The study determined that supportive and trusting relationships with intimate partners, high levels of maternal warmth toward children, and low levels of partner violence between adults characterized families in which mothers but not children experienced maltreatment from those in which mothers and children both experienced maltreatment.
"Safe, stable nurturing relationships between intimate partners and between mothers and children are associated with breaking the cycle of abuse in families," the authors wrote.
And that, Dr. Garner said, is where pediatricians can make a difference: By getting involved with families early, staying involved consistently, and advocating not only for children’s health, but for the health of the family unit, pediatricians can protect every child’s right to lifelong health.
The AAP report urges clinicians to assign themselves the crucial task of identifying children threatened by toxic stress, and offering families the tools they need to stave off its damaging effects. The paper calls on pediatricians to become "more than checkers of throats and ears," Dr. Garner said. "It elevates us to becoming guardians of the life-course trajectory. We have always known in our hearts that we work best when we partner with families to help children. But it’s a transformational view to see our role as also helping the environment in which the child lives."
As in any long-term health assessment, the first step should be screening, Dr. Garner said. That process can start with seeing a child who is already showing problem behaviors – a sign that something upstream might be the real issue. But screening can also start much earlier – in some cases, before birth.
Prospective parents who come in "shopping" for a pediatrician, and parents-to-be who already have a child in the practice, offer a crucial window to assess family stressors. Stepping in with guidance even that early may improve things not only for the current child, but also for the one to come.
"The data tell us that most parents are willing to give you this information," Dr. Garner said. "Families are often looking for help. Most want to do a good job, and when the discussion revolves around helping them do that, they are usually receptive."
What gets uncovered could be daunting, though. "Spousal abuse, parental depression, unemployment, substance abuse, housing are just a few," he said.
Identifying problems is one thing – the next big question is what to do about it. "It will be a tremendous challenge and require an unprecedented level of collaboration between the medical home and all systems of early child care, education, and even child protective services."
It’s going to take some time, too, he said. And time means money.
"We are working on reimbursement," Dr. Garner said. "AAP has already endorsed a specific code that assesses environmental risk for maternal depression, and some states do reimburse for that."
Others don’t however, maintaining that screening for maternal depression represents treatment for the mother, not the child. "That attitude right there is part of the whole problem – not seeing the importance of the mother-child dyad," Dr. Garner said.
He and other proponents of this new paradigm said that implementing it will stimulate "trickle-up" economic gains. "If we do a good job of addressing toxic stress, we’ll spend less time treating somatic illness, which takes a lot of time out of any practice. And if we can prevent some of the long-term effects of toxic stress – like drinking, smoking, drugs, promiscuity – that will be a huge value to the entire health care system. The effects won’t be seen tomorrow. But they will be seen. And that’s where the real value is," Dr. Garner said.