Introduction to Advocacy In PediatricsKelly Burke

“The reason that advocacy is so much embedded in the work of pediatrics is that children have little political voice of their own and rely on the proxy voice of others including pediatricians to speak out on their behalf. This voice is so important

because of the overrepresentation of our children among the poor and

underserved.” ~ Charles N. Oberg

What is Advocacy?

•The act or process of pleading in favor of or supporting or recommending a cause or proposal.

•Rudolph et al defined a pediatric problem requiring advocacy as “any child health problem where the system is at fault and political action is required.”

•Tompkins et al defined child advocacy as, “a process that seeks to champion the rights of all children and to make every child’s needs known and met.”₁

The History of Pediatric Advocacy

In the US, Dr. Abraham Jacobi is the first recognized leader of

pediatrics.

• He was the first professor of pediatrics in America at NY Medical College.

• Established the first pediatric clinic in the US.

• Published over 200 articles and books including Midwifery and Diseases of

Women and Children. • He was an advocate for children despite the opposition he encountered from other

health care providers.2

Abraham Jacobi was also involved in the origins of the APS and the AAP

•Organized the pediatric section of the AMA and was founding member of the APS.

•In the early 20th century the pediatric section began to move away from the AMA.₁

•The Sheppard-Towner and Infancy Protection Act of 1921 was the first piece of maternal and child health legislation passed by the US government.3

•In June 1922, the AMA passed a resolution condemning the Act.₁

•Soon after, the AAP was formed in 1930.

MISSION STATEMENTThe mission of the AAP is to attain

optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. To accomplish this

mission, the AAP shall support the professional needs of its members.

• The American Academy of Pediatrics believes that the law ought to protect the health and well-being of children just as

arduously as pediatricians do.• As a unique and diverse group of individuals, children have health care

needs that are distinct from those of adults.• Advocate at both the state and government

levels

Access Principles•Every child must have quality health

insurance•Quality health insurance should be a

right, regardless of income, for every child, pregnant women, their families, and ultimately all individuals

•Comprehensive age-appropriate benefits package directed to the special needs of the pediatric population as recommended by the AAP

•Medical home with a primary care pediatrician and access to pediatric medical sub-specialists, pediatric surgical specialists, pediatric mental and dental professionals, and hospitals with appropriate pediatric expertise

•Payment rates that assure that children receive all recommended and needed services

Access Principles

•Health insurance should be fully portable and provide continuous coverage.

•Administrative aspects should be streamlined and simplified.

•Families should have a choice of clinician(s).

•Health plans should complement and coordinate with existing maternal and child health programs to ensure maximum health benefits to families.

Access Principles

News Releases• Media, Kids and Obesity: It's Not Just About Couch Potatoes (June 27,

2011) • Better Sleep Through Media Management (June 27, 2011) • Are Pediatricians Screening for Developmental Delays (June 27, 2011) • Helping Adolescents Transition to Adult Health care (June 27, 2011) • My Child Is Sick! Helps Parents Make the Right Decision About How

to• Treat their Child’s Illness (June 23, 2011) • AAP Applauds FDA on New Cigarette Warning Labels (June 21, 2011)• 8 Percent of U.S. Children Have Food Allergies (June 20, 2011) • Portable Pools Claim Over 200 Children's Lives (June 20, 2011) • How News Coverage Impacts Obesity Solutions (June 20, 2011) • Parents Give Ratings Systems a Poor Grade (June 20, 2011) • Blunt Trauma a Factor in Sports-Related Deaths; Football Most

Deadly (June 20, 2011) • AAP Statement on New FDA Rules on Sunscreen (June 14, 2011) • Formal Child Care can Buffer Effects of Maternal Depression (June

13, 2011) • Brady Center, Ropes & Gray Intend to file Suit Today on Behalf of

Doctors to Strike• Down Florida Gun Law Limiting Free Speech (June 6, 2011)• AAP Statement on House Appropriations Committee Acceptance of

FDA Amendment (June 1, 2011)

The underpinning principle that runs throughout the

history of pediatrics and is conveyed by the AAP is the

need to advocate on behalf of the children that we serve.

Some pediatricians still feel uncomfortable with the topic…

Why?•Little familiarity with the body of

literature on health services research, policy analysis, and system change

•Assumption that lobbying and advocacy are synonymous terms rather that lobbying being a small subset of policy and advocacy activities in general

•Intimidation of the law-making process•Underestimation of the value of a

pediatrician’s voice 3

Residency Curriculum•Expose residents to current legislative

efforts, issues, and needs surrounding children's health.

•Teach techniques for researching current legislative issues that pertain to children’s health.

•Provide a forum for residents to share their work on current issues, legislation, and advocacy efforts with medical students, residents, and attendings.

*Taken from Community Pediatrics website

The 3 A’s of Advocacy• Awareness–Your own, friends, family, colleagues,

legislators.• Advancement–By getting involved, you can help

advance a movement or effect a policy change.

• Action–Make contacts, write letters, call or visit

your elected officials, support an organization.

*Taken from Community Pediatrics website

•Why would the members of Congress want to hear from us?▫They want our vote▫They want our expertise▫They want our patient experience

• What can we offer?• Letters• Visits• Verbal messages• Fact sheets• Development of coalitions

Now let’s take a look at a specific issue we should advocate

against…

Bullying and Our Role As Pediatricians

Bullying•Bullying is a form of aggression in which

1 or more children repeatedly and intentionally intimidate, harass, or physically harm a victim who is perceived as unable to defend herself or himself.

•An issue of emerging concern has been the association of bullying behavior, particularly among young school-aged children, with the subsequent development of serious assault and suicidal behaviors.₄

Violence in the U.S.•Over the last 2 decades of the 20th

century, violence emerged as a major public health problem.

•The United States continues to lead the industrialized world in rates of youth homicide and suicide.

•Approximately 3% of direct medical expenses in this country for pediatrics are related to interpersonal assault injuries.₄

“6 Teenagers Are Charged After Classmate’s Suicide”

Phoebe Prince hung herself after sustaining taunting and physical threats by her classmates after having a brief relationship with a

senior boy soon after moving to the US from Ireland.

http://www.nytimes.com/2010/03/30/us/30bully.html

“Private Moment Made Public, Then a Fatal Jump”

Tyler Clementi was an 18-year-old Rutgers University freshman killed himself in September 2010 after discovering that his

roommate had secretly used a webcam to stream his romantic interlude with another man over the Internet.

http://query.nytimes.com/gst/fullpage.html?res=9B07E6D91638F933A0575AC0A9669D8B63

In Pediatric Offices•An AAP survey in the late 1990s indicated

that injury as a result of violence is a substantial problem being confronted by pediatricians in practices across the country.

•More than half of the respondents reported having recently seen a child who had sustained an intentional injury as a result of child maltreatment, and more than one third reported having recently treated a child with an injury resulting from domestic or community violence.₄

Why does it matter to us at pediatricians?

•The potential risks and behavioral consequences associated with early childhood exposure to violence in the community are profound.

•Headaches, stomachaches, dizziness, backaches, sleeping difficulties, depression, anxiety, irritability, injuries that require medical care, and suicidal attempts.

•More likely to exhibit school absenteeism and poor grades.₅

Suicide and Bullying6

•Brunstein Klomek A, Sourander A, Gould M. 2010 http://www.ncbi.nlm.nih.gov/pubmed/20482954

•Klomek AB, Sourander A, Niemelä S, et al, 2009 http://www.ncbi.nlm.nih.gov/pubmed/19169159

•Kim YS, Leventhal BL, Koh YJ , 2009 http://www.ncbi.nlm.nih.gov/pubmed/19123106

•Kim YS, Leventhal B.2008 http://www.ncbi.nlm.nih.gov/pubmed/18714552

What makes some kids vulnerable?

•Great deal of overlap among contextual factors that play critically important roles in determining individual outcomes, including: ▫Family dynamics▫Community norms▫Cultural beliefs and practices₄

Our Role As Pediatricians

Types of bullying•Physical aggression – hitting,

punching, kicking, shoving, etc. •Verbal aggression - teasing, calling

names, making fun, taunting, daring somebody to do something dangerous or inappropriate in exchange for acceptance or favors.

• Indirect aggression - spreading rumors, ostracizing.₆

Factors Associated with Bullying•Height•Weight•Physical disabilities•Dental features•Speech/language impairment•Wearing glasses₆

Factors associated with bullying

•Social anxiety•Social relations impairment•Pregnancy•Gender atypical behavior•Race, religion, nationality•Name ₆

Do not prevent bullying by treating predisposing factors

•It may be irrelevant to inquire about triggering factors to bullying in order to promote its prevention.

•This line of inquiry could make the person who is bullied feel responsible for his/her victimization.₆

Locations where bullying can occur

• At home• In the neighborhood• Walking to and from school• On the school bus• At school• During after school programs• In extracurricular activities• During religious services, school and programs• At summer camp• In dating relationships• In the workplace• During military training• Via telephones or the Internet ₆

AAP•Today’s teens are connected to one another,

and to the world, via digital technology  more than any previous generation.

•Recent data suggests that social media venues have surpassed e-mail as the preferred method of communication in all age groups.₇

•Online expressions of offline behaviors, such as bullying, clique-forming, and sexual experimentation, that have introduced problems such as cyberbullying, privacy issues, and “sexting.”₈

Cyberbullying

Cyberbullying•Cyberbullying is deliberately using digital

media to communicate false, embarrassing, or hostile information about another person.

•Current data suggest that online harassment is not as common as offline harassment.

•On the other hand, cyberbullying is quite common, can occur to any young person online, and can cause profound psychosocial outcomes including depression, anxiety, severe isolation, and, tragically, suicide.₉

Sexting •“Sending, receiving, or forwarding

sexually explicit messages, photographs, or images via cell phone, computer, or other digital devices.”

•Offenders threatened or charged with felony child pornography charges.

•Additional consequences include school suspension for perpetrators and emotional distress with accompanying mental health conditions for victims.

•In many circumstances, however, it is not found to be distressing at all.₉

What Can We Do As Pediatricians?

Pediatricians Should Advocate For:

•Adequate publicly supported community-based behavioral health services.

•Protection of children from exposure to firearms.

•Bullying awareness by teachers, educational administrators, parents, and children coupled with adoption of evidence-based prevention programs.

•Responsible programming that minimizes youth exposure to violent images, messages, and themes.4

Practice •Protocol for anticipatory guidance,

screening, and counseling of children and families during the course of routine health maintenance.

•Appropriate and timely treatment and/or referral for violence-related problems identified.

•Maintenance of an accurate database of community-based counseling and treatment resources.4

Connected Kids• Connected Kids: Safe, Strong, Secure

primary care violence prevention protocol offers child health care providers a comprehensive, logical approach to integrating violence prevention efforts in their practices.

•Each counseling topic discusses the child’s development, the parent’s feelings and reactions in response to the child’s development and behavior, and specific practical suggestions.4

Education•Formal continuing medical education

or professional development programs.•Learning about community resources

for children and adolescents.4

Assist Parents•Advise parents to talk to their children

and adolescents about their online use and the specific issues that today’s online kids face.

•Advise parents to work on their own participation gap in their homes by becoming better educated about the many technologies their youngsters are using.4

And…we can become involved in the legislation of anti-bullying

laws• SAVE (Schools Against Violence in Education)

http://www.nyscenterforschoolsafety.org/files/filesystem/save_summary.pdf• Dignity For All Students Act

http://www.nyclu.org/files/OnePager_DASA.pdf• Senate just recently passed the LEAD (Law to

Encourage the Acceptance of All Differences)10

LEAD•This law will help prevent cyberbullying as well as conventional bullying

•Gives NY schools the tools to help reduce bullying by requiring school employees to report incidents of bullying.

•Requires school districts to create policies and guidelines to encourage awareness of and to prohibit acts of bullying.

•Increase education about bullying prevention for teachers and students.10

•Regardless of whether or not pediatricians want to advocate for stricter bullying laws, they must be aware of the presence of bullying in their patient population and take part in preventing the possible repercussions of bullying.

•Have any of you seen patients recently who have experience cyberbullying or other types of bullying?

•Do you think our clinics would benefit from Connected Kids?

Questions?

Works Cited1. Paulson, Jerome MD. “Pediatric Advocacy.” Pediatric Clinics of

North America: Volume 48. Issue 5(2001): pp 1291-1305.2. Burke, Edmund MD. “Abraham Jacobi, MD: The Man and His

Legacy.” Pediatrics Vol. 101 . Issue 2 (1998). pp. 309 -312. 3. Oberg, Charles MD. “Pediatric Advocacy: Yesterday, Today and

Tomorrow.” Pediatrics :Vol. 112 . Issue 2 (2003): pp. 406 -409.4. Committee on Injury, Violence, and Poison Prevention. “Role of

the Pediatrician in Youth Violence Prevention.” Pediatrics: Vol. 124. Issue 1 (2009). pp. 393 -402.

5. http://www.aacps.org/aacps/boe/board/newpolicy/towardsAnneArundelpolicyfinal.pdf

6. http://www.childrensnational.org/files/PDF/ForDoctors/cnhn/FOP-2011/2-Srabstein-BullyingRelatedMorbidity.pdf

7. http://www.aap.org/advocacy/releases/june09socialmedia.htm8. Okeefe, GS. “The Impact of Social Media on Children,

Adolescents, and Families.” Pediatrics Vol. 127. Issue 4 (2011). pp. 800 -804.

9. http://www.covenanteyes.com/2011/05/17/social-media-and-your-childs-safety-report-from-the-american-academy-of-pediatrics/

10. http://www.nysenate.gov/press-release/senate-passes-anti-bullying-legislation