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Got to go: A path to biosocial medicine

21489754564_2598a55604_zA 6-year-old girl in kindergarten at a charter school serving mostly black and Hispanic students was struggling, according to an October 2015 story in the New York Times. “She racked up demerits for not following directions or not keeping her hands folded in her lap. Sometimes, after being chastised, she threw tantrums,” the article states. In response, the administration placed her on its “Got to Go” list, which meant those in charge intended to have her mother withdraw the girl and move her to another school.

It seems likely that this girl was exhibiting impaired development of the executive function necessary to control her emotional impulses — possibly a consequence of growing up in a highly stressful home environment. Research suggests she may have had a combination of amygdalar hyperactivity and impaired hippocampal development as the neural basis for these behaviors.

If we were to have this 6-year-old as our patient, how could this knowledge help us guide her to a healthier road? Any child given the “Got to Go” label is at risk of developing a low sense of self-efficacy. Combined with this girl’s cognitive delay, the negative psychological impact may drag her further and further behind as she goes through school. Population data suggest she will be at risk for dropping out of high school, perhaps becoming a teen parent, and adopting health behaviors that may contribute to a lifetime of reduced well-being.

In a policy statement published in 2012, the American Academy of Pediatrics recommended that pediatricians “be armed with new information about the adverse effects of toxic stress on brain development, as well as a deeper understanding of the early life origins of many adult diseases.” This approach to care would enable pediatricians to develop “innovative strategies to reduce the precipitants of toxic stress in young children and to mitigate their negative effects on the course of development and health across the life span.”

This is what biosocial medicine is all about. In this model, the care provider would follow the levels of stress and adversity the Brooklyn girl was experiencing and how it affected her neural development. Her physician would consider the factors that contribute to her personality characteristics. How are these characteristics affecting the girl’s motivation, especially her motivation to succeed in school and move on to higher education?

The physician would also need to determine how the girl’s social and cultural environment might influence these factors as she moves into adolescence. Perhaps most important, what types of interventions have demonstrated the potential to redirect her trajectory of well-being?

How should pre-med students incorporate biosocial medicine into their preparation for the study of medicine? Given the traditional separation of higher education into distinct academic disciplines, one might suggest that, in addition to biology, they should also take introductory courses in psychology and sociology. I believe that colleges and universities must instead develop new approaches to teaching the foundations of biosocial medicine that integrate historically separate discipline such as psychology, sociology and biology.

Now, back to our 6-year-old from Brooklyn. What if she had health providers versed in biosocial medicine? What if they worked closely with an educational system that offered alternative approaches to learning for at-risk children? In a supportive environment like that, this child might be able to find a more desirable path through school and into adulthood than the troubled path on which her teacher had placed her. And as a poet from New England once pointed out, that could have made all the difference.

Donald A. Barr, MD, PhD, is a professor of pediatrics and education at Stanford and author of Introduction to Biosocial Medicine: The Social, Psychological, and Biological Determinants of Human Behavior and Well-Being.

A longer version of this essay originally appeared in the Association of American Medical Colleges Reporter. 

Photo by Keith Survell

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