Marian F. Earls

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.

Clinical Report—Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice

Every year, more than 400 000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pediatric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.

Setting the Stage for Success: Implementation of Developmental and Behavioral Screening and Surveillance in Primary Care Practice—The North Carolina Assuring Better Child Health and Development (ABCD) Project

Early identification of children with developmental and behavioral delays is important in primary care practice, and well-child visits provide an ideal opportunity to engage parents and perform periodic screening. Integration of this activity into office process and flow is necessary for making screening a routine and consistent part of primary care practice. In the North Carolina Assuring Better Child Health and Development Project, careful attention to and training for office process has resulted in a significant increase in screening rates to >70% of the designated well-child visits. The data from the project prompted a change in Medicaid policy, and screening is now statewide in primary practices that perform Early Periodic Screening, Diagnosis, and Treatment examinations. Although there are features of the project that are unique to North Carolina, there are also elements that are transferable to any practice or state interested in integrating child development services into the medical home. Included here are lessons learned and a listing of practical tools for implementation.

Literacy promotion: An essential component of primary care pediatric practice

Reading regularly with young children stimulates optimal patterns of brain development and strengthens parent-child relationships at a critical time in child development, which, in turn, builds language, literacy, and social-emotional skills that last a lifetime. Pediatric providers have a unique opportunity to encourage parents to engage in this important and enjoyable activity with their children beginning in infancy. Research has revealed that parents listen and children learn as a result of literacy promotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary care practice. The American Academy of Pediatrics (AAP) recommends that pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry by (1) advising all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills; (2) counseling all parents about developmentally appropriate shared-reading activities that are enjoyable for children and their parents and offer language-rich exposure to books, pictures, and the written word; (3) providing developmentally appropriate books given at health supervision visits for all high-risk, low-income young children; (4) using a robust spectrum of options to support and promote these efforts; and (5) partnering with other child advocates to influence national messaging and policies that support and promote these key early shared-reading experiences. The AAP supports federal and state funding for children’s books to be provided at pediatric health supervision visits to children at high risk living at or near the poverty threshold and the integration of literacy promotion, an essential component of pediatric primary care, into pediatric resident education. This policy statement is supported by the AAP technical report “School Readiness” and supports the AAP policy statement “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.”

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.

The pediatrician's role in optimizing school readiness

School readiness includes not only the early academic skills of children but also their physical health, language skills, social and emotional development, motivation to learn, creativity, and general knowledge. Families and communities play a critical role in ensuring children’s growth in all of these areas and thus their readiness for school. Schools must be prepared to teach all children when they reach the age of school entry, regardless of their degree of readiness. Research on early brain development emphasizes the effects of early experiences, relationships, and emotions on creating and reinforcing the neural connections that are the basis for learning. Pediatricians, by the nature of their relationships with families and children, may significantly influence school readiness. Pediatricians have a primary role in ensuring children’s physical health through the provision of preventive care, treatment of illness, screening for sensory deficits, and monitoring nutrition and growth. They can promote and monitor the social-emotional development of children by providing anticipatory guidance on development and behavior, by encouraging positive parenting practices, by modeling reciprocal and respectful communication with adults and children, by identifying and addressing psychosocial risk factors, and by providing community-based resources and referrals when warranted. Cognitive and language skills are fostered through timely identification of developmental problems and appropriate referrals for services, including early intervention and special education services; guidance regarding safe and stimulating early education and child care programs; and promotion of early literacy by encouraging language-rich activities such as reading together, telling stories, and playing games. Pediatricians are also well positioned to advocate not only for children’s access to health care but also for high-quality early childhood education and evidence-based family supports such as home visits, which help provide a foundation for optimal learning.

Integrating Mental and Physical Health Services Using a Socio-Emotional Trauma Lens ☆

This article provides a synthesis of the lessons learned from the Pediatric Integrated Care Collaborative (PICC), a SAMHSA-funded project that is part of the National Child Traumatic Stress Network. The high prevalence of trauma exposure in childhood and shortage of mental health services has informed efforts to integrate mental and behavioral health services in pediatric primary care. This article outlines strategies to integrate care following the six goals of the PICC change framework: create a trauma/mental health informed office; involve families in program development; collaborate and coordinate with mental health services; promote resilience and prevent mental health problems through a particular focus on trauma-related risks; assess trauma-related somatic and mental health issues; and address trauma-related somatic and mental heath issues. We conclude with a summary of key strategies that any practice or practitioner could employ to begin or continue the process of integration.