OCTOBER • 2019
Origins and Opportunities of October

October has origins of committees and board members
Opportunities for ACES Screening and Resilience Building in Foster Care
For mental health solutions in the Central Valley
And ongoing oral health updates.
President's Column
Raelene Walker, MD, FAAP
We held our annual Chapter Board Retreat on September 7 and had a very successful and well-attended day. Thank you to all the people who drove to Pleasanton, joined by video call, and submitted reports even if you couldn’t attend. I’d like to share with you some of the highlights and give our members a preview of some of the work that will be upcoming.  

In the morning, we held our quarterly board meeting and unanimously voted in 2 new Members-At-Large, and our Early Career Physician. Dr. Thiyagu Ganesan will be representing the North Valley and Dr. Lauren Steele is representing the North Coast. In addition, Dr. Tashya Whitehead is our new Early Career Physician representative. We look forward to getting to know all of you better and working with you!

Prior to the board retreat, we sent out a brief survey to all chapter members asking about member priorities for our chapter, broken down into 3 broad categories: Child Health, Member Health, and Chapter Health. After reviewing the progress and accomplishments of the past 3 years, we engaged in multistage strategic planning activities to hone our top priorities for the next 3 years. It was an engaging, exciting process and as always when I participate in AAP activities, I was impressed with the knowledge, passion and skill that pediatricians have and our dedication to making things better. In the afternoon, the board was joined by chapter committee chairs and representatives who presented on past committee activities and goals moving forward. We also had district leaders present on district issues. Thank you to all of you for your leadership, past, present, and future. We will be continuing to work on our priorities and I will highlight them in future newsletters as we advance our strategies to achieve our goals.

I’d like to give special notice to one of the most exciting outcomes from our Board Retreat, which is the unanimous creation of a new chapter committee, Climate Change and Health. This will be co-chaired by Dr. Amanda Millstein and Dr. Lisa Patel . More information on the goals, planned actions, along with a call to join this committee are within this newsletter. Thank you in advance for your leadership on this important topic.  

In addition, I would like to thank our Executive Director, Isra Uz-Zaman for all the work she did in planning and executing this productive and fun event. This was her first Board Retreat since she joined us in January 2019 and one of the best meetings we’ve had. We appreciate you, Isra, and look forward to implementing and continuing to meet our chapter goal! 
New Committee: Climate Change
Amanda Millstein, MD, FAAP & Lisa Patel, MD, FAAP

Climate change is a medical emergency. Increasing temperatures, more extreme storm events, worsening air quality, rising sea levels, and a spread of vector-born diseases with warming habitats all have a direct impact on health. Children, especially those living in communities of color and in poverty, will be among the people most directly hurt by climate change. 
We have already seen the destabilizing effects of a rapidly warming climate in California. Each year, wildfires of increasing severity due to drought conditions are decimating entire communities and bringing air quality to dangerous levels. The threat has been deemed so severe that PG&E is taking the unprecedented step this year of cutting off power to entire counties to mitigate the risk. Homes and businesses around the Bay have started to experience flooding events, which will only worsen as sea levels continue to rise. Heat waves of increasing severity and duration result in increased hospital admissions, increased suicide rates, interpersonal and group violence, and increased deaths particularly in already vulnerable populations.
There is hope -- the International Panel on Climate Change says that the worst effects of climate change can be avoided if we act within the next 10 years. But it requires that all of us step in and speak up. Pediatricians are one of the most trusted voices in the eyes of the public. Our voice, counseling, and advocacy matters-- in our clinics, in schools, in the Bay Area, and across the U.S. and the globe. We can shape the narrative, the policies, and public opinion to enact the bold change this crisis demands.
We are starting a new AAP California Chapter 1 Committee on Climate Change, which will be chaired by Amanda Millstein and Lisa Patel. Our broad goals are to engage our chapter and Bay Area pediatricians around these issues to influence policy around climate change. If you are interested in joining this committee -- and in helping to shape its goals and mission -- please email us (amanda.millstein@gmail.com and lisa.patel@gmail.com).
South Valley Member At Large Report:
Mental Health Solutions for the Central Valley
Jolie A. Limon, MD, FAAP
VP of Academic Affairs, Valley Children's Healthcare
The Central Valley and Valley Children’s Healthcare is very excited to host its first ever CME symposium offered by California Chapter 1, AAP . Like so many other places in the country, the Central Valley has been seeing an increased number of children with mental health and behavioral issues that cannot be addressed given the dearth of mental health services. We have seen a steep increase in the number of hospitalizations needed for our kids ages 5-14 since 2013. One of the goals of this CME offering is to empower and arm our first line providers with the tools and resources they need to care for these children.

Valley Children’s recognizes mental and behavioral health services, specifically for children, are one of the largest gaps and greatest healthcare concerns in the Central Valley. As a pediatric healthcare network, we are committed to being the trusted champion for all children, ensuring access to whatever healthcare needs a child might have. In addition to the CME event hosted and sponsored by Valley Children’s we are excited to announce a partnership with Universal Health Services (UHS) , one of the nation’s largest hospital management companies. UHS is set to construct an 81,600-square-foot, 128-bed behavioral health hospital for children and adults on the western portion of the Madera hospital’s campus. The facility will include a 24-bed inpatient unit dedicated to children and adolescents, ages 5 -17, representing a 49% increase in available beds for kids from Kern to San Joaquin counties.

This hospital is set to open its doors in 2022. While the permitting and construction process gets underway, UHS will work closely with Valley Children’s to invest resources in meeting immediate behavioral health needs, establishing additional telepsychiatry services and a new psychiatry residency program in the region.
Hospitalizations for Mental Health Issues, by Age Group: 2002 to 2016
(Age Group: Ages 5-14)
Definition: Number of hospital discharges for mental health issues per 1,000 children and youth ages 5-19, by age group (e.g., in 2016, there were 9.8 hospital discharges for mental health issues per 1,000 California youth ages 15-19).
Data Source: As cited on kidsdata.org , California Office of Statewide Health Planning and Development special tabulation; California Dept. of Finance, Population Estimates by Race/Ethnicity with Age and Gender Detail 2000-2009; Population Reference Bureau, Population Estimates 2010-2016 (Aug. 2017).
Children’s Mental Health Program: Uplift Family Services Survey

Emerging behavioral health conditions represent recurring challenges for pediatrician. Up to 25% of children in pediatric practices have these issues, sometimes beginning at an early age. With limited time and resources as well as a lack of preventive community resources to refer to, pediatricians are frustrated and children and families are not getting important needs met. Uplift Family Services will be piloting a project that aims to demonstrate how integrating behavioral health services can support and enhance pediatrician’s health promoting messages. The data from this survey will identify this need in primary care settings for governmental agencies and policy makers. Please consider completing the survey . It takes 5 minutes.
Foster Care Committee Update: Adverse Childhood Experiences (ACES) Screening and Resilience Building Opportunities in Foster Care
Katy Carlsen, MD, FAAP

“Safe, stable, nurturing relationships and environments for children and their caregivers provide a buffer against the effects of potential stressors such as Child Abuse and Neglect and other ACEs and are fundamental to developing healthy brain architecture.”
Essentials for Childhood, CDC.gov

Many of you are probably already aware of the term Adverse Childhood Experiences or ACES and have heard of the initial CDC/Kaiser study done in 1998 by Dr Vincent Felitti et al. Many of you may also be aware of the multiple studies and technical report done by the AAP regarding the lifelong effects of toxic stress and ACES and impact on adult health outcomes. In this article I hope to review briefly the information regarding ACES both in terms of the categories, and the prevalence of ACES in California. In addition, there is a current questionnaire/screening tool for ACES being recommended and actually receiving Medi-Cal reimbursement for use starting in January of 2020. There are exceptional articles already written regarding the importance of this screening tool. Children and youth placed in foster care by definition have at least 1 adverse childhood experience which led to their removal from the home. Resilience however can form an effective buffer to the risk of ACES in childhood and we as pediatricians are on the front lines to not only assess these children for ACES but also connect them to resources either within their placement setting our outside of it to build resilience. As noted in the quote from the Center for Disease Control, the treatment and preventative strategy most effective in dealing with toxic stress and ACES is helping children form safe, stable nurturing relationships with caregivers. Our current California Surgeon General, pediatrician Dr Nadine Burke Harris, is a champion of this work and has done many studies to aid in the identification and treatment of this vulnerable population of youth.

Adverse Childhood Experiences (ACES):
There are three general categories identified in the original work done regarding ACES: Neglect, Abuse and Household Dysfunction, and within each category there are subcategories to record a total of 8 areas. Neglect and Abuse both have subcategories of physical or emotional and Household Dysfunction is broken into 4 subcategories of Mental Illness, Incarcerated Relative, Mother treated Violently, and Substance Abuse. Although there have been expansions made in many studies on these categories, this list is the baseline for the original ACES work. As you may imagine children and youth in foster care would have likely elevations to 3-4 ACES on any screening tool. In fact, the National Survey of Child and Adolescent Well-Being (NSCAW), which is a longitudinal study of the well-being of 5,873 children who had contact with the Child Welfare system in a 14 month period starting in February of 2008 notes that 51% had 4 or more ACES on screening placing them at 12x the risk for alcoholism, drug abuse, depression, and suicide attempt ! The ACES screening tool is only another measurement much like an additional vital sign such as Temperature or Blood Pressure. Knowing this population has an elevated ACE score does not always indicate their level of toxic stress or resilience in response to these experiences. The ACEs score can help us tailor resources for the children and youth in foster care to help them build better relationships and resilience tools within their specific case scenario through linkages with mental health services or parenting supports for biological and or foster parents, CASA referrals or just reaching out to the child’s teacher to get further information.  

ACES Screening Questionnaire survey
The screening tool being utilized and reimbursed for by Medi-Cal is known as the Pediatric ACES and Related Life Events Screener (PEARLS). It was developed by the Center for Youth Wellness in the San Francisco Bay Area and studied by our current CA Surgeon General Dr. Nadine Burke Harris. The questions are as follows:

Of the statements below, how many apply to your child and please write the total # in the box. Since your child has been born…
  1. Your child’s parents or guardians were separated or divorced
  2. Your child lived with a household member who served time in jail or in prison
  3. Your child lived with a household member who was depressed, mentally ill or attempted suicide.
  4. Your child witnessed household members hurt or threaten to hurt each other.
  5. A household member swore at, insulted, humiliated or put down your child in such a way that scared your child OR a household member acted in a way that made your child afraid that he/she might be physically hurt
  6. Someone touched your child’s private parts or asked your child to touch their private parts in a sexual way.
  7. More than once your child went without food, clothing, a place to live or had no one to protect him/her.
  8. Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that he/she was injured or had marks
  9. Your child lived with someone who had a problem with drinking or using drugs
  10. Your child often felt unsupported, unloved or unprotected. 

These questions are in two formats identified vs. de-identified in which the de-identified forms ask the person completing the screening to give a total number of positive responses without specifically identifying which question is a yes answer thereby allowing more honest replies without fear of reporting requirements. In addition there is a form for parental/caregiver completion for ages 0-12 and one for self report for adolescents ages 13-19. 

Reimbursement for ACES screening:
If performing an ACES screening, there is the ability to receive an additional $29 per screening effective reimbursement from Medi-Cal with CPT coding 99160 or 99161 . For further information regarding the billing codes, the AAP has a useful coding fact sheet for Treating Trauma on their website. 

Training Protocols for ACES Screening in your Practices:
There are many useful tools within the American Academy of Pediatrics to receive appropriate training for creating a Trauma Informed approach in general as well as specifically toward ACES screening in a foster care population of patients. Here are a few suggestions if you are interested in implementing ACES screening in your practice setting and in preparing your office and staff for use of this additional tool to serve your patients.
  1. Center for Youth Wellness ACES-Q User Guide for Health Professionals accessible on the website www.centerforyouthwellness.org
  2. National Pediatric Practice Community on ACES has information on implementation strategies and ongoing studies; www.nppcacesmembers.org
  3. AAP ECHO projects with training on ACES and Trauma Informed Care at www.aap.org
  4. Centers for Disease Control has information and statistics regarding ACES at www.cdc.gov
  5. Essentials for Childhood, www.cdc.gov

As I completed the writing of this article submission, I realized how it mimicked closely my Chapter article for the May newsletter which was during Foster Care Awareness Month. This month, October, is Child Abuse Awareness Month and Adverse Childhood experience screening plays a strong role in prevention of child abuse and neglect. Therefore I hope my renewal of this topic with the additional resources regarding training and reimbursement, help spark further interest in beginning this work around the communities served by Chapter 1 of the California AAP. Please feel free to contact me with any questions or concerns at katypc64@gmail.com.
School Health Committee

Upcoming meeting is on Monday October 28 at 7 PM at the ACCMA headquarters (6230 Claremont Ave, 3rd Floor, Oakland, CA). If you are interested in attending and/or being part of the leadership of this committee, please contact current chair Renee C. Wachtel, MD, FAAP at drrwachtel@aol.com.
Oral Health Update: Identification and Management of Lip and Tongue Ties in Infants and Children
Kim Nichelini, D.M.D.
Board Certified Pediatric Dentist, Director North and AAP Liaison, California Society of Pediatric Dentistry
The SGA Side
Your Key to State Government Affairs

Immigration Policy Update:
Last month, federal Judge Dolly Gee of Los Angeles ruled against the current administration’s new regulations which would permit the detention of immigrant children for indefinite periods of time. AAP-CA and National AAP had previously submitted an amicus brief in this case and the judge cited a section of this brief as an influence in her decision. For more information on the case, view this Washington Post article

Other updates from the October SGA meeting:
AAP-CA now supports SB 541 (Bates) , which is a bill regarding school lockdown drills. Initially we were in opposition of the bill as there was not much evidence that regular lockdown drills in schools were effective and that in fact, they could be potentially traumatic and harmful to children. After proposed amendments were put into place, we are now in support. The bill has been amended to require the State Dept. of Education to collect data pertaining to drills and study best practices for age-appropriate drills. This data is then to be submitted before November 1st, 2021.

A number of bills are currently “enrolled,” meaning that the governor has a limited amount of time to sign them. Please visit the Bills section of the AAP-CA website to see which bills are currently “Enrolled: To Governor.” The bills with this label are the ones to act on now--call/write to the Governor’s office to voice your support for him signing these bills into law. Our high priority bill currently with the governor is SB 622 (Durazo) : Deaths in Immigration Detention Facilities.
Upcoming CME Conferences
Opportunities for Your Benefit
Attend the 2020 AAP Legislative Conference
Registration for the 2020 AAP Legislative Conference is officially open ! The conference will take place April 5 – 7 in Washington, DC. Each year, the conference brings together pediatricians, residents and medical students from across the country who share a passion for child health advocacy. Participants attend skills-building workshops, hear from guest speakers, learn about policy priorities impacting children and pediatricians and go to Capitol Hill to urge Congress to support strong child health policies. For the fifth year, the conference will feature a Pediatric Subspecialty Advocacy Track with specific legislative and skills building workshops uniquely focused on the interests and needs of pediatric medical subspecialists and surgical specialists.
For more information and to register, please visit aap.org/legcon .

Scholarship Opportunity for Pediatric Residents to attend AAPCA 41st Annual Las Vegas Seminars
AAP-CA Foundation has been granted funding from Abbott Nutrition to support continuing medical education for California pediatric residents! This grant will fund one pediatric resident's travel, registration, lodging, and meals for the AAP-CA’s 41st Annual Las Vegas Seminars on November 21-24, 2019. If you are interested in receiving this scholarship, please email us at info@aapca1.org with a 250 word brief explanation on what you would like to learn at the meeting, what topics are particularly interesting to you and why. We will select one resident from our chapter to attend the conference. Deadline: October 29, 2019 at Midnight

Pipeline Event: Volunteer Opportunity at Annual Healthcare Careers Conference
Saturday, Nov 16th at 2101 35th Avenue , Oakland (Life Academy)
9:30AM - 3:30PM (AM, PM, and full day shifts available) 
Seeking volunteers who work in ANY aspect of healthcare/bioscience to help adolescent understand more about the work you do! Goal is for 250 13-18 year olds from Oakland to attend and engage. Volunteer Registration: https://tinyurl.com/HCCVolunteer2019 
Tabling Registration (if you are connected with a health or bioscience organization interested in recruiting Oakland youth): https://tinyurl.com/HCCTabling2019
Questions can be directed to Emily Frank, MD, FAAP at emily.frank@ousd.org or 207-841-5168 (email is better)

Child & Adolescent Psychiatry CME Presentation and Round Table Discussion
UCSF Child and Adolescent Psychiatry Portal (CAPP) - Free CME event on psychiatric presentations in primary care for pediatricians at UCSF Benioff Children's Hospital Oakland on Sat Oct 26 8:30 am -2:30 pm. Earn up to 4 CATEGORY 1 CMEs. Breakfast & lunch are provided. For more information, view the flyer HERE .

October 25-29, 2019:   AAP National Conference & Exhibition , New Orleans

November 9, 2019:   Pediatric Mental Health Day , Valley Children's Hospital - Madera

November 21-24, 2019: AAP California 41st Annual Las Vegas Seminars - Pediatric Update

December 7, 2019:   4th Annual Pediatric Puzzles Interactive CME Conference , San Francisco

Our mission is to promote the optimal health and development of children and
adolescents of Northern California in partnership with their families and communities, and to support the pediatricians who care for them.

President: Raelene Walker • Vice President: Nelson Branco
Secretary: Janice Kim • Treasurer : Nivedita More • Past President: John Takayama
Executive Director: Isra Uz-Zaman