As a medical student, I was just beginning to understand all the beeping machines surrounding my patient’s crib in the Pediatric Intensive Care Unit. My attending physician, a pediatric neurologist who also happened to be my father, methodically demonstrated the neurological deficits in a 9 month old with shaken baby syndrome and traumatic brain damage due to child abuse. Another physician, a pediatric intensivist, prepared to intubate her as she struggled to breathe on her own.
This was one of my first experiences with child abuse, and I asked myself “how in the world could someone do this to their own child?” Over the years, with experience, reflection and study coupled with the invaluable perspective that comes from raising four children of my own, I’ve come to believe exactly how it happens. Another memory from a different case is seared into my brain: an immigrant father, tortured by his conscience, breaks down with a tearful confession in broken English. “I was so stressed!” he repeated, over and over.
Those experiences are part of why I am a strong believer in a “biopsychosocial” approach to practicing medicine. In past years, medicine had traditionally taken a strictly biomedical view of health, concerned with just the pure machinery of the body- the functioning of organs, cells and tissues, etc. But in modern times we have begun to explore how behaviors, socioeconomic standing, culture, community and mental health each play into those physical processes that drive the development of good or poor health.
This is relevant to understanding both how a child’s environment affects their health and also how stress in parents’ environment affects the environment they are able to create for their children. Parents may be surprised when we take what they see as an “expanded role” when as pediatricians, we strive to look at the whole child.
We’ve learned about how “social determinants of health” such as a child’s family life, socioeconomic status, mental health, connected-ness with their community, and the presence or absence of social problems, actually go a long way to determine a child’s mental and physical health. Watch this really good brief introduction video to social determinants of health.
We learned a lot of this from the landmark ACEs study, which looked at children who experienced so-called “adverse childhood events” or ACEs during the first three years of life (such as food or housing insecurity, parental stress, mental illness, or drug use, or domestic violence as well as abuse or neglect). These children were not only more likely to have mental health problems later in life, but were also much more likely to have physical health problems, including heart disease, obesity, autoimmune disorders and diabetes. Watch this short video primer explaining the ACE study. In other words, many mental and physical health problems in adults can be traced back to the presence of adverse events or conditions in children’s early lives. The more ACEs a child experienced their first three years, the higher their risk became of health problems the rest of their life.
Furthermore, ACEs are intergenerational- children who experience ACEs are more likely to have parents who experienced ACEs themselves during early childhood. If we were able to prevent ACEs from happening where we can, and help children and families learn resilience and coping where we can’t, we could not only prevent child abuse, but also prevent a lot of health problems. This could help break the cycle of intergenerational poverty.
It’s important to point out here that ACEs occur throughout all socioeconomic strata and demographics. On a less severe scale, even mild or moderate stressors, like financial difficulties, busy schedules, parental conflict, and mental health challenges in parents, can be associated with developmental delays and behavior problems in children, especially when they are very young. I see this in my practice frequently. In fact, up to 2/3 of children in this study had ACEs occur during their childhood.
COVID-19 has brought these issues to the forefront. The pandemic is not just a biomedical problem, it is a psychosocial pandemic as well. Utah has seen an increase in domestic violence calls to police. Many teenaged and school aged kids are struggling with worsening anxiety and depression. Some locations are reporting spikes in child abuse while others are seeing reports plummet (which in some ways is even more worrisome- see info on what we can all do to protect children). Substance abuse problems often spike during catastrophes due to stress but also increase a person’s COVID19 risk. These all have ramifications for children’s health.
However, it would still be unwise to do nothing to protect ourselves and others from COVID-19. These things all remind us how socioeconomic health is closely linked to physical health, and vice versa. Our task is not to figure out how to choose one or the other, but to find ways to support both.
The truth is that this COVID19 pandemic did not cause this psychosocial pandemic. It has only exacerbated it. It has always been there. COVID19 has shown us the fault lines in our psychosocial landscape. The pandemic has disproportionately affected minority communities whose members have up to 2.4x higher risk of dying from COVID19 than whites. These communities have lived with persistent racial disparities in health outcomes and the constant stress of systemic racism for generations. This is also true of the Latino community. The pandemic has disproportionately affected the poor, regardless of ethnicity, who were on a less stable socioeconomic standing to begin with, who live in higher density housing and have fewer resources to draw from during difficult times. And even though it’s hardly getting them sick or killing them, COVID-19 will continue to affect children through this on-going psychosocial pandemic.
As a pediatrician, an important part of my job (now more than ever) has always been to find out if adverse childhood events (ACEs) are happening or at risk of happening in my patients’ lives and to support families in making their environment healthier and safer.
This is an important part of our work during well checks– we have started using a short screening questionnaire called the “SEEK screen” (Safe Environment for Every Kid) to ask about how families are doing at home: How is their child’s and parents’ mental health? Are parents stressed out? Do they have adequate food? Do they need help with housing? Do they feel safe in their neighborhood? Is there conflict within their home? Parents can answer how they feel comfortable answering. But asking is the first step towards an open, nonjudgmental conversation. Having that conversation helps us support families by helping them connect with community resources. We hope to brainstorm with parents how to support their children’s development and emotional health. Studies show that having these conversations actually does prevent child abuse, neglect and other ACEs!
Community resources, supported by local and national governments, are essential to help with this- such as early intervention services through Root for Kids (who provide developmental assessments and services for free in families’ homes), the Family Support Center, (emergency and respite child care, parenting support and counseling), the Dove Center (assistance with domestic violence including counseling), Switchpoint (assistance and counseling for homeless families or families at risk of homelessness), Utah Food Bank, etc. I point families toward 211utah.org or the Utah 211 app in the Google Play store or Apple App Store to access information on resources. They can email, text, call, or chat with a human who will guide them to the appropriate resource for their needs. Other resouces for older children and teens include youthfuturesutah.org and encircletogether.org.
Every such conversation we have is also one step forward in educating and improving our community. By writing this blog post, I’m hoping to bring greater awareness to this psychosocial pandemic going on all around us and its implications for the health of our society as a whole.
I strongly believe in the words of a prominent faith leader who recently said, “When we have conquered [COVID19] — and we will — may we be equally committed to freeing the world from the virus of hunger and freeing neighborhoods and nations from the virus of poverty. May we hope for schools where students are taught — not terrified they will be shot —and for the gift of personal dignity for every child of God, unmarred by any form of racial, ethnic or religious prejudice.”
Maybe one silver lining of the COVID-19 pandemic and all its ramifications will be a greater awareness and altruism among us where there were less before.