Elevating Relational Health in Pediatric Primary Care
Douglas Russell, MD
PAL Consultant
As a child and adolescent psychiatrist, I bear witness to the many ways stress can exceed a child’s ability to cope. I see the anxious child who absorbs his parents’ unspoken dread and expresses it as his own. The preteen with unrecognized ADHD who thinks of herself as less capable than her neurotypical peers. The depressed adolescent whose search for personal identity has ground to a halt by two years of pandemic-related uncertainty and isolation.
Due to the lack of ready access of evidence-based mental health care professionals, the burden of diagnosis and treatment is increasingly falling on the shoulders of our primary care in the United States. As pediatricians and other primary care providers valiantly exceed their comfort zone while waitlists for outpatient mental health services lengthen and children in mental health crisis pour into overtaxed emergency rooms, we must decide now how to address the collective misery of a generation of young people.
I join my colleagues from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry in calling for more access to collaborative mental health services, including greater integration of mental health professionals into pediatric clinics. But if we want to do more than meet the acute need, if we want to equip future generations to meet future crises, we must also turn our attention toward prevention. We know that stressful life events during early childhood can predict internalizing (mood, anxiety) and externalizing (emotion regulation, impulse control) disorders later in life. And we are beginning to understand how the quality of a child’s relationships during the first years of life changes the brain to chart that course.
Resilience is the capacity to successfully adapt to adversity and process the psychosocial stress that accompanies it. Some of this capacity is innate, that is, related to the unique combination of genetic material bestowed upon a child by their biological parents. But as those in pediatrics and family medicine know so well, the quality of personal relationships during the earliest stages of life, or “early relational health,” also plays a fundamental role. The seeds of resilience are sown each time a pregnant mother places a loving hand on her belly, and later, each time a parent picks up their crying infant, changes a diaper, reads a story, or whispers a lullaby. These ordinary micro-interactions between a parent and child create what pediatrician and psychoanalyst Donald Winnicott called a “holding environment” that helps define how individuals see themselves in the world.
The birth of a child tests a family’s resilience regardless of privilege. Trauma, racism and other social and structural inequities compound the stress of parenthood and can negatively impact the quality of the parent-child relationship, potentially altering the course of a child’s neurodevelopment. Medicine has been slow to recognize the impact of social and structural inequity on health outcomes, including mental health. By ignoring the fundamental needs of families and contributing to healthcare inequity, our medical institutions have eroded the trust of the communities they serve. The Covid-19 pandemic has highlighted this shame, and presents us with a historic opportunity to change the way we approach pediatric care. If we in medicine are truly committed to the social-emotional wellbeing of children, we need to expand our focus beyond the individual to include the whole family.
Concretely, at the clinic level this could mean things like improved screening of parents for postpartum depression during first year of life and universal screening for social/structural determinants of health at regular intervals. At a systems level, this could mean more streamlined communication between prenatal and postnatal care providers to identify at-risk families. But what about the policy level? Included in the recently passed Washington State budget is new funding to help establish community health workers in pediatric primary care. These non-licensed individuals would focus on restoring trust, connecting families in need to social and community resources, and increasing engagement in preventative care, including early relational health needs. The community health worker is not necessarily a new concept, but the emphasis on pediatric primary care and the focus on early relational health is. How this will play out remains to be seen of course. But it is a sign that change might be coming.
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News & Notes
Join us for our upcoming virtual conference this Saturday!
April 30, 2022
8:00 am - 12:30 pm PST
Register here!
Featured Topics & Presenters:
- Updates in Teen Suicidality | Dr. Nicholas Weiss
- Pediatric Depression in Primary Care | Dr. Erin Dillon-Naftolin
- Cannabis Use in the Perinatal Period | Dr. Nadejda Bespalova & Dr. Laurel Pellegrino
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 PAL Spotlight
Dr. Will French joined the PAL team in the summer of 2013. He is originally from Lexington, Kentucky and has lived in Seattle with his family since 2008 when he joined the University of Washington faculty and began working at Seattle Children’s. He received his undergraduate degree in English from the University of Kentucky in 1988 and then taught English in San Diego and Japan for a number of years before returning to Lexington where he attended medical school and completed his residency in general psychiatry and fellowship in child and adolescent psychiatry.
One of Dr. French’s main clinical interests is in improving mental healthcare delivery through collaborative care partnerships with primary care agencies and providers. In addition to his role with PAL, he provides psychiatry consultation to the outpatient pediatric clinic at Harborview Medical Center and to several school-based health centers operating in public schools in the Seattle area. Over the last several years, he has served as a faculty member developing child-specific curricula and providing didactics for the UW Integrated Care Training Program. This psychiatry fellowship is the first of its kind in the United States and has currently expanded its program to offer online/virtual training in integrated care to non-psychiatric providers in Washington State.
Dr. French enjoys supervising child psychiatry fellows, who provide psychiatric consultation to local schools during a second year school-based rotation. In addition to consultation and collaboration with primary care, Dr. French has experience and interests in disruptive behavior disorders, including ADHD, foster care youth, complex developmental trauma, and severe mood dysregulation. He has outpatient practices and provides fellow supervision at Seattle Children’s main campus, Odessa Brown Children’s Clinic in the Central District, and in the pediatric clinic at Harborview Medical Center. When not at work, he enjoys spending time with his wife and two children, gardening, taking walks with his dog Jax, riding his bike, running, hiking, and skiing in the winter, as long as Mother Nature will cooperate!
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Upcoming CME Conferences
Virtual Conference (Formerly listed as "Vancouver, WA")
April 30, 2022
Register here!
Virtual Conference (Formerly listed as "Spokane, WA")
June 11, 2022
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Conferences run 8:00 AM - 12:30 PM and are FREE to attend.
Registration opens two months in advance.
CME credits are available.
Visit our website for the most updated information on upcoming conferences and to view slides from our previous conferences.
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