toxic stress

Building Resiliency

As pediatricians, we often care for children that may have had exposures to neglect, maltreatment, family violence, family separation or extreme poverty. Over time, we see the negative consequences of these experiences on our patients in the form of poor academic success, substance abuse, and medical and mental health problems. These experiences are termed adverse childhood experiences or ACEs and it is estimated that about 60% of the adult population in the United States has experienced at least one ACE. Pediatricians should identify and attempt to prevent ACEs: we can support and coordinate efforts to build resilience in children by understanding the effect of toxic stress and providing early interventions and continuity in care.

The hallmark ACE study conducted in 1998 by the CDC and Kaiser Permanente in California categorized ACEs into three major categories: physical and emotional abuse, neglect and household dysfunction (e.g., parent with mental illness, substance abuse or experiencing separation or divorce). The study showed dramatic associations between ACEs and risky behavior, psychological illnesses, serious illness and even a lower life expectancy in the children.

In a child’s life, experiencing ACEs can lead to toxic stress. Toxic stress occurs when a child stays in a constant state of elevated stress. Often children have a caregiver to give them comfort during normal times of stress. In these cases, the levels of stress hormones will return to baseline. However, when no supportive caregiver can comfort the child, such as in cases of neglect, emotional or physical abuse, the child’s stress hormone level remains high.  This can affect other aspects of a child’s health and development.

The link between adverse childhood experiences and adult health and well-being has been well studied. We know that as the brain develops, more frequently used circuits are strengthened, while those that are not used can eventually fade away in a process called pruning. Stronger circuits are associated with higher-level functioning, improved memory, emotional and behavioral regulation and language. In children exposed to toxic stress, the circuits are weaker and fewer, especially in the areas of the brain dedicated to learning and reasoning. For example, the excessive stress activation shifts mental and physiological resources from long-term development to immediate survival.  This increases the task of vigilance at the expense of focused attention. Ultimately, poor coping habits and mental health problems can develop. We also know that the exposure to stress hormone increases systemic inflammation which contributes to a higher risk of cardiovascular disease and diabetes among other medical problems. Finally, evidence shows that the longer we wait to intervene, the more difficult it is to achieve healthy outcomes.

The concept of resiliency explains why some children overcome stress better than others. As pediatricians, understanding this concept can help us to build stronger individuals. Resiliency is thought to be related to a greater number of positive experiences compared to negative experiences. We know that a very important part of developing resilience is at least one stable and committed relationship with a supportive caregiver. Promoting regular physical exercise, stress-reduction exercises and promoting strong core life skills for both the child and the adult are additional ways pediatricians can promote resiliency.

Trauma-informed care involves prevention, recognition and response to trauma-related experiences. Early identification is an important first step. As pediatricians, we should consider ACEs-based screening questionnaires for every patient to assess the potential need for other services. The next step would be to link these patients with services such as social work, developmental therapies, or mental health support with experience in trauma. This is often the most difficult part in delivering trauma-informed care, so it is important to identify the resources available in the local area.

Finally, to address prevention, we should work with our families to reduce the stress of daily life, such as connecting them to resources like  food pantries or substance abuse programs. We should teach skills to families regarding parenting and safe dating practices. To promote strong relationships with other adult caregivers, we should be know of available after-school and mentoring programs. The overall goal should focus on changing the environment and behaviors in ways that will prevent ACEs from happening in the first place.  

Amisha Patel M.D.

Sources:
Fox  SE, Levitt  P, Nelson  CA  III.  How the timing and quality of early experiences influence the development of brain architecture.  Child Dev. 2010;81(1):28-40.

Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998;14(4):245-258.

Shonkoff JP. Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr. 2016;170(10):1003–1007. doi:10.1001/jamapediatrics.2016.1559

Kuehn BM. AAP: Toxic Stress Threatens Kids’ Long-term Health. JAMA. 2014;312(6):585–586. doi:10.1001/jama.2014.8737


Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE). http://www.cdc.gov.foyer.swmed.edu/violenceprevention/acestudy/index.html. Accessed February 5, 2020.

Mistreatment of Immigrant Children at the Southern Border

It was a little over a year ago when I first heard about the child separations happening at the U.S.-Mexico border. I had recently had my own son and it gave me a visceral feeling of horror imagining someone taking him away from me, not knowing where he was going, when I would see him again, or who would take care of him. I read a story of a 4-month-old taken from his mother as I held my own infant of a similar age. I imagined what kind of fear would drive me to make a dangerous journey with a newborn and beg for safety in a foreign country.  Children continue to be separated from their parents and caregivers. They are kept in conditions unfit for anyone, and especially damaging for children. We need to speak out against the treatment of migrant children that is occurring and demand more humane solutions.

Whether unaccompanied or as part of a family unit, when children present for asylum, they are brought first through a Customs and Border Protection facility where by law, they are not to be detained for more than 72 hours (Linton et al., 2017). However, some children and families are being held for much longer (Linton et al., 2017). There are small, unwashed and underfed children taking care of younger, filthy toddlers without proper sanitation available, like clean diapers (Raff, 2019). Studies have shown negative physical and emotional symptoms among detained children under any circumstance (Linton et al., 2017), then their source of resilience might be stolen away- their caregivers. Even a short time in detention can have damaging psychological effects (Linton et al., 2017). Interviewed parents have described regressive behavior in their children after detention along with increased aggression and self-injurious behavior (Linton et. al 2019). They might come with parents or they may come with extended family members hoping to join their parents already in the U.S. (Linton et al., 2017). In 2016, “Family Case Management” was terminated, a short-lived program that was 99% effective in having these families in court, even by ICE’s own statements (Singer, 2019). The former program cost taxpayers about $38 a day, while the current system costs hundreds per day (Singer, 2019).  

Children are dying. They are dying. They are kept in ‘prison-like conditions’ (Linton et al., 2017) and in the last year, at least 7 children have died in immigration custody after almost a decade of no deaths (Acevedo, 2019). Dr. Dolly Lucio Sevier, a pediatrician who visited a Customs and Border Protection facility in McAllen Texas, one of the facilities where immigrants are not to be held for longer than 72 hours. She met a baby whose uncle was forced to feed him for days from an unwashed bottle (Raff, 2019). She met a teenage mom whose baby was wrapped in diapers and plastic because they refused to give her clean clothes for her infant. This facility is known as the hielera, or ice box (Raff, 2019). This mom was trying desperately to keep her baby warm when she had nothing but concrete and mylar blankets (Raff, 2019). Dr. Sevier saw unmistakable signs of mental trauma and illness. The children had not been allowed access to soap, toothbrushes, clean clothes; and many had been in the facility weeks. They smelled, were malnourished, dehydrated, and most had at least a respiratory infection. The baby who had been drinking from a dirty bottle was fevered and ill (Raff, 2019).

Exposure to the ‘prison-like’ conditions present in the immigration facilities causes high levels of stress (Linton et al., 2017). It has been well documented that toxic stress will have lasting effects on the health of these children, even if they manage to somehow get past the mental effects of their trauma. They will be at higher risk for heart disease, cancer, diabetes, etc (Garner et al., 2015). Their present health and their future health are being destroyed in one fell swoop. The recognition and reduction of toxic stress in children should be a priority for all pediatricians (Garner et al., 2015), and should be part of a routine evaluation for the care of immigrant children (Linton et al., 2017).

The American Academy of Pediatrics  issued a policy statement about the detention of immigrant children. The policy outlines many concerns and recommendations including that separating a parent or primary caregiver from their children should never occur unless there is a concern for the safety of the child (Linton et al., 2017). Practices in the CBP processing centers are inconsistent with AAP recommendations for the care of children, and therefore children should not be subjected to them. Community-based case management should be implemented for the children and their families (Linton et al., 2017). Children should receive timely and comprehensive medical care.  “Treat all immigrant children and families seeking safe haven who are taken into US immigration custody with dignity and respect to protect their health and well-being” (Linton et al., 2017). 

It is easy to feel helpless and overwhelmed. I urge you to not become complacent. Write your own opinion. Write your congressional representatives. Donate to the Annunciation House, which helps to house some immigrants. You can also give to RACIES (Refugee and Immigrant Center for Education and legal Services) or to the Human Rights Initiative of North Texas, both of which seek to help immigrants gain asylum and legal status, among other services. I encourage my fellow physicians to look for immigrants among our patients. Recognize the trauma they have been subjected to. Practice trauma-informed care and do your best to refer to services that can help.

Marie Varnet, MD

My son and I protesting the treatment of immigrant children in Dallas, Tx

Acevedo, Nicole. “Why Are Migrant Children Dying in U.S. Custody?” NBCNews.com, NBCUniversal News Group, 30 May 2019, http://www.nbcnews.com/news/latino/why-are-migrant-children-dying-u-s-custody-n1010316.

Garner, Andrew S., et al. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.” Pediatrics, American Academy of Pediatrics, 1 Jan. 2012, pediatrics.aappublications.org/content/129/1/e224.short.

Linton, Julie M., et al. “Detention of Immigrant Children.” Pediatrics, American Academy of Pediatrics, 1 May 2017, pediatrics.aappublications.org/content/139/5/e20170483#xref-ref-10-1.

Raff, Jeremy. “What a Pediatrician Saw Inside a Border Patrol Warehouse.” The Atlantic, Atlantic Media Company, 4 July 2019, http://www.theatlantic.com/politics/archive/2019/07/border-patrols-oversight-sick-migrant-children/593224/.

Singer, Audrey. “Immigration: Alternatives to Detention (ATD) Programs.” Congressional Research Service, 2019, fas.org/sgp/crs/homesec/R45804.pdf.

Child Health and Poverty – A Call to Action

It has been well described that poverty is associated with poor health, starting from time in the womb all the way into adulthood. Poor children have higher rates of infant mortality, low birth weight, food insecurity, and unintentional injuries. They also have a higher incidence and worse severity of chronic diseases such as asthma and obesity. As these children grow older, they are at higher risk of poor educational achievement, teen pregnancy, and inability to escape poverty. Finally, most poor children unfortunately grow into poor adults with higher rates of diabetes and cardiovascular disease, depression, substance abuse, and ultimately shorter life expectancy. Lately, a growing body of evidence has shown that toxic stress experienced by developing children fundamentally changes their biology – altering brain development, the immune system, hormones, and metabolism in ways that predispose to illness. As pediatricians, we should understand that addressing the effect of poverty on our patients’ health requires more than seeing families individually in the office. It will require our voices in broader social institutions. (more…)

AAP supports increased funding for pediatric mental health services

The AAP responds to a request from the Senate Finance Committee regarding our nation’s mental health system.

In the wake of the tragic shootings at Sandy Hook Elementary School in Newtown, CT, the Administration and Congress are looking for ways to improve our nation’s mental health system. Exposure to violence causes toxic stress in childhood, which can have long-term negative effects on children. Managing adult mental health disorders begins with ensuring that children have access to quality mental health services. (more…)