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Peds 21 program offers strategies for tackling toxic stress :

November 9, 2015

Six experts shared strategies to help pediatricians identify toxic stress in their patients at the Pediatrics for the 21st Century (Peds 21) program held prior to the AAP National Conference & Exhibition.

AAP President Sandra G. Hassink, M.D., M.S., FAAP, introduced the half-day program titled “The Trauma-Informed Pediatrician: Identifying Toxic Stress and Promoting Resilience.” The speakers described their approaches to caring for children and adolescents who have been exposed to toxic stress, including screening for adverse childhood experiences (ACEs).

The concept is derived from the original ACEs study from 1995-’97, which highlighted the strong dose-response relationship between adverse childhood experiences like abuse, neglect or violence and consequences on health and well-being lasting into adulthood. In addition, an AAP policy statement and technical report drew attention to the need to address toxic stress in children.

Patients with higher ACEs scores are seen as having a significantly increased risk for a multitude of health, developmental and behavior problems over their lifetime such as cancer, heart disease and depression.

Learning how to integrate the screening process into daily practice remains challenging, however.

While ACEs screening instruments have not yet been validated, failure to screen is more harmful, said keynote speaker Nadine Burke Harris, M.D., M.P.H., FAAP. Toxic stress, she told the audience, is a public health crisis, and pediatricians play a critical role.

“We can be on the frontlines … by simply doing what we do every day,” said Dr. Burke Harris, founder and CEO of the Center for Youth Wellness in San Francisco. “There is no community where we don’t need to be looking at this.”

Early identification and referral can help patients learn to handle stress better. A deeper understanding of an individual’s toxic stress also can shed light on problem behavior, which may be a child’s way of coping with unrelenting stressors.

“Keep trauma in the differential diagnosis,” said Heather Forkey, M.D., FAAP, who described common behavioral presentations of trauma in everyday practice. She said families and patients are not aware that obvious trauma is the preceptor of many problems. Even a child presenting with signs of attention-deficit/hyperactivity disorder may be hypervigilant due to relentless stress.

Asking parents if anything “scary” has happened to their child since the last visit is one way to ease into the questioning, Dr. Forkey added.

Instituting a screening program does not mean pediatricians should feel they must solve every problem, said Robert Gillespie, M.D., M.P.H.E., FAAP. Simply listening is therapeutic, he said. At the 4-month well-baby visit, Dr. Gillespie’s office also screens parents for ACEs, part of an expanded anticipatory guidance approach.

When counseling patients or families, a calm, nonjudgmental demeanor also is important, according to Lawrence Wissow, M.D., M.P.H., FAAP. He described effective ways to give compassionate care, highlight strengths and “rewrite the narrative.”

Before instituting a screening process, primary care offices should be aware of community resources and continue to build relationships to broaden those resources, the speakers noted.

Cooperative partnerships have been the key to success of a Kansas City, Mo., program described by emergency medicine physician M. Denise Dowd, M.D., M.P.H., FAAP, who accepted the Arnold P. Gold Foundation Humanism in Medicine Award during the program.

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