A single question asked at an annual checkup — whether parents have trouble making ends meet — could help pediatricians identify children at risk for serious health problems associated with poverty and the chronic levels of stress that often accompany it.

The American Academy of Pediatrics urges members to ask if their patients’ families are struggling financially and then commit to helping them get the resources they need to thrive. And some communities are trying to make that happen.

Since almost half of young children in the United States live in poverty or near poverty, it’s no small challenge.

The Center for Youth Wellness, located in San Francisco’s low-income Bayview Hunters Point neighborhood, is working with the pediatricians’ organization on a national campaign, Children Can Thrive, to raise awareness about the impact of a range of childhood stressors, known as adverse childhood experiences, or ACEs. These experiences of abuse, neglect or household dysfunction can have grave implications for both child and adult health.

In screening children for ACEs, the Center recognizes a “high relationship” between low incomes and harmful stressors. Although children from any economic status can live with ACES, exposure is greater for children who live in poverty, says Mark Cloutier, executive director of the Center.

The ACE screening test is simple; 10 questions that an adult or child can answer in a few minutes. (You can take it below.) But doctors aren’t taught about ACE scores in medical school, and some are reluctant to give patients the test because they think it’s too invasive or brings up problems that can’t be treated. That’s not true, researchers say.

Knowing that a child lives in poverty “changes everything,” says Dr. Susan Briner, medical director at the Bayview Child Health Center. Briner knows to expect that there may be more emergency room visits in families with low incomes “because if parents miss a day of work for an office visit, that can be catastrophic to their housing or family budget.”

Earlier this year the AAP, which represents 64,000 pediatricians, published a policy statement and technical report on how poverty affects children’s health in the academy’s journal Pediatrics. Lead author James Duffee, a child psychiatrist in Columbus, Ohio, says the policy represents “a new emphasis on the health of children in communities, trying to get pediatricians to think broadly about the context in which a child is born.”

According to the report, poor children have higher rates of low birth weight, infant mortality and chronic illnesses such as asthma, Type 2 diabetes and obesity.

According to Duffee, toxic stress has also been proved to disrupt the architecture of the developing brain, damaging the prefrontal cortex, which is responsible for impulse control, planning and thinking about consequences.

But the effects of poverty can be mitigated, and that’s where early intervention can help. “There is a way that we can change toxic stress into tolerable stress,” says Duffee. He cites the developing science on resilience, which shows that growing up in a close, supportive relationship with an emotionally attached adult can help a child overcome adversity.

By promoting those early attachments, pediatricians and other adults can help young people develop protective factors and head off potentially serious health effects. “One of the changes in pediatric practice is looking for ways we can promote relational health and not just physical or medical health,” says Duffee.

Families aren’t as averse to talking about their economic situation as doctors may think.

“I think it’s a great question to ask,” says Lottie Titus, a San Francisco resident who shares parenting of her three grandchildren. Titus says talking about finances with a family doctor “can establish why there are so many illnesses, so many challenges, so much depression.”

Titus’ grandkids “have been exposed to a lot,” she says. “All their lives they’ve lived in public housing.” The children, ages 10 to 14, also have health problems, from Type 1 diabetes to asthma and emotional problems. All three children see a therapist.

They are also involved in community programs such as Big Brothers Big Sisters of the Bay Area and the youth development organization City of Dreams. Titus said it was the children’s pediatrician who ensured that Titus was connected with these services: “She referred me to many programs that have been beneficial to the children, pointing them in the direction of the services that they needed, that helped them to be well-rounded.” Titus has since become a community liaison with City of Dreams, providing information and resources to youth and families living in San Francisco public housing.

That’s the model of engaged pediatric practice the pediatricians hope to see replicated nationwide.

This story was produced by Youth Today, a national news source for youth-service professionals, including child welfare and juvenile justice, youth development and out-of-school-time programming.

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Scientists and doctors say the case is clear: The best way to tackle the country’s opioid epidemic is to get more people on medications that have been proven in studies to reduce relapses and, ultimately, overdoses.

Yet, only a fraction of the more than 4 million people believed to abuse prescription painkillers or heroin in the U.S. are being given what’s called medication-assisted treatment.

One reason is the limited availability of the treatment. But it’s also the case that stigma around the addiction drugs has inhibited their use.

Methadone and buprenorphine, two of the drugs used for treatment, are themselves opioids. A phrase you often hear about medication-assisted treatment is that it’s merely replacing one drug with another. While doctors and scientists strongly disagree with that characterization, it’s a view that’s widespread in recovery circles.

Now, the White House is pushing to change the landscape for people seeking help. In his 2017 budget, President Obama has asked Congress for $1.1 billion in new funding to address the opioid epidemic, with almost all of it geared toward expanding access to medication-assisted treatment.

The White House is also highlighting success stories. At the National Prescription Drug Abuse and Heroin Summit held in Atlanta in March, President Obama appeared on stage with Crystal Oertle, a 35-year-old mother of two from Ohio. Oertle spoke of her spiral into addiction, which began with prescription painkillers and progressed to heroin. She tried unsuccessfully to quit on her own several times, before being prescribed buprenorphine a year ago. “I personally couldn’t get through the withdrawal symptoms,” Oertle said in Atlanta. “I couldn’t tough it out. I know some people can. I couldn’t do it. This last time has been the most successful recovery for me.”

Her experience isn’t unique.

“I’ve seen people with opioid-use disorders go through inpatient treatment without medications time and time and time again, without ever being offered alternatives,” says Michael Botticelli, director of National Drug Control Policy at the White House. “We wouldn’t do that with any other disease. If one treatment failed for you, we’d say, let’s look at other possible treatment options.”

David Lidz runs the organization Ladders to Leaders in Hagerstown, Md., where he offers both beds and jobs for men transitioning out of drug treatment. Meredith Rizzo/NPR hide caption

toggle caption Meredith Rizzo/NPR

Botticelli says patients should consider the evidence for medication-assisted treatment and together with their doctors make a decision about what’s best for them.

Methadone and buprenorphine have been tested in scores of clinical trials. Researchers have found that when combined with counseling, they significantly reduce opioid use and keep people in treatment longer.

“We have tons of experience with patients who remain in treatment for months and years, who do very well on relapse-prevention medicines,” says Dr. Marc Fishman, medical director at Maryland Treatment Centers in Baltimore. He says among his patients, primarily young people, about half remain with the program six months into treatment. Studies have shown far worse outcomes for patients who detox without follow-up medications, with relapse rates topping 90 percent.

Still, there are many people who stand by the so-called abstinence route — recovery without the use of medications. Their views are informed by personal experiences and deeply-held beliefs about what constitutes true recovery.

For years, Juan Ramirez, 56, led a high-risk lifestyle to support his use of prescription painkillers. “When you start robbing drug stores and drug dealers because of your drug habit, your life is not working right,” he says.

A friend told Ramirez about a doctor in Baltimore who prescribed Suboxone, a brand of buprenorphine. He liked the way Suboxone made him feel, so he would often exceed the dosage, buying pills from other patients so he wouldn’t run out. The good news was he stopped using other narcotics and, overall, he felt more functional. Still, after three years of seeing the doctor, he never felt like he’d achieved full recovery. “I was still an addict,” he says. “It was just legal.”

Lidz runs a group home in Hagerstown, Md., for men who are moving from drug treatment back into daily life. Meredith Rizzo/NPR hide caption

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That line of thinking extends to some people whose mission is to help people in recovery, including David Lidz, a recovering alcoholic, who runs a group home in Hagerstown, Md. The home has 10 beds for men who are transitioning out of intensive drug treatment back into daily life. In addition to beds, Lidz offers the men work with his contracting business, refurbishing houses. The emphasis is on hard work, personal responsibility and purpose. It’s what worked for Lidz in his recovery, but even he knows it doesn’t work for everyone.

When he started his work as a recovery advocate, Lidz knew little about medication-assisted treatment and had yet to form an opinion about it. Soon, he started getting reports from the group home that someone’s Suboxone had been stolen, or someone looked high, or that people were trading, selling, and snorting Suboxone. “That to me just looks like heroin,” Lidz says.

So he made a decision: He wouldn’t accept anyone on it.

Today, that stance is threatening the group home and his business. “Now we’ve been told by clinical settings that we’re essentially blacklisted, that they can’t even mention our program if we won’t take people on opiates, on Suboxone,” Lidz says.

He worries it could lead to missed opportunities for people like Charles Testerman, who came to Lidz’s group home after several months in drug treatment. Testerman describes his years of drug use as “doing everything to excess.” He drank, smoked marijuana, and got hooked on prescription painkillers and later heroin. When he couldn’t afford heroin, he bought Suboxone on the street, hoping it would help him stop using other drugs. It didn’t work.

“I was doing Suboxone in the mornings, as well as Adderall to bring myself up. Then at night, I was taking Xanax, smoking weed and drinking, just to go to sleep every night,” Testerman says. “It was just a constant cycle.”

Charles Testerman (left) learns from David Gibney how to restore an early 19th century barn in Waynesboro, Pa. Meredith Rizzo/NPR hide caption

toggle caption Meredith Rizzo/NPR

Today, he has an apprenticeship with a master woodworker at a place called The Stoner Farm, Anglicized from Steiner, the name of the family that built the place. Testerman is working to restore an early 19th century barn there. “I feel great, happy to be out here doing this,” he says. “It’s just nice to wake up in the morning and not have to do anything to feel normal.”

Testerman left an intensive drug treatment program and now lives in a group home run by Lidz. Meredith Rizzo/NPR hide caption

toggle caption Meredith Rizzo/NPR

Fishman, the addiction doctor in Baltimore, knows there are people like Testerman who find the strength to have what he calls a life-changing conversion without medications. But, he cautions, not everyone can do it, and it’s not scalable. He wants to persuade the doubters that medication-assisted treatment is the best tool available at the moment, and, in making his case, he’s willing to acknowledge its limitations.

“This doesn’t change my claim that it should be the standard of care,” he says. “But we don’t have the penicillin for addiction. These are not curative medications. In having a nuanced, thoughtful discourse with people who might disagree with us, acknowledging those limitations I think would make us more credible.”

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