The American Academy of Pediatrics(AAP), the major organization representing pediatricians in this country, has just issued an important policy statement: Early Childhood Adversity, Toxic Stress and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.
Citing a large body of evidence on the long-term effects of "toxic stress" in early childhood, on not only psychological health but physical health, they address the pediatrician's role in promoting first relationships that can be protective against the effect of this stress. They write:
In contrast to positive or tolerable stress, toxic stress is defined as the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships..toxic stress early in life plays a critical role by disrupting brain circuitry and other important regulatory systems in ways that continue to influence physiology, behavior, and health decades later.Much of the evidence they site comes from what is referred to as the ACES study. On ongoing study begun in 1995, it documents the close correlation between adverse childhood experiences, including abuse and neglect, parental mental illness, substance abuse and family discord, and long term health outcomes, not only in the form of mental illness but also chronic illnesses such as obesity, diabetes and heart disease. The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego.
It is the absence or insufficiency of protective relationships that reinforce healthy adaptations to stress, which, in the presence of significant adversity, leads to disruptive physiologic responses... that increase the risk of health- threatening behaviors and frank disease later in life.
Not to toot my own horn, but this is exactly what I have been writing about on my blog for the past two years and in my book Keeping Your Child in Mind.
For example, a post from March 20011, Early Relationships and Brain Development as the Core of Medical Practice describes an outstanding pediatric practice in California run by Dr. Nadine Burke, that incorporates the ACES study into the everyday care of children. I raise the issue of the emotionally challenging of this work for the doctor, who in the absence of a culture that values careful listening, may suffer from "burnout" taking in so many stories that often involve significant trauma. The beauty of Dr. Burke's program is not only that they take the time, but also that the culture of the practice supports collaborative care. Multidisciplinary team meetings give clinicians an opportunity to share not only ideas and insights, but also the burden of carrying these stories.
One place where the AAP policy falls short is in describing exactly what implementation would look like in a pediatric practice. This policy states
Because the essence of toxic stress is the absence of buffers needed to return the physiologic stress response to baseline, the primary prevention of its adverse consequences includes those aspects of routine anticipatory guidance that strengthen a family’s social supports, encourage a parent’s adoption of positive parenting techniques, and facilitate a child’s emerging social, emotional, and language skillsIt then goes on to list some programs. But what does the pediatrician actually do? The bottom line is taking the time to listen. As I write in my book
Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world.The new policy statement recognizes the potential value of the relationships between pediatricians and the families they care for.
High expectations are grounded in the public’s deep respect for pediatricians as trusted guardians of child health.As a culture we need to value the primary care clinician, not only in the form of payment equal to the more lucrative subspecialties, but in the form of recognizing the role of relationships in healing. It makes sense that if we are recognizing the importance of family relationships in preventing poor health outcomes, that we should recognize the importance of doctor-patient relationships in supporting these families.
When primary care clinicians take time to carefully listen to stressed parents, parents feel supported in their efforts to carefully listen to their children, thus promoting healthy development. In turn, our culture needs to support and value primary care clinicians ( and its not only pediatricians, the subject of this policy statement, but all those entrusted with primary care of children.) As the report wisely states:
Rather than continuing the current trend of “doing more with less,” as pediatricians take on a wide range of additional responsibilities, payment reforms should reflect the value of pediatricians’ time and knowledge, as well as the importance of a pediatrician-led medical home serving as a focal point for the reduction of toxic stress and for the support of child and family resiliency.
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