The truth is that depression does not affect only adults, but children and adolescents, too. Depression is a disease as are diabetes, or high blood pressure. It is believed to be the disease of the future. World Health Organisation estimates that it will soon become the second public health issue in the world.
Toxic stress in childhood is a theme of significant and increasing interest. There are numerous reasons for that, accumulated through the years of research, which provide conclusive evidence that stress/trauma causes many short and long term effects in children, thus imposing a risk for a series of diseases in their adult life. For example, it significantly increases the incidence of myocardial infarction and lung cancer, as well as immunological and malignant diseases in adulthood, in comparison with the population not exposed to stress in childhood. We are not writing here about the stress related to everyday activities and challenges of growing up, but about the stress related to family violence, to witnessing physical violence, exposure to corporal punishment, neglect, sexual abuse, peer bullying and similar.
Key role of paediatricians in identifying toxic stress
American Academy of Pediatrics presented six experts who conceptualized a strategy aiming at empowering paediatricians in identifying toxic stress in their patients. That plan was presented within the programme Pediatrics for the 21st Century which was scheduled before the National Conference of the American Academy of Pediatrics. Sandra G. Hassink, the President, organised half-day programme ‘The Trauma-Informed Pediatrician’.
Especially significant attention was focused on recognising toxic stress and promoting defence techniques against it. Speakers talked about approaches to children and adolescents exposed to toxic stress, including the screening of children exposed to adverse childhood experiences (ACEs). That concept was derived from the original ACEs study conducted from 1995 to 1997 on more than 17,000 examinees. Results conclusively showed a strong causal relationship between adverse childhood experiences, like abuse and neglect, and the consequences to health and welfare in later life. That completely changed the paradigm of the phenomenon and its significance.
Patients with higher ACEs had significantly higher risk for chronic diseases, mental disorders and increased incidence of suicides.
The challenge is how these findings can be integrated in the screening processes in everyday practice.
Behavioural changes caused by trauma
Toxic stress is an element of the public health crisis, dr Nadine Burke Harris pointed out publicly, and paediatricians play the key role in that process. “We can do much, simply doing what we do every day” said dr Burke Harris, paediatrician, the founder and CEO of the Center for Youth Wellness in San Francisco. “There is no community where we do not need to think about that”, were her words.
Early identification and referral to treatment can help patients to learn about stress management. Working with patients visiting due to the effects of toxic stress, we can resolve the causes of problematic behaviour, which can be the child’s way of coping with external stressors.
“In establishing your differential diagnosis, think about trauma” said dr Heather Forkey, who described behavioural changes caused by trauma, which she encounters in her everyday practice. She also said that more often than not, neither the family, nor the patients were aware that trauma was at the onset of many problems. The child who presents with symptoms of attention disorders or hyperactivity can be hyper vigilant due to the relentless effects of stress. Stress and trauma also underline numerous deviations, like disproportionately lower academic accomplishments, behaviour disorders, linguistic disorders and similar.
Paediatricians in primary health care can simply obtain data by asking parents if something ‘terrible’ happened to their child.
Introducing the screening programme does not mean that paediatricians have to solve all problems, said dr Robert Gilespie. Simple listening has a therapeutic component, because they need to be heard.
Before the commencement of the screening procedure in primary health care system, we need to be aware of community potentials and continue to build relationships expanding these potentials, in order to sensitize the public for the identification of toxic stress in childhood.
Written by: Vanja Slijepčević Saftić, MD, Sc.D., paediatrician, subspecialist in child neurology
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