Seeing the Inner Child in Everyone - Part I

By John J. Nava, MD, 2023 BCMS President

I hope to explore what each of us can do to better the health status of children in San Antonio, Bexar County, and the surrounding counties. In part one, I will discuss frameworks that have been used to address the needs of those children and the larger population. In part two, I hope to report and frame a snapshot of the current health status of those children and families, and offer some ideas about how best to improve their status, from a community health perspective.

During my undergraduate education, I took many Sociology classes. I learned about Maslow’s hierarchy of needs, typically represented as a pyramid, each being built upon the next as the lower needs were met. These progress through physiological needs, safety needs, love, and belonging, esteem and self-actualization. This theoretical structure was first proposed in 1943, and though outdated, gives us something to hang our hat on. The theory has been much criticized for lacking conclusive validating evidence, and the construct as proposed by Maslow required that progress could not occur until a lower level had been completed. Nevertheless, it has still been used to explain how effort and motivation are correlated in the context of human behavior. I recall studying how Russian and American child rearing practices differed with regard to guidance into professions, with individualism emphasized in the USA over the needs of the collective in the USSR. Of course, cultural differences abound. Though I continued as a pre-med student with a curriculum heavily weighted in hard science, I always remembered the principles of that area of human behavior. As I furthered my studies, I hoped to eventually become a pediatrician.

When I was in medical school, I enjoyed ambulatory pediatrics, as children with minor ailments bounced back quickly. Then I rotated through inpatient pediatrics, where I met a three-year-old child, that had never spent a day outside of the ICU due to complications after repair of a tracheoesophageal fistula. After seeing children with terminal cancer, I knew I wouldn’t be able to handle a career filled with those sorts of cases. I imagined I would have been miserable trying to meet their major needs.

I then chose family medicine, where I could still see ambulatory pediatric patients, followed by public health practice. It was during these years that I was first sensitized to the social determinants of health

(SDOH). Tools were developed to assess five need areas, specifically food, housing, utilities, transportation and safety. Then more areas of needs were added, with various lists of up to 15 total being developed.1 Currently, Healthy People 2030 continues to prioritize many of these same issues.2 Thankfully, diagnostic codes to compensate clinicians for the time it takes to address these items have been developed and efforts are underway to make these industry standards.

After decades of discussion of these risk factors, what has changed? Specifically for our community of San Antonio and Bexar County, has the political will developed to modify these risk factors, and improve the health status of the people living here? Maybe in some areas, but a larger consensus has been elusive. Anytime it involves tapping into the tax base, many skeptics must be convinced that early investment in prevention is better than waiting to address costly health problems.

Trauma Informed Care (TIC)

A couple of years ago, a local public health leader was invited to a meeting of the BCMS Public Health and Patient Advocacy Committee. I asked that person about the theoretical connection between ACEs (Adverse Childhood Experiences) and epigenetic changes later discovered in families of trauma victims. I was promptly informed by this community leader that it was not just a theory, but a proven fact, and there had been developed a large body of evidence to support this. Maybe I am just an old country doctor, but to help me convince others to support using tax dollars to direct resources at the root causes of ACEs, I wanted to see the data, and make my own conclusions. Last year in the August 2022 issue of our San Antonio Medicine magazine, Drs. Edward Dick and Kristen Plastino co-authored an article on TIC and provided resources. Here in San Antonio, the South Texas TraumaInformed Care Consortium (STTICC) is active and willing to help.

I wonder how SDOH intersects with TIC, and how can this inform clinical care? Is TIC an evolution of the concept of SDOHs, or are they separate structural frames of reference? I have noted that some agencies involved with TIC have recently shifted the focus from ACEs to resiliency factors that protect against the long-term health problems associated with higher ACEs scores on screening tools. I hope this does not portend a similar fate for this newer effort. Have the leaders of the TIC movement realized that the concept is too large for people to wrap their minds around, especially when it requires collaboration to fund a response? We will see how this plays out.

Specifically, to address early childhood development, Medicaid expansion would meet some needs of the most at risk children in Texas. Just ensuring that Medicaid coverage is extended from 6 months to 12 months for both the newborn and the mother is a step in the right direction. As the legislative season continues, let us keep this in mind for what it represents as a worthy investment. Our advocacy voice, as a profession, can easily be lent to this effort

Coming in Part II: Healing the inner child and inner child work. Can an app help people do this without actual face to face interaction with a therapist/counselor?

References

1. United States, US Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2017, September 05). Accountable Health Communities Model. https:/ /innovation.cms.gov/initiatives/ahcm.

2. Office of Disease Prevention and Health Promotion. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople

John J. Nava, MD, is the 2023 President of the Bexar County Medical Society. He is interested in Primary Care, Clinical Research and Public Health.