- Email: [email protected]
American Academy of Pediatrics’ Connected Kids Program
American Academy of Pediatrics’ Connected Kids Program Case Study Robert D. Sege, MD, PhD, FAAP, Elizabeth Flanigan, MS, Rebecca Levin-Goodman, MPH, Vincent G. Licenziato, Edward De Vos, EdD, Howard Spivak, MD, FAAP
Introduction
T
he American Academy of Pediatrics (AAP) is a professional organization of 60,000 pediatricians, pediatric subspecialists, and pediatric surgical specialists in the United States, Canada, and Latin America dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. The AAP provides information for clinicians and patients on a wide variety of topics, ranging from up-to-date information concerning immunization recommendations, safety, and availability to complete programs to support quality improvement in the diagnosis and care of children with attention deficit disorder. In response to the growing epidemic of youth violence and the concerns of its own membership in defining a role to prevent violence, the AAP published a policy statement describing the role of pediatricians in preventing youth violence, advocating physician counseling about relevant topics beginning in infancy.1 This policy complemented other AAP policies promoting the reduction in youth exposure to violent media,2,3 access to firearms,4 the use of corporal punishment,5 and the effects on children of domestic violence.6 Demand for such a program has been demonstrated repeatedly through national surveys of practicing pediatricians7 (conducted by the AAP) that showed that as many as 85% of practicing pediatricians would use a program focused on violence prevention. Other surveys suggest that families look to their child’s healthcare provider for information concerning community violence.8 This clinical interest resulted in the development of local9 and national10 programs, described in detail elsewhere in this supplement.11,12 Nevertheless, pediatricians feel uncertain of their abilities to effectively counsel patients and families From the Pediatric and Adolescent Health Research Center (Sege, Licenziato, De Vos, Spivak), the Floating Hospital for Children at Tufts–New England Medical Center; Harvard Youth Violence Prevention Center (Sege, De Vos, Spivak), Harvard School of Public Health, Boston, Massachusetts; and the American Academy of Pediatrics, Elk Grove Village, Illinois Address correspondence and reprint requests to: Robert D. Sege, MD, PhD, Director, Pediatric and Adolescent Health Research Center, NEMC Box 351, 750 Washington Street, Boston MA 02111. E-mail: [email protected]
regarding community violence. The same national surveys cited above also find that less than one in four pediatricians surveyed in 2003 had received adequate professional training in violence-related injuries, and only a minority felt confident in their own abilities to advise parents on violence prevention strategies. The vast majority (85%) endorsed a new AAP initiative to address these training needs. Similar results were obtained by an independent national survey conducted in 1999.13
Development of the Connected Kids Program To provide support for clinician training in violence prevention, in 2002 the AAP sought and received funding from the U.S. Department of Justice to develop a comprehensive set of resources to support the incorporation of violence prevention into routine clinical care. In seeking these funds, the AAP adopted the strategy of developing a comprehensive program, including the development of new resources for clinicians, as the most effective method of bringing violence prevention into the routine care of infants, children, and adolescents. Effective practice change in support of violence prevention requires comprehensive tools to support primary care providers, in the context of the health care delivery system in which they practice.14 The focus of this project is to develop a program for the primary prevention of youth violence, based in the delivery of primary care to U.S. children. This comprehensive new program was published by the AAP in December 2005. This report provides a brief description of the program development and plans for further training and evaluation activities. In developing its comprehensive program, the project team identified and involved stakeholders. Project development proceeded in a series of three phases. In the first year (2002), input was solicited from important stakeholders: families and adolescents, AAP leadership, practicing pediatricians, and public health experts. In the second year (2003), the process was started to develop the materials that will compose the new program to be disseminated by the Academy. In 2004 –2005, materials were developed and focus groups
Am J Prev Med 2005;29(5S2) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.08.026
215
and field trials were conducted in preparation for public release in 2005. After initial dissemination, the AAP is planning a variety of training activities to engage and support primary care clinicians. The first year (2002) of development focused on gathering input and information, including the creation of a new online catalogue of existing materials, focus groups to gather information from pediatricians and parents, and a modified Delphi process to obtain expert opinions. The online catalog of violence prevention items began with a compilation of materials collected by the AAP Task Force on Violence1 and the federally funded Children’s Safety Network. This was augmented by project staff through personal contacts and Internet searches. Relevant materials whose themes reinforced existing AAP policies and are currently in print or otherwise available from their producers were included. The resulting resource database can be found online (www.aap.org/ vipp). Parent opinions were obtained through nine focus groups (n ⫽49 total) in selected U.S. locations. Twentysix practicing pediatricians were enrolled in three focus groups held at a single national continuing medical education conference. The methods and results of these focus groups have been published elsewhere.15 Parents provided specific feedback about corporal punishment and firearms and raised a number of general issues regarding the scope of pediatrics, provider attitudes in presenting information, and effective communication techniques. Pediatricians reported that anticipatory guidance was important to them but cited cultural and reimbursement issues as barriers to practice. Both physicians and patients reported that the written material helps to communicate specific suggestions for childrearing, and stressed the importance of placing violence prevention in the context of child health and development. Expert opinion was obtained using a modified Delphi process using a modification of published techniques.16 The Violence Intervention and Prevention Program (VIPP) project team selected professionals based on expertise, the diversity of the target audiences, and the earlier work of the AAP’s Task Force on Violence. In addition to individual experts in relevant fields, 20 national organizations representing key stakeholders were identified. Each relevant AAP committee was asked to appoint a participant to represent its area of expertise and interest, including, for example, injury prevention, child abuse, adolescence, and the psychosocial aspects of child and family health. In all, 50 experts agreed to participate. The process was conducted electronically and moved from an open-ended generation of ideas to a final schematic of the entire project in four discrete phases. During this process, the experts graded each proposed concept on criteria of strength of evidence, likely effect size, feasibility, and 216
overall importance. The results of this Delphi process formed the basis of subsequent counseling guidelines and product development. At the beginning of 2003, the VIPP project team and advisory board synthesized and discussed the project data that had been gathered in the first year. The group embraced an approach to violence prevention that is based on the promotion of personal strengths (psychological resilience17) for the child in the context of enhanced social assets for the child18 and family, rather than on risk assessment and referral. This shift in philosophy grew from careful review of the focus group and survey data, combined with a recognition that the positive predictive value of existing screening and assessment tools is too low to be recommended for broad clinical use. In recognition of the program philosophy, the name of the new program for clinical use will be “Connected Kids: Safe, Strong, Secure.” The implementation of the program would be modeled on the successful AAP “The Injury Prevention Program” (TIPP®), a program that addresses unintentional injuries in the context of primary care.19,20 TIPP promotes the introduction and reinforcement of specific injury prevention topics at each office visit, provides highly focused brochures for families, and is familiar to most pediatricians. After this meeting, the VIPP team began the preparation of brief individual parent education brochures to support office-based counseling as well as a clinical guide. The program provides 21 patient education brochures to reinforce provider counseling and a clinical guide. Brochure text was developed as described above and Artists for Humanity, a nonprofit arts and entrepreneurship program for Boston teens, designed the graphics. Sample graphics are reproduced in Figure 1. Each brochure is linked to a specific recommended health maintenance visit, described in the accompanying clinical guide. Multiple rounds of review were included in the development process, as summarized in Table 1.
Connected Kids: Safe, Strong, Secure Clinical Guide Modeled after the Massachusetts Medical Society guidebook,21 the Connected Kids clinical guide is divided into two general sections. The first section contains an introduction that provides background research data and a description of the theoretical model that underlies Connected Kids; the second section begins with a summary of the Connected Kids protocol in tabular form and provides clinical information for use at each age-based routine healthcare maintenance visit. A grid is provided for each developmental period that identifies the specific topics to be addressed in each routine health maintenance visit. A sample grid for adolescent patients is shown in Table 2. Because children grow in an ecology of family and community,22 each suggested
American Journal of Preventive Medicine, Volume 29, Number 5S2
Figure 1. Sample Connected Kids cover graphics (produced for the AAP by Artists for Humanity, Boston Teen Arts and Entrepreneurship Program). (A) Your Child is on the Move (firearms safety). (B) Expect Respect (teen dating violence prevention).
counseling topic includes information about the child’s development, the parent’s feelings and reactions in response to the child’s development and behavior, and specific practical suggestions to help families connect to existing community resources. The guide suggests methods for identifying community resources for health promotion. Providers are trained in the use of the program through the clinical guide and a multi-media presentation. The AAP also intends to use a variety of training Table 1. Review process for Connected Kids: Safe, Strong, Secure public education materials 1. Expert author solicited to provide first draft of each topic 2. Editors re-write draft for reading level (target 5th– 6th grade) and consistency with other materials 3. VIPP project team reviews draft and provides feedback 4. Expert panel reviews draft 5. Original author reviews content of working draft 6. AAP leadership reviews drafts of all materials for each age group 7. Artists for Humanity design team adds graphic elements and designs layout; review by VIPP team 8. Selected titles submitted to parent or teen focus group testing 9. Focus group input included in final draft for field testing 10. Final revisions from field testing 11. AAP board review and final copyediting 12. First edition released, Fall 2005 AAP, American Academy of Pediatrics; VIPP, Violence Intervention and Prevention Program.
venues that it typically uses to support physician training and continuing medical education. These venues include lectures and workshops at national meetings and national CME programs, resource support for local initiatives, and the development and support of quality improvement initiatives. In addition, the AAP will ensure coordination of this program with its existing Bright Futures initiative and other activities.
Evaluation of Connected Kids Connected Kids offers resources for clinical use, and evaluation will focus on both the integration of the material into practice and its effectiveness in improving family and child outcomes. Evaluation of Connected Kids thus will address the following concerns: 1. How is Connected Kids implemented by primary care clinicians? 2. How well is Connected Kids accepted by families and patients? 3. When implemented, how well does Connected Kids achieve its immediate objectives (i.e., increasing the use of informal social supports by families of infants and young children)? 4. How effective is Connected Kids at promoting healthy development, and therefore reducing youth violence? Formative evaluations using both focus groups and field trials were conducted during the last phase of Am J Prev Med 2005;29(5S2)
217
Table 2. Sample Connected Kids counseling schedule Connected Kids Counseling Guide: Adolescence (aged 11 to 21 years) Visit
Introduce
Reinforce
Brochures
Early: aged 11 to 14 years
Family time together Peer relationships Support system Staying safe Teen mental health Conflict-resolution skills Healthy dating Gaining independence Plans for the future Firearms and suicide Depression Resiliency Transition to independence Negotiating a new environment (posthigh school)
Firearms Establishing routines and setting limits Alcohol and drugs School performance
Talking With Your Teen: Tips for Parents Staying Cool When Things Heat Up Expect Respect: Healthy Relationships Teen Dating Violence: Tips for Parents Teen Suicide and Guns Next Stop Adulthood: Tips for Parents
Middle: aged 15 to 17 years Late: aged 18 to 21 years
Alcohol and drugs Peer relationships Healthy dating Gaining independence Peer relationships Plans for the future Depression
Help Stop Teenage Suicide Connecting With Your Community
Similar schedules have been prepared for infancy and early childhood (aged 0 to 4 years), and middle childhood (aged 5 to 10 years).
development to address the first two concerns. Sample Connected Kids brochures were presented to parents and teens in focus groups held in several U.S. cities. These groups indicated a high level of general acceptance of the materials and also led to specific format and content changes. To assess provider acceptance in practice, working drafts of the materials were field tested by 33 volunteer AAP members located in all regions of the country and in urban, suburban, and rural settings. Volunteer practitioners were recruited through existing AAP communication channels. These volunteers each tested one of three age-specific subsets of the materials. They received the materials, the clinical guide, and a disk containing a training program in PowerPoint format. After a 2-week self-training period, each volunteer implemented the Connected Kids program for 1 month. Feedback was obtained via an online survey and conference call. The results of these formative evaluations were encouraging: for example, 82% felt that Connected Kids was easy to implement; several commented that the program allowed them to more easily address “delicate issues.” All reported using the Connected Kids approach when discussing these issues with families although many were selective and only addressed families they considered high risk. Two thirds (65%) reported that parents reacted favorably and none thought parents had a negative reaction. During the conference calls after implementation, practitioners noted that the material was clear and useful even for patients with lower literacy levels. Outcome evaluations are being planned with the assistance of regional and national practice-based research networks. 218
Discussion Youth violence is a complicated social problem, and the interventions to support young people need to reflect that complexity. Public health efforts in the prevention of youth violence engage multiple sectors of society, all of which interact with children and youth, including schools, police, community-based organizations, and the mass media. This program can help fill in the medical and healthcare system component of the broader public health effort. In carefully evaluating the proper role of primary care pediatricians in violence prevention, the AAP has enlisted the support of scores of experts throughout the country and commissioned efforts to obtain detailed input from families and healthcare providers. The resulting primary prevention program will stress the use of routine health maintenance visits as an opportunity to support families in raising psychologically strong, resilient children with multiple connections to the communities in which they live. Other efforts will be needed to focus on the role of the medical care system in the secondary and tertiary prevention of youth violence. Connected Kids program represents the collaboration of over one hundred contributors, including those who participated in the Delphi process, contributed, edited or reviewed the public education or professional training materials, or consulted on specific aspects of program development. In addition, scores of parents, teens, and physicians participated in focus groups and field tests. We are grateful to all of those who participated. This project was funded by a grant to the American Academy of Pediatrics from the United States Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
American Journal of Preventive Medicine, Volume 29, Number 5S2
No financial conflict of interest was reported by the authors of this article.
References 1. American Academy of Pediatrics Task Force on Violence. The role of the pediatrician in youth violence prevention in clinical practice and at the community level. Pediatrics 1999;103:173– 81. 2. American Academy of Pediatrics. Media violence. Pediatrics 2001;108:1222– 6. 3. American Academy of Pediatrics. Children, adolescents, and television (RE0043). Pediatrics 2001;107:423– 6. 4. American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population (RE9926). Pediatrics 2000;105:888 –95. 5. American Academy of Pediatrics. Guidance for effective discipline (RE9740). Pediatrics 1998;101:723– 8. 6. American Academy of Pediatrics. the role of the pediatrician in recognizing and intervening on behalf of abused women (RE9748). Pediatrics 1998;101:1091–2. 7. Trowbridge MJ, Sege RD, Olson L, O’Connor K, Flaherty E, Spivak H. Intentional injury and management prevention in pediatric practice: results from 1998 and 2003 American Academy of Pediatrics periodic surveys. Pediatrics 2005;116:996 –1000. 8. Kogan M, Schuster M, Yu S, et al. Routine assessment of family and community health risks: parent views and what they receive. Pediatrics 2004;113(suppl):1934 – 43. 9. Sege RD, Stone DA, Perry C. Adolescent violence: development of a multi-faceted health care systems approach. Int J Adolesc Med Health 1999;11:439 –53. 10. Knox L, ed. Connecting the dots to prevent youth violence: a training and outreach guide for physicians and other health professionals. Chicago: American Medical Association, 2002.
11. Knox L, Lomonaco C, Elster A. The American Medical Association’s youth violence prevention training and outreach guide. Am J Prev Med 2005; 29(suppl):226 –9. 12. Sege RD, Licenziato V, Webb S. Bringing violence prevention into the clinic: the Massachusetts Medical Society violence prevention project. Am J Prev Med 2005;29(suppl):230 –2. 13. Borowsky IW, Ireland M. National survey of pediatricians’ violence prevention counseling. Arch Pediatr Adolesc Med 1999;153:1170 – 6. 14. Lannon C, Stark AR. Closing the gap between guidelines and practice: ensuring safe and healthy beginnings. Pediatrics 2004;114:494 – 6. 15. Sege RD, Hatmaker-Flanigan E, DeVos E, Levin-Goodman R, Spivak H. Anticipatory guidance and violence prevention: results from family and pediatrician focus groups. Pediatrics (in press). 16. Adler M, Ziglio E. Gazing into the oracle: the Delphi method and its application to social policy and public health. London, UK: Jessica Kingsley, 1996. 17. Bell CC. Cultivating resiliency in youth. J Adolesc Health 2001;29:375– 81. 18. Murphey DA, Lamonda KH, Carney JK, Duncan P. Relationships of a brief measure of youth assets to health-promoting and risk behaviors. J Adolesc Health 2004;34:184 –91. 19. Bass J, Mehta KA, Ostrovsky M, et al. Educating parents about injury prevention. Pediatr Clin North Am 1985;32:233– 49. 20. Bass JL, Christoffel KK, Widome M, et al. Children injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics 1993;92:544 –50. 21. Sege RD, Licenziato VG, eds. Recognizing and preventing youth violence: a guide for physicians and other health care professionals. Waltham, MA: Massachusetts Medical Society, 2001. 22. Bronfenbrenner U, Moen P, Garbarino J. Child, family, and community. In: Parke R, ed. Review of child development research. Chicago: University of Chicago Press, 1984:283–328.
Am J Prev Med 2005;29(5S2)
219
Introduction
T
he American Academy of Pediatrics (AAP) is a professional organization of 60,000 pediatricians, pediatric subspecialists, and pediatric surgical specialists in the United States, Canada, and Latin America dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. The AAP provides information for clinicians and patients on a wide variety of topics, ranging from up-to-date information concerning immunization recommendations, safety, and availability to complete programs to support quality improvement in the diagnosis and care of children with attention deficit disorder. In response to the growing epidemic of youth violence and the concerns of its own membership in defining a role to prevent violence, the AAP published a policy statement describing the role of pediatricians in preventing youth violence, advocating physician counseling about relevant topics beginning in infancy.1 This policy complemented other AAP policies promoting the reduction in youth exposure to violent media,2,3 access to firearms,4 the use of corporal punishment,5 and the effects on children of domestic violence.6 Demand for such a program has been demonstrated repeatedly through national surveys of practicing pediatricians7 (conducted by the AAP) that showed that as many as 85% of practicing pediatricians would use a program focused on violence prevention. Other surveys suggest that families look to their child’s healthcare provider for information concerning community violence.8 This clinical interest resulted in the development of local9 and national10 programs, described in detail elsewhere in this supplement.11,12 Nevertheless, pediatricians feel uncertain of their abilities to effectively counsel patients and families From the Pediatric and Adolescent Health Research Center (Sege, Licenziato, De Vos, Spivak), the Floating Hospital for Children at Tufts–New England Medical Center; Harvard Youth Violence Prevention Center (Sege, De Vos, Spivak), Harvard School of Public Health, Boston, Massachusetts; and the American Academy of Pediatrics, Elk Grove Village, Illinois Address correspondence and reprint requests to: Robert D. Sege, MD, PhD, Director, Pediatric and Adolescent Health Research Center, NEMC Box 351, 750 Washington Street, Boston MA 02111. E-mail: [email protected]
regarding community violence. The same national surveys cited above also find that less than one in four pediatricians surveyed in 2003 had received adequate professional training in violence-related injuries, and only a minority felt confident in their own abilities to advise parents on violence prevention strategies. The vast majority (85%) endorsed a new AAP initiative to address these training needs. Similar results were obtained by an independent national survey conducted in 1999.13
Development of the Connected Kids Program To provide support for clinician training in violence prevention, in 2002 the AAP sought and received funding from the U.S. Department of Justice to develop a comprehensive set of resources to support the incorporation of violence prevention into routine clinical care. In seeking these funds, the AAP adopted the strategy of developing a comprehensive program, including the development of new resources for clinicians, as the most effective method of bringing violence prevention into the routine care of infants, children, and adolescents. Effective practice change in support of violence prevention requires comprehensive tools to support primary care providers, in the context of the health care delivery system in which they practice.14 The focus of this project is to develop a program for the primary prevention of youth violence, based in the delivery of primary care to U.S. children. This comprehensive new program was published by the AAP in December 2005. This report provides a brief description of the program development and plans for further training and evaluation activities. In developing its comprehensive program, the project team identified and involved stakeholders. Project development proceeded in a series of three phases. In the first year (2002), input was solicited from important stakeholders: families and adolescents, AAP leadership, practicing pediatricians, and public health experts. In the second year (2003), the process was started to develop the materials that will compose the new program to be disseminated by the Academy. In 2004 –2005, materials were developed and focus groups
Am J Prev Med 2005;29(5S2) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.08.026
215
and field trials were conducted in preparation for public release in 2005. After initial dissemination, the AAP is planning a variety of training activities to engage and support primary care clinicians. The first year (2002) of development focused on gathering input and information, including the creation of a new online catalogue of existing materials, focus groups to gather information from pediatricians and parents, and a modified Delphi process to obtain expert opinions. The online catalog of violence prevention items began with a compilation of materials collected by the AAP Task Force on Violence1 and the federally funded Children’s Safety Network. This was augmented by project staff through personal contacts and Internet searches. Relevant materials whose themes reinforced existing AAP policies and are currently in print or otherwise available from their producers were included. The resulting resource database can be found online (www.aap.org/ vipp). Parent opinions were obtained through nine focus groups (n ⫽49 total) in selected U.S. locations. Twentysix practicing pediatricians were enrolled in three focus groups held at a single national continuing medical education conference. The methods and results of these focus groups have been published elsewhere.15 Parents provided specific feedback about corporal punishment and firearms and raised a number of general issues regarding the scope of pediatrics, provider attitudes in presenting information, and effective communication techniques. Pediatricians reported that anticipatory guidance was important to them but cited cultural and reimbursement issues as barriers to practice. Both physicians and patients reported that the written material helps to communicate specific suggestions for childrearing, and stressed the importance of placing violence prevention in the context of child health and development. Expert opinion was obtained using a modified Delphi process using a modification of published techniques.16 The Violence Intervention and Prevention Program (VIPP) project team selected professionals based on expertise, the diversity of the target audiences, and the earlier work of the AAP’s Task Force on Violence. In addition to individual experts in relevant fields, 20 national organizations representing key stakeholders were identified. Each relevant AAP committee was asked to appoint a participant to represent its area of expertise and interest, including, for example, injury prevention, child abuse, adolescence, and the psychosocial aspects of child and family health. In all, 50 experts agreed to participate. The process was conducted electronically and moved from an open-ended generation of ideas to a final schematic of the entire project in four discrete phases. During this process, the experts graded each proposed concept on criteria of strength of evidence, likely effect size, feasibility, and 216
overall importance. The results of this Delphi process formed the basis of subsequent counseling guidelines and product development. At the beginning of 2003, the VIPP project team and advisory board synthesized and discussed the project data that had been gathered in the first year. The group embraced an approach to violence prevention that is based on the promotion of personal strengths (psychological resilience17) for the child in the context of enhanced social assets for the child18 and family, rather than on risk assessment and referral. This shift in philosophy grew from careful review of the focus group and survey data, combined with a recognition that the positive predictive value of existing screening and assessment tools is too low to be recommended for broad clinical use. In recognition of the program philosophy, the name of the new program for clinical use will be “Connected Kids: Safe, Strong, Secure.” The implementation of the program would be modeled on the successful AAP “The Injury Prevention Program” (TIPP®), a program that addresses unintentional injuries in the context of primary care.19,20 TIPP promotes the introduction and reinforcement of specific injury prevention topics at each office visit, provides highly focused brochures for families, and is familiar to most pediatricians. After this meeting, the VIPP team began the preparation of brief individual parent education brochures to support office-based counseling as well as a clinical guide. The program provides 21 patient education brochures to reinforce provider counseling and a clinical guide. Brochure text was developed as described above and Artists for Humanity, a nonprofit arts and entrepreneurship program for Boston teens, designed the graphics. Sample graphics are reproduced in Figure 1. Each brochure is linked to a specific recommended health maintenance visit, described in the accompanying clinical guide. Multiple rounds of review were included in the development process, as summarized in Table 1.
Connected Kids: Safe, Strong, Secure Clinical Guide Modeled after the Massachusetts Medical Society guidebook,21 the Connected Kids clinical guide is divided into two general sections. The first section contains an introduction that provides background research data and a description of the theoretical model that underlies Connected Kids; the second section begins with a summary of the Connected Kids protocol in tabular form and provides clinical information for use at each age-based routine healthcare maintenance visit. A grid is provided for each developmental period that identifies the specific topics to be addressed in each routine health maintenance visit. A sample grid for adolescent patients is shown in Table 2. Because children grow in an ecology of family and community,22 each suggested
American Journal of Preventive Medicine, Volume 29, Number 5S2
Figure 1. Sample Connected Kids cover graphics (produced for the AAP by Artists for Humanity, Boston Teen Arts and Entrepreneurship Program). (A) Your Child is on the Move (firearms safety). (B) Expect Respect (teen dating violence prevention).
counseling topic includes information about the child’s development, the parent’s feelings and reactions in response to the child’s development and behavior, and specific practical suggestions to help families connect to existing community resources. The guide suggests methods for identifying community resources for health promotion. Providers are trained in the use of the program through the clinical guide and a multi-media presentation. The AAP also intends to use a variety of training Table 1. Review process for Connected Kids: Safe, Strong, Secure public education materials 1. Expert author solicited to provide first draft of each topic 2. Editors re-write draft for reading level (target 5th– 6th grade) and consistency with other materials 3. VIPP project team reviews draft and provides feedback 4. Expert panel reviews draft 5. Original author reviews content of working draft 6. AAP leadership reviews drafts of all materials for each age group 7. Artists for Humanity design team adds graphic elements and designs layout; review by VIPP team 8. Selected titles submitted to parent or teen focus group testing 9. Focus group input included in final draft for field testing 10. Final revisions from field testing 11. AAP board review and final copyediting 12. First edition released, Fall 2005 AAP, American Academy of Pediatrics; VIPP, Violence Intervention and Prevention Program.
venues that it typically uses to support physician training and continuing medical education. These venues include lectures and workshops at national meetings and national CME programs, resource support for local initiatives, and the development and support of quality improvement initiatives. In addition, the AAP will ensure coordination of this program with its existing Bright Futures initiative and other activities.
Evaluation of Connected Kids Connected Kids offers resources for clinical use, and evaluation will focus on both the integration of the material into practice and its effectiveness in improving family and child outcomes. Evaluation of Connected Kids thus will address the following concerns: 1. How is Connected Kids implemented by primary care clinicians? 2. How well is Connected Kids accepted by families and patients? 3. When implemented, how well does Connected Kids achieve its immediate objectives (i.e., increasing the use of informal social supports by families of infants and young children)? 4. How effective is Connected Kids at promoting healthy development, and therefore reducing youth violence? Formative evaluations using both focus groups and field trials were conducted during the last phase of Am J Prev Med 2005;29(5S2)
217
Table 2. Sample Connected Kids counseling schedule Connected Kids Counseling Guide: Adolescence (aged 11 to 21 years) Visit
Introduce
Reinforce
Brochures
Early: aged 11 to 14 years
Family time together Peer relationships Support system Staying safe Teen mental health Conflict-resolution skills Healthy dating Gaining independence Plans for the future Firearms and suicide Depression Resiliency Transition to independence Negotiating a new environment (posthigh school)
Firearms Establishing routines and setting limits Alcohol and drugs School performance
Talking With Your Teen: Tips for Parents Staying Cool When Things Heat Up Expect Respect: Healthy Relationships Teen Dating Violence: Tips for Parents Teen Suicide and Guns Next Stop Adulthood: Tips for Parents
Middle: aged 15 to 17 years Late: aged 18 to 21 years
Alcohol and drugs Peer relationships Healthy dating Gaining independence Peer relationships Plans for the future Depression
Help Stop Teenage Suicide Connecting With Your Community
Similar schedules have been prepared for infancy and early childhood (aged 0 to 4 years), and middle childhood (aged 5 to 10 years).
development to address the first two concerns. Sample Connected Kids brochures were presented to parents and teens in focus groups held in several U.S. cities. These groups indicated a high level of general acceptance of the materials and also led to specific format and content changes. To assess provider acceptance in practice, working drafts of the materials were field tested by 33 volunteer AAP members located in all regions of the country and in urban, suburban, and rural settings. Volunteer practitioners were recruited through existing AAP communication channels. These volunteers each tested one of three age-specific subsets of the materials. They received the materials, the clinical guide, and a disk containing a training program in PowerPoint format. After a 2-week self-training period, each volunteer implemented the Connected Kids program for 1 month. Feedback was obtained via an online survey and conference call. The results of these formative evaluations were encouraging: for example, 82% felt that Connected Kids was easy to implement; several commented that the program allowed them to more easily address “delicate issues.” All reported using the Connected Kids approach when discussing these issues with families although many were selective and only addressed families they considered high risk. Two thirds (65%) reported that parents reacted favorably and none thought parents had a negative reaction. During the conference calls after implementation, practitioners noted that the material was clear and useful even for patients with lower literacy levels. Outcome evaluations are being planned with the assistance of regional and national practice-based research networks. 218
Discussion Youth violence is a complicated social problem, and the interventions to support young people need to reflect that complexity. Public health efforts in the prevention of youth violence engage multiple sectors of society, all of which interact with children and youth, including schools, police, community-based organizations, and the mass media. This program can help fill in the medical and healthcare system component of the broader public health effort. In carefully evaluating the proper role of primary care pediatricians in violence prevention, the AAP has enlisted the support of scores of experts throughout the country and commissioned efforts to obtain detailed input from families and healthcare providers. The resulting primary prevention program will stress the use of routine health maintenance visits as an opportunity to support families in raising psychologically strong, resilient children with multiple connections to the communities in which they live. Other efforts will be needed to focus on the role of the medical care system in the secondary and tertiary prevention of youth violence. Connected Kids program represents the collaboration of over one hundred contributors, including those who participated in the Delphi process, contributed, edited or reviewed the public education or professional training materials, or consulted on specific aspects of program development. In addition, scores of parents, teens, and physicians participated in focus groups and field tests. We are grateful to all of those who participated. This project was funded by a grant to the American Academy of Pediatrics from the United States Department of Justice, Office of Juvenile Justice and Delinquency Prevention.
American Journal of Preventive Medicine, Volume 29, Number 5S2
No financial conflict of interest was reported by the authors of this article.
References 1. American Academy of Pediatrics Task Force on Violence. The role of the pediatrician in youth violence prevention in clinical practice and at the community level. Pediatrics 1999;103:173– 81. 2. American Academy of Pediatrics. Media violence. Pediatrics 2001;108:1222– 6. 3. American Academy of Pediatrics. Children, adolescents, and television (RE0043). Pediatrics 2001;107:423– 6. 4. American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population (RE9926). Pediatrics 2000;105:888 –95. 5. American Academy of Pediatrics. Guidance for effective discipline (RE9740). Pediatrics 1998;101:723– 8. 6. American Academy of Pediatrics. the role of the pediatrician in recognizing and intervening on behalf of abused women (RE9748). Pediatrics 1998;101:1091–2. 7. Trowbridge MJ, Sege RD, Olson L, O’Connor K, Flaherty E, Spivak H. Intentional injury and management prevention in pediatric practice: results from 1998 and 2003 American Academy of Pediatrics periodic surveys. Pediatrics 2005;116:996 –1000. 8. Kogan M, Schuster M, Yu S, et al. Routine assessment of family and community health risks: parent views and what they receive. Pediatrics 2004;113(suppl):1934 – 43. 9. Sege RD, Stone DA, Perry C. Adolescent violence: development of a multi-faceted health care systems approach. Int J Adolesc Med Health 1999;11:439 –53. 10. Knox L, ed. Connecting the dots to prevent youth violence: a training and outreach guide for physicians and other health professionals. Chicago: American Medical Association, 2002.
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