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AAP explains shift from focus on the problem of toxic stress to solutions


It might seem odd that President Theodore Roosevelt, who was described as “aggressive,” ”over-engined” and had a talent for delivering insults, would be hailed as a proponent of nurturing relationships. But that’s exactly how Dr. Andrew Garner referenced him in describing a paradigm shift in policy by the American Academy of Pediatrics (AAP).

“They don’t care what you know until they know that you care,’” said Garner, referring to a quote often attributed to Roosevelt.

Garner, who is a clinical professor at Case Western Reserve University School of Medicine and provides care at Partners in Pediatrics in Westlake, Ohio, was speaking at a webinar about the August AAP policy statement entitled Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health. This updates a policy statement on toxic stress issued nearly a decade ago. The webinar was hosted by Dr. David Willis, a senior fellow with the Center for the Study of Social Policy, and included AAP President Dr. Lee Ann Savio Beers.

The driver of the policy update was essentially this: Focus on solutions to the problem of toxic stress rather than the problem itself. More specifically, prevent or mitigate childhood adversity in individuals, families and communities by teaching and promoting safe, stable and nurturing relationships. In other words, promote relational health, often described as interpersonal interactions, that foster growth and are mutually empathic and empowering.

The problems were highlighted in the 2012 AAP policy statement entitled Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.

That initial policy guide spelled out the critical and catastrophic, lifelong effects—biological and behavioral—that toxic stress from adverse childhood experiences (ACEs) could have on someone in the absence of nurturing and buffering relationships. The statement was an outgrowth of more than a decade of research, including the 1998 landmark ACE Study by the Centers for Disease Control and Prevention and Kaiser Permanente. The ACE Study showed the remarkable connection between 10 types of childhood traumas, such as experiencing abuse or living with a parent with mental illness or addiction issues, and chronic health problems in adulthood, such as cancer or heart disease.

Garner said that while understanding toxic stress is critical, particularly coming out of a pandemic that laid bare economic and health inequities as well as systemic racism, “The problem is [toxic stress] doesn’t point the way forward.”

The way forward is through relational health, Garner said. This idea has its underpinnings in the work of Dr. Christina Bethell of Johns Hopkins University and others who have researched how positive childhood experiences (PCEs) could offset the potential physical and mental health harm of childhood adversity. Safe, stable and nurturing relationships are the building blocks of PCEs. “They not only buffer adversity, they actually proactively build the skills that are needed for all kids to thrive and flourish,” said Garner.

The new policy statement, co-authored with Dr. Michael Yogman of Harvard Medical School, recognizes that childhood adversities are not simply the result of actions and behaviors within a family, but are also often rooted in systemic racism, poverty, war, global pandemics, climate change, deportation, gender identity and sexual orientation discrimination.

To help children and families navigate the shoals of adversity, the new statement encourages pediatricians to deploy a universal, multi-tiered approach. This could include praising and encouraging parents for bonding activities, such as breastfeeding, embracing or comforting their children, playing with them or reading together. It also urges health care providers to refer families for therapy or to community organizations that can help with barriers that create stress, such as hunger, homelessness and job loss. The figure below outlines this preventive approach.AAPFigureRelationalHealth

The AAP’s policy statement highlights how emerging research increasingly documents the biological benefits of strong bonding between mother and infant.

"Early supports that allow new mothers more opportunities to bond with, breastfeed, and simply stroke their children are associated with [a decrease in stress-related changes to the epigenome], perhaps allowing infants to down regulate their stress responses more effectively," the statement explained.

“This is not just another way of saying be nice to kids,” Garner said. “This is grounded in science, and I think that as we learn more about the bio-behavioral synchrony that's happening in those magical moments, we're going to see that all that we have learned about toxic stress is really just setting us up to really understand how positive experiences become biologically embedded as well.”

Other research cited in the AAP policy statement demonstrates synchronicity between parents and infants who connect through bonding, as shown through matching heart rhythms, brain waves, and the release of the” love hormone” oxytocin. Such synchronicity “builds the child’s lifelong capacity for intimacy, socio-affective skills, adaptation to the social group, and the ability to use social relationships to manage stress,” according to an expert quoted in the policy statement.

The science behind relational health gives pediatricians new tools to advocate for crucial systemic changes, according to AAP President Beers.

“I was testifying about paid family medical leave, so I could talk about how the science tells us that this time [between parents and their infants] is really important. And when parents don't have that time, or they're worried about not getting paid or, the impact that will have on their family, it really does impact kids for a lifetime.”

Editor’s Note: We at PACEs Connection realized earlier this year that focusing only on ACEs wasn’t fully capturing what happens in our lives. And, although the knowledge of ACEs science liberated a lot of people by explaining their lives, it also depressed a lot of people if they weren’t provided information about resilience. And sometimes, even if they were, it wasn’t emphasized or explained sufficiently.

For the PACEs movement, it’s obvious that we need to figure out how to better describe this amazing knowledge and increase the understanding of PACEs. We need to make PACEs science clear to everyone, so that we can talk about and use this knowledge in our individual lives, our community lives, our organizational lives and our systems lives. And at all stages, we must always consider how racism, the elephant in the room, relates to the discussion.

For more information about why we at PACEs Connection adopted the approach taken by AAP, please read this article that we published in March.


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  • AAPFigureRelationalHealth

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