Texas is home to approximately 4.7 million immigrants (an estimated 17% of the state population), including approximately 317,000 immigrant children1. Of these immigrants, approximately 1.7 million are naturalized US citizens, nearly 1 million are eligible to become naturalized US citizens, and nearly 2 million are undocumented immigrants1,2. The number of US-born children in Texas who live with an undocumented family member is reported to be approximately 1 million, with approximately 500,000 children with an undocumented parent1,3. Obtaining permanent residency status is a lengthy process and a source of anxiety for many immigrants. Recent changes to the US Department of Homeland Security (DHS) rules regarding which public benefits count negatively towards obtaining permanent residency may impact these families and children. Pediatric healthcare providers should be prepared to help immigrant families understand how the use of public benefits could impact changing their immigration status.(more…)
Prices of prescription drugs in the United States are among the highest in the world. Most recently, the skyrocketing price of the epinephrine pen, EpiPen, has been the subject of major news headlines. Many have been enraged by the dramatic price increase of the EpiPen ($100 to over $600 in the span of a few years). Unfortunately, the EpiPen is one of many prescription drugs that has been affected by such dramatic inflation. Many fear that the rising cost of life-saving medication will limit access to those who need it. Healthcare providers cannot stand idly as these changes negatively impact patients. We need to have a better understanding of the prescription drug industry so that we can find reasonable solutions for our patients. (more…)
Despite the large role that technology plays in our society, delivery of health care continues to mostly occur in a face-to-face setting between doctor and patient. Telemedicine offers the opportunity for providers and patients to communicate remotely via video interfacing and mobile technology while still allowing for accurate diagnosis, quality doctor-patient interactions, and monitoring for complex medical needs. As healthcare providers, we must acknowledge that this form of interaction allows physicians to easily follow a patient’s progress, and save time and resources for our patients.
Children are indirectly exposed to acts of violence and terrorism almost continuously via the media. News media continually cycles global events onto screens in every household. The stress of witnessing a shooting is no longer limited to the bystanders and civilians caught on the scene, but is spread diffusely across state and national borders to viewers in their homes including children. Pediatricians can help children and their caretakers process these tragedies better.
Exposure to such news stories can contribute to a stressful environment for the child. In recent years the AAP has focused on ‘toxic stress’ in a child’s life. Toxic stress has been defined as “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships” (National Council of Science: Excessive stress disrupts the development of brain architecture). A growing body of evidence suggests that ecology and biology interact to effect development, i.e., the ecobiodevelopmental framework. In the case of toxic stress, a stressful ecology inculcates lasting detrimental effects in biology and behavior. It can lead to development of poor coping skills, unhealthy lifestyle choices, chronic cardiovascular diseases and serves to perpetuate health disparities to mention a few.
Opinions vary on the extent and significance of the effect of exposure to news media coverage of acts of terror and violence. Increasingly, after such an incident, many articles emerge suggesting how parents should talk to their children about violence. Unfortunately, many children do not have the “buffering protection afforded by stable, responsive relationships” with their parents. Parents themselves may face a difficult time coming to terms with the same tragedies. This gap can be bridged by the pediatrician, school and public policy.
Pediatricians can routinely screen for toxic stress. The AAP has put forward many helpful resources which advise parents on how to talk to their children regarding media violence, tragedies they may have witnessed, school shootings and disasters. Whenever such news is circulating, pediatricians can ask parents if they have trouble communicating with their children about it, expand on their anticipatory guidance using the pre-existing AAP guidelines and recommend appropriate resources to them. Further, pediatricians in collaboration with mental health professionals can meet with parent-teacher associations to share how children are able to best process these events.
Schools can engage their own mental health services and counselors to have a discourse with children in an age-appropriate manner. In the absence of adequate resources, these sessions could be done in groups and limited to when the event is local.
Finally, state government officials can improve funding for mental health services for children and implement strategies to incentivize an increase in the mental health professionals catering to the pediatric population. Legislators can formulate guidelines for Social and Emotional Learning (SEL) curriculum for grades K-12 as exist for pre-kindergarten. As of December 2015, free-standing guidelines for Social and Emotional Learning exist only in the states of Illinois, West Virginia and Kansas. Bills proposing training of teachers and principals to address social and emotional development needs of students have been previously introduced in the U.S. House (H.R.850; H.R.497) and the U.S Senate (S.897) in 2015. In the same year, a bill (HB 3289) was also introduced in the Texas Legislature proposing formulation of a local school health advisory committee to address mental health concerns existing in school efforts and to make recommendations to the school district concerning the integration of social and emotional learning into the academic curriculum.
Adopting such a multi-pronged approach will better preserve the childhoods of the current generation and safeguard their adult lives as well.
1. National Scientific Council. Excessive stress disrupts the development of brain architecture. Journal of Children’s Services. 2014 Jun 10;9(2):143-53. Accessed July 11, 2016. URL: http://developingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Developing_Brain-1.pdf
2. Shonkoff, J.P.; Garner, A.S. Technical Report: The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012. doi:10.1542/peds.2011-2663
3. Committee on psychosocial aspects of child and family health, committee on early childhood, adoption, and dependent care, and section on developmental and behavioral pediatrics. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012. doi:10.1542/peds.2011-2662
4. Busso, D.S.; McLaughlin, K.A.; Sheridan, M.A. Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston marathon bombings. Depress Anxiety. 2014 July ; 31(7): 551–558. doi:10.1002/da.22282
5. Marie Leiner, M.; Peinado, J.; Villanos, M.T.M.; Lopez, I.; Uribe, R.; Pathak, I. Mental and emotional health of children exposed to news media of threats and acts of terrorism: the cumulative and pervasive effects. Frontiers in Pediatrics. 2016. doi: 10.3389/fped.2016.00026
6. Collaborative for Academic, Social and Emotional Learning. Identifying K-12 Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: https://pedsadvocacy.files.wordpress.com/2016/07/a46cb-state-scorecard-summary-table-for-k-12-12-16-15.pdf
7. Collaborative for Academic, Social and Emotional Learning. Identifying Preschool Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: http://static1.squarespace.com/static/513f79f9e4b05ce7b70e9673/t/55df7c05e4b031d82f728c5d/1440709637809/preschool-table-8-27-15.pdf
8. Texas Education Agency. Accessed July 9, 2016. URL: http://tea.texas.gov/index2.aspx?id=2147495508
Gohar Warraich, M.D.
Recent figures show that approximately 31 million (or 42%) of U.S. children receive health insurance through Medicaid or CHIP.1,2 These programs have been critical in improving access to pediatric care, which studies show improves medical utilization and leads to better personal, educational, and societal health outcomes. Thus, as healthcare providers, it is critical that we understand how these systems function if we hope to advance our nation’s health. (more…)
Dr. Rachael Johnston posted a thoughtful piece about a year ago about the impacts of Texas’ refusal to accept additional funding for Medicaid that is available through the Affordable Care Act. This week, on the heels of the opening of a brand-new Parkland Hospital in Dallas, a hospital that provides care for thousands of low-income patients, the Dallas Morning News has published and editorial outlining the impact that this policy decision has had on the state.
In January 2015, a bipartisan group of U.S. Senators and Representatives introduced the Advancing Care for Exceptional Kids Act of 2015 (ACE Kids Act), S. 298 and H.R. 546. If passed the Act will improve Medicaid care for the children with complex medical conditions. The legistation currently has 136 co-sponsors in the House of Representatives and 19 co-sponsors in the Senate. The bill has been referred to committees in both the House and Senate, but it has not progressed further. To move the legistlation forward for a vote, I encourage you to contact your Congressional Representative and the Texas Senators to express your support for this bill.
We often hear about the shortage of general practitioners when it comes to adult medicine. Our newly minted doctors are foregoing primary care and opting to pursue further fellowship training in preparation for careers as subspecialists following their residency training in internal medicine. Interestingly, pediatrics has the opposite problem. Adult medicine has 36 specialists for every 100,000 patients whereas pediatrics only has 13 specialists for every 100,000 pediatric patients. We have a gross shortage of pediatric subspecialists ready to take care of the complex medical problems which are beyond the scope of practice for the general pediatrician. (more…)
Medicaid and CHIP are essential to children’s healthcare in the United States. It is critical that we continue to fund both of these programs to ensure that our nation’s children continue to receive well child care from their primary care provider. Well child care includes routine visits for vaccinations, ongoing surveillance visits for chronic health conditions, or yearly “check-ups.” (more…)