Family support in the family-centered medical home: an opportunity for preventing toxic stress and its impact in young children. Child health care providers offer valuable support and connections for families

Family and Neighborhood Resilience Are Associated with Children's Healthcare Utilization

OBJECTIVE

To evaluate the association of external factors of resilience, neighborhood, and family resilience with healthcare use.

STUDY DESIGN

A cross-sectional, observational study was conducted using data from the 2016-2017 National Survey of Children's Health. Children aged 4-17 years were included. Multiple logistic regression was used to determine aOR and 95% CIs for association between levels of family resilience, neighborhood resilience and outcome measures: presence of medical home, and ≥2 emergency department (ED) visits per year while adjusting for adverse childhood experiences (ACEs), chronic conditions, and sociodemographic factors.

RESULTS

We included 58 336 children aged 4-17 years, representing a population of 57 688 434. Overall, 8.0%, 13.1%, and 78.9% lived in families with low, moderate, and high resilience, respectively; 56.1% identified their neighborhood as resilient. Of these children, 47.5% had a medical home and 4.2% reported ≥2 ED visits in the past year. A child with high family resilience had 60% increased odds of having a medical home (OR, 1.60; 95% CI, 1.37-1.87), and a child with moderate family resilience or resilient neighborhood had a 30% increase (OR, 1.32 [95% CI, 1.10-1.59] and OR, 1.31 [95% CI, 1.20-1.43], respectively). There was no association between resilience factors and ED use, although children with increased ACEs had increased ED use.

CONCLUSIONS

Children from resilient families and neighborhoods have an increased odds of receiving care in a medical home after adjusting for the effects of ACEs, chronic conditions, and sociodemographic factors, but no association was seen with ED use.

Role of Individual, Family, and Community Resilience in Moderating Effects of Adverse Childhood Experiences on Mental Health Among Children

OBJECTIVE

Mental health outcomes such as attention-deficit/hyperactivity disorder (ADHD), behavior disorders, anxiety, depression, and adverse childhood experiences (ACEs) are common disorders among children in the United States. Little is known on how potential resilient factors may moderate the relationship between exposure to ACEs and mental health outcomes. This study examines associations between ACEs and resilience on mental health outcomes using the 2018 National Survey of Children's Health (N = 26,572).

METHOD

Logistic regression and interactions examined the association between ACEs, resilience, and mental health outcomes. ACE exposure and low resiliency were associated with an increased likelihood of mental health outcomes.

RESULTS

There were significant interactions between exposure to ACEs and family resilience as well as significant interactions between ACE exposure and community resilience. On stratification, the presence of individual resilience and having all resilience measures decreased the odds of ADHD, behavioral disorders, anxiety, and depression and the presence of community resilience decreased the odds of depression among individuals who had experienced 4 or more ACEs.

CONCLUSION

These results illustrate the need to promote resilience measures for tackling mental health problems and reducing the negative effect of trauma in children.

Locating Infant and Early Childhood Mental Health at the Heart of Social Work

Infant and early childhood mental health (IECMH)-an interdisciplinary field dedicated to advancing understanding of early relationships, socioemotional development, and cultural and contextual influences on caregiving-offers essential tools for social workers to support the well-being of infants, toddlers, preschoolers, and their families. Even though social worker Selma Fraiberg was a founder of the field, and social workers are central to the work of assessment and intervention with young children and their caregivers in many settings, few schools of social work offer training in IECMH, and few social workers are familiar with its core principles, scholarship, and intervention approaches. In this article, faculty members from four U.S. social work programs address the vital role of IECMH in social work training, research, and practice as well as issue a call to the field to recover and renew commitment to a practice perspective and knowledge base with roots in social work. Twenty-five years ago, Social Work published a similar call, but the request has gone largely unheeded. The authors examine the changing landscape and argue that it is more important and timelier than ever for social workers to learn and integrate the relationship-based approach to promotion, prevention, intervention, and treatment offered by IECMH.

The Nature, Logic, and Significance of Strong Communities for Children

High levels of stress and low levels of support for parents have significant implications for child safety, particularly for families living in neighborhoods which are dangerous and disadvantaged. Building on this knowledge about the causes and correlates of child maltreatment, the U.S. Advisory Board on Child Abuse and Neglect (1993) recommended a neighborhood-based child protection strategy. This article describes Strong Communities for Children, a community-based child maltreatment prevention intervention designed to carry out the Board’s recommendations. During an initial period of development and evaluation (lasting more than 7 years) of the first such initiative (located in communities near Greenville, SC), Strong Communities added substantially to the knowledge base on the role of community factors in children’s safety. It also advanced understanding of ways to operationalize some of the ideas underlying the Board’s proposed strategy. This article (a) describes the conceptual foundation, the logic model, and the engagement strategies that comprise Strong Communities; (b) provides an overview of the results from the first comprehensive initiative; (c) discusses their significance; and (d) concludes with discussion of the possibilities for Strong Communities in the current context.

Challenges to School Success and the Role of Adverse Childhood Experiences

OBJECTIVE

To examine the association between adverse childhood experiences (ACEs), by multiple types and counts of ACEs, and challenges to school success.

METHODS

A cross-sectional study was conducted using data from the 2016 National Survey of Children's Health using the ACE module and 3 measures of challenges to school success: lack of school engagement, school absenteeism, and repeated grade.

RESULTS

In multivariable analysis adjusting for selected demographic and other characteristics, children with 4 or more ACEs had higher odds of nonengagement in school (adjusted odds ratio [aOR] 2.15; 95% confidence interval [CI], 1.51-3.07), reported school absenteeism (aOR 1.75; 95% CI, 1.12-2.73), and of repeating a grade (aOR 1.71; 95% CI, 1.19-2.47, Table 4) than children with exposure to less than 4 ACEs. Risk factors for all 3 challenges to school success included age of child and special health care needs, with older children and children with special health care needs more likely to have challenges to school success, across all 3 measures.

CONCLUSIONS

Our findings confirm that ACEs can have an impact in childhood and adolescence, not just later in adulthood, as demonstrated by the association between ACEs and measures of school success. These findings further illuminate the connection between ACEs and childhood outcomes of education and health. Future research should examine frameworks that effectively support collaboration between educators, social service providers, and pediatricians as they seek to prevent or reduce the impact of ACEs and other childhood trauma.

Prioritizing Possibilities for Child and Family Health: An Agenda to Address Adverse Childhood Experiences and Foster the Social and Emotional Roots of Well-being in Pediatrics

OBJECTIVE

A convergence of theoretical and empirical evidence across many scientific disciplines reveals unprecedented possibilities to advance much needed improvements in child and family well-being by addressing adverse childhood experiences (ACEs), promoting resilience, and fostering nurturance and the social and emotional roots of healthy child development and lifelong health. In this article we synthesize recommendations from a structured, multiyear field-building and research, policy, and practice agenda setting process to address these issues in children's health services.

METHODS

Between Spring of 2013 and Winter of 2017, the field-building and agenda-setting process directly engaged more than 500 individuals and comprised 79 distinct agenda-setting and field-building activities and processes, including: 4 in-person meetings; 4 online crowdsourcing rounds across 10 stakeholder groups; literature and environmental scans, publications documenting ACEs, resilience, and protective factors among US children, and commissioning of this special issue of Academic Pediatrics; 8 in-person listening forums and 31 educational sessions with stakeholders; and a range of action research efforts with emerging community efforts. Modified Delphi processes and grounded theory methods were used and iterative and structured synthesis of input was conducted to discern themes, priorities, and recommendations.

RESULTS

Participants discerned that sufficient scientific findings support the formation of an applied child health services research and policy agenda. Four overarching priorities for the agenda emerged: 1) translate the science of ACEs, resilience, and nurturing relationships into children's health services; 2) cultivate the conditions for cross-sector collaboration to incentivize action and address structural inequalities; 3) restore and reward for promoting safe and nurturing relationships and full engagement of individuals, families, and communities to heal trauma, promote resilience, and prevent ACEs; and 4) fuel "launch and learn" research, innovation, and implementation efforts. Four research areas arose as central to advancing these priorities in the short term. These are related to: 1) family-centered clinical protocols, 2) assessing effects on outcomes and costs, 3) capacity-building and accountability, and 4) role of provider self-care to quality of care. Finally, we identified 16 short-term actions to leverage existing policies, practices, and structures to advance agenda priorities and research priorities.

CONCLUSIONS

Efforts to address the high prevalence and negative effects of ACEs on child health are needed, including widespread and concrete understanding and strategies to promote awareness, resilience, and safe, stable, nurturing relationships as foundational to healthy child development and sustainable well-being throughout life. A paradigm-shifting evolution in individual, organizational, and collective mindsets, policies, and practices is required. Shifts will emphasize the centrality of relationships and regulation of emotion and stress to brain development as well as overall health. They will elevate relationship-centered methods to engage individuals, families, and communities in self-care related to ACEs, stress, trauma, and building the resilience and nurturing relationships science has revealed to be at the root of well-being. Findings reflect a palpable hope for prevention, mitigation, and healing of individual, intergenerational, and community trauma associated with ACEs and provide a road map for doing so.

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

Adverse childhood experiences (ACEs) occur when children are exposed to trauma and/or toxic stress and may have a lifelong effect. Studies have shown that ACEs are linked with poor adult health outcomes and could eventually raise already high health care costs. National policy interest in ACEs has recently increased, as many key players are engaged in community-, state-, and hospital-based efforts to reduce factors that contribute to childhood trauma and/or toxic stress in children. The Affordable Care Act (ACA) has provided a promising foundation for advancing the prevention, diagnosis, and management of ACEs and their consequences. Although the ACA's future is unclear and it does not adequately address the needs of the pediatric population, many of the changes it spurred will continue regardless of legislative action (or inaction), and it therefore remains an important component of our health care system and national strategy to reduce ACEs. We review ways in which some of the current health care policy initiatives launched as part of the implementation of the ACA could accelerate progress in addressing ACEs by fully engaging and aligning various health care stakeholders while recognizing limitations in the law that may cause challenges in our attempts to improve child health and well-being. Specifically, we discuss coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models.

Promoting Early Brain and Child Development: Perceived Barriers and the Utilization of Resources to Address Them

OBJECTIVE

Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent-child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers.

METHODS

Data were analyzed from 304 nontrainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease nonresponse bias. Bivariate comparisons and multivariable regression analyses were conducted.

RESULTS

At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent-child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent-child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent-child relationships, screening tools, and community resources.

CONCLUSIONS

Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.

Social support and child protection: Lessons learned and learning

Social support has been a topic of research for nearly 50 years, and its applications to prevention and intervention have grown significantly, including programs advancing child protection. This article summarizes the central conclusions of the 1994 review of research on social support and the prevention of child maltreatment prepared for the U.S. Advisory Board on Child Abuse and Neglect, and surveys advances in the field since its publication. Among the lessons learned twenty years ago are (a) the diversity of the social support needs of at-risk families and their association with child endangerment, (b) the need to supplement the emotionally affirmative aspects of social support with efforts to socialize parenting practices and monitor child well-being, (c) the desirability of integrating formal and informal sources of social support for recipients, and (d) the importance of considering the complex recipient reactions to receiving support from others. The lessons we are now learning derive from research exploring the potential of online communication to enhance social support, the neurobiology of stress and its buffering through social support, and the lessons of evaluation research that are identifying the effective ingredients of social support interventions.

"Someone will notice, and someone will care": How to build Strong Communities for Children

Derived from the recommendations of the U.S. Advisory Board on Child Abuse and Neglect, Strong Communities for Children is a universal community-wide approach to prevention of child maltreatment. It is intended to change community norms-to facilitate informal support for families and to strengthen parents' belief that they can improve the quality of life for their own and their neighbors' families. A phased intervention, Strong Communities begins with recruitment and mobilization of volunteers, initially to spread Strong Communities' messages and ultimately to provide direct assistance to families of young children. Principle-driven, Strong Communities uses assets in the community to expand and strengthen networks of supportive relationships and, in particular, to increase support to parents. At least in concept, Strong Communities appears to be applicable in highly disparate communities and societies.