I just wanted to write a quick check-in. I have been keeping to home with 4 children out of school and my husband working from home since mid-March. I've had thoughts of things I could be writing to put good information out there, but I really wanted to be sure I'm taking care of my own family first, sort of like making sure I don't have a rod in my eye while I point out the speck in others' as the Bible says. Thankfully, I can report we are doing okay. If this had happened a year ago when I had two children with pretty significant behavioral health concerns I would not be saying that. We have come a long way in a year with good therapies. I've written 2 articles which will be linked below about how to cope with stress and how to be the buffer for your child and others during this time and I'd love it if you'd share those with others. I am getting ready to start a fellowship in Development Behavioral Pediatrics this July 1st. I'm really excited to get started (and get out of the house!) but I am also mentally preparing that we are likely to see a major uptick in pediatric mental and behavioral health needs in the next few months and years. Unfortunately, some parents are not prepared to be the buffer for their child in a time of stress and we are likely to see an increase in child abuse going on. It may not be reported right now as kids aren't seeing the adults who normally report, but there will be the consequences to deal with for years to come. What can you do to help? There are a lot of nonprofits who work in this area that need continued funding during economic downturns. But closer to home, I want to encourage you all to be reaching out to family and friends who have kids at home, and if you have the ability to relieve some of their stress, do it. We are supposed to be social distancing, but in times of crisis especially, people should still be able to rely on their circle of support that includes extended family and friends who live close by. Don't be afraid to help those who need it. Get to know your neighbors from a distance and just look out for others.
As a pediatrician and mom of four, I have been following the growing area of research in pediatric mental health over the last few years, including the study of adverse childhood experiences. Given the current information overload, I wanted to share the single biggest way we can help kids through this time without causing long-term consequences.
Think for a minute about a boxer’s glove. The function of the glove is to provide padding for the hand. It is a shock absorber. When a hand with a glove punches a hard surface, the thick padding absorbs a lot of the shock of impact. The glove allows the hand and arm to get stronger while absorbing enough of the impact to prevent breaking bones or other injuries.
In the same way, parents, or primary caregivers like grandparents or foster parents, play the role of buffer or shock absorber for the kids in their care. It’s not that we want to wrap kids in bubble wrap and prevent any stress from reaching them. That would not prepare them for life as an adult. Rather, we want to be present to help them navigate the life stresses they are experiencing in a way that helps them learn they can do hard things, solve problems, learn how to respond better next time or just grieve a loss and move forward in life.
How does a parent do this well? A lot of it is instinct if you have grown up with a nurturing caregiver who did this for you. However, some parents did not grow up in a nurturing home. Sometimes, as adults we have to practice new skills to give our kids a better chance than we had.
For kids and parents who have already suffered traumatic events, especially during childhood, they may be even more affected by this feeling of uncertainty. They may also have less ability to put feelings into words. Supporting adults can help by talking through feelings of uncertainty in a calm way, putting thoughts into words.
Many people also benefit from journaling, artwork and music as a way of processing feelings. Good information for parents and grandparents dealing with their own stress can be found at stresshealth.org and developingchild.harvard.edu/.
Adults who are suffering from big losses such as loss of a family member through death or divorce, or loss of a job may need to put all their energy into processing their own feelings.
When this happens, they may become unable to act as the buffer for their kids. It becomes necessary for other adults to step in and support that parent and their children. In this time of isolation, it’s important to stay socially connected in whatever way we can. It does take a village to raise children especially during difficult times.
If you are an adult who is struggling with your mood right now and you think it may be affecting how you interact with your children, the best thing you can do for your family is to get help for yourself.
You can call your family doctor or the Oklahoma Department of Mental Health and Substance Abuse has a great website as well as phone numbers you can call to get help. You can text TALK to 741741 or call 1-800-273-8255. Nearly half of all adults (46%) will have a mental health diagnosis requiring support during their lifetime.
People who have never needed mental health support before are likely to during this time. It is common and treatable so don’t be afraid to reach out for help so that you can continue to do the best job of buffering for your children.
Dr. Laura Shamblin, MD, is an Oklahoma City pediatrician, founder of TraumaInformedMD.com and sits on the board of directors for the Oklahoma Health Care Authority and the Oklahoma Chapter of the American Academy of Pediatrics.
The above is an op-ed published by the Tulsa World at https://www.tulsaworld.com/opinion/columnists/dr-laura-shamblin-parenting-in-a-pandemic/article_f85b17ef-4029-531b-810d-cdd32a9fecbe.html
I’d like to take a few minutes to highlight some information I hope will be helpful to those who are currently experiencing a prolonged period of increased stress. As a physician I have been watching as my fellow physicians mentally and logistically prepare for what we expect to be a very difficult time. I liked the Washington Post article by Alison Block titled “Doctors and nurses are already feeling the psychic shock of treating the coronavirus.” The medical community is preparing for unprecedented measures in the United States. In the midst of this, we are also making decisions about who will care for our children, how much contact we will have with spouses and children, and how to plan for childcare without exposing our elderly parents. In today’s world of living apart from close family many have to find support from friends and neighbors. In the article Dr. Block refers to this as “pre-trauma.”
This concept is very similar to the concept of secondary post-traumatic stress, which is something healthcare workers also frequently experience. Secondary traumatic stress is the emotional duress that results when an individual hears about the firsthand trauma experiences of another. The essential act of listening to trauma stories may take an emotional toll that compromises professional functioning and diminishes quality of life. When you couple this with the stress of the work environment in healthcare settings right now you can expect that your body is putting out a surge of cortisol. Cortisol is useful for short periods of time under stress. It works to raise blood pressure, shunts blood to essential organs, raises blood sugar, and temporarily suppresses immune system function. Normally a period of intense stress should be short and then over, allowing the body to get back to normal functioning. But when you have a job or life situation that involves frequent traumatic events or hyper-vigilance to danger, cortisol remains high for long periods of time or indefinitely. As you can imagine, this would result in persistent high blood pressure, high blood sugar, immune system suppression, and the resulting organ damage over time.
The good news is there are some things we can do to proactively lower our physiologic stress and cortisol levels on a daily basis. Here is a list of activities you can incorporate into your daily schedule right now to give your body a pause.
2. Mindfulness/Meditation - apps like YouTube, Calm, Headspace, MoodTools, Abide
4. Grounding exercises – sitting with eyes closed and focus on your other senses – feeling the floor, your chair, smells, sounds, breathing, etc.
5. Tactical breathing – breathe in while counting to four, hold for four, breathe out for four, hold for four,etc.
6. Spend time with family
7. Spend time with pets or animals
9. Gardening, hiking, spend time in nature
10. Journaling - If you don't like to write a lot, you can write 3 things you are grateful for, 3 good things that happened today, and 3 things you are looking forward to tomorrow.
11. Connecting with faith communities
12. Talk to a colleague who understands
13. Humor, comedy
14. Create something – draw, paint, craft, knit, carpentry, write, sort photos, etc.
It’s a great idea to schedule a few of these throughout your day even at this difficult time. This is called making a coping strategy.
Morning – prayer or mindfulness app
Work – stop and do tactical breathing for one minute twice during your shift, talk to a colleague about your day at the end of shift, call a friend
Evening – go for a walk/run, spend time with family/pets
Bedtime- prayer, do stretches or yoga, listen to a sleep story on a mindfullness app
I also like the idea of combining these as much as possible. Exercising outside is better than indoors. I like to walk outside while listening to a book or podcast that lowers stress. Walking with a pet, watching a comedy with your kids, or working on a project or hobby outdoors or with family are some ways you can think about combining them.
Being intentional to lower our stress is the best way we have available to function at our best and get through this without adverse consequences to our health. As you begin to use these, share with your colleagues and create a culture of intentional coping strategies.
Laura Shamblin, MD
During her exam he was able to disguise very inappropriate touch as a form of treatment and do it with her mom in the room, not realizing what was going on. This went on for over a year, escalating in nature. At the time, the reputation of Larry as the premier sports doctor for USA gymnastics, as well as a teacher of other physicians at Michigan State University, made it seem impossible to suggest he may be guilty of this evil. Due to the climate of victim-blaming, Rachael and her mother had to wait to see if an opportunity to speak out ever presented itself.
In the meantime, Rachael articulates so well the fallout of being a sexual assault survivor. She describes a heightened state of awareness and fear in public places. A fear of men standing behind her, even in a fast-food line. The inability to verbalize what had happened to her, making it impossible to consider going to see a mental health professional. With her family’s support she attempted to process her feelings through journaling and prayer. This part of the book is, I think, the most enlightening to readers who have not been a victim of abuse. The physiological changes, the emotions, and the way memories, nightmares, and fears resurface time after time for the rest of a survivor’s life is something we need to understand more in order to truly support those we come in contact with who are survivors. She explains every cultural bias against victims, point by point, making it easier to see how these biases are played out around us when we don’t even realize it.
For Rachael, as a person of strong Christian faith, her interactions with her church are also worth learning from. She describes sitting in Sunday School and discussing stories like Bathsheba and Dinah and the messages that can be transmitted to children about issues of sexual assault. If you grew up in church, like I did, it is easy to be desensitized to the horror of these stories. But when you think about them from the perspective of a survivor, it is easier to look at the messages we are often sending our children when we teach these stories, including when inappropriate comments are made by other students and not addressed by the teacher. They are a part of the Word of God and therefore have value in teaching. But it is so helpful to listen to the point of view of a survivor before discussing these issues, to help us avoid the pitfalls of our cultural biases.
Some of the messages of this book that translate to a better understanding of being trauma informed are these: Survivors need as many choices as possible as they deal with the aftermath or reporting of their abuse. Choice is a form of control and abuse always represents a loss of control for the victim. In order to recover, find their voice, and retake control of their lives, it is important to give them as many choices as possible when telling their story or seeking help. (I do want to be sure to say that when the victim is a minor at the time of disclosure, there is no choice in reporting for any adult who becomes aware of the abuse or the victim discloses to. Choices should be given when possible in who they talk to, the setting, who is present, etc. Whether or not it is reported to law enforcement or child protective services, is not a choice. It must be done.)
Something else it’s important to remember for being trauma informed is that a survivor’s perception of safety is more important than leadership’s perception of the safety of their organization. This can be called Felt Safety. If you are in leadership – a teacher, pastor, CEO – and you feel your organization is a safe place, both preventing abuse and open to receiving a disclosure of abuse about a leader or staff member and able to follow best practices in reporting and supporting the victim while investigating the claim, your opinion is secondary to whether a survivor feels safe enough to come forward in your organization. When we discuss outside instances of abuse whether in the news, books, movies, or religious texts, we are sending messages to survivors about how safe they would be discussing their abuse in our presence.
Another message that she grapples with and expresses so well is that God loves justice just as much as He loves forgiveness. The Bible teaches that vengeance belongs to Him, and there will be an eternal judgement for the evil we commit. Whether that justice is meted out in our lifetime or after life is not always in our control. But when it can be meted out by our courts, the message that sends to survivors is important. When considering the punishment for abuse, the sentence reflects the worth of the victim. That is the meaning of the book title, What is a girl worth? The answer should be everything. The punishment for victimizing the innocent should be the maximum the law allows. When we try to minimize or mitigate the evildoing of an abuser, we diminish the perfection and beauty of the goodness of God.
The story of Rachael Denhollander, to me, is an Esther story. Esther is told to use her position in a time of crisis, for "who knows but that you have come to your royal position for such a time as this?" Esther 4:14. Rachael developed the gifts God had given her which included an analytical mind and the ability to become an attorney, her supportive family, and her faith. With these three things she became the one person who could bring a police report against Larry Nassar in such a way that she could withstand the institutional push-back from Michigan State University, and get her story out into the public sector where other survivors could see it and join her in coming forward. Without the support from family and personal faith, as well as a few perfectly placed individuals who also sought truth, including a reporter, a detective, and a prosecutor, her story would not have been able to pierce the public arena and bring the judgement of our courts down on Larry Nassar.
I hope that others will take this opportunity to look at the institutions we are a part of, whether they be schools, churches, clubs, corporations or other spheres, for how we can make sure they are as prepared as they can be to both protect the innocent and to be a safe place for victims to disclose their abuse, seek help in reporting, and get support for healing.
One organization I've seen that provides this expertise is https://ministrysafe.com/ They have some great short videos about this issue on their site as well at https://ministrysafe.com/who-we-are/
By Laura Shamblin, MD FAAP
Most of us have now heard of the Adverse Childhood Experiences Study published by Drs. Felitti and Anda in the American Journal of Preventative Medicine in May of 1998. The study and many follow up studies have shown a direct and dose dependent relationship between adverse childhood experiences, or abuse, neglect, and household dysfunction, and adult risky behaviors and health outcomes. As a Pediatrician and advocate for Trauma Informed Care, I’d like to take this opportunity to address some of the objections to screening for ACEs that I have come across. It is true that some areas of research are still emerging, such as protocols, but in other ways we are twenty years behind using the information we have to make a positive difference in our patients lives and in training new physicians to be more comfortable addressing social and experiential determinants of health.
Myth #1 People don’t want to talk about their personal or family traumas.
In several studies, the vast majority of patients did not mind answering a screening tool at a primary care visit. (1,2) Clinics who have adopted ACEs have found using a cover page with a short explanation of the relationship between childhood traumas and adult health outcomes to be helpful. It has also helped to have ACEs screening papers given to the patient to be filled out either at home before the visit, or in a private patient room before seeing the doctor rather than in the public waiting room. Any adoption of a new screening tool should ideally have input from a patient advisory group before implementation to account for concerns of different patient populations. (3)
Myth #2 Filling out a questionnaire may cause someone to remember suppressed memories of childhood abuse and have a sudden onset or worsening of mental health issues.
This concern has been brought up in a couple of published articles (4), however there are many more articles recording the use of ACEs screening tools in various outpatient settings without reference to this situation actually happening. The ACEs questionnaire has also been given and shown to many, many large audiences at conferences and trainings and again, there has never been a case brought to light of any major mental health consequences, to my knowledge. On the contrary, many people express appreciation and even relief to learn the associations between childhood experiences and adult behaviors and health outcomes. They know there is a problem, and it is helpful to put a name to it and therefore be able to get more information about treatment and recovery steps that can be taken. There is mention of patients being uncomfortable with the information on health outcomes being given without being accompanied by information on resilience, buffering, and positive and compensatory experiences. (5)
Myth #3 There aren’t any truly evidence-based interventions for childhood trauma. We shouldn’t make families aware of the negative health outcomes, because there is nothing proven to help them.
This assumes that all positive screens will need a behavioral health care referral. In a large study of 3 community pediatric clinics in the Chicago area, screening for ACEs only resulted in referral for mental health care in 2% of patients. (6) In a feasibility study in a family medicine practice including adults, no new referrals were made. (1) When those services are needed, there are several modalities of treatment that have good evidence for use in children and are recommended by the AAP. At the top of the list would be Trauma-Focused CBT followed by PCIT and CPP. TBRI is also a growing modality with good results among the adoption community and schools but less research funding nationally. More information about treatment modalities can be found here. https://www.traumainformedmd.com/treatments.html#/
For the many who do not need a referral, parenting resources such as local parenting classes (check with churches, hospitals, and pregnancy centers), as well as anticipatory guidance and education provided by the physician, is likely the most helpful resource and is the most asked for by parents. There is growing evidence that positive experiences in childhood as well as healthy attachment relationships with at least one adult both have a buffering effect on children who experience multiple ACEs. These positive experiences and relationships provide resilience as well as support for healing. (7,8)
Myth #4 There aren’t enough mental health professionals available to provide follow up for all of the positive screens we would get, so it’s better to just not ask the questions.
Behavioral health providers who use evidence-based methods of treatment for childhood trauma may be more available than most providers are aware. If you know the modality you would like to be used such as TF-CBT or CPP it is possible to use several search methods to find the nearest provider to your community. Links to these search sites are listed on the Treatments page of www.TraumaInformedMD.com here https://www.traumainformedmd.com/treatments.html#/. SAMHSA also has a search function you can find here https://findtreatment.samhsa.gov/ and most state Mental Health Departments also have search capabilities and resource lists. Another helpful search website is https://www.psychologytoday.com/us which has a way to filter for therapists that provide different modalities or types of therapy. By searching, you can quickly find what behavioral health resources may be near you, even in a rural location.
Myth #5 If we ask about abuse, we may uncover events that would fall under the mandatory reporting obligation. We may overwhelm the Child Protective Services and kids may be removed from the home who didn’t need to be, further traumatizing them.
First of all, if a child is in an unsafe situation there should be no problem with reporting it, despite the time and effort it may require from the provider. However, situations that are serious enough to involve your local Child Protective Services will be evaluated for safety and many of them will not require removal from the home, but they will give the family the opportunity to receive prevention services. The Family First Prevention Services Act is a federal law that was put into effect on October 1st, 2019. It allows state human services agencies to use federal matching money that was previously only used for out-of-home foster care to be used for preventions services given to the family with the child remaining in the home. This law requires some benchmarks in quality to be reached before using it and most states have not put it into effect yet, however, the national trend is changing toward keeping children in the home and providing services to the biological family when possible. (11)
Myth #6 I’d love to screen for ACEs but there is no way I have time during a patient visit to delve into those issues.
In most feasibility studies, practices have found that using a deidentified screening tool – one that just has the patient list the number of ACEs that are positive for them but not specify which ones – allows the physician to talk to them generally about being intermediate or high risk and what they can do to counteract those factors, rather than needing to hear the story of each one. Of course, if a patient wants to explain a positive answer, this may happen and opens the relationship to be a safe space for talking about these issues at this and future visits. When a deidentified screener was used, the time added to most visits was found to be 5 minutes or less in multiple studies. (1,9)
Myth #7 As a doctor, my focus is on my patients’ health, and knowing how many ACEs they have will not affect my diagnosis and treatment of current health issues.
The number of ACEs may not affect a specific diagnosis directly because there are other genetic and resilience factors that also play a role for each individual. However, universal screening makes it more likely that an environment or history of childhood trauma will come to your attention as you are treating chronic illnesses that have been shown to have direct correlations with childhood trauma and toxic stress, such as failure to thrive, asthma, obesity, ADHD, anxiety/depression, substance use, self-harm, and even things like syncope, headaches and chronic abdominal pain. ACEs are present in families of all socioeconomic backgrounds and you may fail to ask about such influences if the family appears to be well-functioning in your clinic.
I’d like to specifically point out the relationship between ACEs and ADHD diagnosis. Patients seem to have a dose dependent relationship between number of ACEs and likelihood of ADHD diagnosis. (10,12) It is also known that one symptom of PTSD is hypervigilance, which in a child includes behaviors such as inattention, inability to sit still, and other behaviors that mimic those of ADHD. Because the DSM-V does not allow for an ADHD diagnosis if another mental health disorder may explain the symptoms, it seems that a screening for ACEs and PTSD may be warranted in any person being screened for ADHD to further inform the diagnosis. As Guanfacine is an accepted treatment for both PTSD symptoms of hypervigilance and ADHD, it is logical that it may be a better first line treatment for a child with both ACEs and ADHD than a stimulant would be. Further research on this and elucidation of protocols are still being worked on.
Myth # 8 The ACEs screen was developed for adults and should not be used on children.
Depending on your purpose there may be value in screening both parents and children. In the case of parents there is some evidence that increased ACEs are related to developmental delays in their children. Surprisingly, there was even a stronger relationship between fathers’ ACEs and children’s developmental delays. (13) This would suggest that screening parents early on may be a way of knowing which to refer for more supports in parenting such as parenting classes or adult mental health services. Early adopters have suggested the 4-month well check visit as being a good time to screen as there are fewer other concerns at that visit. (3) Screening children, either having parents report for young children or having older children report for themselves, would be most helpful for reference when working up health and mental health conditions as stated above such as asthma, failure to thrive, ADHD, etc. These could be done either at well checks and referred back to during illness or could be done at times of work-up for these chronic conditions.
Given the many demands on physicians’ time and paperwork requirements it can be easy to be so busy in our practices that we wait for government or professional organization mandates to dictate how we practice. I hope this helps to bring some resources and research to the forefront to help us use the information that ACEs screening would provide. We should NOT be screening if we are not comfortable with what we will do with the information. And what we will do is usually just have a conversation with the caregiver or patient about the results and things they can do to combat the effects of ACEs on their child, such as getting parenting support, keeping mom healthy, trying to have high quality, safe childcare, trying out things like mindfulness and exercise in the home, leaning on extended family and friends at times of stress, coordinating with teachers, etc. Of course, we will need to have mental health professionals in place that we can refer to when needed. For help with that look back at Myth #4.
The State of California has put together a short online training for physicians and other healthcare or mental health workers to learn more about ACEs and implementing ACEs screening in the medical setting. I just did this training myself and I was impressed at how many references they include with the research and how much of the biology and physiology of stress was included. I received 2 hours of CME credit and 2 hours of MOC credit for the American Board of Pediatrics. This is the training that is being required of California physicians before they can bill for Medicaid reimbursement of administering ACEs screens. However, any healthcare provider can create a login and take the course for free. I appreciated the inclusion of the screening tools and an algorithm for how to interpret results and when referrals are recommended. Please take a look if you are a healthcare provider. It will be worth your time!
You can find it at https://www.acesaware.org/
The National Center on Safe Supportive Learning Environments has a few free online learning tools to help teachers and school administrators to learn the basics of trauma informed schools and to collaborate with their local colleagues in how to implement trauma sensitive changes in their schools. I took a quick look at them and it looked like the ones labeled Understanding Trauma and Its Impacts and Building Trauma Sensitive Schools would be best for classroom teachers. I just wanted to point out this free national resource as many are looking for tools to help with this.
Here is the LINK.
When we talk about counteracting the outcomes of childhood trauma, most of us have heard of resilience. Resilience is something that is determined both by the child, based on aptitudes and personality, and by the environment and relationships. Something you may not have heard of yet is the science of hope. When I think of hope, I personally think of spiritual connotations. But in Hope Rising, How The Science Of Hope Can Change Your Life by Casey Gwinn, J.D. and Chan Hellman, Ph.D., I learned about the relatively new science of hope. Did you know that hope can be measured? At the Hope Research Center at the University of Oklahoma in Tulsa, Dr. Hellman leads a team of researchers who have developed a screening tool to measure hope in both children and adults. The Hope Score is then predictive of outcomes in the short term and long term. And not just the current score is important, but whether or not a person’s score rises over time. Once we understand the science of hope and how to build it in others, we can then use it to develop activities or conversations in our circle of influence to help ourselves and others increase in hope. Rising hope is desirable to all of us but it is especially something needed by those who have been affected by childhood trauma. Hope can counteract feelings like shame and apathy that often accompany childhood trauma. If you are interested in helping yourself or others in pretty much any area of life, Hope Rising will be an interesting and helpful read. There is a lot of information packed into this book, but it is helpfully broken down into very short chapters with anecdotal stories to illustrate the concepts at the beginning of each chapter. Many of these stories relate to the authors, making it read like a memoir at times. For me this brings in the human element and makes the science more captivating. I read a lot of both fiction and nonfiction and I usually read straight through a book. For this book, I found myself wanting to read a chapter or two a day and then think about it before going on. I also want to say that my favorite chapters came at the end, those on spirituality, the workplace, and leaving a legacy of hope. So, I encourage you to finish the book, as the end is worth it. There is something in Hope Rising for everyone, whether you have experienced grief, cancer, abuse, domestic violence, workplace harassment, or spiritual crisis, or you work with those who have, you will find helpful information that can be applied in conversations or activities with others. As someone interested in helping communities and families counteract the generational effects of childhood trauma, this book is one of the staples for understanding how to help. The concepts can be applied in one-on-one relationships, as well as in large organizations. Currently in Oklahoma, the State Department for Human Services is rolling out training for their staff, using Hope Rising, to help staff relate to our citizens in ways that raise hope. Speaking of hope, that is something that raises my hope for future generations in our state!
by Laura Shamblin, MD
You may not have heard yet about the change in federal law that allows states to use federal matching dollars to pay for child abuse prevention services for biological families rather than solely for foster care services after the child has been removed from the home. This law was included in a large omnibus funding bill and so did not get a lot of notice, but nationally it is a huge change in perspective for how we have been dealing with families and children. There is much evidence that the removal of a child from her parent is a trauma similar to the trauma of abuse or neglect. If we can prevent families from descending into this level of dysfunction by providing mental health, drug abuse services and parenting support, we should be able to prevent this type of childhood trauma on a large scale. If you'd like to hear more about the new law, how it works, and my personal take on why it is needed you can listen HERE.
Laura Shamblin, MD
One of the best uses of TraumaInformedMD.com is to find out information about types of mental health treatments and to find mental health providers. The list of mental health resources was getting a bit long for the Healthcare page, so I decided to create a new page for only mental health resources in Oklahoma. It is listed as OK-Mental Health at the top of the website. If you live in another state there are still ways to search for resources in your state on the Treatments page. If you live in Oklahoma, this is a more comprehensive list and some search options which are great! These resources are helpful for patients, family members, and physicians as we try to find places to refer to that are close to our patients.