Pediatricians have long had a window into the troubles facing young patients and their families. Now, emerging data on how early exposure to adversity can impair long-term health and development have led the American Academy of Pediatrics (AAP) and other thought leaders to call for more effective and aggressive intervention for children in distress.
In June, the AAP convened a symposium on the long-term dangers of childhood toxic stress—early exposure to chronic unmitigated stress—and urged pediatricians, policy makers, and federal agencies to develop a stronger national response. To facilitate these efforts, the AAP announced it will launch the Center on Healthy, Resilient Children to help pediatricians and others identify toxic stress in children and connect them with appropriate resources.
“We are now recognizing in medical science and practice that there are real and significant effects when children grow up with toxic and persistent stress,” said Robert W. Block, MD, past president of the AAP, in an interview. “Those effects take a toll on the ability to learn in school and informally.”
(jama.jamanetwork.com)
THE SCIENCE OF STRESS
A growing body of evidence supports a link between adverse childhood experiences and adult health and well-being (http://bit.ly/1qHotsH).
Both genes and experiences shape young brains. As the brain develops, neurological circuits that are used frequently are strengthened, while those that are not are pruned away, explained Jack P. Shonkoff, MD, director of the Harvard Center on the Developing Child. These circuits support higher-level functions, including memory, emotional and behavioral regulation, and language.
But repeated adverse experiences, such as physical or sexual abuse, neglect, and malnutrition, increase the likelihood that a child will fall behind developmentally and require special education.
“When bad things happen early in life, the brain and other parts of the body don’t forget,” he explained.
Epidemiologic studies had long associated disadvantaged childhoods with poorer outcomes, but now biological research is helping to reveal the underlying mechanisms. For example, emerging evidence suggests that exposure to chronic unmitigated stress increases inflammation, which contributes to higher risks of cardiovascular disease and other physical ailments, Shonkoff said.
Even so, stress itself is not necessarily “bad,” he said. “It’s part of life. We need to learn to master it.”
He explained that a normal response to stress triggers the release of adrenaline and other hormones. Under normal circumstances, a child can rely on support from a parent or other adult, relieving the stress. But in some situations, there is no supportive adult, and the child stays in a constant state of elevated stress—toxic stress.
One early childhood intervention comes from the Nurse Family Partnership (NFP), which sends nurses to the homes of new parents to help them learn about child development and development skills, Shonkoff noted in an editorial earlier this year (Shonkoff JP. JAMA Pediatr. 2014;168[2]:105-106). He also noted 3 randomized trials suggesting that high-quality early childhood education programs are associated with short-term effects on cognitive measures, improved graduation rates, and economic self-sufficiency. One of the trials also found reduced rates of incarceration. However, Shonkoff noted that most early education programs do not follow the same models as those tested. He argued in the editorial that there is a need to develop interventions that produce bigger effects. Innovative models need to be developed, tested, and, when successful, disseminated.
“A brighter future for children whose life prospects are threatened by adversity requires that we build on the seminal contributions of programs like the NFP and leverage advances in 21st-century science to catalyze fresh thinking that changes the narrative for early childhood investment,” he said in the editorial.
Shonkoff explained at the symposium it’s important to address the problem of toxic stress through interventions and policies that create healthier “ecosystems” in which children can grow up. He cautioned against just increasing prescribing of medications such as statins to reduce inflamation. “It’s about doing something more ecological to deal with stress,” he said.
ENLISTING PARENTS
The data suggest that providing quality early childhood education and child care is just one piece of the puzzle. Support for parents is also essential.
Perri Klass, MD, a professor of journalism and pediatrics at New York University, explained that in many cases parents are struggling to do the right thing. Some may be dealing with mental illness, poverty, or their own history of negative childhood experiences.
“How do you do for your child what nobody did for you, or how do you not do to your child what someone did to you?” Klass said. “How can physicians, society, and your community help you do that?”
Klass said that pediatricians have an important role to play because they are in a unique position to observe adversity in their patients’ lives. For example, Klass said, a pediatrician asking a young mother if she has any questions might get a response such as “What can I do to prevent my son from going over to the bad like his father did?” Similarly, a pediatrician might learn that a child is not sleeping well after witnessing her grandfather being assaulted or that a child is carrying her possessions everywhere because she doesn’t have a consistent place to stay, Klass said.
Andrew Garner, MD, PhD, chair of the AAP early brain and child development leadership work group, said medical homes provide a good platform for reaching both parent and child. Pediatricians can help identify families at risk, provide support for positive parenting, and connect families with community services.
Pediatricians can help parents by giving them confidence in their abilities to help their child through adversity.
For example, Klass is the national medical director of a program called Reach Out and Read that encourages parents to read to their children and teaches them best practices for reading to their child. Through the program, pediatricians and nurse practitioners give children new books and coach parents on the importance of reading and strategies for making reading interactive. The program has reached 4 million children in 5000 clinical settings since it was created by a group of pediatricians in 1989.
“The child’s job is to learn,” Klass said. Through positive parent-child interactions, such as reading, she said, “they learn how the world works, how relationships work. It’s what they are programmed to do.”
Parents need help to build positive parenting skills, Shonkoff said. The evidence demonstrates that actively engaging parents in early childhood education substantially improves outcomes, compared with good-quality education alone, he said. And many of the skills parents need are also necessary in the workplace, so programs that shore up these skills make parents more employable and boost families’ economic well-being, Shonkoff said.
BUILDING CAPACITY
To help support and coordinate efforts to build resilience in children, the AAP announced the launch of its Center on Healthy, Resilient Children during the symposium.
Block, who will serve as medical director of the center, said the center will promote education for pediatricians and other clinicians on protecting the brain during development. It will also provide tools to help pediatricians screen families for toxic stress, provide support for families, and connect them with community resources.
The center will also work with federal and state agencies, nonprofits, and other partners to advance research, advocacy, and policy based on the science of toxic stress.
Several nonprofits and government agencies participating in the symposium have already begun to work to build support for healthy child development.
James S. Marks, MD, MPH, senior vice president of the Robert Wood Johnson Foundation, explained it’s in society’s best interest to focus resources on early development. He noted evidence that children who don’t receive quality early childhood education are 25% more likely to drop out, 40% more likely to become teen parents, 50% more likely to require special education services, and 70% more likely to be involved in violent crime. Intervening early in a child’s life and preventing these outcomes—and the societal costs they entail—yields a better return on investment for both society and the child, he argued.
One program led by business leaders is trying to leverage the potential cost savings associated with early childhood education to fund it. Robert H. Dugger, PhD, chair of the advisory board of the nonprofit ReadyNation (http://www.readynation.org), explained that in Salt Lake City, early childhood education programs were expanded to include 600 more children with loans from Goldman Sachs, the Pritzker Foundation, and other funders. The loans will be paid back with school district savings on special education.
Several federal programs were also highlighted. Elizabeth Doggett, PhD, deputy assistant secretary for policy and early learning at the US Department of Education, described how President Obama’s $4 billion Race to the Top (http://1.usa.gov/1rv0omD) initiative will provide $1 billion to 20 states for early childhood education and child care to ensure consistent program quality for all children.
Marks said it’s important to bring public policy, social programs, and other societal forces into alignment with the emerging science. Otherwise, advances based on the science of toxic stress will stall.
“We feel our nation needs to build a culture of health,” he said. “We need to act quickly or we will lose a generation of children.”
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