Lenore Jarvis Archives

The role of healthcare providers in adolescent relationship abuse

March 14, 2024

Healthcare providers can play an important role in adolescent relationship abuse.

Adolescent relationship abuse (ARA) or “teen dating violence” is a significant public health concern that affects millions of adolescents in the United States and globally. Providers who care for adolescents must be prepared to promote healthy relationships and support ARA survivors given that adolescents experiencing this are at increased risk for negative health and psychosocial outcomes.

What this means

In a new article published in the journal Pediatric Clinics of North America, the authors comment on the opportunity healthcare providers have for ARA prevention using a universal education approach that provides information on healthy and unhealthy relationship behaviors and ARA resources. A shared decision-making approach when responding to ARA disclosure may facilitate patient-provider trust, safety, resource utilization and adolescent autonomy.

“It is important to consider several concepts that apply broadly across work with adolescents: adolescent development, healing-centered engagement, intersectionality, co-occurring forms of violence and ARA prevention,” said Lenore Jarvis, M.D., director of Advocacy and Health Policy for the Division of Emergency Medicine at Children’s National Hospital and the article’s author. “Linkage to resources that are not disclosure dependent may increase connection to resources, youth empowerment and autonomy.”

Why it matters

The study equips healthcare providers with concrete ways to address ARA within the healthcare setting. Providers can use the steps outlined to learn more about examples of abusive relationship behaviors, ARA indicators, healing-centered engagement approaches, universal education and screening recommendations, and ARA resources.

“Recommended language and scripts are also provided to further illustrate limits to confidentiality, universal education, indicator-based assessment, response to disclosure (victimization and perpetration), when mandatory reporting is indicated and safety planning,” Dr. Jarvis added.

Moving the field forward

A universal education approach that provides all youth with information on healthy relationships and resources for ARA provides opportunity for youth to access resources regardless of disclosure. A survivor-centered response to ARA disclosure includes validation and shared decision-making with the adolescent about resources and support, including a warm hand-off to victim services resources and connection to a trusted adult. Providers should address both immediate and long-term health needs and ongoing support after ARA disclosure.

“I find the development of healing-centered engagement approaches with adolescents to be exciting. Healing-centered engagement emphasizes both trauma and resilience as universal experiences, recognizes that trauma and healing occur within relationships and empowers adolescents to actively participate in their healing process,” Dr. Jarvis explained. “General practices that may facilitate healing-centered engagement in healthcare settings include ensuring awareness of limits to patient provider confidentiality, opportunity for resource connection that is not disclosure dependent, and a shared decision-making approach when ARA is disclosed. These practices can foster patient-provider trust, empower adolescents and minimize risk for potential unintended harm related to healthcare provision.”

The article also incorporates some of the lessons learned from Dr. Jarvis’ Centers for Disease Control and Prevention K01 grant award on “Addressing Relationship Abuse in a Pediatric Emergency Department.” Further, the co-authors work together in a national ARA and intimate partner violence workgroup to discuss evidence-based recommendations to provide the best care possible for patients and families with regards to interpersonal violence. Dr. Jarvis recently did a podcast on the subject of ARA for “Pediatric Meltdown.”

Lenore Jarvis, M.D. participates in congressional briefing on maternal mental health

July 26, 2023

Lenore Jarvis, M.D., M.Ed., recently participated in a congressional briefing about maternal mental health.

Lenore Jarvis, M.D., M.Ed., director of advocacy and health policy for the Division of Emergency Medicine and an affiliate faculty member of the Child Health Advocacy Institute at Children’s National Hospital, recently participated in a congressional briefing about maternal mental health. The goal of the briefing was to bring awareness to the devastating impact of untreated perinatal mood and anxiety disorders (PMADs) on moms, babies and families and to eliminate the pervasive stigma around seeking care, including in communities of color and military populations.

PMADs are one of the leading causes of maternal mortality and morbidity in the U.S., responsible for nearly one quarter of all maternal deaths. Evidence shows that 1 in 5 women experience a PMAD during pregnancy or the postpartum period. All maternal mental health conditions are treatable, yet over 75% go untreated.

Dr. Jarvis spoke about the importance of screening caregivers for PMADs not just in outpatient settings, but also in emergency departments and NICUs. She said that an emergency department can serve as a safety net for high-risk patient populations who may have limited access to primary or mental health care, or for those who use the emergency department at a time of increased stress, anxiety or depression. Similarly, the NICU population is comprised of caregivers coping with stressful scenarios like traumatic perinatal or birth experiences and life altering diagnoses.

“At Children’s National, our primary care clinics screen for PMADs, but we also provide universal screening by approaching caregivers with infants six months and younger in both the emergency department and the NICU. Our philosophy is that by offering this screening and education to families, we are providing a higher standard of care for the patients seen in these settings,” said Dr. Jarvis. If a caregiver screens positive, meaning they are exhibiting enough symptoms that they could be at risk for experiencing PMADs, a member of our social work team meets with that caregiver to complete an additional assessment and provide further support, including to understand if there are suicidal or infanticidal ideations and intent to act. Our social workers can then make referrals to connect them to more care and follow up with those caregivers to confirm they have connected with the appropriate resource.

Dr. Jarvis was asked how to make it easier to support caregivers and families regarding PMADs. “Caregivers need education regarding PMADs. We need them to know it’s common and it doesn’t make them bad parents. We also need to ensure that providers are screening and that they have increased time for visits that include addressing mental health concerns.” She also stressed that the healthcare system can be difficult to navigate. “We need to decrease barriers to care, like the long wait times to get into mental health care and insurance coverage issues.”

Improving post-partum depression screening in the NICU and ED

November 29, 2022

A universal screening program is a critical first step for hospitals caring for postpartum caregivers, both inpatient and outpatient.

Perinatal Mood and Anxiety Disorders (PMADs) — particularly postpartum depression — are more prevalent among parents who have newborns admitted to a Neonatal Intensive Care Unit (NICU). Children’s National Hospital sought to increase the number of parents screened for PMADs in the NICU and Emergency Department (ED), where there was a high incidence of people seeking care. The team found that a universal screening program is a critical first step for hospitals caring for postpartum caregivers, both inpatient and outpatient.

The big picture

Without treatment, PMADs affect the caregiver and disturb their interaction with their infant, impacting the child’s cognitive and emotional development.

“What surprised us was how many people we saw that screen positive for postpartum depression and anxiety disorders. The percentage of our population is higher than what is reported in the literature,” said Sofia Perazzo, M.D., program lead at Children’s National.

What we did

The team initiated a multifaceted approach, using an electronic version of the Edinburgh Postpartum Depression Screening tool.

A part-time family services support staff was hired to screen caregivers. Funding later expanded the team to cover more days and hours.
Real-time social work interventions and linkage to resources were provided to all caregivers.
A part-time psychologist was hired to provide telemedicine therapy to NICU parents.
Remote screening was implemented for those who could not be screened in-person.

In the NICU, 1,596 parents were approached from August 2018-April 2022. Of those approached, 90% completed the screen, 26% screened positive, 4% indicated having suicidal thoughts and about 13% of caregivers were fathers.

What we learned

Action plans need to be in place for positive screens at start.
Electronic tools can aid significantly in expanding screening.
Trained personnel and multidisciplinary approaches are key.
Screening in two different settings can be challenging as they present different systems.
Being flexible and adapting tools and the system are key to success.
Good team communication with the nurse is vital.

“We’re working on improving our screening system to make it more efficient. We also realized that we need to make more resources available to these families,” said Dr. Perazzo. “Our team is constantly looking for community resources that can help them along the way. There is also a big need to educate our families on mental health issues, so we use this encounter as an opportunity to do that as well.”

This work was made possible by an investment from A. James & Alice B. Clark Foundation to Children’s National that aims to provide families with greater access to mental health care and community resources. Read more about the work of the Perinatal Mental Health Task Force at Children’s National.

An integrated approach to address perinatal mental health treatment

January 6, 2022

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth, with suicide as a leading cause of postpartum deaths.

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth, with suicide as a leading cause of postpartum deaths. PMADs are associated with poor maternal, infant and family outcomes. A new advocacy case study in Pediatrics led by a collaborative team of physicians at Children’s National Hospital describes the creation of the Task Force to formalize collaboration between hospital divisions, promote systems-level change and advocate for health care policy solutions.

Spearheaded by the Division of Emergency Medicine, the Goldberg Center for Community Pediatric Health and the Division of Neonatology at Children’s National, the #1 rated neonatology program in the country, the physicians who led this case study hope it can serve as a model for advocates looking to integrate PMAD screening within their own institutions. Children’s National is currently one of only a few children’s hospitals in the country that have implemented universal PMADs screening.

Lenore Jarvis, M.D., director of advocacy and health policy for the Division of Emergency Medicine at Children’s National, and Lamia Soghier, M.D., medical director of the Neonatal Intensive Care Unit (NICU) and the NICU Quality and Safety Officer at Children’s National, discussed this important work:

Q: What were you looking at with this case study?

A: Dr. Jarvis: This case study describes the implementation and outcomes of a multidisciplinary Perinatal Mental Health Task Force created at Children’s National in Washington, D.C. It was created to promote systems change and health care policy solutions for improved identification and treatment of PMADs.

Using the social-ecological model as a framework, the Task Force addressed care at the individual, interpersonal, organizational, community and policy levels. It then applied lessons learned from division-specific screening initiatives to create best practices and make hospital-wide recommendations.

This foundational work enabled us to build community bridges and break down internal barriers to shift our hospital toward prioritizing perinatal mental health. As a result, screening expanded to multiple hospital locations and the Perinatal Mental Health Screening Tool Kit was created and disseminated within the community. Task Force members also testified in governmental hearings and joined national organizations to inform policy, and Task Force and community collaborations resulted in significant grant funding.

Q: How is this work benefitting patients?

A: Dr. Soghier: Identification and early intervention for PMADs are imperative for improving health outcomes – not only for mothers but for their children and families too. Given the prevalence and negative consequences of untreated PMADs, we continue to innovate to improve the care we provide for infants and their families. We hope that this case study inspires others who value family mental health and are looking to integrate PMAD screening within their institutions.

Q: What are some of the barriers to getting this work implemented more widely?

A: Dr. Jarvis: One important thing to note is that families and medical providers alike may be unaware of how common PMADs truly are. On top of that, they’re unaware of the downstream negative impact it can have on the infant and family.

As a society, we must realize that PMADs can affect paternal caregivers. We need to have resources that also address fathers in addition to culturally and racially competent systems and resources for referral and linkage to care.

A: Dr. Soghier: Within medical systems, fragmented and siloed care delivery systems continue to be a barrier. Medical staff may also feel untrained and uncomfortable with addressing positive PMADs screens. Within the pediatric practice, differential access to services and reimbursement continue to be a concern, especially in a system where the parent is technically “not our patient.”

Identifying PMADs in our families and providing real-time resources and linkage to care has been invaluable to us. Ultimately, we seek to improve the care we provide to our infants and families and improve patient-family outcomes.

Read the full case study in the journal Pediatrics.

Timeline of major Task Force events. CES-D, Center for Epidemiologic Studies Depression Scale; DC, District of Columbia; PCORI, Patient-Centered Outcomes Research Institute.

Firearm-related injuries are leading causes of child and adolescent deaths and are preventable

June 19, 2017

Lenore Jarvis, M.D., M.Ed., F.A.A.P. addressed Congressional staff on behalf of the American Academy of Pediatrics in an effort to reduce gun injuries and deaths in the home by encouraging parents to ask about safe firearm storage.

“I see firsthand in my emergency department practice children getting shot: Unintentional, accidental injuries and shootings, homicides, suicides. And it’s terrible. If I never had to treat another child … for a gun-related injury, I would be so happy,” Lenore Jarvis, M.D., M.Ed., F.A.A.P., Pediatric Emergency Medicine Attending at Children’s National Health System, told Congressional staff. “I will never forget … a 5-year-old shot and killed by a family member who mistook him for a home intruder.”

Dr. Jarvis’ comments on behalf of the American Academy of Pediatrics came during briefings for Congressional staff working in the U.S. Senate and U.S. House of Representatives just days after a gunman targeted Republicans practicing for a Congressional baseball game wounding five, including House Majority Whip Steve Scalise.

The June 16, 2017 Congressional briefings were intended to draw attention to National ASK Day, an annual effort to reduce gun injuries and deaths in the home by encouraging parents to ask about safe firearm storage.

“It’s pretty simple,” Dr. Jarvis told attendees. “I think that there is a mutual recognition about what a public health problem this is: Firearms … are leading causes of deaths in children and adolescents through homicide and suicide by firearms. And they are preventable.”

Her comments echoed a recent firearms review paper published May 23, 2017, by a Children’s National research team that found firearms are present in 18 percent to 64 percent of U.S. homes, and 20,000 U.S. children are transported to Emergency Departments each year for firearm-related injuries. According to the study authors, pediatricians can play a pivotal role in helping to reduce gun violence by encouraging safe storage of firearms in the home and supporting research into firearm-related injury prevention.

In addition to Dr. Jarvis, speakers during the Congressional briefings included a Johns Hopkins Hospital surgeon who decided to pursue a medical career after surviving a gunshot wound to the throat while he was a teenager, a Missouri state representative who co-founded the Children’s Firearm Safety Alliance and a Brady Campaign strategist.

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