Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
Me? Address social determinants of health? How?
When I heard the American Academy of Pediatrics call for pediatricians to address poverty and social determinants of health, I – and maybe you, too – thought, “Great idea. But how am I, as a practicing pediatrician, supposed to help with such overwhelming and socially determined factors?”
It seems that the best way to reduce poverty, homelessness, and inadequate education is to advocate and vote to maintain or expand proven social programs. But there are also more proximal “relational” (relationship) factors we can address. The Adverse Childhood Experiences (ACE) study showed that the number of ACEs reported in their pasts by adults has a nearly linear relationship to long-term morbidities, including suicide, depression, obesity, smoking, substance abuse, heart disease, and early death. The ACE events during childhood – besides lack of food – came from the child’s relationships: abuse (emotional, physical, or sexual) and family dysfunction (mother abused; loss of a caregiver through divorce, separation, or death; household members with alcohol or substance abuse, mental illness, or time in prison).
The most important step you can take to prevent your patients from ACEs is detection. You have to ask parents, either verbally or with a screening tool about current factors that could be harmful to the child. You may think, “My patients don’t have these problems,” but abuse, intimate partner violence (IPV), depression, substance use, and loss occur in families of all kinds and means. Even the presence of food insecurity and imprisonment in some of my “put together” families has surprised me.
There are a number of tools available to screen for individual factors such as parental depression (Edinburgh Postnatal Screening, Patient Health Questionnaire-2 and -4), IPV, substance use (CRAFFT, which stands for Car, Relax, Alone, Forget, Friends, Trouble), and food insecurity. Tools covering multiple risk factors also are available on paper (Safe Environment for Every Kid [SEEK], Survey of Well-being of Young Children [SWYC]) or online (CHADIS). Rather than being overly intrusive, parents report accepting these questions as representing your caring about them as well as their child.
Coverage for screening and counseling for depression and IPV is mandated by the Affordable Care Act. As of July 2016, screening for maternal depression by pediatricians is paid for by Medicaid and many other insurers, often as part of the well-child visit, according to the Center for Medicaid and CHIP Services’ Informational Bulletin of May 11, 2016. For patient-centered medical homes, there is a mandate for referral and care coordination (AHRQ Publication No.11-M005-EF, December 2010). New value-based payment mechanisms are likely to pay you based on such screening and referral processes (e.g. New York), so we had best prepare (“Value-Based Payment Models for Medicaid Child Health Services,” Report to the Schuyler Center for Analysis and Advocacy and the United Hospital Fund, July 13, 2016).
But what to do when the screen or questions reveal a problem? Your first impulse is likely to be to refer. But unlike referrals for a physical health issue such as severe anemia for which the parent calls the hematologist immediately, in the case of these touchy, embarrassing, or emotionally charged problems, accepting help may not be so easy. It may be the financially critical partner who is the substance user or the mother herself who is too depressed to move towards help. For problems such as lack of food or the need to get a GED (general education development), the referral may be successful by supplying phone numbers. Referrals for IPV, one of the most common (greater than 29%) and damaging ACEs to the child, who is exposed to violence and often abused, have been found to mainly fail from simply making a referral.
Just as for a positive blood screen, for a referral to be effective more information is needed. In the case of a family stressor, you need to find out the nature and extent of the problem, the immediacy of the danger, and what has been done so far to reduce it. Research now shows that the most effective way to collect this information is using motivational interviewing (MI) techniques that nonjudgmentally determine not just the facts, but engage parents in weighing the pros and cons of changing the status quo, their readiness to change, the types of interventions that might be acceptable, and what would tell them that it was time to act. When using MI, you are actually doing more than making a referral, you are beginning to address the problem you uncovered.
The MI process strengthens the trust in your relationship with the parent, starting with reflecting on the issue (“It sounds as though you don’t always feel safe at home”), empathizing (“That must be really scary. I am sorry you are going through that”), and assessing (“May I try to help you with this?”).
After collecting the pros and cons for making a change, either in the interview or via the screening tool SEEK Plus in CHADIS, your job is to help the parent weigh them (“On the one hand you love him and need his income, but on the other hand you are so afraid that you can’t sleep and your children are too nervous to concentrate in school.”) Then you need to elicit what would be enough to move them (“How will you know when it is time to act?”) and to assess readiness to change (“What kinds of help would you be open to?”), then offer that kind of help (“I would like to connect you to a professional who has a lot of experience helping people in your situation. Is it okay if we call her right now?”). Provide written contact information, of course, but actually assisting by calling the appropriate resource or even doing a “warm handoff” in person is more effective.
Obviously, to make an effective referral, we need resources assembled in advance for the most common issues. UnitedWay.org is a good place to include on your list.
Our job, however, is not over with an “accepted” referral. Most referrals are not kept, help is never received, and risk to the child is not averted. There are many potential barriers to families’ accessing help – time off work, money, transportation, or child care – but difficulty generating the courage to change is understandable and may resolve only gradually with your work and support. It is wise to tell the parent that “I (or someone on your staff) will check in on how this goes, okay?”
Making a follow-up appointment with you is important, even if you feel helpless to do more than refer. Why? A return visit is a chance to show that you care, to be sure they went, and to get information on the quality and appropriateness of the care provided so you can support it or refer elsewhere. Perhaps most importantly, it shows that you do not reject them for revealing what they may see as personal failure or immoral behavior so that you can continue caring for and monitoring their at-risk child.
What if they decline help, no resources are to be found, or the damage has already occurred? You still have valuable help to provide. Our goal is to ameliorate the impact of the stressors on the child now and in the future. Just as relational factors can stress the child, improving supportive relationships is key to reducing their effects. Parents with ACE risk factors are often self-absorbed in their pain, using smoking, substances, or alcohol to dampen it and moving from one troubled relationship to another in response to past trauma; thus they are emotionally unavailable to the child.
You can help them by focusing on the wonders of their child, encouraging daily individual time for play, and modeling Reach Out and Read as a supportive, calm activity they can do even when stressed. You can encourage the practice of mindfulness – an exercise of letting thoughts pass over them without judgment while breathing rhythmically – for stressed parents and school-aged children. It has been shown to be an effective intervention for recovering from past as well as current stress. Children also should receive any needed mental health care.
An emotionally available, supportive, nurturing parent is the most important protective factor for the child’s development of emotion regulation, resilience, and the ability to cope with adversity throughout their life. Referring parents to services such as home visiting, Healthy Steps, or parent-child therapy to build these skills has evidence for improving relational health. Helping the parents avoid ACEs for their children and assisting them in ameliorating them, if they occur, are important investments in long-term health that you can provide.
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical
Communications. E-mail her at email@example.com.