By Anndee Hochman
Do you ever have nightmares? What’s different for you since Mommy and Daddy got divorced? Do you feel safe at school? What happens when you misbehave?
In an ideal world of health care for children, questions like these would be routine, as commonplace as asking about whether a family has pets, guns or cigarette smokers in the house. And the answers would cue pediatricians about stresses—at home, at school, in the neighborhood—that can have enormous impact on their patients’ well-being.
Past and ongoing studies of—Adverse Childhood Experiences (ACEs)—have driven home a stark conclusion: abuse and neglect, as well as other significant negative life experiences, shape the way children learn, play and grow. Emerging developmental science is showing that repeated trauma re-wires the brain. Stress can make you sick. What happens at home absolutely affects your health.
At a January meeting of the Philadelphia ACE Task Force, a citywide group of pediatricians, nurse practitioners, mental health professionals, scholars, and other community members convened and led by the Institute For Safe Families, discussed how to bring their understanding of ACEs into practice: What questions do pediatricians ask, or should they ask, to learn about sources of stress in their patients’ lives? What are the barriers to finding out about ACEs? And if providers do learn that something disturbing is happening in a child’s life, what can they do about it?
Practitioners agreed that childhood trauma should not be a secret. “We need to talk about ACEs and bring these issues out of the closet,” said Maria D. McColgan, assistant professor of pediatrics and emergency medicine at St. Christopher’s Hospital for Children and director of the hospital’s child protection program.
Some pediatricians said that while they may not ask direct questions about ACEs, they will go “through the back door,” engaging children and caregivers in discussions about sleep, eating habits and discipline. “I might say [to a child], ‘Who do you sleep with? Would you like to sleep alone? Do you have scary dreams?’…Sometimes I will say [to the parent and child], ‘I’d like to see you both separately,’” said Beth Rezet, a pediatrician at Children’s Hospital of Philadelphia.
Task Force members agreed that they must walk a delicate line, learning about possible stresses in children’s lives while building trust and rapport with their adult caregivers. Parents may fear that disclosing trouble at home—family violence, an incarcerated adult, mental illness—will put them at risk of losing their children to protective custody.
And what if parents or patients do tell pediatricians what’s really happening? Several members of the Philadelphia ACE Task Force said they hesitate to ask about family violence, substance abuse or other at-home stresses when referrals or follow-up care are not readily available. Others noted that doctors, eager to “fix” what’s wrong, may shy away from probing into areas where there are no quick remedies or easy answers.
Ideally, they said, pediatric care settings would include a behavioral health specialist, and behavioral assessments would be part of every visit. Ingre Walters, assistant professor of psychiatry and behavioral science at Temple University School of Medicine, said that a psychiatrist “embedded” in every pediatric office could provide support to parents who are suffering from depression or post-traumatic stress, as well as to their children.