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Training Future Pediatric Providers to See Health Beyond Our Clinic Doors
The school shooting in Parkland, Fla., hit me close to home. I’m from Broward County; in fact, I grew up about 2 miles from Marjory Stoneman Douglas High School, and the gunman, Nikolas Cruz, was apprehended in my parents’ neighborhood.
As a neonatal nurse practitioner, I can’t help but wonder about the gunman’s childhood. From what I’ve seen in the news, he appears to have experienced at least half-a-dozen adverse childhood experiences, or ACEs, as they are called in the research world, and those traumatic experiences surely had an impact on his development. For a person with an ACE score of four or more, the relative risk of developing depression is 4.5 times that of someone with an ACE score of zero.
The Parkland tragedy underscores the importance of broadening health professions education, especially in pediatrics, where we have not focused enough on the social determinants that have powerful—and lifelong—impacts on kids’ health and early brain development. Clinicians who care for kids need to become more attuned to where and how they live their everyday lives outside our clinic doors. Do our patients have enough nutritious food to eat? What’s the condition of their home? How are they doing at school?
Many of these factors have to do with growing up in poverty. One in five U.S. children lives in poverty. Fundamentally, living in poverty can change the way in which a child interacts with her or his environment, develops, and learns.
ACEs—including exposure to abuse, neglect, or violence, as well as having a parent who has a serious mental illness or drug or alcohol problem—can alter a child’s brain development. Dr. Vincent Felitti at Kaiser Permanente and Dr. Robert Anda at the Centers for Disease Control and Prevention led the Adverse Childhood Experiences Study almost two decades ago. They found that ACEs are incredibly common: 67 percent of the population had at least one ACE and 1 in 8 people had four or more ACEs. They also found a dose-response relationship between ACEs and health outcomes—the higher your ACE score, the worse your health outcomes.
We can do a better job preparing future pediatric nurses and doctors on how to address the effects of social factors like poverty and trauma in children. Studies suggest that only 4 percent of pediatricians screen for ACEs. Nursing providers probably don’t do much better, given the general lack of education around this topic.
As a Macy Faculty Scholar, that’s what I’m working to change. Future doctors and nurses need to know more than how to diagnose and treat pediatric illness. They need to know how to recognize the warning signs of ACEs and how to use the ACE screening tool to understand the impacts that ACEs have on children across a lifetime of health. Our pediatric clinicians need to be aware that if a baby isn’t thriving, they should look beyond disease and consider formula stretching —and that many kids who come in with asthma may be living in housing infested with mold and vermin.
And our future clinicians need to know what to do about these problems—how to ask parents about the factors in their kids’ lives that affect their health and how to refer them to services and supports that can help them.
At George Washington University, my colleagues and I have developed a multidisciplinary elective called “Pediatric Adversity” for nursing and medical students who want to learn about the social factors that shape health. It includes lessons like role-playing to assess ACE scores and simulating what it’s like to live in poverty. Parts of this course will be made available through a new National League for Nursing ACE. P toolkit. Ultimately, we want everyone training clinicians to have access to this resource.
We are also developing an integrated curriculum across our program at GWU to educate future pediatric clinicians so that they understand and know how to address these drivers of health in children.
Too often we think of health in terms of biology and disease. But growing up amid poverty and trauma can affect a child’s biology at the cellular level, and across the lifespan, making him or her more susceptible to a range of illnesses.
Through this project, I hope to educate and train a generation of clinicians who recognize that health goes far beyond our clinic doors and resides where children live, learn, and play.