Healthy Families and Communities Support Healthy Children

Commentary From the AAP Committee on the Psychosocial Aspects of Child and Family Health

The American Academy of Pediatrics (AAP) Committee on the Psychosocial Aspects of Child and Family Health (COPACFH) is the latest iteration of the original Committee on Mental Hygiene. The committee was created in 1931, just 1 year after the founding of the AAP. The creation of a committee focusing on the child’s social, psychological, and emotional well-being reflected the views of the small group of maverick physicians who had founded the AAP. These physicians had been inspired by Abraham Jacobi who, in the prior century, had controversially promoted a focus on children’s development and the physician’s role as an advocate for the poor and disenfranchised. The committee continues its work in the spirit of its founders, promoting healthy emotional and social well-being of children through advocacy for their families and their communities. Inextricably linked to these goals are the promotion of equity, social justice, and anti-racism, some of the most pervasive social threats to healthy development of children in our society.

Healthy Families and Communities Support Healthy Children

Arwa Nasir, MBBS, MSc, MPH¹, Paul H. Dworkin, MD², Arthur Lavin MD, FAAP³

Affiliations: ¹University of Nebraska Medical Center, Omaha, NE; ²Connecticut Children’s Office for Community Child Health, University of Connecticut School of Medicine, Hartford, CT; ³Akron Children’s Hospital, Akron, OH

Highlighted Articles From Pediatrics

• Deisher RW, Engel WL, Spielholz R, Standfast SJ. Mothers’ opinions of their pediatric care. Pediatrics. 1965;35:82-90
• Schor EL, American Academy of Pediatrics Task Force on the Family. Family pediatrics: report of the Task Force on the Family. Pediatrics. 2003;111(6 Pt 2):1541-1571
• Chamberlin RW. “It takes a whole village”: working with community coalitions to promote positive parenting and strengthen families. Pediatrics. 1996;98(4):803-807
• Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246; doi: 10.1542/peds.2011-2663
• Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339; doi: 10.1542/peds.2016-0339
• Trent M, Dooley DG, Dougé J, et al. The Impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765; doi: 10.1542/peds.2019-1765

Much of the COPACFH published policy over the years has reflected a growing understanding of the role of the family in promoting children’s optimal health, development, and well-being; the importance of social and psychological factors on children’s developmental trajectories; and the importance of engaging sectors beyond that of child health services alone in strengthening families and their children.

The Family as the Key Promoter of Children’s Well-Being

In 1965, Robert Deisher and colleagues addressed the importance of parents’ opinions on care for their children, foreshadowing the importance of recognizing parents as the key drivers of their children’s optimal health, development, and well-being and engaging parents as partners in the process of developmental promotion.¹ This article is relevant background to the evolution of parent/family engagement from a unidirectional process of advice-giving; the acknowledgement of the importance of the “voice of the family”; family co-production of interventions, programs, and services; and currently the advancement of the concept of “family-driven care.” Barbara Korsch had powerfully advocated for improving doctor-patient communication during the clinical encounter to address issues “at the level of parents’ cultural, cognitive, and psychological readiness.”

The focus on the family as the key promoter of children’s optimal health, development, and well-being further evolved with the publication of the landmark article, “Family Pediatrics: Report of the Task Force on the Family,”² which highlighted the crucial impact of family dynamics on the health and development of all family members, particularly children. This report pointed out that the assessment of the psychosocial well-being of the family is an integral part of the assessment of the child. This concept was subsequently expanded to address a wide range of critical family-related issues with major implications for children. In 2010, screening for maternal depression was incorporated into pediatric care. This represented a paradigm shift in health care delivery and further emphasized the importance of the mother’s well-being in ensuring the health of their children. In 2013, despite widespread controversy and diverse opinions, COPACFH championed support of diverse families through its policy statement on same-sex parenting and recognizing non-traditional families.

Acknowledging the key role of families and parents in promoting children’s optimal development suggests the importance of both strengthening parents’ understanding of their children’s development and their capacity to engage in development-promoting activities, as well as eliciting parents’ opinions and concerns for their children’s development and behavior. Several key articles speak to enhancing the capacity of parents to engage in developmental promotion. Positive parenting, quality time, and shared play and reading are keys to enhancing children’s strong, secure attachments and the emotional regulation skills needed by children to learn and to solve problems. Three development-promoting, brain-building interventions are addressed in statements about play, shared reading and literacy promotion, and positive discipline. These practices enable the pediatrician to go beyond treatment, and even prevention, to promote children’s optimal development. Bringing developmental promotion to scale would fulfill the dreams of the idealistic founders of the discipline of pediatrics.

Promoting optimal development also involves early identification of developmental delays or disorders. The 2006 statement, “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening,” recommended routine surveillance and screening during the well-child visit. This statement encouraged the elicitation of parents’ opinions and concerns for their children’s development and behavior and spurred educational programs for parents and childcare workers to increase public awareness of developmental disabilities and to promptly identify at-risk children.

Social, Environmental, and Behavioral Factors as Drivers of Children’s Development

In 1972, Robert Haggerty coined “the new morbidity” to describe the rising toll of behavioral and mental health problems among children. Although a number of articles, such as “The Pediatrician and the New Morbidity” and “The New Morbidity Revisited” made suggestions for clinical practice and educational transformations to address this burgeoning problem, clinicians, academicians, public officials, and policymakers are still grappling with the scale and implications of this epidemic today. In 1996, Robert Chamberlin, a colleague of Haggerty, authored “It Takes a Whole Village: Working With Community Coalitions to Promote Positive Parenting and Strengthening Families.”³ This commentary proposed that child and family support should include community-based programs and services, in addition to those offered through the child health services sector.

The 2012 landmark article, “The Lifelong Effects of Early Childhood Adversity and Toxic Stress,”⁴ revealed a remarkably strong relationship between childhood adversity and poor health outcomes in later life. These findings and subsequent articles which focused on scientific advances in our understanding of epigenetics and the biology of adversity suggest that pediatric practice can evolve in the near future to enable specific interventions tailored to children’s risk and resiliency profiles.⁵

Cross-Sector Collaboration to Address Key Impediments to Children’s Well-Being

The capacity of pediatricians and other child health providers to strengthen families to promote children’s optimal health, development, and well-being is ultimately predicated on the child health services sector collaborating with other key sectors, such as early care and education, family support, child and family legal services, and economic development. If one acknowledges that social, environmental, and behavioral factors have tremendous influence on children’s health, development, and well-being, then the devastating impacts of poverty and racism clearly demand our critical attention. The policy statement, “Poverty and Child Health in the United States,”⁶ and its accompanying technical report, “Mediators and Adverse Effects of Child Poverty in the United States,” highlight how poverty affects health outcomes. These publications call on pediatricians to screen families for poverty and its effects. These statements also advocate for both support programs and coordinated efforts to end poverty through policies such as the child tax credit.

The past decade has witnessed an increasing awareness of the ubiquity of the vicious and pervasive impact of racism in our society. As painful as it may be for many to confront the legacy of racism and to consider steps that lead to a fairer future, some publications have begun to earnestly explore medicine’s role in perpetuating racism. In 2022, Joseph Wright published the policy statement “Eliminating Race-Based Medicine.” The AAP has also apologized for its past racist practices against African American physicians and recognized the profound role that racism plays in disparities in health and health care.⁷ It will require much difficult work for the impacts of poverty and racism to be eliminated by the 150-year milestone as effectively as the scourges of diseases such as smallpox have been vanquished over the past 75 years.

References

1. Deisher RW, Engel WL, Spielholz R, Standfast SJ. Mothers’ opinions of their pediatric care. Pediatrics. 1965;35:82-90
2. Schor EL, American Academy of Pediatrics Task Force on the Family. Family pediatrics: report of the Task Force on the Family. Pediatrics. 2003;111(6 Pt 2):1541-1571
3. Chamberlin RW. “It takes a whole village”: working with community coalitions to promote positive parenting and strengthen families. Pediatrics. 1996;98(4):803-807
4. Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246; doi: 10.1542/peds.2011-2663
5. Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339; doi: 10.1542/peds.2016-0339
6. Trent M, Dooley DG, Dougé J, et al. The Impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765; doi: 10.1542/peds.2019-1765