Build the therapeutic alliance; promote positive parenting; encourage developmentally appropriate play. In the presence of SSNRs, a limited degree of childhood adversity (eg, normative childhood frustrations and setbacks) can lead to the positive stress responses that build the rudiments of resilience: a set of social and emotional skills that allow children to adapt to future adversity in a healthy manner. Prepare residents to work as part of the interdisciplinary teams144 that transform FCPMHs into hubs for medical neighborhoods.161. 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. Below we briefly discuss each of the five components, review relevant empirical support, and identify enduring questions. 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. Early exposure to environmental chaos and children's physical and Vulnerability theory recognizes that the human experience of constant vulnerability varies as a result of stages in the life-course, social institutions, and law, which often trace intersecting forms of oppression on the basis of race, gender, sexuality, disability, and class. The AAP remains committed to respond when empirical evidence and the latest developmental science shine new light on the issues and trends of the day. Acronym for the family-centered pediatric medical home; in an FCPMH, the pediatrician leads an interdisciplinary team of professionals providing care that is: family-centered: the family is recognized and acknowledged as the primary caregiver and support for the child, ensuring that all medical decisions are made in true partnership with the family; accessible: care is easy for the child and family to obtain, including geographic access and insurance accommodation; continuous: the same primary care clinician cares for the child from infancy through young adulthood, providing assistance and support to transition to adult care; comprehensive: preventive, primary, and specialty care are provided to the child and family; coordinated: a care plan is created in partnership with the family and communicated with all health care clinicians and necessary community agencies and organizations; compassionate: genuine concern for the well-being of a child and family are emphasized and addressed; and. 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? Although this term is frequently used to refer to the childs experiences (child ACEs), it has also been applied to the adversities that parents experienced during their own childhoods (parental ACEs). 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. The toxic stress and its impact on development in the Shonkoff's All authors have filed conflict of interest statements with the American Academy of Pediatrics. intel director salary. The currently ascendant Ecobiodevelopmental Theory argues that severe childhood stressors (known as Adverse Childhood Experiences or ACEs) affect children's genetic predispositions, brain. For many resource-poor families and older children, overall relational health is dependent not only on dyadic serve and return interactions with family members but also on trusted, SSNRs with others in the community through interactions at the medical clinic, school, recreation leagues, faith-based and civic organizations, community improvement efforts, and employment opportunities. This emphasis on universal primary preventions is congruent with the fact that more children are mentally and socially well and flourish as adults, regardless of their level of childhood adversity, if they also are afforded positive relational experiences and high family resilience and connection during childhood.59,121 Relational health includes more than nurturing in its traditional, spoken sense (eg, verbal warmth or responsivity); it also includes the activities that support the relationship more broadly (eg, reading aloud and a prescription to play), and research has documented that nurturing words and actions are inextricably linked.137 Although there are both practice-based (eg, Reach Out and Read [ROR],129,138,139 the Video Interaction Project [VIP],66,72 HealthySteps84,85) and community-based programs (eg, positive parenting programs,140,141 home visiting programs,142,143 quality early child care settings69,71) that promote these early positive relational experiences, they are not funded at levels that would make them universally accessible. 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. Acronym for Trauma-Focused Cognitive Behavioral Therapy; TF-CBT is an evidence-based, manualized, skills-based therapy that allows parents and children to better process emotions and thoughts related to traumatic experiences. The importance of engaged and attuned adults does not end in the newborn period. Measures of both resilience and flourishing despite adversity suggest that much more can be done to build the SSNRs and overall relational health that buffers adversity and builds both the skills and contexts necessary for children to thrive. Psychology - 9.2: Lifespan Theories by CNX Psychology is licensed under CC BY 4.0. Implement home visiting; support extended family medical leave. Search for other works by this author on: National Scientific Council on the Developing Child, Young Children Develop in an Environment of Relationships: Working Paper No. First, last and always. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. Acknowledge that a wide range of adversities, from discrete, threatening events to ongoing, chronic life conditions, share the potential to trigger toxic stress responses and inhibit the formation of SSNRs. 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. The Ecobiodevelopmental Model of Health. Toxic stress refers to the biological processes that occur after the extreme or prolonged activation of the bodys stress response systems in the absence of SSNRs. For example, positive relational experiences, such as engaged, responsive caregivers,59,6265 shared childrens book reading,6668 access to quality early childhood education,6971 and opportunities for developmentally appropriate play with others66,7274 are associated with positive impacts on learning, behavior, and health. The ecobiodevelopmental framework asserts that the ecology becomes biologically embedded, and there is an ongoing but cumulative dance between the ecology and the biology that drives development over the life span. Toxic stress defines the problem. Childhood trauma can alter developing brain, creates lifetime of risk Acute threats to childhood wellness such as abuse need to be taken seriously; similar attention should be given to the social inequities and ongoing, chronic life conditions that similarly imperil a childs biological wellness and life-course trajectory. 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 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. 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. These techniques come from family therapy, cognitive therapy, motivational interviewing, family engagement, family-focused pediatrics, and solution-focused therapy. An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. ecobiodevelopmental theory asserts that: - mekina.et 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). 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. Communication could be further enhanced by cultural humility,164,165 implicit bias training,166171 a more diverse health care team (eg, providing families and patients the opportunity to seeing themselves reflected in the sex, ethnicity, and cultural backgrounds of the team members), and access to professional interpreters. Biological Sensitivity to Context/Adaptive Calibration Model. If nothing else, pandemic-mandated stay-at-home orders should increase our collective awareness of the distress associated with being socially isolated or vulnerable. Periods of Development 1. 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. University of Utah, Department of Psychology, College of Social & Behavioral Science. Refers to efforts to repair the harm that occurs with unjust behaviors, as opposed to retributive or punitive justice, which simply punishes those who have acted unjustly. Bioecological Systems Theory 3. 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. "The . (2) Challenge to Dominant Ideology: CRT challenges the claims of neutrality, objectivity, colorblindness, and meritocracy in society. Any conflicts have been resolved through a process approved by the Board of Directors. 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. Acronym for child-parent psychotherapy; CPP is an evidence-based, psychoanalytic approach for treating dysfunctional parent-child relationships based on the theory that the parent has unresolved conflicts with previous relationships. Relational health is a strengths-based approach because it is focused on solutions: those individual, family, and community capacities that promote SSNRs, buffer adversity, and build resilience. Encourage them to become leaders in interdisciplinary early childhood systems work and vocal advocates for public policies that promote positive relational experiences in safe, stable, and nurturing families and communities. 2. 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. The Adverse Childhood Experiences (ACE) Study, The enduring effects of abuse and related adverse experiences in childhood. 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. Traumatic and stressful events in early childhood: can treatment help those at highest risk? Provide or support positive parenting classes; participate in ROR, VIP, and other programs that support the dyad. Scientists now theorize that toxic stress causes epigenetic changes that allow trauma to be transmitted over the generations. Explain how human development is rooted in biological processes that have evolved to promote adaptation and survival. An ecobiodevelopmental framework sheds new light on the biological basis for persistent disparities in education, poverty, and health. Applying a public health approach to the promotion of relational health (see Fig 1) reveals that many of the universal primary preventions for toxic stress are also effective means of promoting the development of SSNRs (eg, positive parenting styles, developmentally appropriate play with others,66,73,74,128 and shared reading129,130). With almost a century of service to children, families, and communities, the field of pediatrics has made critical contributions at the interface of science and public policy. 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. Along these lines, the Aspen Institute has created the Social Fabric Project to incentivize local projects that prioritize the building of relationships and community connections over a focus on self-absorption and hyperindividualism.183 Similarly, more attention could be given to the built environment and need for public green spaces, such as parks, to promote social cohesion and a sense of community belonging.184,185. Transactional theory emphasizes that: Infants/toddlers and their parents are constantly affecting each other. Rather, an integrated public health approach (see Fig 1) is needed to support all children, including those with delays in development and special health care needs.8082 The foundation for any public health approach is universal primary prevention. The use of trusted, supportive relationships within the FCPMH to promote the relational health of families is an emerging focal point for pediatric clinical research, and pediatric primary care is increasingly seen as a venue for fostering social-emotional health.193,194 These universal primary prevention strategies form the base of the public health pyramid (Fig 1 and Table 2), but additional, layered interventions that recognize and address child-level (eg, delays in development and a biological sensitivity to context), family-level (eg, poverty and parent mental illness), and community-level (eg, racism and violence) barriers to SSNRs may also be required for some families, whereas others will need even more intensive, evidence-based treatments (eg, ABC, PCIT, CPP, TF-CBT) to repair relationships that are already strained or compromised. Development of an Eco-Biodevelopmental Model of Emergent Literacy The mechanism offers an explanation for the historical trauma. For children deemed to be at high risk for toxic stress responses, potential barriers to relational health need to be identified and addressed through team-based care144 and collaborative community partnerships (eg, food banks,145,146 medical-legal partnerships147). 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.
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