The editors of the Section on Pediatric Trainees feature in Pediatrics are deeply pleased to share the leading submissions from the feature’s seventh annual essay competition, which focused on the role of adverse childhood experiences (ACEs) in pediatric medicine, and youth welfare more broadly. The runner-up essay, by Dr Alessandra Angelino, appears in this month’s issue. Dr Angelino’s essay presents an intimate and striking account of the disparate impacts of ACEs on Indigenous youth, along with the concrete steps pediatricians can take to combat such structural inequities. The winning essay by Dr Kasey Chelemedos, which focused on the author’s lived experiences with childhood trauma alongside her clinical experiences caring for patients facing similar, although distinct, challenges, appeared in last month’s issue.
“He was late for his scheduled admission again.”
I watched Robert, an 18-year-old American Indian man with newly diagnosed Ewing sarcoma, through the window of his hospital room. He sat in bed with a beanie and signature bright red headphones, ready to camp at the hospital for his chemotherapy admission alone. Why was he late? Why was he alone?
His life narrative was full of context. At age 7, Robert was placed in the foster care system because of neglect stemming from poverty and systemic racism experienced by many in his community. At 18, he aged out of the foster system, lived between relatives, and planned to move out of state for work. In addition to navigating the transition from adolescence to adulthood without a stable guardian, Robert had to process a new cancer diagnosis and the accompanying logistic challenges, including insurance coverage and transportation to an academic hospital center 3 hours from his community while balancing completing high school. With these numerous obstacles and navigating complex medical systems alone, it is no wonder he arrived late.
Robert’s experience exemplifies the impact of ACEs on health care and its delivery. ACEs describe exposure to violence, emotional, physical, or sexual abuse, poverty, and other forms of household and parental dysfunction.1 American Indian youth, along with other minoritized populations in the United States, are disproportionately impacted by ACEs.2,3 ACEs predispose individuals to significant morbidity and mortality in adulthood, including obesity, depression, suicide, alcohol and drug misuse, cardiovascular disease, and cancer. They also affect markers of socioeconomic status, such as educational attainment and occupation.4 Robert’s exposure to household dysfunction and foster care at a young age, compounded by poor access to high-quality health care, a lack of financial support, and challenging transportation, represents a significant ACE burden. Unfortunately, in addition to these exposures and the trauma of a cancer diagnosis, he also experienced discrimination and bias at the hands of hospital staff.
To fully comprehend the impact of ACEs on American Indian/Alaska Native (AI/AN) communities, it is critical to understand historical factors that dictate the social, economic, and political determinants of health (ie, systemic racism) beginning with colonization.
Colonization efforts in the United States attempted to gain dominance over AI/AN populations by systematically eliminating life, culture, and sovereignty.5 Countless atrocities were perpetrated against AI/AN populations, including forced relocation (ie, the Indian Removal Act of 1830, which permitted the “Trail of Tears”) and the Indian Boarding School system, which persisted until the 1960s.6 Colonialism persists today in the United States through patterns of land allocation that affect access to economic, natural, and health care resources, as evidenced by Robert’s challenging circumstances.6 Additionally, policies affecting environmental health and human rights, including the Missing and Murdered Indigenous Peoples crisis, predispose AI/AN individuals to the consequences of historical trauma.7–9
Historical trauma describes the effect of repetitive, intergenerational traumas against a specific population.10 Several mechanisms link historical factors to contemporary health outcomes through epigenetic phenomena and psychosocial models, leading to disproportionate vulnerability to ACEs among AI/AN communities.6,11 Rates of ACEs are higher in AI/AN communities than in other demographics. In one study, 20% of AI/AN respondents in South Dakota identified exposure to 6 or more adverse experiences, relative to 4% of non-AI/AN participants.2 In this sample, increased exposure to ACEs was associated with depression, anxiety, and posttraumatic stress disorder in adulthood.2
Reflecting on Robert’s story, the connection between historical traumas and ACEs is clear. Hailing from a family experiencing poverty and a lack of resources resulting from systemic inequity, he was at increased risk for household dysfunction, familial stress, and, ultimately, ACEs. Although it is essential to acknowledge the systems that served as barriers to his care, it is also vital to recognize and celebrate Robert’s resilience and strengths. He independently found transportation to each appointment and chemotherapy admission, drove 3 hours each way between his community and appointments, and advocated for himself during each interaction. Robert asked insightful questions, shared his love for music, and kept everyone on their toes with his sense of humor. He was a brilliant example of someone transcending ACEs toward success.
Educational initiatives that include AI/AN culture longitudinally, from primary through medical school, can transform awareness surrounding the challenges and strengths of this unique population and reduce bias. To overcome misconceptions about AI/AN communities, curricula should address historical contexts, the demographic distribution of AI/AN communities across the United States, and the unique needs of rural versus urban AI/AN populations. This aim may be supported by the generation of an Accreditation Council for Graduate Medical Education requirement dedicated to understanding the needs of AI/AN populations.
Similarly, pediatric providers play critical roles in identifying and mitigating the impact of ACEs on AI/AN youth. Clinicians utilizing ACE screeners can adapt the tool with culturally informed questions to assess the effects of historical and intergenerational traumas, discrimination, and posttraumatic stress. Clinicians can incorporate questions from the “Pediatric Trauma Score” to evaluate the impacts of trauma on patients rather than solely identifying a traumatic experience.12
In addition to evaluating racially driven discrimination, clinicians must assess gender-based discrimination for Two Spirit and gender-expansive youth. Conventional ACEs screeners may be expanded to incorporate relationships with the natural environment and access to clean drinking water. AI/AN land rights remain threatened in the United States, and AI/AN children are disproportionately affected by environmental exposures, including heavy metals, dumping sites, and organic pollutants.6 Land allocation patterns also predispose low-cost processed food consumption, elevating rates of obesity and diabetes in AI/AN children.13
Highlighting strengths among AI/AN communities promotes healing from historical and modern traumas.6,14 Thus, ACE screeners must assess strengths among youth and their families. This would serve as another means to connect providers with patients and their families and permit a healing environment that builds trust, self-esteem, and confidence. Providers can learn more about assessing positive childhood experiences (PCEs) through programs such as the Alaska Children’s Trust History & Hope. This culturally based program shares the benefits of PCEs and assists providers in identifying personal bias.15
Addressing the findings of these screenings is also important. Utilizing local, community-grounded resources that allow AI/AN youth to connect with their culture is often the most beneficial. Several national campaigns have sought to address ACEs in AI/AN children, including the Family Spirit Home Visiting Program through Johns Hopkins University.16 Mirroring these efforts, clinicians can focus on building or strengthening partnerships with AI/AN communities and elevating tribal sovereignty in advocacy work.17,18 During patient encounters, allowing patients and their families to connect with providers through storytelling (in line with traditional Indigenous knowledge transfer via narration19,20 ) and incorporating traditional healing practices21 is critical in fostering a sense of community and self.
Improving understanding of historical contexts and systemic racism experienced by AI/AN communities, incorporating these into ACEs screening, and encouraging PCEs can support resiliency and improve health across many domains. Each patient interaction has the potential to generate a safe environment for empathy, education, and advocacy, thereby attenuating the effects of ACEs. Each clinic can become a medical home, improving screening and understanding the community’s strengths. Each physician can advocate updating screening recommendations, support the recruitment and retention of providers serving AI/AN populations, and fight for equity to improve the health of AI/AN communities. Each patient like Robert deserves equitable access to care and providers and staff who will celebrate their strengths and resilience, even when they are late, again.
Dr Angelino conceptualized the feature, drafted the initial manuscript, and critically reviewed and revised the manuscript. Dr Burns conceptualized the feature and critically revised the manuscript. Drs Deen and Empey reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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