Learning Objective: Describe the structure and function of genes. Both genetic and epigenetic factors interact with. Toxic stress explains how many of our societys most intractable problems (disparities in health, education, and economic stability) are rooted in our shared biology but divergent experiences and opportunities. 10.1542/peds.2021-052582. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Molecular biological processes play an essential role in human development. Drawing on a framework produced by the Center on the Developing Child at Harvard University,192 this policy statement highlights the following 3 science-informed principles to prevent toxic stress responses and to build healthy, resilient children. The HMG Model System Model, Healthy Steps: a case study of innovation in pediatric practice, HealthySteps: transforming the promise of pediatric care, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, Ensuring the health of children in disasters, DISASTER PREPAREDNESS ADVISORY COUNCIL AND COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, Providing psychosocial support to children and families in the aftermath of disasters and crises, Paid parental leave and family wellbeing in the sustainable development era, Time off to care for a sick child--why family-leave policies matter, Support for restorative justice in a sample of U.S. university students, A neighborhood-based approach to population health in the pediatric medical home, Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health, From medical home to health neighborhood: transforming the medical home into a community-based health neighborhood, Implementing a trauma-informed approach in pediatric health care networks, Cross-cultural interactions and shared decision-making, The relationship between physician humility, physician-patient communication, and patient health, The impact of racism on child and adolescent health, Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: challenges, solutions, and future directions for provider communication training, Implicit bias: what every pediatrician should know about the effect of bias on health and future directions, Tackling implicit and explicit bias through objective structured teaching exercises for faculty, A systematic review of the impact of physician implicit racial bias on clinical decision making, Comparison of physician implicit racial bias toward adults versus children, Translating developmental science to address childhood adversity, Social: Why Our Brains Are Wired to Connect, The Spirit Level: Why Greater Equality Makes Societies Stronger, Bowling Alone: the Collapse and Revival of American Community, The Crisis of Connection: Roots, Consequences, and Solutions, Social isolation: a predictor of mortality comparable to traditional clinical risk factors, Social deprivation and the HPA axis in early development, Prolonged institutional rearing is associated with atypically large amygdala volume and difficulties in emotion regulation, Subjective social status and inflammatory gene expression, The potential protective effect of friendship on the association between childhood adversity and psychological distress in adulthood: a retrospective, preliminary, three-wave population-based study, The Relationship between social cohesion and urban green space: an avenue for health promotion, Exposure to natural space, sense of community belonging, and adverse mental health outcomes across an urban region, Sigmund Freud Collection (Library of Congress). Identify and address sources of inequity, isolation, and social discord (poverty and racism). A public health approach to promoting relational health should also be integrated horizontally (or across sectors) at the local level.81,82,148 SSNRs are easier to form when safe, stable, and nurturing families are able to live in safe, stable, and nurturing communities.124,149,150 The FCPMH is ideally placed to educate families about what a safe, stable, and nurturing family environment looks like for a child, but doing so will require changes at the provider and practice levels (see Table 2). This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. However, FCPMHs are also called to advocate for policies at the federal, state, and local levels that promote safe, stable, and nurturing communities. The ecobiodevelopmental model suggests that, to improve the likelihood of positive developmental outcomes across the life span, efforts should be made to improve the salient features of the child's environment. Acronym for safe, stable, and nurturing relationships; these allow the child to feel protected, connected, and competent. Secondary preventions in the relational health framework are focused on identifying the potential individual, family, and community barriers to SSNRs by developing respectful and caring therapeutic relationships with patients, families, and communities. Universal screening for prevalent barriers seen in that practice; facilitate, track, and follow-up on referrals offered. Emerging data supporting a biological sensitivity to context (see the Appendix for a glossary of terms, concepts, and abbreviations) begin to explain heterogeneous responses to both adversity and interventions at the population level.92,131136 Consequently, there is an urgent need for a battery of biological, behavioral, and contextual markers that might better stratify both the risks and predicted responsiveness to interventions at the individual level.37 FCPMHs (see the Appendix for a detailed description) are well placed to begin matching levels of need with specific types of interventions, a process known as vertical integration.82. For example, the AAP currently recommends screening parents for postpartum depression90 and food insecurity.87,88 Similarly, when clinical markers for an individual childs biological sensitivity to context9194 (see the Appendix for a glossary of terms, concepts, and abbreviations) are available, children of high (versus low) sensitivity may also benefit from different types of interventions.95 In concordance with a layered public health approach, these various targeted interventions will supplement but not replace the universal primary preventions. Andrew Garner, Michael Yogman; COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COUNCIL ON EARLY CHILDHOOD, Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health. Assessed key tenets from the ecobiodevelopmental model regarding environmental chaos. These perspectives offer different interpretations of the nature of society and the role of . In the absence of SSNRs, many different forms of childhood adversity (from catastrophic episodes of abuse or violence to chronic conditions, such as exposure to racism, poverty, and/or neglect) can lead to toxic stress responses that result in changes at the molecular, cellular, and behavioral levels and negatively impact outcomes in health, education, and economic productivity. A medical home builds partnerships with clinical specialists, families, and community resources. Implement home visiting; support extended family medical leave. The FCPMH alone cannot leverage significant change within the community context. The previous policy statement12 and technical report2 on childhood toxic stress noted the 10 adverse childhood experiences (ACEs) studied in the landmark ACEs Study that began in the 1990s: physical, emotional, or sexual abuse; physical or emotional neglect; problematic parental substance misuse; parental mental illness; parental separation or divorce; intimate partner violence; and an incarcerated house member.23 These adversities are associated with a wide array of negative outcomes in a dose-dependent manner, such that the higher the ACE score (1 point for each category experienced before the age of 18 years), the higher the risk for unhealthy behaviors such as tobacco, alcohol, and other substance use; risky sexual behaviors; and obesity.23,24 Dose-dependent relationships have also been found between ACE scores and several of the leading causes of adult morbidity and mortality,23,24 including cardiovascular disease,25 lung disease,26 liver disease,27 mental illness,28 and cancer.29, These well-established associations between ACEs and poor health outcomes decades later highlight the importance of understanding the biological mechanisms that allow adversity in childhood to get under the skin and to negatively impact life-course trajectories.3036 As discussed in the 2012 AAP technical report,2 toxic stress responses, in which the physiologic stress response to adversity is large, chronic, and unmitigated by social-emotional buffers, are one such mechanism. HealthySteps is an evidence-based, interdisciplinary pediatric primary care program that promotes positive parenting and healthy development for infants and toddlers, with an emphasis on families living in low-income communities. FCPMHs could work to reduce these barriers by partnering with their AAP chapter, local organizations (such as schools, businesses, and faith-based organizations), and other community assets (including parents, extended family, child care providers, community health workers, and patients) to form medical neighborhoods149,159,161 that work collaboratively to address the SDoHs while also advocating for policies that support safe, stable, and nurturing families and communities. Toxic stress is a deficits-based approach because it is focused on the problem: those biological processes triggered by significant adversity in the absence of SSNRs. The ecobiodevelopmental model suggests that, to improve the likelihood of positive developmental outcomes across the life span, efforts should be made to improve the salient features of the childs environment. But something happened that few predicted. Posted on June 1, 2022 by Preventing childhood toxic stress responses, promoting resilience, and optimizing development will require that all children be afforded the SSNRs that buffer a wide range of adversities and build the foundational skills needed to cope with future adversity in an adaptive, health-promoting manner. 1, Center on the Developing Child at Harvard University, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics, The lifelong effects of early childhood adversity and toxic stress, Associations between early life stress and gene methylation in children, Differential glucocorticoid receptor exon 1(B), 1(C), and 1(H) expression and methylation in suicide completers with a history of childhood abuse, Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse, Annual research review: childhood maltreatment, latent vulnerability and the shift to preventative psychiatry - the contribution of functional brain imaging, Childhood trauma exposure disrupts the automatic regulation of emotional processing, Enhanced amygdala reactivity to emotional faces in adults reporting childhood emotional maltreatment, Childhood maltreatment is associated with increased neural response to ambiguous threatening facial expressions in adulthood: evidence from the late positive potential, Adverse childhood experiences, allostasis, allostatic load, and age-related disease, Child maltreatment and allostatic load: consequences for physical and mental health in children from low-income families, Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health, Genes, environments, and time: the biology of adversity and resilience, Leveraging the biology of adversity and resilience to transform pediatric practice, Building Relationships: Framing Early Relational Health, Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience: Working Paper No. Ecobiodevelopmental Theory b. Overview of Domain-Specific Theories. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The Adverse Childhood Experiences (ACE) Study, The enduring effects of abuse and related adverse experiences in childhood. Primary preventions in the relational health framework are focused on how to universally promote the development and maintenance of SSNRs. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. This revised policy statement on childhood toxic stress builds on the 2012 policy statement12 and technical report2 by: Acknowledging that a spectrum of adversity exists, from discrete, threatening events (such as abuse, bullying, or disasters) to ongoing, chronic hardships (such as poverty, racism, social isolation, or neglect). Thats number one. Early childhood experiences, both adverse and positive, appear to be biologically embedded and influence both disease and wellness across the life course.30 The ecobiodevelopmental model of disease and wellness explains how the ongoing but cumulative and reciprocal dance between ecology and biology leads to changes at the molecular (eg, methylation patterns), cellular (eg, brain connectivity patterns), and behavioral levels (eg, tobacco, alcohol, or other substance use).2,17 These changes are either adaptive or maladaptive depending on the context, and they are either benefits or risks to future health, academic success, and economic productivity.75. To prevent childhood toxic stress responses and support optimal development across the life span, the promotion of relational health needs to become an integral component of pediatric care and a primary objective for pediatric research and advocacy. Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. Taken together, these diverse lines of inquiry suggest that it may not actually be the wide spectrum of childhood adversity that drives poor outcomes but the degree to which that adversity drives shame, guilt, anger, alienation, disenfranchisement, and degree of social isolation.181,182 If so, the proposed public health approach toward the promotion of SSNRs is needed, not only to buffer adversity and promote resilience but also to begin bridging political, religious, economic, geographic, identity-based, and ideological divides that increase social isolation, encourage tribalism, diminish empathy, and, ultimately, drive poor outcomes in the medical, educational, social service, and justice systems. Ecobiodevelopmental theory asserts that: early experiences create the structure of the brain. A public health approach that cuts across traditional silos and funding streams; a horizontally integrated public health approach also includes the educational, civic, social service, and juvenile justice systems. Efforts to repair strained or compromised relationships are likely to be more effective if other potential barriers to SSNRs are being addressed (eg, parental mental illness and basic needs) and additional efforts are being made to actively promote SSNRs (eg, the provision of developmentally appropriate play). By continuing to use our website, you are agreeing to, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COUNCIL ON EARLY CHILDHOOD, The Ecobiodevelopmental Model of Disease and Wellness, Components of a Public Health Approach to Toxic Stress, The Emerging Science of Relational Health, Links Between Relational Health and Resilience, A Public Health Approach to Build Relational Health, Vertical Integration to Match Levels of Need With Specific Interventions, Horizontal Integration Across Sectors at the Community Level, The Centrality of Relationships in Pediatric Care, Acknowledging the Role and Toll of Social Isolation, A Renewed Commitment to Science-Based Policy Formation, Application of Science-Based Principles to Strengthen Pediatric Practice, Reduce External Sources of Stress on Families, Glossary of Terms, Concepts, and Abbreviations, Committee on Psychosocial Aspects of Child and Family Health, 20202021, Section on Developmental and Behavioral Pediatrics, 20202021, Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health, http://acestoohigh.com/got-your-ace-score, https://psych.utah.edu/research/labs/biological-sensitivity.php, https://developingchild.harvard.edu/resources/wp1/, https://developingchild.harvard.edu/resources/supportive-relationships-and-active-skill-building-strengthen-the-foundations-of-resilience/, https://developingchild.harvard.edu/resources/wp3/, https://developingchild.harvard.edu/resources/building-the-brains-air-traffic-control-system-how-early-experiences-shape-the-development-of-executive-function/, https://developingchild.harvard.edu/resources/the-timing-and-quality-of-early-experiences-combine-to-shape-brain-architecture/, https://helpmegrownational.org/hmg-system-model/, https://developingchild.harvard.edu/resources/three-early-childhood-development-principles-improve-child-family-outcomes/. Relational health defines the solution. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. In the case of toxic stress responses, universal primary prevention means trying to prevent the precipitants of toxic stress responses (eg, advocating to address the spectrum of adversities discussed above) as well as promote healthy, adaptive responses to adversity through the provision of social supports that nurture the development of foundational resilience skills (such as task persistence, curiosity, and self-regulation).16,19,59,83, A public health approach to prevent childhood toxic stress is a public health approach to promote relational health. 2. Doing so will require all trainees to address their implicit biases, develop cultural humility, and provide culturally competent recommendations. Become hubs for medical neighborhoods, horizontally integrating a wide array of local efforts and early childhood initiatives that not only support families with resources and programs but also advocate for the public policies that promote safe, stable, and nurturing families and communities. Acronym for Parent-Child Interaction Therapy; PCIT is an evidence-based intervention to change the patterns of parent-child interactions to improve the parent-child relationship. Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial, A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms, Amygdala response predicts trajectory of symptom reduction during trauma-focused cognitive-behavioral therapy among adolescent girls with PTSD, Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States, Enhancing social-emotional health and wellbeing in the early years (E-SEE): a study protocol of a community-based randomised controlled trial with process and economic evaluations of the incredible years infant and toddler parenting programmes, delivered in a proportionate universal model, Proportionate universalism in practice? "The . In the end, the ability of the FCPMH to leverage change within the family context is entirely dependent on the capacity of the pediatric providers to form strong therapeutic relationships with the patients, caregivers, and families. To move forward (to proactively build healthy, resilient children), the pediatric community needs to embrace the concept of relational health.15 Relational health refers to the ability to form and maintain SSNRs, as these are potent antidotes for childhood adversity and toxic stress responses.57,113 Not only do SSNRs buffer adversity and turn potentially toxic stress responses into tolerable or positive responses, but they are also the primary vehicle for building the foundational resilience skills that allow children to cope with future adversity in an adaptive, healthy manner.16,17 These findings highlight the need for multigenerational approaches that support parents and adults as they, in turn, provide the SSNRs that all children need to flourish. Immediate Past Chairperson, David O. Childers, Jr, MD, FAAP, Program Chairperson, John Takayama, MD, MPH, FAAP, Website Editor, Robert G. Voigt, MD, FAAP, Newsletter Editor, Rebecca A. Baum, MD, FAAP Society for Developmental and Behavioral Pediatrics, Lynn Davidson, MD, FAAP Council on Children with Disabilities, Yekaterina Kokidko, DO Section on Pediatric Trainees, Sherri Louise Alderman, MD, MPH, IMH-E, FAAP, Chairperson, Jill M. Sells, MD, FAAP, Immediate Past Chairperson, Alan L. Mendelsohn, MD, FAAP, Abstract Chairperson, Ami Gadhia, JD Child Care Aware of America, Michelle Lee Section on Pediatric Trainees, Dina Joy Lieser, MD, FAAP Maternal and Child Health Bureau, Lucy Recio National Association for the Education of Young Children. The 3 principles described above, each of which is grounded in the research literature, provide a science-based framework for developing innovative strategies to promote SSNRs at the dyadic level, family level, and community level. Typically, restorative justice allows the victims and the offenders to mediate a restitution agreement that is satisfactory to both parties. Relational health refers to the capacity to develop and sustain SSNRs, which in turn prevent the extreme or prolonged activation of the bodys stress response systems. 2022 avalon exterior colors. Advocate that health systems, payers, and policy makers at all levels of government align incentives and provide funding to promote the universal primary prevention work discussed in this policy statement. Many of the components of a public health approach to prevent, mitigate, and treat toxic stress responses (see examples) are also components of a public health approach to promote, identify barriers to, and repair SSNRs. The Ecobiodevelopmental Theory model of Shonkoff is associated directly to other theoretical models of human development. It was heralded as a good thing. Ecobiodevelopmental theory asserts that: (a)early experiences create the structure of the brain (b)genes are the dominant determinant of brain development (c)early interventions cannot overcome the power of poverty in brain development (d)improving early nutrition could break the cycle of poverty 4. Of the 3 principles, this is the one that aligns most clearly with the core functions of the FCPMH and is, therefore, the primary focus of this policy statement. The second assumption is that the FCPMH will have the capacity to form working relationships with a wide array of community partners. Early childhood behavioral health: can the medical neighborhood move us forward? The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The Ecobiodevelopmental Model of Health. Empirical explorations of an evolutionary-developmental theory, Biological sensitivity to context: I. Society is currently trending toward division, marginalization, alienation, and social isolation.177 In opposing this trend and calling for a public health approach that builds SSNRs, the AAP is working to translate the latest developmental science into practices and public policies (see Table 2) that build healthy, resilient children. Bronfenbrenner's theory explains that there are certain cultural and social factors in the immediate environment of a child affect child development and experience. SSNRs not only buffer adversity when it occurs but also proactively build the foundational social and emotional skills that lead to resilience in the face of future adversity. Many studies show significant correlations between early neglect and later social, emotional and behavioural difficulties, Life Course Theory. The biological theory asserts that most behaviors are inherited and shaped by adaptation to one's external environment. Psychology - 9.2: Lifespan Theories by CNX Psychology is licensed under CC BY 4.0. In the original ACE Study, 10 categories of adversity were examined: emotional, physical, and sexual abuse; 5 measures of household dysfunction, including the mother being treated violently (intimate partner violence), household substance abuse, household mental illness, parental separation or divorce, and incarcerated household member; and emotional or physical neglect. Relational health, in the form of at least one SSNR, is a universal, biological imperative for children to fulfill their potential; to be healthy and resilient; to be successful academically, economically, and socially; and, perhaps most importantly, to be the caregivers that value and build SSNRs with subsequent generations.