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TOXIC STRESS AND YOUTH
Jacqueline Dougé, MD, MPH, FAAP
Medical Director, Bureau of Child Health
Maryland Assembly on School-Based Health Care Annual Conference
Building Healthy Minds and Bodies
May 19, 2016
I have no financial disclosures or conflicts of inters to report
Workshop Objectives
• Understand the effects of toxic stress on children
• Understand the importance of screening for toxic stress
• Discuss the role that school-based health centers play in addressing toxic stress
• a state of mental tension and worry caused by problems in your life, work, etc.
• something that causes strong feelings of worry or anxiety
• physical force or pressure
Source: http://www.merriam-webster.com/dictionary/stress
Source: Center on the Developing Child Harvard University Accessed May 9, 2016. http://developingchild.harvard.edu/science/key-concepts/toxic-stress/
CHILDHOOD ADVERSITY HAS LIFELONG CONSEQUENCES.
Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later.
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
HOW DOES INCOME EFFECT HEALTH?
POVERTY
POOR HEALTH
INCOME & FOOD INSECURITY
HEALTH INSURANCE
POOR HOUSING & HOMELESSNESS
SAFETY & VIOLENCE
IMMIGRATION STATUS
OTHER: DISCRIMINATION, EDUCATION, ETC.
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
CHILDHOOD STRESS
CHANGES IN BRAIN
ARCHITECTURE
CHRONIC “FIGHT OR FLIGHT;”
CORTISOL /
NOREPINEPHRINE
HYPER-RESPONSIVE STRESS RESPONSIVE;
CALM / COPING
IMPACTS OF EARLY STRESS
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
OUT OF BALANCE?
AMYGDALA
Hot cognition
Emotional
Reactive
Impulsive
Just do it
Biological maturity by 18
PREFRONTAL CORTEX
Cold cognition
Judgmental
Reflective
Calculating
Think about it
Biological maturity by 24
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
POOR ADULT OUTCOMES
LINKING CHILDHOOD EXPERIENCES AND ADULT OUTCOMES
CHILDHOOD ADVERSITY
TOXIC STRESS
Epigenetic modifications Disruptions in brain architecture Behavioral allostasis
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
Development Results From an Ongoing, Re-iterative, and Cumulative Dance Between Nurture and Nature
BRAIN DEVELOPMENT
Alterations in brain structure and function
THE DANCE BETWEEN NURTURE AND NATURE
EPIGENETIC CHANGES
Alterations in how the genetic program is read
EXPERIENCE
Protective and personal (Versus insecure and impersonal)
BEHAVIOR
Adaptive or healthy coping skills (vs. maladaptive or unhealthy coping skills)
Adapted from AAP The Resilience Project. Early Adversity and
the Health of the Public ppt. Accessed May 16, 2016.
LINKING CHILDHOOD EXPERIENCES AND ADULT OUTCOMES
CHILDHOOD ADVERSITY Advocacy to minimize childhood
adversity (e.g. - efforts to address poverty, food scarcity, domestic
violence, parental substance abuse)
POOR ADULT OUTCOMES Health and social services to deal
with adverse outcomes (e.g. - efforts to address the behavioral,
social, health and economic consequences))
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
Adapted from AAP The Resilience Project. Early Adversity
and the Health of the Public ppt. Accessed May 16, 2016.
ACEs, TOXIC STRESS & COMPLEX TRAUMA
ACEs Toxic Stress
Complex Trauma
AUDIENCE PARTICIPATION
CASE STUDY Background
• 10 year old male presents for well child exam
• Referred to SBHC because needs immunizations
• Recently immigrated to United States from El Salvador; arrived 1 week ago
Past Medical History
• 30 year old mother
• Full term birth; no complications
• Diagnosed with asthma at age 4
• Immunizations are not up to date
Social History
• Patient lives with mother; she’s 6 months pregnant
• Mother recently separated from her current partner
• Patient’s biological father works and lives in another state
• Family’s preferred language is Spanish
Family History
• Patient’s father diagnosed with Depression and Anxiety
• Patient’s mother was told that she had high blood pressure a few years ago
DISCUSSION
• What other information would you like to have and why?
• What risks to health and well-being have you identified and why are they risks?
• What tools would you used to identify/screen for risks?
• What opportunities to promote wellness and development have already been missed?
• What local resources do you know that you can contact or refer the patient or their family?
• What are your priorities moving forward?
“The pressing questions now confronting[….]is how we can have a greater impact on improving the life
prospects of children and families who face these increasingly complex and persistent
threats to healthy development. -Committee on Psychological Aspects of Child and Family Health, Committee on Early
Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics.
Source: AAP Policy Statement Early Childhood Adversity, Toxic Stress,
and the Role of the Pediatrician: Translating Developmental Science
Into Lifelong Health
ROLE OF SCHOOL-BASED HEALTH CENTERS
OPPRORTUNITIES FOR SBHCs
• Understand impact of toxic stress
• Screen for trauma exposure/toxic stress
• Teach strategies for preventing and mitigating stress/trauma
• Refer for treatment/services as appropriate
Adapted from Michigan Department of Health And Human Services. Young
Children, Trauma & Toxic Stress. Accessed May 18,
2016.www.michigan.gov/traumatoxicstres
SCIENCE OF RESILIENCE
SUMMARY
• Toxic stress affects the developing brain and has long term health consequences
• Important to identify stressors in kids and families life
• School-based health centers have a role in addressing toxic stress
• Safe, stable and nurturing relationships and environments can help to mitigate effects of toxic stress
References
• Early Adversity and The Health of the Public. (n.d.). Retrieved May 16, 2016, from https://www.aap.org/en-us/_layouts/15/WopiFrame.aspx?sourcedoc=/en-us/Documents/resilience_resilience_project_template_powerpoint.ppt
• MDHHS Adult & Children's Services Children & Families Trauma & Toxic Stress. (n.d.). Retrieved May 18, 2016, from http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_69588---,00.html
• Shonkoff JP, Garner A; Committee on Psychological Aspects of Child ad Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics 2012;129;e232
• Strengthening Families. (n.d.). Protective Factors Framework. Retrieved May 16, 2016, from Center for the Study of Social Policy’s Strengthening Families: http://www.cssp.org/reform/strengthening-families/basic-one-pagers/Strengthening-Families-Protective-Factors.pdf
• The Resilience Project. (n.d.). Retrieved May 16, 2016, from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/default.aspx
QUESTIONS?
Jacqueline Dougé, MD, MPH, FAAP
Email: jdouge@howardcountymd.gov
Phone: 410-313-7569
Contact information
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