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March 16, 2021

The COVID-19 pandemic has had an unfortunate impact on childhood vaccinations. As early as April 2020, the Centers for Disease Control and Prevention noted that the administration of childhood immunizations had plummeted, and the Minnesota of Department of Health reported a 70 percent decline in the administration of the MMR vaccine. Shelter-in-place orders and the generalized fear and anxiety about coming into clinic disrupted preventive pediatric practice including well child care and vaccinations. 

Given these barriers and the concern that declining childhood vaccination coverage would leave us vulnerable to outbreaks of measles or pertussis, Hennepin Healthcare (HHC) developed a mobile vaccination program. The Vaccine Mobile was created from a unique partnership between the HHC Community Paramedics and Department of Pediatrics. Every week, a team comprised of a pediatric provider, a community paramedic and a pediatric resident visits the homes of families who are unable to come into clinic.  

Children who are behind or are due for essential vaccinations are identified by active, ongoing surveillance and through HHC provider referrals. During the home visit, the team performs a basic clinical assessment, administers vaccines, screens for various social determinants of health, provides children’s books to promote literacy and offers food bags, if needed. Infants receive a full well child exam including developmental screening and basic labs such as lead and hemoglobin. Over the last six months, the team has also administered influenza vaccines to siblings and adult household members.  

Well received by patients and their families, the Vaccine Mobile has also been supported in neighborhoods. As meaningful community partnerships developed, the Vaccine Mobile expanded its work to conduct pop-up clinics in high-risk zip codes. The team works with trusted community healthcare workers and leaders to bring healthcare to safe spaces in the community, whether it be in parking lots, school gymnasiums, or church basements. 

The COVID-19 pandemic exacerbated health inequities and barriers to receiving optimal healthcare. The Vaccine Mobile demonstrates how a unique and innovative care model developed during the pandemic can reduce these barriers and promote childhood wellness in Minnesota, as well as across the nation. 

 

About the Authors

Dawn Martin, MD, FAAP, is a pediatrician at Hennepin Healthcare and serves as co-chair of MNAAP’s Immunization Work Group. Sheyanga Beecher, APRN CNP, MPH, is a pediatric nurse practicioner at Hennepin Healthcare. Amber Brown is the deputy chief of EMS and lead community paramedic at Hennepin Healthcare.

March 10, 2021

Amidst surges in adult patient volumes caused by the COVID-19 pandemic, trainees in pediatrics faced a strange and paradoxical phenomenon: a dearth of pediatric patients. Social distancing led to a sharp decline in influenza and other childhood illnesses, while school and elective procedure cancellations further lowered patient volumes. Our resident primary care clinics temporarily shut down as visits were postponed and moved to video or phone, disrupting continuity of care for our patients and their families. Traditional residency didactics such as morning reports and noon conferences were not physically possible, and we missed teaching medical students who were removed from the wards. As both learners and emerging teachers in pediatrics, we recognized that COVID-19 demanded creative thinking and prompt action to preserve educational spaces.

On the same day that our Minnesota stay-at-home order began, we launched “CO-VIDEO Learning in Pediatrics,” a resident-led collaborative virtual learning series. Our community of residents, incoming interns, and medical students on pediatrics rotations across four inpatient clinical sites in addition to outpatient electives gathered via the Zoom platform. Interns and residents volunteered to give talks alongside peer-nominated fellows and attendings (including guests from other institutions), sharing our passions and expertise. We now gather three days each week to teach and learn from one another, creating a sense of togetherness despite disruption in our daily routines and uncertainty about the future. 

We challenge CO-VIDEO educators to be creative. Sessions have included powerpoints, chalk-talks, case-based learning, and parent panels. Question prompts throughout presentations encourage learner engagement and problem solving, via audio and chat and break-out rooms. QR-codes enable immediate evaluations which are shared with educators to help improve future teaching. Overall, participants have rated sessions highly effective with a mean score of 4.69 across all sessions (Likert scale of 1-5, with 5 being very effective), and open-ended responses have been overwhelmingly positive. Sessions conclude with a general wellness check-in, without an agenda.

The breadth of knowledge and expertise that we strive to attain as trainees cannot be compromised in light of a pandemic. Our resident-led response to COVID-19 has enabled innovative thinking in health professional education that shows promise of permanency. For programs like ours where trainees rotate across multiple sites, interactive virtual learning can enhance long-term peer-to-peer and near-peer learning and connection as well as improve access to faculty both within and beyond our institution. With resident-led initiatives such as CO-VIDEO, opportunities for collaboration become virtually endless. 

About the Authors

Sarah A. Swenson, MD, DPhil; Zachary R. Shaheen, MD, PhD; and  Trisha K. Paul, MD are resident physicians at the University of Minnesota. Johannah Scheurer, MD, FAAP, is a neonatologist with M Health Fairview and serves as their faculty advisor. 

Amelia Burgess, MD, FAAP

I understand your work at Sage Prairie Addiction Medicine Clinic focuses on adolescents. What a typical day is like for you?

I see patients via Zoom in a walk-in closet. Most of my patients are in late adolescence (18-25).  I’d like to see more patients in middle school and high school. Substance use disorders (SUD) start in adolescence, and as with any illness, the prognosis is better when they are identified and treated early.  All substance use disorders benefit from behavioral interventions, so much of my work involves increasing patient motivation to participate in treatment. I use my prescription pad to support the treatment of opioid use disorder, alcohol use disorder, and nicotine use disorder, as well as common mental illnesses associated with SUD. To patients, I describe the use of medication as helping to stabilize the physiology so that the individual can focus on the work of recovery, which is learning new skills and ways to think about the challenges of life. I also work on a Fetal Alcohol Spectrum Disorder (FASD) education project with Proof Alliance (formerly the Minnesota Organization on Fetal Alcohol Syndrome), and I am the AAP FASD Champion and E-Cig champion.  When I am not seeing patients, I am working on educational materials, or educating myself.

What interested you in serving as the chapter’s e-cigarette champion and what kind of responsibilities does it carry?

Tobacco is our number one killer. In the United States, it is responsible for 480,000 deaths per year, and in the world, more than 8 million. This is more than HIV, malaria, and tuberculosis combined. Helping people quit smoking/vaping is difficult, but it is one of the greatest satisfactions I have.  The e-cig champion role involves being available to teach clinicians, policy makers and the public about prevention and treatment of nicotine addiction.

You speak several languages. How did you come to learn French, Haitian Creole, and Spanish, and do you have a chance to speak those languages frequently?

I started learning Spanish when I was 13, when my father put us on a boat to sail the west coast of Mexico for six months, then a couple of years later I spent a few months in Chile.  I studied French in college.  Then I spent a year in Haiti between my third and fourth years of medical school.  I have used Spanish frequently in clinical care over the years, although I don’t get much opportunity in my current position.  I’m taking advantage of my new comfort with video communication to improve my Spanish with a tutor in Mexico.  I travel to Haiti from time to time to work and teach, using my French and Creole then.  My favorite French story came when I was working on the east side of St. Paul.  I was working with a Hmong family, but I realized that while the Hmong interpreter was translating my English to Hmong, the parents were translating Hmong to French for the children. They had lived in France before coming to the United States.

What are your interests outside of medicine?

Family, hiking, writing, keeping up with old friends and  reading.  I’m currently obsessed with a Mexican telenovela which I watch in Spanish with Spanish subtitles, to learn more idioms.

What would a perfect day look like to you?

In medicine? All my patients are happy and productive, stable in their recovery, children getting along with parents, parents caring for their children, everyone’s Hep C cleared spontaneously, teeth all fixed, everyone quit smoking. No one overdosed, no friends or family overdosed. Plus, it’s warm and sunny, no ice on the ground.

What advice would you give medical students or trainees today?

Substance use disorders drive morbidity and mortality in the U.S., and they affect all other diseases we care for. Know the spectrum of disease and how to diagnose it.  Believe that you can help people quit smoking. Know alcohol really well.  Know the difference between low-risk drinking, risky drinking, heavy drinking and alcohol use disorder.  Know the metabolism of alcohol, and all the pathologies associated with it.

“They made me feel like I wasn’t worthy enough to live,” recounted Junior, a survivor of conversion therapy. 

As physicians who care for Minnesota youth, we know the loving acceptance of a parent is a foundational need for all young people. There is a predatory practice masquerading as medicine that threatens this developmental need. It is our duty as physicians to speak out against “conversion therapy.”  Conversion therapy, also known as “ex-gay therapy” or “sexual orientation change efforts,” is a practice based on a false assumption that classified homosexuality as a mental disorder and that one’s sexual or gender orientation can be changed. Despite being largely discredited and denounced by medical organizations including the American Academy of Pediatrics, American Medical Association and American Psychological Association, it is still practiced in Minnesota.,,

Conversion therapy has been shown to have long-lasting negative effects including depression, self-harm and decreased self-esteem.  According to The Trevor Project’s 2019 report, of the surveyed LGBTQ+ youth who had undergone conversion therapy, 42 percent had attempted suicide, compared to 17 percent for those who had not undergone conversion therapy.  Numerous studies report conversion therapy causes both acute and long-term harms, especially in those who undergo the practice during childhood, adolescence and early adulthood.,,,, Conversion therapy has been unanimously rejected by the medical community as there is insufficient evidence to support its claimed clinical utility and significant evidence documenting its harms. 

As of September 2020, 20 states and more than 70 cities nationwide, including Minneapolis, Saint Paul, West Saint Paul, Duluth, Winona, Red Wing and Robbinsdale, have passed bills to restrict these harmful practices for minors.  In Minnesota, these citywide bans were instituted after a failed statewide ban in 2019.  This current legislative session will provide another opportunity to ban conversion therapy statewide. 

Pediatricians in Minnesota can take a stand against conversion therapy by supporting the Mental Health Protections Act. This bill will ban the practice of conversion therapy by health providers in Minnesota, protecting children and their families from deception and coercion into ineffective and dangerous practices. It will ensure that LGBTQ+ people receive the ethical, evidence-based, affirming and culturally aware mental health care they deserve. This bill will apply statewide, including greater Minnesota, where unregulated conversion therapy providers perpetuate this harmful practice. While the bill will not affect religious counseling, it will prohibit its use by licensed medical providers. 

We urge you to contact your legislators and express your support for the bill, sign the OutFront Minnesota petition advocating for LGBTQ+ mental health protections, and make your voices heard within your professional and personal circles. As physicians, it is our responsibility to advocate for our patients and use our influence to protect them from preventable harms. Conversion therapy is a preventable harm that must be stopped to improve the health and wellness of Minnesota’s LGBTQ+ youth.   

Acknowledgements 

The authors thank OutFront Minnesota for their tireless organizing and advocacy efforts to protect LGBTQ+ people.

Katie Beck-Esmay; Ginearosa Carbone; James Pathoulas; Margot Zarin-Pass, MD; and Hannah Lichtsinn, MD, FAAP collaborated on this article. 

References:

  1. OutFront Minnesota. Junior’s Story: Surviving Conversion Therapy.  YouTube. May 1, 2019. Retrieved from  https://www.youtube.com/watch?v=inAnwM5Zsao&feature=emb_title. 
  2. American Academy of Pediatrics. Homosexuality and Adolescence, 92 Pediatrics 631. 1993. Retrieved from http://pediatrics.aappublications.org/content/92/4/631.full.pdf.
  3. American Medical Association. Issue Brief: LGBTQ change efforts (so-called “conversion therapy”). 2019. Retrieved from https://www.ama-assn.org/system/files/2019-12/conversion-therapy-issue-brief.pdf
  4. American Psychological Association. Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts. 2009. Retrieved from https://www.apa.org/about/policy/sexual-orientation
  5. Shidlo, A., & Schroeder, M. Changing sexual orientation: A consumers’ report. Professional Psychology: Research and Practice, 33(3), 249–259. 2002. https://doi.org/10.1037/0735-7028.33.3.249.
  6. The Trevor Project. National survey on LGBTQ youth mental health. 2019. Retrieved from https://www.thetrevorproject.org/survey-2019/?section=Introduction
  7. Green AE, Price-Feeney M, Dorison SH, Pick CJ. Self-Reported Conversion Efforts and Suicidality Among US LGBTQ Youths and Young Adults, 2018. Am J Public Health. 2020 Aug;110(8):1221-1227. doi: 10.2105/AJPH.2020.305701. Epub 2020 Jun 18. PMID: 32552019; PMCID: PMC7349447.
  8. Ryan C, Toomey RB, Diaz RM, Russell ST. Parent-Initiated Sexual Orientation Change Efforts With LGBT Adolescents: Implications for Young Adult Mental Health and Adjustment. J Homosex. 2020;67(2):159-173. doi: 10.1080/00918369.2018.1538407. Epub 2018 Nov 7. PMID: 30403564.
  9. Meanley S, Haberlen SA, Okafor CN, Brown A, Brennan-Ing M, Ware D, Egan JE, Teplin LA, Bolan RK, Friedman MR, Plankey MW. Lifetime Exposure to Conversion Therapy and Psychosocial Health Among Midlife and Older Adult Men Who Have Sex With Men. Gerontologist. 2020 Sep 15;60(7):1291-1302. doi: 10.1093/geront/gnaa069. PMID: 32556123.
  10. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry. 2020 Jan 1;77(1):68-76. doi: 10.1001/jamapsychiatry.2019.2285. PMID: 31509158; PMCID: PMC6739904.
  11. Higbee M, Wright ER, Roemerman RM. Conversion Therapy in the Southern United States: Prevalence and Experiences of the Survivors. J Homosex. 2020 Nov 18:1-20. doi: 10.1080/00918369.2020.1840213. Epub ahead of print. PMID: 33206024.
  12. OutFront Minnesota. Conversion Therapy is Dangerous. Retrieved from https://www.outfront.org/public-policy#conversion-therapy
  13. Coolican, J. Patrick, Van Oot, Torey. Gay conversion ban gets personal for lawmakers in emotional debate. StarTribune. May 10, 2019. Retrieved from https://www.startribune.com/gay-conversion-ban-gets-personal-for-lawmakers-in-emotional-debate/509765022/.

 

Sam Marzouk, Ph.D, L.P.

 Anxiety disorders are among the most common pediatric mental health diagnoses. The prevalence of childhood anxiety has spurred a wealth of clinical research on the etiology, epidemiology and treatments for childhood anxiety. For any busy healthcare professional, it can be difficult to keep up with the evolving scientific landscape of pediatric anxiety. To help pediatricians stay up to date with the latest research in this area, I performed a literature review examining studies on childhood anxiety published from 2010 to 2020. I have identified four main points that may be particularly relevant to pediatricians.   

A Highly Comorbid Problem

While pediatric anxiety is highly comorbid with other psychiatric conditions, the exact rates of comorbidities remain elusive and vary widely across studies. A 2013 study in The Journal of Anxiety Disorders estimated that as many as two-thirds of children with an anxiety disorder are assigned an additional mental health diagnosis. Not surprisingly, childhood anxiety has a high comorbidity rate with depression. However, although these diagnoses can occur simultaneously, it is often the case that anxiety and depression are sequentially comorbid with anxiety acting as a developmental precursor for depression later in adolescence. Anxiety is also highly comorbid with pediatric ADHD, with co-occurrence rates estimated as high as 40 percent. Finally, for males in particular, anxiety is often comorbid with disruptive behavioral disorders (e.g., oppositional defiant disorder).  

The Key to Long-Term Change: Exposure, Exposure, Exposure

While pharmacotherapy is an effective adjunctive treatment for childhood anxiety, recent research continues to support cognitive behavioral therapy (CBT) as the most efficacious treatment.  Over the past 10 years, however, anxiety researchers have attempted to “dismantle” CBT to identify the “active ingredients” in this therapy that have the strongest influence on sustained clinical improvement.  Researchers have pinpointed exposure as the core element of CBT.  Exposure aims to lower anxiety by systematically having the child come into contact with feared stimuli so the child can learn through experience that the feared stimuli are safe and that the feeling of anxiety is uncomfortable but tolerable.  While there are many psychosocial interventions for childhood anxiety, pediatricians should consider recommending interventions that use exposure-based procedures.   

Brief Interventions in Primary Care Settings 

Last year, collaborating researchers from Arizona State University and Stony Brook University published a study summarizing the literature on brief, non-pharmacological, psychosocial interventions for pediatric anxiety.  Examining the data, the researchers found that many cases of mild to moderate pediatric anxiety can be treated in a primary care setting employing brief psychosocial interventions such as CBT.  While more severe and complex cases may require longer-term treatment, brief interventions can yield statistically significant and clinically meaningful reductions in anxiety symptoms among youth.  Indeed, recent research suggests that pediatric primary care providers with training in CBT are in a position to offer brief yet effective psychosocial interventions.  

The Importance of Parental Intervention

In 2013, researchers from Macquarie University in Australia found that certain parental factors (e.g., parental anxiety) significantly predicted treatment non-responsiveness in anxious youth. Helping parents of anxious children learn how to respond to their child’s anxiety is a critical yet overlooked part of any intervention.  Many parents often go to extreme lengths to protect their children from anxiety.  This well-meaning level of protection unfortunately has the unintended effect of perpetuating the child’s anxiety in the long run. Pediatricians are well-advised to spend time educating parents on how to remain empathetic to their child’s anxiety while simultaneously promoting their child’s ability to independently handle anxiety evoking situations.  

About the Author

Sam Marzouk, Ph.D., L.P. is a pediatric psychologist and owner of Promethean Psychology in Edina, Minnesota.  In addition to his routine clinical work, Dr. Marzouk also enjoys providing trainings on pediatric mental health to pediatricians and other pediatric medical providers.  

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