Fortunately, adversity in childhood is only half the story, as positive experiences in childhood are associated with improved outcomes later in life. Similarly, advocating for a Health in All Policies approach could advance health equity and minimize family and community distress by addressing the underlying economic inequities.198200 The commitment of the AAP to decreasing family stress is manifest in many of its official statements, including poverty,87,88 racism,166 maternal depression,90 disasters,152,153 father engagement,196 home visiting,142 and the importance of play.74,197, The strengthening of core life skills (eg, executive function and self-regulation) is needed for families and communities to provide well-regulated, nurturing environments. Build the therapeutic alliance; promote positive parenting; encourage developmentally appropriate play. Intimate Partner Violence Exposure in Early Childhood: An Ecobiodevelopmental Perspective | Health & Social Work | Oxford Academic Abstract. The toxic stress and its impact on development in the Shonkoff's Ecobiodevelopmental Theorical approach. University of Utah, Department of Psychology, College of Social & Behavioral Science. Integrated behavioral health services as part of the FCPMH team might be the next layer for parents who need additional assistance (eg, parental depression), and the need for more intensive skill building (eg, PCIT) for some parents becomes yet another focus for collaboration with key services within the community (eg, ABC, PCIT, CPP, and TF-CBT). The commitment of the AAP to the well-being of all children requires that it not only address a wide spectrum of adversities but, also, that it speak against public policies, social constructs, and societal norms that perpetuate the ongoing, chronic precipitants of toxic stress responses such as poverty87,88 and racism166 and for public policies that promote relational health, inclusion, and equity.111,188191. Several researchers have noted that many other experiences in childhood are also associated with poor outcomes later in life, and these include being raised in poverty,41 left homeless,4244 exposed to neighborhood violence,4547 subjected to racism,4850 bullied,51,52 or punished harshly.53 This finding suggests that there is a wide spectrum of adversity that runs from discrete, threatening events (such as being abused, bullied, or exposed to disasters or other forms of violence) to ongoing, chronic life conditions (such as exposure to parental mental illness, racism, poverty, neglect, family separation or a placement in foster care, and environmental toxins or air pollution; unrelenting anxiety about a global pandemic, climate change, or deportation; or social rejection because of ones sexual orientation or gender identity). Translating these principles into pediatric practice will require FCPMHs to: Understand the toxic stress framework, which explains how many of our societys most intractable problems, such as disparities in health, education, and economic stability, are rooted in our shared biology but divergent experiences and opportunities (see Table 1). Executive functions are core life skills, and they include capacities like impulse inhibition, working memory, cognitive flexibility, abstract thought, planning, and problem solving. The common factors are communication skills that help to build a therapeutic alliance (the bond felt between the clinician and patient and/or family, a powerful factor in facilitating emotional and psychological healing), which, in turn, increases the patient and/or familys optimism, feelings of well-being, and willingness to work toward improved health. Biological sensitivity to context is a theory with emerging evidence that children differ in their susceptibility to environmental influence in a for better and for worse manner, depending on their psychobiologic reactivity to stress. As a consequence, the very characteristics that are often thought of as childrens frailties (eg, high stress reactivity) can also be their strengths, given the right context.*,91,131,134,206. Although intensive, capacity-building efforts for parents and other caregivers with limited executive function skills is beyond the scope of most pediatric settings, providing information and support around basic child-rearing practices and establishing daily routines is a cornerstone of traditional primary care. The concept of childhood toxic stress taps into a rich literature on the biology of adversity and explains the danger in overlooking significant adversity in childhood. An FCPMH is not a building or place; it extends beyond the walls of a clinical practice. Ecological includes experiences in a child's home environment, such as reading, talking, teaching,. See the Appendix for full descriptions of the abbreviations. Any conflicts have been resolved through a process approved by the Board of Directors. Promote SSNRs by building 2-generational relational skills. The Adverse Childhood Experiences (ACE) Study, The enduring effects of abuse and related adverse experiences in childhood. The first is that pediatric providers will have the financial supports needed to expand their capacity for developing respectful, continuous, trusted, and nurturing relationships with both the patients and caregivers of the patients who they serve. Such an approach will require pediatricians, other pediatric health care professionals, and FCPMHs in general to partner with families and communities in practical and innovative ways to universally promote SSNRs, address potential barriers to SSNRs in a targeted manner, and afford indicated treatments that repair relationships that have been strained or compromised (see Table 2). Empirical explorations of an evolutionary-developmental theory, Biological sensitivity to context: I. Someones got to be crazy about that kid. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. 10.1542/peds.2021-052582. 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. They have been proven useful and effective in addressing mental health symptoms in pediatrics across the age spectrum (as per the AAP policy statement on mental health competencies in pediatric care). 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. The capacity to develop and maintain SSNRs with others; relational health is an important predictor of wellness across the life span. This wide spectrum of adversity underscores the fact that ACE scores and other epidemiologically derived risk factors at the population level are not valid or reliable predictors of outcomes at the individual level.56 Toxic stress, by contrast, refers to an individuals physiologic response to these adversities, and biomarkers of this physiologic response have the potential to be more sensitive and specific measures of experienced adversity at the individual level.37 Validated biomarkers also offer transformational potential as measures of responsiveness to specific interventions.37,57 With these applications in mind, the pediatric research community is hoping to develop clinic-friendly, noninvasive biomarkers for different forms and degrees of adversity. 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. 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). An ecobiodevelopmental framework sheds new light on the biological basis for persistent disparities in education, poverty, and health. 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. Primary preventions in the toxic stress framework are focused on how to prevent the wide array of adversities that might precipitate a toxic stress response. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Trainees need to understand all of these many facets so they are prepared to be effective advocates for their patients and families. Still other techniques keep the discussion focused, practical, and organized. For example, in an abusive context, biological changes, such as the methylation of the glucocorticoid receptor gene,35 an increase in the size or activity of the amygdala,68 and a hypersensitivity to potentially threatening cues9 could be considered adaptive, at least initially, because those changes might promote survival in a threatening environment. Drs Garner and Yogman gratefully acknowledge the contributions of Dr Shonkoff to early drafts of this article. Approximately 15.5 million children in the United States reside in households in which interpersonal violence is recurrent. ACE = Events/Incidents which harm social, cognitive, and emotional functioning causing a dramatic upset in the safe, nurturing environments children require to thrive. These varied adversities share the potential to trigger toxic stress responses and inhibit the formation of SSNRs. In short, a public health approach to prevent childhood toxic stress is a public health approach to promote relational health. The buffering and skill-building roles of responsive relationships are biologically embedded, and they are essential promoters of healthy development.59 Existing AAP reports on managing perinatal depression,90 supporting grieving children,195 fostering male caregiver engagement,196 partnering with home visiting programs,142 encouraging developmentally appropriate play,74,197 discouraging screen time,125 and promoting shared-book reading67,68 include additional recommendations on ways primary care pediatricians might promote SSNRs. Extends the concept of the FCPMH into the local community; in a medical neighborhood, the FCPMH or health system anchors and supports cross-sector efforts to address family needs (eg, the SDoH), promote population level wellness, and collectively advocate for needed funding and policy changes. The mechanism offers an explanation for the historical trauma. In the decade since the first AAP policy statement and technical report on childhood toxic stress were published, even more evidence has accumulated that: What happens in childhood does not stay in childhood.186,187 Adverse experiences in childhood are not destiny, but for many children, significant adversity bends life-course trajectories for the worse. Other common-factors techniques target feelings of anger, ambivalence, and hopelessness, family conflicts, and barriers to behavior change and help seeking. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. Proposing that the public health approach also be integrated horizontally across multiple public service sectors (eg, health care, behavioral health, education, social services, justice, and faith communities) because SSNRs are promoted in safe, stable, and nurturing families that have access to safe, stable, and nurturing communities with a wide range of resources and services. Conceptualizing and operationalizing environmental chaos Be it child labor laws, federal grants to states to promote maternal-child health, support for paid parental leave after childbirth, required immunizations to attend school, the use of car safety seats, the adoption of children by same-sex parents, the harms of corporal punishment, the safe storage of firearms, the care of immigrant children in federal custody, the negative effect of toxins and global warming on child health, or the importance of nutrition and income support for healthy families, pediatric professionals have been a powerful force for bringing a scientifically grounded, evidence-based perspective to public debates. The Healthy Outcomes From Positive Experiences framework promotes relational health through positive childhood experiences, such as being in nurturing, supportive relationships; living, developing, playing, and learning in safe, stable, protective, and equitable environments; having opportunities for constructive social engagement and connectedness; and learning social and emotional competencies.126,127. Periods of Development 1. 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. Part 1 - Overview of Developmental Domains, Periods, and Theories a. Domains of Development b. 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. Theories that support a relationship-based framework 1. The case studies by Chilton and Rabinowich provide poignant and compelling qualitative data that support an ecobiodevelopmental approach towards understanding and addressing both the complex. By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. A public health approach that includes primary universal preventions to promote wellness (like promoting positive parenting practices), secondary targeted interventions for those deemed to be at risk for poor outcomes (like using biomarkers both to identify those at higher risk and to monitor the effectiveness of various interventions), and tertiary evidence-based treatments for the symptomatic (like referring to providers trained in TF-CBT). Foremost on the advocacy agenda will be the need for serious payment reforms that consider the complexity of care attributable to adverse family and community contexts and include financial supports that incentivize families to engage with an FCPMH.204 Payment reforms need to be sufficient to allow FCPMHs to spend more time with families, function as interdisciplinary teams, integrate into their communitys initiatives and services to support children and families (horizontal integration), and anchor medical neighborhoods that not only foster wellness in childhood but promote positive outcomes across the life span. 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. In addition to the domains and timing of chaos, ecobiodevelopmental theory argues that the intensity of environmental chaos is important- that adverse environmental experiences which are deep, prolonged, and extensive are more detrimental to children's health and well-being than unfavorable experiences that . 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/. Foster strong, trusted, respectful, and effective collaborations with the community partners who are well-positioned to provide the individualized prevention, intervention, and treatment strategies. apartments for rent on north avenue. Arwa Abdulhaq Nasir, MBBS, MSc, MPH, FAAP, Sharon Berry, PhD, LP, ABPP Society of Pediatric Psychology, Edward R. Christophersen, PhD, ABPP, FAAP , Kathleen Hobson Davis, LSW Family Liaison, Norah L. Johnson, PhD, RN, CPNP-BC National Association of Pediatric Nurse Practitioners, Abigail Boden Schlesinger, MD American Academy of Child and Adolescent Psychiatry, Rachel Segal, MD Section on Pediatric Trainees, Amy Starin, PhD, LCSW National Association of Social Workers, Peter J. Smith, MD, MA, FAAP, Chairperson, Carol Cohen Weitzman, MD, FAAP.