Tackling Toxic Stress

Listening to a Baby’s Brain: Changing the Pediatric Checkup to Reduce Toxic Stress

Listening to a baby’s heartbeat. Examining a toddler’s ears. Testing a preschooler for exposure to lead. These critical screenings have long been the hallmarks of early childhood checkups.

Now, leading pediatricians are recommending major changes to the checkups of the future. The American Academy of Pediatrics (AAP) wants primary care doctors to screen their youngest patients for social and emotional difficulties that could be early signs of toxic stress.

Doctor examining baby boyThe new screenings are part of a comprehensive public health strategy the AAP is designing to make toxic stress a priority for all pediatricians, as a means of reducing many of society’s most complex and costly medical issues, from heart disease to drug abuse. Any child who shows risk for toxic stress would receive referrals to specialists for treatment. The organization is also preparing to teach parents how best to promote children’s social and emotional development to minimize toxic stress.

“We’re trying to emphasize that much more important than just listening to a baby’s heart is listening to a baby’s brain,” says Robert W. Block, M.D., of Tulsa, Okla., the AAP’s immediate past president and a member of its executive committee. “Mental health is brain health. And brain disease is no different than heart disease or lung disease. We need to identify problems when we can most easily address them.”

In 2012, the AAP published a policy statement on the role of the pediatrician in addressing toxic stress and now is creating detailed recommendations on how to implement prevention, screening, and treatment in clinical practice.

Prevention: Getting It ‘Right the First Time’

Pediatricians routinely advise parents of young children on a wide range of issues, from physical development to sleep to seat belts. The AAP now wants pediatricians to add advice on what children need socially and emotionally—and what they need to be protected from—to support their development.

“We’re trying to emphasize that much more important than just listening to a baby’s heart is listening to a baby’s brain.”

Robert W. Block, M.D.

Andrew S. Garner, M.D., Ph.D., who chairs the AAP’s Early Brain and Child Development Leadership Work Group, and colleagues are drafting a framework to guide pediatricians to help parents “get things right the first time” when it comes to children’s social, emotional, and behavioral health.

Garner, who also practices primary care pediatrics in suburban Ohio, has piloted a parent education program called “Purposeful Parenting.” (The six “Ps” are purposeful, protective, personal, progressive, positive, and playful.) In this program, pediatricians review basic information about social and emotional development at their periodic visits with parents of a new baby for up to three years. They also help parents learn how to respond effectively to typical behavior and problem behavior at each stage.

Purposeful Parenting materials, for example, emphasize “face time” with infants, a type of “serve and return” interaction fundamental to the wiring of the brain: When an infant smiles, the caregiver should smile back—and should do so repeatedly throughout the day. When infants learn early on that smiling, then cooing, then words, are the best way to get attention, they keep using those strategies. But if face time fails to occur frequently enough, infants may learn less healthy ways—such as crying or whining—to get the attention or support they crave. The lack of something as simple as face time can lead to more infant stress and less healthy ways to cope with stress in the future.

“We want to empower primary care doctors to talk about parenting skills before things go awry,” says Garner.

Screening: Identifying Kids at Risk

Screening children for risk of toxic stress is complicated scientifically, logistically, and financially. But it is also absolutely imperative, says AAP member Carol Cohen Weitzman, M.D., director of developmental behavioral pediatrics at Yale School of Medicine.

“The science is pretty compelling, and it’s pretty clear,” Weitzman says. “So there needs to be this bridge between what we know and what we do.”

Weitzman and colleagues are drafting a blueprint for that bridge. They are coming up with recommendations for how pediatricians can implement standardized measures to identify family or community-level factors that put children at risk of toxic stress, such as maternal depression, parent or community violence, and food scarcity.

Children would be screened for signs of social or emotional deficits, such as behavioral outbursts or social withdrawal when pediatricians already look for developmental delays, such as poor speech or motor skills. Pediatricians may also ask parents to fill out questionnaires about subjects such as alcohol use or food insecurity.

In order to make these changes, Weitzman says, pediatricians will need broad systemic changes to support them, including better medical training, payment systems, treatment options, and help to coordinate care.

Treatment: Therapy for the Scars of Toxic Stress

Specialized early interventions to target the causes of early adversity and protect children from the consequences of toxic stress are critical to achieving the best outcomes, says AAP member Mary Margaret Gleason, M.D., of Tulane University School of Medicine. Gleason, who is both a pediatrician and a child psychiatrist, and her colleagues are working on AAP recommendations about treatment options and coordinating care.

Fortunately, Gleason says, there is significant evidence that certain kinds of treatments can help. Parent-Child Interaction Therapy, for example, has been shown to decrease disruptive behaviors in children, helping parents develop skills that promote positive behavior and increase positive parent-child interactions. Another treatment, Child-Parent Psychotherapy, has been shown to be particularly effective in treating young children who have experienced a traumatic event, such as maltreatment, sexual abuse, or the death of someone close to them.

Unfortunately, many families face great difficulty finding treatment, in part because too few professionals are trained to provide evidence-based therapy to young children. Families face many other barriers as well: cost, transportation, time off from work to participate, and sticking with something that can be extremely difficult emotionally. “We have really strong evidence that we can intervene effectively,” Gleason says, “but most children don’t have access to these treatments.”

When multiple types of treatments are needed, coordinating the care generally falls to the primary care pediatricians. They make referrals to mental-health providers, ensure that appointments are scheduled and attended, and provide motivational support to keep going. Ultimately, pediatric leaders would like their efforts to lead to true integration of children’s physical care with their social, emotional, and behavioral care, including the well-being of the whole family over time.

“I am so hopeful that looking at behavioral and emotional functioning and problems in kids will be a fundamental part of routine pediatric care—not extra, not less important than the physical exam, but an integral part of what it means to provide pediatric care,” Weitzman says. “These are steps moving us toward a different configuration of what pediatrics is. It’s very slow, but it’s exciting.”

View more articles from the Tackling Toxic Stress series

Article written by Carol Gerwin, a freelance writer and editor specializing in education and child development, who is based in Newton, Mass.

Published: May 30, 2013

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