Benjamin Siegel

Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health

Advances in a wide range of biological, behavioral, and social sciences are expanding our understanding of how early environmental influences (the ecology) and genetic predispositions (the biologic program) affect learning capacities, adaptive behaviors, lifelong physical and mental health, and adult productivity. A supporting technical report from the American Academy of Pediatrics (AAP) presents an integrated ecobiodevelopmental framework to assist in translating these dramatic advances in developmental science into improved health across the life span. Pediatricians are now armed with new information about the adverse effects of toxic stress on brain development, as well as a deeper understanding of the early life origins of many adult diseases. As trusted authorities in child health and development, pediatric providers must now complement the early identification of developmental concerns with a greater focus on those interventions and community investments that reduce external threats to healthy brain growth. To this end, AAP endorses a developing leadership role for the entire pediatric community—one that mobilizes the scientific expertise of both basic and clinical researchers, the family-centered care of the pediatric medical home, and the public influence of AAP and its state chapters—to catalyze fundamental change in early childhood policy and services. AAP is committed to leveraging science to inform the development of innovative strategies to reduce the precipitants of toxic stress in young children and to mitigate their negative effects on the course of development and health across the life span.

Promoting Optimal Development: Screening for Behavioral and Emotional Problems

By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems.

Integration strategies for using virtual patients in clinical clerkships.

Purpose To explore students’ perceptions of virtual patient use in the clinical clerkship and develop a framework to evaluate effects of different integration strategies on students’ satisfaction and perceptions of learning effectiveness with this innovation. Method A prospective, multiinstitutional study was conducted at six schools’ pediatric clerkships to assess the impact of integrating Web-based virtual patient cases on students’ perceptions of their learning during 2004–2005 and 2005–2006. Integration strategies were designed to meet the needs of each school, and integration was scored for components of virtual patient use and elimination of other teaching methodologies. A student survey was developed, validated, and administered at the end of the clerkship to 611 students. Data were analyzed using confirmatory factor analysis and structural equation modeling. Results A total of 545 students (89%) completed the survey. Overall student satisfaction with the virtual patients was high; students reported that they were more effective than traditional methods. The structural model demonstrated that elimination of other teaching methodologies was directly associated with perceived effectiveness of the integration strategies. A higher use score had a significant negative effect on perceived integration, but a positive effect on perceived knowledge and skills gain. Students’ positive perceptions of integration directly affected their satisfaction and perception of the effectiveness of their learning. Conclusions Integration strategies balancing the use of virtual patients with elimination of some other requirements were significantly associated with students’ satisfaction and their perceptions of improved knowledge and skills.

Enriching Personal and Professional Development: The Experience of a Support Group for Interns.

A pilot support group for interns was established at Boston City Hospital early in the internship year to deal with the personal and professional issues arising out of the stresses of the internship. This report describes the functioning of this group, including a statement of goals, content of weekly meetings, and evaluation by group members. In general, the interns felt that the experience was positive and especially valuable in terms of providing support for personal/professional role conflict.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Health and Mental Health Needs of Children in US Military Families

The wars in Afghanistan and Iraq have been challenging for US uniformed service families and their children. Almost 60% of US service members have family responsibilities. Approximately 2.3 million active duty, National Guard, and Reserve service members have been deployed since the beginning of the wars in Afghanistan and Iraq (2001 and 2003, respectively), and almost half have deployed more than once, some for up to 18 months’ duration. Up to 2 million US children have been exposed to a wartime deployment of a loved one in the past 10 years. Many service members have returned from combat deployments with symptoms of posttraumatic stress disorder, depression, anxiety, substance abuse, and traumatic brain injury. The mental health and well-being of spouses, significant others, children (and their friends), and extended family members of deployed service members continues to be significantly challenged by the experiences of wartime deployment as well as by combat mortality and morbidity. The medical system of the Department of Defense provides health and mental health services for active duty service members and their families as well as activated National Guard and Reserve service members and their families. In addition to military pediatricians and civilian pediatricians employed by military treatment facilities, nonmilitary general pediatricians care for >50% of children and family members before, during, and after wartime deployments. This clinical report is for all pediatricians, both active duty and civilian, to aid in caring for children whose loved ones have been, are, or will be deployed.

Communication and the Medical Interview: Strategies for Learning and Teaching

The broad goal of this article is to direct clinician-educators to ways to improve their knowledge about medical interviewing and their communication skills, as well as to note ideas and resources for teaching in this area. Our specific objectives are to outline the knowledge base, specific skills, and attitudes and values relevant to effective communication in the context of the clinical interview, and to suggest strategies and resources that can be used by clinician-educators to learn and teach them. The article is not intended to be a critical review of the literature on communication and interviewing, nor is it an in-depth discussion of the knowledge base and skills to be learned. For these we refer the reader to specific references, texts, and other resources. This article will provide a summary road atlas to the broad field of communication and medical interviewing; cited literature and suggested learning resources will provide local detail maps for readers who are interested in more in-depth treatments of specific areas. Why should clinician-educators be interested in communication and interviewing? Effective communication in clinical settings increases the likelihood that (1) the information gathered from patients to make diagnostic assessments is accurate and reliable; (2) patients recognize that the physician is genuinely interested in them and their care; (3) physicians and patients reach common ground on diagnosis and treatment; and (4) patients are motivated to play an active role in their own care.1,2 In this way, the interview determines the accuracy of the diagnostic assessment as well as the quality of the doctor-patient relationship, thereby affecting the entire diagnostic-therapeutic process. In short, better communication leads to better diagnosis and treatment. Better communication leads to better outcomes. Research has documented that communication during the interview is positively related to specific illness outcomes,3,4 as well as to satisfaction among patients5,7 and physicians.8 On the other hand, poor communication has been related to such adverse events as malpractice suits9,10 and patient decisions to leave practices or health care organizations.11 In the clinical setting, most physicians and their patients benefit from high-quality, effective communication skills. Clinician educators will find it especially valuable to improve their communication skills, as strong skills will also bring important benefits in the educational and academic settings in which they work. In the educational setting, effective teaching and learning depend greatly on the exchange of information and quality of the relationship between students and teachers.12,13 Skills that promote effective communication in the clinical setting are also effective in the educational setting. Clinician-educators are in a unique position to use this overlap of skills. It is often possible to model specific communication skills for students during teaching sessions, then explicitly point out their parallel use with patients. This can result in powerful experiential learning. Students who directly experience effective communication (e.g., through the teachers expressions of empathy or partnership, or encouragement of active participation and autonomy) may be more likely to use those skills with their patients. The benefits of effective communication also extend to academic life. As clinician-educators interact with peers and superiors in the academic environment, they benefit from their own communication skills such as attentive listening, empathy, negotiation, and limit setting. Again, what is learned in one setting can be appropriately applied to others. Continuing mentoring and reflection will facilitate this transfer of skills among clinical, educational, and academic settings. Some have argued that being an effective communicator is part of the “art” of medicine, implying that the ability to communicate is a natural talent with which one is or is not born.14 We disagree. Communication skills are specific and observable, and can be evaluated objectively. There is ample evidence that continuing education programs designed for physicians in practice improve skills,15 18 and research with medical students has shown that the benefits from training persist years after the course has been completed.19 Knowledge and skills associated with effective communication and interviewing can be improved through practice, using the strategies and resources we outline in this article.

Implementation issues in generalist education.

Devising a strategy for the implementation of a generalist medical educational program can be aided by grouping the many issues to be addressed into developmental stages. In this way, problems can be anticipated and resources marshalled. Initially, leadership and institutional support for the program must be developed. Next, detailed financial, curricular, and site planning must be undertaken. Implementation of the program must contend with faculty, site, and trainee concerns while consolidating financial and institutional support. Finally, in institutionalizing the program, financing must be secured and ongoing evaluation should provide information necessary to regularly reassess the program and renew its goals.

‘Self-Help which Ennobles a Nation’: Development, citizenship, and the obligations of eating in India's austerity years

In the years immediately following independence, Indias political leadership, assisted by a network of civic organizations, sought to transform what, how, and how much Indians ate. These campaigns, this article argues, embodied a broader post-colonial project to reimagine the terms of citizenship and development in a new nation facing enduring scarcity. Drawing upon wartime antecedent, global ideologies of population and land management, and an ethos of austerity imbued with the power to actualize economic self-reliance, the new state urged its citizens to give up rice and wheat, whose imports sapped the nation of the foreign currency needed for industrial development. In place of these staples, Indias new citizens were asked to adopt ‘substitute’ and ‘subsidiary’ foods—including bananas, groundnuts, tapioca, yams, beets, and carrots—and give up a meal or more each week to conserve Indias scant grain reserves. And as Indian planners awaited the possibility of fundamental agricultural advance and agrarian reform, they looked to food technology and the promise of ‘artificial rice’ as a means of making up for Indias perennial food deficit. Indias women, as anchors of the household—and therefore, the nation—were tasked with facilitating these dietary transformations, and were saddled with the blame when these modernist projects failed. Unable to marshal the resources needed to undertake fundamental agricultural reform, Indias planners placed greater faith in their ability to exercise authority over certain aspects of Indian citizenship itself, tying the remaking of practices and sentiments to the reconstruction of a self-reliant national economy.