathy for the abusive parents, particularly if the child was reported to have emotional or behavioral difficulties. There also are missed opportunities for early detection and treatment, particularly if the child does not have a consistent medical home. For example, failure to thrive may be considered part of the child’s condition when in fact it is a sign of neglect. Some children because of their motor coordination difficulties or poor impulse control are at increased risk for repeated accidental injuries which may lessen the suspicion that bruising may be due to nonaccidental causes. Similarly, it can be quite difficult to differentiate self-inflicted injuries from abuse in children with self-injurious behaviors. An additional complication comes from the issue of “reverse causation”. 7 It can be difficult to differentiate cause and effect as abuse and developmental disorders share common pathways. Adverse conditions such as child abuse can cause developmental disorders. In infancy, severe neglect can cause developmental delays. Traumatic brain injury from abuse can lead to severe motor impairments, intellectual disabilities, acting out or more subtle behavioral disorders. It is not difficult to see how this may create a “vicious cycle” of abuse: the injured child demonstrates increased developmental and or behavioral difficulties leading to increased risk of further abuse. Appreciating this interplay of factors, the AAP Committee on Child Abuse and Neglect and the Committee on Children with Disabilities, in a joint statement in 2001, stated “children suspected of maltreatment should be evaluated for developmental disabilities.” 14 Addressing the problem So what are some of the things pediatricians can do to head off this “perfect storm” and stop the “vicious cycle”? We can focus on prevention and identification of abuse.

First, it is necessary to identify a child with a disability as early as possible. In doing so, the pediatrician can help the parents have a better understanding of their child’s abilities, strengths and weaknesses and establish realistic expectations. Identifying, highlighting and promoting both the child’s positive attributes and the family’s strengths can act as a protective factor against abuse. This is the first step in prevention. Once a special health care need is identified, it is imperative that the family is referred for appropriate services and support. For the child from birth to age 3 this would be in the form of early intervention program (EIP) services. New Jersey has a hotline that all families in the state can call to be connected to appropriate EIP services in their area. That number is (888) 653-4463. For the child/ young adult age 3 through 21, special education services can be accessed through each school district’s Child Study Team. All children with special needs can be referred for case management through New Jersey’s Special Child Health services county-based care units. Contact information is available at www.nj.gov/health/fhs/sch/sccase.shtml. As children with behavioral disorders are especially at risk, the NJ Department of Children and Families’ Children’s System of Care services can provide evaluation and intervention including mobile response teams. The contact number is (877) 652-7624 The Statewide Parent Advocacy Network (SPAN) empowers families in need of special services. SPAN can be reached at (800) 654-SPAN or www.spannj.org . Other NJ resources for families include: NJ Parent Link at www.njparentlink.nj.gov Mom 2 Mom at (877) 914-Mom2 or www. mom2mom.us.com In addition, support groups are available for specific conditions, such as Autism New Jersey. Contact information is (800) 4 Autism or www.autismnj.org.

see references on page 30 New Jersey Pediatrics Spring 2016

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Another important proactive step that pediatricians can make is anticipatory guidance in the area of appropriate touch. The AAP recommends that, within the context of a medical home, pediatricians discuss issues of sexuality, personal space and privacy with children and young adults with disabilities on a regular basis15. This must be done on an appropriate developmental level. An excellent discussion on this topic can be found in an earlier addition of New Jersey Pediatrics by Dr Martin A. Finkel16.(Spring Special Issue, 2015) When it comes to identifying abuse in the CSHCN population, pediatricians must recognize that this is a group at increased risk for abuse and neglect. We must be willing to investigate and report as we would for any child in our care. Pediatricians should remain aware that the same red flags that raise suspicion of abuse in typical children are cause for concern in CSHCN. The AAP has updated its clinical report “Evaluation of Suspected Child Physical Abuse” 17 which provides a comprehensive review of the topic. Body surfaces that are not usually accidentally bruised in typical children and therefore likely associated with physical abuse (neck, ears, chin, anterior chest and buttocks) are also not usually the sites of accidental injuries in CSHCN18. When a child with special equipment such as a body jacket or other appliances presents with skin irritation or bruising, the extent/location of the bruising must be evaluated with consideration of the possibility of physical abuse or neglect. Failure to properly apply or maintain the appliance warrants education of the caregiver. In addition, we must consider that neurodevelopmental disorders predispose CSHCN to even more severe sequelae of abuse or atypical presentation compared to typically developing children. Toddlers and even older children with very low muscle tone and poor head control are at increased risk of “shaken baby syndrome” or the more aptly named “abusive head trauma” when handled roughly. Children with Spina Bifida and other sensory deficits may not suffer pain from non-accidental trauma or burns due to abuse or neglect making timely identification of such injuries more challenging. The child with ASD or severe language deficits may not be able to communicate their physical or emotional pain, instead presenting with worsening behaviors. If a non-verbal child suddenly resists going to school or seems agitated near a regular caregiver, maltreatment must be considered.

Throughout the reporting and the investigation into alleged abuse, the pediatrician remains an invaluable resource to the child by providing continuity of care within the medical home. Depending on the circumstances, the physician may also be in a unique position to support the family and prevent recurrence of maltreatment. Certainly the complex management of abuse in the CSHCN population requires more than the actions of individual pediatricians. Optimal prevention, timely identification and effective treatment require a collaboration of multiple experts functioning within a variety of systems. There is a need for increased training of school and other institutional personnel, health care providers and case workers on how to prevent and recognize abuse of CSHCN. Another system weakness that needs to be addressed is the scarcity of mental health services for all children but particularly those with developmental disabilities. Conclusion Pediatricians remain on the front line of preventing, identifying and treating child abuse. Children with special health care needs are particularly at risk for maltreatment. Within a medical home, the pediatrician can best identify and address these risk factors in order to prevent abuse before it occurs or identify and intervene as early as possible. References 1) McPherson M, Arango P, Fox H, et al. A new definition of

children with special health care needs. Pediatrics. 1998;102: 137–140

2) CDC’s National Center on Birth Defects and Developmental Disabilities (NCBDDD) www.cdc.gov/ncbddd/index.html

3) Sullivan P, Cork PM. Developmental Disabilities Training

Project. Omaha, NE: Center for Abused Children With Disabilities, Boys Town National Research Hospital, Nebraska Department of Health and Human Services; 1996

4) Ratnofsky AC. A Report on the Maltreatment of Children With

Disabilities. Washington, DC: National Center on Child Abuse and Neglect; 1994

5) Sullivan PM, Knutson JF. The association between child

maltreatment and disabilities in a hospital-based epidemiological study. Child Abuse Negl.1998;22 :271– 288


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6) Sullivan PM, Knutson JF. Maltreatment and disabilities: a population-based epidemiologic study. Child Abuse Negl.2000;24 :1257– 1273

7) Spencer N, Devereux E, Wallace A, et al. Disabling conditions and registration for child abuse and neglect: a population-based study. Pediatrics.2005;116 :609– 613

8) Kienberger Jaudes P, Mackey-Bilaver. Do chronic conditions

increase young children’s risk of being maltreated? Child Abuse Negl. 2008; 32:671-681.

9) Van Horne BS1, Moffitt KB2, Canfield MA et al. Maltreatment of

Children under Age 2 with Specific Birth Defects: A PopulationBased Study. Pediatrics. 2015 Dec; 136(6):e1504-12. doi: 10.1542/peds.2015-1274.

10) Hibbard RA, Desch LW; American Academy of Pediatrics,

Committee on Child Abuse and Neglect, Council on Children With Disabilities. Maltreatment of children with disabilities. Pediatrics. 2007; 119(5):1018–1025.

For Referral to a Comprehensive Network of Service Providers for Moms with Children with Special Needs, Call 1-877-914-6662 or Visit: http://www.mom2mom.us.com

11) Mandell DS, Walrath CM, Manteuffel B, Sgro G, Pinto-Martin JA. The prevalence and correlates of abuse among children with autism served in comprehensive community-based mental health settings. Child Abuse Negl.2005;29 :1359– 1372

12) Duan G, Chen J, Zhang W et al. Physical maltreatment of

children with Autism in Henan China: a cross sectional study. Child Abuse Negl. 2015; 48:140-147.

13) Manders JE, Stoneman Z. Children with disabilities in the child

protection system: An analog study of investigation and case management. Child Abuse Negl. 2009; 33:229-237.

14) Committee on Child Abuse and Neglect and Committee on Children With Disabilities

Pediatrics. Assessment of Maltreatment of Children with Disabilities. Aug 2001, 108 (2) 508-512

15) Murphy NA, Elias ER for the Council on Children with

Disabilities. Sexuality of children and adolescents with developmental disabilities. Pediatrics. 2006; 118:398-403.

16) Finkel MA.

Discussing personal space and privacy with adolescents. New Jersey Pediatrics. 2015. Spring Special edition; 14-15.

17) Cindy W. Christian and Committee on Child Abuse and Neglect. The Evaluation of Suspected Child Physical Abuse. Pediatrics 2015; 135; e1337.

18) Goldberg AP, Trobin J, Daigneau J, et al. Bruising frequency and

patterns in children with physical disabilities. Pediatrics. 2009; 124:604-609.


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Childhood Physical abuse: A predictor of adolescent behavior Paulette Diah, MD, FAAP Hackensack University Medical Center

In 2013, there were 3.9 million referrals to Child Protective Services (CPS) alleging maltreatment nationally. Of those, one fifth were found to have been victimized and 17.5% of those cases were substantiated for one form of abuse and or neglect. The remaining cases were determined to be nonvictims of maltreatment, according to the US Department of Health. The majority of the victims (23.1%), were under one year of age. And while the rate of abuse is known to be inversely proportional to increasing age, adolescents specifically those between 13 and 18 years of age - accounted for a significant 28.9% of the total victims. Growth spurts, puberty, raging hormones and an unceasing quest for exploration and independence are only a few of the dynamics that make caring for adolescents so challenging. But, when abuse becomes part of the history, that task becomes even more complex, especially considering that the impact of the maltreatment may not rise to an identifiable level until many years down the road. The relationship between childhood physical abuse and adolescent/adult psychiatric disorders has been long-known. In a 1966 study, conducted by Lee N. Robins Deviant children grown up: a sociological and psychiatric study of sociopathic personality (Department of Psychiatry,Washington University School of Medicine, St. Louis, MO.), it was reported that alcoholics who had a psychiatrically-ill parent, frequently reported disruptive childhood family environments and exposure to unfavorable childrearing practices. This article discusses a few of the many negative effects of childhood physical abuse on adolescent behavior. Mood Disorders Kaplan et al, 1998, administered diagnostic interviews and measures of selected risk factors for psychopathology to adolescents and their parents. They determined that, “physical abuse added significantly to other risk factors in accounting for lifetime diagnoses of major depression, dysthymia, conduct disorder, drug abuse, and cigarette smoking. Physical abuse also contributed significantly to prediction of current adolescent unipolar depressive disorders, disruptive disorders, and cigarette smoking.” The authors concluded that physically abused adolescents are at greater risk for the development of psychiatric disorders.

Holmes et al, through administration of the Home Environment Interview self-report, found that individual report of harsh, unfair and inconsistent childhood discipline was strongly related to the diagnosis of major depressive disorder and alcohol disorder. Sugaya et al, Child Physical Abuse and Adult Mental Health: A National Study, found that child physical abuse was associated with significantly increased odds ratio for a broad range of psychiatric disorders, specifically, attention deficit hyperactivity disorder, posttraumatic stress disorder and bipolar disorder. They observed that there was a dose relationship between frequency of abuse and outcome. Brown et al, showed that dysthymia and major depressive disorder were elevated in individuals who had reported a history of abuse and neglect. Substance Abuse Hussey et al, conducted a self-report childhood maltreatment study of 15,197 young adults and found that maltreatment, defined as, physical assault, supervision neglect, physical neglect and contact sexual abuse, were associated with cigarette, alcohol and other drug use during adolescence. There was an increased likelihood of 30-day smoking use, increased likelihood of regular alcohol use and binge drinking during adolescence. There was also a strong association between maltreatment and marijuana use. Likewise, Harrison et al surveyed Minnesota Public School sixth, ninth and twelfth graders through an anonymous selfreport and found that physical and sexual abuse were associated with an increased likelihood of alcohol, marijuana, inhalants and use of other people’s prescription drugs. Simantov et al, asked the question, “Why do adolescents smoke or drink?” among 265 schools from the National Center for Educational Statistics from which 32 urban schools were selected. A total of 6748 fifth through eighth graders randomly selected during English class completed anonymous questionnaires. The researchers determined that there was an increased risk in regular smoking and regular drinking in students with a history of abuse, family violence, depressive symptoms and stressful life events. The authors concluded that routine screening for abuse, violence and other family experiences should be an essential component of adolescent health care visits. Fendrich et al, obtained historical accounts of childhood experiences of physical or sexual abuse from users of inhalants and nonusers. Although a lack of causal inference, the researchers found that there was a significant association between heavy inhalant use and a history of child abuse.


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Suicidal Behavior There is an association between adolescent physical abuse and adolescent suicidal behavior. Traumatic and chronic stressful events can increase an individual’s vulnerability to developing suicidal risk factors. Depression, substance abuse and conduct disorder (due to decreased social support) can negatively affect adolescents’ social, emotional and cognitive development, Kaplan et al, 1997.

Homelessness and Runaway Behavior Adolescent runaway behavior and homelessness have been associated with early physical and sexual abuse. For example, Tyler, et al, sampled 372 homeless and runaway adolescents in metropolitan Seattle; 55% were males and 45% females. A systematic sampling strategy was utilized by trained youth outreach workers. The adolescents were interviewed over a 2 year period. 47% of the sample reported being physically abused as a child. 67% The response to acute stressors through self-destructive and of those reported that the abuse was extremely violent. The risk-taking behavior increases an individual’s likelihood to sui- duration of the physical abuse ranged from 1 to 16 years, with cidal behavior. Kaplan S. et al, Adolescent Physical Abuse and 28% reporting that the abuse lasted 2 years or less. 88% of Suicide Attempts, assessed adolescent vulnerability as defined the physically abused adolescents disclosed the abuse to either in terms of school failure, perception of adequate peer, fam- an adult or a similarly aged peer. 52% of the adults to whom ily social and emotional support, feelings of hostility, hope- they disclosed were not or only somewhat understanding or lessness and lowered self-esteem. The study consecutively concerned. Tyler et al, concluded that early intervention recruited 99 physically abused adolescents from the ages of programs were needed to break the cycle of exploitation and 12 to 18 years from Nassau and Suffolk Counties, New York, abuse that adolescents experience within their families. from the New York State Central Register for Child Abuse. Ninety-nine, non-abused control group adolescents were re- So what can a general pediatrician do? The American Academy cruited from the same community. Both groups had a similar of Pediatrics, Clinical Report, The Evaluation of Suspected proportion of suicidal attempts. There were 8 abused group Child Physical Abuse 2015, provides general pediatrician with adolescents who had attempted suicide. In comparison to guidelines when rendering pediatric care in cases of suspected the 91 nonsuicidal attempts abused group adolescents, the 8 abuse. A few of their suggestions which should be considered suicidal attempts abused group adolescents had increased risk are quoted below: factors. Their perception of a lack of family cohesiveness, lack of maternal support, adolescent hostility ideations scores, ad- 1. Child abuse prevention is important but difficult and reolescent diagnosis of disruptive behaviors and conduct disor- quires efforts that are broad and sustained. der, adolescent substance abuse or dependence and exposure 2. Routine inquiry about physical, sexual, and other safety to suicidal attempt by a family member or friend were of sig- during adolescent health care visits may improve disclosure nificance. Brown et al, conducted a retrospective study of 639 of abuse. young people. They found that adolescents and young adults with a history of maltreatment were 3 times more likely to 3. Privacy should be provided through interviewing adolesbecome depressed or suicidal. Dysthymia and major depres- cents alone when they present with concerning injuries. sive disorder were elevated in those with a history of abuse or neglect. Factors such as, the family environment, parent 4. The pediatrician, as a trusted advisor to parents, caregivers, and child characteristics accounted for an increased risk for and families about health, development, and discipline, can play an important role in abuse prevention by assessing caredepression and suicidality. givers’ strengths and deficits, providing education to enhance Eating Disorders Johnson et al, investigated potential risk fac- parenting skills, connecting families with supportive commutors that may contribute to the development of eating disor- nity resources that address parent and family needs, and proders. Individuals in the study who were confirmed as being moting evidence-based parenting practices that are nurturing abused or neglected were identified from the Child Protective and positive. Services (CPS) Central Registry. Numerous measurement tools and interviews were administered. The study concluded that childhood adversities may contribute to greater risk for the development of eating disorders. Individuals who experienced physical neglect or sexual abuse during childhood were at elevated risk of developing eating disorders during adolescence or early adulthood.

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Cyberbullying: What is it and what can we do about it? Susan R. Brill, MD Chief of Adolescent Medicine, MD, FAAP The Children’s Hospital at Saint Peter’s University Hospital Samit Patel, MD, Pediatric Resident The Children’s Hospital at Saint Peter’s University Hospital Clinical Associate Professor Rutgers Robert Wood Johnson Medical School

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ullying can occur in many forms and at various stages of life from young childhood to adulthood. About 25% of youth experience bullying at some point in their lives, peaking in middle and high school. In recent years, due to the advancement of technology and the internet, cyberbullying has become a common way that bullying takes place among adolescents. Cyberbullying, also known as “online harassment”, is bullying that takes place using electronic technology. This is defined as any unwanted aggressive behaviors online by another person that can be repeated causing intentional harm. This changes the realm of traditional bullying in that it can happen at anytime and anywhere. In addition, cyberbullying is different from traditional bullying as there is aggressor anonymity. This may result in the victim being in a constant state of anxiety because of the fear of continued repetition of the action. Some examples of cyberbullying include rude text or video messages via cell phones, instant messaging (AIM, Skype, chat groups) or nasty rumors sent by email or posted on social networking websites.(Common social networking sites that teens use currently include Snapchat and Instagram as well as the more traditional Facebook and Twitter). In addition, embarrassing pictures and/or videos can be posted on websites or blogs. (Selkie et al. 2014) The prevalence of cyberbullying can range from 7% to 72%, depending on the definition of cyberbullying used. A recent literature review (Hutson E. et al. 2015) recommended that cyberbullying involve all of the following five items: 1. electronic form of communication 2. an aggressive act 3. intention 4. repetition (publicity), and 5. harm to the victim. (usually emotional harm) “Cyberbullies” may have lower empathy, lower self-esteem, and behavioral problems. The positive outcome from the activity may help them feel better about themselves, fit into a crowd or they may be mimicking other individuals to attain social status in their peer group. Several risk factors that increase the likelihood of being a

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“cyber victim” include anxiety, depression, and loneliness. Increased use of the internet is no longer a significant risk factor. The most serious consequence of cyberbullying is suicide. “Cyber Victims” are more likely to carry a weapon to school. They also have higher risks of suicidal ideation and suicidal attempts (Selkie E. et al. 2014). According to the CDC, suicide is the third leading cause of death in adolescents. (CDC 2015) One study published in the American Journal of Public Health reviewed data from questionnaires from over 28,000 adolescents spanning 58 high schools in 2012. About 25% of respondents reported being bullied in any form (relational, physical, verbal, or cyber). About 50% of these victims reported being bullied by all forms (Waasdorp TE et al 2015). Although traditional bullying is decreased in the high school years, this study shows a high overlap between cyberbullying and traditional bullying. Additionally, girls are victimized more than boys (this may be due to girls having increased likelihood of reporting the incident as well as being easier targets). There are many confounding factors such as race and socioeconomic status. More research is warranted to study the risk factors and results of cyberbullying both for perpetrators and victims. Cyberbullying can have many effects on the victims. Some of these include difficulty concentrating, emotional disturbances, behavioral problems, difficulty sleeping, and functional abdominal pain or headaches. In addition, bullying can cause poor social interactions and may lead to high risk behaviors in victims. In 2006, a 13 year old female received an innocent friend request from an “attractive” 16 year old male on MySpace. She had a known history of low self-esteem and weight issues. Finding a boy who accepted her looks really lifted her spirits. They communicated on a daily basis via MySpace. A few months passed and her “online friend” decided he didn’t want to be friends anymore; he stated, “the world would be a better place without you”. She began to receive cruel messages from her classmates on MySpace resulting in increased depression. One evening, twenty

minutes after using the computer, she went to her room and her mother found that she had hung herself. After further investigations it was

discovered that her friend created this MySpace account. Soon after, a cyberbullying prevention act was passed under her name. continued on next page www.aapnj.org

This case is just one extreme example of how cyberbullying can result in psychosocial problems. (NoBullying 2015) All forms of bullying, whether physical or emotional, should be reported to an authority figure at the school or organization where it is occurring. Schools have started to implement anti-bullying programs and many have “zero tolerance” for the behavior. However there is not enough data to prove efficacy of these programs since this is a relatively new behavior. Schools are punishing bullies via suspensions or detentions. Although cyberbullying can happen outside of school, it is important to build a strong foundation of expectation when students are in class. In addition, the home environment is just as vital in building a healthy relationship. Supportive parenting and open communication are two important examples of how parents can build a healthy relationship with their teen at home. Pediatricians are encouraged to counsel parents to become more active in providing a safe and healthy home environment. They can screen for bullying by asking patients about its occurrence in addition to their mood, behavior, sleep, and school grades. Since children spend most of their day in school, the school nurses and teachers should also be trained to screen for bullying behavior in children. Parents and children should be given more educational information about cyber bullying via websites such as www.stopbullying. gov, managed by US Dept. Health and Human Services.

5. CDC website: Suicide Among Youth, www.cdc.gov/ healthcommunication/ToolsTemplates/EntertainmentEd/ Tips/SuicideYouth.html, accessed March 9th, 2016 6. The Overlap Between Cyberbullying and Traditional Bullying. Tracy E. Waasdorp Ph.D.Catherine P. Bradshaw Ph.D. Journal of Adolescent Health, 2015-05-01, Volume 56, Issue 5, Pages 483-488. 7. “The Tragic Megan Meier Story|NoBullying|.” NoBullying Bullying CyberBullying Resources. Updated 10 Sept. 2015. Web. .

References: 1. Cyberbullying, school bullying, and psychological distress: a regional census of high school students. Schneider SK, O’Donnell L, Stueve A, Coulter RW, - Am J Public Health January 1, 2012; 102 (1); 171-7 2. Cyberbullying in Adolescence: A Concept Analysis. ANS Adv Nurs Sci. 2016 Jan-Mar;39(1):60-70. doi: 10.1097/ ANS.0000000000000104. Hutson E1. 3. Correlates of cyberbullying and how school nurses can respond.Van Ouytsel J, Walrave M, Vandebosch H, - NASN Sch Nurse - May 1, 2015; 30 (3); 162-70. 4. Cyberbullying and Online Harassment in Adolescents. Ellen Selkie, MD, MPH, Rajitha Kota, MPH. Adolesc Med 025 (2014) 564-573.


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A predictor of adolescent behavior continued

Bibliography American Academy of Pediatrics,The Evaluation of Suspected Child Physical Abuse Clinical Report. Christian C, Committee on Child Abuse and Neglect, Pediatrics 2015;135(5)e1338-1354 Brown J., Cohen P., Johnson J. G. and Smailes E. M. Childhood Abuse and Neglect: Specificity of Effects on Adolescent and Young Adult Depression and Suicidality. J Am Acad Child Adolesc Psychiatry 1999;38(12):1490-1496 Fendrich M., Mackesay-Amiti M. E., Wislar J. S. and Goldstein P. J. Childhood Abuse and the Use of Inhalant: Differences by Degree of Use, American Journal of Public Health 87;5:765-769 Harrison P. A., Fulkerson J. A. and Beebe T. Multiple Substance Use Among Adolescent Physical and Sexual Abuse Victims, Child Abuse & Neglect 1997;21:529-539 Holmes S. J. and Robins L. N. The Role of Paternal Disciplinary Practices in the Development of Depression and Alcoholism, Psychiatry 1988;51:24-35 Hussey J. M., Chang J. J. and Kotch J. B. Child Maltreatment in the United States: Prevalence, Risk Factors, and Adolescent Health Consequences, Pediatrics 2006;118:933-942 Johnson J. G., Cohen P, Kasen S. and Brook J., Childhood Adversities Associated With Risk for Eating Disorders or Weight Problems During Adolescence or Early Adulthood, Am J Psychiatry, 2002;159(2):394-400 28


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Kaplan S. J, Pelcovitz D., Salzinger S., Mandel F. and Weiner M. Adolescent Physical Abuse and Suicide Attempts J. Am. Acad Child Adolesc Psychiatry 1997;36(6):799-808 Kaplan S. J., Pelcovitz D., Salzinger S., Weiner M., Mandel F. S., Lesser M. L. and Labruna V. E. Adolescent Physical Abuse: Risk for Adolescent Psychiatric Disorders, Am J Psychiatry 1998; 155:954– 959 Tyler K. A. and Cauce A M. Perpetrators of early physical and sexual abuse among homeless and runaway adolescent Child Abuse & Neglect 2002;26:1261-1274 Robins L. N. Deviant Child Grown Up: A sociological and psychiatric study of sociopathic personality, Williams and Wilkins 1966. Simantov E, Schoen C and Klein J, Health-Compromising Behaviors: Why Do Adolescents Smoke or Drink? Identifying Underlying Risk and Protective Factors. Arch Pediatr Adolesc Med 2000;154:1025-1032 Sugaya L., Hasin D. S., Olfson M. and Lin K. Child Physical Abuse and Adult Mental Health: A National Study, Journal Trauma Stress 2012;25:384-392 US Department of Health and Human Services Administration for Children and Families and Children, Youth and Family Children’s Bureau 2015 statistical data on child abuse and neglect.

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The Delta Dental PANDA Program What the PANDA program is: PANDA is an acronym for Prevent Abuse and Neglect through Dental Awareness, an educational program sponsored by Delta Dental of New Jersey through its philanthropic arm, the Delta Dental of New Jersey Foundation, Inc. PANDA trains dental office personnel, as well as teachers, school nurses, and any other groups of people who work with children on how to recognize and report suspected cases of child abuse and neglect. This program is presented free of charge for groups with 10 people or more. The PANDA name was conceived by Delta Dental of Missouri, which began a similar program in 1992. PANDA programs are available in many states. Why the PANDA program is needed: Reported cases of child abuse and neglect are rising at an alarming rate all over the country. Dentists, along with other health care professionals, are mandated by state law to report suspected cases of abuse and neglect. Nationally, about 65 percent of child abuse injuries involve the head, neck, or mouth areas. So dental personnel may be in a good position to note abuse of their patients. In the past, more than 50,000 reports of child abuse and neglect were made each year in New Jersey alone. However, of that number, only a small percentage came from dentists. The extremely low reporting rate by dentists seems to be related to the lack of training dentists receive in how to recognize and report abuse and neglect and concerns about the ramifications of becoming legally involved in such cases. Studies have indicated that dentists are nearly five times as likely to report suspected abuse if they receive education in this area. The PANDA program addresses these issues so that dental personnel will have the information they need in suspected cases of child abuse and neglect. How to get more information on PANDA and schedule a presentation:

For more information or to schedule a presentation in New Jersey, please contact Kimberly Elmore via e-mail or call If you are located outside of New Jersey and Connecticut, please contact yourAMERICAN specific state’s AMERICAN ACADEMY OF PE ADEMY OF PEDIATRIC973-944-4555. DENTISTRY ACADEMY OF PEDIATRIC DENTISTRY Delta Dental company. You can locate your state’s Delta Dental website by visiting www.deltadental.com. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

of Dental Neglect Definition ofDefinition Dental Neglect Originating CommitteeOriginating Committee Child Abuse Committee

Child Abuse Committee

Review Council

Review Council

Council on Clinical Affairs

Council on Clinical Affairs

Adopted

Adopted

1983

1983

Revised

Revised

1987, 1992

1987, 1992

Reaffirmed

Reaffirmed

1996, 2001, 2006, 2010

1996, 2001, 2006, 2010

Dental and caries, periodontal diseases, andDental other oral conditions, Dental neglectoris guardian willful failure parent or guardian to Dental caries, periodontal diseases, other oral conditions, neglect is willful failure of parent to of parent o left infection, untreated,and can loss leadoftofuncpain, infection, lossthrough of func-withseek and follow through with treatment necessar nt necessary to ensure ifa left untreated, can lead to ifpain, seek and and follow treatment necessary to ensure a tion. can These undesirable adversely level of oralfunction heath essential for adequate function e function and freedom tion. These undesirable outcomes adversely affectoutcomes learning, canlevel of oralaffect heathlearning, essential for adequate and freedom communication, nutrition, activities neglect is willful failure of parent ornutrition, guardian and to communication, other activities necessaryand forother from pain andnecessary infection.for from pain and infection. growth and development. follow through with treatment necessary to ensure normal a normal growth and development. al heath essential for adequate function and freedom and infection. to learn more about how your practice can provide comprehensive preventative oral health services within the context of a pediatric medical home, contact: Juliana David at [email protected] New Jersey Pediatrics Spring 2016

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FAMILY SUCCESS CENTERS

New Jersey’s Family Success Centers What are Family Success Centers? • Family Success Centers (FSC) are neighborhood gathering places where local residents can find support, information, and services. • Local residents serve as mentors, helping families identify their strengths and develop skills to solve problems. • Local residents have a voice in governing each FSC, influencing the programs and services local FSCs offer. • FSCs honor and celebrate a local community’s cultural identity and diversity.

The purpose of Family Success Centers is to: • Enrich the lives of children by strengthening families and neighborhoods • Develop networks and provide integrated, locally-based services • Reduce isolation and promote connections • Provide services in a friendly, safe, and non-stigmatizing location

What Core Services do Family Success Centers provide? • Access to child, maternal, and family health services • Parent education • Family-friendly activities • Employment-related programming • Life Skills training (budgeting, nutrition, etc.) • Housing-related services

New Jersey DepartmeNt of ChilDreN aND families

• Advocacy and related support • General information and referrals/linkages


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FAMILY SUCCESS CENTERS - Atlantic/Bergen

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FAMILY SUCCESS CENTERS - Bergen/Camden

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FAMILY SUCCESS CENTERS - Essex

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FAMILY SUCCESS CENTERS - Gloucester/Hunterdon

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FAMILY SUCCESS CENTERS - Morris/Passaic

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FAMILY SUCCESS CENTERS - Union/Warren

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the crAfft screening tool The CRAFFT is a behavioral health screening tool for use with children under the age of 21 and is recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for use with adolescents. It consists of a series of 6 questions developed to screen adolescents for high risk alcohol and other drug use disorders simultaneously. It is a short, effective screening tool meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted. Screening using the CRAFFT begins by asking the adolescent to honestly answer three questions, letting them know in advance that their answers will be kept confidential. These questions can be found on PART A of the CRAFFT SCREENING INTERVIEW sheet on the following page. If the adolescent answers “No” to all three opening questions, the provider only needs to ask the adolescent the first question in PART B - the CAR question. If the adolescent answers “Yes” to any one or more of the three opening questions, the provider asks all six CRAFFT questions. CRAFFT is a mnemonic acronym of first letters of key words in the six screening questions. These questions should be asked exactly as written. C - Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? R - Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A - Do you ever use alcohol/drugs while you are by yourself, ALONE? F - Do you ever FORGET things you did while using alcohol or drugs? F - Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? T - Have you gotten into TROUBLE while you were using alcohol or drugs? The CRAFFT screen has been translated into several languages. These translations have been completed using rigorous best practices, with translation, back translation, and reconciliation of identified discrepancies. The 13 translations are available at http://www.ceasar-boston.org/CRAFFT/screenCRAFFT.php A self-administered version of the CRAFFT is available at www.ceasar-boston.org/CRAFFT/screenCRAFFT.php.

Additional information on the CRAFFT screening tool can be found and downloaded from www.ceasar-boston.org/ CRAFFT/index.php 300 Longwood Avenue, Boston, MA 02115 617-355-5433 617-730-0049 (fax) [email protected] ©2009 Children’s Hospital Boston continued on next page New Jersey Pediatrics Spring 2016

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Our Physician Champions & Current Programs

Jeffrey Bienstock, MD, FAAP PediatricCare Associates

Edwin Bernard-Lopez, MD, FAAP Galloway Pediatrics

Steven Kairys, MD, MPH, FAAP Jersey Shore University Medical Center

Noel Harbist, MD, MPH, FAAP

Paulette Diah, MD, FAAP Hackensack University Medical Center

Your Picture Here

Kathryn MCCans, MD, FAAP Puthenmadam Radhakrishnan MD, MPH, FAAP Bellevue Pediatrics Cooper Medical School of Rowan

Jeanne Craft, MD, FAAP The Pediatric Specialty Center at Saint Barnabas

Marita Lind, MD, FAAP

Julia DeBellis, MD, FAAP Hackensack University Medical Center

Lisa Drago, DO Cooper University Medial Center

Alan Weller, MD, MPH,FAAP Robert Wood Johnson Medical School

Wayne Yankus, MD, FAAP

For additional information on these programs, to arrange for a training or to learn how to become a Physician Champion, contact the CAN Team at (609) 842-0014 or send us an e-mail at [email protected] Suspected Child Abuse and Neglect (SCAN) is a 1.5 hour training that provides attendees with the critical information necessary for properly identifying and reporting cases of suspected child abuse and neglect in the pediatric office including; recognizing the signs of abuse and neglect, reporting child abuse according to NJ law, developing a protocol for handling suspected child abuse and neglect cases in the healthcare setting, aligning families with community-based, family strengthening resources and creating partnerships with CP&P and other state agencies. Suspected Child Abuse and Neglect for Emergency Departments (SCAN ED). This 1.5-hour program expands the basic SCAN training to focus on the specific advantages and challenges to identifying abuse and neglect in a high pressure, fast paced emergency department setting. Training team includes a physician champion experienced in recognizing abuse and neglect in the ED setting. Suspected Child Abuse and Neglect for First Responders (SCAN EMS). This 3-hour training explores the unique perspective and role Emergency Medical Services (EMS) can play in reducing and preventing child abuse and neglect. In addition to an experienced physician champion, SCAN for EMS includes an EMT experienced in identifying and reacting to instances of child abuse and neglect. Suspected Child Abuse and Neglect for Early Intervention Professionals (SCAN EI) The 2-hour training provides early intervention professionals with detailed information on the major risk factors and triggers; national and state statistics; reporting requirements and prevention strategies and education that supports families. The training team for this program includes a former early intervention system representative. Preventing Child Abuse and Neglect (PCAN). This webinar empowers health care providers to be better equipped to appropriately recognize, intervene and prevent child abuse and neglect. The 1-hour program increases healthcare providers’ understanding of the medical home as a systems change concept, details green, yellow and red light strategies for providing appropriate anticipatory guidance and prevention at well-child visits, informs and aligns practices with family-strengthening resources in the community, and fosters a closer partnership with CP&P. Strengthening Pediatric Partners (SPP). This 6-month long, American Board of Pediatrics-approved MOC Part 4 project examines the strategies, approaches and resources utilized in the practice at the 2-month and 24-month well visit to reduce the occurrence of abuse and neglect, focusing specifically on the four global triggers of PPD, Crying, Discipline and Toilet Training. Upon completion, pediatricians earn 25 Part 4 points. 44


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To view, download or order a wide array of free patient-education materials in English and Spanish visit: www.nj.gov/dcf


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Human Trafficking

What to Look for During a Medical Exam/Consultation The following is a list of potential red flags and indicators that can be useful in recognizing a potential victim of human trafficking. It is important to note that this is not an exhaustive list. Each indicator taken individually may not imply a trafficking situation and not all victims of human trafficking will exhibit these signs. However, recognition of several indicators may point toward the need for further investigation.

General Indicators that Can Apply to All Victims of Human Trafficking n Individual does not have any type of legal documentation – i.e., license or state issued identification for US Citizens; passport, Green Card, or other identification for foreign nationals n Individual claims to be “just visiting” an area but is unable to articulate where he/she is staying or cannot remember addresses; the individual does not know the city or state of his/her current location n Individual has numerous inconsistencies in his/her story n Someone is claiming to speak for, or on behalf of a victim – i.e. an interpreter, often of the same ethnic group, male or female; victim is not allowed to speak for him/herself n Individual exhibits behaviors including “hyper-vigilance” or paranoia, fear, anxiety, depression, submission, tension and/or nervousness n Individual exhibits a loss of sense of time or space n Individual avoids eye contact n Individual uses false identification papers – may not be victim’s real name n Individual is not in control of his/her own money

NJ Office of the Attorney General Division of Criminal Justice NJ Human Trafficking Task Force

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Specific Health Indicators The following indicators may present in the context of a physical exam or similar health assessment or treatment n Malnourishment or generally poor health n Signs of physical abuse – in particular, unexplained injuries or signs of prolonged abuse n Bruises n Black eyes n Burns n Cuts n Broken bones n Broken teeth n Multiple scars (including from electric prods) n Evidence of a prolonged infection that could easily be treated through a routine physical/check up n Addiction to drugs and/or alcohol n Individual has no idea when his/her last medical exam was n Lack of healthcare insurance – i.e. paying with cash

Specific Indicators that Apply to Sex Trafficking Victims Victims of sex trafficking may exhibit a unique set of risk factors and warning signs, including the following: SOURCE: Girls Education and Mentoring Services (GEMS) n The age of a individual has been verified to be under 18 and the individual is involved in the sex industry n The age of the individual has been verified to be under 18 and the individual has a record of prior arrest(s) for prostitution 855.363.6548

Hotline: 855.END.NJ.HT www.NJHumanTrafficking.gov www.aapnj.org


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