Introduction To Connected Kids 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. 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 old1 Increase in community violence during 1990s • 21st century rates in the United States still among the highest in the world 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 Why Is This Important? Parents want more doctors to discuss community violence.5 Community violence Provider should ask Provider asked Supportive partner Parent's emotional support Alcohol/drug use in household 0 20 40 % 60 80 100 Results from the National Survey of Early Childhood Health 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 Development Process Development of Connected Kids included6: Input from parents, clinicians, and other experts Testing of program materials in focus groups with diverse families and clinicians7 Incorporation of stakeholder feedback A broad and respectful approach for all of the educational materials Coordination with other AAP efforts Objectives Connected Kids will: Strengthen the connections among children and youth, their families, and their community Reduce risk factors by building resilience8 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 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 Asset- Versus Risk-based Approaches to Guidance Assets: Risks: • Goal: Help improve child’s • Goal: Reduce known risks resilience • Assess family strengths • Link to community resources • Screen for risk factors • Refer to services Connected Kids Includes: Clinical guide Counseling schedule Handouts for parents and families Web site • This training presentation • Database of violence prevention materials • Success stories 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 Building Blocks Connected Kids centers on 4 overlapping themes of anticipatory guidance ChildCentered Community Connections ParentCentered Physical Safety Child-Centered Recognizes: • Child’s changing abilities • Cognitive development of child • Related parental concerns ChildCentered ParentCentered Community Connections Physical Safety 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 ChildCentered ParentCentered Community Connections Physical Safety Positive Parenting Teaching desired behavior begins with a positive and nurturing foundation9 What to do when your child misbehaves How to manage conflict and teach responsibility Ways to nurture your children and prevent misbehavior Community Connections Research underscores the importance of10: • Social capital: a measure of the interconnectedness among people with their community • Community connections Clinicians can help connect families to community resources ChildCentered ParentCentered Community Connections Physical Safety Physical Safety 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 ChildCentered ParentCentered Community Connections families make their own decisions Physical Safety 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 Counseling Schedule Anatomy of a Brochure Front Cover Cover image visually conveys core message Designed by Artists for Humanity, a nonprofit arts and entrepreneurship program for Boston teens. 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 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 Counseling Schedule Infancy & Early Childhood 2 days – 4 years Middle Childhood Adolescence 5 – 10 years 11 – 21 years Counseling Schedule: Infancy VISIT 2 DAYS to 4 WEEKS INTRODUCE • • • • 2 and 4 MONTHS • • • • • 6 and 9 MONTHS • • • • What Babies Do Parental Frustration Parent Mental Health Parent Support Child Care Family Safe Environment Parenting Style Bonding and Attachment Establishing Routines Discipline = Teaching Firearms Modeling Behavior Infancy11-17 • 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 more18-25: • • • • Balanced self-concept Advanced memory processes Sophisticated grasp of emotion Positive understanding of friendship Infancy Counseling Be on the lookout for families who are socially isolated or experiencing family discord. Who helps you with your baby? If there is a gun in the home, how is it stored? Is this what you expected? How much time do you have off from work? Being a new parent can be exhausting. How are you doing? Infancy Brochures 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 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! 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 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! 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 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. 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 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 Counseling Schedule: Early Childhood VISIT 12 and 15 MONTHS • INTRODUCE Child Development and Behavior 18 MONTHS and 2 YEARS • • • Child’s Assets Guided Participation Media 3 and 4 YEARS • • • • Peer Playing Safety in Others’ Homes Talking About Emotions Promoting Independence Early Childhood26-30 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 Early Childhood Counseling Encourage alternatives to TV, such as outdoor activity or reading. “Does your child have opportunities to play with other children this age?” “Teach your child by providing positive reinforcement for desired behaviors.” Normal toddler behavior may be especially difficult for families with little social support. “She really pays attention when we talk; does she understand when you speak to her?” “What do you think your child does best? What does he enjoy doing?” Early Childhood Brochures 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 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 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 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! 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 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 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 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? Counseling Schedule: Middle Childhood VISIT INTRODUCE 5 YEARS • Establishing Routines and Setting Limits 6 YEARS • Teaching Behavior Bullying Out-of-School Time • • 8 YEARS • • • 10 YEARS • • School Connections Alcohol and Drugs Interpersonal Skills Child Mental Health School Performance 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 transition31,32 Children learn by watching and interacting with parents, other adults, and other children • Parents can consciously model and expect respectful behavior33,34 Middle Childhood Play is another way children learn social skills35 • Many parents have concerns regarding safety and supervision for after-school activities Schools can have a significant impact on preventing violence36,37 • Besides academics, children learn how to function in society • Parental involvement with schools improves their children’s experience and attachment Middle Childhood Counseling for the Parent Do you have rules or limits with respect to TV, video games, and computer time? Are you involved in any school-related activities? Who is your child’s best friend? Children grow and develop within a context of family, school, and community. How does your child help around the home? Is your child happy most of the time or withdrawn? Middle Childhood Counseling for the Child Have you been in any pushing or shoving fights? What happens when you and your friends argue or disagree? What do you do for fun? School-age children need to be active participants in learning how to avoid and react to conflict. What do you like best about school? If you see someone being bullied, what do you do? Middle Childhood Brochures 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 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. 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 themselves38,39 Schools can prevent bullying using proven interventions 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: Have you ever been in any pushing or shoving fights? If the answer is yes, it is important to determine the child’s role. 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 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? 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 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 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 How to Use this Tool • 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 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 Counseling Schedule: Early Adolescence VISIT 11 to 14 YEARS INTRODUCE • Family Time Together • Peer Relationships • Support System • Staying Safe • Teen Mental Health • Conflict Resolution Skills • Healthy Dating • Gaining Independence 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 Early Adolescence Talk with teens and parents about activities that help families stay connected; many teens are unsure about family relationships40 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 development41 Encourage teens to get involved in their communities; it is one of the best ways to help them stay safe42 Early Adolescence Teens with friends engaged in risky behaviors are more likely to imitate these behaviors43 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 parents44 Youth who have a variety of ways to solve conflicts are less likely to be hurt in a fight or arrested45 Early Adolescence FISTS Fighting Injuries Sex Threats Self-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. Early Adolescence Counseling for Parents What do you think of your teenager’s friends? How are you monitoring your teenager? What kind of activities does your child enjoy? Address parents’ concerns about safety while still helping them encourage their teen’s independence How do you negotiate rules of behavior? What most concerns you about your teenager’s safety? Early Adolescence Counseling for Youth Whom do you turn to for advice and encouragement? What do you do to stay safe? What after-school activities are you involved with? With independence comes the responsibility for staying safe. Whom do you go to for help if you’re having trouble in your relationship? What do you and your friends like to do? Early Adolescence Brochures 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 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 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 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. 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. 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! At the end of an exam, say: Today we have discussed some of the physical issues of intimate relationships, but the emotional issues are just as important. 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 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 Counseling Schedule: Middle Adolescence VISIT 15 – 17 YEARS INTRODUCE • Plans for the Future • Firearms and Suicide • Depression • Resiliency Middle Adolescence There is a direct link between assets and the risk for violence and future success46 Identify and support a teen’s: • • • • strengths functional abilities positive relationships with others connections to groups, role models, and mentors 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 Middle Adolescence Counseling for Parents If you have guns, how do you store them? How is your teen getting along with friends? Do you talk about future plans? Help parents with the teen’s dilemma of quick decisions and long-term consequences. How do you stay in touch with your teen? What non-school activities is your teen involved with? Middle Adolescence Counseling for Youth Do you have somebody to talk to when you feel sad? What do you want to do after high school graduation? What do you like best about yourself? Teens are living in the moment, but need to think about the future. Can you get a gun if you want to? How do you get along with your friends? Middle Adolescence Brochures 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 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! Use current events: Did you hear about the teen who killed himself last month? I’m talking about this with all of my teenage patients. 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 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 Counseling Schedule: Late Adolescence VISIT 18 – 21 YEARS INTRODUCE • Transition to Independence • Negotiating a New Environment (Post High School) 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 Late Adolescence Counseling for Youth What are your plans down the road? Do you plan to move out of your parents’ home? Can I help with getting you where you want to go? Support patients with the transition to becoming a young adult. Whom do you talk to about your future plans? How do you feel about moving out? Late Adolescence Brochures 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 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 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 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! 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 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 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 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 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 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 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 In Summary All children deserve to grow up: Safe Strong Secure We can help families achieve these goals! 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Neighborhoods and violent crime: a multilevel study of collective efficacy. Science. 1997;277:918-924 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.