How to do Safety Screenings-Video: How to do Safety Screenings

Video: How to do Safety Screenings

Video Transcription

to welcome everyone to today's TCA webinar entitled Special Considerations, Safety Screenings  with Pediatric Patients. So we're happy to have Karen Gudik and Malik Coffey with us today  to go through some of these screening tools that you can use and hopefully you'll be able to  do some role plays and get some of your questions answered on such an important  topic area. So thank you so much for attending and joining us today and thank you Karen and  Malik for this webinar today. So why don't you go ahead and get started. Thank you. Good morning  everyone. My name is Karen and I work at Cardinal Glennon. I've been at Cardinal Glennon about 12  years. I'm the child abuse social worker and the trauma social worker here at Cardinal Glennon.  Good morning. I am Malik. I have been at Cardinal Glennon about three years now and I'm the clinical case manager for our Life Outside of Violence program  which tackles individuals or adolescents who are affected by gun violence,  significant assaults, and stabbings. So we have no financial interest or anything to do  so we have no disclosures to disclose. A couple of things that we hope that you gain out of this  presentation are knowledge of appropriate methods and tools when screening and then able to increase  your strategies and effective communication among pediatric patients. So we want to open up the  presentation with a quote by Plato which says, be kind for everyone you meet is fighting a battle  you know nothing about. We kind of want to open that up with that trauma lens because we know  we're going to dive into some sensitive topics. We encourage you guys to ask questions, use your  chat box, use the Q&A box. It will be monitored. We're looking for that interactive piece but we  also encourage you to take care of yourself. So if something triggers you or something pops up  take a break. The PowerPoint will be available so don't hesitate to step away if you need to.  We want you to take care of yourself. And if this is Christine, if you guys could just speak up a  little bit more that would be great. You're coming in clear just a little bit louder would be great.  Thank you. Okay gotcha. So we're going to open the presentation of course talking about why are  we screening for safety right. So of course the obvious is because we want to identify current  risks and future risks. We want that early detection piece so that we can intervene. If something's  happening we can put services in place but we also want to allow for prevention. So if we can stop  things from happening we know statistics tell us that prevention is best. And as you'll see in the  next coming screen statistics for all of the things that we're going to talk about are extremely high  so again that's why we screen. Absolutely. So screening tools when we think about what's the  function for a lot of screening tools is to serve as a guide right. So you want to be aware of the  tool that you're using and whether it's something that has to be implemented verbatim or something  that really is just there to kind of guide you along to get to a certain point. Most screening  tools are designed to be user-friendly but they're also designed to get in the moment data. So it's  happening right now. They're also designed to be appropriate for diverse populations. However  thinking about that is recognizing if there are limitations to the tool you're currently using.  Is it culturally appropriate? Are there adverse effects? So is it something that's causing more  stress and anxiety? Is it increasing trauma amongst the individuals you're screening for?  And so with that is that something where you need to modify that screening tool you're using or add supplemental pieces to it so that it's more comprehensive.  So for this particular presentation we're going to be focusing on substance use which is  particularly focusing on drugs, alcohol, and of course with adolescents tobacco use. We recognize  that tobacco use while we might not specifically address it is a part of that. We recognize the  type of things they use, vaping instruments, and things like that and how that relates to overall substance use. And the tool we'll be talking about specifically for that is the  CRAF screen but we'll also take a portion of the presentation and talk about violence. So both child  abuse and community violence and how do you screen for that in your environment. Whether that's your  pediatric triage questions or if you have specific intake questions that you use to assess for  community or child abuse. So the first topic we're going to talk about today is pediatric substance  use. And just going through a couple statistics, 60 percent of high school students report having  at least one drink of alcohol in at least one day during their life. Huge number. Alcohol is often  the first substance to be used. So what we have seen is you drink some alcohol you may not like  the effects of alcohol so then you go to marijuana and then marijuana leads to prescription opioid  use. And then the next statistic is 14 percent of students report misusing prescription opioids.  And many of those opioids that are are not even prescribed to them. They're prescribed to their  friend who's then giving it to them or someone else that they know. Or parents. Correct. Because  we know that happens too. So what are some long-term effects on pediatric substance use? It impairs the health and growth of the brain development. We also know that it increases  risky behaviors. We see tons of adolescents come in with STIs because of unprotected sex.  You'll see kids who are are drinking or high who are driving 120 miles an hour on a road that has  a speed limit of 35. We also know that it increases violence. Alcohol and drugs don't  necessarily cause violence but it increases it. So it causes that child who normally is just a bully  verbally to to throw that kid up against the locker or to punch them in the face.  It also increases mental health concerns and your suicide risk. It also causes developmental  issue other developmental health issues such as increased blood pressure, sleep disturbances,  and sometimes heart problems. So when we think about substance use we want to know like what  types of things are contributing to an adolescent's risk for this, right? Are there certain things  that make them more vulnerable? We do know that a family history of substance use does increase an  adolescent's use of picking up some type of substance. We know that parents who have a favorable attitude where they say it's okay to smoke as long as you smoke at home or it's okay  to drink as long as you drink with me. We know poor parental monitoring so lack of supervision  enhances that. We know in vulnerable adolescents such as LGBT youth, trans youth have greater use  of substances as a form of a coping tool. We know that lack of connection to schools, lack of connection to peer supports, history of childhood sexual abuse, existing mental health  conditions maybe that are the byproduct of previous trauma. We know statistics say that single family homes or the absence of a father contribute greatly to an adolescent's risk of  becoming dependent on some type of substance. We know that exposure to domestic violence  and community violence contribute to those increased risks for substance use among adolescents. People who are high or under the influence don't necessarily,  they want to, they forget about the abuse that is occurring. So that's why we see that increase.  If I'm high, I don't have to think about being assaulted by my dad or my significant other.  So that's a huge risk factor. So on the opposite side of that, what are the things that protect  that youth? What are the things that reduce those vulnerabilities? We know that again,  opposite is increased family engagement, right? Parents who are involved, parents who are asking  questions, increased family support, increased presence of supportive adults. Of course, monitoring of course is prevention, but again, that doesn't necessarily mean it stops it. It  just decreases the likelihood. And we know that youth who are connected to things that they have  an investment in. So our students who play sports, who have good friend groups, those things all  contribute to a decrease in the likelihood that they'll either move from just trying something to  actually developing a dependence on substances. And when we talk about that parent and that family  engagement, it's also talking to them about the reason drugs and alcohol aren't good. It's just  not saying, oh, don't use them. And the kids saying, why? And a parent saying, because I said  so. It's actually having that family that explains it, that educates them, that talks about the  effects long-term, short-term. So it's having that engagement within that family and that good support.  So moving on to our second topic, which is non-accidental trauma or child abuse. So again, starting out with statistics, nearly 700,000 children are abused in the US each year.  And that was a statistic from 2018. I believe that number is so underreported. And honestly,  with this pandemic that's going on, I believe so many kids are at home being sexually abused and  physically abused. And no one is there to report them because they're stuck in these households  with these families who are being abusive. They're not going out to schools. They're not going out to  their daycares. They're not going out to their extracurricular activities. So I do believe that  the numbers are extremely, extremely underreported. We see five children a day die from child abuse  and neglect. One kind of breaks down to one in seven kids experience abuse. We also know that  age and gender also influences the type of abuse. It's easy to pick up a one-year-old and slam them  across the room and throw them up against the wall, where that 15-year-old, you're not able to  do that. So the abuse looks different based on the age range. So one thing to take into  consideration when you look at child abuse or non-accidental trauma is what your definition is  for abuse. So every state's definition is slightly different. So for Missouri, abuse is defined as  any physical injury, sexual abuse, or emotional abuse inflicted on a child other than by accidental  means by those responsible for the care, custody, or control, except that discipline, including  spanking, administered in a reasonable manner, shall not be construed as abuse. So again, that's  Missouri's, but Arkansas might have something different, which I know they do. California has  something different, which I know they do. So they may all have similarities, but they all are very  different. So making sure you understand what your state's definition of abuse is is also very  important. So risk factors for child abuse. Families have low levels of education. If you  have a household with multiple people in it and you have small children and you're not able to go  to school because there's no one able to watch your child or not able to go to work because no  one's there to watch your child, you're going to have that low socioeconomic status and that low  education. As I said, you might have families that have multiple people living in them, but  there's no support. So I turn to Malik and say, hey, can you watch my child while I go to school  or work? And Malik's response to me is, no, I got my own kids. There's no support. There's no help.  There's no support, no help going on in that family. We also know that there's a lot of drugs  or alcohol abuse going on in these families. Again, covering up sometimes their own abuse from  past experiences or the abuse that they're going on now. Kids witness domestic violence is a huge  factor. Poor parenting. We also have unrealistic expectations of a child's ability. If I don't know  that a one-year-old is not supposed to be potty trained because nobody's teaching me that or I'm  not learning that in child development in school because I'm not able to go, when that one-year-old pees themselves, I'm going to take out my frustration on that child.  So again, it's also realizing what those expectations are. And how economics play a role in that too, right? So if you need your kid to be potty trained because of diapers or cost  or things like that, those things play a role in increasing the risk. And just recognizing like  COVID, some of the risks have changed too, right? Who's home? And not being able to send your kid  for that. And you have a parent who already has low economic status, but they lost their job  because of COVID and they're frustrated. They're confused. They don't know what to do. It just makes  kids at greater risk. Kids with disabilities and mental health problems also are at greater risk  because a lot of times they can't communicate what's effectively going on to them. So there's  tons of risk factors for child abuse. On the opposite end, protective factors. If you have  families that are supportive that you can reach out to, that's helpful. My son cried a lot as a  child and I was able to contact my mom and my sister on various occasions and say, hey, I need  help. Can you help me? So I had that in supportive environment. I had those people I could reach out  to. I also knew that it was okay to let him cry it out sometimes and to walk away because those  were things that I was gaining from that supportive environment I had. So people who have education,  who have stable families, who have good supportive environments, who can utilize their healthcare  systems to help you out, calling your primary care doctor and saying, what's going on? How can I help this child? Are all preventative factors that go along with child abuse.  So with that, turning to something as far as community violence. So when we think about how  we define community violence, we're talking about types of violence that affect the youth. So that  might be individual conflict, interpersonal, so that's the domestic violence portion,  school-based violence, so that's your bullying. That's tons of fights that are maybe more prevalent  at their school. It's visibility of gangs, the proposed threat of gangs, whether that's for  recruitment or actual involvement in gangs. That is the idea of living in places where shootings  in public areas, so school shootings, or just living in warlike conditions, such as a low  socioeconomic neighborhood where hearing gunshots is extremely prevalent and so much so that it's  almost like the norm. Or just even exposure to, maybe not physical violence, but the fact that  they hear gunshots, they're aware of it, it's coming through the news, it's coming through social media, and so just continual exposure to that concept of violence around them.  We know that children in the United States are more likely to be exposed to violence and crime  more so than adults. We know that 60% of our American children were exposed to violence, crime, or abuse in both homes, schools, and communities, and the U.S. currently has the  highest youth homicide rate amongst the world's wealthiest nations. And so with that being said,  if we just think about even the idea that firearms are the first leading cause of death for Black  children and teens, they're the second leading cause of death for American children and teens.  So when we take that into consideration, what we've come to realize is that gun violence is a  public health crisis. Firearm injuries and violence is a preventable situation, so we can  provide programming, we can provide interventions that will reduce that. But what we also know,  the other side of that is exposure to gun violence and community violence has lasting impact. And  like we said earlier, child abuse, substance use, those are sometimes the byproduct of multiple  experiences of trauma. So that's how you get to the PTSD, that's how you get to the chronic stress,  and some of those other things or other health disparities. And we know that on a behavioral side, some of the potential side effects to exposure to violence and community violence  in particular is increased anger and agitation, being withdrawn, and an overall desensitization  to violence overall. So the long-term impact, similar to as we've said in the other two  categories, is that it has the ability to produce debilitating mental health problems. So that means  increased depression, behavioral issues, decrease in relational ability, right? So being able to  have good interactions with your friends, being able to have a job because now you cannot relate  or interact well with other people. We know it adds to increased strain on systems, right? So  that's more hospitalizations, more children who are in foster care. We talked about this morning,  even just the idea of being able to get a holistic wellness and a full recovery from an injury  because they don't come to follow-up. So they don't utilize their healthcare system to become  comprehensively well, which is a long-term impact because now they may have mobility issues, they may  have long-term physical impact from that injury as well, not just the mental piece. And sometimes  our kids want to do those follow-ups, it's just the parents are lacking the resources and the  ability to get them to follow up. They don't know that there are resources out there to get them to  those appointments if they don't have transportation. So sometimes the kids want to go, it's just not  necessarily our families are able to understand what those resources are to bring them to those  appointments. Or even recognizing the idea of wanting to get back to normal, particularly for  our youth who have had some type of assault or experienced a gunshot wound, the desire to get  back to normal. So if I continue to engage with the hospital, continue to engage in these supports,  I'm not getting back to normal. And so therefore sometimes there's an avoidance there. We lost our clicker.  There we go. So some factors for increased exposure to community violence include, of course, a history. So if you've got youth who are in growing up in environments where they  themselves have been a victim of child abuse, they have had domestic violence in a home, of course, that greatly increases the likelihood, A, that they're going to be re-victimized,  they're going to be re-victimized, or that in turn they're going to become a perpetrator of  violence themselves. We know on an individual basis that's increased early aggressive behavior,  again, thinking back to that idea that they're now become desensitized to the idea of violence. We know that that is a heavy correlation with drug, alcohol, and tobacco use,  whether that's for a coping mechanism or just environmental elements. We know like Karen said,  low parental involvement. If you're not engaged in my recovery, if you're not engaged in how this  is experiencing me or how I'm experiencing this situation, then my likelihood of being okay with  community violence, it goes up. And again, substance use amongst parents and the individual  are factors. And then of course, poor family functioning. So that lack of support piece. So what we see here a lot is when we get these adolescents who come in that are victims of  gunshot wounds, we'll have families come in and we'll ask the parents what was happening prior to  the incident. And what we're realizing a lot of times is families have no idea where their kids  were, haven't seen them sometimes in days. So it's that poor family functioning, that lack of really wanting to know where that kid is and that being supportive to that child.  Yeah, and the other piece, and just saying really quickly, is that also sometimes increased  involvement with other things like youth who are already connected to juvenile systems. That adds  to the likelihood of them either being a victim or later on becoming a perpetrator of violence  themselves. And we see that quite a bit. Yep, very frequent. So as far as on the opposite end,  right, so what buffers are in place to keep this from happening? What reduces the impact?  So for the youth who's living in an environment, maybe they have not become a victim, per se,  of community violence, but they just live in one of those areas that we identify, right,  somewhere where they hear gunshot wounds every night. How do we help put some supports in place  to kind of keep them from becoming a victim? And again, that's connectedness. So we know that  having a attitude of being connected, so are they playing sports? Are they engaged with their  school? Do they have a positive adult in their life? Is it a mentor? Do they have good family  support? Do they have things that promote them to want to have a future? And I think that's the  big word is to have a future. So what we know from all these things that we talked about,  there are definitely common themes among them. We can, some of those common themes are economic  status. We've talked about how they come from poor communities, no jobs, lack of education.  We see that they have a high level of family dysfunction and or multiple people coming in and out of those homes, disorganized neighborhoods, low levels of community participation.  And like lack of activities, you know, like is there, are there things in that neighborhood for  those other basketball courts? Are there other things that promote a different reality? And if there are those basketball courts and there are those playgrounds, is it safe to send  them there? Is it safe to have them go out into those communities to have our kids know that they  can come home? So impact of trauma. We all know that violence and substance abuse are traumatic.  So when we look at the impact of trauma, we have to look at some numbers. 15 times more likely  to attempt suicide. Four times more likely to become an alcoholic.  Four times more likely to inject drugs. So you see a common factor here as well.  Two times more likely to, I'm sorry, 2.5 times more likely to smoke. So again, these are all factors that go along with community violence, substance abuse, and violence in general.  And overall health, right? So all of these things, alcohol, substances, smoking, stress, all impact  the mental health and the mental health in turn impacts overall health, which then leads to some  of those health disparities. So when we take trauma and we look at it, right, we started the  presentation with a quote because we wanted to utilize that trauma-informed lens. And so while  we recognize that trauma-informed care is not a specific set of practices, right, trauma-informed  care is this hot topic, it's a buzzword, we're hearing it everywhere, we're seeing it in magazines,  but it's recognizing that it's not something that we can do that says take A through C and do those  things and now you're trauma-informed. But rather it's a way of thinking, it's an awareness, it's how  you approach situations, how you approach your patients, how are you mindful of the fact that  maybe what I'm seeing right now with Karen may not just be because of this moment, it may be other  things that have happened that have contributed to her presentation today. So just wanting to,  you know, make that point of saying that we want to be aware, we want to increase our awareness,  and we want to understand that there are other things that might be contributing to what you're  getting right now in this current moment, which significantly impact how you engage. The other  piece is recognizing is that while these are sensitive topics, I think sometimes there's a  resistance to wanting to approach these topics because we worry, will we potentially re-traumatize  somebody? I don't want to, you know, re-inflict the wound, I don't want to kick off anything that's  going to create a headache or a problem or create resistance, but we have to recognize that the value  of screening sometimes outweighs the concern of re-traumatizing somebody, and it's a way in which  you approach it which can reduce some of the potential impact for re-traumatizing. Correct,  and if you can limit your amount of people asking these questions also helps as well. It's, you know,  if you have a social worker or a nurse that goes in and asks these screening questions versus the  social worker who asks them, then the nurse who asks them, then the doctor asks them, the more  people that act ask those questions potentially could also re-traumatize someone as well. So  looking at who is the best person on the team to kind of ask those screening questions to get and  to help them through that process. Right, that just circles back to speaking to the idea of being  trauma-informed, right? So if we're aware that this is sensitive, then maybe we don't need six  people going in asking those questions. Doesn't mean that a team approach or being collaborative  is not helpful, but it's just recognizing how much thought are we putting into this, how much  pre-planning are we putting into making sure we're preparing an environment that's supportive.  And asking questions that are not in, like you're not interrogating, that you're not accusing  somebody, that you're asking those open-ended questions so that people are able to engage and answer questions in their own words versus putting words into their thought process.  Absolutely. The other piece is, of course, just a lot of times, Karen and I, we get folks who  like are coming in, particularly in the emergency room type of setting, and the concern is that  there's this idea of PTSD. So if we recognize that with PTSD, it's a prolonged, right? So it's  happening over a duration of time. So if you're in a setting where you're seeing somebody on  outpatient basis and you see persistent symptoms like difficulty sleeping, nightmares, flashbacks,  and it's happening over six weeks, eight weeks, 12 weeks, then we may be looking at a situation of  PTSD versus a lot of times we're seeing acute stress. And so the more aware we are of what  we're seeing, the more we are normalizing it and in turn can help that individual normalize what  they're going through. And again, recognizing that these folks who may have had one experience of  trauma have greater risk for multiple experiences of trauma. So it's not saying PTSD is off the  table, but it's just being aware of like in the moment, we're probably seeing acute stress. How do we normalize it for them? How do we give language and create that environment?  And how to have nurses who work with these kids on the floors when a child has a nightmare or  constantly wants to talk about what just happened or is having flashbacks while they're sitting  there, how we can educate nurses to address those in the moment versus calling somebody else to come  in to address them. And again, it's just being that supportive person. And sometimes you don't  have to say a lot, but would you like to talk about it or what can I do to help you? So again, it's just how to address it in the moment to make a child feel safe.  Absolutely. So taking all that information and absorbing all of those pieces,  kind of getting our pulse on why we're screening. So we want to get started. And so the first thing  we need to be thinking of as we get ready to get started is that these are difficult topics.  They're going to make you feel uncomfortable. They're going to raise your anxiety because  you're asking something very personal. You're getting into things that are going on in somebody  else's household. And so part of that is then from there, after recognizing that they're difficult  topics, is also recognize any bias that we may have. What are our attitudes about substance use  among youth? What do we think about parents who abuse their children? What do we feel about people  who live in environments where communities that are just racked with gunshots and that's their  norm? What are our personal experiences that we come from communities like that? How does that  shape your feeling on these topics and in turn that in relationship to your comfort level?  And taking things into consideration as far as culturally, is there religious reasoning behind  what could be perceived as a child abuse? Like are those religious markings? Do you have a family  who's from a very rural place? So having firearms in the home is very normal because they are hunters  or you know what I mean? So just being mindful of those things and being aware of how they influence  what you're assessing for and what you're seeing. And then checking your comfort level.  The other thing you want to be is become familiar. If you don't know a thing about child  abuse or a thing about substance abuse is making sure you educate yourself and you train yourself.  When I took over the trauma job, I didn't know a whole lot of a lot of stuff. So I attended  trainings. I looked at those screenings. I became comfortable with them, you know, so that I wasn't  walking in completely nervous. And there are times I walk in and I'm completely nervous and  I've been a social worker 25 years and asking questions. But as long as I'm aware that sometimes  it's okay to be nervous and then I'm educating myself and training myself and practicing, that's all that I can do to get started and to feel more comfortable.  So going on to what the craft screening tool is. So we have heard that a lot of people utilize  the craft screening tool to screen for substance abuse. Many people don't have a knowledge base of  what the craft even stands for. So it stands for car, relax, alone, friends, family, forget,  and trouble. So what the craft screening tool is, and sometimes people have it on a card like this,  sometimes people have it in the computer, is a list of questions that you can ask in hopes to  engage people and to ask those questions. And some people will go in and read from the card or  the computer directly, and other people will go in and have conversations with kids in attempts to  gain that same knowledge. I will say going in and having a conversation versus reading directly off  the card or the computer definitely gets you more information. It engages them more, but there's nothing wrong with, again, reading from the card or the computer screen.  So what we're going to do now is we have a couple of role plays we're going to do throughout this,  but this first role play is we are going to go through the craft screening. We are going to go  through it with somebody who utilizes the card and or the computer to directly get those  information. But we're hoping that what we can do is also show that if you read it directly from the  card, you can try to get some rapport building and some engagement with that child. And then if  you can, if you have thoughts about this role play, things that pop up, things that maybe you do,  please don't hesitate to put things in the chat because we do want this part to be a little  interactive based on what you guys observe. Hi Malik, my name is Karen and I work here at the  hospital. One of my jobs is to talk to kids. How are you feeling today? I'm good. You're good. I'm  sorry that you're in the hospital, but hopefully you can get in and out of here as quickly as  possible. So as I said, one of my jobs is to talk to kids and sometimes I have to talk to kids about  sensitive topics. So I'm going to talk to you just a little bit about some drugs and alcohol.  All right. Does that sound okay? Yeah, that's cool. Do you or have you ever drank alcohol? What's alcohol? Alcohol would be things like vodka, rum, schmierinoff. Nope,  don't drink alcohol. No alcohol? Nope. Have you ever had any sips of any alcohol?  Uh, maybe like, yeah, but no, nope. Have you ever smoked marijuana?  No. What about use anything to get high? Um, uh, any other kind of substance?  Nope. Have you ever ridden in a car or, um, with somebody who was under the influence of alcohol  or drugs? I don't ride in cars. I don't like cars. Do you ever use alcohol or drugs while you  are by yourself or alone? I don't use drugs. Why you keep asking me that? Yeah, I know. Again, sometimes these topics are a little bit difficult and we have to ask these questions.  Do you ever forget things you do while using alcohol or drugs? I don't, I don't use drugs.  Why do you think I use drugs? You think I use drugs? No, again, these are just questions that  I have to ask as part of a protocol. Do your friends or families ever tell you that you should  cut down on your drinking or using of alcohol? I don't use drugs. Sounds like you're getting really  frustrated. Again, I'm really sorry, but these are asking me the same question. These are just questions that I have to ask as part of our protocol here. Have you ever gotten into  trouble while using alcohol or drugs? No. Again, I can hear that you're getting a little bit  frustrated with the questions, but I appreciate you asking them. Is there anything that you want  to talk about or you want to share? No. Again, if at any point in time you want to talk about  anything or want to share anything, you can come grab me, have a nurse come get me. I'll be more  than happy to talk to you about those things. Cool. Thank you again for talking with me.  So this was an example of someone reading kind of directly from the card again or the computer,  however you did, however you have it. It wasn't very engaging, but it got the responses that we  needed. We were able to get an answer to those questions. Did anyone have any specific questions  about that role play? This is Christine. I have one comment in the chat from Laura Collins. She said, one thing to remember with interviewing is to speak at their level,  use words that make sense to them. Many patients, when I ask them if they smoke, they say no because vapes, et cetera, aren't seen as smoking. And also when you ask about drugs,  they don't think about weed as a drug. We agree with all of those things. And again, this was just an example of kind of going from those cards. But yes, you definitely want to  talk to their level. You want to use their terminology. You want to engage with them as much as you possibly can. That's all I've got on my end. Oh, wait, wait. One question just  popped up. Let me see. Is there a way to share this role play with nurses at our facility?  I think, I know that this webinar is being recorded. So that would be a way, would be a way, or if you have any specific questions, we can, Malik and I could always  address those at the very end, or you can even reach out to us and we can talk about that as  well. And again, we are going to do two other role plays that are going to just be a little, based on the CRAFT screening, but just a little bit different later on.  And as we're saying, it's not that using the car verbatim is ineffective, but again, it's just being aware that there's probably ways to make it a little bit more, A, you to be more  comfortable using it, and then B, for it to be able to get to the goal, which is truthful answers  to these questions. And trust me, I've seen multiple people take this card, stick it in  front of their face, read the question, and then peek over. And that's not what we want. If you're  going to use the card, kind of holding it down lower, trying to engage, looking at them, putting  the card away when you can, so that you can attempt to engage them. Okay, great. Thank you.  Thank you. So coming out of that role play, thinking about doing the screening, it's about  communicating, right? And so we recognize that communication is both verbal and nonverbal. So  thinking about communication, particularly with this tool, is about building some rapport. Karen  did a great job of asking me, like, how was I doing? She attempted to kind of engage me in some  ways, but we'll stretch how you can build on that. You want to use a conversational approach.  Very much like the comment in the chat boxes is that it's true. You want to speak at a level,  but you also want to make it conversational, so that it's relatable. Creating a comfortable  environment. So if you have the opportunity to screen, maybe if it's an outpatient scenario or  something, maybe it's waiting until they're back in their normal clothing, something where they  feel more comfortable, less vulnerable. You want to use open-ended questions. You want to remember  that this isn't an interaction. It's not an interrogation, right? We're not coming in accusatory,  like, I know you smoke weed, so you're going to tell me when you smoke, who you smoke with, right?  We're really just opening the door to that conversation. We don't want to interrupt. So if  they start to give you some things, maybe if it's not one of these questions, but they're sharing  stuff, it's to take that information and then, again, build on it. The nonverbal piece is being  mindful of your physical proximity. It probably would have been very uncomfortable to me non-COVID.  Karen standing close to me, in my personal space, over me. So just being aware of that. And then  optimizing privacy when you can. Again, there may have been other people in the room. How does that  impact how forthcoming I'm going to be with you? If my mom's there, I probably don't want to tell  you about riding in the car because she doesn't know that I do that or things like that. So just  having that increased awareness. The other piece to that is also knowing what your statute is if you're regarding drugs and alcohol use, talking about it in front of parents.  Because some states basically say drug and alcohol abuse, if you're over a certain age, you should be doing those without your parent present. So that, again, you're getting more  information. You might be getting more truthful information than if the parent is standing over  you as well. So we've talked about a couple of times so far, the value of open-ended questions.  So if you look at what a closed-ended question is, a closed-ended question is usually a one-word  answer. It's usually very short. It provides very little insight. And it doesn't elicit rapport building, which is what some of these questions on here. Drink any alcohol? It is a  closed-ended question. Your answer is going to be yes. Your answer is going to be no.  It's also the same thing as are you safe? We see that a ton in our triage questions. Are you safe?  Well, are you safe can mean so many things to so many different people. And so it says yes, it says no. It doesn't elicit those things. But if you do use a closed-ended question,  what would be helpful is if you use an open-ended question to follow it up with. So if the question would be, do you drink any alcohol? And they say yes. The next question would  be, tell me more about that. Can you explain to me how much alcohol you drink on a regular basis? So  it's then following it up with an open-ended question. Where an open-ended question elicits  that a narrative. It allows you to use your own words. It facilitates rapport building and allows  for engagement. And the example I have down here is, tell me about a time when you have not felt  safe. The other piece to when you ask an open-ended question is making sure you use the words,  tell me. Because if you say, can you tell me? Now you're back to that closed-ended question. No,  I can't tell you. But if you say, tell me more about that. Or tell me about a time you didn't  feel safe. Or tell me, that's the best way to answer. And I always tell people, if you don't  know what to say, just always say, tell me more about that. Because tell me more about that is  going to get you a bigger answer. And one piece to is during that role play, Karen asked me,  while it was a closed-ended question, it was a supplemental question that wouldn't be on the  screening. But it's valuable because she asked me, have I taken any sips right so again that that opens the door for maybe I say well maybe my dad  lets me sip off his beer or something but it also gives me another opportunity to think through the  question um because maybe I was like no I don't drink alcohol because my context is I'm not  drinking on a regular basis but I may have tried it which again is that piece of screening for  prevention right. So if you have to use a closed-ended question make sure you follow up with  an open-ended question if possible because that open-ended question will facilitate rapport  building. So now we're going to do our second role play. It's going to be asking some very  similar questions that were on the craft screening but doing it in a more conversational piece so  this will be a little bit longer kind of a role play and again if you have any questions please throw them in the chat because afterwards we'll be more than happy to answer them.  Hi Malik, my name is Karen. I work here at the hospital and one of my jobs is to talk to kids.  How are you feeling today? I'm all right. You're a nurse? No, I'm a social worker. Okay. And one of  the roles of the social worker is to talk to kids and sometimes we talk to kids about a variety of  things so it's kind of why I'm in here to talk to you. Cool. Can you tell me a little bit about  yourself? What do you want to know? Anything. Where do you go to school? I go to school at Oak Park.  Oak Park? Yep. And what grade are you in? I'm in 10th grade. Is there anything exciting that  you do at school? I play football. You play football. Tell me about what position you play  and a little bit more about football. I'm not too familiar with football. Oh man, I love football.  Football is everything. Football is life. You know, I like football. What? I'm a wide receiver. I'm the  best one on the team. That's good. I'm not sure really what a wide receiver is. What does a wide  receiver do? I gotta catch the ball. I gotta make touchdowns. I make plays. I make things happen.  Oh, so you're that guy that gets the ball thrown to him. Yeah, not quite like a running back but  I make moves. So do you score touchdowns a lot? Yeah. Again, I'm not too familiar with football.  So let me tell you a tip about football. All you know is don't root for the Rams. We don't like the  Rams. Don't go for the Rams. Not even sure who the Rams are. I guess it's a football team. Are they  in our area? It's a long story. It's a long story but just know that. If I gave you no tip, that's  all you gotta know. Gotcha. Okay, well maybe some other time you'll have to fill me in a little bit  more about some football stuff. Yeah, I'll get you up to speed. Okay, good. So as I said, one of my  jobs here is to talk to kids and sometimes I talk to kids about some sensitive topics. So we're going  to talk right now a little bit about some drugs and alcohol. Okay. Has there ever been a time that  you used any alcohol? No, I don't drink. I care about being able to be good on the field. I don't  drink, no. Do your friends drink? I mean, people drink. They drink at parties and stuff but like I  said, I'm trying to be in the NFL so I don't want those problems. Tell me more about going to a  party. I mean, we go to a party a lot because we win a lot. So we always party like all the time.  Tell me what you mean by partying. Oh man, we have get-togethers. People throw stuff at their house.  People come together. We hang out. We listen to music. We party. You know, party. You party. You  know. Gotcha. So when you're at those parties, you said that others around you smoke alcohol or  smoke alcohol, drink alcohol, but you said you don't drink that alcohol, correct? No, I don't  drink. I don't drink. Is there anything else that's going on like smoking? I mean, people vape. People  smoke. People get high. I mean, but like I said, I try to stay away from that stuff because trying to keep me right. Gotcha. And when people are smoking, what are they smoking?  Oh man, people smoke weed. They smoke. I mean, it's a couple people like, you know, the nerdy  kids. They do that other stuff, but I don't roll with that. The nerdy kids do the other stuff? Yeah.  Tell me about that. You know what they do. Come on, Miss Karen. Gotcha. So when you leave those  parties, have you ever left with anybody who's been under the influence? I mean, sometimes the  quarterback, he drink, he smoke all the time. So I mean, but he drop us off. He take us to practice,  you know, so that's my ride. So there have been times that you've probably been in the car with  him? I mean, he don't be that drunk. I mean, you know, he swerve a little, but nothing too crazy.  Nothing too crazy. And you're always wearing your seatbelt, correct? Most of the time. Well,  you should probably wear your seatbelt. And you should probably not get into a car with someone  who's under the influence. That's risky behavior. Yeah. Okay. Good. No, no. I'm all right. Gotcha.  Yep. Okay. Is there anything else you'd like to talk about? No. I mean, I got to get you up to  speed on football, but I mean, we don't have to do that. So again, just like a quick role play, little bit different way we did it, more conversational. I still got some of those  questions that are on that craft screen answered. Any thoughts, questions?  We have a comment. Great role playing. I feel like I have had this conversation.  We do the craft screening here at Cardinal Glennon, and it's really up to the social worker's job here. And we very rarely actually go in with the craft screen. It's very much a  conversation. And we always know that there's that opportunity that a kid is going to say, no, they've never used, and really in reality that they do. But again, we're not here to  interrogate. We're not here to second guess somebody. All that we can do is try to get that information as best as we can. Any other questions? One other comment. Deb, actually,  she says, great method. He gave her permission to come back to chat with him.  Thanks, guys. Thank you. So shifting gears a little bit and thinking more specifically about  screening for violence or engaging somebody around the conversation of violence. We recognize that  this is based individually to the hospital, and that the types of questions can be different.  There are certain screening tools that you could use for screening for violence. But again,  you get much more if it's in a conversational space. Be aware, again, of other factors such as timing, who's present when you ask these questions, and then recognize that when you  think of violence, be broader in your thought process. I think we're very conditioned to think  about being safe at home. But again, where do kids spend a majority of their time? School,  with friends, at other friends' homes. So being aware that the idea of violence is much broader  than just in the home. Here at Cardinal Glennon, our questions are, do you feel safe at home?  And then the second piece is, have you ever been hit, hurt, or felt threatened? The other piece  is that, particularly because I do the Life Outside of Violence program, I'm always screening,  do you have firearms in the home? We can offer things like gun locks and other interventions,  but it's having that radar of access to firearm increases the likelihood that they will either  use it or have it used against them. So those are some things to think about. Incorporating is a question particularly about firearm or history of exposure to gun violence or things  like that, so you get a better pulse on what their level of sensitivity is to violence.  The other thing is, when you ask the question, do you feel safe at home, and the child says,  no, they don't feel safe at home, is making sure you follow up with an open-ended question then,  because do you feel safe at home can mean a variety of things. They might not feel safe at home because their neighbor is a dealer, or every night at two o'clock in the morning,  they're hearing gunshots. So making sure you then follow up with that open-ended questions to get a  little bit more information about what's going on. So Kerry and I kind of chatted, we kicked around  with some ideas of some common myths that come up, so we just kind of briefly want to touch on those.  Of course, the first one is you must get the whole truth, and that's false, because honestly,  you may not, and you may get it in pieces and parts. I think collaboratively, where it's maybe  with the nurse or the social worker or the physician, you each may get a portion of the story, and that's okay. The other piece is recognizing that do kids always disclose?  Absolutely not, and so it may happen over a period of time. If they come back, they work with you,  it's an outpatient setting or something of the nature, and you get more rapport built. And then  third is, of course, violence is always physical, which we know is false, because violence is even  just the environment that you're in. So your access to hearing gunshots on a regular basis,  and then recognizing that it's about where and how they feel safe is about violence.  So going to documentation, we always want to make sure we use the patient's words. If a child discloses that they've been sexually abused, and they tell you that their  their papa put their fingers in his hoo-ha, we would want to document that exactly. We wouldn't  want to change the wording, so we would want to say that exactly. You would also want to source,  you would also want to source, cite the source of the information. So if a parent says to me, I have concerns about A, B, C, and D, I would want to put that, a parent says that,  so that when I then ask the child about that, I would then want to document that I talked to the  child. So making sure that you're citing where you get that information. Be sure to document any violence that is reported. So if a child discloses something, you have to make sure  you're documenting it, again, in their words. And then acknowledge any discrepancies, such as  you're doing that CRAF screening, and they say no, no, no to all of the questions, but then when you get that drug screen back as part of your protocol, it comes back positive.  So we're going to throw in just another little quick scenario here to kind of go back and show somebody how to talk to somebody about when those discrepancies happen.  Hi, Malik. I'm Karen, just in case you forgot who I was in this short bit of time. I know you've  met a lot of people coming in and out of the room. So again, my name is Karen, and as we talked earlier, I'm a social worker. We also talked earlier about your drug and alcohol  lack of usage. You denied using any of that. Well, part of the protocol here is that we do  a urine drug screen. And when we did that urine drug screen, we noticed that your drug screen  came back positive for opioids. And I looked at to make sure that that was nothing that we had  given to you at the hospital. So we had done your drug screen prior to us giving you any medication.  So I'm sorry, I didn't hear what your question was. So what's an opioid? An opioid is some kind of narcotic. It's some kind of pain pill.  Yeah, I don't do that. So you don't take prescription pain medication.  No. Has there ever been a time that somebody has given you something that wasn't prescribed to you?  I mean, like I take Motrin, like our coach, he gives us medicine like when we get hurt on the  field or during practice, like when I tell him my knee hurts. So sometimes he'll give me medicine.  So what I hear you saying is that your coach gives you medication after practice at times.  Yeah. Like if we, me, the QB, like all his best players, like we hurt, he give us something to  take so that we can be back at practice tomorrow. Gotcha. How often has he done that for you? I mean, I don't get hurt that much, but sometimes, like I said, my knee,  I got to be back ready to play. So he'll give me something to tell me I should go to sleep.  Gotcha. And does he tell you what he's giving you? He just said, take it for the pain. You'll be good.  Like, you know, it's like Motrin, I guess. Gotcha. But he hasn't said that it's Motrin. He hasn't even  told you what it is. I mean, nah. I just be like, oh, it's my knee hurting real bad. I might not be  able to come to practice. He'd be like, no, just take this. You'll be good tomorrow. Gotcha. And  how does it, after you take that, how does it make you feel? I mean, I just, I'll be ready to go to  sleep. But I need to go to sleep anyway, because I ain't going to practice tomorrow. And then the next day, how do you feel?  I mean, I feel okay. Sometimes, I mean, sometimes my knee hurts. So then I, it might be like off-season.  I go to him, like, okay, take this. You need to be ready for when it's time to practice again.  Has anyone else ever given you anything that's prescribed to you? I mean, my quarterback, but  that's the one that we riding with us, you know, but that's the coach saying. So sometimes he'll  be like, man, you got, you limping. You need this. Take this. You'll feel better tomorrow. Are they giving you the same type of pill? I mean, my granny gave me motion as orange.  The coach gave me motion as white, but he says all the same. So.  So just a little quick role play there, how to go back in. But we added a unique piece to this,  because now we added that his coach is providing him with drugs that aren't his. So that then  raises to the next level of potentially abuse and neglect going on. And if you are a nurse that  are doing, asking these questions and you don't feel very, and you don't feel comfortable exploring  that piece of it, but you have social workers on your staff, you could then get the information  that you need and then go back and have that social worker address that. Because he's now  disclosing that adults is giving him drugs, drugs that aren't prescribed to him. I would then need  to make that report as a mandated reporter. But the other piece to do is when you go back in, kids still may say, no, no, no, I don't use your drug screen is, is wrong. And again,  you're not interrogate them. You're just letting them know that this is what it showed. And then  you're offering them the opportunity to have resources. So again, knowing what your resources  are in your community would be helpful as well. Knowing what those drug and alcohol centers are  that deal specifically with adolescents. So I would then document my conversation. I would  document that he reported that his football coach and the football coaches on the quarterback are  providing him with medication. And then I would be making that hotline, hotline call. So I would be  documenting, they made that hotline call. I would also potentially be giving him resources,  such as if he has knee issues, maybe referring him to somebody that can deal with, with those knee pains and those knee concerns. Do you have any questions about that role play?  We do have a question about, about adult centers. And, and the question is, you know, what one thing do you wish adult center staff knew about how to do this kind of thing?  I, I think comfort, I mean, as we know, just with kids, adults aren't going to tell you the truth either. So I think just knowing they, the community  resources that are out there, there are certain community programs that we have in the St. Louis  area that specifically help with opioid usage or, you know, that we can refer people to. And you  can't make somebody, especially an adult, change their behavior if they don't want to. So as long  as you're screening for it or asking those questions and you're providing good resources, or at least offering those resources, would be basically all that you can do.  And again, still being mindful of that trauma-informed lens  and continue to be understanding that this might be the byproduct of multiple traumas.  Kind of tagging on with this, mandating reporting. I said that I was a mandated reporter and would  need to report that this coach is providing Malik here with some medication that isn't his.  But you also, just as you have to know the definition of child abuse and neglect for your state, you also would want to know what, who is a mandated reporter. And every state  has a little bit differently. And I did some research on this and every state was so totally, completely different on who mandated reporters are and what they're required to report.  It was actually interesting. Not only do you have to know what you're reporting for the child abuse  and neglect, you also have to know if you're a mandated reporter for gunshot wounds and or  stabbings. So Missouri, a hospital has to report a gunshot wound, but they don't have to report a  stabbing. And there is no timeframe. So we just put a little example down here. Montana, when we  were looking, gunshot wounds or stab wounds need to be reported and they have to be reported within  so many hours. So again, it's knowing what each of your state requirements are and then documenting  what they are. And again, found it very interesting on how different every state is  regarding, especially the gun and stabbing mandated reporting was very interesting.  So to wrap up, we just kind of want to have some reminders, the do's and don'ts. You do want to be  as supportive as you can. You want to be genuine and authentic, particularly with adolescents  because they read that, right? You want to be aware. So whether that's trauma informed, just  raising your awareness to the possibilities. Work collaboratively. So if you have a team and you can  use a team approach, that is always helpful. Remember patients don't always open up and that's  okay. One big thing is finding language that's comfortable for you. And if you are not comfortable  saying things like weed or more slang words, don't use them because again, you want to be authentic  and genuine. And then of course, always promoting healthy behaviors and choices. Again, we've said  it a few times. You don't want to interrogate. You don't want to be confrontational. We don't  want to make assumptions or accusations. And of course, you don't want to forget to practice.  This only gets easier with more familiarity and we can only do that by practicing and doing that  training piece. The big piece for me with the don't interrogate is especially when you're  concerned about child abuse. If you ask a child, tell me how that happened. And they report that  they fell out of bed, but yet that injury doesn't quite make sense to them falling out of bed,  just documenting that. And then as a physician or a healthcare professional or a social worker  or a nurse, you could then put injury doesn't fit mechanism based on what child said. It's not  consistent. You wouldn't want to go back to the child and then say, well, really tell me what  happened. We know you didn't fall out of bed. My bet is they did fall out of bed at some point  in time. It's just, they're either afraid to disclose maybe because they were threatened,  but again, just document that. So definitely don't interrogate, don't be confrontational,  just document what you can. And letting people know that at any point in time they could come  back if they need resources. I tell people that I'm concerned about with sex trafficking, at any  point in time, you need a safe place to come to get resources where that safe place to come. So  being supportive and genuine. We're kind of running out of time. So we just want to see if you guys have any questions, anything we can help you with comments, anything.  And also letting you know, you can take down our information. We will be more than happy to answer any questions, give you feedback, help you as much as we can.

Video Summary

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