Pediatric Meltdown: Parent-Led Health Care Transformation

Girl wearing a stethoscope.

As pediatricians face enormous challenges maintaining practices amid growing expectations, there is optimism that transformational change in pediatric primary care delivery could further support providers and bring about the often-elusive outcomes we have long sought.

Paul Dworkin, MD, executive vice president for community child health at Connecticut Children’s and founding director of the Help Me Grow National Center, detailed his reasons for optimism during a recent Pediatric Meltdown podcast episode. Host Lia Gaggino, MD, a pediatrician based in Michigan, launched the podcast to provide innovative guidance to pediatric providers related to children’s mental health and well-being.

Listen to the Pediatric Meltdown podcast episode.

During the episode, Dr. Dworkin discussed his motivation for becoming a developmental-behavioral pediatrician, as well as his focus on the promotion of children’s health, development and well-being.

“I always felt that the science of development and behavior were key to enhancing the impact of child health services, particularly through general pediatrics,” stated Dr. Dworkin.

He framed the evolution of his work as a series of questions.

“The driving question for me for many years was, ‘What if our goal for child health services was not only to treat or even prevent childhood diseases, disorders and delays, but was also to promote children’s optimal health, development and well-being?’” stated Dr. Dworkin.

Unsure as to what the answer to that question was, or whether an answer even existed, Dr. Dworkin explained that over a number of recent years, he has become more confident than ever that child health providers should strive for health promotion, in addition to treating, and even preventing, delays and disorders.

This realization prompted Dr. Dworkin to ask another question, “How do we strengthen child health services to promote children’s optimal health, development and well-being?” Dr. Dworkin stated that this theme has guided his work and the work of Connecticut Children’s Office for Community Child Health for a number of years now.

During the podcast, Drs. Dworkin and Gaggino discussed the many ways in which pediatricians are stretched today, including the COVID-19 pandemic, an evolving list of recommended topics for well visits, managing chronic diseases, the escalating behavioral health crisis, documentation demands, and reimbursement restrictions. They also discussed whether providers have the bandwidth to adopt the transformational approach Dr. Dworkin advocates for, which includes utilizing a parent-led agenda and embracing cross-sector partnerships and payment models.

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At the conclusion of the Pediatric Meltdown podcast episode, Dr. Gaggino offered 12 takeaways on the discussion. Those included:

  • Actionable steps: Dr. Dworkin offers a vision for child health reform that includes doable actions at the grassroots primary care level.
  • Big ideas: What if child health providers move beyond prevention to focus on child health promotion and what if the focus is parent-driven?
  • Science: Dr. Dworkin’s work follows knowledge learned during the 1990’s, the so-called “Decade of the Brain,” and the subsequent enhanced understanding of the biology of adversity. It takes into account the implications of adverse childhood experiences, toxic stress, and epigenetics while also encouraging resilience building. Could the answers lie in embracing a strength-based approach, rather than the deficit model so prevalent in clinical medicine?
  • Impact of poverty and racism on children: The impact on children affected by adverse childhood experiences, poverty and racism is described in detail in policy statements from the American Academy of Pediatrics. Providers see these effects on children so the next step is up to us.
  • Embracing reform amid the daily challenges of pediatrics: Pediatricians are busy trying to keep our heads above water to meet the needs of patients and then we have to document all of that, so is transformational change possible at the pediatric practice level? Dr. Dworkin says one of the most impactful changes we can make is embracing a parent-led agenda.
  • Cross-sector efforts are necessary: This work is not an individual sport. It requires a cross-sector team from different disciplines to collaborate in meaningful ways and it must include closed-loop communications.
  • Help Me Grow: Help Me Grow is a bold strategy that looks for children already on at-risk trajectories and links them and their families to resources before a need arises. Rather than exclusively screening for delays, the model searches for opportunities. Learn more about the Help Me Grow National Center.
  • The Help Me Grow model: The Help Me Grow model includes four steps: 1) outreach and detection through surveillance and screening, 2) community outreach and linkage based on parent-expressed needs, 3) single point access for care coordination with effective linkages, and 4) data collection for meaningful outcomes.
  • Reach Out and Read: This program offers a great example of an upstream effort that builds on the strengths of the parent-child relationship, enhances vocabulary and language skills, fosters reading skills, and improves academic success and social-emotional well-being.
  • Return on investment: Is this work cost-effective? Is there a return on investment? Yes! Dr. Dworkin says research has shown that for every dollar spent, there are three to seven dollars saved.
  • Track meaningful measures: We have to look beyond the traditional, medically-oriented measures like screening rates and body mass index, and also look at long-term outcomes like graduation rates, involvement in juvenile justice, mental health, food security, and housing security, which are so meaningful to children and their families.
  • Using a parent-led agenda to inform anticipatory guidance: Where can we start today? First, elicit parent opinions and reorient office visits to a parent-led agenda that informs your anticipatory guidance and support. If the concern the parent has is about a child’s sleep, go there because that is where you are likely to make impact. Include other guidance, but make sure to connect with parents on their areas of concern.
  • Big changes feel overwhelming…at first: While big changes feel overwhelming, it can start with you. Be brave, be bold, be innovative and always be the voice for children and families, because that is what matters most.

To learn more about Connecticut Children’s Office for Community Child Health, click here.

To learn more about the Pediatric Meltdown podcast, click here.