Public Policy Advocacy

Leveraging Science to Transform Pediatric Primary Care

“This field is too rich and too precious to settle for modest impacts. We should be raising the bar,” stated Jack Shonkoff, MD, the founding director of Harvard University’s Center on the Developing Child, in advocating for leveraging science to transform pediatric primary care to better serve children’s needs.

Dr. Shonkoff delivered the annual Dworkin lecture at Connecticut Children’s Medical Center, which is a Grand Rounds session named in honor of Paul Dworkin, MD, the executive vice president of community child health at Connecticut Children’s, the former physician in chief at Connecticut Children’s, and the founding director of the Help Me Grow National Center.

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“I really have very special feelings and insights into my early experiences sharing an office with Paul at the beginning of our careers and I do want to celebrate this coming full circle because we did begin together,” said Dr. Shonkoff at the start of his presentation.

The presentation served as the 6th annual Dworkin lecture.

“Not only is he capturing, translating, and operationalizing the basic science advances that should be directing how we deliver our services, he is also heavily involved in determining how we best capture the efficacy of interventions and how we take interventions and build the types of comprehensive systems that will enable us to ultimately promote children’s optimal health and development,” said Dr. Dworkin.

During his presentation, Dr. Shonkoff pointed out that the need to transform pediatric primary care is not a new idea. However, he explained, the problem in achieving transformation has not been with envisioning new strategies, but rather with implementing them.

He pointed out how the current practice of increasing parenting education; offering enriched learning experiences for children; ensuring that children have access to primary health care and sound nutrition; and empowering communities to promote healthy development is conceptually sound. However, he also stated such a practice is limited in impact because there are still populations of children who are exposed to significant adversity that impairs development and hinders school readiness.

“There’s this kind of nagging problem that doesn’t go away and that’s for some part of the population, this isn’t enough,” stated Dr. Shonkoff. “It tends disproportionately to be a part of the population that is dealing with significant adversity related to the usual suspects: poverty, racism, violence, maltreatment, and maternal depression. This is a hypothesis now, that the level of adversity overwhelms what we know should be producing a good outcome.”

The solution lies in leveraging 21st century science to determine an effective path to resolve the problem, stated Dr. Shonkoff.

“The time has ended for us to use science to just make the case for why early is important. That case has been made over and over again,” stated Dr. Shonkoff. “It’s time to use science to ask the question of what are we going to do differently. How are we going to be more effective? Not just to say we know what to do, we just don’t get all of the money we need. Nobody gets all of the money they need.”

He offered a thought-provoking example based on research practices that led to dramatic improvements in survival rates for children diagnosed with Acute Lymphoblastic Leukemia (ALL), which he says should serve as a model to achieve breakthrough developments in the child development field.

In 1964, the five year survival rate for those under age 15 diagnosed with ALL was three percent. Two years later, it jumped to 60 percent and today it’s at 90 percent.

“This movement from 60 percent to over 90 percent over a 30 year period has been accompanied by no new discoveries of any new treatment for ALL. Not one. It’s stratification of risk,” stated Dr. Shonkoff. “What people learned from the multiple treatments they had, they realized if they could match different treatments to different subtypes of leukemia based on the genetics of the disease, or the genetics of the kids, or other factors, with no new treatments you went from 60 percent to 90 percent.”

In drawing a parallel to the field of child development, Dr. Shonkoff stated, “What are we thinking when we ask what’s the best program for kids in poverty? What’s the best program for families that are dealing with burdens and threats of racism and violence? So this is the key to moving forward. It’s stratification. It’s understanding differential susceptibility, differential response to intervention. That’s where 21st century biology becomes I think the critical part of the future of early childhood programs.”

Dr. Shonkoff noted difficulties the child development field has encountered in bringing successful models to scale.

“If we figure out for whom it’s working, we can start scaling and we should not do that for the kids and families it is not working for,” he stated. “We should go back to the drawing board and figure out how to develop more effective interventions thinking about these three principles: how do we strengthen relationships, how do we reduce sources of stress, and how are we building the kinds of skills that will produce better outcomes?”

“In the end, like the treatment of ALL, is a suite of programs and policies, not one treatment, across sectors. Some of it will be in health, some of it will be in education, some will be in human services,” he stated. “Think Help Me Grow. Think about the need for a system that will help us do that, not a lone practitioner or a single program trying to defend how people should come to it rather than something else.”

In concluding his remarks, Dr. Shonkoff discussed current research The Center on the Developing Child is leading to develop biological and behavioral measures to assess the impact of stress on children. Preliminary findings measuring EEG and Isoprostane levels in children as young as two months old are yielding evidence of elevated stress responses, he stated.

“There are things we can measure in babies that will tell us differential sensitivity to stress at an early point when there’s no reason to think any permanent damage has been done, that we can do something to strengthen the buffering for that child and at the same time be able to reassure parents who are in very stressful circumstances that yes, this is very hard, but that their children are showing resilience or their children are showing sensitivity to this and we can do something about it,” Dr. Shonkoff stated.

“We are eager to work with Help Me Grow and the measurements and laboratories we have been developing to basically think about not just tweaking around the edges but how do we build a new model for primary care that actually makes the old model a precious and cherished predecessor to what we’re doing in the 21st century,” stated Dr. Shonkoff. “Thank you for the opportunity to honor Paul Dworkin.”

Read additional articles on the Advancing Kids Blog related to health promotion.

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