Category Archives: doctors

Social capital can alleviate youthful stressors that predict poor adult health

Flickr/meganskelly

Just finished a very interesting New Yorker article entitled “The Poverty Clinic” by Paul Tough that focuses on Nadine Burke who runs a San Francisco-based low-income health clinic and her conviction, supported by various studies, that youth trauma scars young people’s health for life.

They cite the ACE (Adverse Childhood Experiences) study of 1998 that showed that adults’ retrospective childhood ACE memories were a strong predictor of all kinds of negative adult health outcomes and this exhibited a dose-response linearity — i.e., exposure to more categories of childhood adversity meant both greater likelihood of negative adolescent outcomes (depression, suicide, binge drinking, etc.) and greater likelihood of poor adult health outcomes.

These ACEs measure youth stress in four areas: 1) physical; 2) sexual; 3) psychological; 4) substance abuse; 5) mental illness; and 6) criminal activity.  Actual list of items appended to this post.

While it is possible that these retrospective memories are flawed (i.e., sick adults are more likely to recall childhood stresses), a basically prospective New Zealand Dunedin study is finding the same thing for early trauma.  And Bruce McEwen (Rockefeller Univ.) and Frances Champagne (Columbia Univ.) have shown that “repeated, full-scale activation of this stress system, especially in early childhood…actually alerts the chemistry of DNA in the brain, through a process called methylation….This process disables these genes [methyl groups], preventing the brain from properly regulating its response to stress.”  Even a decade or more after the stress, these teenagers find it harder to sit still, exhibit higher rates of aggression, show weaker brain function, and can’t as adequately distinguish between real and imaginary threats.

While some doctors are looking at whether drugs (psychopharmacology) could have an impact, social capital can often overcome these stressors.

“Other researchers have produced evidence that they can mend children’s overtaxed stress-response systems by changing the behavior of their parents or caregivers.  A study in Oregon drew this conclusion after assessing a program that encouraged foster parents to be more responsive to the emotional cues of the children in their care.  Another study, in Delaware, tracked a program that promoted secure emotional attachment between children and their foster parents.  In each study, researchers measured, at various points in the day, the children’s level of cortisol, the main stress hormone, and then compared these cortisol patterns with those of a control group of foster kids whose parents weren’t in the program.  In both studies, the children whose foster parents received the intervention subsequently showed cortisol patterns that echoed those of children brought up in stable homes.

“In terms of helping older children and adolescents who have experienced early trauma, the research is less solid.  There is evidence that certain psychological regimens, especially cognitive-behavioral therapy, can reduce anxiety and depression in patients who are suffering from the stress of early trauma.  But, beyond that, little is known…”

Kaiser Permanente started asking about these stressors on intake questionnaires, since the were markers of health problems in the same way as say high cholesterol was.  The article points out that eliminating the negative effects of four ACEs would lower the risk of heart attacks as much as lowering cholesterol below the warning threshold.

With regard to work we are currently doing on a growing social class gap among adolescent youth, it is possible that methylation and ACEs might help explain lingering and persistent growing social class gaps that we see among high schoolers over the last several decades.

Read “The Poverty Clinic” (New Yorker, March 21, 2011)

See earlier post “Doctors Prescribing Social Capital

See early article on Childhood stressors and adult health: Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al JS. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998;14:245-258.

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Specifically ACE questionnaire asks whether:  parent or other adult in household (HH) often or very often swore at you, insulted you or put you down; often or very often acted in way that made you afraid that you would be physically hurt;  often or very often pushed, grabbed, shoved, or slapped you; often or very often hit you so hard that you had marks or were injured; person five+ years older than you ever touched or fondled you in a sexual way; had you touch their body in a sexual way; attempted oral, anal, or vaginal intercourse with you; actually had oral, anal, or vaginal intercourse with you; whether you lived with anyone who was a problem drinker or alcoholic; lived with anyone who used street drugs; whether anyone in HH was depressed or mentally ill; whether HH member attempted suicide; whether your mother was treated violently ; whether your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her; whether mother/stepmother was sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard; whether mother/stepmother was ever repeatedly hit over at least a few minutes; whether mother/stepmother was ever threatened with, or hurt by, a knife or gun; whether HH member ever went to prison.

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Doctors prescribing social capital?

Flickr photo by carf

I wrote earlier about some insurers using social capital in making decisions of whom to insure.

That post and a story sent to me by Lew Feldstein about doctors prescribing outdoor time got me thinking about doctors and social capital.  In the same way as doctors ask questions of patients around smoking, exercise, diet, etc., why shouldn’t doctors also ask patients to fill out a short survey about social capital activities they engage in:  number of confidants, how many of their neighbors’ first names they know, how often they go to friends’ houses or entertain others in their home, etc.?

These data could be used for 3 purposes:

1) to track real changes in the patient over time:  e.g., if a patient used to report 2 confidants and now reports zero it would be a chance for the doctor to find out what had triggered this (a friend moving, serious arguments, a close friend dying, etc.) that might help identify patients at risk of being socially isolated or going through stressful times.

2) to benchmark against others of the patients’ education, race and age.  In larger practices, or if this information was aggregated anonymously by affiliated hospitals, the computer could help patients understand the degree to which they far less involved in community or other associations or less trusting than comparable others nationwide or in their area.  If one was significantly below what others were, the doctor might want to bring this to the patient’s attention:  “did you know that most others like you are far more active in their community?”  or “did you know that most others like you volunteer much more their community?”  “This is something that has clear health impacts;  would you like more information about how to get more involved?”

3) to prescribe social capital “treatments”.  We’re far more used to a doctor prescribing an antibiotic or an aspirin than recommending that a patient get actively involved in a group (on a topic he/she cares about).  And some social capital deficits are more easily treated than others — it’s hard to suddenly develop a confidant.  But doctors might note to patients that there are real health consequences of being socially isolated and being socially and civicly uninvolved: i.e., getting sick more often and recuperating more slowly.  If acquiring a confidant in the next year is not a doable goal, maybe deciding which of ones’ friends have the potential to be confidants and taking some steps to start to deepen these relationships might be doable over the next 6-12 months.   Patients might agree to certain steps they want to take and put them on a card in a sealed and addressed letter that gets sent to them in 4 months.  Nudges can also be used to help people keep promises (through ongoing social groups that hold their members accountable for their promises, checks that go to disliked groups if commitments are broken, etc.).

And as to why?  Doctors might point out that they would rather be prescribing social capital now than prescribing hypertension drugs five years down the road.

[Read related story in NY Times about prescribing outdoor time: “Head Out for a Daily Dose of Green Space” (Jane Brody, 11/30, 10]