Bronx Community Action for
Prenatal Care (CAPC) Initiative
Annual Conference
Childhood Sexual Abuse and Trauma as a
Risk Factor for HIV in Women
March 17, 2010
Conference Proceedings Report
.
Report prepared by The Bronx Health Link, Inc.
Sponsored by: NYS Department of Health/AIDS Institute, Bronx-Lebanon Hospital
Center/Department of Obstetrics & Gynecology, BLHC/Office of Development and
External Affairs, Bronx Health Link/Infant Mortality Reduction Initiative,
New Yankee Stadium Community Fund
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About the Bronx Health Link, Inc.
The Bronx Health Link, Inc. (TBHL) is a unique collaboration created in 1998 by
Bronx-Lebanon Hospital Center, Montefiore Medical Center, Our Lady of Mercy
Medical Center, and St. Barnabas Hospital—and the office of the Bronx Borough
President. The shared vision was to build an organization that addresses community
concerns by creating linkages between the different providers, organizations, coalitions
and stakeholders that serve Bronx communities. The goal of TBHL is to create a platform
for the involvement of residents and other stakeholders in public health planning,
programming and decision-making, TBHL currently works with over 150 community
organizations and providers. While TBHL serves the entire borough, the focus is on low
income neighborhoods with the highest risk poor health outcomes, many located in the
16th Congressional District, the poorest Congressional District in the entire United States.
The Bronx Health Link, Inc. is an organization that serves as a clearinghouse for the
members of the health and human service delivery system of the Bronx. In this capacity,
we reach over 900 members and agencies that actively participate in an electronic
mailing list and numerous workgroups, advisory boards and task forces. We also
coordinate the Perinatal Information Network and thus work extensively with the
community and health care providers with the aim of improving birth outcomes, prenatal
care and the reproductive health of women in the Bronx. The Bronx Health Link works
with many community partners to improve the overall health of Bronx women, children
and families.
Copies of this report can be obtained by calling the Bronx Health Link at
(718) 590-8512 or emailing [email protected].
Acknowledgements
The creation of this report was a collaborative effort. We appreciate the efforts of the
CAPC staff (Nancy Genova, Maribel Montanez, and Josie Perez), who provided us with
the PowerPoint presentations, the biographies, the evaluation forms, and access to the
notes and other information relevant to the planning and implementation of this
conference.
Thanks also to the staff of the Bronx Health Link -- Jocelyn Camacho, Luisa Solis,
Esperanza de los Santos, and Jamel Walters -- who all worked on specific portions of this
account of the proceedings.
Finally, thanks to Robert Lederer, also of the Bronx Health Link, who diligently
coordinated the challenge of memorializing the effort, strength and commitment of all the
speakers, organizers and participants.
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Table of Contents
Page
Purpose of the Conference………………………………………………………. 3
Conference Program…………………………………………………………….. 4
Morning Plenary……………………………………………………………….... 6
Afternoon Performance…………………………………………………………14
Afternoon Workshops…………………………………………………………...15
Summary of CAPC Forum Evaluation Responses………………………….....29
CAPC Forum Evaluation Data…………………………………………………35
Biographies of Presenters……………………………………………………….37
PowerPoint Presentations
Bronx CAPC Statistics and Accomplishments, by Nancy Genova, M.P.A.
Intimate Partner Violence and HIV, by Rodney Wright, M.D.
Childhood Sexual Abuse and Trauma as an HIV Risk Factor in Women,
by Dana Diamond, C.A.S.A.C.
Centering Pregnancy Plus Project, by Abbe Kirsch, C.N.M., M.S.N., M.P.H.
Assessing Need for Mental Health Referral in HIV-Positive Women in
Pregnancy, by Elizabeth Lorde-Rollins, M.D., M.Sc.
Impact of Trauma on Children in the Child Welfare System,
by Sharon Cadiz, Ph.D.
Stress Management Strategies, by Wendy Packer, R.N., C.H., C.I.
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Purpose of the Conference
This year’s conference, held on March 17 at Villa Barone in the Bronx and attended by
149 people, was designed to provide attendees with the latest HIV perinatal transmission
facts and guidelines. This one-day forum encouraged networking, collaboration and
sharing of information and resources. Strategies for keeping women safe and utilization
of the Bronx Community Action for Prenatal Care Program (CAPC) were promoted. The
forum engaged physicians, midwives, nurses, social workers, case managers, outreach
workers, consumers, faith-based community members, administrators and police officers
from organizations and programs which care for women, children and families.
The objectives were as follows:
• Increase awareness of the impact of childhood sexual trauma & abuse in women
• Review HIV perinatal transmission facts, treatment guidelines and statistics.
• Discuss the coordination and collaboration of coalition resources.
• Celebrate the diversity of CAPC Women
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Conference Program: Taking on the Challenges of Change
Morning Session
8:30
Registration, Exhibits, Networking, Continental Breakfast
9:30
Greeting by Rev. Nancy Rosario
9:45
Welcome by Magdy Mikhail, M.D. and Rodney Wright, M.D.
10:00 Bronx CAPC Statistics and Accomplishments by Nancy Genova, M.P.A.
10:15 Keynote Address by Dorothy Ogundu, M.D., AngelDocs
10:45 Surviving Trauma by April-Lee Hernandez
11:15 Break, Exhibits, Networking, Refreshments
11:30 Panel Discussion: Link Between Trauma and HIV Risk Factors in Women
Panelists: Rodney Wright, M.D.; Dorothy Ogundu, M.D.; Quentin Walcott/
CONNECT; Dana Diamond/Exponents; Abbe Kirsch, C.N.M., M.S.N., M.P.H.
Afternoon Session
12:30 Buffet Lunch, Exhibits, Networking
1:30 Special Performance by April-Lee Hernandez, Caridad De La Luz
"La Bruja" & Rhina Valentine from the off-Broadway play “The Death of a
Dream”
2:00 Workshops
1. Assessing the Need for Mental Health Treatment for
HIV-Positive Pregnant Women by Elizabeth Lorde-Rollins, M.D., M.Sc.
2. Abuse and Childhood Sexual Trauma, by Sharon Cadiz, Ph.D.
3. Why Men Batter, by Quentin Walcott
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4. Incorporating Complementary Medicine Toward Wellness,
by Aradia Caraballo and SoJourner McCauley
5. Stress-less Strategies, by Wendy Packer, R.N., C.H., C.I.
4:00 Break, Networking
Adjourn
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Morning Plenary
Bishop Nancy Rosario welcomed the participants. She urged all providers to be the
voice for those victimized by domestic and sexual abuse – particularly women and
children. She lamented that religious leaders had in the past denied the widespread
existence of abuse and the endangerment and using of women. Recently, however, faithbased organizations have taken steps to protect abused women. She told the story of one
religious leader who urged an abused woman to take back her husband and urge him to
attend church, which he did. The woman finally agreed, and a few months later, he killed
her.
Bishop Rosario expressed gratitude for conferences like this one. She said that clergy
have to get involved in community issues. She introduced her husband, Bishop Angelo
Rosario.
Bishop Angelo Rosario strongly denounced the abuse of women. He prayed for God to
help politicians to make the right decisions so we all have a better life.
CAPC Statistics and Accomplishments, by Nancy Genova, M.P.A., Program
Director of Bronx CAPC
Ms. Genova began by citing data that most abused women do not leave their batterers for
a long time – on average, it take eight attempts before such women finally leave. She
urged care providers to engage male partners of abused women.
Ms. Genova summarized the major activities of CAPC in 2009, which included several
new initiatives and five new organizational partners that have extended the program’s
outreach range. She noted that the number of intakes has increased from last year’s level,
primarily through the work of CAPC’s 34 outreach workers from 15 agencies. She
characterized the intake efforts as “finding needles in a haystack” – that is, seeking hardto-reach women. Although they are navigated to services, many do not stay in care.
The number of outreach events has also significantly increased since last year. The
workers don’t work for CAPC directly; they are on the staffs of their respective agencies.
Part of their work is picking up and dropping off women for various events; they also
distribute baby clothes, maternity clothes, and hygiene items. Despite a major cut in the
budget for outreach, CAPC workers stayed on target last year. She said that the program
kept women in prenatal care for $7 – 9,000 per woman [per year?], whereas HIV
medicines average $2,000/month ($24,000/year), which shows the cost-effectiveness of
the program. She acknowledged the outreach worker “superstars,” and noted that anyone
who reaches 2000 consumers gets an incentive.
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Ms. Genova then cited 2008 data showing that the Bronx is the borough with the most
annual deliveries by HIV-positive women (140). This is the population which CAPC was
established to serve. She listed the methods for serving this population:
•
•
•
•
•
•
Coalition building links numerous organizations (she cited this conference as a
prime example) to help mobilize and remain responsive to community needs
Outreach workers (described earlier) are picked from various agencies and given
enhanced training.
Community mobilization is done through various major events.
Prenatal care is now offered at 20 Bronx sites. This includes the one program
outside the Bronx – “Choices,” which makes connections to HIV-positive pregnant
women discharged from Rikers.
Consumer involvement through the LIPS group, consisting of patients from the
CAPC clinics (“very vocal…play a key role in development of our program”)
Staff development, including trainings (and evaluations of them), curriculum
development, observation of workers, and monthly meetings to discuss challenges
and accomplishments.
She spoke about CAPC’s efforts to increase domestic violence services for women in the
Bronx. She noted that Hunts Point and Concourse are the areas with the highest
incidences of domestic homicide in the city.
Ms. Genova noted that CAPC is not a case management program, but rather focuses on
outreach and referrals – 33% of clients are referred by outreach workers, 12% by
community-based organizations. Virtually all clients are in crisis, and many are not in
prenatal care. She cited an article last year in the New England Journal of Medicine,
stating that HIV is out of control in the U.S., and that 20% of those infected are unaware
of their status. She noted that these women have interconnected problems including
improper nutrition, domestic violence, and community violence.
She summarized the challenge ahead: “We have to see ourselves as agents of change.”
She cited the racial disparities in HIV infection. She praised the CAPC outreach workers
who go way beyond their official role. She concluded, “As a community, we have to rise
up and work together.”
Finally, she awarded a plaque on behalf of CAPC to Pat Doyle of the NYS Health
Department, calling her a “hero who really listened and helped us believe that change is
possible.” In particular, she cited Ms. Doyle’s role in helping remove barriers to
obtaining prenatal care for women who are more than six months pregnant. CAPC has
developed a substance abuse provider network, which is more amenable to working with
their clients. Ms. Doyle also helped initiate a dialogue between CAPC and the PATH
(Preventing AIDS Through Health) program, which has been denying emergency
housing to pregnant women. No decisions have been made yet.
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Keynote Address, by Dorothy Ogundu, M.D., Founder, AngelDocs, Inc.
Dr. Ogundu began by describing her personal journey: She came from Nigeria to the U.S.
at age 15 and has traveled back and forth to Africa since then. “I have become a quasiuniversal citizen,” she commented. Since becoming an M.D., she has - because of her
outsider status (an “African doctor” when in the U.S., an “American doctor” when in
Africa) - been accepted in places whether others might not be.
She said that whenever you have children being abused, you also have women being
abused. She observed that worldwide, men say they wage war for “human dignity.” Yet
they use the most devastating weapon of mass destruction – rape. She decried this “old
weapon used over and over” against 51% of the world’s population. It becomes so
common that it’s accepted. She explained in some cultures, women are killed for
“honor”—which can mean some behavior done by a brother or other relative. She
recounted a case of a 15-year-old boy in North Carolina who repeatedly complained that
his stomach hurt, but no physical cause could be found. Finally, he committed suicide by
shooting himself in the stomach, and it turned out he had been raped by his mother’s
boyfriend in retaliation for his mother supposedly being “bad.” Dr. Ogundu noted that
such crimes don’t just destroy the person violated, but the whole community – it has a
ripple effect and the anger continues.
Dr. Ogundu emphasized the difference between victims and victors. She said that it is not
enough simply to be a survivor – using anti-depressants, alcohol, cocaine, crack or
whatever to deaden the pain. She cited the women of Rwanda as victors – she said the
view of many of them is that “you may have conquered my body, but not my soul.”
She explained that another, legal form of violence against children is based in poverty –
in some countries, young girls are married off when they have their first period.
Meanwhile, the age of menstruation onset has been dropping from 16 to 12 now in some
cases to 8. On one trip to Africa, Dr. Ogundu met young girls who had been ostracized
from the community because their babies were stillborn, the girls developed fistulas
resulting in serious medical complications and incontinence. Because of their conditions,
the girls emitted odors that led to their being cast out. Dr. Ogundu built a place where
girls and women could start to get their lives back – give them medical care and teach
them a trade. She did 67 fistula repair surgeries within three months – probably, she said,
more than those done in the last century in Western countries. “If we want to help people,
we must forget about being right,” she commented.
She concluded by urging everyone to take a stand against violence, including sexual
violence, against women and children. She especially urges fathers, brothers, uncles and
other relatives of girls and women to speak up. “Don’t keep quiet,” she implored the
audience. “Talk to your neighbor. Do something – even if it just reaches one person.”
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Surviving Trauma, by April-Lee Hernandez, Actor, Seen in Freedom Writers with
Hillary Swank
Ms. Hernandez recounted the violence perpetrated against her by a former boyfriend.
After an argument in her apartment, he choked her, tried to rape her, and hit her, causing
her to bleed profusely. “I really thought he was going to kill me,” she said. Yet when it
was over, he began to clean her cuts. She recalled walking down the street the next day
“like a zombie – dead woman walking.”
She noted that her situation was not as bad as that of some other women. She said that
shame is what keeps many women down. “When you’re expected to live a certain way
[i.e., with a man who treats you right] and now you’re living a lie, you live in shame,”
she said.
At age 19, Ms. Hernandez had an abortion, which was very traumatic. For years
afterwards, she couldn’t stand the sight of children.
She said that when it came to the domestic violence she had experienced, “I knew in my
heard I had to do something about it.” So she developed a play dramatizing the
experiences of women. “By acting I can heal people.” She added that she hoped to inspire
and ignite people to get involved. She noted that domestic violence is not just physical –
it’s also verbal, such as statements like “shut up” and “you’re stupid.” She noted that
even in gay relationships there can be abuse.
In closing, she urged the audience to “awaken the spirit within you.”
Panel Discussion: The Link Between Trauma and HIV Risk Factors in Women
Rodney Wright, M.D.; Dorothy Ogundu, M.D.; Quentin Walcott/CONNECT; Dana
Diamond/Exponents; Abbe Kirsch, C.N.M., M.S.N., M.P.H.; with Joann Casado,
J.D., of the Bronx Health Link as moderator
Rodney Wright, MD, Co-director of Women’s HIV Services at Bronx Lebanon
Hospital Center, observed that the Bronx has one of the country’s highest rates of
interpersonal homicide. He said that the rate almost triples during a woman’s pregnancy.
He also noted that rape can increase the risk of contracting HIV, because of the physical
trauma that can act as a portal for the virus. Meanwhile, male violence and the fear of
such violence reduces or eliminates condom negotiation. Until we can empower women,
he asserted, this will keep happening.
He noted that violence prevents women from getting information about HIV, and that
women exposed to childhood sexual abuse are at risk for engaging in high-risk behaviors.
He gave the example of an African immigrant woman who was brought in for testing by
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her abusive, HIV-positive husband. The woman tested positive and then was further
battered, with the husband claiming “she brought shame on the family.” In fact, he
almost killed her. CAPC helped her get into a shelter.
He reviewed what the research from other countries shows:
• Women who experience forced sex are six times more likely to not use condoms
consistently.
• Abusive men are more likely to engage in extramarital sex, acquire STIs and place
their wives at higher risk of HIV.
• Women who experience partner violence and controlling behavior are one and a half
times more likely to be HIV infected.
He said that in order for this situation to change, people have to stand up and say that this
type of behavior is unacceptable in any culture.
When asked why domestic violence increases during pregnancy, Dr. Wright theorized
that when a macho man gets frightened, he acts out. Many men, he said, feel out of
control when the woman they are with is going through such dramatic body changes. Dr.
Ogundu added that some men simply don’t understand those changes, and if they’re
“borderline,” the pregnancy pushes them over the edge.
In response to the question of how to use the conference as a platform for community
awareness about HIV and domestic violence, Dr. Wright emphasized the importance of
education. He said that the film “Precious” is a realistic portrayal of what goes on – “I see
Precious in my office every day.” Dr. Ogundu talked about the stigma attached to HIV,
which does not apply to hepatitis C or gonorrhea. She urged audience members to start
talking about hepatitis. If the client is willing to test for HCV, they might also be willing
to test for HIV. In Africa, she said, promiscuity doesn’t kill – marriage does. She noted
that in some cultures, if the husband dies, the brother has to marry the widow. If he has
HIV, this becomes a method of spreading the infection. Dr. Ogundu also noted that
female circumcision is another form of violence that creates a risk of spreading HIV
infection.
Asked to give advice for practitioners seeking cultural competence in treating African
immigrants, Dr. Ogundu offered this: “Don’t say, ‘My friend is African, so I know
Africans,’” – get to know each person as a human being by talking to them and not
judging them. You need to be able to say, ‘I don’t know.’”
Asked about the role of male privilege in domestic violence, Dr. Ogundu said that women
are 51% of the world, but “the 49% sit on our heads.” Almost every society values its
men above its women, she said.
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Quentin Walcott, Director of the CONNECT Training Institute and Community
Empowerment Programs, said that domestic violence, HIV, and trauma are all related,
and that we need to talk about these issues daily. He said that he has been working with
abusive men for 14 years. The staff of his agency sees domestic violence as a community
issue that at its core is about power and control. People generally consider this a women’s
issue, but actually the problem is sexism/patriarchy/male privilege, which exists in every
culture. To address this, he said, he have to work with men. He said those in this field
tend to be very reactive – “when we talk about DV, we start with the survivor.” But, he
said, we need to start with the men, since 90-95% of DV cases are men abusing women
and girls. The first question is why men batter and abuse.
He noted that the problem of DV is certainly not limited to Black and Brown people in
the Bronx, contrary to misleading media coverage. The difference in perception also has
to do the access of some communities to the resources to cover up the problem. He
emphasized the importance of looking at the role of all the contributing factors: race,
class, gender, sexual orientation. He urged changing the lens to the question “Why is he
doing what he does?” He noted, “If you dig into why kids get STIs, ADHD, gang
involvement, it’s very likely that they have DV at home.” He also suggested that if a
person has HIV, it’s important to consider that this might be the result of domestic
violence. DV-related trauma weakens the immune system. Also, for HIV-positive
women, a man may use psychological/emotional abuse to hold her HIV status over her.
In general, he said, 20% of DV is physical, and the rest is emotional and financial.
Mr. Walcott reported that only about 20% of DV cases are reported, and of those, only
20% are in services. He urged providers to get out of their offices and link their work to
social justice issues. The key is to empower people to have resources and networks.
He urged agencies to collaborate rather than compete. “We believe that men can change.
We show them the benefits they get from abuse. You have to be proactive – work to
change men’s and boy’s belief systems.”
Mr. Walcott was asked how we can begin the conversation about race, class and DV,
given that those topics make people uncomfortable? He responded, “Simply by having
the conversations in language people can understand. I use racism to talk about sexism. I
tie white privilege to male privilege. I talk about institutional racism as in the different
quality of food available in different neighborhoods. Be creative.”
Dana Diamond, C.A.S.A.C., Director of Case Management and Treatment
Adherences, Exponents, explained that she works in a program to support HIV-positive
women. She said that research has established that a large proportion (40-43%) of HIVpositive women had experienced childhood sexual abuse. This then leads to a higher
chance that these women will engage in risky behavior, either shared needle use or
exchange of sex for drugs.
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Ms. Diamond created a risk-reduction program called “Play it Safe” collages, which
taught male and female anatomy, body image, and condom negotiation. The collage part
involved asking men and women – separated into separate groups – to cut images from
magazines and create collages to express how they see themselves sexually, and then
discuss the collages. Many women expressed how isolated they felt, and how they felt
they were to blame for becoming HIV-positive. When they heard other women tell
similar stories, it created an atmosphere for identification with others and feeling support.
An informal study of this part of the program showed that it had a profound effect on the
women and men – and it was especially empowering for the women. More than 80-85%
of the women in the group had experienced sexual abuse at some point, and most said
they had never spoken about it until that moment.
Ms. Diamond said that although the full program is no longer in practice, she has taken
portions of it and incorporated it into one-on-one women-supportive services at her
agency.
Abbe Kirsch, C.N.M., M.S.N., M.P.H., Assistant Midwifery Director and PCAP
Coordinator, Bronx Lebanon Hospital, said that half of all births are unintended. She
described the program she runs called Centering Pregnancy. She noted that pregnancy
offers an opportunity for healthy behavior change – quitting smoking, healthy eating,
taking vitamins, etc. Every year, 25 percent of sexually active teens get STIs. In a single
sexual act, 1% of people are at risk of acquiring HIV, 30% risk getting herpes, and 50%
risk getting gonorrhea. At Bronx Lebanon, women wanting midwife care are put on a
separate waiting list from those wanting traditional care.
The Centering Pregnancy Program was developed by midwives and involved “bundling
care”—“one place, one time” for the woman to see all the medical professionals together
with other women at a similar stage of pregnancy. Two large studies at Yale and Emory
compared traditional care and Centering Pregnancy Plus (the “plus” is an added unit on
STI and HIV prevention). They found that bundling produced 10 times the amount of
time with the providers, clear social support, and a safe environment for the women to be
empowered and gain knowledge and skills. Ms. Kirsch observed that many of the women
feel isolated when they first enter the program, and that “we’ve created a new village.”
The two-hour sessions are “a group, but not a class” and follow the ACOG model. They
are a collaborative effort between the facilitator and the participants. They include the
traditional provider assessments – blood pressure, weight, belly check – but then go
further to go through a checklist of self-checking. There are lots of games and rolemodeling. They integrate HIV into all topics. Some of the groups have held reunions after
giving birth and they have built strong connections with other women.
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According to the Yale and Emory studies, Centering Pregnancy has resulted in an
extreme reduction in preterm deliveries and a reduction in rapid repeat pregnancies and in
STIs.
A study is currently underway of five New York City sites using Centering Pregnancy to
see if the program can reduce incidence of HIV and other STDs.
Janet Lugo-Campbell, survivor of many forms of abuse, spoke about her painful
experiences. From ages 8 to 13, her stepfather sexually abused her. She told her mother,
who denied it. He also beat her and gave her alcohol and marijuana. Eventually, after Ms.
Lugo-Campbell told a teacher “to protect my siblings,” she said, the Bureau of Child
Welfare (predecessor to the Agency for Children’s Services) put her and her sister away
into foster care. Her mother was angry and did not speak to her the whole time she was in
foster care. At age 15, after her stepfather died, she was returned to her mother’s home,
which was very hard. Later, after her marriage, when she was five months pregnant, her
husband began physically abusing her and he raped her. “I didn’t want to feel,” she said,
and began using crack and cocaine. Finally, she “needed to break the cycle,” and she left,
living in a succession of shelters. Later, she went on a blind date and was raped. She
isolated herself for a long time. The next man she began seeing verbally abused her – but
at the time did not realize it was a form of domestic violence. In 1990, she had a child
and shortly thereafter, while being treated for a hernia, was HIV tested and turned out to
be positive. But she got no real counseling or education about the disease. She told her
mother, who proceeded to tell everyone in her world. Past lovers started to harass her.
She felt miserable.
Finally, she went to the Highbridge Community Center, where a woman on staff
educated her on the difference between HIV and AIDS and other aspects of the infection.
She told her husband, who at first was OK with the news, but suddenly left two months
later. Her baby boy was originally HIV-antibody-positive, but later seroconverted to
negative. When she told her daughter, she got upset, but support groups helped.
Eventually, she attended presentations by United Bronx Parents that taught her to do
condom presentations. They later hired her to be an HIV peer educator and then to do
CAPC trainings. All of these experiences empowered her. She concluded, “TO be aware
is to be alive – that’s my motto.”
Nancy Genova commented that Ms. Lugo-Campbell’s story “shows us the impact of our
work in the community.”
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Afternoon Performance
Special Performance by April-Lee Hernandez, Caridad De La Luz “La Bruja,” and
Rhina Valentine from the off-Broadway play “The Death of a Dream”
The three actors delivered a moving and heart-felt performance of a small part of this
play. Afterward, Ms. Genova, who wrote the play, offered some reflections. She said she
was abused for many years. People still say to her, “You don’t look like the type.” Her
experience is that multi-modality treatment is the best – not just psychotherapy, but also
yoga, weight-training, faith, and other practices. For victims of severe childhood sexual
abuse, without therapy, it can take up to five years even to tell their entire narrative. At
the NYU Trauma Center, intensive therapy prepares survivors to tell their narrative
within 16 weeks. Studies have now shown that this type of abuse does physical damage
to the brain, and “you have to be well for a long time to undo the damage,” Ms. Genova
concluded.
Melissa Cebollero, the Bronx Borough President’s Director of Health and Human
Services, commented that these performances are excellent as a “training device.” She
said that her office has a play on domestic violence that it does in “road shows” to
promote education aimed at stopping the violence.
The actors were asked why they took their roles in the play. All said that either they or
family members were survivors of one or another form of domestic violence, and that
they wanted to contribute to building awareness. One commented that there is also
violence within the lesbian/gay/bisexual/transgender community, but that many providers
are not open to discussing that problem.
Asked her opinion of anger management classes, Ms. Genova said that studies have
shown that they do not work. “When people are mandated to do something, it doesn’t
usually help,” she said, adding that such classes “are not getting to the root of the
problem.”
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Afternoon Workshops
After lunch, participants dispersed into five workshops:
1. Assessing the Need for Mental Health Treatment for HIV-Positive Pregnant
Women, by Elizabeth Lorde-Rollins, M.D., M.Sc.
This workshop introduced participants to an overview of the various mental health
disorders that can affect patient populations, particularly HIV infected pregnant women
from low-socioeconomic backgrounds. In addition, the workshop provided information
about how those working with HIV-positive pregnant women can most effectively
identify/screen for mental health issues among their patient population.
The objectives of the workshop were as follows:
1. Define the conditions that can trigger mental health referrals.
2. Identify practical strategies that can be used to screen female patients in the short
time frame allocated to each visit.
3. Review strategies to identify what kind of patient is most at risk, who needs to be
carefully considered for a mental health referral on initial evaluation.
Defining the Conditions
Dr. Lorde-Rollins began the discussion by introducing a list of conditions requiring a
mental health referral based on the Diagnostic and Statistical Manual of Psychiatric
Disorders, also known as DSM-IV. These include Axis One disorders, which usually
trigger a need for a medical intervention, as well as the co-morbid disorders, which can
also be associated with Axis One conditions and can complicate treatment of Axis One
conditions.
Dr. Lorde-Rollins then discussed the DSM-IV definition of depression. Of the five
symptoms present in this disorder (loss of energy, sleep disturbances, difficulty
concentrating, suicidal ideations or intentions, feelings of sadness and loss of interest in
activities once found pleasurable), she said that the latter two items are the most robust of
all measures when screening patients for depressive disorder. She stated that when using
these two questions alone (Are you feeling down? Are things that used to bring you
pleasure not bringing you pleasure anymore? – followed by: Have you been feeling this
way for everyday for the past two weeks?), it has been shown that practitioners will pick
up 90% of their depressed patients. She also noted that when screening for these
symptoms, it is important to remember that if a patient is currently substance-using,
bereaved or suffering some sort of medical condition, they can also present with these
symptoms. These other elements must be removed in order to re-evaluate for depression.
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Dr. Lorde-Rollins emphasized the prevalence of depression in our communities by
stating: “When we look at depression in socially disadvantaged females, we find
depression in 25-35% of all women; you add HIV-positive into the mix and then you’re
talking about rates greater than 50% of that population. That holds the same for socially
disadvantaged, HIV-positive women, and women who are not pregnant who fall into
that.”
Dr. Lorde-Rollins went on to note that bipolar disorder is actually even more
underdiagnosed than depression and very frequently confused with depression. It affects
women more than men but is even more prevalent among socio-economically
disadvantaged women than economically advantaged women. She informed workshop
participants of the types of bipolar disorder which can be present in patients. Bipolar I
occurs in recurrent episodes in which people are manic and then depressed, and these
episodes will alternate for cycles of seven days or longer. With Bipolar II, the manic
phase is less marked than in Bipolar I but still present. These episodes can be shorter -approximately four days to qualify for Bipolar II. However, she noted that Bipolar I and
II are not nearly as common as “Bipolar disorder not otherwise specified,” which is
characterized by the presence of cyclical mood changes without meeting the criteria for
full bipolar disorder. These differences can been seen when comparing the levels of
incidence in the population, which is 1% for Bipolar I, 1.1% for Bipolar II and 2% for
Bipolar disorder not otherwise specified.
Dr. Lorde-Rollins went on to define schizophrenia as disorders of the thinking processes
often characterized by illusions and hallucinations, although these symptoms may not be
present in all schizophrenic patients. She indicated that the real indication for the
presence of this condition is the extensive withdrawal of an individual’s interest from
other people. This condition is found in 1% of the population.
She said she found it interesting to note that the Axis One disorders are prevalent in 1%
of the population, and that as more is learned about these conditions, it has been seen that
they are brain-chemistry-based and are not as responsive to psychological stress and
reactive stress going on in a patient’s life.
Dr. Lorde-Rollins defined substance abuse disorders as the overdependence of an
individual on a drug, and in many cases there can be polysubstance involvement. When it
is polysubstance, it is usually a specific combination of drugs that are being used.
Moving onto anxiety disorders, Dr. Lorde-Rollins stated that she finds it interesting how
much unreferred anxiety she is finding among her patient population—she noted that she
probably sees about one person suffering from anxiety every day. She shared that some
of the symptoms seen in anxious patients include restlessness, edginess, irritability,
becoming easily tired and difficulty concentrating. These symptoms need to cause
functional impairment to count as anxiety.
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She noted that exposure to violence is something that she sees among the majority of her
patients. She stated that exposure to violence is associated with PTSD, even if the person
was not directly victimized him- or herself. In order to illustrate the critical effect which
exposure to violence can have on one’s health and overall well-being, she shared this
story:
“One of my favorite patients has had a very hard time. She is 17 years old, she was
15 when this happened, she went to a school dance with five or six friends and
shots broke out, there was a fight in the gym, and her best friend was shot and died
right in her arms. It was a week before thanksgiving in 2008, and that patient of
mine has suffered ever since -- she has chest pain, stomach aches, headaches -- you
name it, she’s got it. And she really was fairly well, she was a little on the obese
side but she was very well prior to this happening to her.”
She also mentioned that it is important to keep in mind that when we talk about exposure
to violence, yes there are emotional problems, yes there are physical problems, but
exposure to violence can really affect the way that people think – the earlier the exposure,
the greater the effect. When we are exposed to violence, the world is not safe anymore
and some of the assumptions we have about our place and our safety in the world are
fundamentally shaken.
Screening and Identifying Patients
Dr. Lorde-Rollins stated that when screening for mental health issues, providers can
search for some clues with their patients. She finds that with her patients, the clues come
from them. Nine times out of ten people know what’s wrong with them. Nine times out of
ten they even know what’s going to make them better.
Referring to a list of risk issues for HIV-positive pregnant women which she compiled
(lack of social support, trauma, substance use and depression), Dr. Lorde-Rollins noted
that she finds it helpful to look at how those risk issues affect women if they’ve never had
the experience, if they are currently experiencing this risk during their pregnancy, and if
they are experiencing this risk following their pregnancy. She recognized that these risks
go together and certainly are not unrelated. For example, lack of social support and
certainly early trauma predispose someone to substance use; they self-treat to try and get
over the traumas they’ve experienced. Substance use is not independent of depression,
and depression is a direct consequence of trauma and lack of social support.
But she said she finds that among these four domains we see very specific risks. For
example, she stated that trauma can really give us physical brain damage, which then
predisposes us to difficulty with actualizing, finding jobs, and advancing in life -- which
then predisposes us to depression and substance use. Lack of social support can make it
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difficult to access prenatal care. As she put it, “You can have all the prenatal care in the
world, you can have all the PCAP insurance in the world, but if you currently have one
child and you have absolutely no social support for transporting yourself to the clinic,
without a program like CAPC, how are you going to make it there?”
Dr. Lorde-Rollins again noted the prevalence of depression among HIV-positive pregnant
women, stating that depression is found to be present in 23% of pregnant women in
general. Among men, the lifetime incidence of depression, depending on the population
one is looking at, is about 10-15%. For major depressive disorder in pregnancy among
women who are not HIV-positive, the figure is 12%, although in disadvantaged
communities, Kim Yonkers has measured major depressive disorder in pregnancy to be
more than 15%. Major depressive disorder in pregnancy among HIV-positive women is
approaching 30% percent. And major depressive disorder in HIV-positive women who
are not currently pregnant has been measured at 50%. So the scope of the problem is
actually quite high.
She explained that the risk factors for perinatal depression in HIV-positive women are:
being female as an independent risk factor, being low-income, being HIV-positive, and
having psychosocial risks. When she sees a patient with a history of psychiatric illness or
who had depression in a prior pregnancy, all kinds of red flags need to go up, she noted,
because that woman needs to be referred at her very first visit.
Dr. Lorde-Rollins made reference to a question during the plenary regarding how you can
help somebody who doesn’t want to come into care, who doesn’t want a mental health
referral. She offered these observations:
In working with my patient population, because they are young, I think there are two
things going on: [The first problem is] when you are young, you don’t want to be
different, you want to be normal--whatever you deem normal to be…. So the thought
that you’re going to go speak to the person that all the crazy people go speak to--no
thank you, that’s not for me.
The other problem is that at the adolescent health center….a lot of our positive kids
have come up in some really, really tough neighborhoods, and they’ve had very
rough life circumstances. And there is a feeling in those communities, and certainly in
my community where I grew up, that going to shrinks is for these white people on TV
who sit in a chair and moan to someone about how rough their mama treated them,
and that’s not me. And if I think if we are really going to get around the sort of
underdiagnosis or the undertreatment of mental health issues that goes on in our
communities, we need to deal with that head on, and say to that person head on –
“Have you ever felt that going and talking about your problems is for white people?”
And just put it out there and see what they say. “Have you ever felt like that makes
you abnormal?” “Do you think I’m calling you crazy because I’m telling you I want
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you to go see the counselor today?” And if that patient still says no, I don’t press it at
all -- because my major job is to get the most rapport that I possibly can, because
that’s gonna get them back.
I’m not as good as the social workers that I work with in dealing with mental health
stuff, and I’d never put myself out there as a psychologist or someone qualified to do
psychiatric work, but there is some benefit to that patient really coming and talking to
me. It certainly increases the likelihood that I’m going to get them to go to some of
those professionals if they keep coming back and seeing me. Most of my patients who
end up with mental health referrals, their first six mental health visits were with me,
ostensibly for their pelvic pain. So the most important job you can do is to keep
people coming back.
Dr. Lorde-Rollins when on to describe social stress and referred to a list of some of the
parameters that have been called social stress by the AIDS researchers who looked at
perinatal depression in HIV-positive women:
•
•
•
•
•
•
•
•
•
Domestic violence
Intimate partner violence
Marital problems
Financial problems
Housing issues
Lack of transportation
Bereavement
Lost or threaten custody
Incarceration of a spouse or other family member
She then went on to talk about testing for depression during pregnancy and how it has its
own challenges, because some of the symptoms of depression like appetite changes and
energy changes are also present in pregnancy. So it’s not that easy to simply separate out
psychosomatic symptoms from those of pregnancy. She noted that it’s important to
remember that antiretroviral medicines can sometimes cause also some of the complaints
that are found in depression, so the provider needs to tease those out. The most important
thing providers need to do, she said, is to ask the patients themselves, because studies
have found that patients actually self-refer for depression more often than the condition is
picked up by the providers. In many studies fewer than one out of four women who meet
the criteria for mood or anxiety disorders are actually identified by their providers.
Dr. Lorde-Rollins also emphasized that when you look at these studies regarding
depression screening, what really seems to work is that it’s not just one person doing the
screening—it’s on every level. The best pick-up rates come when the people who actually
make appointments for the clients are also educated about depression during pregnancy,
besides all the medical providers, social workers, and techs. She expressed that she felt it
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is not so much the screen that you use but how systemic your evaluation is. Is it systemwide? Is there a culture of communication in the clinic where you meet once a month to
actually talk about a patient or patients? That gets people thinking that their contribution,
the things they’ve observed, are important.
Scales That Can Be Used
Depression: Dr. Lorde-Rollins said that she considers the 10-question Edinburgh Scale to
be a very good scale for measuring postpartum depression, and there are studies of its use
ante-partum and its sensitivity and specificity have been found to be more than 90%. But
it has not been tested with HIV-positive women. Dr. Rollins added that most of the
measures covered in her presentation have not been validated for use with HIV-positive
women.
She went on to note that pregnant women are generally going to be on antiretrovirals
even if their health status and T-cells are not demanding that they take the meds. In some
cases they are going to be completely unfamiliar with this medicine, getting really sick
from it and dealing with the changes from pregnancy. In that case, the woman has all this
hitting her at once, so providers need to make sure the instruments are going to be
specific for that, or at least validated for someone in those circumstances – but that is not
now the case.
The clinician-administered questionnaire is also a way to go, she said. The patientcompleted questionnaire can also be used, but providers need to be very careful with this,
because not all patients are on the same level and not all feel comfortable with reading. It
may make them feel less competent, and that will make them less forthcoming.
She then discussed the pros and cons of some of the available depression and moodchange screening tools:
•
The Beck Depression Inventory is very comprehensive but it is fairly long -- 25
questions. It was originally developed in the late 1960s, but then revamped in the late
1990s.
•
The Sig E Caps is an eight-question instrument based on the DSM IV criteria
discussed earlier in the presentation (sleep, interests, etc.)
•
The Brief Depression Screen is two questions on mood and anhedonia (inability to
gain pleasure from enjoyable experiences). According to a study done last year, this
picked up more than 90% of antepartum depression.
•
The Hospital Anxiety Scale was initially developed for cardiac patients, but it has
been found to be useful in pregnancy as well.
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•
The CESD (Center for Epidemiologic Studies Depression) screen, available online, is
one that Dr. Lorde-Rollins said she found especially helpful. It has been validated for
African American and Latina populations in pregnancy, whereas a lot of the others
have not. It has not been validated for use with HIV-positive pregnant women
specifically.
•
Prime MD is the mood-change section of the primary care screen, also available
online.
•
There is also a simple screen which has been published and validated, but not in HIVpositive populations. It simply asks: Have you ever had four continuous days in
which you felt so good, high, excited or hyper, that the people around you told you
were not yourself? Or have you gotten into trouble -- either a fight with somebody or
you went out and spent too much money, etc.? Also, have you ever had four
continuous days you were so irritable you found yourself shouting at people and
getting into arguments?
Bipolar disorder and schizophrenia: As inadequate as the information is regarding
what works for HIV-positive pregnant patients with depression, Dr. Lorde-Rollins said,
the data for bipolar disorder and schizophrenia is even worse—there are no validated
instruments in this population. Family history is very often significant with regard to
bipolar disorder and also with the thought disorders like schizophrenia.
Adjustment disorder: is a debilitating reaction usually lasting less than six months to a
stressful event/situation. It is distress in what would be excess that does not meet the
criteria for another stress-related disorder. She commented that not a single person in the
room wouldn’t qualify as having an adjustment disorder. This has to be separate from
bereavement or substance use; otherwise it doesn’t quality. Screening for adjustment
disorder is typically adapted from scales for anxiety, depression or both. She said she
found that just talking to people—what is their distress level, are they upset because they
are upset, do they find the way they react to events in their life is an additional problem,
and how is their functioning -- because function is key.
Substance use: She comments that as a screening tool, she finds late entrance to care to
be a real tip-off. Missed appointments may be a sign, but this has to be evaluated in the
context of social support, finances and related issues. When a patient is not forthcoming
and Dr. Lorde-Rollins suspects substance use, after a few visits she asks her, “What’s
going to be the best thing for you about not being pregnant once the baby is born? What
is the first thing you’re going to do once you get out of the hospital?”
Violence: These are the questions Dr. Lorde-Rollins uses with her patients to get at past,
present or future exposure: What is/was the best thing about your family home now and
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when you were little? What was the worst thing? How did people settle arguments in
your family when you were little? Have you lost anyone you love to violence? What
happened? Were you there? How do arguments get settled in your family, between you
and your spouse, etc.? She emphasized the need to be aware of one’s biases—for
example, don’t assume that just because a couple is gay or lesbian there is not domestic
violence. Have you ever been afraid that your loved one might hit you or hurt you in
some way? Has he or she ever done that?
She emphasized that she does not ask, “Have you ever been a victim of domestic
violence?” She finds that those are not words that her patients use.
Because the immediate postpartum period is the most dangerous for women in domestic
violence situations, it is important to ask about the future: Do you ever worry that your
spouse will have a hard time coping with a crying baby? How are you going to cope with
a crying baby? What are you going to do if the baby will not stop crying? She urged
providers to get the women to think about it before they deliver.
Failure to refer: What happens if providers fail to refer? Dr. Lorde-Rollins said:
When we talk about HIV-positive pregnant women, we are talking about a difficulty
that happens in their entire home because women are the pillars of the family for
many families in our communities. So if they are having a hard time with mental
health and not getting any help for it, then they and the children are suffering as well.
But what about the progression of their disease? We know that when folks are
involved in a mental health issue, they can’t adhere to their antiretroviral therapy.
They have a hard time making appointments. And even with adherence, there is no
mind-body separation, and studies have shown that T-cells are low and viral load is
high when people are stressed or depressed. And if they are not adherent, they may
have problems with that drug and a whole class of drugs in the future.
She noted that increased social isolation—the interaction between poverty and the stigma
of mental illness—is a real concern because it just gets worse; it doesn’t get better. What
is really important is that this will lead to decreased educational and occupational
attainment. When a woman is depressed, she is unlikely to get her GED. She commented
that one of the best things she can do for her patients’ health is to get them to finish high
school, and after that to go to college and then to get a master’s degree. “Because the tide
that raises all boats is gone, the best thing they can do for their health is not to be poor—
in this country that’s the way it is. And if they are depressed, that directly impacts what
their educational and occupational attainment is going to be.”
When women are depressed in the immediate postpartum period and afterward, she said,
all communication to the child tends to be negative and that directly impacts upon
language development.
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She summarized that multiple measures have been found helpful when assessing
depression. Her take-home message was that every HIV-positive woman seen by a
provider should get a mental health referral. She urged letting the mental health
professional decide whether multiple sessions are needed or whether the client needs
anticipatory guidance. She described anticipatory guidance as follows: Even if the
provider asks about childhood abuse and answer is no, the provider should then say,
“OK, I just want to let you know that if you have this history -- and many of us do -many of us don’t remember. So if you are with your loved one and if you notice you go
other places when you are physically intimate, that is a tip-off. And if it starts getting in
your way, you should come see someone here.” She advised leaving it there.
2. Impact of Trauma on Children in the Child Welfare System, by Sharon M. Cadiz,
Ed.D., Director of the Clinical Consultation Program, New York City
Administration for Children’s Services (ACS)
The goal of this interactive session was to raise awareness about the impact of child
trauma within a selected system of care. This was used as a reference point for
considering the issues that arise in other service systems.
Specific objectives were for participants to:
• be helped to identify trauma in the lives of children
• examine the impact of trauma and possible patterns of coping and adaptation
• explore a service system view of childhood trauma and recommendations for
possible service delivery responses.
Dr. Cadiz opened her talk with a quote from Dr. Bruce Perry: “What we are as adults is
the product of the world we experienced as children.” This quote helps to understand
what occurs in the life of child who is affected by trauma and how the abuse creates a
maladaptive way of living which carries into adulthood. She added that punishing those
responsible for creating this outcome is not enough to solve the global issue of childhood
trauma, but rather using models of effective system change, along with improved service
delivery and collaboration, will serve as the catalysts to bring about meaningful change.
Dr. Cadiz explained that trauma creates a new “normal” for a child. A child may believe
that those who love him/her are supposed to hurt him/her. Therefore, adaptation for this
child can mean trying to survive in a world that is hostile, violent and uncaring. In this
world of crisis, the person working with this child in the welfare system becomes the
trusted person. However, if this practitioner does not understand the factors involved in
what they have adapted to, like unresponsiveness due to inattentive care, there will be
more difficulty in deciding on the appropriate methods to help the child. As Dr. Cadiz
said, the provider should “look at the child’s adaptive coping and take it from there.”
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In addition to adapting to specific conditions, such as the absence of a safe home or
overwhelming feelings of fear, inevitably, children who experience trauma exhibit
characteristics such as overactive stress response, hypervigilance, avoidance and
defiance, since these feelings accompanied their state of normal. As they grow, they can
experience altered states that carry a survival-driven range. For example, one of these
ranges can be apprehensive calm, which represents a state of calmness that is
accompanied by the anticipation that something will go wrong. Furthermore, in order to
cope in these altered states, the child develops short-term strategies such as, “I survived
because I decided to do drugs with him,” which results in a maladaptive way of coping.
With their altered states of normal and adaptive ways of coping, children affected by
trauma then enter the welfare system, where the intended outcome is to help, yet can
come with unintended outcomes. For example, the goal of the welfare system to protect
the child can be viewed as a form of policing and service plans can be perceived as power
plays, since this is how they have been programmed to think of those that cared for them
or inflicted the trauma.
Dr. Cadiz ran short on time when she arrived at the 9th slide, so she informed participants
that she would email them her PowerPoint. She closed by saying that in helping children
who experience trauma, “we have to start with ourselves, by holding organizations like
ACS accountable to their mission.”
3. Why Men Batter and Abuse, by Quentin Walcott, Director of the CONNECT
Training Institute and Community Empowerment Programs
The goals of this workshop were for participants to:
• critically examine the cultural and historical belief systems, particularly gender
socialization that can lead to family violence
• explore how men who are marginalized in society maintain power, male privilege
and entitlement within their intimate and communal relationships, and
• review preventive and intervention strategies available to fathers/men struggling
with abuse in their relationships to stop abusive cycles of behavior, while keeping
women and children safe.
Mr. Walcott began by stating that not all men are physically abusive in domestic violence
situations – it can take the form of verbal, psychological, sexual, or financial abuse. He
also said that domestic violence does not discriminate—it happens among all racial,
ethnic and income groups. There are many theories that attempt to explain why some
men use violence against their partners. Some of those theories are: chemical
dependency, economic hardship, family dysfunction, lack of spirituality, poor
communication skills, provocation by the woman, and stress. While these issues can be
associated with the abuse and battering of women, they are not the causes. If the
associated factors are removed, the violence of men against women will not come to an
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end. The abuser begins using violence as an effective method for gaining and keeping his
control over someone else. He continues the abuse and battering for the same reasons.
Mr. Walcott said that although it is sad to say, the abuser usually does not usually suffer
any adverse consequences because of his behavior.
Alcohol abuse is not a reason why domestic violence happens. Most men are sober when
they abuse, though alcohol can exacerbate it. Mr. Walcott said that in some cases when
the abuser is under the influence, it may be the safest time for the victim to get out.
Mr. Walcott went on to explain that history shows that violence against women has not
been treated as a “real” crime. Lack of severe consequences such as economic penalties
and incarceration for the men guilty of abuse and battering makes this apparent. Men who
are known abusers and batterers are rarely ostracized. Most abusers and batterers are
accepted by the people in their communities regardless of how they treat their partners.
Usually no one can tell by looking at them that they are abusers and batterers because
they come from all backgrounds, groups and personality profiles. But there are some
characteristics that Mr. Walcott said fit the profile of abusers and batterers, such as:
•
•
•
•
•
An abuser/batterer sees women as objects. He does not view women as people.
He has no respect for women as a group. He sees women as property and sexual
objects.
An abuser/batterer has low self-esteem. He feels powerless and ineffective.
Although he may appear to be successful, inside he feels inadequate.
An abuser/batterer finds external excuses for his behavior. He will blame his
violence on having had a bad day, alcohol or drug use, his partner’s behavior or
anything that comes to mind to excuse his violent actions.
An abuser/batterer may be charming and pleasant between his acts of violence.
Outsiders may view him as a nice guy.
An abuser/batterer may display some warning signs such as: a bad temper, cruelty
to animals, extreme jealousy, possessiveness, verbal abuse and/or
unpredictability.
Mr. Walcott closed with the following general advice for how to talk with people in the
community: Has your partner displayed any of the above warning signs? Have you
experienced any abuse or battering from your partner? If you have, begin making your
plans to get out and stay out. Once the abuse and battering starts, it will usually escalate,
so leave before you end up dead.
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4. Incorporating Complementary Medicine Towards Wellness, by Arcadia
Caraballo, yoga practitioner, and SoJourner McCauley, aromatherapist:
The goals of this workshop were to introduce participants to yoga and present the benefits
of aromatherapy. The objective was to help participants benefit from balance in their
daily lives.
Sojourner McCauley informed the participants about the lavender scent in the room and
its properties. Lavender is an anti-stress and relaxing scent. Ms. McCauley
recommended the following remedies: To relieve stress from work or other stressors, boil
cinnamon to make a tea. If one has a particularly rough day, boil camomile for calmness.
She suggested eucalyptus for congestion. Ms. McCauley said that women never take
time for themselves - it's always the kids, work, dinner or something. She said that it's
essential to incorporate some time for themselves in order to be able to function. She
recommended finding an aromatherapy scent that meets their needs and to take time to
relax. She urged participants to relate that message to others, especially to the women we
serve in the community. "Women carry the world on their shoulders," she said, "and we
better start being good to ourselves, so that others will be good to us as well."
Both presenters sent the message that if women do not take care of themselves, how are
they going to take care of everything that goes on in their lives? Women need to be in a
good mind and body condition to be able to carry out their many daily tasks, which can
sometimes be daunting.
5. Stress-less Strategies, by Wendy Packer, R.N., C.H., C.I., Reiki Master
The objectives of this workshop were for participants to:
• understand the dynamics of stress
• identify contributing factors which add to a stressful life
• calculate one’s stress level
• learn physical and attitudinal recommendations which aid in becoming destressed
• experience hypnosis and understand its effectiveness in taking control of one’s
thoughts.
Ms. Packer began by asking each participant to self-administer a questionnaire to
measure the degree to which they experience stress. She noted that this was a useful tool
to use for oneself or clients. She explained that if you have coping skills in a stressful
situation, you will be OK. If not, in such a situation you will develop physical and
emotional symptoms. This creates “wear and tear” on the body, which eventually will be
detrimental. There can be positive stress – such as great happiness – which can lead to
negative stress – such as a surprise party that causes anxiety. Imagined stress can be just
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as detrimental as real stress – your subconscious mind accepts it as real. You can harness
that power to imagine yourself as you want to be.
An important consequence of stress is the “fight or flight” response which activates
adrenaline – an ancient instinct to either become aggressive or run away. Adrenaline
stresses the heart and lungs, and is detrimental to all body functions.
Ms. Packer led the group through a brainstorming of various contributing factors and
situations to negative stress:
Environmental factors: other people’s aggressiveness on the subway; road rage;
economic crash; bright lights; loud noises; crowds; working in a small cubby; clutter (She
commented that she works with people on removing emotional clutter, which often
succeeds in getting the person to remove physical clutter in their space).
Social situations: co-workers may not want to be sociable; family gatherings may include
criticism and evaluation of your life.
Work issues: fear of losing your job; tensions with co-workers or boss
Major life changes, such as the death of a close person – often leads to regret about things
left unsaid.
Daily hassles: supermarket lines; flat tire; heavy traffic; difficult parking; 7 kids and 1
bathroom. Ms. Packer said when she needs a parking place, she visualizes finding it
quickly and “it has never failed.”
Ms. Packer outlined the major ways we manifest stress:
•
•
•
•
Physical symptoms – many different types
Emotional symptoms – irritability; insomnia; being hypercritical; lack of
enthusiasm
Relational symptoms – argumentativeness; withdrawal
Behavioral symptoms – acting out; drinking; smoking; doing drugs; fighting.
She then outlined some strategies for de-stressing:
•
Adequate sleep quantity and quality (Many elderly people have sleep problems,
start thinking of past problems.) Some tips: don’t watch the news before bed (it
stimulates adrenaline flow); play soothing music; just “be”; do breathing
exercises; play a hypnotic sleep CD; take a warm shower; drink warm milk.
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•
Eat healthfully – lots of carbs and sugar lead to crash, crankiness. She
recommends a high-protein breakfast.
•
Exercise – walking, swimming, yoga; also some form of resistance exercises such
as using canned foods as weights or pushing the wall.
•
Who’s the most important person in your life? “Women tend to put others first.
You need to put yourself first.”
•
If you can’t take a vacation, at least set aside some special break time for yourself
– think about and do what pleases you.
•
Organize your living space – try to reduce stress-producing clutter.
She also laid out some reframing tools:
•
•
If you think a lot of negative thoughts, use positive tools. Example: Keep photos
of your children or grandchildren nearby, or if that’s not possible, think about
them.
Think intensely about what puts a smile on your face – whether it’s a loved one, a
beach, a dog, or whatever.
Finally, she gave a short description of the practice she does professionally – hypnosis.
She noted that it is natural and safe, and has been scientifically proven effective for
several conditions. She then led participants through a very gentle, short relaxation
exercise based on the principles of hypnosis, after which many participants reported
feeling more relaxed.
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Summary of CAPC Forum Evaluation Responses
A total of 106 attendees returned evaluation forms, a response rate of 71%. Evaluations
of most of the presentations were highly positive – the vast majority (79-84%) gave
overall “excellent” ratings, with lesser numbers (16-28%) deeming them “good,” and
none “poor.” Only two presentations got somewhat lower marks: Nancy Genova’s review
of CAPC Statistics and Accomplishments was rated “excellent” by 72% and “good” by
28%, and April-Lee Hernandez’s talk on Surviving Abuse was rated “excellent” by 67%,
“good” by 31%, and “poor” by 2%. For the ratings of overall program quality – which
included opportunity for discussion, usefulness of information, clarity of information and
overall panel quality and expertise – 68-71% gave “excellent” ratings, 29-30% “good,”
and only on “opportunity for discussion” did a few (3%) rate it “poor.”
As to the workshops, ratings were similarly quite high. The one on Assessing the Need
for Mental Health Treatment received 83% “excellent” and 17% “good” marks. For
Abuse and Childhood Sexual Trauma, the numbers were 77% “excellent” and 23%
“good.” For Why Men Batter, the numbers were 87% “excellent” and 13% “good.” For
Complementary Medicine, the numbers were 90% “excellent” and 10% “good.”
The overall positive assessment of the Forum can be seen in the many highly favorable
comments: Numerous participants wrote “great job” or “excellent.” One person wrote,
“This gathering was informative, it confirms my mission: serving to make a difference.”
Another wrote, “This is my first conference. I enjoyed obtaining knowledge and gained a
great networking team.” Yet another wrote, “Amazing speakers! My first conference for
CAPC, but not my last!”
Participants had a variety of suggestions for topics to be covered in future conferences
(complete list below). Several requested more sessions on various topics concerning
domestic violence, including reaching young people in schools; how parents can educate
children about HIV and DV; trauma and DV; and more about why men batter. There
were also requests for such topics as: increasing HIV testing; outreach to teen women
about family planning and HIV prevention; and ways to get help to people.
One suggestion echoed by several participants was that more time should be allocated to
the workshops, so the topics can be explored in more depth – in turn, this would require
shortening the earlier parts somewhat.
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2010 CAPC Conference
Comments on Evaluation Forms
Favorable (overall conference)
• Excellent (5)
• Excellent presentation (3)
• Excellent program overall. Very well organized and diversified. Keep up the good
work!
• Everything was excellent (2)
• Good/excellent flow. Knowledge very useful and interesting.
• Great job (7)
• Great morning
• Great! A very inspiring forum, those live experiences were a plus
• Very powerful speakers, great!
• Very informal and motivational
• Very nice forum
• Everything was good, I loved it! (2)
• Everyone did a very nice job!
• Keep up the good work
• I think this is the best forum I ever been to
• This forum was very informative
• I had a wonderful time – the workshop and play was great.
• This informative gathering confirms my mission: serving to make a difference
(within the ministry) for the afflicted/infected with HIV/AIDS/substance
abuse/sexual issues/mental health.
• Good presentations
• Incredible groups of speakers
• All of the speakers were amazing both in content and delivery
• Amazing speakers! My first conference for CAPC, but not my last!
• This is my first conference. I enjoyed obtaining knowledge and gained a great
networking team. Overall the forum always exceeds my expectations when it
comes to continuing opening my mind.
• The presentation by Dr. Ogundu and Janet Lugo-Campbell made those of us
working in the field realize the importance of the work we do.
• There was only one panelist who touched on the topic briefly that we need to
teach our “boys.” I agree that all these problems can be prevented tremendously if
the school system would get more involved.
• I had a wonderful time. The workshop and play were great.
• The venue was very nice and comfortable
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Re: Overall schedule
Shorter AM panel so workshops can have enough time. Next time don’t spend so
much time on CAPC stats - we came here for the workshops.
Statistical info could be reduced, [intro] time could be reduced, start time could be
moved to 8:00 AM to allow for more time to cover Murphy’s Law.
Start the conference earlier so that there is more time for all of the events.
I wish there had been more time for workshops – extremely informative and very
interesting.
Needed more time for the workshop.
Trainers did not have significant time to complete workshop.
Great morning! Some pieces too long, but good.
Trainer did not have sufficient time to complete workshop.
Re: Nancy Genova
I love to hear Nancy talking about CAPC
Re: April-Lee Hernandez
• The “surviving abuse” speaker was great. We need more speakers like her to
motivate women and young girls.
• I’m truly grateful for the survivor’s experience, strength and hope.
I didn’t appreciate Ms. Lee Hernandez’s comments on abortion
Presentation was too loud and too intense. I didn’t like her commentary on being
“pro-life.” That was offensive. One in two women have abortions.
She was too loud and added nothing. Also shocked that anti-choice speaker was
given a platform at a conference dedicated to women’s empowerment.
Re: Panel
The panel was very detailed and informal, learned a great deal!
Great panel, very emotional
For the panel it would have been helpful to allow the audience to ask questions as
well – not just the canned/moderator questions
The panel discussion may want to have the audience ask questions as well.
Allow for questions to the panel by the audience.
Re: Quentin Walcott
• Quentin’s talk really went to the core issues: Male privilege/ sexism/ racism and
sexual orientation. Give him more time next year
• Mr. Walcott’s presentation covered many excellent points that were not covered
by the other presenters. Great educator!
• Quentin was great! Wish it was a longer workshop.
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•
•
•
•
•
•
•
•
Mr. Quentin Walcott presented a great deal of awareness on domestic violence
issues and was a real character informing that we do have to identify the issue
(DV) in all aspects - starting with the bodega, church, local programs and in our
language. It really motivates me to start mobilizing leadership from now on and
always.
Excellent presentation
Would like more information on “why men batter”
It was great to hear a male perspective on domestic violence.
Was great! Wish it was longer
Quentin Walcott was most useful. Excellent points.
Mr. Walcott gave an excellent presentation given the time. More time is needed.
I felt so uncomfortable being white. Once panelist Quentin Walcott spoke, he
polarized the room and induced and perpetrated the racial divide speaking about
white male privilege. I saw very few white males in the audience. The peace and
love in the room was gone. I couldn’t wait to leave.
Re: Janet Lugo-Campbell
• Testimony was phenomenal! Representing the lives of most of our women
enrolled in the program.
• Really loved Janet, she was awesome.
• The patient who shared her life story made the entire morning for me;
she adds more motivation to continue doing social work!
• Excellent panelist Ms. Lugo-Campbell presentation was powerful and insightful.
Wish we had more time to hear her presentation.
• Thank you for having Ms. Lugo-Campbell share her story – impacting!
Re: workshops (overall)
• Was intrigued by all the information during the workshop.
• Asking questions is dangerous – need to set ground rules, because people become
critical and judgmental.
Re: Dr. Sharon Cadiz (workshop)
Presentation was excellent, but it was very rude to cut her off right in the middle.
She only got through a few slides. Moderator should be included at each talk to
guide speakers.
Re: Dana Diamond (workshop)
• Dana’s was not useful – we can read.
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Suggestions and Recommendations for Next Year:
Topics:
• It would be great if there were types of programs that were geared for schools to
teach young people about domestic violence.
• How do children or teens or young adults deal with HIV and DV or vice versa –
parents with children/teens/young adults with HIV or DV?
• How do you empower someone that only wants to forget? How can you help
break the cycle of child abuse/incest/repeater for someone who doesn’t want help
but knows they need it.
• More workshops on trauma and DV
• Would have liked more information on the batterer. Less allowance for what
seemed like a personal session. Possibly more handouts on statistics.
• Handout for the DV will give attendees good understanding of the training
• “Why do men batter” should come back and do part 2 of the workshop
• How can we target the community that is not getting tested for HIV?
• Teen women need education on family planning, HIV prevention, STDs marketing more outreach.
• How do you help someone get help?
• We need as females to continue to empower ourselves more and more. Every day
I learn to understand that I need to take in some of the free choices that I do in the
workshops that I provide.
• I need to have more resources for pregnant homeless mentally ill women ages 1850.
• To bring more organization to more communities to be part of the solution.
• Reading materials or sheets with information and resources.
Logistics (complaints and suggestions)
• The location was too inconvenient, out of the way and detached from the
community.
• Please find a location that is central to the community
• Was not found easily - GPS could not pick up the address
• Room too cold
• Offer fruit platters for breakfast.
• Make announcement at beginning of forum to turn off or vibrate cell phones, and
personal calls to be taken outside the conference.
• The registration process was a waste of time for those who are pre-registered and
the sign-ins were too many.
• Poor coordination at registration.
• Try to have media coverage at maybe one forum
• Have media coverage
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•
•
•
If you mention partners, you should have a list of them so others don’t feel left
out. For networking purposes, there should always be a table for all partners to
advertise services since collaboration is so important.
Please send participants the data slides providing the numbers and explain how to
use the data to target outreach and education efforts.
Please connect people with studies that assess the magnitude of co-morbidity and
links to low self-efficacy.
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CAPC Forum Evaluation Data
Morning Program
Bronx CAPC Statistics & Accomplishments/
Nancy Genova, MPA
Poor
Good
Excellent
1. Presenter’s knowledge of the subject
0
19%
81%
2. Usefulness of information
1%
31%
68%
3. Overall presentation quality
0
28%
72%
Keynote Address
Dorothy Ogundu, M.D.
Poor
Good
Excellent
1. Presenter’s knowledge of the subject
0
12%
88%
2. Usefulness of information
1%
16%
83%
3. Overall presentation quality
1%
16%
83%
Special Speaker: Surviving Abuse
April Lee-Hernandez
Poor
Good
Excellent
1. Presenter’s knowledge of the subject
2%
34%
64%
2. Usefulness of information
5%
31%
64%
3. Overall presentation quality
2%
31%
67%
Panel Discussion
Poor
Good
Excellent
1. Presenter’s knowledge of the subject
0
15%
85%
2. Usefulness of information
0
19%
81%
3. Overall presentation quality
0
16%
84%
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Afternoon Program
Special Performance
The Death of A Dream
Poor
0
Workshops
Assessing the Need for Mental Health
Treatment for HIV+ Pregnant Women/
Dr. Lorde-Rollins
Abuse & Childhood Sexual Trauma/
Dr. Cadiz
Why Men Batter/
Quentin Walcott
Incorporating Complementary Medicine
Towards Wellness
Good
21%
Poor
Good
Excellent
79%
Excellent
0
17%
83%
0
33%
77%
0
13%
87%
0
10%
90%
Workshops (Combined)
Poor
Good
Excellent
1. Presenter’s knowledge of the subject
0
26%
74%
2. Usefulness of information
0
25%
75%
3. Overall presentation quality
2%
27%
72%
Overall Program Quality
Poor
Good
Excellent
1. Opportunity for discussion
3%
29%
68%
2. Usefulness of information
0
29%
71%
3. Clarity of information presented
0
30%
70%
4. Overall panel quality and expertise
0
30%
70%
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Biographies of Presenters
Morning Session
Nancy Genova, M.P.A.
Nancy Genova is currently the Program Director of The Bronx Community Action for
Prenatal Care Initiative (CAPC) and the Program Coordinator of Family Centered Care at
Bronx-Lebanon Hospital Center, for the Department of OB/GYN, Women’s HIV
Services. She has been in the field of HIV/AIDS since 1993. Ms. Genova holds a
Master’s in Public Administration with a concentration in Health Care Administration
from Long Island University and a B.A. in Social Work and Fine Arts from Lehman
College.
Ms. Genova oversees and maintains a coalition of 600 participants and establishes,
negotiates and monitors contracts with collaborating agencies. She is also responsible for
the continued funding of the CAPC program by writing proposals and fundraising. She
has developed a program promotion DVD and other social marketing materials for the
programs she manages. In addition, she is responsible for the yearly multidisciplinary
Bronx CAPC forum. Considered a social activist by her peers, and acknowledged in a
report issued by the NYS AIDS Advisory Council Women In Peril: HIV & AIDS - The
Rising Toll On Women of Color. She has been called to testify before the NYC Council
Chambers to the Women’s Committee on the impact HIV/AIDS has had on women in the
Bronx and gave similar testimony to NYC’s Medical Delegation.
Ms. Genova serves on the board of the Bronx Health Link/Perinatal Information Network
and T.O.U.C.H. She is a board member of 100 Hispanic Women and is on the planning
committee of their yearly Mind, Body, Spirit conference. She was appointed to the
Human Rights Commission of Rockland County in April 2008 by the county Executive
Scott Vanderhoof. Ms. Genova was awarded the Manager of the Year Award in 2009 by
the Association of Hispanic Health Care Executives.
The play that she authored, “The Death of a Dream,” had its off-Broadway debut in
October 2009 at Roy Arias Theater and received coverage by numerous media. The show
will now be going on a college tour throughout the United States.
Dorothy Ogundu, M.D.
Dorothy Ogundu received her Bachelor of Science and Master of Arts in Clinical
Psychology from Loyola University and M.D. degree from Chicago Medical School,
Chicago, Illinois. Board certified in Obstetrics and Gynecology specialty, she maintains a
pluralistic-based medical and healthcare practice out of two respective locations in
Queens, New York. At Aki Life Health Centers I & II, the practice is in translating
science into sound clinical practice while incorporating time-tested centuries-old
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common-sense applications to health and wellness from all corners of our world. She
serves as a public speaker, consultant, health workshop organizer, and television/radio
host.
Internationally, Dr. Ogundu and partners collaborate with health ministries in India and
sub-Saharan Africa in research and development of an innovative health care model,
“Save a Women Save a Nation” (SAWSAN), to address the unique health needs of
women, especially in the rural regions. In addition to public health advocacy that includes
clean water access, maternal morbidity and mortality reduction, malnutrition, infections
and female fetocide, Dr. Ogundu operates a free Obstetric Fistula Intervention program
for young girls and women in West Africa. She built and supports and Empowerment
Widows village in Nigeria that empowers and encourages independence through
economic sustainability. Locally and internationally she advocates health literacy as the
cornerstone of the human right to health as a birthright. She is the founder of AngelDocs,
Inc., which under her leadership has embarked upon making the public aware of the
health implications and financial consequences of remaining ignorant of G6PD
deficiency. This is accomplished through a series of public lectures, health fairs,
workshops and radio and television presentations. Dr. Ogundu is host to Health Matterz,
a health and social production on Public Television.
The deep belief that the “place” where one is born, raised and lived to a large extent
determines one’s health status, access to health, access to quality school, social contacts
and privileges, including employment and housing, is not lost to her. It led to her
involvement in Southern Queens Park Association-New York (SQPA-NY), where she is
the Chairwoman of the Board of Directors. SQPA-NY, an IRS 501(c)(3) not-for-profit
human services organization located in a 56-acre parkland serving over 230,000 people
who live in the neighborhoods of South Jamaica, St. Albans, Springfield Gardens,
Cambria Heights, Rochdale Village, Rosedale, Queens Village, Laurelton, and South
Ozone Park, and low income individuals. The agency addresses a multitude of economic,
health, educational, social, emotional, and family issues as the lead partner of over
sixteen other community-based organizations that includes AngelDocs, Inc. Amongst
other activities, she is a member of the Greater Jamaica Development Corporation and a
member of the Advisory Board to the President of York College of the City University of
New York (CUNY).
Dorothy Ogundu, M.D., is a fierce advocate for family but especially for young women
and single mothers. These she perceives as important links in mankind’s future, the
fulcrum of society being nurturers and future mothers, wives and decision-makers of
future generations. In addition to leading an intergenerational-ethnic-cultural-faith
Female Mutual Mentoring Empowerment program, she also holds a series of preadolescent and adolescent programs geared toward knowledge-based wise decisions.
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Joann Casado, J.D.
Joann Casado was born in the Bronx. Her parents, Felipe and Dolores Casado,
immigrated to the United States from Puerto Rico. She is a graduate of City College’s
Center on Legal and Urban Education and received her Juris Doctor from New York Law
School. She has worked in the non-profit and government sector for over 20 years. Ms.
Casado spent 13 years working with men and women with HIV and AIDS, first with the
Latino Commission on AIDS and then at the Hunter College Center on AIDS, Drugs and
Community Health, conducting a CDC-funded study on the development of a jail-based
health intervention for men who have sex with men. As Executive Director of The Bronx
Health Link, Ms. Casado came back to work in the Bronx toward the goal of improving
the health of all women in this community. Ms. Casado continues to live with her
husband and three children in the borough of her birth.
Rodney Wright, M.D.
Rodney L. Wright, M.D., M.S., is currently the Director of Women’s HIV Services at
Bronx Lebanon Hospital. In addition, he is an Assistant Professor of Obstetrics &
Gynecology and Women’s Health at the Albert Einstein College of Medicine. Dr.
Wright is a graduate of the University of Pennsylvania School of Medicine and
completed his residency in obstetrics and gynecology at the University of California,
Irvine. He was on the faculty at the UCLA prior to joining Montefiore and the Albert
Einstein College of Medicine. After caring for inner city women in South Central LA
and the Bronx for 5 years, Dr. Wright completed a fellowship in Maternal Fetal Medicine
at the Albert Einstein College of Medicine, focusing on the care of women with HIV.
Dr. Wright is very active in research on HIV in women and obtained a Master of Science
Degree in Clinical Research Methods in 2007. He has been actively involved in the
Pediatric AIDS Clinical Trials Group (PACTG) and the Adult AIDS Clinical Trials
Group (ACTG) where he is currently the vice chair of a protocol evaluating the long-term
effects of short courses of antiretroviral therapy given during pregnancy.
Dr. Wright is a member of the Physician’s Research Network, the Society of Maternal
Fetal Medicine, the American College of Obstetricians and Gynecologists and the HIV
Medicine Association. Dr. Wright also serves on the Board of Directors of the AIDS
Healthcare Foundation, which is the largest provider HIV/AIDS medical care in the
United States and internationally provides care to over 90,000 patients in 22 countries.
Quentin Walcott
At CONNECT, Quentin is the Director of the CONNECT Training Institute (CTI) and
Community Empowerment programs. Quentin also spearheads the Male Anti-Violence
initiatives, where he creatively develops programming training, educational programs
centered on males to cultivate participation and leadership by men in the anti-violence
movement. Recent projects include the Verizon Joint Labor Management Committee
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initiative, Men & Women as Allies, with management and craft from CWA Locals 1106
and 1108, which creates awareness on domestic violence, bullying and workplace
violence. Quentin developed a curriculum and training for young adult males that
examined violence against women and girls at V-Day’s New York Stop the Violence
Festival as part of the newly created V-Day Men’s Committee. Quentin and his team of
anti-violence educators have launched city-wide workshops for men and boys looking to
transform them form bystanders to allies to activists against family and gender violence.
Quentin -- trained, supervised and mentored by Dr. John Aponte -- has facilitated
Batterer’s Intervention groups throughout New York City for over 14 years. Quentin is
currently the Co-Chair of Committee on Working with Abusive Partners, a committee of
men and women that run program batterers programs throughout New York City.
Quentin has previously worked with the Educational Alliance Early Head Start, piloting
their Father Involvement Program and Southern Queens Park Association’s Families In
Need Preventive Services Program as a teen group facilitator and Domestic Violence
Specialist. Quentin has a wealth of experience facilitating groups for young and adult
males on masculinity, manhood development, fathering, batterer’s intervention and
accountability. Quentin combines his experience working with social agencies and
several years of human rights work Harlem, Brooklyn and Queens bringing a new and
fresh perspective to the work to end family violence.
With Quentin’s combined prevention and intervention experience he has developed
“ThinkfFirst!” groups for men to address issues ranging from batterers intervention,
fathering to healthy non-violent relationships. ThinkFirst! is unique in that it’s one of
only a few men’s programs that accepts volunteer and self-referrals in New York City
and is independent of the criminal legal system.
Dana Diamond, C.A.S.A.C.
Dana Diamond has dedicated the last 12 years working in the field of HIV/AIDS and
substance abuse at Exponents. As an employee of Exponents, Dana has held numerous
positions, including Facilitator/Interviewer for the Exponents/Columbia Project, Case
Management Coach and Trainer for Project Access, Group Facilitator and HIV Counselor
for clients in Exponents’ Outpatient Drug Treatment Program, Coordinator/Primary
Prevention for Exponents’ Health and Sexual Risk Reduction Program, Assistant
Director of Prevention for the same program and her current position of Director of Case
Management & Treatment Adherence, She has conducted primary prevention work with
women with the goal of reducing the risk of HIV transmission. Dana’s area of expertise is
in Human Sexuality, Prevention and Substance Abuse. Dana sits on the board at NDRI
(Training and Dissemination Committee), and occupies a seat on the DOH/AI-Office of
the Medical Director-Quality of Care (QOC) Community Advisory Committee.
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Abbe Kirch, C.N.M., M.S.N., M.P.H.
Abbe Kirsch is a Certified Nurse-Midwife at Bronx Lebanon Hospital Center. Ms. Kirsch
has been working with at-risk adolescents for twenty years in New York City, both as a
public health and sexuality educator and as a clinician. She is the Site Principal
Investigator of the NIH-funded study: “Integrating Prenatal Care to Reduce HIV/STDs
Among Teens” at Bronx Lebanon. Ms Kirsch implemented the Centering Pregnancy Plus
program (group prenatal care) in the adolescent clinic one year ago and continues to
facilitate groups. She is the Assistant Midwifery Director and PCAP Coordinator at
BronxCare Fulton, and teaches and precepts students and residents, in addition to
managing a busy clinical midwifery practice.
Workshops
Elizabeth Lorde-Rollins, M.D., M.Sc.
Elizabeth Lorde-Rollins, MD, currently holds dual appointments as Assistant Professor of
Pediatrics and Assistant Professor of Obstetric and Gynecology at Mount Sinai Medical
School, where she concentrates her clinical time in adolescent gynecology at the Mount
Sinai Adolescent Health Center. She completed a master’s degree in Research Methods
in 2006 and is currently engaged in a National Institute of Health sponsored study on
oral, anal and cervical human papilloma virus.
Dr. Lorde-Rollins was born and raised in New York City by her mother, Audre Lorde,
her father, Edwin Rollins, and her parent, Frances Clayton. After graduating from
Radcliffe College of Harvard University in psychology, she taught third grade in a
Harlem public school for three years. She also taught adult education in English grammar
and composition at District Council 37 for four years. After receiving her medical degree
from Columbia College of Physicians and Surgeons in 1993 and completing her
residency in obstetrics and gynecology at Columbia-Presbyterian Medical Center in
1997, she briefly served as a clinical instructor at Harlem Hospital before joining a busy
private practice in Honesdale, Pennsylvania. Dr. Lorde-Rollins returned to the New York
area in 2002, as an attending at the Ryan Community Health Center.
Sharon M. Cadiz, Ed.D.
Sharon M. Cadiz, Ed.D., is currently Director of the Clinical Consultation Program
(CCP) for the New York City Administration for Children's Services within the Office of
Child and Family Health. The program assists child welfare staff in the areas of chemical
dependence, mental health and domestic violence. A national speaker and outspoken
advocate, Dr. Cadiz conducts seminars that deal with self-care and wellness; actively
supports cross-system collaboration; and heads an expert consultation group specializing
in implementing women and children's services within communities, organizations and
diverse care settings. She has many years of experience in launching innovative
treatment models dealing with chemical dependence, mental illness and violence; as well
as initiatives focused on family strengthening and early intervention. Dr. Cadiz is the
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author of a self-directed guide for women in treatment that supports them on their journey
of healing and recovery, and has written on integrated service delivery and ways to
empower organizational change. She was one of the original members of the National
Trauma Consortium and takes an active role in raising awareness about the impact of
trauma across systems of care.
Arcadia Caraballo
Arcadia Asa Reyes Caraballo is a certified Hatha Yoga instructor who has spent over a
decade studying movement healing and dance techniques. A native New Yorker who is
fully bilingual (English-Spanish), Arcadia views yoga as a constantly evolving path to
self-discovery and works within the principles of Hatha Yoga to assist individuals in
discovering their full potential.
Arcadia's instruction is inspired and informed by a multitude of diverse sources. She is
also trained in Chair Yoga (for individuals with restricted movement) and is certified in
both Prenatal and Postpartum yoga. Arcadia has also worked with individuals with HIV
and communities such as the Queens Women's Health Center, 100 Hispanic Women,
Bronx Community Action for Prenatal Care Initiative and the De Alma’s Women's
Collective.
In 2004, Arcadia received the Kripalu Yoga Teacher's Association Award, "Teaching for
Diversity" funded by the Ritter Foundation in recognition of her work with underserved
communities. Arcadia currently teaches yoga at Bronx Community College where she is
an Adjunct Professor and provides private instruction for individuals and organizations.
The Integral Yoga Institute, Castle Hill YMCA, Lehman College, Hostos Community
College and Ta-Yoga House in Harlem are among the many institutions that are included
in Arcadia's client base.
SoJourner McCauley
SoJourner McCauley, Coordinator of Community Services at Bronx AIDS Services was
born and raised in the Bronx. Mother of two and grandmother of five she is a political
grassroots agitator/organizer for over 40 years. She has taken her personal experiences
and organized for change in the lives of women of color on many different levels. Her
life motto is “Improve Don’t Move” which is why she stills works in the Bronx with
communities of color in the enhancement of their quality of life and community
improvement. Her HIV/AIDS work in Traditional and Non-Traditional Faith
Communities has brought her recognition from the AIDS Institute Faith Communities
Project on Common Grounds. The devastation of HIV/AIDS in the Bronx calls out to all
for change and that change must start with our young people. As an elder and
grandmother, she continues to spread the words that will make the change possible, “Get
Educated! Get Tested! Get Involved!” She has been initiated in the Yoruba Tradition for
the past 26 years to the Orisha Yemonja (Goddess of the Ocean) and as such is
knowledgeable on the subject of medicinal herbs and aromatherapy.
The Bronx Health Link
CAPC Conference – March 17, 2010
Conference Proceedings Report
Page 43
Wendy Packer, R.N., C.H., C.I.
Wendy Packer is a Registered Nurse/NGH Consulting Hypnotist/ Certified
Instructor/HypnoCoach/Certified in Forensics/Pediatrics/Basic NLP and President of the
NGH Westchester NY Chapter/Reiki Master. She has worked in hospitals, clinics and
private offices in NYC and Westchester. Wendy maintains a private practice in New
Rochelle, NY working with adults and children.
Wendy is a contributing author of the book Tipping the Scales, Attention! It Is Not
About DIEting, It's About Living. Her chapter is titled, "Unlock Your Brain and Seek
Hypnosis for Weight Loss." Wendy participates in corporate health events in New
York City where she educates employees of various corporations on the benefits of
hypnosis, does mini-relaxation sessions and sells her dynamic and life changing CDs.
She lectures and gives seminars educating groups and organizations on the power of
hypnosis and self hypnosis and the importance of stress management in one’s life. She
works with physicians in Westchester as well as NYC assisting their patients with
hypnosis and Reiki for various concerns. Her websites are www.hypnonurse.com and
www.careforthecaring.ning.com.
4/22/2010
Bronx CAPC
B
CAPC: St
Statistics
ti ti &
Accomplisments
Nancyy Genova,, MPA
Program Director
On Behalf Of Dr. Mikhail, Dr. Wright, &
Ms. Timoney
•
•
•
•
Bishop
Bi
h N
Nancy Rosario
R
i
Keynote Speaker; Dr. Dorothy Ogundu
Special Speaker; April Lee Hernandez
Panelists; Dana Diamond, Quentin Walcott, Abbe
Kirsch,
• Special Presentation; Caridad De La Luz, Rhina
Valentin
• Workshop Facilitators; Dr. Lorde-Rollins, Dr. Cadiz,
Sojourner McCauley, Arcadia Caraballo, Wendy Packer
• Our special guests from the DOH: Patricia Doyle, JoAnn
Beasley, & Barbar Warden
1
4/22/2010
2009 Activities
•
•
•
•
•
•
•
•
•
•
•
•
J
January:
Hi
Hire off new Assistant
A i t t Coordinator
C di t
February: AI Comprehensive Site Visit
March: Forum 10
April: NYPD Domestic Violence Squad rere-joins steering committee
May: Meeting with Jacobi interdisplinary team
June: In servicing @ Jacobi a CAPC prenatal site
July: Lincoln Hospital becomes active prenatal
August: Back to School Event
September: New phase of CAG/L.I.P.S./ Currriculum from B.U.
October: Customize training for Bronx CAPC Workers
November: Clothing Boutique for CAG/L.I.P.S. members
December: Annual Networking Event
Forum X
2
4/22/2010
Our New Partners
•
•
•
•
•
MIC
NY Harm Reduction Educators (NYHRE)
Dennelisse Corp
Community Health Care Networks
Latino Commission on AIDS
Intakes
• From the months of January – November
2009
• We’ve received 379 intakes
• More than at this time last year/ 360
• Most referrals continue to come through
the efforts of our outreach workers
3
4/22/2010
Outreach Events
• We currently have 34 active outreach workers
• They represent 15 agencies
• We distributed $37,050 in outreach incentives to
our workers for the closing of 09 fiscal year
g Bernal/
• The new members of the team are;; Olga
MIC, Maria Alonso/ AECOM, Luz Sierra/ UBP
• We participated in 237 outreach events, same
time last year 141
Distribution JanuaryJanuary-November 2009
•
•
•
•
•
Metro Cards: $1,412
Lunch Vouchers: $1,501
Cab Fare: $619
Additional Items: gift cards, baby items,
This year our outreach budget has been
significantly reduced/ we were left with 1/3
of budget
4
4/22/2010
Outreach Superstars
•
•
•
•
•
Norma Cancel/ 5360
Dwight Brown/ 5215
Janet Camacho/ 5050
Pablo Antonnetti/ 4955
Marianne Carlo/ 2200
Number of HIV+ Women Delivering
in NY (1/2008-12/2008) N=488
200
180
160
140
128
140
99
120
100
71
80
60
37
40
9
20
4
0
Bronx
Bronx
Brooklyn
Brooklyn
Manhattan
Manhattan
Queens
Queens
Staten Island
Staten Island
Out of State
Out of State
Rest of State
Rest of State
5
4/22/2010
How Do We Do It?
•
•
•
•
•
Coalition Building
Outreach (34 workers)
Community Mobilization
Prenatal Care (20 sites)
Consumer Involvement (L.I.P.S.)
Coalition Building
• Linkage agreements with numerous
agencies
• Steering Committee comprised of key
players in the community
• Yearly
Y l community
it fforum (thi
(this year
attended by over ??? participants)
6
4/22/2010
Staff Development
• Cicatelli Associates, Inc
• Development of Curriculum Lead
Agencies Collaborated in the Process
• Evaluation of Trainings
• Observation of workers in the field
• Monthly meetings to discuss challenges
and accomplishments
Prenatal Sites (20)
•
•
•
•
•
•
•
•
•
Bronx Lebanon Hospital (3)
Lincoln Hospital (2)
Jacobi (2)
North Central Bronx (4)
AECOM (1)
( )
Monterfiore (2)
Promesa (2),
Dr. M.Luther King H.C., Family Practice, Choices,
Community Health Care Network
7
4/22/2010
Responsive Approach
• Lead agencies reported to funding source
challenges of getting SA women into
residential treatment at 6 months or more
of pregnancy
• They developed a substance abuse
provider network where we meet quarterly
to ensure our women are getting this
much needed service
PATH
• Pregnant American women being found
ineligible
• Funding source invited PATH to a meeting
• Funding source developed a survey
• Lead agencies provided feedback
• We are negotiating to ensure that our
women are not disqualified
8
4/22/2010
Risk Factors* of Women Enrolled in Bronx CAPC
2008
(N=694 risk factors for 352 clients)
100%
80%
60%
48%
41%
39%
40%
24%
20%
16%
11%
12%
0%
Substance
Use
Immigrant
Homeless
Sex worker
8%
7%
1%
3%
Mental
illness
Domestic
violence
Prison
releasee
Unprotected
hetero
contact
Minority
Adolescent
Pregnant/at
risk
Risk at intake
*Categories are not mutually exclusive. A client may have more than one risk factor.
Client Pathway into Bronx CAPC 2008
N=352 Pathways for 352 Clients
100%
80%
60%
34%
40%
20%
5%
5%
9%
7%
4%
1%
11%
1%
1%
Other
SU program
Shelter
Self
Physician
Outreach/education
Client Pathway
Social Marketing
HIV C&T
Health center
Friend/family
Rikers
CBO/CSP
0%
12% 10%
Other consists of: Designated AIDS Hospital, Other Hospital, Adolescent Service Program, Supportive Housing Provider,
Local Social Services.
9
4/22/2010
CAPC Pregnancy Status-2008
N=352
100%
80%
60%
42%
40%
20%
11%
6%
1%
10%
2%
2%
Missing
Woman who
suspects
pregnancy
Pregnant woman
not in prenatal
care
Pregnant woman
at Rikers
Pregnant woman
in crisis
Other
Newly diagnosed
postpartum
HIV+ woman not
getting HIV care
0%
26%
Pregnancy Status
Risk Factors* of Women Enrolled in Bronx CAPC 2009
(N=442 risk factors for 316 clients)
100%
83%
80%
60%
40%
20%
9%
1%
2%
0%
Substance
Use
22%
15%
17%
Immigrant
Homeless
Sex worker
4%
Mental
illness
9%
4%
Domestic
violence
Prison
releasee
Unprotected
hetero contact
8%
Minority
Adolescent
Pregnant/at
risk
Risk at intake
*Categories are not mutually exclusive. A client may have more than one risk factor.
10
4/22/2010
American Journal College Medicine
• Th
The N
New E
England
l d JJournall off M
Medicine
di i published
bli h d a shocking
h ki reportt
that states that HIV has gotten beyond out of control in the United
States. Certain populations in America have higher rates of HIV
infections than in Africa, the distinguished medical magazine
claims.
• The New England Journal of Medicine says black and Hispanic
women make up more than 25 percent of all new HIV contraction
cases in the United States today. “Lower-income black Americans
with poor education and unstable housing are disproportionately
affected “ and worse,
affected,
worse “More
More than 20 percent of the estimated 1
million HIV-positive Americans are unaware of their status.”
Next Steps
•
•
•
•
What Is Our Role?
What Can We Do?
Who Should We Recruit to Help Us?
Why Has This Happened?
11
Intimate Partner Violence and HIV
Rodney L. Wright, M.D., M.S.
Co-director, Women’s HIV Services
Bronx Lebanon Hospital Center
1
Intimate Partner Violence Against Women in New York City, 2008 Report from the New York City Department of Health and Mental Hygiene
Intimate Partner Violence Against Women in New York City, 2008 Report from the New York City Department of Health and Mental Hygiene
2
• Rape can result in physical trauma which
increases the risk of acquiring HIV
• Violence and fear of violence makes it
difficult for women to negotiate safe sex
including the use of condoms
World Health Organization, Violence Against Women and HIV/AIDS Information Sheet
• Women who are exposed to childhood sexual
abuse are more likely to engage in HIV –related
risk behaviors (e.g. early sex, more partners,
use of drugs and alcohol
• Fear of violence prevents women from
accessing HIV/AIDS information, being tested,
disclosing their HIV status, accessing services
for pMTCT, and receiving treatment, care and
support
World Health Organization, Violence Against Women and HIV/AIDS Information Sheet
3
IPV and HIV
• Many risk factors associated with
domestic violence also associated with
increase risk of contracting HIV
– Annual income < $10,000
– Trading sex for drugs or money
– Having sex with men who use drugs
– Drug abuse
– Alcohol abuse
Koenig et al, Mat Child Health J, 2000 Jun;4(2):103-9
What the research shows
• Study from South Africa
– Women who experience forced sex are 6x more
likely to not use condoms consistently
• Study from India
– Abusive men are more likely to engage in
extramarital sex, acquire STIs and place their wives
at higher risk of HIV
• Study from South Africa
– Women who experience partner violence and
controlling behavior are 1.5x more likely to be HIV
infected
4
What we need to do to change
• Develop programs that:
– Mobilize leadership at global, national, and
community levels to clearly state that violence
against women is unacceptable
– Build evidence on the social, ecomonic and
health consequences of violence against
women including its links to HIV/AIDS
World Health Organization, Violence Against Women and HIV/AIDS Information Sheet
5
4/22/2010
Childhood Sexual
Abuse & Trauma
as an HIV Risk
Factor in Women
Dana Diamond, CASAC
• “In doing HIV/AIDS work , it is critical to operate with the awareness that a large proportion of adolescents and adults were sexually abused as children and that abuse has had a profound and devastating effect on their consequent psychosocial development”
Written by Risa Denenberg, R.N., F.N.P., M.S.N. for The Body
1
4/22/2010
What we have seen statistically?
• “Childhood sexual abuse has been strongly associated with further domestic violence, adolescent pregnancy, child abuse, drug and alcohol abuse, depression, prostitution, bulimia, self‐mutilation, running away from home, dropping out of school and sexually transmitted infections” (Rosenfeld
transmitted infections
(Rosenfeld, 1993; 1993; Boyer, 1992).
• Therefore the risk for HIV, as well.
The Link…
• Of the 771 women enrolled in the HIV Epidemiology Research Study (HERS) through Epidemiology Research Study (HERS), through structured interviews at sites in Baltimore, Detroit and the Bronx, 43% had been sexually abused as children and 45% had been sexually abused as adults. (Vlahov, 1996).
• In the Women’s Interagency HIV Study (WIHS), g
y
y(
),
data from 1560 women enrolled in NYC, Chicago, DC and LA reveled that 40% reported a history of childhood sexual abuse (Cook, 1997)
2
4/22/2010
For these women, a history of sexual abuse, physical abuse or domestic abuse was highly correlated with b d
ti b hi hl l t d ith engaging in risk behavior for HIV. In particular, childhood sexual abuse was significantly associated with: use of IV drugs, exchange of sex for drugs, money or shelter; higher number of sexual partners; and having a sexual relationship with a person at high risk for HIV Additionally childhood sexual abuse was risk for HIV. Additionally, childhood sexual abuse was significantly related to adult domestic violence as well as adult sexual abuse.
What have we seen working in this field?
• “Play it Safe” Collages
• Creating a forum to discuss how they view themselves sexually (from past to present to future)
3
4/22/2010
What have we seen in “Play it Safe”?
• 80‐85% of women participating had a history of childhood sexual abuse or sexual abuse at another time in their life.
4
Abbe Kirsch, MSN, MPH, CNM
Assistant Midwifery Director
PCAP Coordinator
Site Principal Investigator for CP+ NIH Study
Bronx Lebanon Hospital
TRADITIONAL
PRENATAL CARE
ROUTINE
PHYSICAL
ASSESS
LABOR
PREPARATION
LAB
TESTS
SOCIAL
WORK
NUTRITION
WIC
LINKAGE TO
OUTSIDE
RESOURCES
MENTAL
HEALTH
SMOKING
CESSATION
INSURANCE
LACTATION
CONSULT
1
CENTERING PREGNANCY (CP+):
BUNDLED CARE
PHYSICAL ASSESSMENT
LAB TESTS
NUTRITION/WIC
SOCIAL WORK
MENTAL HEALTH
SMIOKING CESSATION
INSURANCE
LABOR PREPARATION
LACTATION CONSULT
LINKAGES TO OUTSIDE RESOURCES
HIV PREVENTION
STD PREVENTION
BIRTH CONTROL
CENTERING PREGNANCY
(CP+)
PHYSICAL ASSESSMENT
LAB TESTS
NUTRITION/WIC
INFORMATION
SOCIAL WORK
SOCIAL
MENTAL HEALTH
IMPROVED
SUPPORT:
SMIOKING CESSATION
LEARNING
IN/FORMAL
INSURANCE
LABOR PREPARATION
∆ SOCIAL NORMS
ENHANCED
LACTATION CONSULT
INSIGHT
LINKAGES TO OUTSIDE RESOURCES
SKILLS BUILDING
INTIMACY
HIV PREVENTION
RESOURCES
STD PREVENTION
$$$ COST
BIRTH CONTROL
TIME
10x
NEUTRAL!
2
3
CP+ SESSION OUTLINE:
PRIMARY TOPICS
11.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Nutrition & Fetal Development
Common Discomforts
Relaxation & Labor, Infant Feeding
Family & Parenting Issues +HIV/STI prevention
Birth Experience, Tour Birthing Unit
Labor & Decisions of Pregnancy +HIV/STI prevention
New Babyy Care & Infant Feedingg
Post-Partum Adjustment & Birth control +HIV/STI prevention
Baby Care
Baby Care, Mother Care , Nurturing Families
Reunion: Time to reconnect, (booster) +HIV/STI prevention
Preterm Delivery, Stratified by
Study Condition, for Entire Sample
and African Americans Only
20
10
15 9
15.9
13.9
15
9.8
10.1
CP/CP+ Group PNC
Indiv PNC
5
0
Total Sample
(n=995)
OR=.67, (.44-.99)
33%
African Americans
(n=796)
Per 1000 women in
group, 40 preterm
deliveries averted; 60
per 1000 for African
American women
OR=.59 (.31-.92)
41%
Note: All analyses controlled for study site, factors that were different by study condition despite randomization (race, prior preterm
delivery prenatal distress) and clinical risk factors assoc with birth outcomes (smoking, prior miscarriage/stillbirth).
Ickovics et al, Obstetrics & Gynecology (The Green Journal). 2007;110:330-339.
4
RAPID REPEAT PREGNANCY:
6 MONTHS POST-PARTUM
14
12.9
12
10
7.9
8
5.6
6
4
2
0
INDIV CARE
CP GROUP
CP+ GROUP
OR = 0.49 (.27-.91), p=.02, planned contrast CP+ vs CP/control
Kershaw et al., Am J Public Health, in press
STI (CT/NG) Incidence:
12 Months Post-Partum by Intervention
Condition and Age
25
20
15
10
20.3
12.6
10.5
9.3
7.5
7.6
INDIV CARE
CP GROUP
CP+ GROUP
Overall Chi2 = 6.61,
6 61
p<0.01.
5
0
Adolescents (14-19)
OR=0.37 (.17-.77), p<0.05
Young Adults (20-25)
OR=0.67 (.30-1.45), NS
Kershaw et al., Am J Public Health, in press
5
POTENTIAL MECHANISMS
FOR ENHANCED OUTCOMES
|More knowledge and skills
|Health behaviors
|Decreased infection
|Social support
|Reduced stress
Integrating Prenatal Care to
Reduce
e uce HIV/STDs
/S s Among
o g
Teens: A Translational Study
Yale University, Clinical Directors Network &
Centering Healthcare Institute
National Institute of Health
PA-01-123 Collective RO1s for Clinical and Services Studies of
Mental Disorders for AIDS
6
7
4/22/2010
Assessing Need for Mental Health R f
Referral in HIV+ Women l i HIV+ W
in Pregnancy
Elizabeth Lorde­Rollins, M.D., M.Sc.
Assistant Professor of Obstetrics and Gynecology Assistant Professor of Pediatrics
Mount Sinai Adolescent Health Center
Consultant, Cicatelli Associates
Faculty Disclosure
• No conflicts
• Current research support: NIH
• No stocks
• No interest in pharmaceutical firms
• Medical Education Speakers Network
1
4/22/2010
Course Objectives
Following this training, participants will be able to:
• Define conditions that require mental fi
di i
h
i
l
health referral in HIV+ pregnant women
• Identify clients/patients most at risk • Screen HIV+ women during pregnancy for depression, adjustment disorder, and substance use
Conditions Requiring Mental Health Referral • Axis I psychiatric disorders
• depression
• bipolar disorder
• schizophrenia
• Adjustment disorder
• Comorbid conditions
•
•
•
•
•
•
substance use
anxiety
violence exposure
eating disorders
cognitive limitations
autism spectrum
2
4/22/2010
Depression
DSM‐IV Definition:
•
•
•
•
•
•
•
•
Depressed mood
Anhedonia
Appetite disturbance
Sleep disturbance
Physical agitation or psychomotor retardation
Fatigue, decreased energy
Feelings of worthlessness or inappropriate guilt
Decreased concentration or inability to make decisions
• Recurrent thoughts of death or suicidal ideation
J Payne. Am Jnl Psychiatry 2007;
164(9): 1329-1332
Bipolar Disorder
DSM‐IV Definition:
• Bipolar I disorder: characterized by recurrent episodes of mania and depression • Bipolar II disorder: characterized by recurrent episodes of hypomania and depression
• Bipolar disorder NOS: illness is punctuated with manic and depressive episodes not reaching DSM­
IV threshold for full mania or depression Sharma V, Burt VK, Ritchie HL. Bipolar II
postpartum depression: detection, diagnosis, and
treatment. Am Jnl Psychiatry 2009; 166:1217-1221
3
4/22/2010
Schizophrenia
A common type of psychosis characterized by a disorder in the thinking processes, such as delusions and hallucinations, and extensive withdrawal of the individual’s interest from other people p p
Substance Use Disorders
DSM‐IV Definition:
• A psychological or physiological over­
d
dependence of an individual on a drug
d
f i di id l d
• Used in cases in which there has been long­
term abuse leading to impaired social and/or occupational functioning
• Usually a specific drug or combination of d
drugs is used
i d
4
4/22/2010
Anxiety Disorder
DSM‐IV Definition:
• For more than half the days in prior 6 months, individual experiences excessive anxiety and worry about several events or activities
• Trouble controlling these feelings
• Symptoms associated with this anxiety and worry, present for over half the days in prior 6 months
•
•
•
•
•
•
Feels restless, edgy, keyed up
Tires easily
Has trouble concentrating
g
Is irritable
Has increased muscle tension
Experiences sleep disturbance
• Symptoms cause clinically important distress
• Symptoms cause functional impairment
Exposure to Violence
• Associated with post traumatic stress, even if individual was not victimized him/herself
• Doesn’t have to be current to affect health outcomes
• Damage may be emotional, cognitive, or physical
• Physical damage may be neurologic or non­
neurologic
• Neurologic damage may be peripheral or central (affecting brain)
5
4/22/2010
Eating Disorders
• Hyperemesis of pregnancy may introduce similar nutritional risk, but may not require i il t iti
l i k b t t i mental health referral
• Anorexia
• Bulimia
• Very often seen as a continuum rather than just one disorder
Although we can’t treat everything all at once…
www.bridalbuds.com
6
4/22/2010
Understanding how these pieces fit helps us to quantify risk in our clients/patients…
jigsaw puzzle:
each piece usually has a small
part of a picture on it;
when complete, a jigsaw puzzle
produces a complete picture
www.wikipedia.org, accessed 2/14/2010
Risk Issues for HIV+ Women
Risk Domain Ever/Remote Experience
Lack of Social Support
1.
2.
Increased risk of comorbidities
No framework for positive interactions with medical, mental health, and social service organizations
During Pregnancy
Following Pregnancy
1.
Associated with lack of resources
Nutritional risk
Less access to care, especially if pt has other children
Increased incidence of depression
1.
2.
Substance use
Direct harm to mother and fetus
Unprotected sex with non­
monogamous partner; subsequent increased risk of other STIs
1.
2.
3.
4.
Trauma
1.
2.
3.
4.
Risk of poor parenting
Brain damage
PTSD, anxiety disorder
Self­tx with SA, EtOH, cigs
1.
2.
3.
3.
4.
2.
3.
4.
Substance Use
1. Low educational attainment/occupational readiness
2. Poor financial resources
3. Liver damage and/or overly­
induced cytochrome systems (may affect pain control)
1.
2.
3.
4.
Depression
1.
1. Self­tx with substance use
2. LGA, SGA, prematurity
3. Increased incidence of hypertensive disorders
4. Poor adherence to medication
2.
3.
Increased risk of later depression
Uncompleted developmental
tasks
Delays in starting ART upon dx
LGA, SGA, prematurity
Poor adherence to medication
Placental abruption
Neonatal addiction and withdrawal syndromes
Poor parenting
Decreased ability to get to medical visits
Increased incidence of PP depression
Stress­related effects on immunity
Unprotected sex, increasing risk of acquiring resistant strains and rapid repeat pregnancy
Morbidity and mortality to mother and baby
Increased isolation
Decreased academic pursuit/ occupational fulfillment
1. Poor parenting
2. Poverty
3. Medical sequelae of each substance
4. Decreased academic/occupational pursuit
5. Poor adherence to medication
1. Poor adherence to meds, visits
2. Poor parenting
3. Developmental delay in offspring
4. Nutrition/cognitive effects
of MDD, HIV, ART
7
4/22/2010
Prevalence of Depression in HIV+ Pregnant Women • Depression rates higher in women than in men • Similar rates of depression have been documented in pregnant and non­pregnant women
• HIV diagnosis is often associated with i
increased depressive symptoms
d d
i • Individuals with HIV have higher depression rates than HIV negative counterparts
Psaros C, Geller P, Aaron E. Importance of identifying and
treating depression in HIV-infected pregnant women. Jnl
Psychosom Obstet Gynecol 2009; 30(4): 275-281
Scope of Problem
Kapetanovic S et al. Correlates of perinatal depression in HIV-infected women. AIDS
Pat Care STDs 2009; 23: 101-108
Psaros C, Geller P, Aaron E. Importance of identifying and treating depression in
HIV-infected pregnant women. Jnl Psychosom Obstet Gynecol 2009; 30(4): 275-281
8
4/22/2010
When You Hear Hoofbeats Outside Your Window…
Risk factors for perinatal depression in HIV+ women
• Demographic
• Female
• Low­income
• HIV positive
Kapetanovic S et al. Correlates of perinatal
depression in HIV-infected women. AIDS
Pat Care STDs 2009; 23: 101-108
• Psychosocial
• History of psychiatric illness
• Social stress
• Medical
M di l
• HIV­related: Low T­cell counts, high viral load, high symptom level
• Thyroid abnormalities
• Nutritional deficiencies
• Substance use in pregnancy
What Do We Mean By “Social Stress”? •
•
•
•
•
•
•
•
•
Domestic violence and intimate partner violence
M it l Marital problems
bl
Financial problems
Inadequate housing or threat of losing housing
Lack of transportation
Lost or threatened custody of children Recent death of loved one
Incarceration of spouse or other family member
Sick family member, especially if caretaker
9
4/22/2010
Assessing Depression During Pregnancy
• Many symptoms of depression may overlap with somatic complaints of pregnancy
• In HIV+ women, HIV­related symptoms or reactions to anti­retroviral medication may also mimic depressive symptoms
• In many studies, fewer than 25% of women who meet criteria for mood or anxiety disorders are id tifi d b th i h lth identified by their health care providers
id
Psaros C, Geller P, Aaron E. Importance of identifying
and treating depression in HIV-infected pregnant women.
Jnl Psychosom Obstet Gynecol 2009; 30(4): 275-281
Screening Strategies
• Patient­completed questionnaire
• Clinician­administered questionnaire
• Social workers and/or case managers meet with patients at intake
• Social workers and/or case managers meet with patients during every visit
• Review of records detailing previous care
10
4/22/2010
Screening Tools for Depression •
•
•
•
•
•
Edinburgh Postnatal Depression Scale
Beck Depression Inventory
SIG E CAPS + Mood (patient self­report)
CES­D
Brief Depression Screen
Hospital Anxiety and Depression Scale
Jesse DE, Graham M. Are you often sad and
depressed? Brief measures to identify women at risk
for depression in pregnancy. 2005; 30(1): 41-45.
What Do We Use to Screen Our HIV+ Pregnant Patients for the Other Axis I Disorders? • Bipolar Disorder
• No validated instrument in this population
• Family history is often significant
y
y
g
• PRIME­MD
• Simple screen
• “Have you ever had 4 continuous days in which you felt so good, high, excited, or ‘hyper’ that people said you were not yourself or you got into trouble?”
• “Have you ever had 4 continuous days when you were so irritable you found yourself shouting at people, or getting into fights and arguments?”
• Schizophrenia
• No validated instrument in this population
• Family history is very significant Smith MV et al. Screening for and detection of depression,
panic disorder, and PTSD in public-sector obstetric clinics.
Psychiatric Services 2004; 55(4): 407-414
11
4/22/2010
Adjustment Disorder
DSM‐IV Definition:
• Debilitating reaction, usually lasting less than 6 months to a stressful event or situation
months, to a stressful event or situation
• Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). • Clinically significant criteria: •
•
•
•
distress in excess of what would be expected
significant functional impairment
i ifi
f
i
l i
i
symptoms are not caused by bereavement
stress­related disturbance does not meet criteria for another specific disorder
Risk Issues for HIV+ Women
Risk Domain Ever/Remote Experience
Lack of Social Support
1.
2.
Increased risk of comorbidities
No framework for positive interactions with medical, mental health, and social service organizations
During Pregnancy
Following Pregnancy
1.
Associated with lack of resources
Nutritional risk
Less access to care, especially if pt has other children
Increased incidence of depression
1.
2.
Substance use
Direct harm to mother and fetus
Unprotected sex with non­
monogamous partner; subsequent increased risk of other STIs
1.
2.
3.
4.
Trauma
1.
2.
3.
4.
Risk of poor parenting
Brain damage
PTSD, anxiety disorder
Self­tx with SA, EtOH, cigs
1.
2.
3.
3.
4.
2.
3.
4.
Substance Use
1. Low educational attainment/occupational readiness
2. Poor financial resources
3. Liver damage and/or overly­
induced cytochrome systems (may affect pain control)
1.
2.
3.
4.
Depression
1.
1. Self­tx with substance use
2. LGA, SGA, prematurity
3. Increased incidence of hypertensive disorders
4. Poor adherence to medication
2.
3.
Increased risk of later depression
Uncompleted developmental
tasks
Delays in starting ART upon dx
LGA, SGA, prematurity
Poor adherence to medication
Placental abruption
Neonatal addiction and withdrawal syndromes
Poor parenting
Decreased ability to get to medical visits
Increased incidence of PP depression
Stress­related effects on immunity
Unprotected sex, increasing risk of acquiring resistant strains and rapid repeat pregnancy
Morbidity and mortality to mother and baby
Increased isolation
Decreased academic pursuit/ occupational fulfillment
1. Poor parenting
2. Poverty
3. Medical sequelae of each substance
4. Decreased academic/occupational pursuit
5. Poor adherence to medication
1. Poor adherence to meds, visits
2. Poor parenting
3. Developmental delay in offspring
4. Nutrition/cognitive effects
of MDD, HIV, ART
12
4/22/2010
Screening Tools for Adjustment Disorder
• Typically adapted from scales for depression, anxiety or both • Interview
• Individual’s own distress at her emotional state is critical
• How is she functioning?
• assess baseline
• rule out substance abuse
Comorbid Conditions Requiring Mental Health Referral
•
•
•
•
•
Substance use
Anxiety
Eating disorders
Exposure to violence
Perpetration of violence
13
4/22/2010
Substance Use Disorders
DSM‐IV Definition:
• A psychological or physiological over­
d
dependence of an individual on a drug
d
f i di id l d
• Used in cases in which there has been long­
term abuse leading to impaired social and/or occupational functioning
• Usually a specific drug or combination of d
drugs is used
i d
Screening Tools for Substance Use •
•
•
•
•
Urine toxicology
Late registrant
Frequently misses appointments
Ask directly ­­­ at every visit
“What’s going to be the best thing for you about not being pregnant after the baby is born?”
14
4/22/2010
Anxiety Disorder
DSM‐IV Definition:
• For more than half the days in prior 6 months, individual experiences excessive anxiety and worry about several events or activities
• Trouble controlling these feelings
• Symptoms associated with this anxiety and worry, present for over half the days in prior 6 months
•
•
•
•
•
•
Feels restless, edgy, keyed up
Tires easily
Has trouble concentrating
g
Is irritable
Has increased muscle tension
Experiences sleep disturbance
• Symptoms cause clinically important distress
• Symptoms cause functional impairment
Screening Tools for Anxiety Disorders • Interview
• PRIME­MD of the Brief Patient Health PRIME MD f th B i f P ti t H lth Questionnaire (BPHQ)
• For posttraumatic stress disorder, consider PTSD module from the MINI International Neuropsychiatric Interview
• The BPHQ has been used in validated in obstetric populations for diagnosing panic disorder
• Neither measure has been validated in HIV+ pregnant women Smith MV et al. Screening for and detection of depression,
panic disorder, and PTSD in public-sector obstetric clinics.
Psychiatric Services 2004; 55(4): 407-414
15
4/22/2010
Eating Disorders
• Hyperemesis of pregnancy may introduce similar nutritional risk, but may not require i il t iti
l i k b t t i mental health referral
• Anorexia
• Bulimia
• Very often seen as a continuum rather than just one disorder
Screening Tools for Eating Disorders •
•
•
•
Stay concrete
A k b t fi
Ask about finances
Ask about food habits in family of origin
Bulimia may deplete electrolytes and cofactors out of proportion with lost calories ­­­ if you suspect it, order complete metabolic profile with amylase and lipase
• If eating disorder is suspected, begin USG at 32 weeks to check growth and umbilical flows
16
4/22/2010
Exposure to Violence
• Associated with post traumatic stress, even if individual was not victimized him/herself
• Doesn’t have to be current to affect health outcomes
• Damage may be emotional, cognitive, or physical
• Physical damage may be neurologic or non­
neurologic
• Neurologic damage may be peripheral or central (affecting brain)
Screening Tools for Violence
• Past
• “What was the best thing about your family/home growing up? What was the worst?”
• “How did people settle arguments in your family when you were little?”
• “Have you lost anyone you loved to violence? What happened? Were you “H
l t l
d t i l
? Wh t h
d? W
there?”
• Present • “How do arguments get settled in your family/between you and your spouse/boyfriend/girlfriend?”
• “Have you ever been afraid that your loved one might hit you or hurt you in some other way? Has he/she ever done that?”
• Future
• “How do you think disagreements will get settled after the baby comes?”
• “Do you ever worry that your spouse/boyfriend/girlfriend may have a hard time coping with a crying baby? What do you think you would do if the baby is crying and you are (at the end of your rope/on your last nerve, etc.)?”
17
4/22/2010
Risk Issues for HIV+ Women
Risk Domain Ever/Remote Experience
Lack of Social Support
1.
2.
Increased risk of comorbidities
No framework for positive interactions with medical, mental health, and social service organizations
During Pregnancy
Following Pregnancy
1.
Associated with lack of resources
Nutritional risk
Less access to care, especially if pt has other children
Increased incidence of depression
1.
2.
Substance use
Direct harm to mother and fetus
Unprotected sex with non­
monogamous partner; subsequent increased risk of other STIs
1.
2.
3.
4.
Trauma
1.
2.
3.
4.
Risk of poor parenting
Brain damage
PTSD, anxiety disorder
Self­tx with SA, EtOH, cigs
1.
2.
3.
3.
4.
2.
3.
4.
Substance Use
1. Low educational attainment/occupational readiness
2. Poor financial resources
3. Liver damage and/or overly­
induced cytochrome systems (may affect pain control)
1.
2.
3.
4.
Depression
1.
1. Self­tx with substance use
2. LGA, SGA, prematurity
3. Increased incidence of hypertensive disorders
4. Poor adherence to medication
2.
3.
Increased risk of later depression
Uncompleted developmental
tasks
Delays in starting ART upon dx
LGA, SGA, prematurity
Poor adherence to medication
Placental abruption
Neonatal addiction and withdrawal syndromes
Poor parenting
Decreased ability to get to medical visits
Increased incidence of PP depression
Stress­related effects on immunity
Unprotected sex, increasing risk of acquiring resistant strains and rapid repeat pregnancy
Morbidity and mortality to mother and baby
Increased isolation
Decreased academic pursuit/ occupational fulfillment
1. Poor parenting
2. Poverty
3. Medical sequelae of each substance
4. Decreased academic/occupational pursuit
5. Poor adherence to medication
1. Poor adherence to meds, visits
2. Poor parenting
3. Developmental delay in offspring
4. Nutrition/cognitive effects
of MDD, HIV, ART
What if We Fail to Refer?
HIV+ pregnant women are at increased risk for:
• Disease progression
• non
non­adherence to anti­retroviral therapy
adherence to anti retroviral therapy
• independent depression­related immune system suppression
• resistance to entire classes of anti­retroviral drugs
• Increased social isolation due to interaction between poverty, societal stigma, and mental illness
• Decreased educational and occupational attainment
• Emotional and cognitive effects in children
Psaros C, Geller P, Aaron E. Importance of identifying and
treating depression in HIV-infected pregnant women. Jnl
Psychosom Obstet Gynecol 2009; 30(4): 275-281
18
4/22/2010
In Conclusion
When evaluating HIV+ pregnant women’s mental health requirements: • Multiple measures are often helpful when assessing p
p g
y
depression in pregnancy
• Adjustment disorder rates are high; over­refer if necessary • Bipolar spectrum disorders are frequently under­diagnosed and require timely psychiatric intervention
• Schizophrenia risk is very elevated in those with positive family history
• Maintain a high index of suspicion for comorbid conditions
• substance use
b t
• personality disorders
• anxiety disorders
• violence exposure and PTSD
Psaros C, Geller P, Aaron E. Importance of identifying
and treating depression in HIV-infected pregnant women.
Jnl Psychosom Obstet Gynecol 2009; 30(4): 275-281
Thank You!
Elizabeth Lorde­Rollins, M.D., M.Sc. Consultant, Cicatelli Associates
elizabeth.lorde­[email protected]
19
Impact of Trauma on
Children in the Child
Welfare System
Sharon M. Cadiz, Ed.D., Director of Clinical
Consultation Program/NYCACS
Beginning with the end in
mind…
z
“What we are as adults is the product of the
world we experienced as children.”
Bruce D. Perry, M.D., Ph.D.
The Vortex of Violence: How Children
Adapt and Survive in a Violent World
1
Trauma Creates a New
“Normal”
z
Adaptation becomes a means for survival in
what can appear to be a hostile, violent,
uncaring world.
What are children adapting to?
z
z
z
z
z
The absence of a safe, secure caregiver bond
and/or pattern of attachment
Uncertain, unpredictable, unstable conditions of
life
Unresponsive, inattentive care giving related to
basic needs (food, clothing, shelter, etc.)
Occasional, consistent or repetitive instances of
emotional psychosocial or physical abuse or
emotional,
neglect
Overwhelming feelings of fear, threat, danger,
alarm, arousal and terror
2
How are they adapting?
z
z
z
z
z
z
z
Overactive Stress Response
Hypervigilance/Hyperarousal
Avoidant/Compliant/Passive
Resistant/Defiant/Aggressive/Violent
Dissociated/Detached/Robotic
Regressed/Rocking/Flashbacks
Panicky/Fretful/Crying/Sleep Difficulties
Adaptive Coping
They can experience altered states that have a
survival-driven range
z Apprehensive CALM
z Anticipated AROUSAL
z Emotional ALARM
z Overwhelming
O
h l i FEAR
z TERROR
3
Short & Long Term Impacts
z
z
Survival coping is about self-preservation in
the moment or in the short-term
The same strategies in the long-term can be
seen as maladaptive coping
Welcome to Child Welfare
z
“Children who enter the child welfare system
are typically affected by abuse, neglect
and/or domestic violence.”
“Traumatic Stress and the Child Welfare
System” by Janet S
System
S. Walker &
Aaron Weaver
Focal Point, Winter 2007, Vol. 21, No.1
4
Intended & Unintended
Outcomes
z
z
z
z
z
Protection can be perceived as policing
Placement can be perceived as punishment
Service plans can be perceived as power
plays
Decisions can be perceived as policy
St d d off safety
Standards
f t can be
b perceived
i d as
painful
Translating the Trauma
Lexicon
How do we define safety?
z When home is the most unsafe place to be, what
does it mean to a child to be placed in a “safe home”
z
“The home is the most violent place in America.”
(Straus, M.
(Straus
M 1974/Cultural and organizational influences on violence
between family members. In R. Prince & D. Barried (Eds.),
Configurations: Biological and Cultural Factors in Sexuality and
Family Life. Washington, D.C.. Health
5
Cultural Responsiveness
z
z
z
Family of origin, like society, can be the
delivery system for a culture of violence that
fails to protect and nurture children
How do we deliver a message of safety and
protection when both have never been
experienced?
p
Normative views of culture do not always
work to communicate intentions about safety
The Mother Knot…Recognizing
Recycled Trauma
z
z
z
z
What’s love got to do with it?
It’s more about pain…
Seeing an HIV Positive Mother, addicted to
drugs who abuses or neglects her child(ren)
with an open child welfare case SCREAMS
multi-generational
multi
generational trauma
Safety for the child cannot be achieved
without unraveling the knot
6
Name Calling
Other names for FATHER
z Abusive Partner
z Paramour
z Boyfriend
z Common Law Husband
z Abuser
z Perpetrator
z Biological Father
First Steps to Safety
z
z
z
The his – story
The her – story
The mys – story
What happened?
What is happening?
Why?
7
Demystifying the Impact
z
“A child of any age can be affected by
violence.”
i l
” Silent Realities: Supporting Young Children and
Their Families who Experience Violence, Elena Cohen & Barbara
Walthall/The National Child Welfare Resource Center for FamilyCentered Practice-Washington, D.C., January 2003
z
z
Research supports that even infants retain
recall of traumatic experiences
Childh d iis d
Childhood
dangerous and
d children
hild
are
highly vulnerable and dependent on adults
for survival NOW and for centuries past
Label Making
z
z
z
z
z
z
z
Oppositional Defiant Disorder (ODD)
Attention Deficit/Hyperactivity Disorder
(ADHD)
Abusive Head Trauma- “Shaken Baby”
Learning Disabled
“B d Kids”
“Bad
Kid ” – “Acting
“A ti O
Outt Teens”
T
”
“Conduct Disordered”
HIV+
8
Remove the Label
See what is under the label…
Next Steps
At the Organizational Level:
z Create Trauma-Informed System Change
z Stop denying
z Break through veils of secrecy
z Shatter myths that minimize impact
z Make Meaningful Partnerships/Collaborations
z Pay Attention to Child Development
9
Next Steps
At the Service Delivery Level:
z Let
L t hi
history
t
and
d experience
i
b
be th
the guide
id ffor d
decoding each child’s set of meanings and
understandings about the world, safety, culture, etc.
z Be predictable, responsive and consistent
z Look at Protective Factors, Resiliency, Family
Strengths/Resources, and Family Supports
(See Matrix to Enhance Decision Making)
z
z
Let expectations be guided by child development
milestones
Create stable, secure, safe, supportive environments
Models of Effective System Change,
Improved Service Delivery & Collaboration
z
z
z
The AIDS Institute and CAP-C have undertaken the
task of becoming a Trauma-Informed
Trauma Informed System of
Care
NYC Administration for Children’s Services
has implemented a Child Trauma Institute and InterDisciplinary Clinical Consultation Program that has
been enhanced with additional resources that
include Investigative Consultants and Medical
Services Consultants
Today’s collaborative Training Workshop
presentation by Dr. Sharon M. Cadiz & Bronx
Community Action for Prenatal Care Initiatives
10
4/22/2010
STRESS MANAGEMENT
STRATEGIES
PRESENTED BY
WENDY PACKER R.N.,CH,CI
Reiki Master
WENDY PACKER R.N., CH, CI
•
•
•
•
•
•
•
•
•
•
•
Registered Nurse/Consulting Hypnotist
NGH Certified Instructor
NGH HypnoCoach
Certified in Forensics & Pediatrics
Lecturer
Contributing author to “Tipping the Scales”
Pres. Westchester NY Chapter NGH
NGH Instructor,
Inst cto Adjunct
Adj nct Fac
Faculty
lt Membe
Member
Reiki Master
www.hypnonurse.com
www.careforthecaring.ning.com
1
4/22/2010
It’s not the stress that
kills us; it is our reaction to it
y
~ Hans Selye
YOU Become What
You Think About…
THE CHOICE IS YOURS
OUR OBJECTIVES
STRESS “Exposed”
Exposed
What are the contributing factors?
Calculating ones level of STRESS?
How to De
De-- Stress
Why HYPNOSIS for Stress Relief?
2
4/22/2010
STRESS “Exposed”
• Dr. Hans Selye,
Selye, the father
•
•
•
•
of stress theory, defined
stress as “the nonspecific
response of the body to
any demand made upon
it.”
“Wear and Tear” on Body
Positive and Negative
Imagined vs. Real
Fight or Flight
What are the contributing factors?
•
•
•
•
•
•
•
Environment
Social situations
Work issues
Major life changes
Daily hassles
Negative selfself-talk
Stress personality types
3
4/22/2010
How do we know if we have
STRESS?
What is your Stress level?
• When one experiences physical,
emotional, relational and behavioral
symptoms
• Results of STRESS REPORT CARD
How to De
De--Stress
Physical Relievers
Attitude Changes
4
4/22/2010
Wendy’s Reframing Tools
Why HYPNOSIS for STRESS RELIEF
• Natural and safe
• Effective
Scientifically proven
• Experience it and you’ll know why
SO SIT BACK, TAKE A DEEP BREATH
&
RELAX
5
4/22/2010
THANK YOU AND ALL THE BEST
ON YOUR JOURNEY TO A…
STRESS FREE LIFE
Jan. 4, 2010
www.worldhypnotismday.com
World Hypnotism Day
A Global Day of
Learning and Awareness
6
4/22/2010
Always remember
“Everyday in every way
You get better and better”
BELIEVE
7