pediatric care of children in poverty

Introduction

About 43 percent of children in the United States grow up in poor or near poor families. Some groups are more at risk than others, including children of color, those in immigrant families and those whose mother is young and alone. Although urban poverty remains dense, suburban and rural poverty have grown faster than urban since the Great Recession of 2007 to 2008. Homelessness, hunger and hopelessness have all increased in frequency in the context of an economic recovery that left out many families and increased both the gap between rich and poor as well as inequality in health care access.

In the neighborhoods close to Dayton Children’s Hospital, estimates of child poverty exceed those of the nation and the state of Ohio. Almost half (48.2 percent) of children in the city of Dayton live at or below the federal poverty level compared to 27 percent in Montgomery County and 21.2 percent in all of Ohio. The rate is even worse for children under the age of 5. About 80 percent of children under 5 live in poverty and nearly one in five lives in deep poverty, defined as less than half of the federal poverty level. One out of four children in Montgomery County experienced food insecurity in 2014.

Poverty is strongly associated with poor health. Clinical health care (both access and quality) account for less than 20 percent in estimates of the drivers of health outcomes. Social, economic and environmental factors are the strongest drivers and are referred to as social determinants. Individual health behaviors add less than 30 percent to health outcomes and are strongly influenced by early childhood adversity, especially poverty.

Many factors beyond the control of pediatricians influence the health of children, perhaps most obviously structural racism and ethnic bias. However, awareness of the influence of social determinants on child health allows pediatricians the opportunity to design the delivery of health care to buffer the effects of early adversity and to improve the developmental trajectory of each child. Adapting the pediatric medical home to care for children in poverty may include the following six objectives:

1.            Build a medical home that blends family-centered and trauma-informed care.

2.            Apply two-generational interventions.

3.            Promote relational health in early childhood.

4.            Integrate behavioral health into primary care.

5.            Promote early childhood literacy.

6.            Engage community partners in a comprehensive early childhood system of care.

Build a Medical Home

Having a medical home reduces child health disparities by improving access to high-quality, comprehensive care. The medical home philosophy, first developed to promote care for children with special health care needs, involves combining the basic principles of family-centered care with trauma-informed policies and procedures. The American Academy of Pediatrics (AAP) 2012 policy outlined basic principles of family-centered care including respecting the experience of each child and family, sharing decisions, building on family strengths and providing formal support for identified needs. The advanced medical home includes robust care coordination services that respond to the results of universal screening for social determinants of health. Financial insecurity is the most common early childhood adversity reported in national surveys. The landmark ACE study, which associated adverse childhood events (ACEs) with life-long health outcomes, limited its scope to intrafamilial adversity, such as child abuse, neglect, parental mental illness and intimate partner violence.

More recent investigators have expanded the list of adversity to include community and other exposures, including poverty, violence, ethnic or racial bias, bullying, foster placement and medical stress. Because children in poverty are at greater risk than wealthier counterparts for both intra- and extra-familial adversity, enhanced family-centered medical homes include trauma-informed policies and procedures.

Trauma-informed care (TIC) in pediatric health systems follow organizing principles outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA). Trauma in this sense refers to events or a series of events that are experienced by an individual as physically or emotionally harmful and that have long-lasting adverse effects. In application of TIC, knowledge of the potential effects of exposure is incorporated into practice management, especially in the service of physical and emotional safety of children, families and providers. Recognizing and addressing symptoms of trauma in children and families may include formal screening for exposure as well as formalized strategies to link families to appropriate community services.

Both clinical and non-clinical staff are trained in TIC, including recognizing and addressing evidence of secondary trauma, compassion fatigue and burn-out in providers of care.

Screening for particular deprivations related to poverty has become routine for many pediatric practices. Food insecurity is a very reliable indicator for other specific problems such as housing, energy and overall financial insecurity. Food insecurity can be detected using the two question survey now known as the Hunger Vital Signs (Figure 3). In operation, practices can screen formally during the nurse’s assessment prior to the pediatric provider entering the room. A non-clinical staff member could be given the responsibility to keep a list of local resources, including food pantries and free meals, and link the family to community agencies at any point during the visit. As the practice becomes more confident about addressing social determinants of health (SDH), other linking needs can be included as agencies or community resources are identified. A good basic tool is provided on the AAP’s Face Poverty resource page.

Apply Two-Generational Strategies

DW Winnicott, a British pediatrician turned child psychiatrist from the first half of the 20th century, quipped that there is no such thing as a baby. By this he meant that care of babies cannot be removed from care of the mother-child dyad and, in fact, from the social milieu in which the child and mother are found. This insight has recently informed strategies that simultaneously address the needs of both parent and child, producing global effects on family functioning and financial stability.

The two-generational strategy that is most important to primary care is the management of maternal depression. Although pediatricians are rarely in a position that they can treat depressed mothers, many practices include adolescent mothers and maintain a doctor-patient relationship until the young adult is either emancipated or otherwise independent. Evidence-based management strategies for primary care are available and based on universal screening that promotes early detection, intervention and therapeutic referral for mothers who bring their newborns for routine care. Depression and poverty are multiplicative in that depression makes coping more difficult, and problems such as food insecurity and homelessness magnify stress and hopelessness. Maternal depression occurs in all socioeconomic levels, but mothers who are also experiencing poverty are more likely to have a major depressive episode and less likely than more wealthy peers to have access to or seek treatment.

There is some indication that the best outcomes are achieved when the child is included in therapy. Dyadic interventions such as Parent-Child Interaction Therapy (PCIT) address the reaction of the child to parenting impaired by depression. Other models combine cognitive-behavioral therapy for maternal depression and early childhood developmental stimulation both provided by home visitors. About 80 percent of people with depression improve with appropriate treatment, emphasizing the potential benefit of standardized screening and referral by pediatricians.

Promote Relational Health

Recurrent or persistent exposure to potentially traumatic experiences, in the absence of modifying or protective factors, has deleterious effects on brain architecture, neuro-endocrine function, immunologic balance, the capacity to form trusting relationships and adoption of healthy behaviors. These changes in psycho-neurophysiology are associated with life-long poor health and early death. The most important protective factor against long-term changes related to traumatic stress is a stable, safe relationship with a supportive and caring adult. Pediatricians, by applying principles embedded in the AAP’s Bright Futures and other evidence-based primary care strategies, have the opportunity to support protective factors and promote relational health in children and families during health supervision visits in early childhood.

One of the most accessible approaches to redesign of primary care is the Strengthening Families Framework (Figure 4) as presented by the Center for the Study of Social Policy. The five protective factors are parental resilience, knowledge of parenting and child development, social connections, concrete support in times of need and the socio-emotional competence of children. For example, a pediatrician might take advantage of the opportunity to improve the emotional connection between a parent and child by observing and verbally praising, during a health supervision visit, an effective serve-and-return interaction or by modeling calm limit setting in the exam room. The episode could be enriched by identification of appropriate developmental expectations, improving knowledge of child development and reducing the likelihood of punitive parenting resulting from unrealistic expectations for behavior.

Integrate Behavioral Health Services

Integrating behavioral health into primary care is a cost-effective, evidence-based strategy to provide comprehensive and family-centered care in the pediatric medical home. Primary care integration improves access to behavioral health services, recognizes that social and emotional heath is intertwined with physical health, addresses the shortage of mental health services for children and improves health outcomes by applying a comprehensive multi¬disciplinary treatment plan. An integrated model in a pediatric medical home adapted for children in poverty addresses other objectives of practice transformation including promotion of relational health in anticipatory guidance and application of two-generational interventions.

Universal screening for social-emotional health is essential for understanding of the health and development of children and families. Instruments such as the ASQ-SE, Strengths and Difficulties Questionnaire, M-CHAT-R, Screen for Child Anxiety Related Disorders (SCARED) and the CRAFFT substance abuse screen can supplement the recommended depression screens for adolescents and post-partum mothers.

Screening for exposure to potentially traumatic experiences risks re-traumatization but can be done safely with TIC principles in mind. Face to face surveillance may be a preferred option using a question such as "Has anything sad, bad or scary happened to you or your family since last time we met?" Screening should be universal in order to avoid potential stigmatization. A positive screen

should be considered a disclosure and must be met with compassion and understanding. Practices that screen regularly should have resources, both on-site and by referral, to address the emotions that sometimes accompany the disclosure. If a child reports one type of trauma, other types should be explored because one positive increases the chance of multiple or ongoing exposures. Re-screening should be avoided. Some basic elements of TIC are captured in the mnemonic DEF (Figure 5) and can be applied in any pediatric setting.

Behavioral health services are mandated in Federally Qualified Health Centers (FQHC) but, because of various administrative and funding obstacles, primary care offices may find full integration extremely difficult. Other models such as facilitated referral or collocation are possible alternatives. For instance, a pediatric practice may lease exam or family conference rooms to a local community mental health organization in order to approximate full integration. Other practices may adopt an evidence-based program with fidelity such as Triple P, Incredible Years or Video-Interaction Project (VIP). The Ohio chapter of the AAP offers a quality improvement program called Building Mental Wellness that can be accessed on the chapter’s home page. Still other practices may decide to implement a comprehensive primary care strategy such as Healthy Steps for Young Children or Circle of Security.

Promote Early Childhood Literacy And Parental Health Literacy

Promotion of early childhood literacy is one of the most important activities available to pediatricians during early childhood visits. Reach Out and Read is the most tested strategy and has been shown to achieve an advantage of at least six months at kindergarten for children who participate compared to those who do not. In addition to improved receptive and expressive language, parents who participate in Reach Out and Read are more likely to spend time with their children, thereby presenting the opportunity for improved relational health.

About one in three parents in poverty do not have basic health literacy; many, perhaps 10 percent, are unable to interpret an over-the-counter dosage chart. Low parental health literacy is associated with poor child health outcomes and, generally, with impaired developmental success including academic and behavioral. Health literacy is a cross-cutting priority to address child poverty. Pediatric practices can screen parents for literacy, adopt plain language written materials, practice strategies such as Teach Back known to improve adherence and maintain resources for parents to participate in adult literacy programs.

Engage Community Partners

The pediatric medical home is most robust when it collaborates with other community agencies that serve families and young children as a central part of an early childhood system of care. Collaborative engagement with governmental organizations, particularly the local health district, can examine opportunities to collocate many safety net services including Medicaid eligibility, early childhood home visiting, WIC and county foster care programs. Other non-governmental, faith-based and philanthropic organizations might include Medical-Legal Partnership, food pantries, pastoral care, substance abuse programs and the local women’s shelter or other services to protect parents from intimate partner violence. Special education and habilitation specialists may offer on-site evaluations and participate in comprehensive care planning.

Home-visiting services are particularly effective for improving comprehensive care of families experiencing poverty. The evidence is strong for perinatal home visiting by nurses to improve maternal and child health. Some programs that extend home visiting into early childhood have documented improvements in positive parenting as well as school readiness. Home visitors, including trained community health workers, may link families with community services such as vocational training and adult education that improve the possibility of family financial stability. The pediatric medical home can be a base for collocated services or be actively involved with home-visiting activities through facilitated communication with specialized electronic portals.

Changing The Trajectory

Leo Tolstoy, speaking as an educationalist, said “From a child of five to myself is but a step, but from a newborn baby to a child of five is an appalling distance.” The origins of lifelong health are in early childhood; therefore, pediatricians are in a perfect position to influence the developmental trajectory of all children, especially those exposed to adversity. The influence of direct medical care, with the exception of immunizations, may be secondary to the effects of the social determinants of health, such as the availability of food, safe housing and, most important, the presence of a safe, secure, nurturing adult relationship.  The transformed pediatric medical home can become the hub of community early childhood programs, combining family-centered care with trauma-informed care, in order to ameliorate and buffer the effects of early childhood adversity.

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This article is part of a recent issue of Pediatric Forum, a journal for physicians by physicians. 

References

1. APA Task Force on Childhood Poverty. http://www. academicpeds.org/public_policy/pdf/APA_Task_ Force_Strategic_Road_Mapver3.pdf. Published 2013.
2. AAP Council on Community Pediatrics. Poverty and Child Health in the United States. Pediatrics. 2016; 137(4):e20160339 (lead authors: Duffee JH, Kuo AA and Gitterman BA).
3. Dreyer B, Chung PJ, Szilagye P, Wong S. Child poverty in the United States today: Introduction and executive summary. Academ Pediatr. 2016;16(3 suppl):S1-S5.
4. Garner AS, et al. Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics. 2012;129(1):e224-31.
5. Pascoe JM, Wood DL, Duffee JH, Kuo A, Committee on Psychosocial Aspects of Child Family Health and Council on Community Pediatrics. Mediators and adverse effects of child poverty in the United States. Pediatrics. 2016;137(4):e20160340.
6. Shonkoff JP, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-46.

Websites of Interest

1. Ohio Association of Community Action Agencies http://oacaa.org/2017/03/23/2016-state-of-poverty-a-portrait-of-ohio-fa…
2. Hunger Vital Signs http://childrenshealthwatch.org/ public-policy/hunger-vital-sign/
3. Poverty Resource Page https://www.aap.org/en-us/ about-the-aap/Committees-Councils-Sections/ pediatric-trainees/Pages/FACE-Poverty.aspx
4. Strengthening Families Framework http://www.cssp. org/reform/strengtheningfamilies
5. AAP Building Mental Wellness http://ohioaap.org/ projects/building-mental-wellness/
6. Reach Out and Read http://www.reachoutandread.org/
7. Teach Back http://www.teachbacktraining.org

James Duffee, MD, MPH, is a general pediatrician at Dayton Children’s Hospital with clinical appointments in Pediatrics and Child Psychiatry at Wright State University Boonshoft School of Medicine. He is vice chair of the execu¬tive committee of the AAP Council on Community Pediatrics and chair of the Medical Advisory Council for Children with Medical Handicaps at the Ohio Department of Health. He is a lead author of the AAP policy on “Poverty and Child Health in the US” and a forthcoming poli¬cy on “Early Childhood Home Visiting.”