Thursday, December 5, 2013

Kids on a playgroundThe first years of life are critical to a child’s healthy development. It is accepted that good prenatal care for a child’s mother can prevent prematurity and low birth weight, that proper nutrition and physical activity help a child’s body and brain grow, and that access to stimulating toys and environments set the foundation for a child to thrive in school. These early years are also critical for a child’s emotional health. Exposure to high levels of stress and adverse childhood experiences (ACEs) can have profound effects on a child that lead to developmental, mental, and even physical problems later in life. However, there is strong evidence that protection and support from parents and caregivers can mitigate these ill-effects, and there are proven programs that help parents and caregivers learn positive parenting styles.[1] [2]

ACEs and toxic stress. Adverse childhood experiences (ACEs) are experiences of abuse and neglect and exposure to strong negative events such as domestic violence and drug use in the household. Toxic stress is continued exposure to difficult circumstances, such as poverty without adequate support from parents or caregivers. A newly released report by Child Trends and the Robert McCormick Foundation on the health of children aged birth to two in this country, The Youngest Americans, tells us that these experiences are not as rare as we would hope:

  • A quarter of U.S. children aged birth to two lived in poverty in 2012, with 13% in deep poverty (less than 50% of the Federal poverty limit).
  • Over 15% of children experienced maltreatment in 2011, with the most prevalent form (13.4%) being neglect, or a lack of sufficient attention from and protection by caregivers.
  • In 2011, 16% of children experienced crowded housing and 4.7% experienced frequent moves, both of which are associated with poor health and behavioral outcomes.
  • Nearly one out of every four children have experienced one adverse experience, with 4% experiencing two and 3% experiencing three or more.[3]

Toxic stress is a related term that refers to overexposure to stressful situations, including those described as ACEs. Not all childhood stress is toxic. The Center on the Developing Child at Harvard University distinguishes between positive stress caused by normal developmental milestones, such as a first day at school; tolerable stress that is caused by more difficult circumstances, such as natural disasters or a death in the family; and toxic stress. Toxic stress is the result of “strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support.”[4] While exposure to positive stress, or to tolerable stress with proper support from adults, can help children develop healthy emotional responses to adversity, exposure to toxic stress causes lasting damage to both physical and mental health.[5]

How toxic stress and adverse experiences hurt. A seminal 1998 study on ACEs surveyed over 9,500 adults on their adverse childhood experiences and measures of risky health behaviors, health status, and disease. This study found a significant relationship between the number of ACEs and adult health behaviors and outcomes. The more exposures a person reported, the more likely they were to have health risk factors and disease conditions. Researchers found a significant relationship between ACEs exposure and heart disease, cancer, poor lung health, poor liver health, fractures, and overall poor self-rated health. This paper hypothesized that the link between ACEs and adult ill health is the result of an increase in health behaviors, such as substance abuse, tobacco use, and risky sexual activities, used as coping devices to deal with the social, emotional, and cognitive impairment caused by exposure to early stress.[6] A more recent study on ACEs in urban Philadelphia corroborated these results, with adults who experienced high numbers of ACEs reporting higher rates of diagnosis of mental health conditions, risky health behaviors, such as suicide attempts and multiple sexual partners, and poor health outcomes, including cancer, diabetes, obesity, and asthma.[7]

While describing the exact biochemical pathways is beyond the scope of this blog, it is important to understand that ACEs and toxic stress lead to changes in the brain that can affect how a person responds to stress in the future. Stressful situations cause the body to release stress chemicals that prime the body for “fight or flight,” and overuse of this stress response causes the response to become stronger in future situations. Overexposure to these stress chemicals can cause inflammation in various part of the body, and scientists have found strong evidence that these changes impact a variety of brain functions and can lead to impaired memory, difficultly learning, difficulty moderating strong emotions, lowered impulse control, and other outcomes. In addition, the impact of stress-related chemicals in the body can lead to other poor health outcomes, including cardiovascular disease, cirrhosis, type 2 diabetes, and depression.[8] [9] [10]

These stress-related changes are particularly harmful for the developing brains of infants and young children. Stressful experiences have been shown to alter the relative sizes of parts of the brain responsible for learning, memory, decision-making, and anxiety. These changes can make it harder for a child to thrive in school and learn how to handle strong emotions later in life. Exposure to toxic stress or ACEs has been linked to:

  • Drinking earlier in life, and using alcohol as a coping mechanism
  • Higher tobacco and other substance use
  • Higher rates of risk-taking behaviors in adolescents, leading to a higher risk of school failure, unemployment, and other negative economic outcomes
  • Poor parenting, leading to an intergenerational cycle of toxic stress[11]

In addition to effects on the individual, toxic stress has been linked to higher health care costs for society, along with lost economic productivity and the costs of engagement with the criminal justice system.[12] As discussed in this recent Health Policy Forum blog on the value of investments in health, early interventions that help avoid these outcomes can have positive societal and financial reverberations far into the future.

Support the parents, support the child. As noted above, parents and caregivers can mitigate the harms of exposure to these stressors by providing emotional support and protection. Healthy parenting practices can help protect children from toxic stress even in the face of such stressors as illness, accident, and poverty.[13] However, the parent or caregiver has to be resilient him- or herself, and adults who were exposed to toxic stressors as children may need help developing this resiliency and learning to parent. These parents may also need help breaking the patterns of substance abuse or violence already present in their lives.[14] In 2011/2012, 7% of parents of children aged birth to two reported frequent stress from parenting, which can lead to poor health outcomes for both the parents and the child. For parents at or below the poverty level, the proportion of parents reporting frequent parenting stress rose to 13%.[15]

The influential Institutes of Medicine report, From Neurons to Neighborhoods: The Science of Early Childhood Development, notes that the quality of the relationship between caregiver and child is “influenced most often by the goodness of fit between the styles of both contributors”[16]—in other words, how well the caregiver and child understand and appreciate one another. To this end, parent-focused programs are often intended to help the parent understand the child and develop parenting skills that reduce parenting-related stress.[17] Parent education programs and parent–child interaction programs have been shown to have positive impacts on parenting outcomes, such as increased sensitivity to child needs, reduced detachment, and fewer negative parenting behaviors, such as harsh discipline. In addition, parents involved in these programs report lower levels of stress, less anger, and better relationships with other adults.[18] [19]

Several evidence-based programs help support parents and caregivers who are struggling with raising children in adverse environments. Home visiting programs have been recognized by researchers and policymakers as effective, evidence-based programs that help parents at risk provide a safe and nurturing environment for new children. With the passage of the 2010 Affordable Care Act, the Federal government authorized the creation of the Maternal, Infant, and Early Childhood Home Visiting program (MIECHV) grants to states to provide either evidence-based (75% of funding) or promising (25% of funding) home visiting programs.[20] [21] Nurse-Family Partnerships, a program that has been in existence since the 1970s, is one example of home visiting that has been proven effective through randomized-controlled trials. Child FIRST, a Connecticut-based home visiting intervention that was selected as one of 12 national evidence-based models by the Health Resources and Services Administration (HRSA), brings parent–child mental health counseling and parenting resources to the homes of families at risk for emotional or developmental problems or child mistreatment. A randomly controlled trial of this program found that children in the program were significantly less likely to have behavioral problems and language delays; had a higher rate of access to needed services, such as early intervention and medical services; and were significantly less likely to become involved with child protective services than children in the control group.[22]

The Altarum Institute is working with another type of evidence-based parenting education program, Triple P (Positive Parenting Program), to assess the implementation of this program by partnerships between local health departments and Federally Qualified Health Centers. This work is supported by the National Association of County and City Health Officials (NACCHO), the Centers for Disease Control and Prevention (CDC), and the CDC Foundation. A 2008 meta-analysis of 55 studies on Triple P found that the program has reliably positive effects on child behavioral problems, parenting behavior, and parental well-being in all settings measured.[23] Triple P is delivered in a variety of ways, from a universal communications strategy, to seminars and group interventions, to targeted, one-on-one intensive support strategies for families with greater need.[24] [25]

Integrated support for parent and child emotional health. Beyond direct parent and caregiver interventions, integrating socio-emotional development and mental health support into the systems that support young children and their parents is a crucial part of mitigating the effects of toxic stress. Parent support must be delivered in concert with other family support programs, such as those that promote economic stability, that facilitate enrollment in needed health care, and that address such acute problems as substance use, untreated mental illness, and child abuse and neglect. [26] Mental and emotional health has a strong impact on risky health behaviors and on future physical health. The evidence shows that helping parents and caregivers learn how to protect their children from the harmful effects of exposure to stressful situations is a successful way to influence the future mental and physical health positively for both caregivers and their children.

 

[1] Tout, K., Halle, T., Daily, S., Albertson-Junkans, L., & Moodie, S. (2013). The Research Base for a Birth Through Age Eight State Policy Framework. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/10/2013-42AllianceBirthto8.pdf

[2] Bronstein, D. (2013, October 30). Protecting children from toxic stress. The New York Times. P. SR4. Retrieved 11/12/13 from http://opinionator.blogs.nytimes.com/2013/10/30/protecting-children-from-toxic-stress

[3] Murphy, D., Cooper, M., & Forry, N. (November 2013). The Youngest Americans: A Statistical Portrait of Infants and Toddlers in the United States. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/11/MCCORMICK-FINAL.pdf

[4] Center on the Developing Child. (2013). Toxic Stress: The Facts. Cambridge, MA: Harvard University. Retrieved 11/12/13 from http://developingchild.harvard.edu/topics/science_of_early_childhood/toxic_stress_response/

[5] Shonkoff, J., & Garner, A. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. doi:10.1542/peds.2011-2663

[6] Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. American Journal of Preventive Medicine,14:245–258.

[7] Public Health Management Corporation. (September 2013). Findings from the Philadelphia Urban ACE Survey. Philadelphia, PA: Public Health Management Corporation. Retrieved 11/14/2013 from http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407836

[8] Garner, A. S. (2013). Home Visiting and the Biology of Toxic Stress: Opportunities to Address Early Childhood Adversity. Pediatrics, S65-S73. doi:10.1542/peds.2013-1021D

[9] Tout, K., Halle, T., Daily, S., Albertson-Junkans, L., & Moodie, S. (2013). The Research Base for a Birth Through Age Eight State Policy Framework. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/10/2013-42AllianceBirthto8.pdf

[10] Shonkoff, J., & Garner, A. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. doi:10.1542/peds.2011-2663

[11] Shonkoff, J., & Garner, A. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. doi:10.1542/peds.2011-2663

[12] Shonkoff, J., & Garner, A. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. doi:10.1542/peds.2011-2663

[13] Bronstein, D. (2013, October 30). Protecting Children from Toxic Stress. The New York Times. P. SR4. Retrieved 11/12/13 from http://opinionator.blogs.nytimes.com/2013/10/30/protecting-children-from-toxic-stress

[14] Center for the Study of Social Policy. (2013). Parental Resilience – Protective & Promotive Factors. Washington, DC: Center for the Study of Social Policy. Retrieved 11/12/13 from http://www.cssp.org/reform/strengthening-families/2013/SF_Parental-Resilience.pdf

[15] Murphy, D., Cooper, M., & Forry, N. (November 2013). The Youngest Americans: A Statistical Portrait of Infants and Toddlers in the United States. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/11/MCCORMICK-FINAL.pdf

[16] National Research Council and Institute of Medicine (2000) From Neurons to Neighborhoods: The Science of Early Childhood Development. Committee on Integrating the Science of Early Childhood Development. Jack P. Shonkoff and Deborah A. Phillips, eds. Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press. P. 353

[17] National Research Council and Institute of Medicine (2000) From Neurons to Neighborhoods: The Science of Early Childhood Development. Committee on Integrating the Science of Early Childhood Development. Jack P. Shonkoff and Deborah A. Phillips, eds. Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

[18] Tout, K., Halle, T., Daily, S., Albertson-Junkans, L., & Moodie, S. (2013). The Research Base for a Birth Through Age Eight State Policy Framework. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/10/2013-42AllianceBirthto8.pdf

[19] Bornstein, D. (2013, February 20). The benefits of positive parenting. The New York Times. Retrieved 11/12/13 from http://opinionator.blogs.nytimes.com/2013/02/20/helping-the-parents-to-spare-the-children/

[20] Administration for Children and Families. (n.d.). Affordable Care Act Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and Tribal MIECHV. Washington, DC: US Department of Health and Human Services. Retrieved 11/15/2013 from http://www.acf.hhs.gov/programs/ecd/programs/home-visiting

[21] Tout, K., Halle, T., Daily, S., Albertson-Junkans, L., & Moodie, S. (2013). The Research Base for a Birth Through Age Eight State Policy Framework. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/10/2013-42AllianceBirthto8.pdf

[22] Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs-Gowan, M. J. (2011). A Randomized Controlled Trial of Child FIRST: A Comprehensive Home-Based Intervention Translating Research Into Early Childhood Practice. Child Development, 82(1), 193-208. doi:10.1111/j.1467-8624.2010.01550.x

[23] Nowak, C., & Heinrichs, N. (2008). A comprehensive meta-analysis of Triple P-Positive Parenting Program using hierarchical linear modeling: effectiveness and moderating variables. Clinical Child And Family Psychology Review, 11(3), 114-144. doi:10.1007/s10567-008-0033-0

[24] Triple P. (n.d.). The System Explained. Queensland, AUS: Triple P – Positive Parenting Program. Retrieved 11/15/13 from http://www.triplep.net/glo-en/the-triple-p-system-at-work/the-system-explained/

[25] Bornstein, D. (2013, February 20). The benefits of positive parenting. The New York Times. Retrieved 11/12/13 from http://opinionator.blogs.nytimes.com/2013/02/20/helping-the-parents-to-spare-the-children/

[26] Tout, K., Halle, T., Daily, S., Albertson-Junkans, L., & Moodie, S. (2013). The Research Base for a Birth Through Age Eight State Policy Framework. Bethesda, MD: Child Trends. Retrieved 11/12/13 from http://www.childtrends.org/wp-content/uploads/2013/10/2013-42AllianceBirthto8.pdf


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