Ethical Issues and Dilemmas in Caring for Children and Adolescents

FOREWORD

Child Well-being and Adverse Childhood

Experiences in the United States

Christina D. Bethell, PhD, MBA, MPH; Lisa A. Simpson, MB, BCh, MPH, FAAP; Michele R. Solloway, PhD, MPA

From the Johns Hopkins Bloomberg School of Public Health, Child and Adolescent Health Measurement Initiative, Department of Population, Family and Reproductive Health (Drs Bethell and Solloway), Baltimore, Md; and Academy Health (Dr Simpson), Washington, DC The authors have no conflicts of interest to disclose. Address correspondence to Christina D. Bethell, PhD, MBA, MPH, Johns Hopkins Bloomberg School of Public Health Department of Population, 615 N Wolfe Street, Rm E-4152, Baltimore, MD 21205 (e-mail: [email protected]).

ACADEMIC PEDIATRICS 2017;17:S1–S3

THIS SPECIAL ISSUE of Academic Pediatrics on pro- moting child and family well-being and addressing adverse childhood experiences (ACEs) through health services research, policy, and practice comes at a time of great concern in our nation about the future of children and youth, particularly the many already exposed to or at high risk for multiple threats to achieving optimal health. This special issue represents the culmination of a 4-year effort to engage stakeholders in child and family health across multiple sec- tors and includes a comprehensive national research and ac- tion agenda, 13 articles, and 15 commentaries. The issue opens with a commentary on alignment of this special issue with the Robert Wood Johnson Foundation’s Culture of Health framework (Davis et al1) followed by commentaries representing a range of experts and key stakeholders. The papers begin with a summary of a national health services research, policy, and practice agenda to advance effective ef- forts to address ACEs and promote child and family well-be- ing (Bethell et al

2 ). Papers are organized into 4 sections: 1)

frameworks and measurement, 2) systems of care and clin- ical practice, 3) community and family approaches, and 4) implications for policy.

The national agenda identifies 4 priority goals, 4 priority research areas, and 16 priority actions that leverage existing research, policy, and practice systems and structures. Taken together, these priorities are recommended in order to cata- lyze the paradigm shift called for by the science of ACEs and the emerging sciences of thriving. A new integrated sci- ence of thriving is taking shape and points to the untapped potential for health in the face of adversity. Research now places relationship-centered health care and family and community engagement at the center of our work to prevent and mitigate the effect of ACEs-related stress and trauma, establish resilience, promote positive health skills, and improve child health and well-being. The agenda summarizes the multidisciplinary support found for: 1) widespread education and other actions to shift individual, collective, and institutional paradigms, aware- ness, and action, 2) the need to build greater capacity for

ACADEMIC PEDIATRICS Copyright ª 2017 by Academic Pediatric Association S1

relationship-centered care and skills simultaneous with rapid cycle innovation and learning around coping with and healing trauma, and 3) the importance of addressing in- equities through advocacy, education, and policies needed to both prevent and help buffer and attenuate the effects of the social determinants of health like ACEs on child and family stress and trauma through the life course. The articles in the frameworks and measurement section

review the current state of ACEs-related measures and pro- pose new frameworks. Bethell et al3 characterize existing and emerging methods and models for assessing ACEs as a risk for trauma and poorer health across the life course; outline the application and rationale for measuring ACEs; and compare the properties of existing and emerging mea- sures. The validity and psychometric properties of the National Survey of Children’s Health ACEs measure is spe- cifically evaluated. Halfon et al

4 explore inequities in eco-

nomic, social, and health factors among children with ACEs and the implications for child health. Sege and Harper-Brown5 introduce “HOPE: Health Outcomes from Positive Experiences” – a framework that expands the con- ventional approaches that focus on risks by elevating the importance of proactively promoting positive experiences for children. Ellis and Dietz6 propose a transformative approach to achieve synergies across child health and community-based agencies to address the root causes of toxic stress and childhood adversity and build community resilience. Commentaries related to this section include that of Hargreaves et al,7 who reflect on approaches to eval- uating strategies to increase capacity at multiple levels and address ACEs; and Ford8 shares lessons learned from con- fronting ACEs as the CEO of a Medicaid managed care plan. He outlines a vision and framework for community and public well-being and the training and curriculum needed to support this vision. Articles in the systems of care and clinical practice sec-

tion take on different dimensions of the opportunities and challenges of addressing ACEs through health care sys- tems. Brown et al9 explore models for integrating primary

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S2 BETHELL ET AL ACADEMIC PEDIATRICS

and behavioral health care as a strategy to address ACEs. They offer key lessons from a national learning collabora- tive on how integration can promote resilience, positive health outcomes, and more seamlessly address ACEs in pediatric practice. Magen and DeLisser10 provide a review of approaches being used in a growing number of health professional training programs to improve relational skills. The authors posit that proficiency in building a relational collaboration with children and families that is founded on safety and trust is a fundamental skill in the provision of trauma informed services. Soleimanpour et al11 focus on what is known about ACEs in the adolescent population and provide recommendations for how clinical and commu- nity systems can coordinate to support adolescents’ healthy development. Much has been written about the extent to which—and for whom—the patient-centered medical home model improves care and outcomes. However, much of this literature is focused on improving the treat- ment of chronic diseases rather than on addressing psycho- social adversity. Vu et al12 gathered key stakeholder input about how patient-centered medical homes might feasibly and sustainably address psychosocial adversity within their patient populations.

Commentaries related to this section bring in the voices of various stakeholders in health care, each working to respond to the multifaceted challenges presented by ACEs, making clear the critical importance of integrated team approaches. Two commentaries speak poignantly of the imperative for pediatricians to engage more forcefully in the identification, prevention, and management of ACEs (Hassink

13 and Burke Harris

14 ). Girouard

15 outlines the

critical role of nurses, and Grimes16 speaks directly to the challenges of meeting the mental health treatment needs of children.

In the community and family approaches section, Bruner17 discusses neighborhood characteristics that contribute to exposure to trauma and stress as well as char- acteristics that can serve as mitigating protective factors. He emphasizes the important role that community health care organizations (eg, health centers) can play as anchor institutions and sources for community-building for such neighborhoods. Also working at the level of the broader community, Pachter et al18 report on a citywide, multisec- tor collaboration, the Philadelphia ACEs Task Force, to address ACEs and promote resilience for Philadelphia residents. Several commentaries related to these themes highlight the voices of families and other community pro- viders (Vickers and Wells19) and demonstrate the impor- tance of culture and the centrality of local efforts as a focal point for effective intervention (Porter et al20 and Jones21). Stevens22 further illustrates the role of journalism and the media as a tool for promoting widespread educa- tion and leveraging collective impact.

The final set of articles focus on implications for policy in our current health care system’s context. Srivastav et al23 focus on how to leverage the various policy opportunities put in motion by the Affordable Care Act. Steverman and Shern24 go beyond the health system dominant focus of Affordable Care Act-related policies

and explore a broad range of public and private financing mechanisms to support the primary prevention of ACEs, including more recent innovations such as pay- for-success contracts. Their article provides examples that link various funding mechanisms to innovations in the field, discusses the incentives created under each mechanism, and the relationship between financing mechanisms and ACEs. Biglan et al25 advance a vision for evolving a more nurturing society through the transla- tion of prevention sciences into policy and practice across sectors. Commentaries related to this final section offer insights and perspectives from a range of child health stakeholders in different policy sectors including the role of early childhood programs (Beckman26), state Maternal and Child Health programs (Planey

27 ), and the

criminal justice system (Garbarino28). Rosenbaum29

also promotes the use of Medicaid and makes the case for the enduring role of Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment as a primary mech- anism to address and treat childhood trauma. This special issue of Academic Pediatrics has been a

labor of love, commitment, and contribution by many. It is our hope that our efforts inspire all who read it to redouble their individual and collective efforts to make this world a more welcoming, nurturing, and ultimately safe place for children to flourish for decades to come.

ACKNOWLEDGMENTS Financial disclosure: Publication of this article was supported by the

Promoting Early and Lifelong Health: From the Challenge of Adverse

Childhood Experiences (ACEs) to the Promise of Resilience and

Achieving Child Wellbeing project, a partnership between the Child and

Adolescent Health Measurement Initiative (CAHMI) and Academy-

Health, with support from the Robert Wood Johnson Foundation

(#72512).

We thank the hundreds of individuals who contributed to this effort.

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