Stress is nothing new to American families, who—over the generations—have endured wars, epidemics, natural disasters, and numerous economic downturns.
Today's dismal economic climate with continuing unemployment poses real challenges for families.
You should be especially attuned to warning signs that more children in your practice may be at risk for hunger, displacement from their homes and schools, and poverty-associated trauma, both physical and psychological.
The statistics are sobering.
In June 2010, unemployment stood at 14.6 million people, or 9.5% of the working-age population nationwide. Even more people are jobless in some unfortunate states and cities—more than 14% in Nevada, for instance; 14.5% in Las Vegas, Nev.; and 27.6% in tiny El Centro, Calif.
Homelessness among American families is growing, with 170,000 families seeking shelter in 2009, up from 159,000 the year before, according to the U.S. Department of Housing and Urban Development.
Every 3 months, another 250,000 families' homes enter foreclosure, putting one child in every classroom at risk of losing his or her home, according to the Mortgage Bankers Association. That statistic is so stunning—home foreclosures impacting one child in every classroom—that it bears repeating as it indicates every pediatric practice has more red flags in terms of psychosocial stressors then at any time in most pediatrician's career.
Families, as always, face crises unrelated to the economy as well: illness, marital discord, substance abuse, and intergenerational pressures, but economic downturns increase the prevalence of almost all of the crises on this list.
Poverty is the elephant in the room, exposing children to a host of contributors to an unstable environment that sets the stage for poor academic performance, increased mental health disorders, conduct problems, substance abuse, and difficulties in relationships.
The first red flag raised by a family in economic trouble probably isn't even seen in the examining room, but in your billing department, where reimbursements are likely down and delinquent accounts are likely up.
A family may be unable to produce a copay for a visit, or may have lost health insurance along with mom or dad's job. They may report multiple changes in their address. Mail from your office may be returned as undeliverable.
This is, of course, an economic problem for you and your practice, but it likely heralds medical and psychosocial problems as well. A child whose family cannot pay for your services may be twice as likely as a financially secure child to have depression, anxiety, and learning problems at school.
Your office staff may want to alert you to financial red flags not only as they appear on the office balance sheet, but as they relate to your care of the child as well.
Moving, for example, has many implications for a child's development and well-being.
A new address may mean changes in a child's school and after-school activities, the loss of friends and close access to extended family members, and a shattering of the security of familiar places and routines. If the move was involuntary, say, a forced exit from a foreclosed home, parents may be so distracted and emotionally spent, they may not have devoted time to calmly explaining to the child what will change and what will stay the same.
I always think it's a good idea, but especially so in hard times, for you to ask one screening question of every family during routine office visits.
That bushel basket question is, “Are there any ongoing tensions affecting the family?”
Answers can potentially cover a lot of ground, and may open the door to a family sharing financial concerns, as well as any other issues that may be troubling them: a recent move, concern about a family member, or signs of domestic strife.
Red flags may appear during your examination as well. Immunizations may not be up to date, problems are suddenly arising at school, or a there may be a change in trajectory of the child's weight curve due to a lack of nutritious food.
Fatigue and stress associated with family troubles may be cloaked in somatic diagnoses: headaches, stomachaches, chest pain, weakness, or dizziness in a child who never had such complaints before or where these symptoms previously have signaled stress.
Take a good look at the parent accompanying your patient as well. Does the mother or father seem more withdrawn, sadder, or more anxious than expected?
Often, you have an internal red flag, a vaguely unsettled feeling that something is not right. Do not underestimate the value of this clinical sixth sense. Listen to it. It may not be anything specific that you can put your finger on or diagnose, but if you're getting that signal from within, sit down and take the pulse of the family in these troubling times.