Screening and intervention for childhood stressors

A PHS student came across a compelling article in the Washington Post describing the importance of addressing the link between early childhood adversity and later outcomes by mitigating stress and trauma.  The success of these interventions seems to rely on effective screening — which takes time and resources from already resource-strapped primary care practices. They write:

Preventive medicine is definitely a front-runner when it comes to promoting public health and minimizing the effects of chronic diseases. This article reviews the proactive screening process, pediatrician, Nadine Burke Harris, uses in order to reduce the long term influence of traumatic childhood experiences. Furthermore, these events, e.g. physical abuse, neglect, living with a family member addicted to drugs or alcohol, ultimately, induce chronic stress at a young age, which has disparate health outcomes, not only as a child, but also as an adult. Harris identifies these stressors and connects patients to interdisciplinary programs aiming to curtail childhood exposure to stress. It is promising that a simple, although time consuming, measure such as screening can be implemented to facilitate a healthier future and higher quality of life.


8 thoughts on “Screening and intervention for childhood stressors

  1. This is a great example of health care diving into the socioecological determinants of health. Throughout this course, and others, we’ve learned that it really should be part of a pediatrician’s job to address stress and trauma–which can lead to life long health consequences.

    In light of articles we’ve been reading about improving health care quality, I wonder what kind of health care system and reimbursement system Harris works under (she has her own clinic, but does she have complete autonomy over the kind of care she gives?). The health effects of her screening and interventions will probably appear years from now, and they might be very difficult to measure. Is she indeed one pioneering woman, showing us a new and better way to address children’s (and adults’) health despite reimbursement and pay schemes that do not encourage that very thing, or is she supported by some new health care reimbursement or quality-improvement scheme that makes addressing the social determinants of health both right and easy? Knowing this would be important to scaling this kind of model up and making a difference for more children and families.


  2. I am extremely impressed that Dr. Harris was able to create an entirely new clinic for individuals with a social history of trauma. Specialization of care centers is an excellent way to ensure that the patients that need extensive mental health treatment receive the care they need, while not overburdening the primary care clinic that has to treat a high volume of patients. One of the problems that the article brought up was the sustainability of the model – the ability for primary care providers to administer this screening at the beginning of every care visit.

    I completely understand why there could be hesitance to adopt this screening across already overburdened primary care facilities, particularly in high-need communities. One model that I’ve seen being promoted throughout my time in the healthcare tech industry is screening tools in the clinical waiting room. If we could supply clinics in low-income or high-risk communities with tablets to fill out while patients are in the waiting room that screen for a variety of social determinants and factors, we could take that information to ensure that the patient is referred to a clinic where they could receive the best care, whether that be a combination behavioural health/primary care facility, a case manager to assist with social issues, or another innovative care model. This is a great way to reduce overall cost of care for individuals who may otherwise have frequent re-admittance and burden the healthcare system while at the same times improving public health outcomes – it’s a win-win.

    I also know (though I’m no expert) that the outcome-based payment model that is replacing fee-for-service includes a lot of incentives and grant money for clinics and hospitals that adopt innovative technology to address social determinants and healthcare inequity. The kind of deeper-level thinking about how to improve health for those at the highest risk that Dr. Harris is doing is exactly the kind of thing that healthcare reform is trying to encourage. Though there are certainly concerns, this is a very promising anecdote that I hope we continue to see more of in years to come.


  3. While this new clinic is great and touches on so many unmet needs, I’m curious about the perception the parents have when they receive a referral to this clinic. Do they feel angry? Guilty? Embarrassed? A variety of any of these things? Do these emotions keep them from helping their child get the care that they need? It’s being talked about more and more, but there is still a stigma associated with needing mental health services or social services. A child’s care is highly influenced by the parent as they are dependent on the parent for rides, billing, etc., and so there is a risk that an upset parent will prevent a child from utilizing these services. I’m sure this isn’t news to Dr. Harris’s clinic staff, but I’d love to know how they approach these issues or if anyone has any thoughts.


  4. This article was really interesting! It is so important to be able to ask these questions with parents to understand the background, rather than just focus on the symptoms and prescribe medicine. I really like the quote, “This is a culture shift. We’re here to support families.” Changing the norm, whether the norm for a provider or the norm of a parent, is a long process but a much needed process. The article talks about how difficult is is to get psychiatrists and other medical professionals to understand how important it is to prevent childhood adversity. If a provider isn’t used to asking questions about social problems, I would think that it would be hard to start and keep asking these hard questions, especially with the limited time they often have to see a patient. This article really shows how important it is to patients to feel like their physician is interested in their lives, rather than just the medical problem, which is something that I haven’t really thought about. Like Mandi, I wonder if some parents will feel offended when asked these questions, rather than relieved. Screening for ACEs has so much potential, but it comes with many challenges to implement the new process.


  5. I found this article quite relevant to Dr. Deborah Ehrenthal’s lecture on determinants of health across the life course and the fetal origins of adult disease hypothesis. Although Dr. Ehrenthal spoke about exposure to risk factors during gestation and the development of disease later in life, this article builds on that idea and suggests that trauma during infancy and early childhood can also lead to disease. I’m curious to know if Dr. Harris’s screening also includes risk factors during pregnancy. This information would be great to know as it could potentially lead to further support for Dr. Ehrenthal’s research.
    What I also found extremely interesting was how this article essentially was about public health in practice. Two of the three core functions of public health (assessment and assurance) were executed and I’m sure that as we learn more about stress and its effects on child development, policy developments will occur (if not already).
    Although not explicitly mentioned, the idea of epigenetics was also implied within the article. Such screenings could provide great insight into this field and provide further evidence of cross-generational stress effects. Being that Dr. Harris serves low-income minority communities, it won’t be surprising to see such associations.
    A side note- I wish I knew had known more about this topic four years ago when I was involved in a Community Asthma Coalition in NYC. We focused more primary care access for asthmatic children rather than these other contextual factors. Dr. Harris’s screening method would definitely benefit the large Dominican community in the Washington Heights Inwood neighborhood.


  6. This article is a really great case study in integrating the social determinants of health into clinical care on the part of a physician. During this class, we heard first had that childhood trauma and the accumulation of stress from birth and throughout the life course has a significant impact on a child’s health outcomes, making this screening technique and community resource center created by Doctor Harris an invaluable intervention to improve the health of her community.

    I’m really interest to see data from this clinic and the community in ten years. The resources center she created to be paired with mindfulness practice, stress reduction, and mental health, is one step in the ladder of creating change for children and families, but I’m curious as to how measurable outcomes data from that center could be used to create policy level change for this community in terms of the expansion of mindfulness based practice in schools or more funding being directed to mental health and social workers if the health outcomes for many of these children improve. My fear is that without those things happening in tandem – changes in care and changes in policy to compliment one another – the changes seen in health may not be sustainable or even present from the onset of the new clinic. The funding and support she is amassing is tremendous, but I am curious as to how the clinic may be leveraging it’s outcomes to create long lasting policy change in how the mental health of children is connected to their environment and adverse life events from birth onward.


  7. I think Dr. Nadine Burke Harris’s work is incredible – it seems so obvious in today’s day and age that chronic stress would lead to bad health outcomes. However, I think one point in the article is particularly important to discuss: “childhood adversity is prevalent nationwide. Respondents for the original ACES study were middle or upper-class, and nearly three quarters had college degrees; 69 percent were white.”

    This quote comes towards the end of the article and is barely discussed, but I think it should be. Yes, when pediatric practitioners screen for adverse childhood experiences they are likely to understand their patients better and hopefully treat them more effectively. However, it seems to me that ALL pediatric patients should be screened for ACEs given the prevalence of stressful situations across the entire population. This is not to say that those in lower SES are just as badly off as those in higher SES. Of course this is not always the case – those in lower SES are more likely to have a higher volume of stressful experiences and do not typically have access to resources that can help offset the negative impacts of stressful experiences. But what if stress could be prevented and/or treated earlier on in life overall? Would that help reduce some of the negative impacts seen later in life, such as chronic disease rates? If so, shouldn’t everyone be treated as if they likely experience stress and should be screened to see if there is anything a medical professional could do to help?

    All that being said, I think we are now at the point where more qualitative studies need to be added into this data. We need to more clearly determine whether or not stressors, whether they stem from not having enough food to pressure from the boss, do have the same physiological impact on individuals from many different walks of life. Does a stressor an individual experiences going to cause the same bodily reaction as a stressor a different individual experiences? In other words, do we have enough information to support the conclusion that stress is a relative experience that can and does have the same physiological effect on individuals as long as the individual labels the experience as “stressful”? If this is the case, it would be strong evidence that screening any and all pediatric patients for ACEs should be the best standard of care.


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