Reverse the Trend of Irreversible Actions: Ohio AAP Store it Safe - PowerPoint PPT Presentation

Reverse the Trend of Irreversible Actions: Ohio AAP Store it Safe Program September 28, 2019 Ohio AAP Annual Meeting

Panelists • Jeremy Hardjono – Student Advocate • Michael Gittelman, MD, FAAP – Cincinnati Children’s Hospital • Michele Dritz, MD, FAAP – Cornerstone Pediatrics • Sarah Denny, MD, FAAP – Nationwide Children’s Hospital • Denise Meine-Graham – Franklin County LOSS • Discussion and Questions

1HELPS Jeremy Hardjono

Jacob Bice

Remembering Jacob

Becoming Something More...

Hello Empathy Learn Parents & Professional # 1 H E L P S Save

Hello Be a friend ● Greet them whenever you see them ● The little things matter ● Photo by Eliott Reyna on Unsplash

Empathy Actions rather than words ● Care, and show it ● Take them seriously ●

Learn Signs ● Get to know them… but be subtle ● Have a conversation with them about what is bothering them specifically ● Photo by nikko macaspac on Unsplash

Parents/Professional Better chance getting them to talk to professionals ● Parents play a vital role in treatment ● Parents can take important steps to prevent ● Monitor closely- every teen responds different to medication ●

My story...

We have, as documented, no financial relationships to disclose or Conflicts of Interest (COIs) to resolve

Think about why you Wanted to be a Pediatrician????

Leading Causes of Death Among US Children Ages 1-19, 2016- 2018 Cerebrovascular Influenza & Pneumonia Heart Disease Congenital Anomalies Malignant Neoplasms 59.3% Homicide Suicide Unintentional Injury 0% 5% 10% 15% 20% 25% 30% 35% 40% -CDC, 2017

Leading Causes of Injury Death, 1-19 year olds Cause Annual % Total Fatality Unintentional MV 3780 27% Traffic Suicide 2669 19% 28 Children Die Every Day!!!! Homicide 2682 19% Unintentional 1310 9% Suffocation Unintentional 913 7% Drowning Unintentional 797 6% Poisoning Unintentional 539 4% Pedestrian Unintentional 281 2% Fire/Burn Unintentional 114 1% Firearm Other Injury 772 6% Total Annual 13,857 100% Fatalities

Firearm Safety is a Public Health Issue • Child Protection : Daily, 7 children or teens are killed with guns • Domestic Violence : Monthly, 51 women are shot to death by intimate partners • Mental Health : More than 60% of deaths by firearm are suicides • Racial Justice : Guns are the leading cause of death for black males ages 15- 34

Compared to other countries, American Children (< 15) are: • 12 times more likely to be killed by a gun • 17 times more likely to be a gun homicide victim • 9 times more likely to die of an accidental gun injury • 10 times more likely to die of a gun suicide

15-19 year olds: Suicide on the Rise • 2 nd leading cause of death • 30% increase since 2000 • Ratio of attempted to completed suicide 50-100:1 • Males 3x greater completion, Females 2x more attempts • A death every 3 hours • 28% increase ED visits past 5 years -Miron, JAMA 2019 -Shane, Pediatrics 2016

Suicide Completion by Mechanism Other 6% Falls 3% • Over 1/2 of all US homes have a firearm Poisoning 6% – > 200 million guns – Majority are handguns • Ohio – 37% of households report a firearm – 46% reported gun was in unlocked location • Teens are impulsive Firearm 42% – 91% fatal if attempt by gun vs. 23% by ingestion Behavioral Risk Factor Surveillance System

Time Elapse Between Decision and Attempt • Interviews with survivors of near-lethal su icide attempts – 25% made attempt within 5 minutes of decision – 50% within 20 minutes – 71% within 1 hour • Most made decision within 1 hour of a crisis (eg. break-up or fight)

Many Families Have a Misconception about the Risk of Firearms • 6 in 10 Americans believe that guns in the home make people safer • However, a gun with an impulsive teen makes them less safe – Homicide of a household member is 3x more likely – Suicide: 5x more likely – Intimate partner homicide: 7x more likely for women • 2/3 of unintentional gun-related deaths could be prevented if guns are stored locked and unloaded.

Storing Firearms Safely/Lack of Firearm Reduces Suicide • Facts – Suicide risk present for all family members in a house with a firearm; especially impulsive teens – Higher risk no explained by mental illness or history of suicidality – If a gun is not present or available, it is rarely used as a method for suicide Miller M, Annual Review Public Health 2012

Link Between State Gun Ownership and Suicide Rates State Suicide Rate % Household (per 100K) gun prevalence AK 15.2 59.8 SD 14.9 59.9 WY 11.9 65.5 RI 3.1 12.4 MA 3.0 11.5 NJ 2.6 11.4 Knopov, AJPH 2019 Each 10% increase gun ownership, 27% increase youth suicide rate

Types of Interventions to Prevent Injuries (4 E ’ s) • Engineering/Technology – Airbags, smoke alarms, booster seats • Environmental Modification – Bike lanes, traffic signals, window guards • Enforcement/Legislation – Child safety seat laws, speed limit enforcement, GDL • Education – Screen for modifiable risk and educate families and patients about prevention

Why Talk to Patients About Guns? • Primary care providers interact with teens prior to suicide – 45% saw PCP within 1 month, 77% within 1 year • Physicians are supposed to inquire and counsel patients about health- related behaviors, conditions and risks • Physicians have opportunity to educate patients about: – household risk factors – how to mitigate risk • This education is particularly important where increased risk factors apply

Missed Opportunities Weighted % (95% Confidence Interval) Injury Topic ICARIS-2 ICARIS-1994 P a Any topic – Overall 42.4 (39.9 – 44.9) 39.3 (36.2 – 42.3) .12 0-1 62.8 Psychiatric patients PED 2-6 44.6 • 5% screen for firearms 7-12 39.0 by resident 13-14 27.3 • 20% screened by all Smoke detectors, 0 – 14 y 14.9 (13.0 – 16.8) 8.8 (7.2 – 10.5) <.01 parties Poison control number, 0 – 6 25.7 (22.5 – 28.9) 24.9 (21.1 – 28.6) .75 y Firearm storage, 2 – 14 y 10.0 (8.3 – 11.8) 6.3 (4.8 – 7.8) <.01 Bicycle helmets, 5 – 14 y 30.4 (27.5 – 33.3) 18.6 (15.5 – 21.7) <.01 Naureckas, Arch Peds 2019 Car seats/seat belts, y 0 – 14 28.7 (26.4 – 31.0) 25.4 (22.7 – 28.1) .07 0 – 6 38.5 (34.9 – 42.0) 30.7 (26.8 – 34.6) <.01 7 – 14 19.0 (16.2 – 21.9) 20.5 (16.9 – 24.2) .52 Chen, Pediatrics 2007

Barriers to Discussing Guns with Patients • Ketabchi 2019 • Ohio AAP Members – Time constraints – Lack of training/information about guns and gun safety – Fear of negative reaction – Don’t feel part of routine practice

Education vs Behavior Change • Screening tools help assess current behaviors • If family is unfamiliar - may just need education – Likely change will be made if simple request • Example - poison center number by phone • If information was heard before – What would encourage the change in behavior? – What are some approaches to having action occur?

Body of Evidence for Injury Prevention Counseling in the Office Setting

• 7 reviewers from the AAP (former) Section on Injury, Violence, and Poison Prevention • Reviewed articles from 1964-1991 • Inclusion – Original report – IP counseling in a primary care setting • Rated strength of study design and outcomes Bass et al. Pediatrics . 1993

MV Restraint Non-MV Restraint Bass et al. Pediatrics . 1993

• 10,330 citations • 103 randomized clinical trials • 22 studies evaluated • Most assessed effect on a safety behavior not injury rate • No studies on pedestrian, drowning, motorcycle or firearm injuries DiGuiseppi and Roberts. Future Child . 2000

Counseling About Firearms Works • Pediatric ED setting • Pediatric practices, 8% gun ownership • Prospective follow-up of adults • 1 month follow-up surveys presenting with child for psych • Counseling at-risk groups by • Counseling by pediatrician physician vs. control – No significant difference in gun removal – 63% locked up or disposed firearm – 62% improved storage in home vs 27% controls – 0% controls made any change Carbone, Arch Peds Adol Med 2005 Kruesi, J Am Acad Adoles Psych 1999

Summary of Findings for Office-based Firearm Counseling • Suicidal ideation and attempts are on the rise • Firearm access increases suicidal completion • Teens are impulsive • All parties on both sides of firearm discussion agree guns should be stored safely in the home • Counseling about firearm storage by pediatricians – Is the same as other prevention discussions – Changes behavior in the home setting

Questions?

Th The Teen e Teen Bra Brain in: Development, Impulsivity & Keeping Teens Safe Michele Dritz, MD, FAAP Adolescent Medicine

Teen Brain, Harvard Magazine, 2008

Teenage Brain, National Geographic, 2011