1. Introduction To Connected Kids

2. Key Goal Connected Kids: Safe Strong Secure is an AAP program designed to support clinicians’ efforts to prevent youth violence by promoting the development of resilient children.

3. Why Is This Important?  Violence is a major cause of childhood morbidity and mortality in the United States.  Homicide is the 2nd leading cause of death for 13- to 21-year-olds The leading cause of death for African Americans 13 to 21 years old 1  Increase in community violence during 1990s 21st century rates in the United States still among the highest in the world

4. Why Is This Important?  Many parents and pediatricians feel community violence screening should be routine in well child care. 2-5  Results from the 1998 and 2003 AAP Periodic Surveys of Fellows show that a majority of pediatricians feel unprepared to manage community violence. 2-4

5. Parents want more doctors to discuss community violence. 5 Results from the National Survey of Early Childhood Health Why Is This Important?

6. Connected Kids provides… Tools and strategies to help parents raise resilient children:  Educational materials for parents and youth  Effective anticipatory guidance  Developmentally appropriate guidelines  Easy-to-use Clinical Guide with links to research

7. Development Process Development of Connected Kids included 6 :  Input from parents, clinicians, and other experts  Testing of program materials in focus groups with diverse families and clinicians 7  Incorporation of stakeholder feedback  A broad and respectful approach for all of the educational materials  Coordination with other AAP efforts

8. Objectives Connected Kids will:  Strengthen the connections among children and youth, their families, and their community  Reduce risk factors by building resilience 8

9. Presentation Goals 1.Become familiar with the underlying theoretical model for Connected Kids 2.Review the counseling schedules for Infancy and Early Childhood, Middle Childhood, and Adolescence 3.Learn how to prepare a strategy for implementing this program in your practice

10. Connected Kids...  Uses an asset-based approach to prevention that: Emphasizes the identification and enhancement of strengths Enhances clinician-family alliance  Helps parents with strategies to: Promote positive development Develop prosocial interpersonal skills Obtain support and resources to help raise children

11. Asset- Versus Risk-based Approaches to Guidance Assets: Goal: Help improve child’s resilience Assess family strengths Link to community resources Risks: Goal: Reduce known risks Screen for risk factors Refer to services

12. Connected Kids Includes:  Clinical guide  Counseling schedule  Handouts for parents and families  Web site This training presentation Database of violence prevention materials Success stories

13. Clinical Guide This presentation supplements the clinical guide, available online at www.aap.org/ConnectedKids Clinical guide contains Background information Counseling schedule Visit-by-visit suggestions from birth to age 21

14. Building Blocks Community Connections Physical Safety Connected Kids centers on 4 overlapping themes of anticipatory guidance Child- Centered Parent- Centered

15. Recognizes: Child’s changing abilities Cognitive development of child Related parental concerns Child-Centered Parent- Centered Physical Safety Community Connections

16. Parent- Centered  Addresses the importance of parental supports  Incorporates the idea that parents develop along with the child  Contributes to the quality of family life  Promotes positive parenting Child- Centered Physical Safety Community Connections

17. Positive Parenting Teaching desired behavior begins with a positive and nurturing foundation 9 Ways to nurture your children and prevent misbehavior How to manage conflict and teach responsibility What to do when your child misbehaves

18. Community Connections  Research underscores the importance of 10 : Social capital: a measure of the interconnectedness among people with their community Community connections  Clinicians can help connect families to community resources Child- Centered Parent- Centered Physical Safety

19.  Counseling schedule focuses on violence and intentional injury Complements AAP’s TIPP ® (The Injury Prevention Program)  Handguns in the home placed in the context of child development Provides objective information to help families make their own decisions Physical Safety Child- Centered Parent- Centered Community Connections

20. Connected Kids Counseling Schedule  Lists topics to introduce and reinforce at each visit  Provides asset-based assessment and anticipatory guidance for each visit  Links to use of parent and patient brochures: Distributed when a topic is first introduced Promote discussion between provider and family Give useful information to foster the development of strong, resilient children

21. Counseling Schedule

22. Anatomy of a Brochure Front Cover Cover image visually conveys core message Designed by Artists for Humanity, a non- profit arts and entrepreneurship program for Boston teens.

23. Anatomy of a Brochure Content  Each brochure addresses one specific issue  Content based on all four building block themes  Reading level: 2nd to 6th grade  Contains concrete examples for key concepts

24. Anatomy of a Brochure Back Cover  Summarizes topics  Space provided for: Parent/patient guidance Follow-up suggestions Community resources Next appointment Practice name and address

25. Counseling Schedule Infancy & Early Childhood 2 days – 4 years Middle Childhood 5 – 10 years Adolescence 11 – 21 years

26. Counseling Schedule: Infancy Establishing Routines Discipline = Teaching Firearms Modeling Behavior 6 and 9 MONTHS Child Care Family Safe Environment Parenting Style Bonding and Attachment 2 and 4 MONTHS What Babies Do Parental Frustration Parent Mental Health Parent Support 2 DAYS to 4 WEEKS INTRODUCEVISIT

27. Infancy 11-17 Early caregiver relationships set the stage for future relationships Securely attached young children have an easier time developing positive, supportive relationships Emerging evidence shows that securely attached young children are found to have more 18-25 : Balanced self-concept Advanced memory processes Sophisticated grasp of emotion Positive understanding of friendship

28. Infancy Counseling Being a new parent can be exhausting. How are you doing? If there is a gun in the home, how is it stored? How much time do you have off from work? Is this what you expected? Who helps you with your baby? Be on the lookout for families who are socially isolated or experiencing family discord.

29. Infancy Brochures

30. Welcome to the World of Parenting! Visit: 2 Days to 4 Weeks  Helps parents understand the normal development of newborns  Provides information about coping skills for parents  Discusses changes in the ways parents may now relate as a couple

31. How to Use this Tool Whenever appropriate, include both parents in the conversation Discuss infant crying and ways to handle it: Crying is normal Crying upsets parents Sometimes, parents just need to let the baby cry Helpful Hint! Support new parents with positive statements: I love the way your baby looks at you, soothes to your voice. You’re doing a great job!

32. Parenting Your Infant Visit: 2 and 4 Months  Helps parents understand normal development of 4- to 9-month-old infants  Stresses importance of building family connections  Discusses 3 problems: Colic Trouble sleeping Clinging to parents

33. How to Use this Tool Reiterate messages about crying and parental frustration Emphasize to parents the importance of having time together without their baby Helpful Hint! Support new parents with positive statements: Your infant is alert, growing well, and has a beautiful smile!

34. How Do Infants Learn? Visit: 6 and 9 months  Offers practical suggestions to parents based on a newborn’s brain development Encourages activities like reading or singing to promote brain growth  Helps parents understand that exploration is a natural developmental need

35. How to Use this Tool Ask parents about their social connections. Refer to sections “Others Who Care for Your Baby” and “Taking Care of Yourself” Utilize the “Social Connections” worksheet from the Clinical Guide Talk about child care arrangements Helpful Hint! Notice infant’s new behaviors and parent-child interaction: Wow, your baby is really interested in my stethoscope! I like the way she lets me examine her, but she is always looking over at you for assurance.

36. Your Child is on the Move: Reduce the Risk of Gun Injury Visit: 6 and 9 months  Correlates childhood injuries/ deaths due to firearms and presence of handguns in the home  Emphasizes that a child’s curiosity about guns overwhelms any lessons learned about gun safety  Provides information needed to make informed decisions

37. How to Use this Tool Discuss handguns in the context of other household hazards Since some parents may not be in agreement concerning the presence of handguns in the home, encourage them to look at the brochure together to make an informed decision Helpful Hints! In areas of country with high rates of gun ownership, some practices offer reduced price or free gun locks Be aware of the potential lethality of domestic violence in homes with handguns

38. Counseling Schedule: Early Childhood Peer Playing Safety in Others’ Homes Talking About Emotions Promoting Independence 3 and 4 YEARS Child’s Assets Guided Participation Media 18 MONTHS and 2 YEARS Child Development and Behavior 12 and 15 MONTHS INTRODUCEVISIT

39. Early Childhood 26-30  Communication skills allow young children to sustain bouts of play  How young children learn to react is greatly influenced by: Parental relationship Parental behavior Home environment

40. Early Childhood Counseling “She really pays attention when we talk; does she understand when you speak to her?” “Does your child have opportunities to play with other children this age?” “What do you think your child does best? What does he enjoy doing?” “Teach your child by providing positive reinforcement for desired behaviors.” Encourage alternatives to TV, such as outdoor activity or reading. Normal toddler behavior may be especially difficult for families with little social support.

41. Early Childhood Brochures

42. Teaching Good Behavior: Tips on How to Discipline Visit: 12 and 15 Months  Describes the basics of a behavioral approach to parenting toddlers Positive reinforcement for desired behaviors Limit setting  Advises parents about effective alternatives to corporal punishment

43. How to Use this Tool Start conversations about toddler behavior with gentle inquiries “Your child is growing and developing well. Have tantrums started? How do you handle them?” “What is your child doing new since last visit? What do you want to change?” Endorse the core message: a simple approach for teaching toddlers how to behave well Helpful Hint! Be on the lookout for children with difficult temperaments, families who are socially isolated, and families experiencing discord

44. Playing is How Toddlers Learn Visit: 18 Months and 2 Years Helps parents understand normal toddler behavior and advises them how to Provide a stimulating environment during this period of major brain development Understand the natural curiosity and exploration of toddlers

45. How to Use this Tool Discuss normal toddler play behavior Provide parents with guidance on the types of toys that stimulate imagination Help parents identify places where they can meet other toddlers and their parents Helpful Hints! Check in with parents about how their family relationships are faring Support toddler’s parents with positive statements: What a delightful child you have! He is really curious about the world. This is great to see!

46. Pulling the Plug on TV Violence Visit: 18 Months and 2 Years  Provides information about the influence of TV violence on children  Offers tips for parents Set limits on TV time Know what children are watching Watch programs with children Do not put TV in a child’s room

47. How to Use this Tool Identify alternatives to TV, such as toys that use imagination or outdoor play when possible Recognize that alternatives can be challenging, as TV often provides free in-home child care for families who cannot afford organized activities or who live in unsafe areas Helpful Hint! Ask the child: What’s your favorite TV show? The child’s response often indicates the kind of TV programs being watched, which provides a topic to open discussion with parents

48. Young Children Learn A Lot When They Play Visit: 18 Months and 2 Years  Introduces the importance of peer playing  Includes tips on how to make play opportunities successful  Assists parents in solving common difficulties, such as aggression and rejection

49. How to Use this Tool Ask if child has opportunities to play with other children of the same age Use parent’s answer to discuss how the child plays or how to find other children Help parents problem solve any play or playmate issues Helpful Hint! Try to notice something about what children are wearing, the toys they bring, or their behavior: I see you really like trucks. Do you and your friends play with trucks a lot?

50. Child Mental Health School Performance Counseling Schedule: Middle Childhood School Connections Alcohol and Drugs Interpersonal Skills 8 YEARS Teaching Behavior Bullying Out-of-School Time 6 YEARS Establishing Routines and Setting Limits 5 YEARS INTRODUCEVISIT 10 YEARS

51. Middle Childhood  Rapid development of knowledge and skills characterizes middle childhood  Routines and limits will help children feel loved and secure during this time of transition 31,32  Children learn by watching and interacting with parents, other adults, and other children Parents can consciously model and expect respectful behavior 33,34

52. Middle Childhood  Play is another way children learn social skills 35 Many parents have concerns regarding safety and supervision for after-school activities  Schools can have a significant impact on preventing violence 36,37 Besides academics, children learn how to function in society Parental involvement with schools improves their children’s experience and attachment

53. Middle Childhood Counseling for the Parent Is your child happy most of the time or withdrawn? Who is your child’s best friend? How does your child help around the home? Do you have rules or limits with respect to TV, video games, and computer time? Are you involved in any school-related activities? Children grow and develop within a context of family, school, and community.

54. Middle Childhood Counseling for the Child If you see someone being bullied, what do you do? What do you do for fun? What do you like best about school? Have you been in any pushing or shoving fights? What happens when you and your friends argue or disagree? School-age children need to be active participants in learning how to avoid and react to conflict.

55. Middle Childhood Brochures

56. Growing Independence: Tips for Parents of Young Children Visit: 5 Years  Emphasizes importance of beginning parent-child communication about peer relationships early  Teaches parents how to: Listen to children Help children assume more independence and responsibilities

57. How to Use this Tool Address parents’ fears about children’s safety in the outside world Ask about how the child is doing in school and address any behavioral or emotional issues Helpful Hints! Let the child know that secrets are not OK Discuss child sexual abuse during or after examination of the child’s genitals I’m here with your mother so it’s OK. No adult should ever tell you to keep a secret from your parents.

58. Bullying: It’s Not OK Visit: 6 Years  Provides guidance for parents of victims, bullies, and bystanders  Victims may seek medical attention, but the poorest future outcomes are among bullies themselves 38,39  Schools can prevent bullying using proven interventions

59. How to Use this Tool Place brochure in the waiting room; it may be of interest to both parents and children Discuss specific strategies with those families whose children are being bullied Use brochure as a guide when speaking to community groups Helpful Hint! Ask the child: If the answer is yes, it is important to determine the child’s role. Have you ever been in any pushing or shoving fights?

60. Drug Abuse Prevention Starts With Parents Visit: 8 Years  Discusses connection between a teen’s use and abuse of drugs and/or alcohol and: Parent behavior and attitudes Media influences Communication  Addresses parental role in modeling and maintaining open communication

61. How to Use this Tool Encourage parents to talk with and listen to their children For parents who smoke, discuss the ease of starting and the difficulties of quitting; address other substance abuse problems if apparent Have substance abuse resources on hand Helpful Hint! Start conversations about drug abuse with the recent news: Did you hear about _____ being charged with _____? What do you think about that?

62. Friends Are Important: Tips for Parents Visit: 8 Years  Focuses on importance of peer relationships Encourages parents to get to know their child’s friends  Provides guidance on monitoring behaviors to prevent unsafe activities  Reiterates Connected Kids theme of clear, consistent, and positive communication

63. How to Use this Tool Encourage parents to know their child’s whereabouts and talk about expectations for staying in touch Encourage parents to help their child develop a sense of belonging through prosocial youth groups and community-based organizations Helpful Hints! Address friendships and community activities while discussing school progress and promoting physical activity Ask parent: “Who is your child’s best friend?” to initiate discussion

64. Everybody Gets Mad: Helping Your Child Cope With Conflict Visit: 10 Years  Developed for parents of pre- and early adolescents  Describes the physiology of anger and offers strategies to avoid fighting when angry  Guides parents in teaching their children how to respond to conflict

65. Introduce the topic with general questions such as “Are there a lot of fights at school?” or “What happens when you get angry?” Discuss the body’s physical response to anger and how to stay calm How to Use this Tool Helpful Hints! Ask patients who avoid fights if they have hints for other kids Consider the possibility of abuse, exposure to violence, or history of ADHD or minimal brain trauma in children who have difficulty dealing with anger

66. Counseling Schedule: Early Adolescence VISITINTRODUCE 11 to 14 YEARS Family Time Together Peer Relationships Support System Staying Safe Teen Mental Health Conflict Resolution Skills Healthy Dating Gaining Independence

67. Early Adolescence  Independence is an overarching characteristic of the early teen years  Becoming independent means being more responsible for one’s own safety  Help teens stay safe by teaching them how to avoid violence through good communication skills  Effective communication is the common thread for the Connected Kids early adolescence counseling

68. Early Adolescence  Talk with teens and parents about activities that help families stay connected; many teens are unsure about family relationships 40  Parents influence their teen children; discuss parental use of alcohol, tobacco, and other drugs  Involving adults from outside the family has a positive effect on teen development 41  Encourage teens to get involved in their communities; it is one of the best ways to help them stay safe 42

69. Early Adolescence  Teens with friends engaged in risky behaviors are more likely to imitate these behaviors 43  Conversely, friends involved in constructive, prosocial activities encourage healthy and safe behaviors  Teen dating violence affects approximately 1 in 8 high school students. Discuss healthy dating with both teens and their parents 44  Youth who have a variety of ways to solve conflicts are less likely to be hurt in a fight or arrested 45

70. Early Adolescence F I S T S F ighting I njuries S ex T hreats S elf-defense Use this mnemonic as the basis for assessing an adolescent’s risk for involvement in violence. See the Connected Kids Clinical Guide for more details.

71. Early Adolescence Counseling for Parents What most concerns you about your teenager’s safety? What kind of activities does your child enjoy? How do you negotiate rules of behavior? What do you think of your teenager’s friends? How are you monitoring your teenager? Address parents’ concerns about safety while still helping them encourage their teen’s independence

72. Early Adolescence Counseling for Youth Whom do you go to for help if you’re having trouble in your relationship? What do you do to stay safe? What do you and your friends like to do? What after-school activities are you involved with? Whom do you turn to for advice and encouragement? With independence comes the responsibility for staying safe.

73. Early Adolescence Brochures

74. Talking With Your Teen: Tips for Parents Early Adolescence  Describes typical teen behaviors and feelings and emphasizes parent-child communication as independence increases  Teaches parents how to: establish reasonable limits encourage safety as independence increases

75. How to Use this Tool Initiate discussion at puberty by asking,“I’m sure there are many other changes going on that you can’t see with your eyes, aren’t there?” Speak with parents regarding concerns about their child’s puberty Helpful Hints! Having both teens and parents read this brochure may encourage better communication between parent and child Ask parents to think about their own adolescence and how they behaved and coped at this age

76. Staying Cool When Things Heat Up Early Adolescence  Encourages teens to think about ways to resolve conflicts other than fighting  Discusses the role bystanders play in promoting violent behavior

77. How to Use this Tool Use different approaches based on violence history: “You’re very healthy, but I’m worried about all the fights you’re getting into.” “Your exam looks good and I’m also glad to hear that you haven’t been getting into a lot of fights.” Helpful Hints! Some clinicians leave this brochure in the waiting room for patients to read beforehand It may help to let patients know that this information came from other teenagers.

78. Expect Respect: Healthy Relationships Early Adolescence  Discusses healthy relationships and ways to recognize and prevent partner violence  Teens are still experimenting with intimate relationships and may be more open to improving the quality of their relationships  While designed for all teenagers, it had the most resonance with young female teens in focus groups.

79. How to Use this Tool Introduce when teens show an interest in relationships, dating, and sexual behavior Discuss healthy relationships along with physical concerns such as sexually transmitted diseases Can be used with sex education courses in schools Helpful Hints! Today we have discussed some of the physical issues of intimate relationships, but the emotional issues are just as important. At the end of an exam, say:

80. Teen Dating Violence: Tips for Parents Early Adolescence  Discusses parental response when partner abuse is suspected  The main concern for parents is their child’s happiness and welfare, not pointing out what is wrong with the abusive partner

81. How to Use this Tool Encourage parents to: empathize with what their child is experiencing support their child in finding and maintaining non-abusive, healthy relationships Helpful Hint! Give this brochure to parents at the same time Expect Respect: Healthy Relationships is given to teenagers

82. Counseling Schedule: Middle Adolescence VISITINTRODUCE 15 – 17 YEARS Plans for the Future Firearms and Suicide Depression Resiliency

83. Middle Adolescence  There is a direct link between assets and the risk for violence and future success 46  Identify and support a teen’s: strengths functional abilities positive relationships with others connections to groups, role models, and mentors

84. Middle Adolescence  A key in helping teens avoid violence is to teach them how to: assess risk and make an immediate decision think about the long-term consequences of that decision

85. Middle Adolescence Counseling for Parents What non-school activities is your teen involved with? Do you talk about future plans? How do you stay in touch with your teen? If you have guns, how do you store them? How is your teen getting along with friends? Help parents with the teen’s dilemma of quick decisions and long-term consequences.

86. Middle Adolescence Counseling for Youth Can you get a gun if you want to? What do you want to do after high school graduation? How do you get along with your friends? What do you like best about yourself? Do you have somebody to talk to when you feel sad? Teens are living in the moment, but need to think about the future.

87. Middle Adolescence Brochures

88. Teen Suicide and Guns Middle Adolescence  Discusses the risks of guns in the home and the link to completed teen suicides  Objectively discusses guns and gun storage

89. How to Use this Tool Use on an individual basis to support counseling Can be distributed to schools and community groups Parents of teens with mood disorders may benefit from this along with the brochure Help Stop Teenage Suicide Helpful Hints! Did you hear about the teen who killed himself last month? I’m talking about this with all of my teenage patients. Use current events:

90. Connecting With Your Community Middle Adolescence  Teenagers who are involved in their communities are less likely to be involved with: alcohol drugs violence promiscuous sexual activity

91. How to Use this Tool As relationships with their parents become more complex, additional adult role models become more important for teens Support teens in finding adults in the community who believe in and support them Helpful Hints! Schools and community groups can help find opportunities that meet the interests and talents of young adults It may be beneficial for clinics to develop a resource guide for teens about local community groups

92. Counseling Schedule: Late Adolescence VISITINTRODUCE 18 – 21 YEARS Transition to Independence Negotiating a New Environment (Post High School)

93. Late Adolescence  Transitioning to independence is a gradual process  Bringing closure to this process is essential  Many older teenagers are likely to be moving out of the home to: higher education their own living situation an entirely new community  This is exciting and stressful for both teen and parent

94. Late Adolescence Counseling for Youth How do you feel about moving out? Can I help with getting you where you want to go? Whom do you talk to about your future plans? What are your plans down the road? Do you plan to move out of your parents’ home? Support patients with the transition to becoming a young adult.

95. Late Adolescence Brochures

96. Help Stop Teenage Suicide Late Adolescence  Talks about common myths, gives the warning signs, and stresses that many teen suicides occur with little forethought  Designed for teens, parents, and other caregivers

97. How to Use this Tool Use with patients with mental health issues, especially mood or conduct disorders, that often develop during these years Stress link between presence of a handgun and increased likelihood of lethal suicide attempts Helpful Hint! Teens who think they may be gay, lesbian, bisexual, or transgender are at an increased risk for suicide; help them and their families find additional support

98. Next Stop Adulthood: Tips for Parents Late Adolescence  Teens are renegotiating parental relationships as they transition into adult responsibilities  Helps parents let go while encouraging teens to seek guidance from their parents

99. How to Use this Tool Use as a catalyst to discuss increasing independence Teens who are already in trouble may need a social worker to help better understand and implement these concepts Helpful Hints! It is helpful to discuss employment, community service, sports, clubs, and other pursuits Teenagers need positive engagement with their outside community in order to thrive!

100. Ideas for Optimal Use While implementing Connected Kids with an individual family depends on a family’s starting point—and the family’s interest in our input—we can begin to consider some strategies for implementation in the following areas: Intake Forms Counseling Educational Materials Practice Changes Community Connections

101. Intake Forms  Use the Bright Futures Pediatric Intake Form Introduce Connected Kids in a cover letter to families  Use information gathered to prioritize issues for families and tailor the program  As your relationship with a family evolves, it may become easier to discuss sensitive topics  Use the information gathered at every visit

102. Counseling  Be sensitive to issues that might be difficult for a particular family  Include both statistics and stories  Prioritize topics covered on the families’ needs  Use the adolescent brochures to facilitate new ways for parents and teens to talk

103. Educational Materials  Use brochures to introduce sensitive topics, such as domestic violence  Encourage the parent to share the information with other adults caring for the child  Ask support staff to help distribute materials while patients are waiting to be seen

104. Educational Materials  Personalize the brochures: Circling or underlining a passage increases the likelihood that your advice will be followed Write down family-specific information in the box on the back cover during the visit  Suggest placing it on the refrigerator so the cover image can be a reminder of what to do  Encourage parents/patients to write questions in the box on the back while they are waiting

105. Practice Changes  Involve all office staff; receptionists observe how parents and children interact  Use the Counseling Schedule from the Clinical Guide to document when you have introduced and reinforced topics  Talk with colleagues about how they have successfully implemented Connected Kids

106. Community Connections  Become familiar with programs in your community  If resources do not exist, advocate for services  Get involved: Join coalitions working to rid the community of violence Speak to community and school groups Talk with the local media

107. In Summary All children deserve to grow up: Safe Strong Secure We can help families achieve these goals!

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114. Acknowledgments Howard Spivak, MD Robert Sege, MD, PhD Elizabeth Hatmaker-Flanigan, MS Bonnie Kozial Vincent Licenziato Kimberly Bardy, MPH This project was supported by Grant No. 2001-JN-FX-0011 awarded by the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.