Workshop Sessions - Saturday, March 21

11:15 a.m.-12:45 p.m.

An Introduction to Medical Legal Partnership: Mitigating Unmet Health-Harming Legal Needs Among Adolescent and Young Adult Populations
Amy Lewis Gilbert, JD, MPH
Indiana University School of Medicine

Track: Clinical Advances

Description: Medical-legal partnership (MLP) is defined as a health care delivery model that improves the health and well-being of low-income and other vulnerable populations by addressing unmet legal needs and removing legal barriers that impede health and contribute to existing health disparities. It has been well established in the health disparities literature that health outcomes are closely related to degrees of social and economic disadvantage, and that interventions addressing social determinants of health can help reduce disparities. Consider, for example, poverty-induced hardships such as food insecurity, utility shut-offs and substandard housing or homelessness – all of which clearly have the potential to negatively impact a family’s health.  In the United States, there exist a variety of public policy programs and legal public health protections designed to help address such issues, and legal remedies are often available to those who know how to access them.  Much like access to nutritious food, however, access to legal assistance may be limited by social and economic disadvantage.  Fewer than one in five legal problems experienced by low-income individuals are addressed with the help of an attorney who understands how to successfully navigate the legal system.    

The MLP model brings medical, legal and other professionals together in the healthcare setting to: (1) provide direct legal advice and assistance to patients; (2) improve health care delivery by creating internal systems for identifying and managing patients’ health-harming legal needs; and (3) collectively promote policy change on a broad scale to improve the health and wellbeing of vulnerable populations. Implementation of MLP is gaining momentum nationally and studies are beginning to show favorable outcomes such as improved health outcomes, reductions in self-reported stress, improved medical compliance and increased revenue for providers in the form of insurance reimbursements and government benefits.   Adolescence and young adulthood represent critical stages of human development during which social and economic factors significantly impact access to health care and health outcomes, and it has been well established that these populations are disproportionately impacted by disparities related to mental health, substance abuse, sexual/reproductive health and relationship violence. Certain subpopulations of vulnerable youth, including those with special health care needs, experience elevated legal barriers that further impede access to care and negatively impact health.  

Part I of the proposed workshop will provide a brief didactic overview of the health disparities literature, an introduction to the MLP model of health care delivery and a review of the existing MLP evidence base. Part II will provide an overview of tools that may be used to screen for unmet health-harming legal needs and a clinical case study, at which time participants will be divided into small groups and asked to identify health harming legal needs that are appropriate for MLP intervention. Part III will introduce a number of existing MLP programs that vary in terms of the populations served, the specific legal needs addressed, and the workflow logistics. Participants will be encouraged to share descriptions of known MLP programs to help illustrate the range of possible MLP arrangements.

Educational Objectives:
  1. Describe the Medical Legal Partnership (MLP) model, the health disparities framework upon which it is based and its emerging evidence base.
  2. Identify common health-harming legal needs among adolescent and young adult populations.
  3. Describe a minimum of 3 existing MLP programs in terms of the populations served, the specific legal needs addressed and the workflow logistics.

Vulnerabilities of Transition-age Youth with Mental Illness Navigating Pediatric and Adult Mental Health Care Services
Alene Toulany, MD1; Cathleen Steinegger, MD1; Gina Dimitropoulos, PhD2;  Seena Grewal, MD1; Miriam Kaufman, MD1
1The Hospital for Sick Children and University of Toronto, 2University Health Network

Track: Clinical Advances

Most mental health disorders begin in adolescence and early adulthood and are major contributors to the burden of disease in young adults. Child and adult mental health care services use inflexible age cut-offs to delineate service boundaries, creating fragmentation and discontinuities in provision of care. Across the United Kingdom, Australia, United States and Canada, researchers are demonstrating huge gaps in systems of care between adolescent and adult mental health services which may potentially lead to adverse clinical outcomes. Despite the wealth of research on transition age youth with chronic physical illnesses, there is a dearth of knowledge about how to prepare, plan and transfer young people with mental illness from pediatric to adult care. Through small group work and structured activities, this interactive session will highlight why transition is particularly difficult for youth with mental illness including eating disorders, depression, self-harm, and psychosis. Workshop participants will engage in discussions on how to work with families to assist them in gradually shifting parental responsibility to the young adult.   We will further discuss interventions to promote independence and autonomy in young adults and the skills to enable them to learn how to access and navigate the adult health care system for continued management of their mental illness. Novel models of care for mental health transition will also be presented and discussed, as simply strengthening existing pediatric and adult mental health care systems may not be enough to improve outcomes across the critical transition period.

Educational Objectives:
  1. Describe the challenges that are unique to transitioning youth with mental illness to adult care as compared with youth with physical conditions.
  2. Identify facilitators and barriers to the provision of a seamless coordination of efficient and effective services for youth with mental illness graduating from pediatric care and moving into primary, tertiary and community-based adult mental health services.
  3. Discuss novel models of mental health care transition and the importance and role of primary care in improving outcomes for transition-age youth with mental illness.

College Bound: Helping Adolescents With Eating Disorders Transition to College
Abigail A. Donaldson, MD1; Allison L. Hall, LCSW2; Fortunato Procopio, MD3;  Eva-Molly Pettito-Dunbar3
1Brown University Warren Alpert Medical School and Hasbro Children’s Hospital, 2Hasbro Children’s Hospital, 3University of Rhode Island

Track: Clinical Foundations

Description: Workshop participants will engage in a case-based discussion on the challenges of transition to college for adolescents with eating disorders, as well as identifying and treating a new onset eating disordered patient in the college setting.  Workshop leaders will facilitate a discussion of the obstacles eating disordered patients and their providers face in striving to establish and maintain health in the college setting.  Strategies for addressing barriers to success will be presented and discussed.  Workshop leaders include an interdisciplinary panel of experienced professionals who will explore the challenge of transition from the medical, psychosocial, and student perspectives; leaders include an eating disorder medical specialist, eating disorder program social worker, college health medical provider, and a University of Rhode Island graduate student peer mentor.  Specific cases will focus on ways to transition from a family-based eating disorder treatment model to independent living at college; how to initiate a medical leave of absence from college for a young adult who is a risk to themselves but not to others; and how to support a patient newly diagnosed with an eating disorder who remains on the college campus. The peer mentorship perspective will be explored using a program established by one of the workshop leaders (Dunbar) at the University of New Hampshire and in process under her leadership at the University of Rhode Island called “Eating Concerns Mentors (ECM).”  ECM has two main components: peer mentoring and prevention. Peer Mentors are undergraduate students who are trained to provide individual support for students struggling with body image difficulties, eating concerns and eating disorders, as well as for individuals with concerns about friends/family members' eating disordered symptoms.  ECM mentors are educated and trained to refer students to professional resources on campus and in the community and work collaboratively with Health Services and other campus-providers to identify the most appropriate referrals for each individual seeking support. Factors important to the campus-wide success of such programs will be discussed. Audience participation will be strongly encouraged both in the discussion of presented cases, and also in contributing cases to the workshop.  At the end of the workshop, participants will be able to identify at least 3 ways in which they can assist adolescents with eating disorders in a safer, healthier college experience.

Educational Objectives:
  1. Describe several challenges and supportive methods for transition of patients with eating disorders to college.
  2. Compare your current college transition practice for patients with eating disorders to that of your colleagues.
  3. Identify at least 3 ways that you as an eating disorder care provider can collaborate with the primary provider team (in the case of college health providers) or the college health team (in the case of primary/subspecialty providers) to transition individuals to the college setting.

To DUB or Not DUB: A Multidisciplinary Case Discussion of the Evaluation and Management of Adolescents with Abnormal Uterine Bleeding
Tanya L. Kowalczyk Mullins, MD1; Rachel J. Miller, MD2; Eric S. Mullins, MD1
1Cincinnati Children's Hospital Medical Center, 2Children’s Hospitals and Clinics of Minnesota

Track: Clinical Foundations

Description: In 2011, the International Federation of Gynecology and Obstetrics (FIGO) introduced a refined system of nomenclature to standardize the description of abnormal uterine bleeding in women: PALM-COEIN. The American College of Obstetricians and Gynecologists (ACOG) subsequently endorsed the adoption of this new naming system.  The overall intent of this workshop is to educate participants about this new classification system and to review management of abnormal uterine bleeding from a multidisciplinary perspective. The session faculty represent three different subspecialties that treat adolescents with abnormal uterine bleeding (AUB):  adolescent medicine, pediatric and adolescent gynecology, and pediatric hematology. This multidisciplinary format will allow for interactive discussion between session faculty and participants. This session will use a variety of formats to meet the educational objectives. A didactic portion will review the recent changes in the classification system and terminology related to AUB (as described in the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice Opinion, “Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women”), led by Dr. Miller.  Didactic review of important elements of history and physical exam findings will be presented by Dr. T. Mullins.  Dr. E. Mullins will review the laboratory evaluation for AUB, including pros and cons of different laboratory tests for bleeding disorder evaluation. Drs. T. and E. Mullins will review medical management of AUB, and Dr. Miller will review surgical management of AUB, including indications for surgical intervention.  The session faculty will gather cases of adolescents with AUB from their own practices in order to illustrate important topics related to diagnosis, evaluation, and management of AUB.  In addition, session participants will be asked to present their own cases and to ask relevant clinical questions of the session faculty.

Educational Objectives:
  1. Describe recent changes in the classification system and terminology related to abnormal uterine bleeding.
  2. Determine which adolescents presenting with abnormal uterine bleeding warrant further evaluation.
  3. Formulate a plan for clinical and laboratory evaluation of adolescents with abnormal uterine bleeding and discuss the management options for an adolescent with abnormal uterine bleeding.

The Role of Adolescents and Parents in Medical Decision-Making: Ethical and Clinical Challenges
Victoria A. Miller, PhD; Carol A. Ford, MD, FSAHM
The Children's Hospital of Philadelphia

Track: Professional Development

Description: Ideally, as youth mature they move along a continuum from parent-directed to adolescent-directed decision-making, but navigating this transition can be challenging.  Furthermore, there are a number of adolescent, parent, and provider factors that may interfere with or facilitate adolescent engagement in medical decision-making. Involving adolescents in medical decision-making is an important step in teaching them to take care of their own health effectively and independently.  Decision-making involvement is hypothesized to teach adolescents what factors to consider when making decisions, the consequences of different decisions, and the communication skills that are necessary to negotiate and influence decisions. In addition, adolescents’ involvement in decision-making may: enhance self-efficacy; facilitate open communication among providers, parents, and patients; increase satisfaction with medical care and cooperation with treatment; and promote the ability to cope with illness.   Much of the prior research related to adolescent medical decision-making has focused on the concepts of assent and consent and addresses the question, who should make this decision?  This research has primarily examined cognitive factors, such as understanding and decision-making competence.  In contrast, a relational approach to decision-making focuses on how decisions are made. This approach recognizes that decision-making typically occurs in a family context and attends to the role of collaborative decision-making in normative development. It reflects the view that adolescents can be involved in decisions in various ways and that parents play an important role as sources of support and advice across development.  

In this workshop, we will explore ethical and developmental concepts related to adolescent decision-making involvement. These concepts will help learners to frame questions and dilemmas that arise in the course of clinical practice with adolescents and their families when adolescents are being seen for routine care, management of illness, or sensitive health issues. We will review current research related to adolescent involvement in medical decision-making, including parent-adolescent relationship factors, decision-making preferences, associations with health-related outcomes, and the role of provider communication in facilitating adolescent involvement.

Finally, we will review models of adolescent involvement and implications of each model for patients, providers, and families. Small group discussions and case studies will be utilized to foster active engagement with the material and encourage discussion of participants’ experiences related to barriers/facilitators of adolescent involvement in decision-making in clinical settings.

Educational Objectives:
  1. Describe key ethical and developmental concepts relevant to adolescent decision-making involvement for a range of health-related decisions
  2. Analyze current research on adolescent decision-making involvement and relevance to health outcomes
  3. Identify barriers to and facilitators of adolescent decision-making involvement and implications for clinical practice

The Importance of Close Relationships for the Health and Well-being of Boys and Young Men
Niobe Way, MSW, MPH, PhD, ACSW1; David L. Bell, MD, MPH2; Jason R. Rafferty, MD, MPH3
1New York University, 2Columbia University Medical Center, 3Brown University

Track: Clinical Foundations

Description: Adolescent and young adult (AYA) males have a much higher mortality and morbidity than their female peers.  Yet, beginning in late adolescence, healthcare utilization rates for males decline below females and this trend is consistent throughout adulthood.  This two-part workshop will explore some of the barriers to engaging male youth in healthcare, particularly prevention and risk reduction.  At the root of this challenge, one must be able to understand the notion of “health” from the perspective of the AYA males we serve.  The workshop will feature three speakers who will dissect this concept of “young men’s health” focusing on how it relates to traditional notions of masculinity.  Using a developmental perspective, new frameworks will be proposed to contextual the emotional and relational needs of AYA men in today’s society.  In particular, it will be argued that young men desire intimacy in close friendships and relationships, and that achieving it is important for their overall well-being.  Implications for healthcare providers and those working to promote adolescent male health will be reviewed, such as peer leadership strategies and using social networks in recruitment efforts.    

In the second part of the workshop, a clinical, evidence-based toolkit to promote AYA male health developed by a multi-disciplinary team of nationally known clinicians and researchers will be introduced.  The underlying assertion of the toolkit is that this population has unique needs which require a specialized clinical approach.  Audience members will invited to provide feedback on the toolkit and their thoughts in the context of personal experiences working with this population.  In particular, the goal is to address the process by which the toolkit was developed and whether it achieves its goal to reframe AYA male “health” in light of the earlier discussion.   This workshop is open to both experienced providers to AYA males as well as those who are new to the field.  The toolkit can be reviewed prior to the presentation at:

Educational Objectives:
  1. Analyze the challenges and barriers that adolescent and young Adult (AYA) males face due to traditional notions of masculinity and its impact on their relationships and well-being, and recognize the importance of intimate relationships in the physical and psychological health of AYA males.
  2. Analyze and critique an evidence-based clinical toolkit for AYA males that appreciates their unique health, emotional, and relational needs.
  3. Identify and verbalize how such a framework for understanding AYA male health applies to different clinical and research settings.

Developing Effective Policies, Protocols, and Practices to Address Sexual Exploitation and Sex Trafficking of Adolescents and Young Adults
Abigail  English, JD1; Tonya  Chaffee, MD, MPH2; Evelyn  Eisenstein, MD3;  Andrea  Goddard, MSc4; Elizabeth  Miller, MD, PhD5
1Center for Adolescent Health & the Law, 2University of California, San Francisco San Francisco General Hospital, 3University of the State of Rio de Janeiro, Brasil, 4Imperial College Healthcare NHS Trust, 5Children’s Hospital of Pittsburgh of UPMC

Track: Professional Development

Description: Adolescents and young adults worldwide are at risk for being sexually exploited and trafficked for sexual purposes. Although accurate estimates of prevalence are not readily available, there is little doubt that young people everywhere have been victimized: the available evidence suggests that commercial sexual exploitation and sex trafficking of adolescents and young adults has occurred in every region and country and that victims come from diverse backgrounds in terms of geography, income, race, ethnicity, religion, gender, and sexual orientation. Nevertheless, some populations of youth are likely to be at heightened risk for victimization. In the United States, these include young people who have been sexually abused; youth who lack stable housing or live in dysfunctional families; sexual and gender minority youth; youth who have used or abused drugs or alcohol; and youth who have experienced homelessness, foster care placement, or juvenile justice involvement. Globally, young people living in poverty and communities where violence is structurally or culturally prevalent may also be at increased risk.   Health care professionals can play a significant role in addressing sexual exploitation and trafficking of adolescents and young adults through clinical care, research, and policy. For their work to be most effective it should be based on carefully developed policies, protocols, and practices based. Although recognition of the extent and importance of sexual exploitation and trafficking of adolescents and young adults is relatively recent, such guidance is beginning to emerge from the dedicated and innovative work of NGOs and professionals in diverse settings in the U.S. and globally.  

In a 2013 report, the Institute of Medicine/National Research Council identified organizations in several communities in the U.S. that have developed promising approaches to the identification, care, and support of victims and young people at risk. Some states and local communities have enacted laws or adopted policies based on health and human rights principles and designed to prevent sexual exploitation and trafficking or assist victims and survivors. Noteworthy efforts are also being developed and refined in other countries. This workshop will demonstrate examples of such policies and approaches used in the U.S. and globally.   Promising policies, protocols, and practices that directly address sexual exploitation and trafficking of adolescents are relatively new, few in number, and not yet evaluated. Thus the evidence base so far is limited. Nevertheless model policies, protocols, and practices exist in other fields that have been tested over a longer time and, in some cases, rigorously evaluated. This has occurred with respect to both child abuse and domestic and sexual violence prevention and intervention among adolescents and adults. These arenas provide fertile ground from which to draw models for practice and policy to address sexual exploitation and sex trafficking.   Through a combination of brief didactic presentations, small group interactions, and large group discussion, this workshop will offer an opportunity for participants to learn about ways in which policies, protocols, and practices developed for child abuse and domestic and sexual violence can inform those that are emerging for sexual exploitation and trafficking, nationally and internationally.

Educational Objectives:

  1. Identify multiple risk factors associated with commercial sexual exploitation of adolescents and young adults that are also known to be risk factors for victims of child abuse and domestic and sexual violence.
  2. Describe promising policies, protocols, and practices currently emerging and being developed in the U.S. and other countries to address sexual exploitation and sex trafficking of adolescents and young adults.
  3. Adapt existing policies, protocols, and practices currently shown to be effective in areas of child abuse, domestic violence, and sexual assault to help identify and assist adolescent and young adult victims of sexual exploitation and sex trafficking.
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