There is a major change underway in how patients are treated at the Le Bonheur Children’s Hospital pediatric clinic. Pediatricians at Le Bonheur, who see 95,000 outpatient visits annually, ask their young patients about food, housing and transportation security during regular medical checkups.
Le Bonheur trained staff to ask these additional questions and interpret the responses to incorporate awareness of adverse childhood experiences, or ACEs, into their diagnosis and treatment.
“We had never asked because we didn’t know what to do about it,” said Dr. Jonathan McCullers, pediatrician-in-chief at Le Bonheur and pediatrics department chair at the University of Tennessee Health Sciences Center.
“You get paid to treat asthma, but you don’t get paid to prevent that hospitalization."
This shift is part of a Le Bonheur and UTSHC partnership called the Family Resilience Initiative, which screens for ACEs in order to provide wraparound services and aims to prevent adverse experiences altogether through comprehensive programs that focus on maternal care.
According to McCullers, two-thirds of the Memphis children that come through the clinic have at least four ACEs that they express, and one-third have both food and housing insecurity. ACEs are potentially traumatic life events that can range from the incarceration of a parent to exposure to neighborhood violence.
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Amir Gooden is treated by Dr. Jason Yaun at Le Bonheur Children's Hospital as part of the Family Resilience Initiative clinic. (Brandon Dahlberg)
After discovering theses ACEs, the doctors can do what McCullers called “a warm handoff” to the more than 20 community programs Le Bonheur and the University of Tennessee Health Science Center have developed to address common issues.
They have partnered with Lyft to provide transportation to the clinic so that children do not miss their appointments. For issues related to domestic violence, guardianship or housing, they often refer patients to the Memphis CHiLD legal clinic. For the food insecure, the provide patients with connections to local food banks. Le Bonheur’s CHAMP program sends community health workers into homes to find solutions to high-risk asthma patients, which has resulted in a 60 percent decrease in hospitalizations, McCullers said.
However, in the American healthcare model, it doesn’t pay to be innovative.
Traditionally, hospitals are paid for their services through insurance reimbursement. Treatments, tests, surgeries, and any care provided because of an illness or injury fall under this umbrella.
What is often not covered are preventative measures to prevent these injuries and illnesses from ever developing. One illness prevalent among children in Memphis, for example, is asthma, which can be developed due to environmental factors related to substandard housing.
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Social determinants of health are seen as related to public policy decisions and include factors such as stress, social exclusion, food and housing insecurity, race, gender, and education. But some medical practitioners, like Le Bonheur and UTHSC, are stepping up to incorporate ACE awareness into their treatments and confront the social determinants of health alongside genetic predispositions.
In a majority-black city where the child poverty rate is 44.7 percent, the adoption of ACE aware practices leaves the lives of thousands of children hanging in the balance.
Measuring ACEs
While Le Bonheur has invested in community programs for the last 40 years, beginning with child abuse interventions, it was just last May that they launched the Family Resiliency Initiative in Le Bonheur’s pediatric clinic to screen for ACEs.
Studies on the later-in-life effects of ACEs have concluded that negative experiences such as poverty, neglect, and abuse in childhood lead to risky behaviors like alcohol and drug abuse and chronic health potential later in life as well as early death.
In the seminal ACE study, researchers Felitti and Anda found that compared with people who had no history of ACEs, those who faced adverse childhood experiences were more likely to become alcoholics, attempt suicide and be diagnosed with cancer or heart disease.
While the study, which assessed the health outcomes of patients in the San Diego area between 1994 and 1998, has gained a national following with ACE-related practices and conferences popping up in the last decade, the medical field has not fully embraced ACE awareness. Venturing into an emerging discipline, Memphis has joined the movement.
Preventing ACEs
ACEs are not inevitable, but some can be prevented. Le Bonheur’s nurse-family partnership partners one nurse with one first-time mother who follows her from pregnancy for two years to help prevent ACEs by providing physical assessments, prenatal care, immunizations, as well as coaching on healthy mother-child interactions and parenting techniques.
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Lisa Asbill, psychologist, and Christian Pickerson, outreach coordinator, meet at the Family Resilience Initiative clinic at Le Bonheur Children's Hospital.
Adoption of these techniques, the logic goes, will prevent some of the ACEs from ever happening, leading to better adult health outcomes and behaviors.
According to Le Bonheur, since 2010 more than 600 mothers and their babies have completed the program. Of the participants, 89 percent of babies are born full-term, 75 percent of mothers initiate breastfeeding and 97 percent of toddlers are current with immunizations.
“It’s been proven that home visiting is one of the most effective ways to reduce the impact of ACEs on the lives of families,” said Marilyn Smith, clinical director of the nurse-family partnership at Le Bonheur.
“Being able to be in the homes and develop relationships are the things that help build resiliency within a family.”
According to Le Bonheur’s studies, which began with a trial in 1990, mothers in the home visitation program were less likely to die of external causes like suicide, drug overdose and homicide and unintentional injuries. They also concluded that the nurse-family partnership reduced preventable child death from birth to age 20.
Smith describes the nurse-family partnership as “relationship-based.” The nurses educate first-time mothers on all aspects of parenthood from feeding to play. Nurses in the program conduct an ACE assessment early on so that the parents can identify adverse experiences in their own childhoods that they would like to avoid repeating for their children.
“We know what children need to thrive — stable families, strong relationships, supportive neighborhoods," Smith said. "We give them to tools they need."
It’s these sorts of preventative measures that Dr. McCullers hopes will reduce the number of ACEs that will have to be addressed and treated at his clinic later in childhood.
Challenging the medical establishment
However, McCullers says that the current medical model is not built for this ACE-aware approach. Le Bonheur relies on nontraditional sources of funding such as private donors and grants to pay for their community programs, like the nurse-family partnership. Locally, Urban Child Institute and the Plough Foundation are among the supporters.
“You get paid to treat asthma, but you don’t get paid to prevent that hospitalization. Until we can change that mindset to address root causes … there won’t be jobs and there won’t be money,” McCullers said.
McCullers' team is recording their findings regarding ACEs and hopes to publish results in order to encourage more hospitals to incorporate ACE awareness. McCullers says that medical schools focus more on genetics than social determinants of health and that there are shortages for child psychologists and social workers because their work is not reimbursed by insurance companies in the same ways that direct medical treatments are.
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Pediatricians at the Family Resilience Initiative clinic incorporates awareness of adverse childhood experiences into their diagnosis and treatment. (Brandon Dahlberg)
“Young people want to [incorporate ACE awareness],” he said. “But there are no jobs because it’s not reimbursed.”
McCullers says that he does see a subtle shift happening and hopes that more studies like the CANDLE study based out of UTHSC, which follows children from birth to age four to isolate what impacts development and ability, will help to further shift the narrative to consider the holistic determinants of health.
The purpose of the CANDLE study is to identify factors during a pregnancy and baby's first three years that impact the baby's development and ability to learn. They specifically focus on the child’s home environment and habits as well as genetics so that they can see how all factors influence the child’s development.
According to McCullers, Le Bonheur and UTHSC are among the first to measure the health outcomes of the children that come through the clinic and hope that they can lead the way in ACEs aware treatment being adopted nationally.
Innovative models take a long time to affect teaching and reimbursement,” McCullers said.
“Pediatrics are here because they’re passionate about children and they see beyond medical needs.”
Support for this story was provided in part by the Urban Child Institute; it is one article in a series highlighting the impact and importance of early childhood education. The Urban Child Institute focuses its grantmaking, advocacy and community support on kindergarten readiness and third-grade literacy in an effort to improve the education, health and well-being of children and families in Shelby County.