WINTER 2016
Dedicated to the Health of Arizona Children
PEDIATRIC DIGEST
AzAAP Strategic Priority: Early Brain & Child Development
President’s Report: AzAAP dedicated to
Pediatric professionals play a pivotal role in early brain and child development promotion which is essential for the health and well-being of children.
improve the ability of children to have a better start—Page 2
A LOOK INSIDE 4
Childhood Trauma’s Impact on Health Over Time
6
Developmental Screening: It Matters and We Can Do Better!
13
Self Regulation in Early Childhood: Help Needed!
AzAAP President’s Report W inter is one of my favorite times of the year with cooler temperatures and more chances to get
outside and enjoy the beauty of Arizona. For the Chapter and our pediatric providers around the
state, it is a busy time with many things to do to improve the health and well-being of children.
In our last issue, we introduced a new Arizona Chapter “Agenda for Children” to outline key chapter initiatives in three categories including: poverty and child health, early brain and child development, and quality of care and child safety. Since that time, we have restarted committee meetings and welcomed three new medical directors to lead the areas of focus in the agenda for children:
John Pope’s
President’s
Farah R. Lokey, MD, FAAP (Gilbert, AZ): Medical Director, Poverty and Child Health Catherine S. Riley, MD, FAAP (Tucson, AZ): Medical Director, Early Brain and Child Development Veenod L. Chulani, MD, MSEd, FAAP, FSAHM, CEDS (Phoenix, AZ): Medical Director, Quality of Care and Child Safety
REPORT
This issue will focus on EARLY BRAIN AND CHILD DEVELOPMENT (EBCD) with a general overview of EBCD followed by a series of articles on specific topics including developmental screening, early literacy, adverse
Dr. Pope is AzAAP’s President and has served on the Board of Directors for the past 6 years as well as involvement on several committees and task forces. He is the Chief Medical Officer for the HonorHealth Scottsdale Shea Medical Center.
childhood experiences, quality preschool and child care as well as reports from state programs for children related to EBCD.
The Chapter has developed and implemented programs to address issues that children have with EBCD including our Reach Out and Read program and projects where we have partnered with other state agencies to improve developmental screening tools and provider reimbursement for developmental screening in Arizona, and this is just a start as our focus shifts with our new strategic direction.
Consider these few statistics for children in Arizona and the United States:
In 2011, 35% of 3 and 4 year olds in Arizona were enrolled in a pre-school program compared to 47% nationally.1
In 2016, 60% of third graders in Arizona failed the AZ Merit reading test. 1 Only 57% of parents nationally report that their pediatrician ever assessed their child’s development during a well visit.2
1 in 68 children nationally have a diagnosis of autism.2
Our Chapter looks forward to working with Dr. Catherine Riley and our committees, through our programs, and with state partners to improve the ability of children in Arizona to have a better start to their lives!
Sincerely,
John A. Pope, MD, MPH, FAAP
References: 1 Children’s Action Alliance 2 www.aap.org
Pediatric Digest, Winter 2016 Page 2
AzAAP Medical Director Message: A Look at Early Brain and Child Development CATHERINE S. RILEY, MD, FAAP | TUSCON, AZ Basic health, nutrition, and education are important longstanding priorities for pediatricians, as these areas certainly impact overall child development. More recent attention has been paid to caregiving and early brain development, which should also be a priority area for pediatricians. Programs which promote nurturing care by parents have been shown to have a positive influence on early child outcomes. (Lancet 2016)
Research published by the National Academy of Sciences in 2006 demonstrates that a child’s brain changes dramatically in the first 3 years of life. During these critical years, 700 new neural connections are formed every second; in addition, the brain is most flexible early in life. The National Symposium on Early Child Science and Policy notes that early experiences determine the strength (or weakness) of neuronal brain circuits.
Stable, caring, interactive relationships with adults are required for healthy brain development. Caregiving affects multiple areas of health and development including: language development, cognitive ability, social adjustment, and physical growth.
Positive experiences promote healthy development, while toxic stress can damage the developing brain and ultimately lead to life -long problems. Significant research developments published in Nature Neuroscience in 2015 note that nurturing care in early Catherine S. Riley, MD, FAAP, AzAAP Medical Director, Early Brain & Child Development, Tucson, AZ
childhood can actually attenuate other events like poverty, toxic stress, etc. that are known to have detrimental effects on brain development. This further supports the importance of promoting positive nurturing care to ensure optimum health and
development during childhood.
THE ARIZONA CHAPTER
HAS PRIORITIZED
EARLY BRAIN
AREA OF FOCUS TOWARD IMPROVING THE HEALTH OF PRIORITY INITIATIVES FROM THE NATIONAL
AND
CHILD DEVELOPMENT
ARIZONA
CHILDREN.
THIS
AS ONE CRUCIAL
FALLS IN LINE WITH
AAP.
Supporting and promoting early child development programs enables children to achieve their full developmental potential. Lifelong benefits result from positive early child experiences.
Promoting early literacy and appropriate developmental screening, while also focusing efforts to limit adverse childhood experiences are important steps toward ensuring optimum child health and development. WE AS PEDIATRICIANS HAVE A PIVOTAL ROLE IN THIS PROCESS TO ENSURE THE BEST POSSIBLE OUTCOMES FOR OUR PATIENTS.
In this Issue: page 4 Arizona ACE Consortium: Childhood Trauma’s Impact on Health Over Time page 6 Developmental Screening: It Matters and We Can Do Better! page 7 AzPediaLearning.org: AzAAP Training and Certification Site page 9 Early Literacy, Early Learning, Better Outcomes page 10 Reach Out and Read: A Program for Early Brain & Child Development page 11 EBCD Resources page 13 Self Regulation in Early Childhood: Help Needed! page 14 SWHD: Creating a Positive Future for Young Children page 15 SENSE Program: Substance Exposed Newborn Safe Environment page 17 Promoting Healthy Development of Young Children in Arizona: Arizona Early Intervention Program (AzEIP) page 20 Look to Empower: Advice to Give Families Regarding Child Care page 22 Developmental Preschool Makes a Difference in the Lives of Children: Understanding the Role of the Pediatrician page 25 First Things First: A Pediatrician’s Partner in Promoting Positive Brain Development page 25 AzAAP Member Spotlight: Dr. Robin Blitz Page 27 Children’s Circle Charter Members: Honoring AzAAP’s Philanthropic Society Members
Pediatric Digest, Winter 2016 Page 3
Arizona Adverse Childhood Experience (ACE) Consortium: Childhood Trauma’s Impact on Health Over Time MARCIA STANTON | COORDINATOR OF THE ARIZONA ACE CONSORTIUM | PHOENIX, AZ THE ORIGINAL ACE STUDY WAS CONDUCTED AT KAISER PERMANENTE FROM 1995 TO 1997 WITH TWO WAVES OF DATA COLLECTION. OVER 17,000 HMO MEMBERS FROM SOUTHERN CALIFORNIA RECEIVING PHYSICAL EXAMS COMPLETED CONFIDENTIAL SURVEYS REGARDING THEIR CHILDHOOD EXPERIENCES AND CURRENT HEALTH STATUS AND BEHAVIORS. THE CDC CONTINUES ONGOING SURVEILLANCE OF ACES BY ASSESSING THE MEDICAL STATUS OF THE STUDY PARTICIPANTS VIA PERIODIC UPDATES OF MORBIDITY AND MORTALITY DATA. THE FIRST JOURNAL ARTICLE , “RELATIONSHIP OF CHILDHOOD ABUSE AND HOUSEHOLD DYSFUNCTION TO MANY OF THE LEADING CAUSES OF DEATH IN ADULTS,” WAS PUBLISHED IN THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE IN 1998, VOLUME 14, PAGES 245–258.
We know that ACEs are common in all types of communities in the US. In Arizona, the number of children with two or more ACEs is significantly higher than in the US as a whole. In Arizona children ages 12 to 17, over 44% have experienced two or more ACEs, compared to the national average of 30%.
For children ages 0 to
17, over 31% have experienced two or more ACEs, compared to the national average of 22%. (2011/12 National Survey of Children's Health. Maternal and Child Health Bureau in collaboration with the National Center for Health Statistics. 2011/12 NSCH Data prepared by the Data Resource Center for Child and Adolescent Health, Child and Adolescent Health Measurement Initiative. www.childhealthdata.org.)
It’s estimated that nearly 70,000 AZ children have more than five ACEs. This is roughly equivalent to the population of Flagstaff, our 3rd largest city. (Estimates generated from 2011/12 NSCH data set and 2010 Kids Count population estimates.)
Marcia Stanton, Senior Injury Prevention Specialist,
THE
Center for Family Health and Safety, Strong Families
CONSEQUENCES LATER IN LIFE.
UNHEALTHY STRESS
ACES
BRING CAN HAVE DEVASTATING
OUT
OF
100
PEOPLE
...
Program, Phoenix Children’s Hospital (working to increase awareness of the ACE Research since 2006)
T
he last 20 years have seen an explosion of research on the epidemiology of adverse childhood experiences (ACEs), neurobiology of the impact of trauma on early brain development, the physiology of
the effects of chronic stress on the body, and the epigenetics of how toxic stress can be embedded in DNA. Together, these studies confirm that exposure to adversity can profoundly change the otherwise healthy child development and result in negative health outcomes across the life span. (Statistics from “The High Cost of Adverse Childhood Experiences” compiled by Krista Goldstine-Cole, education director at the Washington State Family Policy Council) Pediatric Digest, Winter 2016 Page 4
Children’s bodies adapt and develop in direct relation to their
policies, and practices that reduce and prevent childhood
environments. In fact, studies have shown a significant
adversity and build resilience in individuals, families, and
correlation between ACE scores and home environment. IN AZ,
communities because we know that adverse childhood
HIGHER
ACE
SCORES WERE FOUND IN CHILDREN WHO:
experiences can last a lifetime, but they don’t have to.
Live in poverty Live in unsupportive neighborhoods
The Arizona ACE Consortium recognizes that well-being doesn’t
Spend hours playing video games and watching television
just happen. It’s built, like a house, through a network of
Have a physically ill parent
relationships and community assets that create stability and help
Take medication for attention deficit hyperactivity disorder
people to thrive. And just like any other construction project, well
(ADHD)
-being requires an investment of resources. Individuals can’t do it
Have problems at school
alone. It takes a strong community to raise strong kids. That’s
Have fewer family supports
why the Arizona ACE Consortium is working to help communities
Are an ethnic minority. What’s more, minority children have
make family mental health and support services available so that
a disproportionately higher share of six or more ACEs.
early interventions can take place. By offering this support early, communities put into place a framework that catches children
County-level child ACE estimates* reveal that some Arizona
before they fall, so they can reach their full potential. Studies
counties are hit harder by ACEs than others. This map shows the
show that these kinds of early investments pay off for everybody,
number of children within Arizona counties who have five or
because a child with a solid foundation becomes a member of a
more ACEs. *Estimates generated from 2011/12 NSCH data set
solid community who contributes to our economy later on.
and 2010 Kids Count population estimates.
CURRENT
INITIATIVES OF THE
ACE CONSORTIUM
INCLUDE:
Creating Trauma Sensitive AZ Schools Strong Communities Raise Strong Kids Train the Trainer Program – eight trainings throughout the state have resulted in over 500 “ACE Ambassadors”
Resilient/Trauma Informed Cities Initiative ACE Clinical Practice Work Group – discussing benefits and challenges of integrating ACE assessments in behavioral and integrated care
LEARN
WHAT YOU CAN DO TO BREAK THE CYCLE.
ARIZONA ACE
FOR
INFORMATION, VISIT:
azpbs.org/strongkids acestoohigh.com cdc.gov/ace cdc.gov/nchs/slaits/nsch.htm childhealthdata.org azdhs.gov/documents/prevention/womens-childrens-health/ reportsfact-sheets/issue-briefs/ACEsreport-2014.pdf
Center for the Developing Child at Harvard: http:// developingchild.harvard.edu/science/key-concepts/
ACEs in Pediatrics: http://www.acesconnection.com/g/acesin-pediatrics
TED Talk: Nadine Burke Harris: How childhood trauma
Founded in 2007, the Arizona ACE Consortium is a diverse group
affects health across a lifetime: https://www.ted.com/talks/
of individuals working together to create a strong and productive
nadine_burke_harris_how_childhood_trauma_affects_health
Arizona, where good health is available to all. We promote ideas,
_across_a_lifetime?language=en
Pediatric Digest, Winter 2016 Page 5
Developmental Screening: It Matters and We Can Do Better! SYDNEY RICE, MD, MSc, FAAP | TUCSON, AZ This year, a 2nd year pediatric resident starting a developmental pediatric mandatory rotation said to me, “I have never changed what I have done for a child based on developmental screening results.”
Many pediatricians may have the same opinion as this resident. In a busy practice, taking the time to complete a developmental screening tool can be challenging with so many needs to address in a wellchild visit. Developmental screening recommendations are complicated by a recent United States Preventive Services Task Force (USPSTF) report 1 that recommends no screening for children if parents do not have developmental concerns. The AAP has published several reports and commentaries on this Sydney Rice, MD, MSc, FAAP,
issue and continues to support routine developmental screening. 2
Developmental Pediatrics, Associate Professor of Pediatrics, University of
Developmental screening is the second level in ongoing review of a child’s development. The first level
Arizona, Tucson, AZ
of developmental review is developmental surveillance; this includes a history, review of clinical findings and a “gut” response to how the child is doing developmentally. The second level is the use of a
screening tool. The AAP recommends the use of a general developmental screening tool at age 9, 18 and 24 months and the use of an autism-specific screening tool at 18 and 24 months. The last level of review is a full evaluation for concerns noted on surveillance or screening.
Developmental surveillance and screening are under the purview of a primary care pediatrician and are not necessarily linked to a diagnosis. Rather, they are associated with a parent or physician concern. Developmental screening may lead directly to a diagnosis, but it may also bring to light an important concern that requires significant further evaluation and the engagement of subspecialists.
WHY PERFORM DEVELOPMENTAL SCREENING? 1.) EARLY INTERVENTION IS EFFECTIVE. In many parts of our state, we do not have easy access to early intervention services and subspecialty services, but identifying a child as high risk developmentally and making appropriate and available referrals is essential (e.g., audiology, early intervention screenings, speech therapy). Parent education can be provided to help parents support their children with simple developmental supports and advice (e.g.: tummy time, increasing verbal interaction at home, reading).
2.) DEVELOPMENTAL SURVEILLANCE IS LESS EFFECTIVE THAN DEVELOPMENTAL SCREENING TO IDENTIFY DEVELOPMENTAL DELAYS. Multiple studies show that experienced pediatricians identify fewer than half of children with developmental delays using surveillance compared with developmental screening tools.3
An example well-known to Arizona pediatricians is our average age at diagnosis of autism in Arizona of *4 years and 7 months. 4 Many children in our state are diagnosed when they start school rather than in their early pediatric care years.
Educators do have the advantage
of seeing children daily in a classroom setting, but we are missing the opportunity to provide early intervention services to many toddler and preschool-aged children. We can do better! *New data from AHCCCS suggests time to diagnose is now 4 years and 10 months.
3.) PARENTAL SATISFACTION IS GREATER IN PRACTICES THAT USE DEVELOPMENTAL SCREENING TOOLS. There have been several studies showing that developmental screening tools decrease the “oh, by the way” comments as your hand is on the door to leave. In addition, there have been several qualitative studies reviewing parental satisfaction with developmental screening. Parents appreciate being asked about their children’s development.
Pediatric Digest, Winter 2016 Page 6
My children were born during my developmental fellowship training and I remember waiting for their pediatrician to ask me questions about their development. They were born before the AAP developmental screening guidelines were published, but I was disappointed that she did not ask much about their development. She may have assumed that I already knew plenty about development. But, in those well-child visits, I was a parent, not a physician and I wanted reassurance and education from an experienced doctor. I don’t think I am alone in that thought as a parent.
My response to the resident was providing developmental screening would help him be a more thoughtful and accessible pediatrician for his patients. I am watching with interest his progress through the residency program.
References:
1
Final Recommendation Statement, Autism Spectrum Disorder in Young Children: Screening, Recommendations made by the USPSTF, JAMA February 16, 2016.
2
Alanna J. Albano, D.O. and Garey H. Noritz, M.D., FAAP, AAP stands by recommendations on universal developmental screening, AAP News
September 1, 2016.
3
Guevara, JP, et al, Effectiveness of Developmental Screening in an Urban Setting, Pediatrics, January 2013, VOLUME 131 / ISSUE 1.
4
Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012, MMWR, Surveillance
Summaries, April 1, 2016 , 65(3);1–23.
AzAAP’s training and certification website, AzPediaLearning.org, offers M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-Up) tool training and certification course, in addition to an updated PEDS (Parents’ Evaluation of Developmental Status) tool training and certification course.
As a reminder, all AHCCCS plans will reimburse qualified medical professional for performing these services with proof of certification to the Council for Affordable Quality Healthcare (CAQH). Certificate trainings on AzPediaLearning.org are free of charge for members and $30 for non-members. PEDS tool is a fast, accurate, inexpensive screening, triage and surveillance tool which meets the accuracy standards set by the AAP. PEDS is an evidenced-based screen that elicits and addresses concerns about children’s language, motor, self-help, early academic skills, behavior and social-emotional/mental health. Description of the training: Users “click through” a slideshow presentation. After the last slide, you will be prompted to complete a post test. Finally, a certificate is generated for you to print for your records.
MCHAT is a 2-stage parent-report screening tool to assess risk for Autism Spectrum Disorder (ASD). It is a screening tool designed to identify children who should receive a more thorough assessment for possible early signs of ASD or developmental delay. Description of the training: At the conclusion of this presentation, participants will: 1) Describe characteristics of ASDs, 2) Identify screening tools for ASD, 3) Recognize effective behavioral interventions for ASD, 4) Indicate community services available for individuals with ASD, 5) Summarize medical treatments, including medications, for ASD.
Pediatric Digest, Winter 2016 Page 7
Early Literacy, Early Learning, Better Outcomes KATHY WATSON, MS, RN, CPNP | TUCSON, AZ Recent research conducted
Childhood literacy is an ongoing
have a more advanced vocabulary. This
in more than 30
concern throughout the United
prepares them for school and gives them
industrialized and
States, and specifically in
an advantage in pursuing additional
developing countries
Southern Arizona. Only 13% of
reading and writing education (Magar et
provides a view of literacy,
the children in this state
al., 2006).
numeracy and problem-
currently enter kindergarten
solving skills among adult
meeting early literacy skills
Yet, parents may not be aware of the
populations. (Hogan et al.,
standards (Literacy Connects,
importance of reading to each child from
2016). An important
2016a). Causes of this problem
birth (Kuo, et al., 2004). This vital
outcome of this study is
include “limited time, limited
information should be provided by the
the finding that the US
parental understanding of the
pediatric healthcare provider (Reach Out
sample of more than 9,000
key role of reading aloud, and
and Read, 2015b), who has a significant
people demonstrated
competition for the child’s
influence on parents of young children. As
interest and attention from
part of each well-child visit, anticipatory
other sources of entertainment,
guidance is conveyed routinely to the
such as electronic
caregiver (Chien et al., 2006). The topics
media” (American Academy of
to be covered during anticipatory guidance
results in the median range for literacy and
Kathy Watson, MS, RN, CPNP, AzAAP Early Literacy Committee
problem-solving, and in
Member, Tucson, AZ
the lowest range for numeracy. Based on these findings, a
Pediatrics, 2014, p.205). Researchers
have been developed by the experts in this
concern about the ability of the US
investigating this phenomenon indicate
field (Chien et al., 2006) including the
population to compete in the global
that children who do not have adequate
benefits of reading (Duursma, Augustyn &
marketplace arises (Hogan et al., 2016).
reading skills and literacy are more likely
Zuckerman, 2008).
According to evidence, one approach to
to drop out of school and/or to develop
improving literacy is to introduce the idea
behavioral concerns (Gurevitz, Geva, Veron
of reading to infants and young children
& Leitner, 2012). Childhood social issues
AZAAP’S EARLY LITERACY COMMITTEE
during visits to the pediatric healthcare
that may arise when reading skills and
REVIEWS AND EVALUATES THE IMPACT
provider (Zuckerman, & Khandekar, 2010).
literacy are deficient include poor school
OF EARLY LITERACY EFFORTS AND
achievement, attention-deficit/
WORKS TO DEVELOP AND PROMOTE
Pediatric healthcare providers have a great
hyperactivity disorders, and other acting
EARLY LITERACY INITIATIVES WITHIN
deal of influence on the parents of their
out behaviors (Gurevitz et al., 2012).
AZ
young patients. An important part of each
contrast, the positive effects of adults
CHILDREN ENTERING SCHOOL READY TO
well-child visit is the anticipatory guidance
reading with children are noted to be more
LEARN.
given to the parents by the provider (Chien
substantial when routine reading is
TO INCREASE PUBLIC AWARENESS OF
et al., 2006). The topics for inclusion in
established before the child reaches three
THE IMPORTANCE OF EARLY LITERACY
the anticipatory guidance have been
years-of-age (Mol, Bus, DeJong & Smeets,
ON CHILDHOOD DEVELOPMENT
developed by the experts in this field
2008). A 2004 study by Kuo, Franke,
INCLUDING THE
(Chien et al., 2006). Reading to young
Regalado and Halfon demonstrates that
PROGRAM, AND FOCUSES ON THE
children is a part of the guidelines for
reading to children beginning at birth has a
UNIQUE RELATIONSHIP BETWEEN
anticipatory guidance for all young
direct association with the child’s
PARENTS AND MEDICAL PROVIDERS TO
children, but is not always included
expressive language ability at three years-
DEVELOP ESSENTIAL SKILLS IN YOUNG
because of time constraints and knowledge
of-age. According to Magar, Dabova-
CHILDREN VIA THE EXISTING
deficits experienced by pediatric healthcare
Missova and Gjerdingen (2006), children
HEALTHCARE INFRASTRUCTURE.
providers (Reach Out and Read, 2015b).
who are read to regularly at a young age
In
TO INCREASE THE RATE OF
COMMITTEE
MEMBERS STRIVE
REACH OUT
AND
READ
Pediatric Digest, Winter 2016 Page 9
Reach Out and Read: A PROGRAM FOR EARLY BRAIN & CHILD DEVELOPMENT month-olds to put books in their mouths.
As a pediatric healthcare provider, you are frequently the only professional trained in child development with whom families have
Be aware that a highly prescriptive approach (“You need to
consistent, one-on-one contact before children enter school. In
read 20 minutes every day or your child will be at risk for
fact, most children see their pediatrician at least 10 times during
failure”) may increase parental anxiety, and make relaxed reading even less likely.
this interval. More importantly, parents view you as a trusted expert in development and genuinely value the guidance you give.
Give developmentally-appropriate guidance about enjoying books with the child. Remind parents to put the book down
The American Academy of Pediatrics (AAP) and the National
when their child begins to show she is totally uninterested.
Association of Pediatric Nurse Practitioners (NAPNAP) have officially
Parents can come back to the book later. Reading aloud should be fun for the parent and the child.
endorsed the Reach Out and Read model of early literacy promotion. Below are some basic tips on how to incorporate the
Sometimes children need to move even when an adult is reading to them. Encourage parents to let them move but
Reach Out and Read intervention strategy in your practice at 2
keep reading because children are often listening as they
patient check-ups (reachoutandread.org):
move around.
1. START
WITH THE BOOK.
Emphasize the importance of parents talking to their children
Give a brand-new book at the beginning of the visit, incorporating
because the more parents talk with their children, the larger
it during the exam. The book should be age appropriate and
vocabularies these children develop. Tell parents talking with
culturally sensitive for the specific child. Do not give it as a gift at
their children, during daily routine activities – in the car, at the
the end; use it to survey gross and fine motor skills, and cognitive
playground, during bath time – is very important.
and speech milestones. Model reading the book aloud to the child
Encourage parents to use books as an important part of bedtime and other transitions/routines. Books can help a child
and explain to the parent what you are doing and why.
settle down and prepare for bed or calm a child during a
2. OBSERVE
HOW THE PARENT AND CHILD INTERACT.
difficult wait.
Listen to the comments and observe behaviors. Give positive feedback or suggestions. Model effective reading techniques to
Interested in learning more about other evidence-based strategies
guide parents: point and name objects and colors, ask child
to enhance development of language and early literacy? Consider
appropriate questions, and employ silly/cute voices (and/or facial
becoming a Reach Out and Read provider. Parents who have
expressions) to make reading fun.
received the Reach Out and Read intervention are significantly more likely to read to their children and have more children’s books in the
3. TIE
EVERYTHING TOGETHER.
home compared to families who have not participated in the
Help the parent understand the importance of language and
program. In addition, children served by the Reach Out and Read
development skills. Talk about routines, power struggles, and
program score significantly higher on vocabulary tests. No other
control issues. Emphasize how reading together helps families
early literacy intervention has this kind of evidence base or impact.
create strong emotional bonds and positive lifelong memories.
FOR
MORE INFORMATION, VISIT
To enrich the anticipatory guidance given to parents about early
WWW.REACHOUTANDREAD.ORG OR CONTACT
AZAAP’S SENIOR
literacy, consider the following suggestions3 (Zero to Three Policy
COORDINATOR
EARLY BRAIN
Brief, Early Language and Literacy Development, February, 2011):
Help parents understand age-appropriate expectations for how their children will handle books and respond to stories i.e.) parents may need to be reassured that it is okay for 6-
Pediatric Digest, Winter 2016 Page 10
AND
OF
HEALTH INITIATIVES
CHILD DEVELOPMENT
FOR
AT LAURIANE@AZAAP.ORG.
References: 1&2
3
www.reachoutandread.org
Zero to Three Policy Brief, Early Language and Literacy Development, February, 2011
EBCD Resources **AZAAP
HAS COLLECTED A VARIETY OF RESOURCES TO HELP YOU CONNECT PATIENTS AND FAMILIES TO PROGRAMS AND SERVICES THAT
ADDRESS EARLY BRAIN AND CHILD DEVELOPMENT
ADAPT SHOP
(EBCD).
(SOUTHWEST HUMAN DEVELOPMENT)
CDC’S LEARN THE SIGN. ACT EARLY.
Unique workshop where young children with physical disabilities
Program aims to improve early identification of children with autism
and their families have access to an assistive technology specialist
and other developmental disabilities so children and families can get
who will identify, design and build individualized products
the services and support they need
https://www.swhd.org/adapt/adapt/
http://www.cdc.gov/ncbddd/actearly/milestones/
AZ DEPARTMENT OF EDUCATION: SPECIAL
CHILD CARE RESOURCE & REFERRAL
EDUCATION
Child Care Resource and Referral Arizona provides no cost consumer
Provides information and resources to parents, public education
education, information and resources to families, providers, and the
agencies (PEAs), state agencies, professional organizations and
community about child care
those who care for children regarding Child Find policies
http://www.arizonachildcare.org/
http://www.azed.gov/special-education/az-find/
CHILDREN’S DEVELOPMENTAL CENTER
(SOUTHWEST HUMAN
AZ EARLY CHILDHOOD REGISTRY
DEVELOPMENT)
The Registry provides professional development and training
Provides comprehensive assessment, diagnosis, therapy, and care
opportunities to early childhood career professionals
coordination to children from birth to age 5 using a blended medical,
https://www.azregistry.org/
developmental, and mental health approach. Referral programs include: Feeding Program, Comprehensive Developmental
AZ EARLY INTERVENTION PROGRAM (AZEIP)
Assessments, DIR/Floortime and ongoing developmental services/
Arizona’s statewide, interagency system of supports and services
early intervention.
for infants and toddlers with developmental delays or disabilities
https://www.swhd.org/programs/disabilities-services/
and their families. AzEIP partners with community providers to support families
DOLLY PARTON’S IMAGINATION LIBRARY
https://des.az.gov/services/disabilities/developmental-infant
Free high quality, age-appropriate books mailed directly to the homes of children age 5 or younger in funded areas of the state
AZ HEAD START ASSOCIATION
https://imaginationlibrary.com/
Provides comprehensive education, health, nutrition, and family services to poverty-level children and their families
EMPOWER PROGAM
http://www.azheadstart.org/aboutheadstart.php
ADHS developed the Empower Program in 2010 as a voluntary program to support licensed Early Care and Education (ECE) facilities’
AHCCCS BEHAVIORAL HEALTH INTEGRATION
efforts to empower young children to grow up healthy
The AHCCCS acute health plan for physical health services; the
https://www.theempowerpack.org
RBHA for behavioral health services https://www.azahcccs.gov/AHCCCS/Initiatives/CareCoordination/
FAMILY INVOLVEMENT CENTER
behavioralhealth.html
Serves as a partner in developing a new system of care for children with emotional, physical, and/or behavioral healthcare needs in AZ
BIRTH TO FIVE HELPLINE
(SOUTHWEST HUMAN DEVELOPMENT)
http://www.familyinvolvementcenter.org/
A toll-free, statewide question line, available Monday through Friday 8 AM to 8 PM, for parents, caregivers and professionals with
FIRST BOOK
questions or concerns about children birth to five
A nonprofit social enterprise that provides new books, learning
http://birthtofivehelpline.org/
materials, and other essentials to children in need https://www.firstbook.org/ Pediatric Digest, Winter 2016 Page 11
FIRST THINGS FIRST A public funding source dedicated to creating a family-centered, comprehensive, collaborative and high-quality early childhood system that supports the development, health and early education of all Arizona's children birth through age 5 http://www.firstthingsfirst.org/
FUSSY BABY PROGRAM
(SOUTHWEST HUMAN DEVELOPMENT)
An extension of the Birth to Five Helpline and offers support, and in some cases, home visiting, to families with infants who are hard -to-soothe https://www.swhd.org/programs/health-and-development/fussybaby/
GOOD FIT COUNSELING CENTER
(SOUTHWEST HUMAN
DEVELOPMENT)
An outpatient clinic that provides both in-home and in-office mental health assessment, treatment and support for infants, toddlers, preschoolers and their caregivers https://www.swhd.org/programs/health-and-development/good-fit -counseling/
PARENT PARTNERS PLUS
(SOUTHWEST HUMAN DEVELOPMENT)
Offers a centralized referral intake system and inter-program cooperation to ensure families in Maricopa County are linked with the most appropriate home visitation program and level of service to meet their unique needs http://www.parentpartnersplus.com/
REACH OUT AND READ Reach Out and Read is a nonprofit organization that gives young children a foundation for success by incorporating books into pediatric care and encouraging families to read aloud together http://www.reachoutandread.org/about-us/
SENSE PROGRAM Substance Exposed Newborns Safe Environment (S.E.N.S.E.) Program includes a coordinated system of care for substanceexposed newborns and their families https://www.swhd.org/programs/child-welfare/in-home-services/
STRONG FAMILIES AZ A network of free home visiting programs that helps families raise healthy children ready to succeed in school and in life with a focus on pregnant women and families with children birth to age 5 http://strongfamiliesaz.com/ **The EBCD Resource Page is not an exhaustive list of the resources available throughout Arizona. The list is intended to provide a starting point to help families access the services they need.
Self Regulation in Early Childhood: Help Needed! LORENZO AZZI, Ph.D.| PHOENIX, AZ Self-regulation, often considered a “cornerstone of early childhood development” (Gillespie & Seibel, 2006) was defined by Shonkoff and Phillips in their 2000 report From Neurons to Neighborhoods: The Science of Early Childhood Development as a child’s ability to gain control of bodily functions, manage powerful emotions, and maintain focus and attention. Babies are born with some capacities to self-regulate (e.g. sucking) and continue to develop these capacities over time and in relationship with caregivers. Parents serve as important allies in this emerging developmental capacity by helping babies regulate in many seamless ways. Parents, hold, rock, sing, talk in a soothing voice and provide many other supports to young children in a process referred to as “co-regulation.” Infant Mental Health experts agree that the experience of being “co-regulated” by a caregiver is fundamental in the healthy development of the emerging capacity of self-regulation. Ideally, the process of “co-regulation” begins in early infancy and individuals continue to experience this throughout their entire lifespan in various forms. Lorenzo Azzi, Ph.D., Clinical Psychologist, Southwest Human In some Western cultures, increased value is sometimes placed on young children being independent or being able to “self-regulate.”
Development, Harris Infant and Early Childhood Mental Health
When parents
Training Institute, Phoenix, AZ
over-value this capacity, they are at risk for missing cues from their child who may need some help or support managing a strong emotion. Professionals working with parents can be of great service by shifting the conversation from a focus on a child’s ability to self-regulate to a conversation about what cues or signals a child gives when they need some help. Professionals can talk with parents about how they recognize when a child’s emotions may overwhelm their capacity to cope and what sorts of strategies have been successful in helping their child manage intense emotions. Sometimes, parents’ managing their own discomfort with the expression of negative emotion and being able to stay with their child in a sensitive and empathic way may be the most challenging component to the process of coregulation.
Pediatric providers can start to help parents reframe children’s inability to cope with intense emotions alone. Different emotions can be
opportunities to provide sensitive nurturance and to teach regulation skills instead of becoming frustrated, losing control or disconnecting. Parents may need to take a few moments to calm themselves down first prior to engaging with a dysregulated child. To the extent that parents can remain calm and communicate verbally, through their facial expressions and body language which conveys to their child that they understand they are struggling with an intense emotion and allow them to get through it together.
In this atmosphere, children will often regulate much more quickly,
develop increased skill in regulating and experience their parent as supportive and available.
Professionals can also assist parents in understanding that self-regulation is not about cutting oneself off from experiencing “negative” emotions (such as sadness, anger and frustration) that are normal and healthy components of the human experience, but rather the capacity to maintain adaptive functioning and/or engagement (in a task and/or relationship) throughout the range of emotional experiences.
Some helpful questions that professionals may ask parents include: How can you tell when your child is upset/angry/frustrated? What signals does your child give to let you know that she needs help from you in calming down? Do you notice yourself having difficulty tolerating your own feelings when your child expresses negative emotions? What sorts of things can you do to remain calm and stay connected in a sensitive/empathic way?
Pediatric Digest, Summer 2016 Page 13
What strategies (such as breathing together, talking quietly, just sitting together) have you found to be most helpful for your child? The cues children give parents vary and will change throughout the course of development, as will parents’ responses to their children’s needs. There are countless ways in which parents can help children regulate their emotions but perhaps one of the most important elements in helping children experience, express and regulate their emotions is merely giving them the permission to do so in a sensitive, non-judgmental way.
Parents and professionals should remember that experiencing the entire range of human emotion is healthy and the ever-developing capacity to function through emotional states should be encouraged. Even as adults many of us sometimes feel overwhelmed with negative emotion and turn to a close confidant to help feel better. This isn’t an indicator of weakness or lack of independence. This doesn’t mean we don’t know how to self-regulate. It means there are times we need a little help from a trusted other. By helping our children regulate when they need help, we’re not infringing on their development of self-regulation. We are teaching them strategies and more importantly, we are teaching them that they are not alone when they need us the most.
Southwest Human Development: Early Childhood Resources CREATING A POSITIVE FUTURE FOR YOUNG CHILDREN Children’s Developmental Center Provides comprehensive assessment, diagnosis, therapy, and care coordination to children from birth to age 5 using a blended medical, developmental, and mental health approach. Our comprehensive team includes: pediatrician, psychologists, speech-language pathologists, occupational therapists, physical therapists, developmental specialists, care coordinators, and registered dietitian. Referral programs include:
Feeding Program, Comprehensive Developmental Assessments, DIR/Floortime (an evidence-based intervention for young children and families with developmental challenges, including autism spectrum disorder),
and ongoing developmental services/early intervention.
(602)468-3430; swhd.org/cdc
ADAPT Shop A unique workshop where young children with physical disabilities and their families have access to an assistive technology specialist who will identify, design and build individualized products. (602)633-8686; swhd.org/adapt
Good Fit Counseling Center
(Maricopa County Only)
An outpatient clinic that provides both in-home and in-office mental health assessment, treatment and support for infants, toddlers, preschoolers and their caregivers. (602)200-0434; swhd.org/goodfit
Birth to Five Helpline A toll-free, statewide question line, available Monday through Friday 8 AM to 8 PM, for parents, caregivers and professionals with questions or concerns about children birth to five. 1-877-705-KIDS (5437); birthtofivehelpline.org
Parent Partners Plus Offers a centralized referral intake system and inter-program cooperation to ensure families in Maricopa County are linked with the most appropriate home visitation program and level of service to meet their unique needs. (602)633-0732; parentpartnersplus.com
Pediatric Digest, Summer 2016 Page 14
SENSE Program: Substance Exposed Newborn Safe Environment SUE SMITH, M.Ed, CPM | PHOENIX AZ
S
ubstance exposed newborns are a growing population
The SENSE program began in Maricopa County, Arizona in 2006 as a
in the United States due to increasing substance and
result of a pilot program, Project Thrive. The program showed positive
alcohol abuse during pregnancy and this includes the
outcomes for families with substance exposed newborns when
rising opiate dependency epidemic. Substance exposed
intensive in home services and substance abuse treatment were
newborns are the most vulnerable of children due to their exposure
provided. Over the last year, DCS started expanding the SENSE
to substances prenatally and they’re at greater risk of abuse and
program to other parts of the state and plans to continue this
neglect if parental substance abuse continues.
expansion.
Child welfare agencies struggle with intervention when a child is born
SENSE
substance exposed, and this often results in the removal of the child
ENSURE CHILDREN ARE SAFE IN THE HOME WHILE THEIR PARENTS
IS A MULTIDISCIPLINARY TEAM APPROACH, INTENDED TO
from the home. A
MAKE BEHAVIORAL CHANGES. To be eligible, the family must have a
removal creates more
DCS report with allegations of a substance exposed newborn. The
trauma, which may lead
children must be able to safely remain in the home and the parents
to multiple out of home
must choose to participate.
placements, longer stays in foster care and disruptions in family relationships.
THE SENSE
TEAM INCLUDES THE:
DCS Specialist In home team (masters level Counselor and a Family Support Specialist)
In Arizona, the Department of Child Safety (DCS) advocates for maintaining a child/
Substance abuse treatment provider Healthy Families Family Support Specialist Home Health Nurse Family
parent relationship. This
Sue Smith, M.Ed, CPM, Department of Child Safety, Prevention Administrator, Phoenix, AZ
is done by keeping
SENSE is a unique service delivery program where communication is
substance exposed
essential. In order to participate in this program, the family must sign
newborns in the parent’s
a Release of Information allowing all team members to communicate
care, when safe to do
about the family and service delivery. SENSE involves up to five in
so, with a program
home visits each week by team members. Collaboration occurs in the
called Substance
family's home where the service plan is developed and reviewed
Exposed Newborn Safe
during at least three critical points in the case. Service providers and
Environment
DCS participate in weekly email communication, to ensure the children
(SENSE).**
are safe, behavioral changes are being made and barriers or concerns
Pediatric Digest, Winter 2016 Page 15
are addressed. As the family progresses in services towards positive outcomes, the number of visits to the family slowly decreases encouraging family independence and self-sufficiency.
The SENSE program is the only program at DCS that incorporates a nurse home visitor as part of the service team. This component is vital to the program and aids in addressing developmental delays, social and emotional development, health and safety concerns, and ensures appropriate interventions outside of the SENSE program.
Families that complete the SENSE program participate in a Protective Factors Survey at the beginning and end of the program, the Ages and Stages Questionnaire, post-partum screenings, random drug testing and SIDS prevention/safe sleep curriculum. Families that complete services report that, although the number of visits was
More notably, 91.9% of those service referrals show families that
overwhelming at first, the team was an integral part of the success.
completed services did not have a child removed 6 months after services. SENSE is a family centered, strengths based approach to serving families, while holding them accountable for healthy choices and behavioral changes.
After DCS case closure, families can continue with Healthy Families home visiting services, up until the child is five years old, and the substance abuse recovery maintenance program, as long as they want to participate. THAT MAKES SENSE!
**Newborns can be enrolled in the SENSE program immediately after delivery.
Data over a 2 year period involving 493 SENSE service referrals,
FOR MORE INFORMATION ABOUT THE SENSE PROGRAM CONTACT DCS PREVENTION ADMINISTRATOR, SUE SMITH, AT SUSANSMITH@AZDES.ORG
shows 90.3% of families that completed the SENSE program had no DCS reports 6 months after completion of services.
Save-the-Date: PEDIATRICS IN THE RED ROCKS CONFERENCE CELEBRATING 40 YEARS The AzAAP CME Committee is happy to host the 40th Annual Pediatrics in the Red Rocks Conference
June 23-25, 2017 at the Hilton Resort
in Sedona. Topics Include: Pediatric Psychiatry, Infectious Disease, Sports Medicine, Gastroenterology, Child Abuse and more.
The conference will provide education for primary care and hospitalist pediatric professionals. Sessions are held in the morning so the afternoons are free to enjoy beautiful Sedona and spend with family. We will again offer opportunities to take part in AzAAP committee meetings, receptions, and multiple networking occasions. We have special activities in store as the conference will be celebrating its 40th year!
Pediatric Digest, Summer 2016 Page 16
Promoting Healthy Development of Young Children in Arizona MAUREEN CASEY, MA | ARIZONA EARLY INTERVENTION PROGRAM (AzEIP) Healthy development supports children
Additionally, the Department
to be ready for school. Luckily, in
of Economic Security
Arizona there is a continuum of
provides vouchers for
programs to support families to keep
families who need child care
development on track and to assist
due to work commitments or
when help is needed.
to enable parents to Maureen Casey, M.A.,
participate in education
MEDICAL HOME
programs. High quality child
As pediatricians, who have frequent
care programs assist
contact with young children and their
families to support their
families, you are at the frontlines to
child’s healthy development.
AzEIP Program Administrator, Arizona Department of
help families to set expectations, and
development. Partnering with families,
ANTICIPATORY GUIDANCE AND SCREENING
you, and your staff, can help families to
Pediatricians, home visitors, and child
learn what to expect across the various
care program staff can all provide
developmental domains, how to
families with information about
support their child’s learning and
developmental milestones, using the
development, and what to do when
CDC’s Learn the Signs. Act Early
they have concerns. Every child should
materials. Screening should take place
have a Medical Home and discussion of
at a minimum when children are 9, 18,
typical developmental milestones
24 or 36 months old. Everyone who
should be a part of those regular visits.
completes screenings with families must
assist them to support their child’s
be properly trained, and should provide
HOME VISITING & CHILD CARE
guidance when there are developmental concerns. AZ Early Childhood Registry
Some families, may require additional
will help you find a screening training
support and assistance and should be
near you (https://www.azregistry.org/).
referred to home visiting programs that can support them to learn more about
HEALTH PLAN SUPPORT
how to help their child to grow and
AHCCCS requires that all contracted
develop. There are home visiting
health plans provide EPSDT (Early
programs that support children who are
Periodic Screening Diagnosis and
at risk for developmental delay due to
Treatment) for children birth thru age
medical environmental or other factors-
18. Pediatricians can refer AHCCCS-
First Things First and Strong Families
eligible children birth to 19 through their
AZ have comprehensive list of available
AHCCCS health plan to evaluate a child’s
home visiting programs by county.
development to address area(s) of
Economic Security, Phoenix, AZ concern (e.g., speech, physical—fine or gross motor. They can also refer children to specialized providers (e.g., neurologists, orthopedists, developmental pediatricians) or to the Regional Behavioral Health Associations (for behavioral health concerns). Similarly, private health plans have procedures for evaluations and referrals to specialists.
SIGNIFICANT DEVELOPMENTAL DELAYS OR DIAGNOSED CONDITIONS For children birth to age 3, AzEIP provides specialized support to families with children with a diagnosed condition with a high probability for developmental delay (Down syndrome, Autism, Grade III hemorrhage, etc.), or a 50% delay in one or more of the developmental domains.
Preschool Special Education programs within local school districts
Pediatric Digest, Winter 2016 Page 17
provide special education and related
whether or not a child is
services to children ages 3-5 who meet
eligible for early
state eligibility criteria because they
intervention services,
are experiencing developmental delays.
and further that if
Knowing which programs support which
eligible, complete a
children and families, can ensure
multidisciplinary
everyone does their part and that when
assessment of the
a family needs more support they are
child’s unique strengths
referred to the most appropriate
and needs, across five
program to help them meet their child’s
domains (cognitive,
developmental needs.
communication, adaptive, social and
Individualized Family Service Plan (IFSP)
emotional, and physical) to determine
team, made up of the family, AzEIP
how the child’s developmental delays or
Service Coordinator and the evaluation
disability affect the child’s ability to
team, develop outcomes that the team
participate and engage in everyday
and family, will work on together to
The Individuals with Disabilities
routines and activities. Families are
assist the child to grow and develop.
Education Act, Part C (IDEA), which
invited to participate in a family
governs the Arizona Early Intervention
assessment which assists the family to
Since 2013, AzEIP has utilized a team-
Program, (AzEIP), is celebrating its
identify their concerns, priorities and
based early intervention services
30th Anniversary this year. IDEA,
resources. Taken together, the
approach statewide, ensuring that every
requires that a multidisciplinary
Evaluation, and Child and Family
family has a team. During the Initial
evaluation team (MET) determine
Assessment data, are used by the
IFSP Meeting, the family and team
TEAM-BASED EARLY INTERVENTION SERVICES APPROACH
select one team member to serve as the Team Lead, or primary provider, who, with support from the other team members, will carry out the IFSP outcomes. AzEIP pays teams to meet weekly to coach one another, and requires that teams discuss each child and family’s IFSP at least once a quarter, during that meeting, to ensure that the family is being supported by the team across all developmental domains. Team members may also perform joint visits, where a second team member may join the Team Lead on a visit with the child and caregiver to provide support to the Team Lead and caregiver.
REFERRAL RESPONSE TIME Under IDEA Part C, teams are required to determine if the child is eligible and complete the Child and Family Assessment and Initial Individual Family Service Plan (IFSP) with 45 calendar days of the referral. In Arizona, service coordinators contact families within 2
Pediatric Digest, Summer 2016 Page 18
days of receipt of a referral, and hold an initial visit within 10 days of that
referral. In FFY 2016, the average number of days from referral to initial
IFSP by Arizona Early Intervention Programs was 38 days.
ELIGIBLE CONDITIONS Arizona defines as eligible, a child between birth and 36 months of age,
who is developmentally delayed or who has an established condition that has a high probability of resulting in a developmental delay.
Hydrocephalus;
WEB LINKS & REFERENCES
Neural tube defects (e.g., spinal
First Things First
bifida);
http://www.firstthingsfirst.org/
Intraventricular hemorrhage, Grade
Strong Families AZ
III or IV;
http://strongfamiliesaz.com/
Periventricular leukomalacia;
Child Care Resource & Referral
Cerebral Palsy;
http://www.arizonachildcare.org/
Significant auditory impairment;
CDC’s Learn the Sign. Act Early.
Significant visual impairment;
http://www.cdc.gov/ncbddd/actearly/
Failure to thrive/pediatric
milestones/
undernutrition;
AZ Early Childhood Registry
Severe attachment disorders; and
https://www.azregistry.org/
Disorders secondary to exposure to toxic substances, including fetal alcohol syndrome.
A child birth to 36 months of age will be considered to exhibit developmental
The state’s definition of an eligible child
delay when that child has not reached
does not include a child who is “at risk”
50 percent of the developmental
of having substantial developmental
milestones expected at his/her
delays if early intervention services are
chronological age, in one or more of
not provided.
FOR QUESTIONS OR TO LEARN MORE ABOUT ARIZONA EARLY INTERVENTION PROGRAM (AZEIP) SERVICES, CONTACT THE PROGRAM ADMINISTRATOR, MAUREEN CASEY, AT ALLAZEIP2@AZDES.GOV OR 602-532-9960.
the following domains:
Physical: fine and/or gross motor and sensory (includes vision and hearing);
Cognitive; Language/communication; Social or emotional; or Adaptive (self-help).
Established conditions that have a high probability of developmental delay include, but are not limited to:
Chromosomal abnormalities; Genetic or congenital disorders; Disorders reflecting disturbance of the development of the nervous system, such as autism spectrum disorders, seizure disorders, and children born addicted to narcotics, alcohol or an illegal substance;
Congenital Infections, such as congenital cytomegalovirus, congenital toxoplasmosis and congenital rubella;
Metabolic disorders;
Pediatric Digest, Winter 2016 Page 19
STANDARD 5: Limit serving fruit juice to no more than two times per week.
STANDARD 6: Serve meals familystyle and do not use food as a reward.
STANDARD 7: Provide monthly oral health education or implement a tooth brushing program.
STANDARD 8: Ensure that staff members and child care providers receive three hours of training annually on Empower topics.
Look to Empower:
STANDARD 9: Make Arizona Smokers’ Helpline (ASHLine) education materials available at all
ADVICE TO GIVE FAMILIES REGARDING CHILD CARE
times.
10 WAYS TO EMPOWER CHILDREN TO LIVE HEALTHY LIVES
STANDARD 10: Maintain a smokefree environment.
Healthy habits begin at home and in child
minutes of sedentary activity at a
IF YOU WANT TO LEARN MORE
care facilities where children spend a
time.
OR SHARE INFORMATION ABOUT THE
large portion of their day. The Arizona
EMPOWER PROGRAM AND
Department of Health Services (ADHS)
STANDARD 2: Practice “sun
SUPPORT HEALTHY CHOICES IN
Empower Program focuses on 10 ways to
safety.”
ARIZONA’S EARLY CARE AND EDUCATION SETTINGS,
Empower is a voluntary program in which
STANDARD 3: Provide a
PLEASE VISIT
licensed child care facilities receive a
breastfeeding-friendly
WWW.THEEMPOWERPACK.ORG
discount on their child care licensing fees
environment.
empower children to live healthy lives.
that meet the needs of the children they
STANDARD 4: Determine whether
serve.
the facility is eligible for the United
BONNIE WILLIAMS, EARLY CARE AND EDUCATION MANAGER AT ADHS, IS
States Department of Agriculture
AVAILABLE TO ANSWER
EMPOWER CHILD
(USDA) Child and Adult Care Food
QUESTIONS AS WELL AT
ARIZONA
Program (CACFP), and participate
602-542-2847 OR BONNIE.WILLIAMS@AZDHS.GOV
by pledging to implement 10 standards
STANDARDS
FOR
CARE FACILITIES
IN
if eligible.
STANDARD 1: Provide at least 60 minutes of daily physical activity, including adult-led and free-play. Limit screen time to three hours or less per week and no more than 60
Pediatric Digest, Summer 2016 Page 20
Developmental Preschool Makes a Difference in the Lives of Children: Understanding the Role of the Pediatrician JUDITH CENTA, M.Ed. AND GAYLE GALLIGAN, Ed.D. | DEER VALLEY UNIFIED SCHOOL DISTRICT
A
child passes a large wooden block to another child calling, “put this on top” while pointing to the towering garage. In the mix of this construction area another child is lying on his
tummy pushing a small green dump truck through the wooden tunnel with exuberant sound effects. In the back of the room, a speech therapist is talking with two small girls while playing bingo. In the corner, several children are dressing in costumes to match the colorfully beaded crowns they created by cutting and gluing at the art station. At first glance this looks like a typical classroom, but at the foundation of all this play are rich learning opportunities created by teachers and therapists for students with specific developmental delays.
Judith Centa, M.Ed.,
Gayle Galligan, Ed.D.,
Literacy Curriculum, Instruction and
Deputy Superintendent of Curriculum,
Assessment Specialist, DVUSD
Instruction and Assessment
Phoenix, AZ
Specialist, DVUSD,
The long-term importance of early childhood learning cannot
Phoenix, AZ
be understated. When learning challenges are identified at a young age, early intervention can build competencies that extend well into elementary and middle school. All children need opportunities to develop adaptive, cognitive, language, motor, and social emotional skills through developmentally appropriate practices with like age peers. Pediatricians play a vital role ensuring children with developmental delays have the opportunity to participate in and experience learning in high quality developmental preschools. For children birth through age five, developmental screenings at yearly well check appointments provide insight and also help rule out potential developmental challenges. Pediatricians are frequently the first professional to notice when a child is exhibiting “red flags”, so it is crucial that the identified concerns are shared with parents. Pediatricians are a highly regarded and dependable source of information for parents. Through this relationship, the trusted pediatrician must encourage and support parents to contact, and then take a child demonstrating delays to their state or local school agency for a full developmental screening.
Child Find** is a component of the Individuals with Disabilities Education Act that requires Public Education Associations to locate, identify, and evaluate all children with possible disabilities who may be in need of early intervention or special education services. Pediatricians are the respected voice and the first link in helping families obtain child therapies during the critical birth to five years; ensuring children have all the necessary skills to be successful when they enter Kindergarten.
Developmental screenings articulate how a child is developing when compared to his/her peers of the same age. Children with identified delays benefit from inclusion within a developmental preschool classroom that offers intensive intervention and an environment conducive to learning. Students participate in preschool classrooms that integrate services from the developmental preschool teacher, as well as speech, occupational, and physical therapists with specially designed instruction to address and meet the individual needs of all children. Services are provided to assist children in reaching their developmental milestones and continue on a path of success.
Pediatric Digest, Summer 2016 Page 22
For children who have developmental delays, the partnership between parent, pediatrician and developmental preschool starts in the earliest of years. When delays have been identified, helping parents understand and embrace the benefits their child will experience through early screening and participation in a developmental preschool program may be the difference between years of struggle or a healthy positive school experience.
**Pediatricians can use a reference to the Child Find mandate in the referral letters they write for families to give to the schools. The Child Find Mandate: Schools are required to locate, identify and evaluate all children with disabilities from birth through age 21. The Child Find mandate applies to all children who reside within a state, including children who attend private schools and public schools, highly mobile children, migrant children, homeless children, and children who are wards of the state. This includes all children who are suspected of having a disability, including children who receive passing grades and are “advancing from grade to grade.” The law does not require children to be “labeled” or classified by their disability. (www.wrightslaw.com)
RESOURCES AND REFERRAL FORMS FOR PEDIATRICIANS If a concern about a student is identified through screening procedures or review of records, the parents of the student shall be notified of the concern within 10 school days and informed of the public agency’s procedures to follow up on the student’s needs.
Testing and results must be
completed in a timely manner which is typically within 60 days. Pediatricians can find resources and referral forms at: http://www.azed.gov/special-education/az-find/
PARENTS CAN FIND THEIR LOCAL SCHOOL DISTRICTS AT: https://www.ade.az.gov/edd/default.asp
Pediatric Digest, Summer 2016 Page 23
First Things First: A Pediatrician’s Partner in Promoting Positive Brain Development KATHLEEN VEDOCK, DO, FAAP | BISBEE , AZ As a mother and a pediatrician, I know that early childhood experiences impact whether a child’s brain develops in ways that promote future learning. Higher quality experiences generally result in increased cognitive development.
Pediatricians are among a family’s most trusted voice for early childhood information – second only to their own parents. Because of this, we are in an excellent position to share information and resources that can help parents feel more confident in their role as their child’s first teacher.
One of the most substantial resources that I continue to experience is First Things First (FTF). FTF represents Arizona’s largest public investment in early childhood development. Working through local
Kathleen Vedock, DO, FAAP, Copper Queen Community Hospital,
volunteer councils, FTF prioritizes and funds programs that strengthen families and improve the
Pediatrics, Bisbee, AZ
quality of early learning in child care settings and preschools, including scholarships for low-income children. FTF also helps families access preventive health care such as oral health and developmental and sensory screenings.
As pediatricians, we focus on providing quality medical care, conducting regular screenings and using the Bright Futures guidelines and materials to promote positive interactions between families and their young children. Now, we can also use FTF as a resource to help families understand the importance of infant brain development and gain access to programs that support their child’s health and learning.
Here are a few suggestions on how pediatricians can partner with FTF:
CONNECT FAMILIES TO HIGH QUALITY EARLY CHILDHOOD INFORMATION: Encourage families to visit FirstThingsFirst.org, and follow First Things First on Facebook or Twitter, so that they have access to a steady stream of high quality early childhood information and resources.
REMIND PARENTS OF SUPPORTIVE RESOURCES AT THEIR FINGERTIPS: FTF provides the Arizona Parent Kit – free of charge – to parents of all newborns in the state before they leave the hospital or birthing center. It is also available for checkout at libraries statewide. The Kit includes early childhood development information and a magnet with the Birth to Five Helpline telephone number. The Helpline offers parents an opportunity to ask a nurse or other early childhood professional their toughest parenting questions at times when parents often need an answer the most.
SPREAD THE WORD: Locate your local Regional Partnership Council at FirstThingsFirst.org and use your region’s Family Guide to Services to learn more about the early childhood programs funded in your community. Share the information with parents and offer the guide to families in your clinics and waiting rooms.
SERVE ON A REGIONAL COUNCIL IN YOUR COMMUNITY: Decisions about which early childhood programs are funded in each area are made by local councils comprised of community volunteers. By law, each of these regional councils must include a health care representative. By serving on a regional council, you can help inform and improve the system of early childhood health and development in your community. You can also help build and expand partnerships with other public and private agencies that ensure children in your area arrive at kindergarten healthy and ready to succeed. Visit FirstThingsFirst.org/serve to learn more.
AS
PEDIATRICIANS, WE WORK DILIGENTLY TO ENSURE INFANTS, TODDLERS AND PRESCHOOLERS ARE AS HEALTHY AS POSSIBLE.
PARTNERING WITH
FTF
AND CONNECTING PARENTS TO THE
FTF
RESOURCES IN OUR COMMUNITIES, WE CAN ALSO HELP ENSURE THAT OUR
KIDS ARRIVE AT SCHOOL PREPARED TO SUCCEED IN KINDERGARTEN AND BEYOND.
Pediatric Digest, Summer 2016 Page 24
BY
AzAAP Member Spotlight
bowling - all of the kids with different special needs and all of the siblings. Then, we had pizza and those who could, went roller skating.
ROBIN K. BLITZ, MD, FAAP | PHOENIX, AZ
I went to kindergarten thinking that everyone
WHAT IS YOUR BACKGROUND? I was born in Cleveland,
had a sister or brother
Ohio, and lived in Ohio until residency, when I moved to DC. After
with a "different ability".
that, I completed a fellowship in Developmental-Behavioral
My parents and my sister
Pediatrics at University of Maryland, Baltimore, MD. I got married
taught me that every
to my late husband, Jon Blitz, during fellowship and lived in
person has something to
Bethesda, Maryland. After fellowship, I started the developmental
contribute, that every
pediatric programs at Prince George’s Hospital Center in Prince George’s County, Maryland. I started our NICU-follow-up program, a program for drug-exposed children and their families (with the health department and the school system), and our ADHD / learning disabilities clinic.
We moved to Arizona in 1996. I initially worked with Dr. Raun Melmed in private practice and started the PIMC Development Clinic with the help of a CATCH grant and then a grant from St. Luke’s Charitable Trust. I also worked at the CRS clinic for 9 years. In 1999, I joined Dr. Danny Kessler at St. Joseph’s Hospital in developmental pediatrics, for 10 years. During that time, I directed the NICU-follow-up program, started a screening and health passport program for children entering foster care, saw children with developmental and behavioral disorders (autism, dev delays, ADHD, learning disabilities, etc.), taught residents and medical students, and we also had a foreign adoption clinic. I moved to Phoenix Children’s Hospital in 2009.
Robin K. Blitz, MD, FAAP,
person has different
Section Chief and Director of
strengths and abilities,
Developmental Pediatrics, Barrow
and that every person
Neurological Institute, Phoenix
deserves the chance to
Children’s Hospital
be happy, healthy, and successful. Being a
developmental pediatrician gives me the chance, every day, to help other families make a difference for their children. As a developmental pediatrician, not only do I get to take care of children and their families, but I also have the privilege of teaching residents, our future pediatricians, to identify, early, those children who may need more developmental and behavioral help.
WHAT’S DIFFERENT ABOUT YOUR PRACTICE AS COMPARED TO OTHERS? I have been at Phoenix Children's Hospital (PCH) for over 7 years. At PCH, Developmental Pediatrics is part of the Barrow Neurological Institute at Phoenix Children’s Hospital along with Neurology, Neurosurgery, Psychiatry,
I am a big supporter of Universal healthcare for our country. Every single career move that I have made has been due to the need for healthcare / health insurance for my family, initially my late husband’s brain tumor, then my eldest son’s Crohn’s disease.
Psychology, Neuropsychology, and Rehab. We now have 4 great pediatric nurse practitioners and Dr. Mark Ruggiero works with us 2 days per week. We are currently the only hospital-based, boardcertified developmental pediatricians in Phoenix. Phoenix Children's Hospital has a large pediatric residency program,
Why did I choose developmental pediatrics? My oldest sister had intellectual disabilities and intractable epilepsy. My parents were wonderful advocates for her, always ensuring that she was able to be part of our family and part of our community. In the 1960's, there were not as many available recreational, educational, and support services that there are today. So, my parents, along with other parents of children with special needs, founded an organization to provide recreational opportunities, a summer camp, and a sheltered workshop. We spent every Saturday morning
training over 110 residents. It is a requirement that the residents receive training in Developmental pediatrics. Therefore, I get to work with all of the residents who train at PCH (pediatrics, medicine-pediatrics, and neurology fellows). In order to improve and expand their training, I worked with a team of people to develop our Developmental-Behavioral Pediatrics website: www.phoenixchildrens.com/dbpeds. We have expanded it to also provide information and resources regarding DBPeds topics for community physicians and other medical providers. It has been very well received by the residents, faculty and community. Pediatric Digest, Summer 2016 Page 25
Because one of my main missions is to train our future physicians
pediatricians in Arizona. Because of this, in 2015, with a generous
to understand the importance of a child's development, behavior,
grant from the Board of Visitors, we started Early Access to Care-
and participation in the family, I developed 3 different clinics in
Arizona (EAC-AZ).
which the residents play an active role - the ADHD Diagnostic
summary article for more information on this**.
I have attached our Q and A and also a
Clinic, the Autism Diagnostic Clinic, and the Developmental Delay Diagnostic Clinic. These are 3 very common disorders seen in
HOW HAS AZAAP HELPED YOU IN OVERCOMING
childhood and this way, our residents learn first-hand evidence-
CHALLENGES AND IMPROVING CARE? I received a
based diagnosis and treatment. On the development rotation, they
CATCH grant in 1997 from the AAP to study and then start the
also visit a variety of community resources / service providers for
Developmental Clinic at PIMC. This clinic has significantly
children with special needs.
improved access to care for Native American children in Arizona. Private organizations have provided funding for many of the other
In Developmental Pediatrics, we have 2 multidisciplinary clinics.
programs at PCH and previously at St. Joseph’s Hospital, including
Fragile X Clinic is for children with Fragile X syndrome and their
the Board of Visitors, St. Luke’s Charitable Trust, First Things First,
families. We are part of the 29 clinics in the country that make up
Leadership Circle of PCH, Arizona Health Department, National
the National Fragile X Clinical and Research Consortium. Our
Fragile X Foundation, and the National Down Syndrome Congress.
Pediatric Down Syndrome Clinic has been up and running for over
The AzAAP has worked tirelessly on behalf of children in
3 years. Having these 2 programs means that families affected
Arizona, promoting developmental and autism screening,
with these two genetic disorders no longer have to travel out of
lobbying for AHCCCS and insurance payment to PCP’s for
state to receive care in a coordinated, comprehensive program.
developmental screening, creating an Autism Consensus
Our goal for both programs is to supplement what the busy
document, amongst many other projects and programs.
primary pediatrician does in practice, provide the treating therapists and school programs with more information and
HOW DO YOU ADVOCATE FOR YOUR PATIENTS AND
recommendations and increased support to provide the child a
THE PROFESSION? I am on the AzAAP Advocacy Committee
medical home. Because I am based at Phoenix Children's Hospital,
and sit on the Governor’s Advisory Committee for Autism Spectrum
all of my patients have access to all of the other medical
Disorder and the Medical Policy Committee for Telehealth and
subspecialties that may be necessary to provide comprehensive
Telemedicine. Through these, I have advocated for statewide
care.
system change to lower the age of diagnosis and entry into intervention for children with ASD. I advocate for my patients, my
In addition to my time at PCH, I work one day a week at the
families, for state services and insurance services daily in
Phoenix Indian Medical Center. I have continued this
everything I do, for patients with autism, fragile x, Down
developmental pediatric clinic at PIMC for the past 19 years and
syndrome, children in foster care, and fetal alcohol spectrum
see Native American children from all over the state of Arizona.
disorders, to name a few.
There are 21 registered tribes in Arizona and all of them can see me at PIMC.
WHAT DO YOU DO FOR FUN? Now that my children are grown and are young adults, I am less likely to be going to the
Diagnoses that we may evaluate and treat at DBPeds at PCH
Arizona Science Center, the zoo, and Harry Potter movies. I still
include: Autism, ADHD, learning differences, developmental
have 2 little dogs at home who enjoy walks and jump up and down
delays, children with multiple disabilities, children who were born
as soon as I put on my tennis shoes. I love to travel and have had
prematurely, children in foster care and in adoptive homes who
the privilege of visiting faraway places such as Ecuador and the
have developmental and behavioral problems, children who were
Galapagos Islands, Hong Kong, Vietnam, Spain, Italy, Malta, and
born exposed in utero to drugs and alcohol, children with Fetal
France, as well as Alaska and the Caribbean in recent years. When
Alcohol Syndrome, children with genetic or neurological disorders
I grow up, I want to be a photographer, so I have been practicing
that are associated with developmental and behavioral problems.
that on my travels. For healthy activities, I enjoy hiking and swimming. For not so healthy, I enjoy dining out, chocolate and
WHAT ARE YOUR CHALLENGES IN CARING FOR
good wine!
CHILDREN? Challenges include lack of access for diagnosis and treatment, due to insufficient numbers of developmental
Pediatric Digest, Summer 2016 Page 26
**EAC-AZ Attachments: http://www.azaap.org/resources/Documents/EACAZ_QA_Overview.pdf; http://www.azaap.org/resources/Documents/ PR_Article.pdf
Children’s Circle HONORING AZAAP’S PHILANTHROPIC SOCIETY MEMBERS On Saturday, November 19th, AzAAP held an appreciation event for its Children’s Circle Charter Members and their invited guests. The reception was held at Durant’s, the up-scale downtown Phoenix restaurant built in the 1950’s where patrons famously enter through the back door to get an insider’s view of the kitchen operation. Members were honored with a gift to say thank you for their generous and impactful contributions. The Children’s Circle was launched to recognize donors who made a cumulative gift of $1,000 or more in a calendar year for AzAAP’ s general, unrestricted purposes. These generous contributors allow AzAAP to actively work to improve the health and well-being of Arizona’s children through innovative and evidence-based programs and initiatives, targeting the needs specific to Arizona:
Michael Arbel Trey Basha Bob Cannell Debra Carsten Arturo Gonzalez Dale Guthrie Stephen Holve
Gretchen Hull Jane (Lyndy) Jones Ruth Letizia Elizabeth McKenna Ruan Melmed Harry and Rosellen Papp Mike Perlstein
Kay and Ron Pinckard-Hansen John Pope Delphis Richardson Mary Rimsza Skip Rimsza Norm Saba
Amy Shoptaugh Barbara Smith Anne Stafford Peggy Stemmler Tamara Ledbetter Rickey Williams
Linda Samson
Right: Children’s Circle Charter Members receive a symbolic appreciation gift, an hour glass, to represent the importance of time in responding to issues that affect the health and wellbeing of children in our state.
QUESTIONS FOR THE EDITOR Above: Long-time AzAAP member, Dr. Ron Hansen, receives his Children’s Circle appreciation gift at the November 19th reception along with other
Dr. Cody Conklin-Aguilera is
fellow contributors, colleagues and friends.
Editor of Pediatric Digest and Secretary to the AzAAP Board
MAKE A GIFT TODAY Your $1,000 or greater donation qualifies you as an AzAAP Children’s Circle member, a philanthropic society with annual benefits including exclusive appreciation events, member communications and recognition (if desired) in AzAAP event programs and publications.
of Directors. She is Chief Medical Officer at the Public Health Department of Yavapai County and Pediatric Program Manager at the Yavapai County Community Health Center in Cottonwood.
To learn more about the Children’s Circle or make a donation, visit www.azaap.org/invest.
Questions and concerns pertaining to the newsmagazine can be directed to Leadership@azaap.org or 602-532-0137. Pediatric Digest, Summer 2016 Page 27
2600 N Central Avenue Suite 1860 Phoenix, AZ 85004
Announcing Member Benefit AzAAP Best Pediatric Practices (BP2) ListServ Network with your peers and learn helpful hints to run your pediatric practice more effectively! The BP2 ListServ, an AzAAP members only service, is a resource for networking with your colleagues about the successes, challenges, and helpful hints in running a pediatric practice. This email service is used to share practice management and administration advice to help best support our member pediatric professionals. Visit the link below for instructions on how to register today.
www.AzAAP.org/Member_Benefits