Tagged Public Health

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! If you’ve been able to tear your attention away from the soap opera that is the ever-escalating (and public and messy!) feud between HHS Secretary Alex Azar and CMS Administrator Seema Verma, you’re a better person than I. (But hey, I’m not alone — the White House itself is apparently riveted by the drama).

The week kicked off with reports that Verma had filed a claim for $47,000 worth of jewelry and other property that was stolen while she was on a work trip. Then came the accusations that HHS leaked the story and then came more accusations that Verma leaked the info that eventually brought down former HHS Secretary Tom Price.

They were both called to a meeting at the White House and told to make nice. (Oh, to have been a fly on that wall …). Because as fun as it is to watch the drama unfold, the feud seems to be derailing President Donald Trump’s health agenda during a time when that is a less-than-ideal thing to happen.

The Washington Post: Infighting Between Alex Azar, Seema Verma Stymies Trump Health Agenda

OK, onward to the rest of the news of the week before I risk turning into a Page Six gossip column.

House Democrats passed a sweeping drug-pricing bill that would allow Medicare to negotiate drug prices, among other things. Like most bills these days, its purpose is more political than anything else — it will live a full life on the 2020 campaign trail long after it’s killed in the Senate.

The New York Times: House Votes to Give the Government the Power to Negotiate Drug Prices

Stat: Drug Pricing Bill Is a Sneak Peek at Democrats’ 2020 Campaign Message

It was all around not a great weak for drugmakers. The industry was spitting mad at what they deemed was an “unforced error” from Trump that “was a reflection of the weakness of the negotiating skills of the president.” The error? Trump stripped a 10-year exclusivity provision for biologics from the new trade deal with Mexico and Canada.  The blow to pharma is just the latest reminder that they can’t assume any wins just because a Republican is in the White House.

Stat: With New Trade Deal, Trump Deals a Blow to Drug Makers

The government’s word was on trial at the Supreme Court this week when the justices heard arguments over the health law’s “risk corridor” program. It was a slice of the financial carrot to get insurers to participate in the risky marketplaces, but then Congress stripped the funds from the budget. Insurers — who say they’re owed $12 billion — were less than pleased. The justices seemed sympathetic to the insurers, with Justice Stephen Breyer summing it up well: “Why doesn’t the government have to pay its contracts just like everybody else?”

Reuters: U.S. Supreme Court Justices Lean Toward Insurers on $12 Billion Obamacare Claims

And speaking of the health law, the IRS inadvertently ran an experiment on the importance of health coverage when it sent a letter to the nearly 4 million people who were fined because they didn’t have insurance. The letter prompted people to enroll and thus that little letter saved about 700 lives.

The New York Times: The I.R.S. Sent a Letter to 3.9 Million People. It Saved Some of Their Lives.

Back to the Supreme Court: The justices decided to leave in place a Kentucky law that requires physicians to show and describe ultrasounds to patients seeking abortions. The law requires the physicians to continue with the process even if the patient objects and shows signs of distress.

Reuters: U.S. Supreme Court Leaves in Place Kentucky Abortion Restriction

Side note: The story below is less about abortion and more about congressional committees and their inner workings, but I found it a fascinating read (at least for all you wonkish types out there).

Politico: Impeachment Committee’s Rancor Forged by Decades of Abortion Battles

South Carolina is the latest state to be granted a waiver to add work requirements to its Medicaid program. It’s the 10th one so far, but the move is still notable. That’s because, unlike other states, South Carolina never expanded the Medicaid to begin with. That means that the work-age population on its Medicaid rolls is made up almost entirely by poor mothers. Research also suggests that research found the population subject to the new requirements is disproportionately black.

The New York Times: South Carolina Is the 10th State to Impose Medicaid Work Requirements

What a roller-coaster ride this year has been for surprise medical bills. It seemed like low-hanging fruit that even in this particular Congress everyone could agree was bad. But alas, we can always find something to argue about, and progress stalled when lawmakers couldn’t agree on how to solve the problem. Then after months of stagnation, a new deal emerged (which the White House backs). How did they manage that? They actually *gasp* compromised between two of the strategies.

Bills under $750 would be paid at a default price; ones over that could be brought to arbitration, and the final price decision would be binding.

But wait, the ride isn’t over. The House Ways and Means Committee released its own version that would at first let insurers and doctors try to work out payment on their own before an arbitration system kicked in. However it all shakes out, it’s certainly not the easy bipartisan win that was expected.

The Associated Press: White House Backs Emerging Deal on Consumer Health Costs

The Hill: Ways and Means Committee Announces Rival Surprise Medical Billing Fix

South Bend, Ind., Mayor Pete Buttigieg released a list of clients he worked with during his tenure at McKinsey, a powerhouse consulting firm that has drawn fire lately for its work with the Trump administration’s immigration plans. One of Buttigieg’s clients was Blue Cross Blue Shield of Michigan, which eventually went on to lay off about 10% of its workforce. Buttigieg defended his work for the insurer, saying he was focused on administrative costs and cutting overhead expenses.

The New York Times: How Pete Buttigieg Spent His McKinsey Days: Blue Cross, Best Buy, U.S. Agencies

There was nothing particularly notable about Dr. Stephen Hahn’s confirmation process, but I’d be remiss if I didn’t include the fact that the Senate approved him as the new FDA commissioner. Hahn during his hearing sidestepped lawmakers’ attempts to pin him down on e-cigarettes, but any concerns about how he’d handle the epidemic weren’t enough to sink his ship.

The Associated Press: Senate OKs Trump’s FDA Nominee Despite Unclear Vaping Agenda

The FCC approved switching to a three-digit number (988) for the National Suicide Prevention Lifeline. Considering how clunky the old one (800-273-TALK ) was, the change has advocates celebrating. It was interesting that the FCC report had to note that the increase in costs associated with the presumed increase in calls would be offset by avoiding medical expenses such as hospitalizations or emergency department visits.

CNN: FCC Unanimously Approves Proposal for New 3-Digit Number As Suicide Prevention Hotline

A group of doctors carried out a three-day protest in front of a Border Patrol regional headquarters in San Diego. They were demanding that the agency offer flu vaccines to detained migrants — an issue made even more relevant by the fact that three children have died in U.S. custody because of the illness. But Border Patrol says it doesn’t make sense to vaccinate all the people who move through the system.

The Associated Press: Doctors End Protest to Demand Flu Vaccines for Migrants

That’s it from me! Have a great weekend.

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In The Fight For Money For The Opioid Crisis, Will The Youngest Victims Be Left Out?

Babies born to mothers who used opioids during pregnancy represent one of the most distressing legacies of an opioid epidemic that has claimed almost 400,000 lives and ravaged communities.

In fact, many of the ongoing lawsuits filed against drug companies refer to these babies, fighting through withdrawal in hospital nurseries.

The cluster of symptoms they experience, which include tremors, seizures and respiratory distress, is known as neonatal abstinence syndrome, or NAS. Until recently, doctors rarely looked for the condition. Then case numbers quadrupled over a decade. Hospital care for newborns with NAS has cost Medicaid billions of dollars.

Studies indicate more than 30,000 babies with the condition are born every year in the U.S. — about one every 15 minutes. Although their plight is mentioned in opioid-related litigation, there are growing concerns that those children will be left out of financial settlements being negotiated now.

Robbie Nicholson, of Eagleville, Tenn., tried to comfort her second child while the baby slowly underwent withdrawal from drugs Nicholson had taken during pregnancy.

“The whole experience is just traumatizing, really,” Nicholson said.

Nicholson’s ordeal began right after her first pregnancy. To help with postpartum recovery, her doctor prescribed her a pile of Percocets. That was the norm.

“Back then, it was like I was on them for a full month. And then he was like, ‘OK, you’re done.’ And I was like, ‘Oh, my God, I’ve got a newborn, first-time mom, no energy, no sleep, like that was getting me through,’” she said. “It just built and built and built off that.”

After developing a full-blown addiction to painkillers, Nicholson eventually found her way into recovery. In accordance with evidence-based guidelines, she took buprenorphine, a medication that helps keep her opioid cravings at bay. And then came another pregnancy.

Robbie Nicholson now works as a mentor with a company called 180 Health Partners that helps women with addiction go through pregnancy. Her own newborn went through drug withdrawals, related to the medications she took to control her opioid cravings. She says most women she works with need a stable place to live and reliable transportation.(Blake Farmer/Nashville Public Radio)

But buprenorphine — as well as methadone, another drug used in medication-assisted addiction treatment — is a special kind of opioid. Its use during pregnancy can still result in withdrawal symptoms for the newborn, although increasingly physicians have decided that the benefits of keeping a mother on the medication, to prevent a potentially fatal relapse and overdose during pregnancy, outweigh the risk of her giving birth to a baby with neonatal abstinence syndrome.

Treatment protocols for NAS vary from hospital to hospital, but doctors and neonatal nurses have become better at diagnosing the condition and weaning newborns safely. Sometimes the mom and her baby can even stay together if the infant doesn’t have to be sent to the neonatal intensive care unit.

But not much is known about the long-term effects of NAS, and parents and medical professionals worry about the future of children exposed in utero to opioids.

“I wanted her to be perfect, and she is absolutely perfect,” Nicholson said. “But in the back of my mind, it’s always going to be there.”

There are thousands of children like Nicholson’s daughter entering the education system. Dr. Stephen Patrick, a neonatologist in Nashville, Tenn., said schools and early childhood programs are on the front lines now.

“You hear teachers talking about infants with a development delay,” he said. “I just got an email this morning from somebody.”

Studies haven’t proven a direct link between in utero exposure to opioids and behavior problems in kids. And it’s challenging to untangle which problems might stem from the lingering effects of maternal drug use, as opposed to the impacts of growing up with a mother who struggles with addiction and perhaps unemployment and housing instability as well. But Patrick, who leads the Center for Child Health Policy at Vanderbilt University, said that is what his and others’ ongoing research wants to find out.

As states, cities, counties and even hospitals go after drug companies in court, Patrick fears these children will be left out. He pointed to public discussion of pending settlements and the settlement deals struck between pharmaceutical companies and the state of Oklahoma, which make little or no mention of children.

Settlement funds could be used to monitor the health of children who had NAS, to pay for treatment of any developmental problems and to help schools serving those children, Patrick explained.

“We need to be in the mix right now, in schools, understanding how we can support teachers, how we can support students as they try to learn, even as we work out [whether there was] cause and effect of opioid use and developmental delays or issues in school,” he said.

New mothers in recovery for opioid addiction meet with a support group in Oak Ridge, Tenn. Most had newborns who endured drug withdrawals at birth, known as neonatal abstinence syndrome.(Blake Farmer/Nashville Public Radio)

But it’s a nuanced problem with no consensus on where money is most needed, even among those who have worked on the problem for years.

Justin Lanning started Nashville-based 180 Health Partners, which works with mothers at risk of delivering a baby dependent on opioids. Most are covered by Medicaid. And Medicaid departments in each state pay for most of the NAS births in the U.S.

“We have a few departments in our country that can operate at an epidemic scale, and I think that’s where we have to focus our funds,” he said.

Lanning sees a need to extend government-funded insurance for new mothers, since in states like Tennessee that never expanded Medicaid, these moms can lose health coverage just two months after giving birth. That often derails the mother’s own drug treatment funded by Medicaid, he said.

“This consistency of care is so key to their recovery, to their productivity, to their thriving,” Lanning said of new mothers in recovery.

Nicholson now has a job at 180 Health Partners, assisting and mentoring pregnant women struggling with addiction. Nicholson said their biggest need is a stable place to live and reliable transportation.

“I just feel kind of hopeless,” she said. “I don’t know what to tell these women.”

There are many needs, Nicholson said, but no simple fix. Those who work with mothers in recovery fear any opioid settlement money may be spread so thin that it doesn’t benefit their children — the next generation of the crisis.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

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Battling The Bullets From The Operating Room To The Community

Dr. Laurie Punch (center), a trauma surgeon at Barnes-Jewish Hospital, shows Melissa Woeppel (left) and Stan Schloesser how to apply a tourniquet during a Stop the Bleed class last month in St. Louis.(Whitney Curtis for KHN)

ST. LOUIS — Dr. Laurie Punch plunged her gloved hands into Sidney Taylor’s open chest in a hospital’s operating room here, pushing on his heart to make it pump again after a bullet had torn through his flesh, collarbone and lung. His pulse had faded to nothing. She needed to get his heart beating.

She couldn’t let the bullet win.

Bullets are Punch’s enemy. They threaten everything the 44-year-old trauma surgeon cherishes: her patients’ lives, her community, even her family. So, just as she recalled doing two years ago with Taylor, Punch has made it her life’s mission to stem the bleeding and the damage bullets cause — and excise them if she can.

In the operating rooms at Barnes-Jewish Hospital, Punch treats gunshot victims, removing bullets that studies show can poison bodies with lead and fuel depression. And in her violence-racked community, she teaches people how to use tourniquets to stop bleeding, creating a legion of helpers while building trust between doctors and community members.

Punch feels a calling to St. Louis, a place with the nation’s highest murder rate among big cities, where at least a dozen children were shot to death this summer alone, including a 7-year-old boy playing in his backyard. Punch believes all she’s learned has prepared her for now, when gun violence kills an average of 100 Americans a day and mass shootings are so common that two this summer struck less than 24 hours apart.

To her, the battle is personal, in more ways than one.

Dr. Laurie Punch, a trauma surgeon at Barnes-Jewish Hospital in St. Louis, is adamant that violence is a true medical problem doctors must treat in both the operating room and the community.(Whitney Curtis for KHN)

Besides being a surgeon, she’s a multiracial single mom living in Ferguson, Mo., just over a mile from where Michael Brown Jr., a black teenager, was shot and killed by a white police officer five years ago.

She has a son the same age as the little boy killed in the backyard in August. And she said, “I hear the gunshots echoing through my 2-acre backyard all the time.”

Stopping A Deadly Disease

In September, Punch brought her message to Washington, D.C., testifying before the House Ways and Means Oversight subcommittee on gun violence. Wearing a jacket and tie, she faced lawmakers to share the story of Shannon Hibler.

The 23-year-old was brought to Punch’s hospital last summer, shot seven times. While the nurses gave him blood, Punch said, she cut open his chest, trying to force life back into his body — to no avail.

“I watched his wife sink, as the floodwaters of vulnerability and risk came into her eyes, thinking about the life of her and her child and how they would live without him,” Punch told the assembled lawmakers. “I watched his father rage. And I heard his mother wail.”

Punch placed the black-and-yellow, blood-splattered Adidas sneakers she’d worn the day of the shooting on the table before her in the hearing room.

“I can’t wash these stains out,” she told lawmakers.

Dr. Laurie Punch testifies in September before the House Ways and Means Oversight subcommittee on gun violence, seated next to a pair of blood-spattered Adidas sneakers. She was wearing them the day she tried to save a 23-year-old who had been shot seven times.(Screengrab from House Ways and Means Oversight Subcommittee via YouTube)

The trauma surgeon was adamant: Violence is a true medical problem doctors must treat in both the operating room and the community. Until they do that, she said, violence victims will continue to be vectors who spread violence.

“The disease that bullets bring does not yet have a name,” she told Congress that day. “It’s like an infection, because it affects more than just the flesh it pierces. It infects the entire family, the entire community. Even our country.”

But healing also can be contagious — spreading among victims, families and the physicians themselves.

Punch, who regularly visits the neighborhoods where her patients live, attended an event last year for Saint Louis Story Stitchers, an artist and youth collective working to prevent gun violence. She remembers spotting a volunteer she knew — Antwan Pope, who’d been shot some years earlier but had found renewed purpose helping young people.

Punch told Pope about Hibler’s case, and learned Hibler was Pope’s cousin. Hibler’s dad was at the community event, too, and he handed Punch a lapel pin with his son’s picture.

She wore it on her white coat for months.

Two Worlds

Punch was born in Washington, D.C., the only child of a Trinidadian father and white Midwestern mother. They separated six months after her birth.

Until she was 7, Punch moved every year with her mom. They eventually settled with Punch’s grandmother in the tiny town of Wellsville, Ohio, a close-knit but segregated community.

Classmates bullied her for being different, Punch recalls.

“I was different in every way because I wasn’t black; I wasn’t white,” said Punch, who later came out as gay.

From the time Punch was 9, she took $2 piano lessons from Elizabeth Carter. The local music teacher had transformed former drug dens into places with music lessons, free clothes and meals, and put all the kids who sought her help to work. Punch’s assignment was serving food.

“You show someone that they can help,” Punch said, “it’s revolutionary.”

That lesson guided her life as a child and when Punch moved on to Yale University, the University of Connecticut’s medical school and then the University of Maryland Medical Center in Baltimore, where poverty and trauma scarred many of her patients’ lives.

Participants listen to Dr. Laurie Punch, a trauma surgeon at Barnes-Jewish Hospital, as she teaches a Stop the Bleed class last month in St. Louis. “It’s far more than teaching people what to do,” Punch says. “They learn: ‘I am not simply a victim or a perpetrator or an observer; I’m a helper. I have the capacity to help.’”(Whitney Curtis for KHN)

Punch spent her early career in the shock trauma center in Baltimore, throwing everything she had into saving others.

After marrying a woman she met as a medical intern, Punch became pregnant with twins at 35.

The next few years were marked by highs and lows in her personal life and the unrelenting stress of dealing with the aftermath of violence at work.

She miscarried at five months. No one could tell her why.

Five months later, she became pregnant again, this time giving birth to a healthy boy, Sollal Braxton Punch. But not long later, she and her wife separated. Now she found herself as a single parent as the pressures of her job mounted.

One morning, three shooting victims arrived at the trauma center, quickly followed by a car crash victim who was pregnant. Punch’s nanny texted her, saying Sollal had a fever of 102.3.

“I realized I can’t do this anymore,” Punch said. “I just can’t.”

The Call Of Community

So, she took a break from trauma for more than two years, focusing on general surgery at Houston Methodist Hospital in Texas.

But in 2015, a former colleague contacted her about a job as a trauma surgeon and educator at Washington University in St. Louis.

She feared going back to another troubled city. Michael Brown Jr. had been killed in Ferguson, Mo., a little more than a year earlier, triggering unrest and riots in that city just outside St. Louis.

Despite the area’s well-known history of violence, she flew to St. Louis for interviews, then rode around Ferguson with Dr. Isaiah Turnbull, an assistant professor. He pointed out the spot on Canfield Drive where Brown’s body had lain in the road for more than four hours.

“It was almost like seeing Ground Zero,” Punch said. “This is where it all went down. And it went down because of deep structural realities that caused the experience of black and brown people in north St. Louis to be fundamentally different. I went from not wanting to go to wanting to be right in the middle of it.”

And now she is.

Project manager Erica Jones (center) shows Tracy Russo (right) how to pack a wound during Dr. Laurie Punch’s Stop the Bleed class last month in St. Louis. The program helps educate the public on how to care for a gunshot victim immediately following the trauma.(Whitney Curtis for KHN)

Project manager Erica Jones demonstrates how to properly apply pressure to a wound. (Whitney Curtis for KHN)

On a recent hot summer evening, 20 people — some black, some white — gathered around Punch. A few feet away, a doctor, a trauma nurse and a medical student stood near tables stacked with “pool noodles,” the long foam cylinders kids play with in swimming pools — these happened to be about the width of a human arm.

Punch told the class that a person can bleed to death in a minute, but an ambulance can take 15 minutes to arrive.

“If you can stop the bleed, you can save a life,” she said. “Time is life and minutes matter.”

Participants practiced packing wounds by pressing gauze into holes in the pool noodles. They tightened tourniquets — first on the foam cylinders, then on each other.

Punch knows one of the doctors who created the “Stop the Bleed” training sessions after the mass shooting at Sandy Hook Elementary School in Connecticut. She realized the same training could save lives after street shootings, too.

Since March 2018, she and her team have trained more than 7,000 community members in the St. Louis metropolitan area. Many come to a rented space she dubbed “The T,” for trauma, tourniquet and time. But Punch’s team has also held classes in schools, a juvenile detention center and a firing range.

“It’s far more than teaching people what to do,” Punch said. “They learn: ‘I am not simply a victim or a perpetrator or an observer; I’m a helper. I have the capacity to help.’”

Dr. Laurie Punch (right) and project manager Erica Jones demonstrate how to apply a tourniquet during a Stop the Bleed class in St. Louis.(Whitney Curtis for KHN)

Contagious Healing

Two years ago, Sidney Taylor was shot outside his brother’s comedy club in north St. Louis County while trying to help a friend who was drunk. When Taylor arrived at Punch’s hospital, profuse bleeding had left his blood pressure dangerously low.

At one point, the father of four technically died on the operating table, but Punch and her team pulled him back.

After 10 days in intensive care, the longtime wrestling coach was still in physical and mental agony.

That’s the point when many patients slip back to their communities unhealed. But Taylor, now 47, showed up in Punch’s clinic a month after he had been shot, and they bonded during a 25-minute visit. Punch described to him how her team had removed part of his lung and inserted a breathing tube.

“Wow,” he told her. “I have another chance at life.”

Punch mulled a thought, then asked. “Would you ever want to share your story?”

Taylor agreed.

Punch recruited his hospital caregivers to create a video of their memories of saving him. When the taping finished, Taylor hugged each one.

Punch uses the video during talks, sometimes inviting Taylor to join her. Giving back to the community in that way has saved him a second time, he said.

After getting shot, “I could’ve basically turned to the dark side and done straight revenge,” Taylor said. “But I didn’t because of her.”

Stan Schloesser (center) practices using a tourniquet with assistance from project manager Erica Jones. (Whitney Curtis for KHN)

Tracy Russo (left) and Brittany Conners listen to trauma surgeon Dr. Laurie Punch as she teaches a Stop the Bleed class last month in St. Louis. (Whitney Curtis for KHN)

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When Teens Abuse Parents, Shame And Secrecy Make It Hard To Seek Help

Nothing Jenn and Jason learned in parenting class prepared them for the challenges they’ve faced raising a child prone to violent outbursts.

The couple are parents to two siblings. They first fostered the children as toddlers and later adopted them. (KHN has agreed not to use the children’s names or the couple’s last names because of the sensitive nature of the family’s story.)

In some ways, the family seems like many others. Jenn and Jason’s 12-year-old daughter is into pop star Taylor Swift and loves playing outside with her older brother. He’s 15, and his hobbies include running track and drawing pictures of superheroes. The family lives on a quiet street in central Illinois, with three cats and a rescued pit bull named Sailor.

Jenn described their teenage son as a “kind, funny and smart kid,” most of the time.

But starting when he was around 3 or 4 years old, even the smallest things — like being told to put on his swimsuit when he wanted to go to the pool — could set off an hours-long rage.

“In his room, his dresser would be pushed across the other side of the room,” Jason said. “His bed would be flipped up on the side. So, I mean, very violent. We’ve always said it was kind of like a light switch: It clicked on and clicked off.”

Jenn and Jason said their son’s behavior has gotten more dangerous as he has gotten older. Today he’s 6 feet tall — bigger than both of his parents.

Jenn said most of the time her son directs his initial anger and aggression toward her. But when the 15-year-old has threatened to hit her, and Jason has intervened, the teen has hit his father or thrown things at him.

“The way he will look at me is just evil,” Jenn said. “He has threatened to slap me in the face. He’s called me all sorts of horrible names. After an incident like that, it’s hard to go to sleep, thinking, ‘Is he going to come in and attack us while we’re sleeping?’”

Drawings made by Jenn and Jason’s 15-year-old son lie on the family’s dining room table in their home in central Illinois. Though his angry outbursts reveal a violent side, his parents say that most of the time he is “kind, funny and smart” — a teen who enjoys drawing pictures of superheroes.(Christine Herman/Illinois Public Media)

People who are victims of domestic violence are advised to seek help. But when the abuse comes from your own child, some parents have said there is a lack of support, understanding and effective interventions to keep the family safe.

While research is limited, a 2017 review of the literature found child-on-parent violence is likely a major problem that’s underreported.

Jenn said she’s concerned about everyone’s safety and worries about her 12-year-old daughter being exposed to recurrent violence in their home.

The stress has taken a significant mental and emotional toll on Jenn. She sees a therapist to cope with the violence at home and to deal with her anxiety.

“There are days when it’s hard to breathe,” Jenn said. “You just feel it in your chest — like, I need a breath of air, I’m drowning. We say to each other all the time, ‘This is insanity. How can we live like this? This is out of control.’”

Blamed And Shamed Into Silence

It’s hard to know exactly how common Jenn and Jason’s experience is, since research is sparse. In one nationally representative survey in the mid-1970s of roughly 600 U.S. families, about 1 in 11 reported at least one incident of an adolescent child acting violently toward a parent in the previous year. In about a third of those cases, the violence was severe — ranging from punching, kicking or biting to the use of a knife or gun.

Other more recent estimates of the prevalence of child-on-parent violence range from 5% to 22% of families, which means several million U.S. families could be affected.

A 2008 study by the U.S. Justice Department found that while most domestic assault offenders are adults, about 1 in 12 who come to the attention of law enforcement are minors. In half of those cases, the victim was a parent, most often the mother.

While most children who are abused or witness domestic violence do not go on to become violent themselves, and while most people with mental illness are not violent, those life experiences have been identified as risk factors for children who abuse their parents.

Lily Anderson is a clinical social worker in the Seattle area who has worked with hundreds of families dealing with a violent child. Along with her colleague Gregory Routt, she developed a family violence intervention program for the juvenile court in King County, Wash., called Step-Up.

Anderson said, in her experience, many parents feel ashamed about their situation.

“They don’t want to tell their friends or their family members,” Anderson said. “They do feel a lot of self-blame around it: ‘I should be able to handle my child. I should be able to control this behavior.’”

Anderson said many of the incidents take place at home, where the assaults are hidden from the public eye. That contributes to the lack of public awareness about the issue and makes it even harder for affected parents to find support.

“The whole issue becomes perceived as being the parent’s problem and the parent is to blame for the youth’s behavior,” Anderson said. “I think the main issue is that we need to talk about this. We need to talk — be willing to put it out there and make it an important issue and bring resources together for it.”

Unpredictable Anger

Jenn said that she has talked to her son’s therapists about why he has such trouble regulating his emotions, and they’ve told her it could be linked to the severe trauma he experienced as a baby and toddler.

When the couple began fostering the siblings in late 2007, the boy was 3 and his sister younger than 1. They had been removed from the home of their birth parents, where police were regularly called for drug and domestic violence issues. Jenn said her son remembers being beaten by men in his home and watching as his biological mom cut herself.

Jenn and Jason started their son in therapy at a young age, and he has been diagnosed with reactive attachment disorder, PTSD, attention deficit hyperactivity disorder and autism.

Jenn, Jason and their kids together at home last spring. Before they were adopted, the kids experienced or witnessed significant abuse in their birth family, Jenn says. That severe trauma, according to therapists, is likely a source of their son’s difficulty in regulating his emotions.(Christine Herman/Illinois Public Media)

The teen has attended art therapy and equine therapy regularly for years. He also participated in a mentorship program and attended a school designed for children with behavioral health needs. Jenn and Jason participated in family therapy sessions with their son, where they learned coping skills and practiced de-escalating situations at home.

The teen was also prescribed medication to help regulate his emotions.

Jenn said her son enjoyed going to therapy and seemed to be making some progress, but his anger remained unpredictable.

During the worst of the conflicts, the teen has kicked holes in walls and broken appliances. He has attempted to run away from home and created weapons to try to hurt his parents and himself. In recent years, Jenn and Jason have had to call police to their house about once a month to get help restraining their son. They’ve also sometimes had to have him admitted to the hospital for brief psychiatric stays.

‘Seems Like It’s Not Enough’

Keri Williams is a writer in North Carolina who advocates for parents raising children who have trauma-related behavioral issues, including attachment disorders that can manifest as intentional violence directed toward parents.

Williams’ own son became so violent that her family had to place him in a residential facility at age 10. He’s now 18.

“I actually thought I was the only person going through it,” Williams said. “I had no idea that this was actually a larger issue than myself.”

Williams manages a blog and Facebook page where parents like herself — who feel isolated and unsure of where to turn — can find others who can relate.

Many parents she meets online struggle to accept that they’re dealing with a serious domestic violence issue, she said.

“You just don’t want to think like that,” Williams said. “That’s just not how our culture is and how parents perceive things. And that denial actually is what keeps parents from getting their kids help.”

Jenn — the mother of the 15-year-old in Illinois — said parenting her son often feels like being stuck in an abusive relationship.

“But it’s different when it’s your son,” she said. “I don’t have a choice. I can’t just, you know, shove him away or break up with him.”

Jenn said anytime she sees a news story about a child who has killed a parent, she worries. Such events are extremely rare, and Jenn doesn’t want to think her son is capable of that.

“But, unfortunately, the reality is, when he is in those rages and in those meltdowns, he really isn’t thinking straight, and he’s very impulsive,” Jenn said. “So, it’s very scary.”

Despite all the challenges, she and her husband both said that adopting their son has brought them a lot of joy.

“It’s made me a better, stronger person, a better and stronger wife and teacher,” Jenn said.

But, she adds, she wishes there were more effective treatments that could help kids like her son live safely in the community and more places where traumatized parents could turn to find help.

“I feel like we’re doing everything that we can for him, but it just seems like it’s not enough,” Jenn said.

A Difficult Decision

Just before the beginning of the school year, Jenn and Jason made the difficult decision to send their son to a residential facility for children with severe behavioral health issues. He’s living there now.

The couple wrestled with that choice for some time. The boy had already spent almost three years in residential treatment all told, starting when he was 10. He’d moved back home last year because they thought he was ready.

But the family continued to deal with almost-daily standoffs involving verbal threats, angry outbursts and property destruction.

The boy’s 12-year-old sister said she has mixed feelings about her brother leaving home again to reenter residential treatment.

“It makes me feel happy and sad,” she said, “because, well, I love my brother. And I know he’ll be getting the help he needs.”

She’s comforted knowing her parents will be safe but said she’ll miss her brother a lot.

“I just love him,” she said. “And I don’t want to see him go through that.”

This story is part of a partnership that includes Side Effects Public Media, Illinois Public Media, NPR and Kaiser Health News.

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Books, Binders, Bleed-Control Kits: How School Shootings Are Changing Classroom Basics

When a student recently opened fire at a California high school, staff members did what they were trained to do. They shepherded students to safe spaces, barricaded doors, pulled shades — and, when gunfire struck, used techniques adapted from the battlefield to save lives.

The staffers used two bleeding-control kits in the Nov. 14 shooting in Santa Clarita, in which two students were killed and three injured before the gunman fatally shot himself, said Dave Caldwell, spokesman for the William S. Hart Union High School District. The kits, a recent addition to the district northwest of Los Angeles, are equipped with tourniquets, compression bandages and blood-clotting hemostatic gauze to prevent excessive blood loss.

Such kits have been pushed in school districts across the country. Georgia pioneered a statewide initiative to equip schools with Stop the Bleed Kits, for the 2017-18 academic year. This year, Texas, Arkansas and Indiana passed legislation to put them into schools. The Arkansas law requires public school students to be trained on the kits as part of the health curriculum to graduate.

Some gun control advocates say the efforts sap the political energy needed to reduce the actual violence. Most of the policies on bleeding-control kits have occurred in Republican-led states, where gun control may be especially unlikely to pass. Still, Democrat-controlled Illinois is among those to have picked up the campaign, with the Illinois Terrorism Task Force announcing in September plans to distribute 7,000 of the kits to the state’s public schools.

There is no statewide mandate for the kits in California. Rather, two students in the William S. Hart Union High School District took the initiative there.

Sisters Cambria, 15, and Maci Lawrence, 13, were worried about school shootings and natural disasters. They said they wanted to help keep students safe. After sharing their worries with their father, Dr. Tracy “Bud” Lawrence, who directs the emergency department of the Henry Mayo Newhall Hospital in Santa Clarita, the sisters raised $100,000 through the “Keep the Pressure” nonprofit they established to get bleeding-control kits into every classroom in the district.

“We just wanted to get them into as many hands as possible,” Bud Lawrence said.

1.5 Million Trained

Stop the Bleed kits were developed following the 2012 mass shooting at Sandy Hook Elementary School in Newtown, Conn., in which 20 children and six adults were killed. Dr. Lenworth Jacobs, who was a surgeon at the trauma center closest to Sandy Hook, said he and his staff prepared for an influx of patients from the attack, but none came to the hospital. They had not survived.

Jacobs, through a coalition known as the Hartford Consensus, led military leaders, law enforcement, trauma surgeons and emergency responders to develop recommendations on how to improve the survival rate in mass casualty events. Among the recommendations was the development of a Stop the Bleed campaign.

The American College of Surgeons, a member of the Hartford Consensus, launched the Stop the Bleed campaign to distribute the kits and to promote training so that more people understand how to stop bleeding if responding to an emergency. Jacobs said the effort has reached 100 countries and trained 1.5 million people.

Advocates for the campaign stress that the kits can help any type of significant traumatic injury.

Most fatal injuries, in fact, aren’t caused by gunfire, said Billy Kunkle, deputy director for the Georgia Trauma Commission. Kunkle said the No. 1 cause of such deaths is falls, followed by car crashes.

In 2018, for example, a fourth-grade student in Georgia was playing with friends on the playground when she fell and a friend fell on top of her. According to news reports, the girl broke her arm and severed her artery. The school’s nurse, using the Stop the Bleed kit her school had received less than 24-hours earlier, applied a tourniquet that the surgeons who treated Lopez credited with saving her life.

Kunkle said the kits should be viewed as an extension of a first aid kit. He likened them to other lifesaving tools, such as defibrillators, that have been installed throughout public spaces.

“We know it works. We know it saves lives,” said Republican Indiana state Rep. Randy Frye, a retired firefighter who authored legislation to put the kits in the state’s public schools. “You can’t wait for 911, even in the best system.”

Limited Reach Of Gun Control

Still, gun control advocates say bleeding-control kit efforts allow lawmakers to avoid dealing with the cause of school shootings.

“On the one hand, anything we do to save lives is good. But, on the other hand, fundamentally, it is allowing lawmakers and officials to ignore the root cause of gun violence,” said Kyleanne Hunter, vice president of programs for Brady, formerly known as the Brady Campaign to Prevent Gun Violence.

“Yes, we need to deal with mental health. Yes, we need to deal with first aid and medical care. And we need to address how easy it is to get guns,” Hunter said. “We don’t believe it should be an either-or.”

Legislators have ignored numerous proposals aimed at reducing gun violence, including Brady’s “End Family Fire,” she said. According to a Wall Street Journal analysis, 75% of school shootings involved guns that shooters found unsecured in their homes. End Family Fire encourages the safe storage of weapons to make it more difficult for children to access unsecured guns.

“I am sure that a lot of school safety legislation allows some legislators to say, ‘We are doing something,’ and that allows a release valve for them to not focus on gun control,” said Democratic Texas state Rep. Diego Bernal, who was a co-sponsor on the Stop the Bleed legislation in his state.

Still, he added, “I suspect, even if there was gun control legislation, we would pursue this bill. I don’t think this is an either-or proposition.”

Among the advantages of having the kits in schools and more people trained on methods to stop bleeding, Jacobs said, is that a lockdown often follows a shooting. That prevents emergency responders from getting in or the injured from getting out. In every kind of trauma, he said, minutes count.

“If, God forbid, something happens, you really want to know there is someone right there beside you who can do something,” said Jacobs. “If you can keep the blood inside the body until you reach the hospital, you have a phenomenal chance for survival.”

In Georgia, the governor allocated $1 million from fees generated by the state’s Super Speeder traffic safety law to pay for the kits. To date, Kunkle said, the kits are in about 2,100 of the state’s 2,300 schools, and have been used seven times.

In Arkansas and Indiana, the cost of supplying kits to schools was covered largely by private donations.

Dr. Marlon Doucet, a Little Rock, Ark., trauma surgeon, is leading efforts to expand access and training on Stop the Bleed kits in schools and elsewhere in his state. He believes strongly that training more people — including cops, teachers and students — will save lives.

Twenty-five people were shot in the July 2017 Little Rock Power Ultra Lounge shooting, and all survived, Doucet said.

“No one died because law enforcement officers were using tourniquets and packing wounds,” he said. “This just makes sense.”

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California Public Health States

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