Pediatricians Need to Take Community-Based Approach to Addressing Chronic Conditions in Children
Aug 29, 2014, 9:00 AM, Posted by James Perrin
James Perrin, MD, FAAP, began a one-year term as president of the American Academy of Pediatrics (AAP) in January. A professor in the department of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, Perrin received a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research in 1997.
Human Capital Blog: Congratulations on your new role as president of the American Academy of Pediatrics! What is your vision for the organization?
James Perrin: We are focused on addressing three main areas, which have really driven a lot of our thinking and, more importantly, our activity and change in the last several years.
First, we are working to help pediatric practices take on more community-based interventions to help young families raise their kids more effectively. There is a tremendous growth in the number of chronic diseases among children in four major areas: asthma, obesity, mental health, and neurodevelopmental disorders. We recognize these are not classic health conditions; they arise from and within communities, and both their prevention and their treatment are really community-based endeavors, as opposed to office-based activities.
Our second, and highly related priority, is an increased focus on early childhood development. We have understood the tremendous importance of early childhood for years, but there is now so much more science behind it. We know a lot more about how negative experiences and toxic stress can affect child development and how it can affect brain growth and neuroendocrine function. On the positive side, we also have more knowledge about the importance of reading to children, increasing language in the home, and other early-childhood interventions.
Thirdly, we have a better understanding of the tremendous impact of poverty on child health. Almost a quarter of American children live in households below the federal poverty line, and almost 45 percent live in households with incomes less than twice the federal poverty line. So a large number of American children are poor or near poor, and we know that poverty affects essentially everything related to child health. It makes those four categories of chronic conditions—asthma, obesity, mental health, and neurodevelopmental disorders—more prevalent and more serious, and it affects children’s responses to treatment. Lower-income kids with leukemia or cystic fibrosis, for example, have higher death rates than kids with the same diseases who are middle class. It’s impossible not to see on a daily basis how poverty affects child health.
HCB: What activities is the AAP undertaking to address these challenges?
Perrin: One thing we’re very excited about is the increasing move from physician-based practice to team-based care in communities. The pediatrics community, in fact, has long championed the notion of the medical home; it’s actually a concept that was first developed in pediatrics several decades ago. Fortunately, it has been picked up more broadly in recent years. What we see happening now is a move from physician-based medical homes to multidisciplinary team-care in communities. Pediatricians have been doing that for years in several subspecialties, to treat diseases like cancer and cystic fibrosis, but now it’s increasingly common in general practices as well.
There is also growing experimentation in the management of chronic health conditions and the use of home visitors, which can help with early brain and childhood development. We think that is a very important function that needs to be expanded and increasingly integrated into pediatric primary care. And then finally is the work to address poverty, and by that I mean helping identify families who need additional services and then linking families actively with those services.
If you think about it, these are all tasks that are really critical for helping families and building communities, but they are all tasks that doctors are not terribly well trained for or capable of doing. For example, I might have a child with asthma in my office who is not doing well and who lives in bad housing, with mold in the kitchen and bathroom, and I don’t know a darn thing about how to help her apply for better housing. But, I can turn to someone in my practice who does know how to do that. That’s really why we’re moving toward team-based care.
"Different parenting norms, growth in media, changes in diet, and change in physical activity have radically transformed what it is like to grow up in America."
HCB: Are you optimistic that these kinds of changes will occur system-wide?
Perrin: One of the questions that we’re working on and want people to understand is the need for change in payment arrangements so we can really make these kinds of transformations occur. Traditional fee-for-service arrangements aren’t very conducive to the development of team-based care, and there is little incentive, or support frankly, for physicians to move from independent practice to team-based care. So, at the AAP, we have had a number of small grant programs over last 30 years to support physicians making these kinds of changes. I’ve always been amazed at the imagination and innovation that we’ve seen in these projects. But, we can’t afford to do this with small grants alone; we need more fundamental changes in how we invest in community-based care.
HCB: How do you explain the explosive growth in chronic conditions in children?
Perrin: Fifty years ago, fewer than 2 percent of America’s children were reported as having a chronic health condition severe enough to interfere with regular activities, like going to school. Today, it’s well over 8 percent—a growth of more than 400 percent. The growth is pretty well documented, but we don’t have a good understanding as to why it’s happening. We know that genes play a role, but we can’t explain the huge growth by genetic makeup alone.
Presumably, the environment plays a role here, but we don’t have much data at this stage. This is a tremendously important area for research in next five to 10 years. We need to know more about how particular toxins may affect the intrauterine growth of fetuses, for example, or how plastics act as endocrine disrupters in children.
The changing social environment also plays a role. The changing food supply, for example, has had a dramatic impact on the obesity epidemic, and that’s one reason the AAP has been so strongly supportive of efforts to improve school nutrition. But that’s just one example. There have been changes in portion size and food preparation, and physical activity is also down substantially among American children, and especially among poorer children. Children are seduced indoors by media, computers, televisions, and iPhones.
Four aspects of our social environment—different parenting norms, growth in media, changes in diet, and change in physical activity—have radically transformed what it is like to grow up in America. It is going to be critical, absolutely critical, that we learn how to make communities healthier for children. And we’re never going to address new or expanding chronic conditions unless we look at new community-based interventions. These are not problems doctors can adequately address only by seeing patients in their offices.
HCB: You have a long history as an advocate for children with autism and their families. How has this experience influenced your role as president of the AAP?
Perrin: I’m a good, old-fashioned general practitioner, so I’m not an expert in neurodevelopment. But it is hard to be interested in chronic diseases without being aware of an increase in autism, because its growth has been phenomenal. When I was a young physician, autism occurred in about one in every 4,000 kids. Now, the Centers for Disease Control & Prevention reports autism occurs more frequently than one in every 100 kids. Part of that growth is changing labels, but part seems to be real growth. Autism fits a broader group of common chronic conditions that we need to know a lot more about.
HCB: This discussion has focused on challenges facing pediatrics. Can you discuss advances in the field?
Perrin: The main advances I’ve seen are probably not in the health and well-being of America’s children, but I do see some things getting better. We don’t see lead poisoning so frequently as we used to. That’s been a real success story. There is far less anemia, and far fewer infectious diseases, and immunizations have really worked and been very successful. That is good news. And it’s particularly exciting how innovative physicians can be when given an opportunity to make a difference. In the pediatric community, there is a tremendous interest in looking for better ways to provide care and improve the health of children and families. Doctors are often accused of being primarily interested in illness and disease, but in pediatric primary care, they are very interested in prevention.
HCB: In 1997, you received an RWJF Investigator Award in Health Policy Research. How did that experience shape your career, and has it influenced your position at the AAP?
Perrin: That period allowed me to explore how other disciplines affected our understanding of the growth of chronic illnesses among children. It led us to understand the effects of economic and social policies in this area that we would not have been able to explore without support of the Investigators program. It also introduced me to a multidisciplinary group of investigators. I have always worked with social and behavioral scientists in my career but it was really nice to meet a whole bunch of other very skillful investigators from other disciplines and be able to continue our dialogue over the years. One of the key outcomes of that collaboration was work that documented the dynamic nature of chronic conditions in children and youth—many children get better while others newly develop long-term conditions. In other words, chronic does not mean permanent, and there is much opportunity for prevention.
This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.