1.  Healthcare Summit October 24, 2014 Kathy Franchek-Roa MD University of Utah Kathy.franchek@hsc.utah.edu

2.  Discuss the association between childhood adversity and lifelong health  Summarize national recommendations for screening patients for IPV victimization  Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting

3.  Discuss the association between childhood adversity and lifelong health Summarize national recommendations for screening patients for IPV victimization Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting

4. Obesity is not the problem– it is the solution Vincent J Felitti MD

5. Felitti 2001

6. Multiple ACE Child Abuse Caregiver -IPV -Mental Illness -Substance Abuse -Incarceration High Risk Health Behaviors Smoking Alcoholism Illicit Drug Use Sexual Promiscuity Unhealthy Diet Physical Inactivity Suicidality 1 Heart Disease 2 Cancer 3 CLRD 4 Stroke 6 HIV/AIDS 7 Diabetes 10 Suicide 12 Liver Disease Felitti 1998

7. Morbidity Mortality Disease, Disability, and Social Problems Adoption of Health Risk Behaviors Social, Emotional, Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences Felitti 2001; www.cdc.gov/ACE

8. Morbidity Mortality HTN CAD Diabetes Physical Inactivity Unhealthy Diet Chronic Depression Disrupted Neurodevelopment leading to physical deregulation Childhood Sexual Abuse Felitti 2001; www.cdc.gov/ACE

10.  Adversity and on-going toxic stress exposure during childhood is of critical concern because it can negatively affect brain development resulting in permanent changes to brain anatomy and function McEwen 2007; 2010

11.  A child’s response to stress may have originated as a biologically based adaptation to the child’s abnormal world Hibel 2011; McEwen 2007; 2010; Stirling 2008; www.developingchild.harvard.edu

12. Up to 30% of Children are exposed to IPV Up to 30% of Children are exposed to IPV McDonald 2006; Moore 2007

13. “Domestic violence…seems to be the most toxic form of violence for children… “For many children, the first lessons they learn about violence are not from television or from the streets, but from their parents.” Groves 2002

14.  Discuss the association between childhood adversity and lifelong health “Patients see doctors because of anxiety, while doctors see patients because of disease. Therein lies the problem between the two.” Michael Balint

15.  Discuss the association between childhood adversity and lifelong health  Summarize national recommendations for screening patients for IPV victimization Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting

16. Maine opens first DV shelter “We will not be beaten” Most US States allow wives to bring criminal action against husband for physical abuse First marital rape law National Coalition Against Sexual Assault is formed HHS establishes objectives for violence 1994 VAWA 1967 1970 1975 1976 1978 1980 1994 SG report listing violence as a priority CDC Violence Epidemiology Branch 2020 Healthy People addresses violence AMA recommends screening women for DV Violence seen as a public health issue National Violence Against Women Survey USPSTF recommendations for screening women for IPV 197 9 198 3 199 0 199 2 199 3 199 4 SG report listing violence as a priority CDC Violence Epidemiology Branch 2000 Healthy People addresses violence AMA recommends screening women for DV Violence seen as a public health issue National Violence Against Women Survey USPSTF recommendation for screening women for IPV 1979 1983 1990 1992 1993 1994 2013

17.  AMA  AAP  ACOG  USPSTF recommends that o Clinicians screen women of childbearing age for IPV and provide or refer women who screen positive to intervention services o This recommendation applies to women who do not have signs or symptoms of abuse ACOG 2012; AMA 2008; Moyer 2013; Thackeray 2010; USPSTF 2013

18. Abuse, Neglect and Exploitation

19.  Policy on Abuse, Neglect and Exploitation is to ensure appropriate guidelines for physicians and staff caring for patients they suspect may be victims of abuse, neglect or exploitation CHIIP Model Domestic Violence Hospital Policy; Futures Without Violence

20.  Intimate Partner Violence  Vulnerable Adult Abuse  Trafficking in Persons  Child Abuse and Neglect  Any patient who presents with concerns of abuse, neglect and exploitation  Further additions: chapter specific to sexual assault CHIIP Model Domestic Violence Hospital Policy; Futures Without Violence

21.  Definitions  Public Health Impact  Standards  Health Consequences  Risk Factors/Presenting Signs and Symptoms  Procedure for Identifying Victims  Procedure Once Victim Identified  Resource and Referral Information  Additional Considerations

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23. “Are you here today to be treated for injuries caused by another person?” “I am concerned that you may not be in a safe relationship. This can affect your health and the health of your children. Here are some resources. I strongly urge you to call the crisis hotline number (800-897-LINK) or speak to a DV advocate. They can help you.” Document what patient stated in her own words and what resources were given to the patient. Perform a thorough exam, documenting/photographing injuries Contact DCFS 855-323-3237 if acts of DV were committed in the presence of a child. NO Physical findings consistent with assault/abuse? “I am glad you are in a safe relationship. Would you like some resources in case you or someone you know ever needs help?” NO YES NO Physical findings consistent with assault/abuse? NO YES Call Law Enforcement Recommend contacting DV Advocate Social Worker/Crisis Worker YES I ask all my patients if they are in a relationship or in a home with someone who may be hurting or controlling them because this can affect people’s health (and the health of their children). In addition, you should know that in some instances what you tell me may need to be reported. Are you in a relationship with someone who physically hurts, threatens or emotionally abuses you?

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25. Vulnerable Adult Abuse Algorithm Presentation Concerning for Vulnerable Adult Abuse If you suspect Elder/Disabled Adult Abuse and patient has no cognitive dysfunction* separate patient from accompanying adults and ask: YES Is patient medically stable? NO Stabilize patient as appropriate-- then proceed with algorithm “Are you here today to be treated for injuries caused by another person?” NO 1) Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals? 2) Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides, other assisted devices or medical care, or from being with people you wanted to be with? 3) Have you been upset because someone talked to you in a way that made you feel shamed or threatened? 4) Has anyone tried to force you to sign papers or to use your money against your will? 5) Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically? YES If YES to question 2,3,4,OR 5 If NO to questions 2,3,4,AND 5 YES  Physical findings consistent with assault/abuse AND/OR  HCP notices: poor eye contact, withdrawn nature, malnourishment, hygiene issues, inappropriate clothing, or medication compliance issues and elder/disabled adult abuse suspected NO Document  What patient stated in her/his own words;  What resources were given to the patient; and  Reports made to authorities  Refer to Social Worker as needed  Reiterate to patient that your hospital is a resource if needed  Ensure follow-up with PCP  Consider referral to Geriatrician  CALL LAW ENFORCEMENT OR  APS 800-371-7897 * If patient has cognitive dysfunction consult:  Psychiatry  Neurology  Consider Geriatrician  CALL LAW ENFORCEMENT OR  APS 800-371-7897

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27. Trafficking in Persons (TIP) Algorithm Presentation Concerning for Human Trafficking Is patient medically stable? NO Stabilize patient as appropriate-- then proceed with algorithm YES < 18 years of age > 18 years of age CONSIDER OTHER RESOURCES:  Notify hospital security if needed  Call Social Worker or Crisis Worker if available  Utah Human Trafficking Task Force801-200-3443  Trafficking Hotline for additional info 888-373-7888  SANE Nurse  Sexual Assault Crisis Hotline888-421-1100 If you suspect TIP ask: If you suspect TIP ask questions alone with the patient:  “Have you ever been forced to do work when you didn’t want to do?”  “Does anyone hold your identity documents?”  “Has your employer threatened you if you leave?”  “Have you ever exchanged sex for food, shelter, drugs, or money?” “Are you here today to be treated for injuries caused by another person?” If YES Assessment of Potential Danger Ask Hotline (888-373-7888) to assist in assessing level of danger. Be vigilant of immediate environment Questions to consider:  Is the trafficker present?  What will happen if the patient does not return to the trafficker?  Does the patient believe he/she or a family member is in danger?  Is the patient a minor? Document what patient stated in her/his own words and what resources were given to the patient. If YES Important Dynamics for Assessment  Keep in mind that the victim may not self-identify as a human trafficking victim  Victims have been conditioned not to trust others  Victims have been conditioned not to tell the truth  Speak to the patient alone without accompanying adults (adults may portray themselves as relatives)  Prioritize the patient’s medical needs and safety as the primary reason for the assessment  Refer to Social Worker as needed  Reiterate to patient that your hospital is a resource if needed  Give the patient the Human Trafficking Hotline Number if safe to do so (888-373-7888; 801-200-3443) If NO  CALL LAW ENFORCEMENT AND  CALL DCFS (IF < 18 YO) 855-323-3237

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29. Child Abuse and Neglect Algorithm Presentation Concerning for Child Abuse/Neglect YES NO Is patient medically stable? Stabilize patient as appropriate-- then proceed with algorithm Physical InjuriesNeglectWitness to IPVSexual AbuseEmotional Abuse Assess for Risk Factors Ask about IPV in the home Carefully document history using quotes when possible Perform a careful, thorough physical exam Use body maps and photography to document visible injuries Labs and Imaging as indicated CONSIDER OTHER RESOURCES Abuse Pediatrician Law Enforcement Children’s Justice Center Assess for Risk Factors Ask about IPV in the home Assess for Risk Factors See IPV Algorithm Assess for Risk Factors Ask about IPV in the home Assess for Risk Factors Ask about IPV in the home Carefully document history using quotes when possible Perform a careful, thorough physical exam For children <14 years: call child abuse pediatrician on call For children >14 years: call SANE nurse Contact Social Worker: If available Carefully document history using quotes when possible Perform a careful, thorough physical exam CONSIDER OTHER RESOURCES Contact Crisis Worker/Social Worker to help families with homelessness, socio-economic factors, educational needs, drug use, food insecurity and health insurance needs Child Abuse Pediatrician to help with evaluation if needed Children’s Justice Center Hospital Security Law Enforcement CONSIDER OTHER RESOURCES Hospital Security Call DV Advocate if parent so desires DV Crisis Hotline:800-897-5465 CALL DCFS 855-323-3237 CALL DCFS 855-323-3237 CALL DCFS 855-323-3237 CALL DCFS 855-323-3237 CALL DCFS 855-323-3237 CONSIDER OTHER RESOURCES Abuse Pediatrician Law Enforcement Children’s Justice Center CONSIDER OTHER RESOURCES Abuse Pediatrician Law Enforcement Children’s Justice Center

30.  Activate your policy o Make it a useful document o Make it relevant

31.  Discuss the association between childhood adversity and lifelong health  Summarize national recommendations for screening patients for IPV victimization If you don’t ask—they won’t tell health care setting

32.  Discuss the association between childhood adversity and lifelong health  Summarize national recommendations for screening patients for IPV victimization  Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting

33.  Realization that many patients seeking behavior services and many other public health services have a history of physical and sexual abuse and other forms of trauma  Trauma-informed care approach to patients provides a more therapeutic interaction and avoids re-traumatization  “What is wrong with you?” “What has happened to you?” http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf

34.  Realization that many patients seeking behavior services and many other public health services have a history of physical and sexual abuse and other forms of trauma  Trauma-informed care approach to patients provides a more therapeutic interaction and avoids re-traumatization  “What is wrong with you?”  “What has happened to you?” http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf

35.  What happened is not nearly as important as what the trauma means to the individual  Screening to identify patients who have histories of trauma and experience trauma- related symptoms is a prevention strategy  With a history of trauma so common it has been suggested that we should use ‘universal precautions’ when interacting with patients SAMHSA TIP Series 57, 2014; Harris 2001

36. Recognize the impact of violence and victimization on development and coping strategies Identify recovery from trauma as the primary goal Employ an empowerment model Strive to maximize a patient’s choices and control over her recovery Are based in a relational collaboration Create an atmosphere that is respectful of survivors’ need for safety, respect, and acceptance Emphasize patient’s strengths, highlighting adaptations over symptoms and resilience over pathology Goal is to minimize the possibilities of retraumatization Strive to be culturally competent Solicit consumer input and involve patients in designing and evaluating services Elliott 2005

37.  Discuss the association between childhood adversity and lifelong health  Summarize national recommendations for screening patients for IPV victimization  Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting Trauma-informed care embraces a perspective that highlights adaptation over symptoms and resilience over pathology. Elliott et al. 2005

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39.  Discuss the association between childhood adversity and lifelong health o “…the need is clear, the opportunities are major…what happens in childhood…commonly lasts throughout life…Time does not heal, time conceals… The impact of a successful approach here might be as great as that of a major vaccine.” Felitti 2009  Summarize the national recommendations for screening patients for IPV victimization o “I will remember that there is an art to medicine as well as a science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” Louis Lasagna MD  Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting o “I wonder how different my life would have been if someone in a white lab jacket had sat down, listened to my story, and seen the health issues lurking in my tomorrows.” Survivor

41.  American College of Obstetricians and Gynecologists. Committee Opinion. Intimate Partner Violence. February 2012, Number 518. http://www.acog.org/Resources-And-Publications/Committee- Opinions/Committee-onHealth-Care-for-Underserved-Women/Intimate- Partner-Violence http://www.acog.org/Resources-And-Publications/Committee- Opinions/Committee-onHealth-Care-for-Underserved-Women/Intimate- Partner-Violence  American Medical Association. Opinion 2.02 – Physicians’ Obligations in Preventing, Identifying, and Treating Violence and Abuse. Available http://www.ama-assn.org/ama/pub/physician-resources/medical- ethics/code-medical-ethics/opinion202.page http://www.ama-assn.org/ama/pub/physician-resources/medical- ethics/code-medical-ethics/opinion202.page  Balint M. The Doctor, His Patient and the Illness. 2 nd Ed. The Bath Press Avon. 1964.  Centers for Disease Control and Prevention. Intimate Partner Violence Consequences. Available http://www.cdc.gov/violenceprevention/intimatepartnerviolence/cons equences.html http://www.cdc.gov/violenceprevention/intimatepartnerviolence/cons equences.html

42.  CHIIP—Connecticut Health Initiative for Identification and Prevention. Model—Domestic Violence Hospital Policy. Available http://www.vdh.virginia.gov/ofhs/prevention/dsvp/projectradarva/do cuments/older/pdf/CHIIP_PROGRAM_Domestic_Violence_Hospital_P olicy.pdf  Dahlberg LL, Mercy JA. History of violence as a public health issue. AMA Virtual Mentor, February 2009. Volume 11, No. 2: 167-172. Available on-line at http://virtualmentor.ama- assn.org/2009/02/mhst1-0902.html. 1976  Delphi Instrument. Available http://archive.ahrq.gov/research/domesticviol/dvtool.pdf  Elliott, DE et al. Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology. 2005:33;461–477

43.  Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. Family Violence Prevention Fund, 1999. Updated 2004. San Francisco, CA. Available at http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf  Felitti VJ et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults—the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245-258  Felitti VJ. Reverse alchemy in childhood: Turning gold into lead. Health Alert. Vol 8 No 1. 2001  Felitti VJ. Commentary—Adverse Childhood Experiences and adult health. Acad Ped. 2009;9:131-132  Groves BM. Children Who See Too Much: Lessons from the Child. Boston, MA: Beacon Press; 2002

44.  Harris M, Fallot RD (Eds.) Using trauma theory to design service systems. New Directions for Mental Health Services, 89. San Francisco, CA, 2001  Hibel LC, et al. Maternal sensitivity buffers the adrenocortical implications of intimate partner violence exposure during early childhood. Develop Psychopath. 2011;23:689-701  McDonald R, et al. Estimating the number of American children living in partner-violent families. J Fam Psych. 2006;20:137-142  McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007;87:873–904.  McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health and disease. Ann NY Acad Sci 2010;1186:190-222.

45.  Moore CG et al. The prevalence of violent disagreements in US families: Effects of residence, race/ethnicity, and parental stress. Pediatrics. 2007:119(S1), S68-S76  Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;158:478-486  Shonkoff JP et al. Technical Report—The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012:129:e232- e246  Stirling J et al. Understanding the behavioral and emotional consequences of child abuse. Pediatrics. 2008;122:667-673  Substance Abuse and Mental Health Services Administration. Trauma- Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014

46.  Thackeray JD et al. Intimate partner violence: The role of the pediatrician. Pediatrics 2010;125:1094-1100  U.S. Preventive Services Task Force Recommendations on Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Available http://www.uspreventiveservicestaskforce.org/Page/Document/Reco mmendationStatmentFinal/intimate-partner-violence-and-abuse-of- elderly-and-vulnerable-adults screening http://www.uspreventiveservicestaskforce.org/Page/Document/Reco mmendationStat