Toxic stress gets the spotlight at St. Louis med schools

It’s June, and the third-year students at St. Louis University School of Medicine are getting out of anatomy labs and lecture halls and into their first clinical rotations with patients.

The doctors in training can be easily identified by their short, white coats and stethoscopes around their necks.

Earlier this month, when those students listened intently to their first grand rounds presentation of the new academic year, it was telling that the topic was toxic stress and children.

It was presented by SLU Associate Professor Kenneth Haller, head of the Missouri Chapter of the American Academy of Pediatrics. It was held at Cardinal Glennon Children’s Hospital, where the effects of toxic stress on children can be seen firsthand: asthma, obesity, child abuse, hyperactivity and depression — all associated with chronic levels of household stress.

“This is their first rotation,” said Haller of the students. “It really challenges them to figure out, what are you going to do with this public health problem?”

SLU neonatologist Dr. William Keenan went so far as to say the presentation was “the most important grand rounds we’ve had this year, probably this decade.”

As the Post-Dispatch chronicled in a February special report based in Ferguson, toxic stress occurs when children and adults don’t get a mental break from chronic worries and extreme burdens. Though such stress can afflict anyone, it is particularly common among families living in poverty and compounded by experiences of past trauma.

The stress turns toxic when the body overproduces stress hormones. An expanding body of research suggests exposure to incidents of trauma and chronic stress adversely changes children’s genetic, neural, physical and behavioral development. Those changes can sometimes start before birth if a pregnant mother suffers from toxic stress.

For the students, much of this was new information and not something they had encountered in their own childhoods. Third-year student James Arpin from Hutchinson, Kan., said there was always food on the table, stable housing and a harmonious family to support him while growing up.

“You realize these families have a lot of problems that you and I may never have to face,” he said.

Arpin said the presentation was the first time he had heard about dire adult health statistics associated with adverse childhood experiences. Research suggests four or more traumatic events in childhood drastically increases chances of developing chronic adult conditions like high blood pressure, diabetes, heart and kidney disease, stroke, obesity, cancer and mental illness.

Seeing it firsthand

As the recent grand rounds presentation indicated, the topic of toxic stress is steadily gaining traction in medical, public health and mental health fields as a major health issue potentially affecting millions of children — many of them growing up in poverty.

The recommendation is intended to bring up the topic of poverty because of its health risk to children. The Academy wants physicians to make better efforts to link families and children to supports like food or diaper banks, or early childhood supports.

But the question remains, are doctors adequately prepared to address toxic stress and its roots in poverty, both in their examination rooms and in the public domain?


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“I learned not to sweat the small stuff,” said Ruth Coleman, whose son Ian, 4, (right) cuddles with her as she fills out a reading log for an older son, Dylan, 8, on Tuesday, Jan. 26, 2016, in their mobile home in Truesdale, Mo. Coleman and her husband John Coleman took a parenting course through a head start program as part of a federal trial study in St. Louis called, “Buffering Toxic Stress.” The couple recently moved after losing their Warrenton home to foreclosure. Photo by Laurie Skrivan,

Robert Block, past chairman of the American Academy of Pediatrics, said medical schools are mostly doing a good job educating students on the issue and teaching them ways to better interact with families and children facing toxic stress.

But because many practicing pediatricians and family doctors are wedded to traditional billing and scheduling procedures, “there are not systems in place for established practices to make big changes to include conversations with families on their parenting circumstances and resources,” he said. It will take years for new doctors to enter those practices and effect change.

At Washington University School of Medicine, for example, students learn about toxic stress and trauma within the first week of school through a program that sends them out to various low-income neighborhoods and medical clinics. They see firsthand the general burdens of poverty including neighborhood violence, food need, debt, housing insecurity and domestic conflict, said Dr. Michael Awad, associate dean of medical education.

“Some of the students are quite moved, quite shocked, and it really gets them from an very early point on in their education thinking about patient care in a different way,” he said.

Awad said the medical students are also tasked with bringing their knowledge into the greater medical community.

“Our students in some way may know more than our experienced physicians on this topic,” he said. “The students do become the teachers, and that’s OK.”

Supporting parents

In February, the Post-Dispatch ran a special report, “The Crisis Within: How toxic stress and trauma endanger our children.” It focused on the stresses among three families in Ferguson already coping with the traumatic shooting death of 9-year-old Jamyla Bolden who lived nearby and was a friend to some of their children. The report further chronicled daily struggles with housing, debt, lack of transportation and past trauma and proposed solutions to lessen that stress on children.

During Haller’s presentation, he referred to two of the children featured in the series as they dealt with this stress. One of them, Destiny Sonnier, had a routine when she played outside with a cousin. They’d stop their cartwheels and pray so they wouldn’t get shot.

Darlene Evans takes a walk with her five youngest children on Wednesday, Aug. 12, 2015, in front of their home in the Northwinds apartment complex in Ferguson. From left are to right, are Warren, 10, Alex, 2, Aaron, 3, Lexi, 2, and Destiny, 9. Since some of her children witnessed a shooting outside their apartment four days earlier during Destiny’s birthday party, Evans has limited her children’s outside playtime. Photo by Laurie Skrivan,

Haller said he treats at least one child a day showing signs of toxic stress at Cardinal Glennon’s Danis Pediatrics, a practice that serves mostly poor and uninsured families. Many parents come to the office seeking help for extreme behavioral problems in their children because of that stress.

He recalled a single father bringing a baby and older boy for a check-up. The father described feeling helpless because of a low-paying, part-time job, lack of parenting support and no child care. He could not give one positive attribute about his child. Haller said the staff linked the father to child care and other support, enabling him to get a break and better bond with his son.

Haller urged physicians to have empathy for families. He said physicians can help empower parents so they better bond with their children and buffer them from stress, he said.

He also told the students their future medical degrees could give them great influence in developing better public policy to help children and families thrive:

“Every single day we can use the power of our white coat.”

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Pediatricians group: Ask parents about poverty

Eyes, ears, throat, check. Parents’ income, check. Pediatricians will soon be asking parents about their financial status because of the negative effects of poverty on a child’s health.

In recommendations to be released Wednesday, the American Academy of Pediatrics urges doctors to ask parents this question at each appointment: “Do you have difficulty making ends meet at the end of the month?”

The question should be asked in all areas of the country, since economic insecurity can affect families in cities, suburbs and rural areas. Parents who answer “yes” will be directed to community resources for housing, nutrition and job assistance.

As detailed in the recent Post-Dispatch special report “The Crisis Within: How toxic stress and trauma endanger our children,” one in four children in Missouri lives in poverty — putting the child at higher risk for asthma, allergies, diabetes, obesity and other long-term health problems.

Poverty can impair children’s development and shorten their life spans. A study from Washington University used brain scans to show that local children living in poverty had smaller areas of white and gray brain matter. Poverty is also linked to teen pregnancy, drug and alcohol abuse, and lead poisoning.

“We need to do something about poverty in childhood because it affects kids’ health,” said Dr. Katie Plax, professor of pediatrics and medical director of SPOT (Supporting Positive Opportunities with Teens) health care. “We really want families and kids to get help.”

In addition to help from local charities, the pediatricians’ group is in favor of policies that support school lunch programs, Medicaid, food stamps and other government assistance for families.

Spending upfront to help children living in poverty will save the state in future health care costs and allow children to become productive citizens, said Dr. Kenneth Haller, president of the Missouri chapter of the American Academy of Pediatrics and associate professor of pediatrics at St. Louis University.

Haller said children living in poverty have stress-related health problems which can turn the body’s immune system against itself.

Stress hormones can cause inflammation in the body’s circulatory system, leading to heart and breathing problems. The hormones can accelerate fat storage and suppress the immune system. The constant stress can permanently change a child’s genes, potentially shortening their lives. The damage is not only physical but mental, causing problems with attention and learning.

Pediatricians already talk to parents about safety concerns such as bike helmets, car seats and guns in the home. Questions about financial security are also of critical importance to a child’s well-being, doctors said.

“Our job as pediatricians is to address the health and welfare of a child, not just whether they have a bad cold or ear infection,” Haller said. “If we can do some screening to help people early in life to meet some minimum goals in terms of nutrition and housing security, it’s not going to be good just for the kid and family but the entire society.”

Should parents change their tune on children and media literacy in the digital age?

Smartphones, tablets, computers at home, computers at school, computers at the library, augmented reality, video games…the list of new platforms that children have available to engage with goes on for miles. Although the platforms for media consumption may be shiny and new, that doesn’t exactly change the way parents should approach media exposure for their children.

“The most important way children learn language, how to socialize, is by their interaction one-on-one with their parents,” said “St. Louis on the Air” panelist Dr. Ken Haller. “Media can supplement that but it can’t substitute it. One of the things we’re learning through research around media and children is that media itself is not so much the problem as it is the fact that we tend to substitute media, electronic media, for one-on-one human interaction.”

“St. Louis on the Air” host Don Marsh moderates a live panel on children and the media for Media Literacy Week.


Haller was one of four panelists that joined “St. Louis on the Air” on Monday for a broadcast in front of a live audience on children and the media as part of Gateway Media Literacy Partners’ 10th annual Media Literacy Week. This year, the week coincides with a national media literacy week as well and people are joining in the conversation on Twitter with the #MediaLitWk hashtag. Panelists included:

  • Art Silverblatt, media literacy scholar and professor emeritus, Webster University
  • Brenda Fyfe, Professor and Dean, Webster University’s School of Education
  • Dafna Lemish, Professor and Dean, College of Mass Communication and Media Arts, Southern Illinois University-Carbondale, author of Children and Media: A Global Perspective
  • Kenneth Haller, Jr., M.D., SLUCare Pediatrician at SSM Cardinal Glennon Children’s Medical Center; Associate Professor of Pediatrics, Saint Louis University

“This is a world where we have electronic media, they’re not going away,” Lemish said. “What we do need to do is find a balance between different forms of activities that we do with young children.”

This is a world where we have electronic media, they’re not going away. What we do need to do is find a balance between different forms of activities that we do with young children.

For example, she said that using an e-book instead of a printed paperback to engage with children is just fine—so long as the parents is helping the child interpret the book, ask questions about it, pointing out particulars as they would with a normal book.

“The most important thing is the interaction,” Lemish continued. “Using electronic media passively, putting the baby in front of the screen and going to do the laundry is not such a good strategy. If you are using it to interact with the baby, whether it is going to the museum to look at the pictures or looking at animals in the street, it is another resource in the environment…one other resource in their holistic environment.”

In the end, media literacy comes down to establishing critical thinking in children and adults. Silverblatt recommended a “production approach” to start conversations: encouraging children to think about media with style questions about production such as “What music is used?” “What colors are being used?” “What point-of-view is the camera capturing?”

“Media literacy focuses on a process not a product; we’re telling people how to think, not what to think,” Silverblatt said.

Haller recommended that parents looking for advice on digital media consumption for their youngsters should look to the sites and “Media literacy, when it comes right down to it has a lot to do with common-sense parenting,” Haller said. “While a lot of media are new, it comes down to engaging with your kids about these things.”


At the crux of it, is time. Many people emailed and tweeted during the conversation to lament a lack of time and money to spend with their kids. Unfortunately, time could very well be the most important part of instilling media literacy in kids.

“Listening is so important, listening to what they’re taking in from the media,” Fyfe said. “Sometimes we just run right over children and guide them and direct them and put them through experiences and never take the time to hear what’s going on in their minds.”

“St. Louis on the Air” discusses issues and concerns facing the St. Louis area. The show is produced by Mary EdwardsAlex Heuer and Kelly Moffitt and hosted by veteran journalist Don Marsh. Follow us on Twitter and join the conversation at @STLonAir.

SLU Care Doctor Worried About Children’s Health Around Landfill

SLU Care Doctor Worried About Children’s Health Around Landfill


BRIDGETON, Mo (KMOX) – Parents living in the West Lake Landfill area are worried what might happen to their kids if an underground fire eventually makes contact with nuclear waste next door.

SLU Care pediatrician Dr. Ken Haller at Cardinal Glennon Children’s Medical Center says an adult getting exposed to radiation might not be a big deal. But the younger you are, the worse it could be due to the rapid production of new tissues found in younger human beings.

“Radiation tends to attack the parts of our body that are replicating and creating new tissues. That’s what kids are, that’s what babies are,” Haller says. “In fact one of the most vulnerable populations is pregnant women because the fetus can be damaged by radiation.”

Haller says the biggest frustration for everyone is no one knows how the situation is going to play out.

“Right now there are more questions than answers,” Haller says.

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Local Pediatricians Disagree with Trump on Vaccine-Autism

by Fred Bodimer

ST. LOUIS (KMOX) – Local pediatricians try to put out the vaccine-autism fire that was recently re-lit by Donald Trump.

During Wednesday night’s GOP debate, Trump renewed his claim that vaccines sometimes can lead to autism.

“Just the other day…two years old, a beautiful child went to have the vaccine…a week later got a tremendous fever, got very very sick, now is autistic,” says Trump.

SLU Care pediatrician Dr. Ken Haller at Cardinal Glennon Children’s Medical Center calls those comments wrong and unfortunate.

“The science is extremely clear that vaccines are safe, they’re effective and they have absolutely no connection to autism,” says Haller.

Haller says that giving smaller doses over longer periods of time does not work because the children need the vaccines as soon as possible.

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Vaccines, Outbreaks, and Personal Choice: Measles by the Numbers


Measles has not reached the St. Louis area this year, but that hasn’t kept it from stoking fears.

Local public health officials are encouraging parents to make sure their children’s vaccinations are up-to-date by checking with their individual health providers. With worries that last month’s outbreak in Disneyland could continue to spread, officials in Illinois are investigating the source of five infants diagnosed with measles at a day care center outside Chicago.

Though Illinois Senator Dick Durbin told a Chicago TV station that another suspected measles case had been identified in Madison County on Friday, the Illinois Public Health Department said they no longer consider it a potential case.

We decided to take a look at the numbers. In fact, vaccination rates are quite high for schoolchildren in both Missouri and Illinois—nearly every county in both states reported vaccination rates above 90 percent for most of the shots required by law.

Common reasons for non-vaccination include allergies, medical concerns, and religious objections. Children under the age of 1 are too young for the vaccine, and can be at risk during an outbreak. The map above includes children who have begun vaccinations, but are on a delayed immunization schedule.

How common are the measles?

Not very, but outbreaks have become more frequent.

644 cases of measles were reported in 2014, the most since the disease was declared eliminated from the US in 2000. More than a hundred cases were reported in January of 2015, most of them linked to an outbreak at Disneyland.

The abdomen of a patient with a measles rash.
Prior to widespread immunization, measles was common in childhood, with more than 90% of infants and children infected by age 12. Recently, fewer than 1,000 measles cases have been reported annually since 1993.

Over the past decade, outbreaks tend to be related to unvaccinated people contracting measles abroad, and spreading among communities of people who are not immunized.

95 percent of school children in the city of St. Louis are up-to-date with their immunizations, according to data obtained from the state of Missouri.

“It’s very disappointing that some parents choose not to vaccinate their children based on rumor and fear tactics, but it’s a very small percentage of people,” said St. Louis Health Department director Pam Walker.

Before vaccines were available, measles was quite common. The CDC estimates that between 3 and 4 million Americans contracted measles each year in the decade before the vaccine was developed, with up to 500 deaths a year.

By comparison, influenza killed 1,532 people in 2010, according to the CDC. (Pneumonia, which is often a complication of the flu, killed about 52,000).

What do measles feel like?

Dr. Ken Haller remembers getting the measles in 1962, at the age of 7.

“I remember being absolutely miserable for two weeks. My muscles were achey, I could barely swallow, the lights were too bright,” Haller said. “It’s just a really horrible disease.”

Today, Haller is a pediatrician at Cardinal Glennon Children’s Medical Center. He says he often talks to parents to allay their concerns about the safety of vaccines, which often stem from a 1998 study linking the measles vaccine to autism, which was later debunked. He published a review of available research in 2012, which can be found here.



“We really want people go get vaccinated, and get kids vaccinated, because you’re not just protecting yourself, you’re protecting other vulnerable people,” Haller said.

Symptoms of measles include a high fever, cough, a runny nose and watery eyes. After a few days, patients may develop a rash of flat red spots and small raised bumps. About one in 1,000 patients will develop inflammation of the brain, which can lead to a loss of hearing or permanent brain damage. The disease is fatal in about 1 in 1000 cases.

Mild reactions to the vaccine, such as a fever or rash, are relatively common. In extremely rare cases, children may develop a severe allergic reaction or other complications. Further information can be found on the CDC’s website.

Who isn’t vaccinated?

Missouri and Illinois allow two exemptions for non-vaccination when children attend school: medical and religious.

Children with immune diseases, blood disorders, or cancer are often unable to get the vaccine for medical reasons. Members of some religious sects, such as the Amish or Christian Scientists, sometimes oppose vaccination. (An outbreak among Christian Science students at Principia College in 1985 led to three deaths and a quarantine).

St. Charles-based chiropractor, Mackenzie Mcnamara, says her patients represent a range of opinions over the issue. Some choose to vaccinate, some choose not to, and others decide to vaccinate on a delayed schedule. Mcnamara separates herself from the ‘anti-vaccine movement,’ but says parents should be able to choose whether or not they vaccinate their child.

Measles are highly contagious, and the death rate if a person contracts the disease is 1 in 1000. But due to the abundant use of vaccines, deaths due to measles have been virtually eliminated in the U.S. Mcnamara says some parents worry about the possibility of side effects from the vaccine.

“Clearly there is a risk, and [parents] should be able to choose if they assume that risk with their child,” Mcnamara said. She adds that friends and clients have felt a sense of backlash against their opposition to vaccines since the outbreak in California.

“I think there’s a definite middle ground, I wish people would see that too,” Mcnamara said.

Follow St. Louis Public Radio’s Durrie Bouscaren on Twitter, @durrieB. 

‘We Need People Working Together’: Discussing Protests, Evidence And How To Talk To Children


Ferguson and St. Louis residents are trying to cope with and understand a grand jury’s decision not to indict police Officer Darren Wilson in the August death of Michael Brown, and the response, sometimes violent, to that decision.

Wednesday on “St. Louis on the Air,” we discussed an upcoming march organized by the NAACP; protests in St. Louis; the response in Washington, D.C.; the grand jury evidence and how to talk about Ferguson and protests with children.


  • Cornell William Brooks (@CornellWBrooks), NAACP president and CEO, will talk about the Journey for Justice march that starts Saturday.
  • Dr. Ken Haller Jr. (@KenHallerMD), a pediatrician and associate professor at the Saint Louis University School of Medicine, will discuss how to talk to children about events related to Ferguson.
  • St. Louis Mayor Francis Slay (@MayorSlay) will discuss the city’s response and plans.
  • Jim Howard (@jimhoward529), St. Louis Public Radio’s Washington correspondent, will update us on the Department of Justice investigation.
  • St. Louis Public Radio reporters Camille Phillips (@cmpcamille) from protests in downtown St. Louis, and Chris McDaniel (@csmcdaniel) and Rachel Lippman (@rlippmann) who have been combing through grand jury evidence.