Life Course Health Development in Pediatric Practice

Health, broadly defined as more than the absence of disease,³  is shaped by the interaction of individual’s biological attributes with their environment, especially during critical periods of development in which the effects of the presence or absence of experience are especially pronounced.⁴  It is more influenced by early life experiences than later ones, and, thus, it is during childhood that the provisional path, the contingent trajectory for future health and well-being, takes shape. This idea has been captured in a life course perspective and the concept of life course health development (LCHD). LCHD provides a framework that views health as a continuous process of precursors, adaptations, and consequences, beginning prenatally and continuing throughout life and, perhaps, across generations.^5–7  The life course perspective has gained salience as health disparities⁸  and chronic illness have begun to be recognized as dominate patterns of illness in all stages of life.^9,10 

In a recent exposition of the LCHD framework, a series of 7 principles have been identified and are presented later in this article.¹¹  They are helpful in understanding how the experiences of children within their families and communities affect not only their immediate health and short-term development but, also, the development of their health and other capacities through subsequent stages of life. These principles can be interpreted to offer guidance about how to provide child health care that takes into account the children’s life experiences and consequent health.

LCHD sees health as the product of competing forces. There are assets that enable children to develop and realize their potential, satisfy their needs,¹²  and interact successfully with their biological, physical, and social environments and risk factors that can erode health status and health prospects.^13–15  Because health is linked to experience, good health can be promoted by increasing assets or protective factors (family resilience and cohesion, maternal education, family income, positive health behaviors, social connections and concrete support, and good mental health) and by reducing risks.¹⁶  Conversely, ill health is more likely when assets are few and risks (maternal depression, poverty, family violence, substance abuse, social isolation or exclusion, discrimination, and an unsafe environment) are many.^17,18  Given the nature of these factors, it is not surprising that the outcomes in terms of health and development are not randomly distributed. The resultant disparities among children mirror the social stratification they experience.¹⁹ 

Pediatrics is differentiated from other specialties not only by the age of its patients but also by its acknowledgment of patients’ ongoing but mutable development and emphasis on primary preventive care and health promotion. For example, the mission of the American Academy of Pediatrics is future oriented because it is to help children attain optimal physical, mental, and social health and well-being. According to Bright Futures, its official guidance for preventive care, these outcomes are to be achieved by soliciting parental and child concerns, surveillance and screening, strengths-based care planning, and anticipatory guidance and other educational interventions.²⁰  The structure for this care is codified in a schedule of preventive services, which are more frequent during children’s early years.²¹  This schedule and related guidance emphasize that each child and family and, presumably, their health development is unique and suggest that additional visits may be necessary, depending on circumstances, including developmental challenges, psychosocial issues, and chronic conditions.²²  Increasingly, that policy has been augmented by admonitions that pediatric health care professionals and health systems should pay greater attention to the social and behavioral determinants of health.^1,23,24  Yet, for various reasons, preventive pediatric care continues to be a series of individual, discontinuous visits with inconsistent attention to the types, nature, and chronicity of the processes it is intended to address. Preventive care is also hampered by poor attendance rates that do not conform to recommended care schedules,²⁵  and pediatric practices remain limited in their ability to effectively take on this broad agenda.^26–28  Given the breadth and, generally, unrealistic expectations of pediatric preventive care,^29,30  how can child health care providers influence the trajectory of children’s health development within the restrictions of a series of individual visits, the contents of which are largely prescribed by tradition and payers?

Clearly, LCHD is not solely the responsibility of the health care system. It requires coordinated efforts with others who can more directly influence population health and the social environments that are so influential in determining children’s outcomes. One key partner to pediatricians is public health, particularly maternal and child health programs. Pediatrics emerged as a medical specialty, in large part, because of concerns about the health consequences of social and environmental factors consequent to urbanization, industrialization, and large-scale immigration in the mid-19th century.³¹  Although pediatrics relies on individualized advice and anticipatory guidance to influence LCHD, public health uses public education and public policy as its primary vehicles to promote positive health behaviors and reduce the deleterious outcomes of adverse circumstances and experiences. Public health, with its focus on populations, and medical care, with its focus on individuals, have great potential to be complementary. However, although both acknowledge and have contributed to understanding the mechanisms that determine health and the value of prevention, neither has clearly articulated a path toward LCHD for its own field or jointly.

Any effort to enhance children’s health development, whether initiated by the profession or public health professionals, immediately faces a series of dilemmas inherent in the value proposition for children’s services.³²  First, effective preventive or health promoting services for children require an extended period of time to be manifest and, thus, demonstrate a calculable return on the investments required for their provision. Second, many of these services are not directed toward the child but, rather, are intended to provide support to families and enhance their functioning. Third, most improved outcomes and lower costs will be accrued by nonhealth sectors of society such as education, child welfare, juvenile justice, and the labor market.

The LCHD framework⁶  provides 7 principles by which to understand how the experiences of children within their families and communities affect their health over their lifetimes. These principles can be used by child health care professionals to guide the provision of preventive child health care that promotes health development.

Health, including the physical, cognitive, emotional, and social, develops over a lifetime. The interdependent developmental processes underlying children’s health and development provide a way for clinicians to evaluate how life circumstances are affecting children at specific developmental stages. It suggests that changes in health status should be viewed through a developmental lens to better understand their origins in recent changes in children’s lives and their potential consequences in terms of future health. It also suggests that when now standard development and psychosocial screening identify children who are developmentally atypical (ie, delayed) at risk for developmental delay or precocious, they should be offered preventive care visits that are more frequent, more exploratory, and, if necessary, of longer duration than is usual. In addition, health care providers should anticipate and respond to changes in physical and mental health as children transition through key developmental stages and challenges. This requires more individualized and less formulaic screening and anticipatory guidance.

Individuals adapt and health changes in response to genetic determinants, epigenetic processes, and the direct effects of the physical, social, and emotional environments. This is a highly sensitive and individualized process of human development that occurs in an ordered, coherent pattern shaped by the experience of the individual and his or her predecessors.¹¹  To some extent, the course of children’s health development can be anticipated on the basis of the health histories of family members^33,34  and the environments in which children live.^35,36  Effective preventive care requires knowledge of and ready access to children’s family histories and their past and current psychosocial circumstances. Obtaining that information requires that care be provided in the context of a trusting relationship. Using that information requires more accessible and clinically useful databases, including medical, educational, and social histories, registries, care plans, and feedback from referrals.

Health development is a dynamic process, an adaptive, perpetual interplay between individuals and their environments. Its complexity derives from the variable interdependence of that interplay and the ecological framework in which it occurs.¹¹  Children are not passive recipients of the experiences provided by their environments. They have the capacity to learn how to both shape and minimize potentially adverse effects of their environments or, alternatively, become more resilient. Throughout life, others, especially family members and friends, can help modify environments or, at least, buffer their impacts on individuals. Family-oriented pediatric care should educate and support patients and their families (so they can better cope with the stresses they are or will experience) and help them adopt positive cognitive skills, such as mindfulness, and health promoting behaviors, such as good nutrition, exercise, and the avoidance of deleterious habits, to enhance a positive health trajectory.³⁷ 

It is understood from studies of embryonic and fetal development and child psychology that physical, cognitive, social, and emotional development are sensitive not only to the quality, intensity, duration, and accumulation of environmental exposures and experiences but, also, to their timing. Clinical care should be guided by knowledge of sensitive periods of development and the challenges that typically occur during them. Guidance for health care supervision should include information to help parents anticipate and maximize these developmental opportunities as “teachable moments” and periods of personal growth. In addition, children interpret experiences. Their interpretations are influenced by their own past experience and their families’ experiences, beliefs, and values.

The structure and functioning of human biobehavioral systems change in response to experience (sensory, motor, hormonal, parent-child and peer relationships, stress, diet. and injury), which accounts for differences among individuals and between infants and adults. This adaptability is lifelong and can yield narrowed or expanded capacities and restricted or optimized health development. Some experiences can be predicted, whereas others are unanticipated; each will affect the brain. Child health care practices should attend to anticipated events, transitions, and milestones, which, although challenging and sometimes harmful, may also contribute to the development of resilience and enhanced LCHD. Pediatricians should encourage children and families to share with them notable experiences and successes as well as challenges, which may lead to adaptive changes; these can be discussed and managed by applying a health development perspective.

Optimal health development reflects individuals’ ability to achieve a state of well-being and function maximally in their various current and future roles. It is, in part, the dominance of individual strengths over adversity. Child health care providers promoting health development should, first, identify and, then, build on the strengths of patients and their families. Recognition of strengths can set the stage for addressing current or future challenges to health and development. Therapeutic interventions that build on strengths help guide patients, often through their families, to seek and acquire the personal, environmental, and social assets necessary to cope with and overcome future challenges to health and development.^38–40 

The development of health rests on harmonious, balanced interactions of numerous aspects of a child’s world: physical, emotional, educational, social, and cultural. Clinical care to promote health development requires the collaborative contributions of a team of people with skills to address or influence these many experiences. Pediatric practices intending to help children achieve optimal health development should have firmly established relationships with a wide variety of practice-based and community-based services and supports.⁴¹ 

Improving the health of children is an important and essential step toward improving the health of the US population. Developing good health is a lifelong process, with the greatest opportunities early in life. Pediatric preventive care visits are a nearly universal point of contact between children, their parents, and professionals committed to their care. Along with the efforts of public health and impact of better public policies, they are an important opportunity to improve children’s health development. Although it is up to the profession to consider and adopt improved approaches to preventive care, in Table 1, I suggest several attributes of that care suggested by the LCHD framework.

LCHD is strongly influenced, although not directly determined, by children’s and physicians’ social environments and life experiences. That environment (including such things as affluence or poverty, discrimination or equality, opportunity or impediment, and hope or fear) is of great consequence. The extent to which health care providers have responsibility for not only recognizing but addressing these factors is not easily answered. Even a measured role requires adequate training, time, information, and partnerships. Practice-based changes, such as the adoption of electronic records, health care teams, development and psychosocial screening and risk-adjusted capitated payment are easily identifiable, although not necessarily easy to incorporate. Even where those capacities are in place, it would be rare for a practice to have much in the way of information about their patients’ family or social circumstances. Such data do exist on a population basis within public agencies and could help inform practices were partnerships established and information shared.

Many programs with a social and developmental orientation have been developed to augment current practice. Although programs such as HealthySteps, Help Me Grow, Developmental Understanding and Legal Collaboration for Everyone, CenteringParenting, and integrated behavioral health care have a focus on child development, they do not necessarily take a life course perspective.⁴²  Also, impeding LCHD is a failure to prioritize interventions early in the life of children in public policy. Although the American Academy of Pediatrics has acknowledged the importance of early experience, other sectors continue to disproportionately support services for children of school-age and later or are designed to address the needs of adults and the elderly. One need only compare the availability of social security with that of family leave and other family support programs to see the differences.

The LCHD framework can be used to inform changes that have been recommended to improve pediatric preventive care so that it is more developmentally and socially focused, emphasizes health promotion as much as or more than disease prevention, and integrates with other service providers and programs.^27,43,44  Such an integrated approach will encourage greater awareness and response to the many social and environmental factors that, for better or worse, impact the health of developing humans, and, although a health development approach is future oriented, its effectiveness comes, in part, from helping to identify those sensitive times and circumstances that affect children’s health and well-being in real time. So, although health development occurs over the life course, it encourages activities to ensure that children live in their moment and experience a healthy, happy, and authentic childhood.

Clearly, much work is to be done within practices as well as within the public policy arena before LCHD becomes a driver of pediatric preventive care as well as other human services. Their understanding of the importance of experience on children’s development places pediatricians and other child health care providers in the position to advocate for needed change.

LCHD

life course health development