Dr. Moira Szilagyi, a pediatrician and interim chief of General Pediatrics at University of California at Los Angeles (UCLA), has a couple of tried-and-true methods of breaking down communication barriers with teenage patients, and they’ve worked well during the COVID-19 pandemic. One way is prefacing any query about mental health by saying that many of her teen patients are having a tough time, so they don’t feel think they’re the only one.
“That’s usually sufficient,” she said, but if it doesn’t work, she has another tool in her toolbox to probe whatever anxiety or depression may be lurking beneath the surface. “I whip out my magic wand and ask them if I grant them three wishes, what would they like to do? And they might roll their eyes, but they often will tell me.”
Sizalgyi, who is also the nominee president-elect of the American Academy of Pediatricsand the section chief of Developmental Behavioral Pediatrics at UCLA, was one of four presenters in an ACEs Aware webinar entitled “Primary Care & Telehealth Strategies for Addressing the Secondary Health Effects of COVID-19.” The others include Dr. Devika Bhushan, a pediatrician and chief health officer in California’s Office of the Surgeon General; Dr. James Hardy, associate clinical professor in the Department of Emergency Medicine at University of California at San Francisco; and Dr. Rachel Stewart, an obstetrics gynecologist and the medical director of FPA Women’s Health in Los Angeles.
Sizalgyi was responding to an attendee’s query about how health care providers should respond to teens who have endured losses amidst the COVID-19 pandemic.
Dr. Devika Bhusan explained that the high death count, high unemployment and social isolation have resulted in various traumas and problematic behaviors: “an uptick in substance use. . . intimate partner violence, and child abuse and neglect.” In other words, an increase in adverse childhood experiences (ACEs).
Adverse childhood experiences is a term that stems from the landmark Centers for Disease Control and Prevention/Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) of 17,000 adults that found a relationship between 10 types of childhood traumas, such as any type of abuse or neglect, and adult-onset of chronic health conditions. Many other types of ACEs — including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)
The ACE surveys — the epidemiology of childhood adversity — are one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, how toxic stress is passed on from generation to generation, and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems. Research has shown how interventions — such as parent education, family therapy, building resilience, providing children and families with basic needs — can offset the impact of toxic stress from ACEs.
The problem during the pandemic, however, is that the kind of care that can help mitigate toxic stress has been limited, said Bhushan.
Dr. James Hardy, the UCSF emergency medicine doctor, agreed. He has seen an increase in the number of people brought to the emergency room for psychiatric issues or for overdoses but doesn’t always have the resources to ensure proper long-term care.
“How do we get a warm handoff to a primary care doctor, or a psychiatrist, or a substance use navigator in the community that can help with the next steps?” he asked. “All of those mechanisms have been disrupted, as you can imagine.”
Stewart described the problem as a “paralysis of health care systems.” At FPA Women’s Health, which has 25 clinics across the state, they’ve been developing interim ways to help patients buffer toxic stress. They’re providing resources by county for substance abuse, suicide prevention, and intimate partner violence, “and then following up in two weeks to ensure [that the clients] were able to access them,” said Rachel. “Unfortunately, a lot of times those resources are at capacity.”
So, given all of the challenges, Tanya Schwartz of Harbage Consulting, who was moderating the webinar asked clinicians to talk about startegies fall back on to best support patients?
“I think I’m going to go back to how important relationships are with our families,” said Sizalgyi. “So [that means] using the phone or telehealth to reach out and stay in touch and to meet them where they are.”
Another strategy is to retool to meet patients’ current needs. Sizalgyi mentioned a medical group in Texas whose visits plummeted to 20 percent of their usual caseload after the pandemic began. At the same time, all three food banks in the town had closed, so the group decided to “recast themselves as the food source for their town,” she said.
She ticked off a few other ways that clinicians can pivot to meet the needs of patients during the turbulence of the pandemic:
- Provide immunizations to patients in their cars.
- Weigh and measure pediatric patients in the parking lot.
- Shift schedules to better accommodate patients’ time.
To view a recording of the webinar click here.