Chapters Transcript Video Building Child and Family Resilience in Pediatric Primary Care So now I would like to introduce our two speakers today, Dr Joanne Cheng is a clinical professor of pediatrics in the Division of Developmental Medicine at U CS F. Her research interests center around innovative programs that strengthen behavioral and developmental health care at capacity in pediatric primary care. She is director of the resilience Clinic at U CS F Benioff Children's Hospital, Oakland, a primary care based caregiver child group intervention for young Children, exposed to adversity. She also serves as senior associate director of U CS F's Child and adolescent psychiatry portal or cap outside of U CS F. Doctor Jung serves on the executive committee for the A A P Council on healthy mental and emotional development. She was also one of the A A P S pediatrician participants in the 2021 summit on youth suicide prevention and from 2017 to 2021 she served on the inaugural executive committee for the section on minority health equity and Inclusion. Doctor Zhang is also an active member of the A A P California chapter one mental health access committee and serves on the advisory committee for the national resource center on Patient and family centered medical home. Thank you for being here this morning. And next, we have Miss Lourdes Suarez who is a pediatric nurse practitioner. She's been dedicated to working with the most vulnerable communities. She is a U CS F assistant clinical professor from the School of Nursing where she earned her master of nursing degree. After completing her bachelor of nursing degree from U C L A. She works at U CS F Benioff Children's Hospital, Oakland Primary Care Clinic there. She has cared for young Children and adolescents with early onset of chronic disease, including pediatric obesity. She provides care to the homeless immigrant asthma and underserved pediatric populations in primary care and divides her time on grant projects focusing on adverse childhood experiences, trauma informed care and the center of excellence on immigrant child health and well-being. She has been a clinical preceptor for U CS F uh pediatric nurse practitioner, graduate students and a mentor to undergraduate students majoring in nursing nutrition or health care. And many of her mentees are underrepresented groups who are first generation like herself to college or have been historically underrepresented in health care. So, what a group we have this morning and I I will turn it over to doctor to get us started. Thank you. Thank you so much and thank you for so much for having us here. It's our pleasure to be here this morning. Um But Lourdes and I will be talking about a matter very close to our hearts. And it's based on the work that we both do in the resilience clinic at um, the Claremont Clinic or the primary care Center for Children's Hospital at Oakland. And um we'll be also talking about um some general tips for promoting child and family resilience in the context of pediatric primary care. So neither of us have any uh significant disclosures of the financial commercial interest to disclose. And this is what we hope to talk about today. We'll be starting with core principles for promoting resilience and mitigating toxic stress in young Children who are exposed to significant adversity. And on that basis, we'll be discussing some clinical pearls for communication and other tips for um addressing adversity when it's discovered within the context of the pediatric primary care visit with some uh tips for anticipatory guidance as well. And finally, we'll be talking about the resilience clinic, which is a primary care intervention that was homegrown in the primary care center at Children's Hospital in Oakland. And this is this intervention specifically designed to promote resilience in young Children and in their caregivers. So let's start with some core principles for promoting resilience in Children. I think most of us have heard of the adverse childhood experiences study. So we're not gonna bother going into that. But the whole idea that psychosocial adversity, things like child abuse or neglect or um family violence or exposure to a caregiver mental illness or incarceration or other significant household challenge. The idea that these social risk factors could somehow get under our skin and translate into risk for disease through the life. Course, I think that was a revolutionary idea for a lot of people and stress is that link between the psychosocial adversity and the poor health outcomes on the other end, but not all stress is bad for you. If the stress is short term, it starts, it ends the fact that your heart rate goes up, your blood pressure goes up, cortisol goes up. That's not a bad thing. It helps you actually to perform at a higher level. And then when the stressor is done that whole cascade turns off H P A axis winds down and your body rests and recovers and you're all good. What happens if the stressor is more serious, more severe, more chronic? It's not a short term thing. It's something more like a separation um from somebody who's very close to you. Um The difference here then comes in the supports that surround you. If you've got supportive relationships around you, that helps create this enough emotional and psychological safety that the H P A axis can still turn off. Sometimes that the inflammatory cascade can turn off sometimes and your body can rest and recover and that stress becomes tolerable. But in the absence of those nurturing relationships around you, then the wear and tear that allo static load on your body just continues and the stress stress becomes toxic. And this is when we see long term health repercussions and the poor outcomes that we have all heard about through the aid study. So those safe, stable and nurturing relationships matter so much. And that's especially true for Children. And that's because there are critical periods in brain development. Um so especially early in childhood, the 1st 1000 days of life, con conception on through the third year, um post natally brain especially is going undergoing very rapid development, key sensory pathways are being laid language and then higher cognitive functions are being developed very quickly. And if toxic stress hits during this period, it affects the development of brain architecture and it also develops every organ system, every developing organ system in the body. And this has outsized effects on that child's health, that child's development and the center on the developing child at Harvard talks about what if we think about adult diseases, the developmental disorders that actually begin early in life because of toxic stress. And so this is why early intervention matters so much because just as risk factors have an outsized effect here in these developmentally critical periods, interventions um carry further as well or at least have the potential to. So you don't have to wait till adulthood to see some of the health effects of average childhood experiences in childhood. So Children with four or more of those aces um have adjusted odds for all kinds of common health problems that we see including asthma with anywhere from 2 to 3 times the adjusted odds or an A DH D diagnosis with five times the odds, depression or teen pregnancy with four times the odds. And then look at this, any learning or behavior problem. We've got 33 times the odds is telling that if, if, if a child has had four or more aces. So what does that mean for us as pedi as pediatric medical providers, providing primary care? Um A we're seeing these kids and we are the system that sees the most commonly in those developmentally critical. First three years, we have the most frequent accidents um through those frequent well, child risks. So number one, we're seeing them and we have the greatest access. Number two, as I just said, those early experiences that are happening as we're seeing the kids like wheel shaping architecture, gene expression through epigenetic modification and kind of withdrew that um epigenetic modification, the physiological stress response that will influence learning behavior development and health risks all down the road. And so because we have this access, we have a real opportunity to partner with caregivers to change these health and developmental trajectories in really profound ways. And this is what excites me about this work is that what potential that we have here? So this also comes from the higher center of the developing child. Three basic principles for promoting resilience in Children and families So first, we want to support responsive relationships. This is what makes the difference between tolerable and toxic stress. This is what lets the body recover. And so this is number one, number two, we want to reduce the sources of stress. Like if there's something that we can do to identify major social determinants of health or stresses, we want to reduce these and we want to strengthen core life skills, especially one called executive functioning. We'll be talking more about that later, but we want to do this, not just with Children, but we want to do this in a two generation way. So we want to work with Children and also with significant adult caregivers in their lives. Um doing all three things in both generations, what we call dia care, the drilling down a little bit more. We want to support responsive relationships and we call this relational health. This is language that's becoming more and more common because um some of the best longitudinal research on risk and resilience in kids has found that the single most common finding in resilient Children was the presence of at least one stable and committed relationship with the support of parent caregiver or other adults. This is what matters full stop and what can we do in primary care to support um these caregiving relationships. And I heard this from the A P trauma for Care con conference where they talked about relationships as a vital sign. So just as we get heart rate, blood pressure, height weight, et cetera. Look at the quality of relationships around the child because that tells you something very important about that health trajectory to come and we can intervene. This is not a fixed thing because relationships are so important to resilience, we can stack the skills in a way towards positive outcomes. So just as there's a dose response relationship between average childhood experiences and poorer outcomes, there is also a dose response relationship between positive childhood experiences, like good play times with adult caregivers, um enrichment activities, strong relationships that can tip outcomes for the better. As I mentioned before. This um taking a two generation a board um approach is extremely important and this really focuses on the parent child relationship based on the scientific research. Um highlighting the importance of the caregiver child relationship for resilience. And so most of the evidence based interventions for childhood trauma really um hone in on supporting that attachment and a caregiving relationship. And um when they really drill down to the re research, what is it about these programs that seem to be making a difference, caregiver characteristics account for a huge portion of what actually is making the difference. And so by building up skills um and building up resources in the family, um we can have a longer term, longer lasting um out um effect on outcomes that outlasts the effect of that outlasts the timing of the program itself. And finally, um we can uh affect outcomes in two generations. Caregivers can have better outcomes. Kids can have better outcomes and the kids outcomes really rest on the caregivers because all their skills are being built on the scaffolding of what their parents know how to do. So, in addition to supporting responsive relationships, we also want to um strengthen core life skills. And the one that we're honing in on here is something called executive function. So executive functioning is what lets us plan. It's that rational thinking capacity. It is what allows us to exercise self control, to regulate our emotions and to regulate our behavior. You can see why this has such a huge impact on a child's development and their ability to succeed in school. You can also see how caregiver executive functioning makes a big difference in the stability of what the home environment can be like. So the aim here is to build this capacity somehow through our programming. And this um has um helps to stabilize families that are encountering a lot of stress. Finally, we want to reduce stress for families and this really has to do with identifying and addressing social determinants of health. And I think all of us or most of us are in practices that are already doing this. And this picture here on the left are many of the fine Navigators at the Claremont Clinic who are doing this work every day of helping to link families with community resources to address things like food insecurity, housing insecurity, caregiver, mental illness, or depression, um parenting, stress and many other things. I want to share a quote from um Doctor Hill Briggs, who's the National Director for Healthy Steps. And this was a personal conversation I had with her a number of years ago, she spoke to the importance of addressing poverty and Ameliorating its effects and she's saying we can provide state of the art treatment and it's not gonna move the needle much unless we turn off the stress and address um turn off the stress of poverty specifically and its known effects on executive functioning. And this is true for any one of us, put us in enough material deprivation and any one of us will be a state of high stress. And what can we do to ameliorate that and allow all the other aspects of the program then to be able to sink in. So I just spoke to three core principles for promoting resilience in Children and in families who have experienced diversity. And I think of that as the thing, what we want to do, these are the things that we want to accomplish, but I want to throw out to you that it's not just about what we do but how we do it. I think this is really where trauma informed care principles come in and a trauma informed culture and trauma informed systems come in So how we hold families, how we communicate, how we approach our clinical encounters, using these trauma formed principles matters just as much as what we do to approach our communication with um with a lens of safety and transparency um with mutuality and a lot of collaboration, providing lots of voice and choice um for our patients and for their caregivers. And with an understanding of the role of historical gender and cultural factors, bigger social systemic issues that are impacting our families. And this how also matters as we seek uh to partner with caregivers in promoting resilience in your Children and themselves. Then based on these principles, let's go into something maybe a little bit more practical when we encounter Children and families um who have experienced a s what do we do? So I want to start with this framework and as a public health framework of primary secondary and tertiary prevention, primary prevention is universal, this goes to everybody and anybody regardless of risk factors. And what this looks like for resilience is basically the positive parenting anti guidance that we provide. It's doing, reach out and read and giving out books and encouraging parents to read with their kids, talk with their kids. So that's primary prevention. And we're already doing this in primary care. And it's something that we, we're very good at secondary prevention really targets Children uh who or other patients who have identified risk factors. So things like A I So we do their A I screening and we find out there are aces there, we do our social determinant screening, find out there are some real needs there. And before this risk has translated into disease, we intervene at that point to prevent that disease from happening to address and mitigate those risk factors. And I would argue that the resilience clinic is secondary prevention. And then finally, what we call tertiary prevention, this is actual treatment when you have signs of disease that are arising on, on account of those risk factors. And there are evidence based treatment programs out there for childhood traumatic stress that are really geared towards repairing um significant strains in that attachment of care giving relationship. So how do you ask about trauma without triggering the family? Well, here are two examples by Doctor Jarrett and the American Academy of Pediatrics. On the left, there's an example more of an open-ended approach. So the last time I saw your child has anything really scary, upsetting happened to your child or anyone in your family. This has been highly studied and proven that families really like to be asked about the past trauma event. And on the right, on the excuse me, on your left is another um analogy with um with a fever, just as fever means the body is dealing with an infection when these behaviors happen. They may mean that the brain and body are responding to a stress or threat do you have any concerns that your child is being exposed to threat or feeling stress at our clinic? We provide the pro screener and we start by asking this question. Many family experience stressful events in their lives over time, these experience may affect the child's health and well-being. This is written on the first page of the screener and we continue to say that it's important to emphasize that families, these experience are their own and no matter what you choose to share with us, we will be there to help you. It's planting that seed with their families so they could feel more comfortable and build trust in a safe environment and perhaps sharing their information at future visit next bit. So addressing the fear of asking sometimes as providers, we hesitate hesitant to ask these questions because we are worried about opening a can of warmth. Do I have time before seeing my next patient? Once the question is asked, there's often a big relief on both sides, family and medical provider, families that can share their aces are already showing courage and feelings and those families who pro screen are are zero. And we know that they have a history of adversity, however not willing or ready to share or talk about it. I remember a recent immigrant family in my primary care clinic. This is a three year old with a history of chronic abdominal pain, seen multiple times in er clinic and specialist with a negative pro screener. After two years and a half of going back and forth to the doctor and visits and all test came out. Negative parents realized that their metal problems were affecting their child's behavior, de develop development and overall well-being. They are now in a better place to accept help through school, the church and open to talk about their next side. So what do you do if you find about trauma? Well help is an a that that stands for hope, empathy, language, loyalty, permission, partnership, and plan. These are common factors that are present in, in every effective form of psychotherapy. However, you don't need to be a therapist to practice these things that help facilitate emotions and healing. Let's talk about each of these elements in greater detail. Age stands for hope. The idea that adversity is not destiny, even a child who has a high age score, they can still have a healthy and productive life. That's what resiliency is all about family. Need, respectful, genuine partnership and communication, the author and Maston calls we can see in or ordinary magic because people do this every day and we see this with our families. You can instill hope by providing realistic goals towards improving their situation. E for empathy, many of us have heard this but one of the main friendship and principles of trauma informed care is to stop asking what is wrong with you and start asking what happened to you, this puts us into a more empathetic and curious mindset that helps us to practice empathy by listening, to acknowledging what is being said, just the act of listening is therapeutic. We listen, we create a space for people to share the story. We allow people to speak about difficult experiences. And when sometimes when something becomes speak, it becomes tolerable, just like my immigrant family with a three year old child. It took mom some time to realize she needed help. I was there along the way to provide that safe and trusting environment so that we can that you can share that story with me as Doctor Gipsy, an early pioneer in pediatric trauma and from care, once shared, the key message is you aren't alone and it's not your fault. And I will help this brings us to another frame, shifting principle of trauma informed care. Let's move from asking how can I fix you. But rather how could I understand you better? Moving from a mindset of fixing to one of understanding, help us to listen more empathetically l loyalty and language. Use the same language as your family, express loyalty and showing it by saying I will be here for you, practice parallel process by treating parents in the same way you want the parents to treat their Children. For example, model that behavior celebrate the small success, notice and knowledge the parent is doing well or ask them what is, what is what do you like about your child? Parents are eager and they wanna share information about their child. P stands for permission partnership and plan ask permission before addressing the problem. May I ask you about what happened? Let the family know that we will work on this together and help family that go. Here's a handout for our parents but from the pace connection, these are great reminders of many things that parents are already doing and can continue to do it intentionally to promote Refin in their kids, for example, move and play, make eye contact, get 22nd hugs, uh slowing down to you set or just being present for your child. And then I I've photocopied a bunch of these color, copy them at Kinkos, give them out all the time. And the wonderful thing is that parents are often already doing a lot of these things and it's a great way of some of those little successes and like wonderful things that families are doing already every day tomo resilience and maybe like coming up with another goal or serving as a nice reminder and moments when we could all use a reminder. Here's some other clinical pearls that may be helpful um in talking about positive parenting. So one is connect and redirect. Um it's very easy to come down hard um on this behavior. But the invitation is try to connect with your child if they're melting down, like figure out what's going on here. Um And the rest then of the connection then allows for um good solid disciplinary teaching to happen afterwards. Another one that we talk about a lot in resilience clinic is be curious, not furious. Again, speaking to encouraging parents to think about why is my child acting this way since behavior often communicates some kind of unsolved problem or unmet need. And so an invitation to be curious about them that rather than jumping straight to just fury and anger, another uh little pearl that we often talk about in Ross Clinic is name it, detain it. And the idea there is that just the act of naming an emotion helps you to regulate it. So this works for parents to be able to say I'm feeling X or Y. But then also to model that for their Children to give language, to give vocabulary for some of these really big feelings that kids may be having and making that connection between the word and the feeling helps to connect thinking brain to feeling brain, which in turn helps to regulate that behavior. So name entertainment, another um I think kind of bumper slogan, bumper sticker slogan that I like to think of these as is catch them being good. And I think this is one that a lot of us pediatricians turn to a lot is um just this understanding that positive parent, this praise goes a longer way than like say like reprimanding or punishing the bad behavior. If we find something that a child is doing, that is good, that is positive. That's an area where they're growing and we can reward that with praise. That is such a powerful motivator for the child to continue to act that way. So catch them being good and then praise them for it. And then finally, this power of undivided attention, undivided parental attention and achievement is gold. Talk about that a little bit more. We often talk about timeouts as a disciplinary measure. But what if we did more time in? And I've also heard this described as special time and what this is, is setting aside a small amount of time every day, 10 minutes is fine and everything else stops. It's one on one undivided attention, parent or caregiver with the child. It's not a time to be doing chores or running other errands. Um, kid picks the activity parent follows along and the whole point is just to have fun together and enjoy each other's company. Important thing is that it's scheduled. It's named and it's kind of sacred, right? Like if you have a good day, you have your special time. If you're having a bad day, you still have your special time, even if you're not very happy with each other. Um And over time, this really helps to build that caregiver child connection and this is money in the bank every time we have to scold our kids. That's money out, right? Every time we have to reprimand them or tell them to do something that's money out, but this is money in and it really helps to reestablish motivation or positive behavior. So now as you can think of is think about like a boss, like how will you behave towards a boss that you like versus a boss that you really dislike and think about like the quality of the interaction, how smooth everything else flows depending on your relationship with your boss. And that might help you understand the value of special time with your kids. So everything I've talked about so far, everything Lourdes and I have talked about so far, this is all primary and secondary prevention. This all can be done in a primary care visit. You can't do all of this, but you can take pieces of this and um and incorporate this into your practice. But sometimes um kids need something more. And so for those Children who have been severely affected enough by traumatic stress or toxic stress that they're showing signs of like behavioral, behavioral or emotional disturbance that's more significant or development delays um or other kind of like more serious kind of uh trauma related conditions. There are evidence based therapies for these, for the youngest kids. There's child parent psychotherapy which was developed here at, it was actually developed right across the bay at San Francisco General Hospital. And it is a dia intervention targeting the caregiver child attachment relationship in the in the context of trauma. And um it should be fairly available on both sides of the day. Parent. Child interaction therapy is um for kids just a little bit older, it combines just kind of parenting education on strengthening. That connection often starts with a lot of special time as well as some behavior management tips. And then the real heart of this is what I call the bug in the air. So the therapist is watching the caregiver and child playing, interacting with each other, either by like by way of like an iphone or an ipad or through a one way mirror if they happen to be in the same building. And then parent has a bug in the air, the airpod and the therapist is giving real time coaching and advice to the parent based on what the therapist is seeing happening um in their interaction in their play together. Wish we had a lot more of this. Um It's a wonderful tool not only for um trauma exposure, but also for any form of childhood disruptive behavior. So fantastic intervention, the evidence based treatment of choice for kids who are old enough and verbal enough to be able to start naming their feelings, articulating them and following commands generally ages five enough, that's trauma focused cognitive behavioral therapy. So it's a form of cognitive behavioral therapy or C BT that was specifically oriented around trauma and both for Children and adults. Um This is the treatment of choice for PTSD. And there are various forms of specialized family therapy that get at complex trauma and one here that's listed as detachment, self regulation and competency. And these can go on through the 10 years. So all of this is stuff that we might be doing in like a one on one primary care encounter, either providing some antis withy guidance, talking a bit about positive parenting or maybe referring on for trauma specific treatment for the kids who need it. Um All that we can do in 15 minutes and we can do a awful lot in 15 minutes because we're pediatricians after all. Um, we're pediatric primary care providers. Um, but uh what if we blew up that 15 minute block? And that's what a group of people started doing and they dei started designing the resilience clinic at um the primary care clinic at Children's Hospital, Oakland. And so I gather together a group of caregivers and Children and having like at least a good hour to like gather together, meet and talk, do activities that were designed to explore these topics in greater detail. What can we do? It's life changing, just bring it back. This is a quote from one of our parents who participated in our routine in it said, doing a focus group we held after the first round doing a hiatus as we were converting from in person to soon visit. She said, it's life changing, changing, just bring it back. So we did. So what is clinic? The recency clinic is a interactive group based intervention for parents of young Children, ages 0 to 5 with a history of significant adversity. Most Children are referred by the primary care provider following a positive a screen or after a verbal disclosure of adversity groups are designed to teach mindfulness and other infinity, promoting skills and promote strong parent and child relationships. Groups are being held right now by Zoom and in person groups are anticipated later on. So we based the design of the resilience Clinic on those same three core principles discussed earlier. So we're seeking to support responsive relationships by using this evidence based curriculum from Circle of Security parenting and more on that in just a minute. Um We are seeking to strengthen the core life skills, particularly executive functioning um by incorporating a mindfulness instruction um in partnership with a group called Dovetail. And finally, um we are partnering with our Fine Navigators in primary care to um address social needs as they are identified. Um And we do some structured screening for social determinants of health and we help connect families with the help of Fine Navigators as um needs become identified. So we are seeking to support responsive relationships and for that, we turned to materials from Circular Security International and this is a widely implemented internationally implemented early intervention program that's based on attachment theory. So the creators took attachment theory and created a series of like short parent facing videos, graphics and other educational tools that are manually and sort of like easier to kind of scale and implement. And um they specifically say you don't need like an advanced degree and a master's degree to um to use these tools. And so, for example, this was implemented in head start programs and head start educators um were using this material to help educate families. And that's where some of the evidence based where this came from through um through a randomized clinical trial at head start programs um where they looked at parent, child interaction in the context of what's called a strange situation where care, mother and child are playing together, kind of like in this observed setting, mother steps away for a short period and then comes back and the researchers code the children's response both when the mother goes away, when the mother comes back and also the mother's sort of response, you know, the child's distress um when she, when she comes back into the room. And so they did find some good evidence that participation circle of security helped to improve like the quality of like the maternal interaction with the child and comforting the child like um upon return. And also in the children's inhibitory control, which is an important aspect of the executive functioning that really speaks to the regulation of motion and behavior. So circle of security really is the basis for the first four sessions of our six week resilience clinic curriculum. In the last few sessions, really speak to mindfulness and mindfulness is based on attention to the present moment and calling attention to this moment without judgment. And with acceptance and meditation tools are really geared towards helping to bring that focus meditation back to the present in this non judgmental way. And there's a good body of evidence linking the practice of mindfulness with changes in brain function and structure and um in improvements in executive functioning. And for Children in turn, improvements in executive functioning are linked to a whole array of positive developmental outcomes. So we're partnering with a group called Dovetail Learning. And they're a nonprofit based here in California and they've developed a curriculum called We are resilient. And I believe many um people probably in this audience have probably undergone training with Dovetail. Um that's um meant to um enrich our anticipatory guidance and clinical practice, but also help us with our own sort of emotional wellness as we practice some of these principles ourselves. But we partnered with dovetail and they looked over our materials and we sought to take pieces of this and bring this into parent facing curriculum um to help teach some of these centering skills um during our last two sessions of the Resilience Clinic to give you a little bit of a background of what we uh clinic. And when it started, we started in 2018 at our federal qualified health funeral primary care clinic. Um 90% of our families are colored back or Latin with a more than 90% at or below federal poverty level. So far, we've had 64 diets. Uh We initially started with in person group from 0 to 17 year old and this was for two years and then we converted to uh zoom session because of the pandemic. In 2020 we focus on 05 year olds due to funding and then we did focus groups with parents to help us cosign our Zoom groups. So our groups consists of six weekly sessions that include uh a child and parent activity, a parent circle and a brief 1 to 1 medical provider visit at the beginning or at the end of of the session. They for ages 0 to 5 and your staffing could include either a licensed clinical social worker or a marriage family therapist. We co facilitate this with a MD or an MP. Um and also with a child activity outreach per person that could be either a health educator or a community health worker. The care packages we deliver care package packages a week before our session starts. These care packages includes um books, bubbles, sensory balls, and our session workbook. This helps us to connect with family and in person was really important during the peak of our pandemic, families were very appreciated for receiving their packages, home delivery, help us to further set our diet and learn a side that side that otherwise we wouldn't have an opportunity to know during our zoom or in person. Also, it helped with attendance some of this stuff or, you know, things that can be verbalized to us when they read, uh how they use these packages is, you know, they mentioned that the child would take sometimes their emotion books to school. Um Mom using a squeezy ball and breathing exercise during a stressful traffic day after picking up kids from school and their child crying in the car. Other have used their notebook as a guide during that session and shared their family uh video links to families and other members. Um Another mom has expressed not knowing how to play with it. Their her child, the packaged toys provided an opportunity to see our therapist play with their child and gave her ideas. These are only a few uh examples of how families are using these tools. And just recently, a mom said that she was gonna take these toys on her family trip. That right, just breathe so simple. Yet everybody needs to be reminded from time to time, just like one of the kids did with her mom. Remember to breathe mommy. So just breathe is one of the videos we show in the in our session has videotaped Children describing what happens when Mad Mad takes over it demonstrates how to take deep breaths and explains how deep breathing helps to calm the body using glitter jars as a visual representation of what happens to our brain when we get stressed or upset. In one of our very first two visits, there was a four year old girl who said at mommy on and off, she was curious, poking in into the camera and this was a family who was living in a very stressful times with not a lot of support. We give you a good as part of our care packages. And a four year old told her dad about the video reminded her mom to breathe. When mom looks stressed. The four year old has practiced deep breathing while sleeping, while looking at the glitter box. I mean glitter ball and her family also doing deep breathing and watching the glitter ball. The mom suggested to us give us two. I need one too as well. So multiple parents describe how they were using these tools. They learned to manage stress and their preschool Children were doing as well. What parents had said is, and this is a quote. My behavior, I was just too rough with my kids. Not too much, but I learned how to breathe and settle down that moment. When I don't think next size, managing big feelings is another topic in our session. In this session, we go over the hand brain mo model by Daniel Fiel. We have care to review their hands as example of their brain and show them what happens when you flip your lid and the upstairs and downstairs brains are now communicating your thumb, which is your big feelings are out of control. We make good decision by gently hugging your big feeling with your upstair brain and make and making a fist. I mentioned before, we also provide families with books in our care packages. One of these books is an Angry octopus in another session where we had a five year old girl being cared by her great grandmother. And this is the grandmother who has been raised, raised four generations of Children. She said this is a different one. Olivia lost her mother about two years ago. Mom was only 34 years, 34 years old at the time and died of file disease complication. We watch a meltdown during one of our school group sessions. Great grandmother came back to the group later inefficient and fit to one of our staff. The group did a good job of holding her. Our therapist. Carlos met 1 to 1 with the grandma after a profession to provide additional support and counseling and help correlate with the girl's therapist. Great grandma described how the book The Angry Octopus help Olivia a lot. The book goes over breathing and relaxation exercise. They did this exercise together in a prior moment and Olivia really liked them. Most kids and adults don't like flipping their lid, giving tools to manage their big feelings and insight into why they act the way they do can help break a vicious cycle. Next side. Another video that we use with our families is shark music. This video came from the circle of security and the lessons focus on parents understanding and managing their feelings as a vital first step before helping Children to regulate their big feelings. Chart music are the distressing scripts, thoughts and feelings that can run through a parent mind when a parent is emotionally triggered by a child's behavior. Chart, music makes it hard to be understanding and patient with one child and lead to difficult parent, child interaction and can be a powerful force affecting parenting in the aftermath of trauma. For instance, in one of our recent sessions, we had a father participating in the background of Zoom. Just listening. Mom was always the one more uh actively participating in the fourth session. We played chart music video. Father was in charge while mom attended her infant. It was the father's first time joining in participating with us via Zoom. To our surprise. He spoke and said after the video, I recognized that last night, I let my emotions get the best of me. He had an aha moment realized that he had been triggered and it had affected his response. He reflected on what had happened the day before, try to understand the situation, make it work and be a better person. Now that was powerful. Next slide in the parent circle we see through circle, we use materials as Joanne mentioned, starting with a protective pattern and automatic defense mechanisms. For example, distrusting, avoidance, hyper vigilant attacking or some of these um patterns that we review parent and staff relate to these feelings of escalating and peeking when feeling threatened. You have only seven factors between a good decision and a bad decision. A quote from a mom in one of our sessions, we asked her to describe how they feel when feeling stressed and what they do when starting to feel this way. What are those protective patterns that you notice escalating along with the caregivers, identifying feelings of escalation? We also have the caregivers focused on what happens with their body. For example, do they notice breathing, their breathing changes? Do they know their heart is beating faster? Do they start to sweat or feel that their body tends up? We also use this video by mindful moments with just time using breath as an anchor. It's a guided meditation on how to relax mind and body next side. So after doing a few rounds on Zoom, um we tried to gather, there's some caregiver feedback as well as some feedback from the participating staff. And here are a few of our lessons learned. Um just that even on Zoom, personal connection matters and um this act of dropping off these like these bags of toys and books, that was a moment of just face to face connection that made a huge difference in ability of caregivers then to connect with us even on Zoom and participate and with that um kind of backdrop, then I was surprised at how deeply so many caregivers were able to share even with a bunch of strangers on Zoom. Um I loved having um this partnership with early intervention services. So we had primary care providers like Lourdes and myself co facilitating groups. And then we had um special to mental health providers from early intervention at Children's Hospital Oakland who were providing um some of the health education as well as the main facilitation and really anchoring the groups. And we've learned a lot in the process of partnering with them. And one of their big lessons was the power of this parallel processing. So, basically treating caregivers the way we want caregivers to treat their Children and infusing this kind of attuned caregiving like in the atmosphere of the group itself. And when we um spoke with caregivers, we um did a series of focus groups and some interviews and the feedback was very positive. You can see some of it here. Most of them would highly recommend resilience clinic and they said that it helped to deal with like children's behavioral challenges as well as helping with their own stress level of mental health. Um Sometimes an hour fell short for the conversation. There were some advantages to Zoom in terms of convenience, like not having to deal with transportation or child care. Um And these are some of the things that they carried away afterwards. Number one was deep breathing, like almost universally, people said we're using the deep breathing and here are some of the other themes that they remembered from the groups um that I that they specifically called out and I was surprised by how often our handouts and those toys and books showed up as being on that list of things that they were taking away and still using um weeks to months later. So this is a cope of one of our Spanish speaking um caregivers that speak to the way in which the connect has helped relieve stress, as she said. But after the program, it helped me a lot because they helped me practice what to do in situations like this. When I have a lot of stress. Here's another quote that speaks to the impact of the students receiving the clinic on the car, child relationship. This program has helped me up have been a lot of help. It's helped me personally with my relationship with my older daughter. This program has helped me a lot with learning about how to have quality time with my Children, how to play with them and how to manage frustration. I remember another family situation on the previous quote and this was a teen accompany mom and child, age sibling that was part of a clinic in an in person session. This screen um was annoyed, upset and disengaged, not wanting to be there at all. By the end of the third session, um we she was participating, she was engaged. She was my mom about arriving on time to the session. And by attending this session, the mom and teen relationship directly improved even though the sessions were focused on the parent and the school's age siblings. Next one. Now this other quote that we have um finally, this caregiver code speaks to the link between the caregiver, mindfulness and centering and parenting practice. How important it is for caregivers to feel calm and in mind and body. In order to help their Children. As she said, the refusing to see clinic has helped me by teaching me tools to be more mindful parent to practice being calm and mind and body as my Children can learn this benefit for when I when they grow up or as then another mother said, equally said, I remember it because it's another way for parents to learn another way to treat our kids and another way to understand ourselves. So we did do some surveys and while the response rate left something to be desired, we got some positive feedback here to indicate at least for some caregivers and we seem to be on the right track. So really high satisfaction overall um with high likeliness to recommend the resilience clinic to other families, everybody who actually responded, said that they learned something that helped them to personally cope with stress. And the great majority said that they were starting to see some positive behavioral changes in their Children as well. So, um we recently got a grant um to pilot the resilience clinic and some other clinics here in Alameda County, as well as some, some community based organizations um with the help of Carry's kids and um verified Alata County Y M ce of the East Bay or Clinic of De La Rosa U BC P, Bancroft, Asian Health Services and Roots Health Center because all places that have um expressed some interest in piloting the resiliency intervention. And um along the way, we were planning to do a lot of training of staff from all these organizations in circle of security as well as in dovetail and giving them all the resilience collect materials um so that hopefully they can um continue providing this intervention going forward. Big part of this ground is working on sustainability mechanisms and there are some new building mechanisms available through um CAL aim um some medical reform initiatives that are currently underway that will hopefully allow us to sustain these programs through medical billing. Um I should also mention that the resilience clinic is part of a multi site randomized clinical trial of multiple primary care based resilience interventions across California. And that was funded by the California Advanced Institute of Physician Medicine um P I uh Zer. So here's some themes I'm hoping um cut came through the some of the shifts in mindset and culture that come with trauma for care. This above all is all about relationships and connection and the importance of relational health and that we model this by listening and validating and um and that this in itself is doing something. So for all of us who are scared to like bring up this topic of like adversity and afraid of opening that can of worms just listening and validating is an intervention, providing some strength based support, offering a little hope, offering some connection in our encounters. And I say pediatricians are pretty good at doing this. Um pediatric medical providers are good at doing this and um we can do this now. Time for questions. Thank you so much. That was such a comprehensive grand rounds and I learned a lot as the mother of an 18 month old. Um So we have a few questions, I should say. The first is a comment um from the audience that we adults need to follow the same guidelines of deep breathing on shark music to help ourselves. Yes, I agree. Um And there is a question about, I think in regards to the tertiary prevention strategies you mentioned um that finding these therapies is hard. Um Can you provide any advice on that? And I think you commented that you wish there was more. Yes, it is hard and there's no way to sugarcoat it. Um This is why I think some of the clinical pearls that we talked about today gives you something to start with. For example, special time is often a bridge thing that I just recommend families start doing because this is a component of some of these therapies. So that's something you can offer. Um in every county there are, I think two possible resources that you might want to turn to. One is first five and like the help me grow line will often help connect families to resources and they may know of things that we don't know about and they can help provide some navigation there. Um In Alameda County Family Paths is another um organization that provides short term like mental health support for Children and caregivers. They also provide a lot of positive parenting, like education and support and their services are free. They have of course the stress line, the parenting stress line that I think a lot of people are familiar with. And that is another great resource just to provide in the short term. But the nice thing is is that they do also provide some short term kind of like bridge, kind of like help and getting to resources in the community. Finally, there is access, I mean, it's it's not easy to navigate. And um and the medical managed care plans are like including Al and Alliance for Health are taking on a larger role in um directly providing uh mental health benefits for male to moderate. The nice thing is is that um CAL aim is providing a medical billing mechanism for mental health services without a mental health diagnosis. Ok. So two year olds don't have clinical depression. So what if they need a dia service like child parent psychotherapy? It was often difficult before for those mental health providers to bill. But now they can like through these reform initiatives to Cala. So hopefully with payment reform, we'll see a greater availability of some of these services coming down the pike. And of course, I mean that availability would be made through our medical managed care plans for m to moderate and our specialty mental health plans um through um through of course, our counties through our county systems finally um wearing my cap hat. Um We do have a resource coordinator and maybe I shouldn't like announce that too loud, but she knows of a lot of resources and um for those who um do have private insurance, there are a lot of telehealth mental health resources available. And um some of those may be found, I believe on our website, but also through our resource coordinator as well. Thank you so much. And one final question before we close out today, um You know, there is the recommendation to do the pro L screening yearly. Um Is there research or anything looking into the benefit of having someone answer that question kind of year after year about their past trauma. I think this is a good question and I think there's room for, let's just say there's room for disagreement. Um There are smart people and um on, on multiple sides of this question of um when to do a screening, how to do a screening. Some people will say let's talk about Parent Aces as a way of opening up a conversation and let's pair Child Ace screening with resilience questions. So we're talking about what's going right and not just about what's going wrong. I think there's a lot of value um to both approaches there. I think at the bottom line of this is trust, communication and connection for, for uh practitioners and for clinics where there is this kind of trust and transparency. This screener is really an invitation to a conversation. It signals that it's ok to talk about these things here. And I think this is one of the major values of doing specific a screening that is compelling is that it's saying you can talk about this here and it's OK to talk about this here. And sometimes it takes multiple rounds and multiple asks before people are comfortable enough to start sharing some of this. And I think that is the biggest argument for bringing this around, not just once that many times, but it works best in a trauma informed environment where there is a lot of trust and where there's connection and I can see how like in a place that feels a little bit more broken and a little less transparent how this might come across the wrong way. Thank you so much for that comment and, and thank you both Lourdes and Joanne for your presentation today. Uh We look forward to seeing everyone next week and I hope everyone has a great day. Thanks again. You're welcome. Bye bye. 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