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Are We Fulfilling Our Promise to Children Facing Health Disparities and Adverse Childhood Experiences?
PRESIDENT’S MESSAGE
Are We Fulfilling Our Promise to Children Facing Health Disparities and Adverse Childhood Experiences? Laura Searcy, MN, APRN, PPCNP-BC, President and Fellow
As pediatric advanced practice nurses, we believe children need to be cared for comprehensively and holistically. They have the right to grow up in a safe, nurturing environment with access to high-quality health care, nutritious food, adequate educational opportunities, and other resources necessary for them to reach their full potential. They need to be protected from harm, and they need to have access to healing support when trauma occurs. Bias or discrimination should not hold back children from the equal opportunities afforded to them as American citizens. We dedicate our lives and our careers to helping achieve this reality of equal opportunity for our patients and their families. We do make a difference. Increasingly, however, I hear words of discouragement and disillusionment from our members who care for children who seem to have very little opportunity to reach their full potential. These children seem to have little chance of living the American Dream. If we are to make it possible for our children to enjoy ‘‘life, liberty, and the pursuit of happiness’’ as promised
Correspondence: Laura Searcy MN, APRN, PPCNP-BC, National Association of Pediatric Nurse Practitioners, 5 Hanover Square, Suite 1401, New York, NY 10004; e-mail: laurafsearcy@gmail. com. J Pediatr Health Care. (2017) 31, 142-144. 0891-5245/$36.00 http://dx.doi.org/10.1016/j.pedhc.2016.12.002
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in our nation’s founding documents, then we must take an honest and objective look where we are falling short. Some answers can be found in examining disparities affecting the health of children and in considering the impact of adverse childhood experiences and toxic stress. Disparities related to health affect large numbers of our nation’s children. Health care disparities refer to differences between groups in insurance coverage and costs, availability and use of facilities and services, and quality of care. Health status disparities refer to the variation in the burden of rates of disease occurrence, mortality injury, and disabilities experienced by one population group relative to another (Artiga, 2016; U.S. National Library of Medicine, 2016). Disparities can be due to factors such as race, age, sex, sexual identity and orientation, geographic location, socioeconomic status, insurance status, and disability status. Health disparities are costly, not only in terms of mortality, morbidity, and quality of life, but also in economic terms. For example, the cost of disparities between ethnic groups in health care alone was estimated at $35 billion in excess health care expenditures, $10 billion in illness-related lost productivity, and $200 billion in premature deaths (Ayanian, 2016). The body of science showing the lifelong consequences of adverse childhood experiences (ACEs) and toxic stress is especially sobering. ACEs are stressful or traumatic events that include abuse and neglect.
Journal of Pediatric Health Care
They may also include household dysfunction such as witnessing domestic violence or growing up with family members who have substance use disorders (Center for the Application of Prevention Technologies, 2016). The landmark ACE study was one of the first to show a link between childhood experiences and adult health (Felitti et al., 1998). This study examined the relationship that childhood emotional, physical, or sexual abuse and household dysfunction had to adult disease and adult health risk behaviors. The original study participants were not from a population at risk for ACEs. Subjects included over 17,000 mostly White, employed, middle and upper-middle class, college-educated, insured persons with good access to health care. Nearly two thirds of participants reported one ACE, and one fifth reported three or more ACEs. As the number of ACEs increased, so did the likelihood of negative physical and mental health outcomes and unhealthy behaviors as adults. Toxic stress results from strong, frequent, and/or prolonged adversity such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship without adequate adult support. Extensive research on the biology of stress shows the significance of toxic stress. Prolonged activation of the stress response systems can disrupt the development of brain architecture and increase the risk for stress-related disease and cognitive impairment. This prolonged activation can have damaging effects on learning, behavior, and health across the lifespan (Harvard University Center on the Developing Child, 2014). Findings from disciplines such as molecular biology, neuroscience, neuroendocrinology, genomics, and immunology confirm that the origin of adult disease is often due to developmental and biologic disruptions during the early years of life from cumulative damage over time or disruptions in neurodevelopment during sensitive developmental periods (Shonkoff, Boyce, & McEwen 2009). I find this information to be profoundly disturbing. Our future depends in large part on how we nurture, support, and care for our children. It is imperative that we address the host of social and environmental issues negatively affecting children. Our child health policies need to promote better awareness of the degree early and continued exposures to stressful environments are related to poor health outcomes throughout their lives. We must implement strategies to reduce risk factors and increase protective factors. The good news is that many ACEs are preventable, and health care disparities and social determinants of health can be addressed. There is much valuable information from many sources available to assist in this work. The Centers for Disease Control and Prevention, Injury Prevention and Control Division (2016) has many resources conwww.jpedhc.org
cerning violence prevention, child maltreatment, and ACEs. Another good resource is the document Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States (U.S. Department of Health and Human Services, 2010), which ‘‘envisions a day when preventable death, illness, injury, and disability, as well as health disparities, will be eliminated and each person will enjoy the best health possible’’ (section 1, para. 2). The authors included individualand population-level strategies for disease prevention and health promotion. Goals and strategies to eliminate preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote healthy development and healthy behaviors across every stage of life are summarized (U.S. Department of Health and Human Services, 2010). As child health advocates, we need to work to be sure that the challenges our children face are continuously put before policymakers to ensure that our public health priorities address these needs. As child health advocates, we need to work to be sure that the challenges our children face are continuously put before policymakers that our public health priorities put kids first. Experience has shown even in polarized political times, it has been possible to come together and address important kids’ issues. I have faith that we can continue to do so. We must. Our future depends on it. REFERENCES Artiga, S. (2016). Disparities in health and health care: Five key questions and answers. Menlo Park, CA: Kaiser Family Foundation. Retrieved from http://kff.org/disparities-policy/issue-brief/ disparities-in-health-and-health-care-five-key-questions-andanswers/ Ayanian, J. Z. (2016). The cost of racial disparities in health care. NEJM Catalyst. Waltham, MA: Massachusetts Medical Society. Retrieved from http://catalyst.nejm.org/the-costs-of-racial-dis parities-in-health-care/ Center for the Application of Prevention Technologies. (2016). Adverse childhood experiences. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http:// www.samhsa.gov/capt/practicing-effective-prevention/preven tion-behavioral-health/adverse-childhood-experiences Centers for Disease Control and Prevention. (2016). About the CDCKaiser ACE Study. Atlanta, GA: Author. Retrieved from https:// www.cdc.gov/violenceprevention/acestudy/about.html Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ., Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14, 245-258. Harvard University Center on the Developing Child. (2014). Key concepts: Toxic stress. Cambridge, MA: Author. Retrieved from http://developingchild.harvard.edu/key_concepts/toxic_stress_ response/ Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252-2259.
March/April 2017
143
U.S. Department of Health and Human Services. Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. (2010). Healthy People 2020: An opportunity to address societal determinants of health in the United States. Washington, DC: Author. Retrieved from
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http://www.healthypeople.gov/2010/hp2020/advisory/Societal DeterminantsHealth.htm U.S. National Library of Medicine, National Institutes of Health. (2016). Medical subject headings. Bethesda, MD: Author. Retrieved from https://www.nlm.nih.gov/mesh/
Journal of Pediatric Health Care
Are We Fulfilling Our Promise to Children Facing Health Disparities and Adverse Childhood Experiences? Laura Searcy, MN, APRN, PPCNP-BC, President and Fellow
As pediatric advanced practice nurses, we believe children need to be cared for comprehensively and holistically. They have the right to grow up in a safe, nurturing environment with access to high-quality health care, nutritious food, adequate educational opportunities, and other resources necessary for them to reach their full potential. They need to be protected from harm, and they need to have access to healing support when trauma occurs. Bias or discrimination should not hold back children from the equal opportunities afforded to them as American citizens. We dedicate our lives and our careers to helping achieve this reality of equal opportunity for our patients and their families. We do make a difference. Increasingly, however, I hear words of discouragement and disillusionment from our members who care for children who seem to have very little opportunity to reach their full potential. These children seem to have little chance of living the American Dream. If we are to make it possible for our children to enjoy ‘‘life, liberty, and the pursuit of happiness’’ as promised
Correspondence: Laura Searcy MN, APRN, PPCNP-BC, National Association of Pediatric Nurse Practitioners, 5 Hanover Square, Suite 1401, New York, NY 10004; e-mail: laurafsearcy@gmail. com. J Pediatr Health Care. (2017) 31, 142-144. 0891-5245/$36.00 http://dx.doi.org/10.1016/j.pedhc.2016.12.002
142
Volume 31 Number 2
in our nation’s founding documents, then we must take an honest and objective look where we are falling short. Some answers can be found in examining disparities affecting the health of children and in considering the impact of adverse childhood experiences and toxic stress. Disparities related to health affect large numbers of our nation’s children. Health care disparities refer to differences between groups in insurance coverage and costs, availability and use of facilities and services, and quality of care. Health status disparities refer to the variation in the burden of rates of disease occurrence, mortality injury, and disabilities experienced by one population group relative to another (Artiga, 2016; U.S. National Library of Medicine, 2016). Disparities can be due to factors such as race, age, sex, sexual identity and orientation, geographic location, socioeconomic status, insurance status, and disability status. Health disparities are costly, not only in terms of mortality, morbidity, and quality of life, but also in economic terms. For example, the cost of disparities between ethnic groups in health care alone was estimated at $35 billion in excess health care expenditures, $10 billion in illness-related lost productivity, and $200 billion in premature deaths (Ayanian, 2016). The body of science showing the lifelong consequences of adverse childhood experiences (ACEs) and toxic stress is especially sobering. ACEs are stressful or traumatic events that include abuse and neglect.
Journal of Pediatric Health Care
They may also include household dysfunction such as witnessing domestic violence or growing up with family members who have substance use disorders (Center for the Application of Prevention Technologies, 2016). The landmark ACE study was one of the first to show a link between childhood experiences and adult health (Felitti et al., 1998). This study examined the relationship that childhood emotional, physical, or sexual abuse and household dysfunction had to adult disease and adult health risk behaviors. The original study participants were not from a population at risk for ACEs. Subjects included over 17,000 mostly White, employed, middle and upper-middle class, college-educated, insured persons with good access to health care. Nearly two thirds of participants reported one ACE, and one fifth reported three or more ACEs. As the number of ACEs increased, so did the likelihood of negative physical and mental health outcomes and unhealthy behaviors as adults. Toxic stress results from strong, frequent, and/or prolonged adversity such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship without adequate adult support. Extensive research on the biology of stress shows the significance of toxic stress. Prolonged activation of the stress response systems can disrupt the development of brain architecture and increase the risk for stress-related disease and cognitive impairment. This prolonged activation can have damaging effects on learning, behavior, and health across the lifespan (Harvard University Center on the Developing Child, 2014). Findings from disciplines such as molecular biology, neuroscience, neuroendocrinology, genomics, and immunology confirm that the origin of adult disease is often due to developmental and biologic disruptions during the early years of life from cumulative damage over time or disruptions in neurodevelopment during sensitive developmental periods (Shonkoff, Boyce, & McEwen 2009). I find this information to be profoundly disturbing. Our future depends in large part on how we nurture, support, and care for our children. It is imperative that we address the host of social and environmental issues negatively affecting children. Our child health policies need to promote better awareness of the degree early and continued exposures to stressful environments are related to poor health outcomes throughout their lives. We must implement strategies to reduce risk factors and increase protective factors. The good news is that many ACEs are preventable, and health care disparities and social determinants of health can be addressed. There is much valuable information from many sources available to assist in this work. The Centers for Disease Control and Prevention, Injury Prevention and Control Division (2016) has many resources conwww.jpedhc.org
cerning violence prevention, child maltreatment, and ACEs. Another good resource is the document Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States (U.S. Department of Health and Human Services, 2010), which ‘‘envisions a day when preventable death, illness, injury, and disability, as well as health disparities, will be eliminated and each person will enjoy the best health possible’’ (section 1, para. 2). The authors included individualand population-level strategies for disease prevention and health promotion. Goals and strategies to eliminate preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote healthy development and healthy behaviors across every stage of life are summarized (U.S. Department of Health and Human Services, 2010). As child health advocates, we need to work to be sure that the challenges our children face are continuously put before policymakers to ensure that our public health priorities address these needs. As child health advocates, we need to work to be sure that the challenges our children face are continuously put before policymakers that our public health priorities put kids first. Experience has shown even in polarized political times, it has been possible to come together and address important kids’ issues. I have faith that we can continue to do so. We must. Our future depends on it. REFERENCES Artiga, S. (2016). Disparities in health and health care: Five key questions and answers. Menlo Park, CA: Kaiser Family Foundation. Retrieved from http://kff.org/disparities-policy/issue-brief/ disparities-in-health-and-health-care-five-key-questions-andanswers/ Ayanian, J. Z. (2016). The cost of racial disparities in health care. NEJM Catalyst. Waltham, MA: Massachusetts Medical Society. Retrieved from http://catalyst.nejm.org/the-costs-of-racial-dis parities-in-health-care/ Center for the Application of Prevention Technologies. (2016). Adverse childhood experiences. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http:// www.samhsa.gov/capt/practicing-effective-prevention/preven tion-behavioral-health/adverse-childhood-experiences Centers for Disease Control and Prevention. (2016). About the CDCKaiser ACE Study. Atlanta, GA: Author. Retrieved from https:// www.cdc.gov/violenceprevention/acestudy/about.html Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ., Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14, 245-258. Harvard University Center on the Developing Child. (2014). Key concepts: Toxic stress. Cambridge, MA: Author. Retrieved from http://developingchild.harvard.edu/key_concepts/toxic_stress_ response/ Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252-2259.
March/April 2017
143
U.S. Department of Health and Human Services. Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. (2010). Healthy People 2020: An opportunity to address societal determinants of health in the United States. Washington, DC: Author. Retrieved from
144
Volume 31 Number 2
http://www.healthypeople.gov/2010/hp2020/advisory/Societal DeterminantsHealth.htm U.S. National Library of Medicine, National Institutes of Health. (2016). Medical subject headings. Bethesda, MD: Author. Retrieved from https://www.nlm.nih.gov/mesh/
Journal of Pediatric Health Care