Hospital-based Violence Intervention for Teens with Dr. Alison Culyba and Sarah London, LSW

Empowering Teens to Thrive Program (PDF)

Division of Adolescent and Young Adult Medicine | UPMC Children’s Hospital of Pittsburgh

The Health Alliance for Violence Intervention (HAVI)

What is a hospital-based violence intervention program (HVIP)? | The HAVI

Identity-Based Bullying Most Common Among Adolescents with Multiple Marginalized Identities | UPMC Children’s Hospital of Pittsburgh

The Office of Violence Prevention | Allegheny County Department of Health

Maslow’s Hierarchy of Needs Explained | YouTube - Expert Program Management

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Allison Williams: Hi, welcome to "That's Pediatrics" here at UPMC Children's Hospital of Pittsburgh. I'm Alli Williams, a pediatric hospitalist here.

Dr. Sameer Agnihotri: And I'm Sameer Agnihotri. I'm an assistant professor at Children's Hospital in the Department of Neurological Surgery.

Dr. Allison Williams: We are so excited to be joined today by Dr. Allison Culyba who is the director of the Empowering Teens to Thrive Program as well as Sarah London, who's a social worker there and the Lead Violence Prevention Specialist. Thank you both so much for joining us today.

Dr. Alison Culyba and Sarah London, LSW: Thank you so much for having us.

Dr. Williams: Dr. Culyba, can you tell us a little bit about this Empowering Teens to Thrive Program and how it developed?

Dr. Culyba: Yes, absolutely. The Empowering Teens to Thrive Program is really built within a national network of violence prevention programs. There's an organization called the HAVI or the Health Alliance for Violence Intervention which supports hospital-based, hospital-linked, and community-based work that really focuses on violence prevention through a holistic and public health lens.

Our program emerged several years ago sort of within the context of many other similar programs across the country and a recognition that we really needed to create focus services to support young people who were cared for within Children's Hospital and our outpatient practice network who had experienced violent injuries. And that was what brought us to this work.

Dr. Agnihotri: Great, and Dr. Culyba and Sarah, who can use this program and what do you envision?

Ms. London: Yeah, and so a lot of our referrals come from or come through the trauma department here at Children's as we obviously work with young people who we are working towards violence prevention or maybe who are in recovery after experiencing a violent injury of some kind like gunshot wound, stabbing, things like that.

And so those young people are referred to us through the trauma social workers who we work with very well, and they get connected with our program by coming to our office or maybe simply having a phone call with myself whether it's with the family or the patient themselves. And we work together on doing kind of like a needs assessment, finding out like what's the immediate or priority things that need to happen after this like really horrific event in their lives, which often they're left like picking up a lot of the pieces and not knowing where to turn next.

And so what I like to do is frame myself as kind of the point person for them. And so if they're not sure who they're supposed to call, what appointment they're supposed to be going to, or like what appointment is coming up next, I let them know and give them my direct phone number and say like, call me, let's talk about it. We'll problem-solve it together.

So I try and work to do that type of like case management with families and patients to give them like a better idea and kind of like realign them as this is something that's kind of shocking to them in most cases. And they needed that help and kind of that handholding that's so important that maybe like most families aren't getting after some event like that. That's what our program hopes to do for everyone.

Dr. Culyba: Yeah, and I will say too that the hospital-based violence intervention or some people may have heard this acronym, HVIP, is what that stands for. Program model is really centered on this idea of the post-injury period being this golden opportunity to really include focused resources for young people and families to help promote healing and recovery.

And so that can often include multiple different pieces, but typically is a multidisciplinary team approach with really intensive individualized case management and linkage to both clinical and community-based support services. And so the ET3 Program very much fits within that overall model and then is tailored to the unique needs of patients and families in our region.

And one piece that's unique with our program as opposed to many HVIP programs around the country is that we actually are situated within the Center for Adolescent and Young Adult Health, which allows us tremendous opportunities to use the network of resources within our health system to be able to support young people and families, and that includes preventive care, sexual and reproductive health care, mental health services as well as connection to many other organizations within the area. And so it allows us that flexibility and continuity to be able to both work with young people within our clinical setting and then also in community.

Dr. Williams: Do your referrals come from solely Children's Hospital or also from outpatient programs as well?

Ms. London: So we have a network of mentors that are actually we have the privilege of having on our team with us. There's about, how many, Alison? We have like solely 10 that we have, often like clinical meetings with who also work in different areas of the community, like in McKeesport and Wilkinsburg as well as with other programs within our like research arm of our clinic such as like groups for young women called like Sisterhood 2.0.

And so those mentors have the opportunity to then kind of like start working with a family or a young person and find out that there might be a need or they might have a recent loss of a family member such as a brother, which is very common, right? As a lot of this is targeted towards young men.

And so if they're losing that person, they then can become part of our program and helping them get connected with resources like Alison just said, such as like mental health resources or even if like, we feel like there's something else in the community that the family might need or be helpful with that we can do that as well.

Dr. Williams: One of the other questions that I had too was, this sounds like a resource that I'm so glad you brought up, the multidisciplinary team. What would it look like for a patient that, for example, we realize has this need, and we then refer this patient. How would this process look for them?

Dr. Culyba: So we typically will ask families and young people to come into our clinic for an initial intake visit, which is really to understand sort of their unique needs and goals. And so that's something that we do together. Often, Sarah and myself or with another provider and another member of our social work team to meet and talk in depth about the ways in which we can be supportive.

And that focuses not only on medical domains and mental health domains but also thinking about reentering school and if there's supports that are needed there. Are there any concerns about safety, other social needs? Are there concerns around any other things going on within the family, other siblings and helping to navigate all those services. And so we use that initial visit to really come up with a plan together about what those needs are and then the ways that we'll be able to meet those goals.

Ms. London: Yeah, I often do like a lot of like psycho education about like Maslow's hierarchy of needs. Like, let's start here. Is your safety like compromised at this point? Right now, is there any risk for retaliation? That's what we wanna cover first and find out. Next is do you have food? Do you have water? What's going on with the electricity bill? What's going on with this? And kind of like being able to have those real conversations with these families and patients to then like help them understand that if you don't have these basic needs down or if these things are being compromised right now, it will be difficult to like go to these next level of resources or maybe this mental health resource isn't what you need right now, but it's something that we're gonna work on together throughout this case management process.

Dr. Williams: So as part of the multidisciplinary team, clearly, we have physicians that are involved in this and social workers. Who else is involved?

Ms. London: Our awesome community mentors.

Dr. Williams: Can you describe those a little bit more to me?

Ms. London: Yeah, so like I said, we have about 10 of them. And so they work in different areas of the community. And their role in our program is really just, like being kind of like our frontline, if you will, after, like I said, how we get other referrals. And so what they're doing is like daily communication with our mentees, if you will, or participants of our program and working with them similarly to like how I would approach it as well as I do training with them and talk to them about like things like Maslow's hierarchy of needs or other like psychoeducation pieces, like motivational interviewing or things like how we perform trauma-informed care or healing-centered care and working with these young people who've experienced cycles of trauma and coming up with ways in helping them do this, like daily problem solving of like, I'm having this issue at school, I need help with this. Or I'm having this issue with money. I need help getting a job.

And so that's kind of like, there are frontline, there are people who are mostly in communication with the young people in our program. And then we have our meetings where we kinda come together and almost do like presentations of like what's going on with their mentorship or with their mentees. And they let us know like any significant issues that are coming up, and Alison and I help them kinda like work through that and how they can best serve that young person, or if the young person needs to come in for an appointment with us, like that's something we can create access to almost immediately. So really, again, like being our frontline and helping creating access and talking more about and promoting like mental health and being more honest about that.

Dr. Agnihotri: Right, and to follow up on that, the other side of the coin is, how can we get our healthcare providers at UPMC and additional healthcare providers to raise awareness about the programs that you guys have spearheaded and get the word out to the community?

Dr. Culyba: Yeah, I really appreciate that. And we have worked closely with the team here through Emergency Medicine as well as with the inpatient trauma services to increase awareness about the programming and to increase referrals for patients. And so we have created a system such that anyone who's coming into the hospital with any kind of sort of peer community violence related injury or concerns ideally is referred to our program or given information such that we can reach out and offer these services. And so that's really the model that we've set up.

And also knowing that our team is a resource for anyone who thinks that they might have a patient that would benefit from these services. And so we do get calls from pediatricians within the CCP network, many referrals from within the General Academic Peds practices as well as other kinda hospital-affiliated programs, other health centers around the city, and other kind of referral networks.

And so I think that anytime someone has a question, they absolutely can reach out to our team and we can help navigate. And even if our program isn't sort of the right resource that we're able to point people in the right direction to get the help that they need for the patients that they're caring for.

Dr. Williams: You had said that you all are fortunate enough to work very closely with the Centers for Youth and Adolescents. Are you all physically located in the same place over in Oakland as them, or are you in a different location?

Dr. Culyba: Yes, so I'm one of the faculty within that group and provide clinical care within that practice and also run the kind of clinical piece of the ET3 Program sort of within that programming space.

Ms. London: Yep, and I'm part of the behavioral health team there. One of the social workers. So I like interact mainly with young people in clinic and also like if a young person comes to our clinic and is like, I've experienced this in my life, that's another way that we can kind of generate some referrals to our program as well.

Dr. Williams: How long is someone usually with your program?

Dr. Culyba: So it's really unique dependent on each person's needs and also whether or not they're interested in sort of getting connected more with longitudinal primary care through our adolescent group or not, which is another wonderful opportunity for those who may not have had a medical home prior to the injury. And so that can sometimes impact on the duration, but generally, that most intensive time is on the order of four to six months or so.

Ms. London: Depending on the injury too. Like we've had a young person who was paralyzed from the waist down. And so like we had worked like longer with that young person as there was much more need to talk about housing and other sorts of like county resources and state resources for that family. But like with other families who maybe who've just experienced a loss and haven't been injured themselves, we often like help get them connected with mental health care and then you just kind of like our resource for them ongoing but don't necessarily interact with us consistently for longer periods of time.

Dr. Agnihotri: Great, and can you please share with us just to to follow up on that, I guess resources and trying to grow the program would be something that you guys wanna do. Can you give us your perspectives on what additional resources you need? Or as you said, if some patients or people you're doing evaluation for four to six months, then obviously, getting more resources would be great for you guys.

Dr. Culyba: Yeah, and I think that's such an important point. And there's been a really elevated national dialogue around this work recently, which has been tremendously exciting. And so sort of within the current administration and priorities, both sort of at the local, state, and national level, there's been a recognition of the need for sustained funding for both hospital and community-based violence prevention work and a lot of exciting sort of legislative proposals and funding allocation that is being considered to really address that sustainability piece.

For a very long time, much of this work sort of here as well as nationally has been funded by philanthropy or other kind of short-term goals, short-term programming that's sort of a year-to-year uncertainty about whether or not things will be sustainable. And you can imagine that has a tremendous impact on the ability to create sort of sustained visions and grow programs.

Here, we've been incredibly fortunate to have a strong partnership with the Allegheny County Department Office of Violence Prevention and to work really closely with the Cure Violence team through that office. And together with that team and funding from the Heinz Endowments really allowed us to not only sort of begin the programming but to build that mentorship and community-based piece into our work.

And more recently, we've been working together with the Department of Human Services through a recently awarded large grant through the substance use and mental health services administration to help support us in terms of growing this work. And that will be something that we look to, additional sources of funding, and to continue to grow this programming. But our goal is really to be able to serve all young people who've been injured or impacted by violence both through sort of the hospital-based and the community-based mentorship pieces.

Dr. Agnihotri: Right, and speaking of the local level, you touched upon the national level. Is this something that's growing? Are there conferences or are there societies that are trying to see, hey, different local communities can come together maybe at a national level, and would that help with awareness and funding some of the issues that you guys encounter?

Dr. Culyba: So locally in Pittsburgh, I think we're really fortunate to be one of many, many organizations that's doing incredible support work for young people and families and really sort of addressing the underlying inequities around racial injustice, economic injustice that drive a lot of the experiences of violence for young people and families.

And so I think there's so many organizations that have been in this space for a very long time, and we're really fortunate to be able to partner and to work together, to think holistically about how do we sort of get that local focus on this work.

I know I recently participated in a round table with local legislators talking about sort of budgetary allocations to this type of programming. And so my hope is that by continuing to have those conversations about how vitally important it is to support young people and families both to prevent violence from happening and then when it does, to really address the ripple effects of these losses within communities. My hope is that that continues to result in more focused and kind of dedicated pieces of funding locally as well.

Dr. Williams: Our community is so fortunate to have such strong advocates in you. So thank you so much for doing that for our community and for your participants, for young folks here in Pittsburgh. If you could kind of summarize one thing to really keep in mind through this program, to let our listeners know what would that be? And maybe we could start with Sarah.

Ms. London: Sure. So I mean, one thing, it's hard to narrow down, but I would say like overall for our program, the idea is support and then providing or at least giving the opportunity to every family that we work with to have some control and confidence over the situation that they're going through.

I think those are kinda like my, excuse me, my three buzz words are like, support, control, and confidence. And I think that often, chaos is like, emits when situations like this happen. And so like anytime I can give a mom, for example, some control over a situation, or I can give a young person some confidence in like sitting up a little bit straighter in the office with me. Like that's something that I think our program, that's a win for me.

Trying to change like all these structural inequities is definitely like long term. Something that everybody's doing a little bit of hard work in, but like those short-term things are really important for our program.

Dr. Culyba: And I think echoing what Sarah said, identifying opportunities where you can recognize young people's strengths and share that back with them and with families. I think that piece is so often missing and gets lost in the shuffle of all of the challenges that people are trying to navigate. And yet, that's truly the remarkable piece, right? That the young people that we have the privilege of working with are so incredible and teaching us so much about what it means to be resilient, what it means means to be able to move forward from a really challenging experience.

And so I think taking those moments for all of us that work with youth or touch the lives of youth and families in any way of really taking those reflective moments. To acknowledge those strengths and those victories is crucially important to that healing process.

Dr. Williams: Is there a website that we can direct our listeners to get some more information about this or a phone number or something that we could kind of share with our listeners?

Dr. Culyba: Sure, so I'm happy to share the phone number for our Adolescent Medicine Clinic, which is a great point of contact. That one is 412-6926-677. And then also on the Children's Hospital website within the Adolescent and Young Adult Medicine page, there's information about the program. And then brochures all around as well.

Dr. Williams: And that's the one that I know that I've used quite often when I'm looking up the number through the UPMC Children's website. There's lots of great information for there too.

Dr. Agnihotri: It's also very humbling about your fantastic program and what you guys are truly doing. And then for our listeners, are there anything in addition to the numbers that you shared, anything else that you could do that they can do to support your goals?

Ms. London: I think overall, just remembering like, not necessarily if we're the program for them but like remembering our concepts in general, I think, just having, giving these families a little bit more like opportunity and patience and I think that's something that Children's Hospital is already very phenomenal at and like teaches very well. But I think that's something that we'd like to, I don't wanna say the word infect, but infect people with like this idea of more of this like support and like trying to build some confidence in the young people that we're working with and giving them more of a voice and opportunity to have that voice.

Dr. Williams: Thank you both so much for coming and sharing about this program. We really look forward to seeing the growth and development of this program and hope that through this podcast, we're able to help support you too.

Dr. Agnihotri: Yes, thank you so much. This has been very enlightening.

Dr. Culyba: Thank you so much for inviting us. It's been a pleasure to connect.

Dr. Williams: Thank you. And "That's Pediatrics" signing off.

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