Thank you to SCCM for supporting this session and for having me join today to talk about the critical need to screen for social determinants of health and adverse childhood experiences during PICU admissions. I have funding from the NICHD and the Patrick Magoon Institute for Healthy Communities for work related to health disparities including some work related to social determinants of health. The objectives of this talk today are to review the justification for screening in the PICU including the biopsychosocial model and toxic stress as justifications for screening, to recognize PICU admissions as an additional form of trauma that can potentiate adverse outcomes, and to discuss outcomes that screening is designed to prevent, to identify perspectives on screening from the parent and family, and to describe the development and validation of a strengths-based PICU social determinant of health and ACEs screening tool. First, just to bring us all to the same page, when we think about achieving justice and social justice in particular, we think about that as counterbalancing racism and other isms and understanding justice as a fundamental concept can help us to understand how to combat these isms from preventing more equity amongst populations. John Rawls developed a concept of justice that is probably oversimplified by these two claims, but they involve two claims including one against political institutions noting that these should be accessible to all and the second a claim against social and economic institutions which basically just described a state in which equity and justice was attained when there was only inequality permitted where the least well-off were made better off. So when we think about the distribution of resources, we ought to think about a distribution that favors making the least well-off better off if we're trying to achieve justice and equity. You've undoubtedly seen this slide before, but I think it's important to remind ourselves that the majority of health is actually framed by social and economic conditions and these are the conditions in which we ought to strive to achieve inequity or reduce inequities in the distribution of resources in order to optimize population and individual health. Just to review, the next three slides go over the consequences of not avoiding adverse childhood experiences and other forms of inequities in contributing to poor health. So we know that adverse childhood experiences both put people at risk in the short term as well as the long term in terms of their mental health, but when four or more ACEs are present there's an increased incidence in lung disease, increased suicide attempts, depression, increased intravenous drug use, and increased liver disease. So really in order to reduce the long-term impact of these experiences, we have to try to prevent and recognize these adverse experiences during childhood. And when we trace really the etiology or the conditions that provide, that permit adverse childhood experiences to develop, what we see is that these form from specific experiences in childhood, but those are based on adverse community environments which collectively are influenced by historical experiences such as mass incarceration, slavery, the Holocaust, poverty, racism, violence within the community, and lack of education and economic opportunity. And really we need to be addressing these roots as we begin to try to think about how to turn the tide on the experience of adverse events during childhood. So how does biology support the idea that adverse child experiences contribute to poor health? One model is through this idea of the development of toxic stress, including your allostatic, increasing your allostatic load, and then that therefore leading to illness. And this model recognizes that the social and structural position of the household influences the level of adverse experiences that one, and toxic stressors that one might experience. That then contributes to the development of allostatic load, which is also contributed to by genetic, epigenetic changes, and social and other vulnerabilities to illnesses also play a role in worsening that allostatic load that influences the body and brain's development, which leads to decreased school readiness, later academic performance, and increased occupational stress. And these factors that one experiences in childhood are intergenerational, intersectional, and they occur both at the level of the person's experience as well as systemic experiences such as poverty within a community and racism. The biopsychosocial model developed by the American Academy of Pediatrics also recognizes the interdependence of one's ecology, biology, and health and development as part of really the basic science of what it means to grow and develop as a child into adulthood, and that these are influenced not only by neuroscience and biology, but also by epigenetics and one's life course and experiences. The PICU literature specifically supports the idea that social determinants are relevant to one's overall health. In the PICU population, it's been demonstrated that social determinants of health impact need for ICU resources. This article by Andrest et al shows that as you increase rates of poverty in the community, the PICU admission rate also increases. Brown and group showed that social determinants also impact access to PICU resources by demonstrating that Black Americans were twice as likely to live in neighborhoods with higher area deprivation indices, meaning areas of less resources and greater need. Katherine Slane and group showed that specific outcomes of the PICU were also influenced by social determinants of health. In this paper demonstrating that children that lived at incomes less than 150% of the federal poverty limit had greater rates of unfavorable clinical outcomes when admitted to the PICU with critical bronchiolitis. This included length of stay that was longer both in the PICU and in the hospital, longer duration of supplemental oxygen use, greater cost, and higher need for mechanical ventilation and high flow oxygen use. So in order to begin identifying adverse childhood experiences and social determinants that impact health, we thought about developing a strength-based PICU screening tool for both social determinants and ACEs. We first thought to understand perspectives on screening both at a community and PICU parent level. In addition to screening for specific exposures to adverse experiences as well as social determinants of health, standardized data collection can also help to establish one's social risk contribution to their health. This includes both person level data in terms of demographics and then system and neighborhood level data through usually the use of different indices that have been developed either at the zip code or census tract level. Several individuals including our own Paula McGee, part of this panel, have looked at neighborhood level indices or the neighborhood environment and thought about its influence on a PICU course. Dr. McGee specifically looking at the impact of neighborhood and built environment on PICU illness severity by looking at the associations between social vulnerability index, neighborhood disorder score, and childhood opportunity index and their influence on the peak organ dysfunction score within 72 hours of admission. While these composite measures in her work did not demonstrate an association with peak PILAD2 scores, she's continuing to explore looking at sub components of these composite measures and their influence on organ dysfunction. The social determinants of health working group of the Polisi Research Network has completed a two-day cross-sectional look at social risks and resources in multiple PICUs across the U.S. and some in Canada as well with the purpose of understanding how hospital characteristics and resources influence social screening practices as well as the availability of social resources and referral patterns to these. And while we still are working through the analyses of the data from this study, we know that there isn't a universal screening tool for use in the PICU that captures both social determinants of health and adverse childhood experiences. A PICU fellow currently at Cincinnati Children's, Rebecca Aspess, is looking at this question specifically and has been developing along with me a social risk screening tool that is really parent-influenced and focused, beginning with parent interviews on feasibility, acceptability, and key domains for screening, moving to a consensus expert panel for what to include in screening, returning to parents in a focus group to review these recommendations and revise a screening tool based on these, and then currently to pilot test that tool to make sure that is performing as expected prior to moving it into a multi-site trial to evaluate social risks and resource referrals based on the standardized tool. We know also, as I discussed, that an ICU experience itself potentiates trauma. The model for post-intensive care syndrome in the pediatric population shows us that one's social health and emotional health are important components of their trajectory of recovery post-critical illness, and so we have to think about this and addressing any additional traumatic experiences as we think about changing their potentially complicated post-PICU course. We can potentially influence the potentiation of trauma through the PICU experience by direct patient-focused activities, but also looking at how well as organizations we do at making our practices trauma-informed. There's some work that is, a lot of work that's been done by trauma-informed care in the mental health field, but also moving this into PICU practice at a local level is important in reducing that long-term effect of the trauma of the PICU experience. One potential component of how an ICU experience can potentiate further trauma is how we use and respond, use tools to respond to parents that have difficulty coping during their PICU experience. Oftentimes we may work through different conflict resolution tools, but ultimately we often arrive at some potentially punitive measures such as behavioral contracts, and looking at how we think about these in our institutional approach to conflict as well as how they might impact individuals in their intra and post-PICU course is an important component to thinking about how to perform trauma-informed care. Alice Olszewski, one of the PICU fellows soon to leave us from Lurie, has focused her fellowship research and her early career on looking at just this question. And as we put all of this together, we need to also begin to think about how we interact with individuals in their post-PICU course to try to reduce the influence of negative experiences that they may have had pre as well as intra-PICU, and the influence of their social determinants on post-intensive care syndrome. One thing that we have tried in the Lurie system is to look at using a group therapy model, purposely recruiting from individuals living in low resource environments where mental health access may be low, to address their mental health in the post-PICU period. And interventions like this, evaluating them on broader scale, will help us to understand whether we can influence that trajectory of the post- PICU experience by having greater knowledge of one's exposures to trauma as well as their social environment once they leave the PICU. Thank you, and if you have any questions I'd be happy to answer them at the email address here or be in touch via Twitter.

social determinants of health

adverse childhood experiences

trauma-informed care

PICU screening tool

mental health interventions