Environment

Adverse Childhood Experiences

The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.

What is an Adverse Childhood Experience?

ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health [1]. These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) [2].

What is the impact of ACEs?

The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors [2]. Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia [3]. Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion [2].

What can we do to help as pediatricians and as citizens?

The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].

As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are [6]:

  • Food security: Are there times when you don’t have enough food?
  • Income: Do you ever have trouble making ends meet?
  • Housing: Is housing ever a problem for you?
  • Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
  • Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?

All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support [7]. Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.

Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.

https://www.aap.org/en-us/advocacy-and-policy/Pages/Advocacy-and-Policy.aspx

https://www.naeyc.org/resources/blog/support-and-advocate

https://www.cwla.org/our-work/advocacy/

http://childwelfaresparc.org/

 

Benjamin Masserano, MD

 

References

[1] https://developingchild.harvard.edu/science/key-concepts/toxic-stress/

[2] https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

[3] https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

[4] http://pediatrics.aappublications.org/content/pediatrics/early/2011/12/21/peds.2011-2663.full.pdf

[5] http://pediatrics.aappublications.org/content/128/6/e1680

[6] http://pediatrics.aappublications.org/content/120/3/e734

[7] http://www.211.org/

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Parental Responsibility to Regulate Screen Time for Children

In 2016, the American Academy of Pediatrics (AAP) revised screen time guidelines for children. The previous guidelines advised no screen time for kids less than 2, and no more than 2 hours in front of the TV for kids over the age of 2. With the advent of smart phones and tablets making screen time and Internet access nearly ubiquitous, many pediatricians and other professionals felt the AAP was long overdue in revising screen time guidelines to be more appropriate for current and future generations of children. Newly revised 2016 guidelines were broken down into four basic age groups with added flexibility to customize screen time to fit the needs of the individual child, as follows:

  • For infants less than 18 months of age:
    • Parents should avoid use of screen media other than video chatting.
  • For infants 18 to 24 months of age:
    • If desired, parent should choose high-qualityprogramming, and watch with children to help them understand what they’re seeing.
  • For toddlers 2 to 5 years of age:
    • Parents should limit screen use to 1 hour per day of high-quality
    • Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them.
  • For children 6 years of age and older:
    • Place consistent limitson the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health.

These new guidelines recognize that visual media can be an important tool for development and educationwhen properly utilized. The problem is that many parents do not properly adhere to these guidelines. Contrary to what some may believe, these guidelines do not relax the parameters for screen time. Rather, these guidelines call for increasedparental investmentin actively regulating their child’s media consumption. Examples of inappropriate screen time, at times even commonly witnessed directly by pediatricians in clinic, include some the following:

  • Parents using video streaming on mobile devices as a means of distracting their infants or children.
  • Parents not adequately supervising screen time.
  • Parents failing to set consistent limits on media use.
  • Parents or children choosing to view poor quality programming with little educational benefit.

Adverse effects of unregulated screen time are well understood to include the following: obesity, sleep problems, problematic internet use (e.g. gaming disorders), negative effects on school performance, risky behaviors (e.g. substance abuse, inappropriate sexual behaviors), sexting, piracy, predators and cyber bullying.

Given the common adverse effects of unregulated media use, it is important to recognize that the above guidelines do not indicate AAP’s endorsement of screen time as a primary learning activity. The AAP recommends that parents prioritize creative, unplugged playtimefor infants and toddlers. The amount of daily screen time for older children depends on the child and family, but children should prioritize productive time over entertainment time.

The AAP provides an important but underutilized tool online that helps families build their own custom Family Media Plan (see link below). Pediatricians who wish to emphasize the importance of regulated screen time should consider providing this resource to families in their clinics. The plan provides a customizable template that includes setting important boundaries in the development of healthy screen time behavior.

Lastly, a quote from Bill Watterson, arguably one of the most creative minds of the late 1980s-early 1990s who is known for his authorship of Calvin & Hobbes, helps reinforce the importance of alternatives to screen time:

“We’re not really taught how to recreate constructively. We need to do more than find diversions; we need to restore and expand ourselves. Our idea of relaxing is all too often to plop down in front of the television set [or internet] and let its pandering idiocy liquefy our brains. Shutting off the thought process is not rejuvenating; the mind is like a car battery—it recharges by running.”

Alex J. Foy, MD

 

Sources and Resources:

Build Your Own Family Media Plan

https://www.healthychildren.org/English/media/Pages/default.aspx#home

10 Tips for Becoming a More Active Family

https://www.choosemyplate.gov/ten-tips-be-an-active-family

Children and Adolescents and Digital Media

http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593

Constantly Connected: Adverse Effects of Media on Children & Teens

https://www.healthychildren.org/English/family-life/Media/Pages/Adverse-Effects-of-Television-Commercials.aspx

Consciously Supporting Concussion Awareness

In recent years, public interest has increased surrounding concussions/mild traumatic brain injuries (MTBI). This is due in large part to the recent hypothesis that concussive forces from contact sports may be a risk factor for the development of chronic traumatic encephalopathy (CTE), a disease seen most often in former boxers and professional football players.

Research, legislation, and documentaries have sought to better define the incidence and risks of concussions, its relationship to these 2 diseases, and to increase public awareness of this issue. Currently, legislation is pending in both the U.S. House of Representatives and the Senate that has the potential to further achieve these goals by increasing general awareness about concussions and giving parents and youth the ability to make informed decisions about the sports in which they participate. We as pediatricians can advocate for the safety of our patients by contacting our local representatives and asking them to become cosponsors for the “SAFE PLAY Act” (H.R. 829).

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Air Quality and Asthma

As bronchiolitis season finally abates, asthma regains its primary place as the most common respiratory complaint at CMC Dallas ED. While we carefully educate patients and their families about preventative measures and ways to alter the home environment to prevent asthma exacerbations, the environment outside of the home is not so easily altered and can have an enormous impact on patient health. Air quality in particular is beyond the patient and the family’s control, and yet it significantly impacts an asthmatic’s ability to breathe. (more…)