A growing body of scientific evidence about the power of severe childhood stress to weaken brain architecture and damage lifelong health is prompting leading pediatricians to call for a seismic shift in pediatric primary care. The American Academy of Pediatrics (AAP), which represents 60,000 physicians, is planning a comprehensive public health strategy to identify and reduce toxic stress in their youngest patients. They see this not only as a way to improve their patients’ health across the lifespan, but also as a means of improving the nation’s health—and economy.
“Unfortunately, as a country we’ve ignored all those things. But it’s time to stop ignoring them,” says Robert W. Block, M.D., of Tulsa, Okla., the AAP’s immediate past president and a champion of the new approach. “As these kids [facing toxic stress] grow older, there become more and more issues that become more expensive to fix. And often they’re not fixed at all, because they’ve become too advanced.”
The cumulative toll increases the likelihood of developmental delays, learning disabilities, and childhood behavior problems, as well as diabetes, heart disease, depression, drug abuse, alcoholism, and other major health problems in adults.
A Top Priority for the AAP
The AAP has made early brain and child development a top strategic priority for two years. In January 2012, the AAP published two major reports in its journal Pediatrics co-authored by Center Director Jack P. Shonkoff, M.D., on the science of toxic stress and the pediatrician’s role in mitigating its negative effects across the life span. Shonkoff is a Board-certified pediatrician.
Since then, the AAP has continued its efforts through an Early Brain and Child Development Leadership Work Group, chaired by Andrew S. Garner, M.D., Ph.D., of Cleveland, Ohio, and co-author of the Pediatrics articles. The work group is coordinating development of an action plan, with detailed recommendations on how pediatricians can prevent, identify, and treat toxic stress. The recommendations will emphasize the importance of collaboration with related providers, including mental health, early childhood education, and child welfare workers.
“We see how early childhood experiences are so important to lifelong outcomes, how the early environment literally becomes embedded in the brain and changes its architecture.”
“We see how early childhood experiences are so important to lifelong outcomes, how the early environment literally becomes embedded in the brain and changes its architecture,” Garner says. “Hopefully, this will drive support. It’s not just the right thing to do ethically. It’s not just the right thing to do economically. It’s the right thing to do biologically. And that framework places it squarely in the realm of pediatrics.”
James M. Perrin, M.D., the AAP’s president-elect, says the need is clear, but it won’t be easy for primary care pediatricians to change their thinking—or their practice. Many already feel overburdened and are reluctant or unable to take on more responsibility, especially for issues they may not be well equipped to handle, such as those that traditionally have fallen to mental health providers.
“For the typical pediatrician, it’s going to require some real action and some change in how we do things,” says Perrin, a professor of pediatrics at Harvard Medical School. While pediatricians have understood for years that early adversity can have a significant negative impact on the lives of children and their well-being as adults, Perrin says that, previously, “There was a thought that this was the way it was—and the way it had to be.”
Treating Children Now for Adult Health Later
The science of toxic stress has been—and will continue to be—an essential part of helping pediatricians understand that they can make a difference in adult outcomes, according to Perrin, who is associate chair of MassGeneral Hospital for Children in Boston and who founded and directed the Massachusetts General Hospital Center for Child & Adolescent Health Research and Policy.
“The attention that the Center on the Developing Child has brought to understanding more about the underlying neurobiology has been, frankly, quite critical to health care communities,” Perrin says.
The AAP is designing a three-step approach of prevention, screening, and treatment to help pediatricians intervene as early as possible. The organization wants pediatricians to routinely screen babies, toddlers, and preschoolers for social and emotional difficulties that can be signs of toxic stress – and to work with specialists to find effective interventions. The AAP is also creating a parent education campaign to teach all caregivers how to support social and emotional development and enhance coping skills.
The efforts will reach well beyond the pediatrician’s office, too. The AAP is bringing attention to broader issues, such as identifying what kinds of changes will be needed in pediatric support structures. Top priorities include better mental health training in pediatric residency and continuing education programs, fair payment systems for the extra time pediatricians will spend on screening and coordinating care of children found to be at risk, and expansion of high-quality specialty services where children can be treated.
“Pediatricians can’t do this alone,” says Garner, the work group’s chair. “That’s why we need a public health approach. There’s no single intervention to fix all of these issues.”
The ideal pediatric practice of the future, he says, would be a comprehensive medical home with all related providers working in the same place – the pediatrician, the psychologist, the social worker, someone doing home visits, and a case manager to coordinate care. This is being done in some leading-edge practices around the country, but not enough, he says.
In the coming months, the AAP will seek feedback through an extensive review process before making official recommendations to the field. And while the details will be difficult to work out, AAP leaders are committed to refocusing pediatric practice.
“It must be done,” says Block. “It’s one of the most important things we can do as pediatricians.”