Childhood experiences, both positive and negative, have a tremendous impact on lifelong health and opportunity. As such, early experiences are an important public health issue with enhanced health equity having the potential to mitigate adverse childhood events, poverty and toxic stress. It is imperative to train health professions workforces in understanding how child development impacts human health and disease across the lifespan.
Baby Joe* came through the ED back to the NICU at 10 days old looking yellow, slightly pale, and generally unwell. After a series of questions to the mother about what happened since this baby was discharged 7 days prior from the newborn nursery, it was clear that he was not eating enough and peeing only once – twice per day. He was losing weight and was dehydrated. After providing care and stabilizing the infant, I sat down and took some time with the mother to discuss what was going on at home and how we could assist in making sure that Baby Joe would thrive after he left the hospital.
After a few teary moments and some basic teaching about breast feeding, supplementation and wet diapers, I stopped and simply said, “tell me about yourself”. The mother smiled and said she was a first-time mom. She lived alone in a large US city; her husband had planned to come join her after his immigration paperwork was completed. She worked full time but had no maternity leave and had gone back to work only one week after Baby Joe was born so her neighbor cared for Baby Joe and four other children. She had enrolled in WIC but learned that she was only able to get either a breast pump or formula, not both. So, she got a pump because she knew “breast was best” and struggled to keep up with the amount of milk he needed. She had to buy formula which was financially challenging. I listened and thought about how I could help this woman get through this hurdle. However, I knew many other challenges would inevitably come up in the early months of Joe’s life. This was almost 15 years ago. I was 22 and a brand new nurse.
Having been educated at a Jesuit University, I was familiar with the idea of Cura Personalis (care of the whole person). I had been taught about social determinants of health in adults, but still didn’t have the words to ask about food insecurity, poverty, adversity or even post-partum depression, though I could hand someone a piece of paper and pencil to take the Edinburgh Postnatal Depression scale.
Recent scientific advances are driving a paradigm shift in the understanding of how child development impacts human health and disease across the lifespan. Early social and environmental experiences and genetic predispositions influence the development of adaptive behaviors, learning capacities, lifelong physical and mental health and future economic productivity. These advances have been slow to enter the curriculum at both nursing and medical schools, leading to a lag in prevention and intervention efforts in our pediatric population. Poverty is a key social determinant of children’s health, one that harms health in its broadest possible definitions: physical, educational, emotional and social, yet 45% of children live in low-income households.1 The American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners are tackling the issue of how poverty affects early brain development and its impact on children’s health.
Without a sustained, multidisciplinary, public-private effort and a change in workforce education however, we cannot achieve lasting, effective change. While social determinants of health have broadly begun to enter into health professions education, we still lack some fundamental curricula on pediatric and family content particularly as it relates to the developing brain. I have long wondered about how the early life experiences of a child affect long-term health, economic, social, and educational outcomes. As I have grown in my education, clinical experience and research trajectory, these are the types of questions I find myself contemplating and attempting to answer in our labs and in our clinics.
As a professor of nursing, I have struggled with how we currently teach, engage and empower our students to assess children and families beyond the presenting illness. How do we teach students to ask about food insecurity? How do we train them to discuss with women how they will care for their child when they have to go back to work after just a few weeks? How do we have difficult conversations and find sustainable solutions within the community? Are we teaching nurses about two-generation cycles of poverty and how to break these cycles in an effort to gain better health and wellness for children? In short, are we training a workforce to understand that health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity?
Patricia Pittman recently wrote “The deteriorating epidemiological profile in the United States requires more than a traditional medical response.”2 She argues that the nursing profession could contribute significantly to addressing this crisis if it embraces its historic role at the intersection of medicine and society: “Nursing roles and the settings in which nurses work are diverse and they will likely continue to diversify. As such, the profession will intersect and overlap with other professions and community-based personnel. Such intersections may not always be comfortable for nurses, but if they are embraced as opportunities for innovation, they could lead to the kind of creative social solutions that characterized Lillian Wald’s vision of nursing in the early 20th century.”
This year, the National Academies of Sciences, Engineering, and Medicine will extend the vision for the nursing profession into 2030 and chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century. Top on the list of challenges they will examine is “[t]he role of nurses in improving the health of individuals, families, and communities by addressing social determinants of health and providing effective, efficient, equitable, and accessible care for all across the care continuum…”
Now is the time for nursing schools to consider how to educate our students to create a workforce that is capable of transforming a society into a culture of health, not one that just reacts to illness. Developing innovative pediatric curricula focused on how poverty affects early brain development and integrating evidence-based research on toxic stress, literacy and poverty will be an important component to creating a culture of health from the beginning of life.
*Names changed for anonymity
-Ashley Darcy-Mahoney, PhD, NNP, FAAN, Community of Practice Member
Ashley Darcy-Mahoney, PhD, NNP, FAAN, a neonatal nurse practitioner and researcher, has worked throughout her career to advance nursing research, education and practice, with a focus on neonatology, infant health and developmental pediatrics. Her research has led to the creation of programs that improve health and developmental outcomes for at-risk and preterm infants. As an associate professor of nursing and the director of infant research at George Washington University’s Autism and Neurodevelopmental Disorders Institute, Dr. Darcy-Mahoney advances the body of research in infant health and developmental outcomes in high-risk infants with a focus on understanding the early brain and development trajectories in this population.
- Jiany, Yang, Ekono, M., Skinner, C. (2016) Yang Jiang, Mercedes Ekono, and Curtis Skinner Basic Facts about Low-Income Children : Children under 18 Years, 2014. National Center for Children in Poverty. Retrieved from http://www.nccp.org/publications/pub_1145.html on April 5, 2019
- Patricia Pittman. Activating Nursing to Address Unmet Needs in the 21st Century. Robert Wood Johnson Foundation. Princeton NJ. March 12, 2019. Retrieved from https://publichealth.gwu.edu/sites/default/files/downloads/HPM/Activating%20Nursing%20To%20Address%20Unmet%20Needs%20In%20The%2021st%20Century.pdf on April 5, 2019.