5/31/06njm

Moderator: Andy Hsi, MD, Univ. of New Mexico

Case #1

You enter the exam room to see a 1 year old child for a follow up visit
after airway surgery. The child has become a regular patient in your
panel. He has had a complicated history of airway related problems
complicated by GERD. He had surgery to repair tracheomalacia. His airway
problem seemed better and his nutrition improved on anti-reflux
medications. When hospitalized, the inpatient team requested a social
work consult and considered a referral to Child Protective Services
because the mother didn't seem to understand the instructions given her
for the post-operative care of the airway and for the child's feedings
and medicines.

During the course of the physical exam, the mother states "I think he'd
do better if I could remember everything I need to do. I'm a pretty good
parent even though I have manic depression." This is the first time
you've heard about the mother's mental illness. You ask if she's okay,
and she says "I do a good job of parenting when I'm on my medications,
but since I delivered and my Medicaid ended, I haven't had medicines."

You ask the social worker to speak to the mother before she leaves. The
social worker finds you an hour later and asks if you've seen the older
children in the family. You know about them, but they've not come to
clinic. The social worker says the mother is very worried about the next
older child because she had seen her husband, the father of all three
children, get mad and hit the child across the head and once kicked the
child hard enough to lift the child off the floor. You haven't heard
about this before and ask what the mother will do. The social worker
says that mother probably won't do much because she's afraid of her
husband. He has acted violently towards her, threatening, yelling and
screaming. By her report, he hasn't hit her. She tried to leave him in
the fall, but as she pulled the family car out of the driveway to escape
to Ohio, he arrived home and insisted in going with the family. Their
move lasted 2 months before the family retuned.

Questions:

What are the resources available to address these health and social
issues?

What are the potential health problems that may arise in the family?

How can the health care system best intervene for the members of the
family?

PS:

Resources available online

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents>

Adverse Childhood Experiences Bibliography

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACEbiblio.doc>

## **Adult Health Problems Linked to Traumatic Childhood Experiences** 

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CDCACEpress.doc>

**Masis, Kathleen (Billings) \[Kathleen.Masis@IHS.GOV\]**

**Tue 5/2/2006 12:17 PM**

One aspect of the questions below:

The social worker is a mandatory reporter to Child Protective Services. 

How can/does the health care team interact/integrate services with CPS?

Kathy Masis MD (Captain, USPHS, ret)

**Ratmeyer, John (GIMC) \[John.Ratmeyer@IHS.GOV\]**

**Tue 5/2/2006 3:11 PM**

Question 1: Locally, depending upon jurisdiction, one could report to
either Statewide Central Intake (SCI) of the New Mexico Children, Youth,
and Families Department (NMCYFD), or to Navajo Nation Division of Social
Services (NNDSS).  If there are immediate safety issues, we could
contact the local Battered Families Services if mom is amenable to
placement in a shelter.  In either case, even without a specific
incident of child maltreament (CM), NMCYFD or NNDSS should respond to
such a report as a high priority call.  In years past, CYFD might not
have assigned a worker without a specific incident of CM, but they have
been more diligent, of late, about recognizing the association between
intimate partner violence (IPV) and CM.  Although there is no mandate in
NM to report IPV, our understanding that *de facto* CM occurs in this
setting *should* make us report.  But, we also have a report of a
specific incident of physical abuse (PA) of a child, perpetrated by the
father, from the mother, who says the other children have witnessed this
violence.  That\'s a mandated report. 

 

In regard to mom\'s discontinuation of medication secondary to loss of
Medicaid, we could refer mom to our Benefits Coordinator right in our
Pediatric Clinic, to assure that both mom and baby are properly
enrolled.  Fortunately, in our setting (Indian Health Service), we would
likely be able to obtain mom\'s medications for her (at least until
mom\'s re-insured), whether or not she\'s insured.  If mom\'s not
already plugged in with mental health services, we could call upstairs
to our Behavioral Health Services (BHS) unit to have mom seen by
the walk-in BHS doc.

 

Question 2: Most of the health problems that would arise in this
situation are directly related to the mother\'s mental illness and IPV. 
Both situations put the children at risk for CM, including child neglect
related to failure-to-thrive (FTT) and/or parental inability to attend
to the other basic emotional needs of the children, as well as PA.  The
children are at high risk of inflicted injury, and the infant is
certainly at risk for death secondary to PA.  Certainly, the
older children are at risk for mental health problems given their
situation.

 

Question 3:  As above (see question 1), mandated report to social work
agency (with cross-reporting to law enforcement), referral to Battered
Families and BHS, referral to Benefits Coordinator.  Schedule all
children for medical visits to evaluate physical and mental health,
hopefully with the same medical provider to consolidate care and provide
continuity.  Attention to specific signs of acute, chronic, or remote
injury or neglect.  Attention to behavior and school problems in the
older children.  

 

John Ratmeyer, M.D., FAAP\
Gallup Indian Medical Center

**Bron Anders \[banders@UCSD.EDU\]**

**Tue 5/2/2006 9:06 PM**

This discussion is very timely, since I am meeting with Dr, Vince
Filetti next week to discuss  interface with pediatricians on this
important research. As pediatricians, I think we are quite used to these
scenarios. We pretty much always look for depression in new moms
(sometimes better than others) and have pretty set protocols for
referring to social services, CPS and Indian Child Welfare. I believe we
also do a pretty good job of screening adolescents for sexuality
(consensual or otherwise) drugs, family issues etc.

So I'm not entirely sure how the data from the ACE folks can allow us to
do better. One new aspect, I believe, is the importance of separation
from a parent, as an ACE with important long term effects. And we are
talking about trying to beef up peri-natal support with family networks
and home health visitors. I haven't answered the questions yet. I was
just sort off flabbergasted and excited to be in on the discussion.

Bron Anders, pediatrician consultant to San Diego Kumeyaay families.

**Andrew Hsi \[AHsi@salud.unm.edu\]**

**Mon 5/8/2006 1:00 PM**

Thanks to everyone who\'s responded to the first case.

What are the resources available to address these health and social
issues?

As Dr. Masis and Dr. Ratmeyer noted, there is a possible report to the
child protection agency in the appropriate jurisdiction. We\'ve found in
our community that the response is variable. Sometimes the worker will
conduct an investigation and substantiate the allegation. In this case,
the case manager or social worker could make a report and the child
protection agency investigator would probably visit the home. With the
mother\'s verification of the alleged abuse, the child protection agency
might take several approaches. If the mother didn\'t verify the
allegation of physical abuse or allegations of domestic violence,
nothing would happen.

If the social worker making the investigation discovered abuse, the
options would be to offer the family a voluntary program, family
services, that involves home visiting with the children remaining in the
physical and legal custody of the parents. A second option would be to
take the kids into custody, place them in foster care, obtain a judge\'s
ruling, and mandate treatment of various types for the parents. This
would result in possible concurrent planning that could either return
the children to the parents or move towards termination of parental
rights. If there were current injuries or signs of abuse, the agency
could move forward with a criminal proceeding against the parent alleged
to have perpetuated the abuse.

Most likely in this case, the report would result in offering family
services as the mother likely would not verify allegations of past
abuse. One potential problem of reporting past abuse is the subsequent
loss of relationship with the family.

It\'s great to know that the IHS has addressed the difficult problems of
mental health care access. That\'s become increasingly difficult in many
medical centers. At UNM, we have a psychiatric ER that might see the
mother, with or without insurance, but she would probably pay out of
pocket for her medications. Unfortunately, the more important follow up
part isn\'t easily accessible. I wonder what the wait time for
appointments is in the communities around all of those reading this.

What are the potential health problems that may arise in the family?

Again, the respondents see the mother\'s bipolar depression as a major
problem for the whole family. In our case, the case manager confronted
the father about the alleged violence in the home. He was able to have a
conversation about his behavior. He came from an abusive home where he
suffered severe physical abuse and witnessed family violence. He alluded
to excessive use of alcohol in his family. At a young age, he left home
and came to the US illegally.

The father recognized the impact his anger and loss of control could
have on his children. He seemed willing to work with the case manager on
parenting skills to respond more appropriately to the behaviors of the
middle child in particular. He had less ability to understand the impact
of his temper and anger towards his wife on their children.

The children have some genetic risk of developing bipolar disorder. It
is difficult in primary care to recognize and diagnose this condition
especially when it appears before school age. I\'m seeing an increasing
number of children under 5 with behaviors that don\'t fit with
well-established behavioral and emotional conditions. All of the kids
need monitoring for behavioral issues.

How can the health care system best intervene for the members of the
family?

Thanks again for the perceptive response that includes ongoing primary
care for the children. We\'d also want to encourage the mother to
establish primary care, probably through the UNM Cares Program for
low-income families. Collaboration with family medicine faculty will
mean that the mother\'s mental wellness can be monitored and other
health issues such as contraception and preventive care will occur.

The case managers will help the middle child enroll in pre-school or
Head Start. That might take him into a supportive half or whole day
setting with special education resources to help his speech and
communication issues.

Andy Hsi

**Ratmeyer, John (GIMC) \[John.Ratmeyer@IHS.GOV\]**

**Mon 5/8/2006 4:41 PM**

Thanks for the summary.  Unfortunately, IHS (neither \'here\' nor
\'there\') has not really effectively addressed the problem of mental
health care access.  As to our individual situation, we\'re about to
lose our child psychiatrist of 4 years, with no prospects for a
replacement.  She is an IHS scholarship recipient who is completing her
obligation and \'moving on\'.  We have plenty of PhD psychology people
(5 at last count?) and an adult-oriented psychiatrist, but none of them
feel \'comfortable\' seeing children.  Who of us doesn\'t feel a bit
uncomfortable doing the things we occasionally need to do?!  We may end
up seeing all these kids on psychotropic meds with little more than
e-mail and/or phone consultation with our big-city colleagues.  And we
simply haven\'t the time or resources to properly manage these kids\'
problems and do the case management it takes to establish and maintain
relationships with the Juvenile Justice system, the schools, social
work, etc., so I\'m not looking forward to life without child
psychiatry!  Fort Defiance (AZ, IHS) has a newly-opened adolescent psych
unit, but it\'s only six beds, can accommodate only the most minimal of
acuity, and doesn\'t yet have a psychiatrist on staff.  As difficult as
it is to staff mental health services for children in the city, it\'s
much harder in rural America.  

 

John Ratmeyer, M.D., FAAP\
Gallup Indian Medical Center

**Bron Anders \[banders@UCSD.EDU\]**

**Tue 5/9/2006 9:04 AM**

It is indeed admirable that the whole family has been able to access
mental health services in your case. I have been impressed by the ACE
data on the negative effects of desertion  by parents on children. To
place them in a receiving home, in foster care or even with relatives
must be perceived as a form of desertion. Getting help for both parents
in this case is a crucial potential break in the cycle. We don't really
know how much we can reverse the effects of these adverse on children by
early and continual interventions but we have to suppose it can bolster
those resilience factors already present in children.

I hope we can discuss more examples and a little the potential role for
pediatricians in this whole dialogue.

Bron Anders

**Byron, Lori (Crow) \[Lori.Byron@IHS.GOV\]**

**Tue 5/9/2006 2:17 PM**

The social worker is a mandatory report but so is the doctor.  I cannot
count the number of times something has not gotten referred because the
nurse thought the doctor would, the doctor thought the policeman would,
etc, etc. 

It is required of ALL of us.

 

Lori Byron MD

Crow Service Unit

**Ratmeyer, John (GIMC) \[John.Ratmeyer@IHS.GOV\]**

**Tue 5/9/2006 4:17 PM**

Recently, on the Special Interest Group on Child Abuse (SIGCA) listserv,
there\'s been some discussion of the so-called \'dual track\' approach
to these kinds of social situations.  While the traditional approach
(one track) has often been to remove children from homes such as the one
in this case (i.e, if one can get social work to properly recognize the
risk of harm in the first place!), other programs (another track) have
brought greater, more intensive resources to bear on the family as a
unit, in an attempt to keep the family together, recognizing that
separation is not benign.  The trick is \'triage\' to decide which cases
are too risky for this approach, for \'one size does not fit all\' when
it comes to social work interventions.  As doctors for children, we can
talk about that all we want, but the ultimate decision is with the
social work agency with jurisdiction.  Our role is to provide
information about the harmful effects of both child maltreatment and
family separation, to help workers balance all concerns as they make the
tough decisions of disposition.

 

John Ratmeyer, M.D.

Gallup, NM

**Bitsinnie, Sylvia (KAY) \[Sylvia.Bitsinnie@IHS.GOV\]**

**Tue 5/9/2006 5:16 PM**

Dr. Ratmeyer I thought there should be clarifications when you mention
social workers, I think you mean tribal social services. Here in Navajo
we refer to Social Workers for those of us who work with Indian Health
Services and are licensed.

**Ratmeyer, John (GIMC) \[John.Ratmeyer@IHS.GOV\]**

**Wed 5/10/2006 6:31 AM**

Thanks for drawing attention to the distinction.  Yes, IHS SWer\'s are
licensed medical social workers (LMSW), for the most part.  As you
imply, such workers do not have jurisdiction in determining child
custody or other social work dispositions.  That is why I used the
phrase, \"the social work agency with jurisdiction\".  Here in Gallup
(and the surrounding areas), we have both state (NM Children, Youth, and
Families Department) and tribal (Navajo Nation Division of Social
Services) agencies with which to deal.  In other \'border\' towns, like
Winslow, Holbrook (both AZ), and Farmington (NM), I imagine health care
providers (as well as hospital- and clinic-based social workers) must
negotiate this difficult landscape of multiple jurisdictions as well. 
Again, as you imply, depending upon the state/tribe and the agency,
social workers have different licensure requirements and levels of
training.  Many tribal SWer\'s do not have social work degrees, nor are
they licensed by the states in which they practice.  Supervisory workers
in those entities often do have degrees and greater levels of
experience.  The irony is that tribal social services often remove their
most capable workers from the \'field\' to take supervisory positions. 

The other route I\'ve seen traveled is that workers who go on to get
degrees after years of working for tribes become LMSW\'s with IHS (which
pays far better); we have two such individuals on our staff at GIMC. 
Until tribes honor and value SWer\'s by encouraging and rewarding the
members of this professional class, many of the most qualified SWer\'s
will continue to seek employment with \'outside\' agencies. 

 

John Ratmeyer, M.D., FAAP

Gallup, NM 

**Bron Anders \[banders@UCSD.EDU\]**

**Wed 5/10/2006 8:05 AM**

In the San Diego area we have Indian Child Welfare (ICW) workers, and a
tribal unit of the county Child Protective workers. Sometimes it works
really well and sometimes not so. ICW folks are sometimes too close to
the families but they work on family preservation as an intermediate
step. This is in line with what Dr. Ratmeyer was describing.

Bron Anders  

**Masis, Kathleen (Billings) \[Kathleen.Masis@IHS.GOV\]**

**Wed 5/10/2006 9:24 AM**

In Billings Area, (Rocky Mountain Region BIA,) there was a
"demonstration" funded, years ago, that provided the "track" of services
that John refers to below.

It "worked" according to the RMR BIA.   Then the funding ended, and so
did the increased family support services.

Kathy Masis

**Andrew Hsi \[ahsi@SALUD.UNM.EDU\]**

**Sun 5/14/2006 3:04 PM**

Thanks again to everyone who responded to the string. This is a rather
long response.

Before discussing various child welfare or the more recent developments
in drug courts, I'd like to refer to the literature on Adverse Childhood
Events and its implications for the care of children.

From the work I've read, the accumulation of 7 specific adverse events
has implications for health risk behaviors among youth and young adults
that lead to chronic health problems in later adult life. Those events
are; psychological abuse by a parent, physical abuse by a parent, child
sexual abuse; living in a home with a parent with alcoholism or drug
abuse, living in a home with violence directed against the mother,
living in a home with a parent with mental illness, and living in a home
where a parent has been incarcerated. When a large population of adults
coming to a health assessment clinic at Kaiser Permanente in San Diego
responded to a survey of health risks, 52% recalled experiencing at
least 1 adverse event in childhood. The average age of those responding
was mid-50's and a majority had started college.

The disturbing part is that having 4 or more of those adverse events
places a person at 2 to 10 times greater risk of many risk behaviors and
later chronic illnesses. For example, experiencing 4 or more of the 7
events increases the risk of initiating regular smoking before age 14.
Similarly, 4 or more events placed an individual at almost 8 times
greater risk of a suicide attempt, 4.5 times greater risk of alcoholism,
4 times greater risk of parenteral drug abuse, and substantially greater
risks of having more than 50 sex partners. Later in adult life, greater
numbers of adverse events in childhood has an association with poorer
health. The association increases in strength as the numbers of adverse
experiences increased. The literature links are listed below:

Thanks to Neil Murphy, I'm able to direct you to the resources on the
web page
[[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents)

Or, here are the items separately with urls....

Adverse Childhood Experiences Bibliography
[[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACEbiblio.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACEbiblio.doc)

Adult Health Problems: Traumatic Childhood Experiences, CDC
[[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CDCACEpress.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CDCACEpress.doc)

These other references examine some additional areas relevant to the
first case:

Intergenerational transfer of psychosocial risk: mediators of
vulnerability and resilience

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14744219]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14744219)

Psychobiology of Depression and Resilience to Stress

[[http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.1.102803.143948]{.underline}](http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.1.102803.143948)

However, the research hasn't been directed at what pediatric providers
might do to prevent, reduce, or intervene for children who might
experience adverse events. Similarly, there isn't any research on what
intervention might mean for reduction of further adult adverse events
and impacts on later health. Our programs at UNM have begun to view
family systems as the target of our intensive service efforts as we
think that sustained behavioral change is more likely when the "family"
around the child experiences better health. We have begun to try to wrap
services around the extended family system.

So, I'll try to address some of the issues raised in the last messages.
I think the programs that Kathy Masis, Bron Anders, and John Ratmeyer
referenced have great potential. They sound something like the Family
Services model currently implemented by the New Mexico Children, Youth,
and Families Department. This service is offered when the family comes
under investigation and allegations of child neglect or parental drug
use or parental domestic violence become substantiated. At that time,
the family may agree to services voluntarily, and the department assigns
a case manager to visit the family frequently. Sometimes this comes with
a mandate for the parent to provide a urine sample for dr. This service
has replaced Family Preservation. It is an alternative to removal of
children from their homes. I think it works if the case manager has the
skills to accurately observe the family environment for risky behaviors
that could harm the safety of the children. I think the workers have
difficulty assessing the emotional and psychological development of
children in the context of the services given the relatively brief time
they have with families.

The UNM FOCUS Program has tried for the past 15 years to provide the
next level of service. We accept referrals of children under 3 years
from hospitals, child welfare, community early intervention programs,
and others of families affected by substance use, domestic violence,
parental mental illness, and unsupported teen parents. I'm sure most of
you reading this see all of these family environment issues occurring
simultaneously as we do. Frequently, our program services are the
alternative to further involvement by the New Mexico Children, Youth,
and Families Department. That is, mothers with positive drug screens at
delivery receive referrals to our program and the department steps out
of the picture. Those families, most often families with newborns, who
choose to engage with us (about 65-75%) receive services designed from
an early intervention perspective with intensive home supports coupled
with a medical home model developed for the entire family. Those who
don't disappear and may then re-enter the system through other incidents
of child neglect or abuse.

The family medical home model we've created attempts to address the
primary care needs of young children while preventing child neglect and
abuse. We also make appointments for the parents and other family
members. For the children in the families, we focus on prevention of
child neglect as for the most part it appears the risk of abuse follows
a pattern of chronic neglect of young children. Through the workers
providing the support services, we schedule the infants and young
children for more frequent medical appointments to monitor growth,
health and development. Our appointments spend more time on the
developmental and growth issues for children with higher emphases on
progression of speech, social emotional, and problem solving development
than the physical exam. We also have the capacity to schedule some
urgent care appointments so that we can maintain continuity of contact
with the families. I staff these clinics 2 half days a week.

For the parents, we try to create a primary medical home also directed
at addressing acute and chronic health needs. One of the biggest is
provision of family planning services. We think this is very important
because increasing the time interval between children gives the parents
more time to concentrate on the needs of the child and improves
attention to the child's needs. Also, helping the mother with family
planning may prevent a pregnancy affected by alcohol and drug use while
the mother seeks treatment or initiates healthier life choices that
reduce or halt use.

We also focus on the safety in the family environment because of the
potential for violence that occurs between partners both using alcohol
and drugs. Obviously, efforts to decrease violence don't always result
in a safer home if the other partner doesn't change use behaviors.
However, the home and center based supports will often detect whether
changes in the use behavior of both partners create environmental
changes that benefit the children in the home.

I received a message from Judy Thierry at HIS Headquarters regarding
presentations made at a joint Administration for Children and Families
and Substance Abuse Mental Health Services Administration conference in
May that presented mandated treatment linked to child welfare
interventions in California. These efforts seem to specifically target
people addicted to methamphetamine. Linked AOD treatment through the
drug court approach has addressed difficult addiction issues for pad
welfare approaches. While I know the drug court model has had increased
acceptance across the country, I think that using the power of the
courts to achieve compliance with initial treatment places the state in
an interesting position. How does the treatment approach deal with
parents with co-morbidities such as mental illness? Have the courts been
successful in mandating mental health treatment providers and AOD
counselors coordinate efforts? Why do federal agencies such as ACF and
SAMHSA view issues related to methamphetamine use as so differently from
the use of crack and cocaine that started those agencies' work in the
1990's? From our experiences, we haven't seen much coordination with the
drug court model. The judges involved don't seem very concerned about
the limited mental health access as long as the parents have clean
urines and report to the court's officers. They haven't made referrals
to child health experts to address the needs of children with prenatal
exposure or environmental exposure. Given the potential of other adverse
events in the lives of the children involved and the prevalence of
health issues, I find this more of a comment on the current status of
treatment models that have traditionally only focused on the client,
ignoring the family issues surrounding them, and separating the needs of
the client from the children.

As an additional aside, I have had some limited experiences starting
mothers on a short term course of SSRI's after diagnosing post-partum
depression. I think pediatricians are in an optimal situation to help
mothers with this problem. I've not been able to convince our mental
health managed care organization that screening mothers with drug use or
family violence issues after they give birth for depression has merit.

These other references examine some additional areas relevant to the
first case:

Intergenerational transfer of psychosocial risk: mediators of
vulnerability and resilience

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14744219]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14744219)

Psychobiology of Depression and Resilience to Stress

[[http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.1.102803.143948]{.underline}](http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.1.102803.143948)

I look forward to the thoughts of the group on the subjects of
preventing or intervening in adverse childhood events and experiences
with the judicial or law enforcement systems.

Andrew Hsi

**Placide, Frances (CIHA) \[Frances.Placide@IHS.GOV\]**

**Sun 5/14/2006 3:38 PM**

Thank you very much for the list of references and for your remarks.

**Gutierrez, Lonna (PIMC) \[Lonna.Gutierrez@IHS.GOV\]**

**Mon 5/15/2006 8:11 AM**

The same 7, childhood adverse events you name have also been identified
in relation to the development of uncontrolled chronic pain in
adulthood. In one impressive study (Gatchel, I believe), in patients
with none of these risk factors, who absolutely had to have spinal
surgery, due to hard neuro sx, 85% did well post-operatively, with no
long term problems/sx. In those who named two or more childhood risk
factors, that same good outcome rate fell to less than 15%. I will try
to find the study for anyone interested. As I recall, this study named
one other risk\-- childhood abandonment by a parent/s.

Lonna Gutierrez, FNP, Pain & Addiction Specialist, CAPT, USPHS Phoenix
Indian Medical Center

**Masis, Kathleen (Billings) \[Kathleen.Masis@IHS.GOV\]**

**Mon 5/15/2006 1:46 PM**

Thank you for this very useful info.

As for Drug Courts, it sounds like the implementation you have witnessed
isn\'t quite up to the model.

The National Council of Juvenile and Family Court Judges will be meeting
in Milwaukee in July, and their agenda includes dealing with
co-occurring mental health and addiction disorders. Judge Geraldine
Benally from Kayenta is on the faculty.
[[www.ncjfcj.org]{.underline}](../www.ncjfcj.org)

Useful reference for the model: American University, Applying Drug Court
Concepts into the Juvenile and Family Court Environments: A Primer for
Judges, rev. 2000.

Kathy Masis

**Kenneth Fleshman \[kfleshman@JUNO.COM\]**

**Sun 5/21/2006 2:31 PM**

As frustrating as it may be in attempting to deal with the behavioral
and psychosocial issues brought out in the resent discussions stimulated
by Andy Hsi, the fact that you all are able, at this time, to address
these issues is outstanding.

 

In 1982 we held the first Indian Health Service pediatric meeting in
Gallup. The theme of the program was to change our focus from just acute
crisis care to better management of chronic illness. A few of the
examples that we explored were low birth weight infants who were not
being followed, meningitis survivors who were not being tested for
hearing or developmental delays and children with cleft palate who were
lost to care following their initial surgery. The Alaska Area presented
their version of a chronic disease registry and Joe Jacobs demonstrated
a rudimentary database from Navajo on his own Apple computer.

 

You and your predecessors were able to start the change in focus that
has continued to the point where you are able, today, to have this
thoughtful, data driven discussion of these most pressing child health
needs.

 

The Indian Health Service has looked at these family risk factors. All
Indian infant deaths in the 9 Northern tier states occurring in the mid
1970's were reviewed in detail. The high number of SIDS was the impetus,
but all deaths, regardless of cause, were reviewed. Because of the
uniqueness of the I.H.S. health record system, the charts of the
mothers, fathers and in some instances the grandmothers were also
abstracted. The documentation of parental abuse, spousal abuse, sexual
abuse, alcoholism, suicidal behavior occurred far in excess in the
families of the infants who died in the first year (regardless of cause
of death). The write up of this study was never completed but all of the
data was passed on to Roger Gollub in Anchorage

 

While at ORD, Tucson, I attempted to use the extensive,
multigenerational RPMS health record database of the Tohono O'odham to
identify children at risk. A search was to be made, looking for the
encounters, in parents, that enumerated the 7 risk factors.
Unfortunately, the search tools were not sufficiently developed at the
time to come to any findings. It would seem that it might be timely to
again attempt to use automated record searches to identify children for
early targeted interventions.

 

My last comments are about intervention. Many of you contributed to this
dialog and described actions that are appropriate, and sometimes
required, in the clinical setting. I don't believe that it is possible
to provide the necessary interventions, teaching, restructuring of a
family in that setting. The most prominently documented intervention
(and perhaps the only one) to be successful is the Nurse Visitation
program developed by David Olds PhD, of the Kempe Center, University of
Colorado Health Sciences Center. Based on research begun nearly 30 years
ago, and using a learned, standardized protocol, the nurses work in the
home to bring about the changes necessary. The pediatric, nursing,
sociology and psychological literature contain documentation of the
history, content and success of this model. A most readable article, in
the lay literature, appeared in the February 6, 2006 issue of the New
Yorker Magazine.

 

Unfortunately, the emphasis on Maternal-Child Health long held and
practiced by the I.H.S. and Tribal Community Health Nurses, as been
vastly eroded by reductions in funding and competing demands. It is my
belief that only by rebuilding a strong MCH nursing program, in
collaboration with the child health care providers and social services,
can effective changes be made.

 

* Papers describing the Nurse Visitation program are attached as pdf
files.*

*(Available upon request* <nmurphy@scf.cc> *)*

*The following website is from the Mental Health and Nursing
perspective:*

<http://modelprograms.samhsa.gov/pdfs/FactSheets/NurseFP.pdf>

 

Kenneth Fleshman, Former Senior Clinician for Pediatrics, Indian Health
Service

**Andrew Hsi \[AHsi@SALUD.UNM.EDU\]**

**Mon 5/22/2006 9:11 AM**

Dear Colleagues:

 

In response to some of the great contributions sent, I wanted to pose
one more case and questions for your consideration.

 

I\'ll send some other thoughts to the list-serve a bit later.

 

Thanks,

 

Andrew Hsi

 

Scenario #2

You enter the exam room to see a 4 month old infant, Angelo, for well
child care. The child comes to clinic with his foster parents and his 4
year old brother also living in the foster home. This visit, unknown to
you, was planned as a supervised visit for the children\'s mother to see
them. The foster parents indicate that the family\'s treatment social
worker at the child protection agency thought the mother should
understand the medical issues for the baby. The 27 year old mother sits
with the baby on her lap.

When you ask about the previous health of the baby, the biological
mother gives the history of a normal birth at term. She had limited
prenatal care starting in Mexico and continuing in public clinics in the
US. She did not have documents to live in the US, but she delivered both
children in the US. The baby\'s father is currently serving a prison
term. He is the father of both children but didn\'t choose to sponsor
the mother for immigration purposes.

The foster mother asks to speak with you outside the exam room. From her
history, you learn that the mother has had a long history of mental
\"concerns.\" This history comes to the foster mother from the
biological mother\'s cousins who had initially agreed to foster her
children. The biological mother began having \"fright spells\" as a
child in Mexico. She claimed to see visions, particularly of fires at
school and home. In Mexico, she had such severe problems that the school
refused to allow her to attend. The family also gives a history that the
mother suffered some type of sexual abuse as a child.

Since adulthood the biological mother has had recurrent mental health
problems. Sometimes she loses track of her whereabouts finding herself
driving with her child miles away from home without memory of the drive.
The mother takes 4 different medications although her diagnosis isn\'t
clear. At least one psychiatrist diagnosed depression. The cousins
witnessed an \"out of body\" event when they went to an EEG test with
the biological mother. She became unresponsive during the test. The
episode lasted 15 minutes and during that time the biological mother
didn\'t respond to her name or touch although she seemed completely
conscious. The technician used smelling salts to arouse her. The EEG
reading hadn\'t been completed so the foster mother didn\'t know if this
represented a seizure. Based on past issues of mental illness and
possible neglect by the biological mother reported to child protection,
upon the birth of the baby both children had initial placement in the
relatives\' home. However, the relatives couldn\'t handle the behavior
of the 4 year old, so the child protection agency placed them in their
current setting.

During your exam of the baby, the mother states she thinks she could do
a better job of mothering Angelo, stating \"I think he\'d do better if I
could remember everything I need to do. I\'m a pretty good parent most
of the time.\" You ask a follow up question about how she\'s managing
her mental condition, and she says \"I do a good job of parenting when
I\'m on my medications, but since I delivered and my Medicaid ended, I
haven\'t had medicines.\"

You ask the social worker to speak to the mother before she leaves
regarding her insurance options. The social worker finds you an hour
later and says the mother knows her 4 year old is very worried about
her. When the mother lost attention during the conversation, the child
told the social worker that his mother needed her \"pastillas\" or
pills. In addition, he seemed to watch every move the mother made with
anxiety. The social worker indicated that the child protection agency
has implemented a \"concurrent plan\" meaning that the children might be
re-united with the biological mother.

You ask what the mother might do to regain custody of her children. The
social worker says that mother probably won\'t do much because she\'s
not able to get medications even through the homeless clinic that can
provide her some of the medications she needs on a limited basis.
Although the mother can work off an on, she hasn\'t held the types of
jobs with health benefits.

Questions:

What are the resources available to address the mental health and social
issues of the biological mother?

What should the agencies interacting with the children and mother do?

How should the health care system intervene for the members of the
family?

**Andrew Hsi \[AHsi@SALUD.UNM.EDU\]**

**Mon 5/22/2006 9:35 AM**

Thanks again to all who have read and responded to the discussion.

I wanted to thank those of you who are having a positive experience
working with drug courts. Thanks to Kathy for the web site reference.
I\'m ready to start a set of community discussions about how the child
health, mental health, and child development communities can work with
the judicial system. In conversing with Dr. Barry Lester, at Brown
University\'s center for child development, drug courts have had a lot
of success in Rhode Island.

The factors related to health consequences from adverse childhood events
seem to recur in many places. There seems to be a relationship to adult
chronic pain, infant death, and adolescent mental illness. As Ken
Fleshman notes, the data systems don\'t seem to allow easy connections.
In the setting where I work, the divisions among various disciplines add
to loss of continuity. I\'ve gravitated to the family practice model
because I see our opportunities to address addiction, mental health, and
chronic health needs with parents while see their children. I\'m
increasingly worried about the health and well being of the elderly
living in the homes of families we serve. While I\'m most interested in
preventing additional adverse events for children, both in the numbers
of a specific event as well as preventing additional events, I worry
about the elderly great grandparents.

An example of our approach to preventing more of a specific type of
adverse event is the concept of harm reduction. If a parent has a
drinking or drug use pattern related to binge use, we ask who will
provide safe care for the children. We talk about parents smoking
outside to reduce indoor emissions. In terms of preventing additional
events, my anticipatory guidance asks the parents who is allowed to
change their babies or children. I ask what the parents communicate to
their children about what to do if someone would try to undress or touch
the children. We talk about strangers and boundaries. These are very
small efforts, but I\'m very interested in what we can do in our medical
homes to address adverse events.

Thanks to Ken for the pdf files for David Olds\' papers. I agree with
Ken Fleshman that the medical visit is too short to really get at family
behavior changes. I greatly admire the work of David Olds. I\'d like his
thoughts about how his teams engage families affected by drug use or
family violence. These families change addresses often, kids stay with
different family members, and the parents suffer many adverse events. Do
any of your programs have experiences with engaging families with
complex behaviors?

Again, I\'ve appreciated the chance to converse with you.

Sincerely,

Andrew Hsi

**William Green \[greenfamil@YAHOO.COM\]**

**Mon 5/22/2006 10:06 AM**

The Gallup conference Ken mentions was very influential to several
pediatricians in Albuquerque IHS in the 80s to make a change in our
focus to coordination of chronic child health issues. Andy Hsi was one
of them at the time who wrote a position paper on the \"new\"
epidemiology of behavioral and mental health issues that helped start a
collaborative Area Child Health committee.

I agree with Ken that the Olds nurse home visiting program has
demonstrated effectiveness as a prevention strategy not only in SIDS
prevention but in a variety of psychosocial risk situations both in
AI/AN populations and others. Despite its documented effectiveness,
funding for and therefore implementation of this model remains very
limited in the US. I believe the New Yorker article he refers to was
about a few days in the life of a visiting nurse in Louisiana in the
Mississippi delta prior to Katrina.

I gave a copy to a nurse practitioner here in Albuquerque who does
outreach to motels on Central for Healthcare for the Homeless, including
many AI/AN urban families.

Overall this discussion has been quite inspiring and informative, a
sharing of some very thoughtful model programs and strategies.

Thanks to Andy Hsi and Neil Murphy for taking the time to coordinate it.

**Murphy, Neil**

**Mon 5/29/2006 6:02 PM**

AUTHORS INVESTIGATE CO-OCCURING MATERNAL CONDITIONS AND BEHAVIOR
PROBLEMS IN CHILDREN

\"Our study suggests that, by 3 years of age, there is already evidence
of the effect of adverse childhood experiences, occurring in this study
in the form of parental mental health problems, substance use, and
domestic violence,\" state the authors of an article published in the
May 2006 issue of the Archives of General Psychiatry. In an effort to
understand the cause of children\'s behavior problems and to prevent
such problems from occurring, researchers have focused on various
maternal conditions that may contribute to behavior problems and that
may be mitigated by clinical intervention. Co-occurring conditions in
the areas of mental health, substance use, and domestic violence can
significantly impair maternal functioning. The purpose of the study
described in the article was to examine how a cumulative measure of
these maternal conditions is related to children\'s social and emotional
functioning.

Mothers and fathers in 18 U.S. cities were surveyed at birth and 1 year
after delivery to assess various aspects of parental well-being. A total
of 2,886 mothers also completed a survey at 3 years after delivery to
assess their child\'s behavior. The pattern of maternal comorbidity was
assessed and, on the basis of that pattern, mothers were classified
according to whether they had conditions in one of three categories:
mental health, substance use, and domestic violence.

A score was then created based on the number of categories in which the
mother reported having a condition in the year after delivery. The
analysis examined the association between child behavior problems and
the maternal condition score (0-3). The final analysis assessed the
cumulative risk of maternal conditions for child behavior problems,
while controlling for sociodemographic factors, prenatal factors, and
paternal mental health and substance use.

The authors found that

\* The risk of behavior problems in 3-year-olds increased with the
number of categories \-- mental health, substance use, and domestic
violence \-- in which the mother reported a condition in the year after
delivery.

\* The graded increase in risk was independent of sociodemographic and
prenatal factors, as well as measures of paternal mental health and
substance use in the year after delivery.

The authors conclude that \"to play their most useful role, health care
providers might wish to consider the health and well-being of the
family, the social unit involved in the transfer of health between
generations, rather than limiting their focus to the individual patient
or to a particular developmental period.\"

Whitaker RC, Orzol SM, Kahn RS. 2006. Maternal mental health, substance
use, and domestic violence in the year after delivery and subsequent
behavior problems in children at age 3 years. Archives of General
Psychiatry 63(5):551-560.

[[http://archpsyc.ama-assn.org/cgi/content/abstract/63/5/551]{.underline}](http://archpsyc.ama-assn.org/cgi/content/abstract/63/5/551)