5/31/06njm

**Adverse Childhood Experiences: Questions**

**Moderator: Andy Hsi, University 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?

**Case #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?

PS:

Resources available online

[[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents)

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 Linked to Traumatic Childhood Experiences

[[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CDCACEpress.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/CDCACEpress.doc)