This blog discusses the social determinants of health (SDH) in the context of recent challenges at the McKinley Elementary School in Boston.
We live in an exciting time of great scientific discoveries that have finally reached clinical practice and key public health stakeholders This year the Center for Disease Control (CDC) within the office of Public Health Genomics is undergoing a new round of reviews and analyses of its programs by stakeholders.
Child psychiatrists are actively trying to translate new knowledge into action. Many researchers have by now recognized that exposure to poverty is a sociocultural risk factor for developmental dysfunction in children. Expanding knowledge derived from genomics and epigenomics offers us a fresh perspective on the relationship between health and social conditions and the ways in which daily stress, which is so difficult to measure, has a fundamental influence on children’s growth and development. New social determinants are being identified, stimulating new debates and interventions for improving society’s capacity to respond, anticipate, and prevent health hazards.
Child psychiatrists agree that health benefits of new scientific discoveries should be reaped for all. Since 95% of American youth are enrolled as students, schools are viewed as a logical point of entry for mental health services for the pediatric population at large (Allensworth et al., 1997).
The coordination of care is a goal shared by both clinicians and public health officials. The CDC’s approach to quality control of school health (CSH) has served as a blueprint for integrating health-promoting practices in the educational system since 1987. The Whole School, Whole Community, Whole Child (WSCC) model is the current expansion and update of the CSH approach. The Children’s Behavioral Health Initiative includes an interagency effort to develop an integrated system of state-funded behavioral health services for children, youth, and their families. Child psychiatrists partner with schools to help them develop policies and procedures for mental health services.
On March 31st, 2016, Boston Mayor, Martin J. Walsh, wrote a joint article with Tommy Chang in the Boston Globe in which they noted that though Boston was the birthplace of public education in America, “Not all children are getting the opportunity to reach their potential. All of our proposals have been, and will remain aimed at closing these gaps, and meeting every student’s needs. It’s imperative that we find common ground now, so that we can tackle them together, build on our program, and give every child the excellent education they deserve.” The next day, the mayor visited the Warren Street building, in which McKinley is located.
The Boston McKinley Schools are actually four schools rolled into one that provides special education for students from kindergarten through grade 12. The school’s focus on the emotional, behavioral, and learning needs of its students is paired with highly structured behavioral management programs as well as clinical and academic support. Wediko Children’s Services is the key partner in the coordinated system of McKinley’s community services. The Wediko agency was founded in 1934 by Dr. Robert A. Young to accommodate children with severe emotional, social, and behavioral disabilities (Time, “Behavior: Retreat for the Troubled”). Its initial goal was to provide a “fresh air” experience for urban children whose behavior made other summer options difficult. Wediko is actually the subject of journalist Katharine Davis Fishman’s book, Behind the One-Way Mirror (1995). “Think City,” the division of Wediko devoted to providing services in schools is committed to the idea that competence in school is fundamental to Children’s Mental Health; teachers should make children see school as a place in which they can do well.
Many students at McKinley come from single-parent families in which the breadwinner is often unemployed. Many have a family history of residential instability or homelessness, domestic violence or abuse, poverty and social discrimination. Many have fallen behind in routine preventive health services, while some do not even have a primary care provider.
Last March I received an urgent call to fill a vacancy in child psychiatry at McKinley. I was told that many school children were taking psychotropic medications and required a child psychiatrist to monitor them. I agreed to come on board.
The McKinley school nurse worked very hard to make sure that all students received their medications on time and also screened them for medical conditions that may have required immediate medical attention. Teachers and clinicians worked tirelessly to maintain a safe milieu as well as to support children’s educational and social-emotional goals and gains. Yet rooms reserved for out-of control children were rarely empty. Despite complex medication regimens, many children were not improving.
The challenges faced by school personnel were overwhelming. I instantly saw how aspirations and opportunities to provide comprehensive child psychiatric service could be lost in the heated daily struggle. The realization that the current infrastructure at McKinley posed limitations on the new clinical platform that I was hoping to implement prompted me to reach out to my colleagues. I thus shared my concerns about the school’s unmet needs due to limited resources in Senator Warren’s office during the American Academy of Child and Adolescent Psychiatry Legislative Conference in Washington, D.C. in April.
As I expected, my trip to Capitol Hill boosted my enthusiasm as it provided me with a firm plan to continue building better psychiatric services at McKinley. Collective efforts by both teams—at McKinley and Wediko—allowed us to begin taking baby steps towards better care for students.
When I arrived at work on June 7th, however, the school was unusually quiet. The day before, Kevin Cullen, a Boston Globe columnist had published an article, “Treating At-Risk Kids as an Afterthought,” in which he reported that “McKinley would be evicted from its Warren Avenue location so the Quincy Upper could replace it there.” In it, Cullen cited a response to the news made by one of the school’s teachers: “What we have labored for decades to build is precious and should not be disrupted. What message does our eviction to prepare for a state-of-the-art facility for another school with a differ population of students send to our students?”
I was shocked. It was clear to me that a move to a different neighborhood meant losing an opportunity to create a safe and stimulating environment. I looked for research data that would validate the argument that relocation of the school might lead to a cascade of health problems among its students. The current literacy gap between science and practice poses limits and compromises the precision of our assessment. Measuring the short-term clinical effectiveness of interventions on children’s mental health may be possible, but “forecasting” long-term outcomes still leaves us with “unknown unknowns.” In such debates conclusions differ depending on the outcomes assessed and the perspective from which they are assessed. I believe, however, that the complexity of the issue should not be used to justify complacency. As Marlow Stern put it, “The more people are comfortable and complacent, the more it plays into things that are destroying the world.”
I thus began reaching out to colleagues again and asked them to help me think of ways to stop “spinning wheels” and “recycling old patterns of thinking.”
How can new policies and scientific advances reach and change the lives of so many American children, but leave those at McKinley untouched? This was the question I addressed to the keynote speaker, John Auerbach, MBA, Associate Director for Policy at the Center for Disease Control and Prevention and the Acting Director of the office for state, tribal, local and territorial support during the Third Annual Kraft Center Symposium, “Power in Partnership,” on June 21st, 2016 at the Harvard Medical School.
His response and the take-home message was to “magnify the resolution” of transparency and join interagency partners whenever and wherever collective effort was needed.
This review of the social determinants of health (SDH) within the context of the challenges at McKinley made me think of one of the hidden ones, best described as social disconnectivity. As in the world of math, disconnectivities stand in the way of space; they become “holes” in human communication that obstruct connection and integration. The lesson I learned here was that the problem lies in the limitation not of resources, but of our imagination and creative thought. We first need to change ourselves, then the environment. I began with myself, inviting any individuals and organizations that had a stake in our children’s future to join me.
Let’s not allow barriers in our communication to trump the triumph of new scientific discoveries that could help us reap health benefits for all children and maximize the public health value of each dollar spent on pediatric programs!
As a physician working primarily with children for more than two decades, I fully understand that children’s health is more than just a medical issue. I feel privileged to be a doctor and, at the same time, I feel a deep sense of responsibility to work towards making a better health care system for this vulnerable part of our population.
There is drastic shortage of child psychiatrists for our nation’s 75 million children and teens. Currently there are only 8,300 child psychiatrists nationwide, some 30,000 short of what is needed. In Massachusetts, waits of four to six weeks for a child psychiatry appointment are common, and several community mental health centers report three month waits.
The American Academy of Child and Adolescent Psychiatry (AACAP) has worked hard to make the government aware of the crisis of limited access to child psychiatrists. I was inspired by AACAP’s legislative program to get involved in persuading policymakers to address the shortage of child and adolescent psychiatrists.
In the spirit of doing my part to address the crisis in access, I have also signed up to volunteer with the National Association of Free and Charitable Clinics to provide free care to homeless women and chidren in greater Boston area and I have created my website as a place where stakeholders can interact and come together on behalf of our children.
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