Next month’s volume of Pediatrics features the winning essay from the Section on Pediatric Trainees’ first annual advocacy
essay competition, written by Dr. Laura Livaditis (10.1542/peds.2017-2916). In her article, entitled “An Interdisciplinary Approach to Toxic Stress: Learning
the Learning,” Dr. Livaditis suggests that the effects of toxic stress may be mitigated
by the development of medical-legal partnerships that support the needs of families
and children. Her article focuses on legal aid as a key component in the prevention
of adverse childhood events and demonstrates that this under-utilized resource can
have profound effects when incorporated into routine medical care.
Medical-legal partnerships revolve around the concept that health is intimately linked
to the presence of social determinants and associated legal issues; thus, without
addressing all aspects of a child’s environment, good health is difficult to sustain.
It is known that the introduction of legal aid to a medical home can have significant
impacts on the reduction of toxic stress and health disparities among children. For
example, children in families randomized to receive legal support showed improved
health outcomes as measured by fewer ER visits, improved immunizations rates, and
increased number of primary care visits within the first year of life (Sege et al Pediatrics 2015). We have also seen that barriers to good health such as poverty, low income housing,
limited access to food and low health literacy can be better addressed with the help
of legal partners who can ensure enforcement of laws that limit health disparities
(Williams et al Pediatrics 2009).
Given the clear benefits derived from the integration of medical-legal services, Dr.
Livaditis suggests that we should foster relationships with legal organizations and
highlight legal aid as a key advocacy focus in order to better combat toxic stress.
For many of us, this will require familiarization with legal jargon (Dr. Livaditis
provides us with several examples such as “mitigation hearings” and “juvenile lifer”)
and an understanding of which laws are most likely to impact toxic stress for children
and families. One such example are federal and state laws that govern incarcerated
youth – a group that Dr. Livaditis points out is at particularly high risk of toxic
stress. Her article describes her experience of partnering with legal advocates to
argue for policies that if enacted, would tremendously reduce the propagation of toxic
Perhaps it is time we reached out to our legal counterparts and combined our expertise
with theirs. Given what we know about toxic stress and its long term effects, it is
not enough to treat a patient’s acute illness if that patient also faces life in prison
without parole; a problem so large scale can best be tackled with an interdisciplinary
approach. Though formation of medical-legal partnerships may sound daunting, as Dr.
Livaditis suggests, the first step is simply to learn the lingo.