A medical home builds partnerships with clinical specialists, families, and community resources. Become hubs for medical neighborhoods, horizontally integrating a wide array of local efforts and early childhood initiatives that not only support families with resources and programs but also advocate for the public policies that promote safe, stable, and nurturing families and communities. Chp 2- evolutionary theories Theories of development Theories give a certain perspective Advantages: narrows down way to look at things Negatives: disadvantages to see everything around that one theory (it filters out too many things) Depending on what you are looking at may add different theories NOT JUST 1 5 theories will be seen (removing evolutionary)-Psychoanalytic theories-Humanistic . Bioecological Systems Theory 3. The capacity to respond to adversity in a healthy, adaptive manner; resilience is the manifestation of skills (eg, social skills, emotional regulation, language, and executive functions) that can be modeled, taught, learned, practiced, and reinforced. Acknowledge that a wide range of adversities, from discrete, threatening events to ongoing, chronic life conditions, share the potential to trigger toxic stress responses and inhibit the formation of SSNRs. To minimize the burden of toxic stress responses at the population level, the entire pediatric community needs to identify and address not only the acute threats to child wellness such as abuse and physical violence but also the ongoing, chronic life conditions such as racism, poverty, and isolation that are rooted in deep-seated social constructs, societal inequities (including those within the health care system), and public policies that inhibit social cohesion, equity, and relational health. Toxic stress defines the problem. The FCPMH alone cannot leverage significant change within the community context. Search for other works by this author on: National Scientific Council on the Developing Child, Young Children Develop in an Environment of Relationships: Working Paper No. Consequently, the challenge is not only to prevent a broad spectrum of adversities from occurring but also to prevent them from becoming barriers to the SSNRs that allow individuals from across the spectrum of adversity to be resilient and flourish despite the adversity.17,58,59. Approximately 15.5 million children in the United States reside in households in which interpersonal violence is recurrent. A convergence of evidence from neurobiology and epidemiology, Insights into causal pathways for ischemic heart disease: adverse childhood experiences study, Adverse childhood experiences and chronic obstructive pulmonary disease in adults, Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway, Adverse childhood experiences and prescribed psychotropic medications in adults, Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study, Putting the concept of biological embedding in historical perspective, How experience gets under the skin to create gradients in developmental health, Brain on stress: how the social environment gets under the skin, DNA Methylation: A Mechanism for Embedding Early Life Experiences in the Genome, Discrimination, racial bias, and telomere length in African-American men, Discrimination and telomere length among older adults in the United States, The link between discrimination and telomere length in African American adults, Capitalizing on advances in science to reduce the health consequences of early childhood adversity, Leveraging the biology of adversity to address the roots of disparities in health and development, Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention, Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Theories that support a relationship-based framework 1. Unfortunately, the two theories are very much at odds regarding what is "right." Shareholder theory asserts that shareholders advance capital to a company's managers, who are supposed to spend corporate funds only in ways that have been authorized by the shareholders. See the Appendix for full descriptions of the abbreviations. Domains, timing, and intensity of chaos were predictive of children's mental and physical health. Finally, to develop the physician leadership for the FCPMHs of the future, pediatric training programs will need to: Educate residents about the ecobiodevelopmental model and the implications for not only health care but education, juvenile justice, and public policy. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. Drawing on a framework produced by the Center on the Developing Child at Harvard University,192 this policy statement highlights the following 3 science-informed principles to prevent toxic stress responses and to build healthy, resilient children. Its components emerge in infancy and are dependent on genetic, medical, and environmental factors. What is ecobiodevelopmental theory? Second, it applies this EBD framework to better understand the complex relationships among adverse childhood circum-stances, toxic stress, brain architec-ture, and poor physical and mental health well into . 10.1542/peds.2021-052582. Trainees need to understand all of these many facets so they are prepared to be effective advocates for their patients and families. Proposing that the public health approach also be integrated horizontally across multiple public service sectors (eg, health care, behavioral health, education, social services, justice, and faith communities) because SSNRs are promoted in safe, stable, and nurturing families that have access to safe, stable, and nurturing communities with a wide range of resources and services. Poverty, food insecurity, housing insecurity, racism, community violence, discrimination, alienation, disenfranchisement, and social isolation are examples that impose significant hardships on families and become potential barriers to developing SSNRs. The mechanism offers an explanation for the historical trauma. The case studies by Chilton and Rabinowich provide poignant and compelling qualitative data that support an ecobiodevelopmental approach towards understanding and addressing both the complex. Conversely, early supports that allow new mothers more opportunities to bond with, breastfeed, and simply stroke their children are associated with decreases in the methylation of the glucocorticoid receptor gene, perhaps allowing infants to downregulate their stress responses more effectively.78,79 This finding is one of the most significant predictions of the ecobiodevelopmental model: the biological mechanisms that underlie the embedding of significant childhood adversity may also underlie the embedding of positive relational experiences in childhood. But these same changes could be considered maladaptive over time because the higher cortisol levels could impair learning, and the infants irritability could impair the formation of a strong parental bond with the infant. This toxic stress framework is powerful, because it taps into a rich and increasingly sophisticated literature describing how early childhood experiences are biologically embedded and influence developmental outcomes across the life course.1214 This was the focus of the original technical report on toxic stress from the American Academy of Pediatrics (AAP) in 2012.2 Current threats to child well-being and long-term health, such as widening economic inequities, deeply embedded structural racism, the separation of immigrant children from their parents, and a socially isolating global pandemic, make the toxic stress framework as relevant as ever. In order to develop normally, a child requires progressively more complex joint activity with one or more adults who have an irrational emotional relationship with the child. Copyright American Academy of Pediatrics. Provide longitudinal experiences that train residents on how to develop strong, trusted, respectful, and supportive relationships with parents and caregivers. Second, it applies this EBD framework to better understand the complex relationships among adverse childhood circum-stances, toxic stress, brain architec-ture, and poor physical and mental health well into . 3. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Pediatrics August 2021; 148 (2): e2021052582. The buffering and skill-building roles of responsive relationships are biologically embedded, and they are essential promoters of healthy development.59 Existing AAP reports on managing perinatal depression,90 supporting grieving children,195 fostering male caregiver engagement,196 partnering with home visiting programs,142 encouraging developmentally appropriate play,74,197 discouraging screen time,125 and promoting shared-book reading67,68 include additional recommendations on ways primary care pediatricians might promote SSNRs. Promoting a public health approach that not only prevents, mitigates, and treats toxic stress but, more importantly, proactively promotes, reduces barriers to, and repairs relational health (the capacity to develop and maintain SSNRs with others). Colocate counseling services (warm handoffs); facilitate, track, and follow-up on referrals offered. Thats number one. Provide or support positive parenting classes; participate in ROR, VIP, and other programs that support the dyad. Social dominance, school bullying, and child health: what are our ethical obligations to the very young? Encourage them to become leaders in interdisciplinary early childhood systems work and vocal advocates for public policies that promote positive relational experiences in safe, stable, and nurturing families and communities. Dara's parents both work for a corporation that expects them to work for 50 hours a week. Conceptualizing and operationalizing environmental chaos The first is that pediatric providers will have the financial supports needed to expand their capacity for developing respectful, continuous, trusted, and nurturing relationships with both the patients and caregivers of the patients who they serve. (2) Challenge to Dominant Ideology: CRT challenges the claims of neutrality, objectivity, colorblindness, and meritocracy in society. Toxic stress explains how many of our societys most intractable problems (disparities in health, education, and economic stability) are rooted in our shared biology but divergent experiences and opportunities. The coronavirus pandemic has highlighted the urgent need to provide all children with the SSNRs that buffer unexpected adversities and build the skills necessary to be resilient. Relational health refers to the capacity to develop and sustain SSNRs, which in turn prevent the extreme or prolonged activation of the bodys stress response systems. Toxic stress refers to the biological processes that occur after the extreme or prolonged activation of the bodys stress response systems in the absence of SSNRs. Taken together, these diverse lines of inquiry suggest that it may not actually be the wide spectrum of childhood adversity that drives poor outcomes but the degree to which that adversity drives shame, guilt, anger, alienation, disenfranchisement, and degree of social isolation.181,182 If so, the proposed public health approach toward the promotion of SSNRs is needed, not only to buffer adversity and promote resilience but also to begin bridging political, religious, economic, geographic, identity-based, and ideological divides that increase social isolation, encourage tribalism, diminish empathy, and, ultimately, drive poor outcomes in the medical, educational, social service, and justice systems. Tertiary preventions in the toxic stress framework are focused on the evidence-based practices that treat toxic stress-related morbidities such as anxiety, depression, oppositional defiant disorder, posttraumatic stress disorder, and substance abuse disorder. It calls for pediatricians to serve as both front-line guardians of healthy child development and strategically positioned, community leaders to inform new science-based strategies that build strong foundations for . That said, the toxic stress framework is a problem-focused model because it is focused on what happens biologically in the absence of mitigating social and emotional buffers. These techniques come from family therapy, cognitive therapy, motivational interviewing, family engagement, family-focused pediatrics, and solution-focused therapy. Changing community contexts will require healthy, trusting, and robust partnerships with a wide array of local community partners from multiple sectors (education, social services, and businesses), not only to facilitate family access to the requisite community interventions but also to coordinate effective advocacy campaigns to secure both those interventions and family-friendly public policies. Tertiary preventions in the relational health framework are focused on the evidence-based practices such as ABC, CPP, or PCIT that repair strained relationships and assist them in becoming more safe, stable, and nurturing. In the absence of SSNRs, many different forms of childhood adversity (from catastrophic episodes of abuse or violence to chronic conditions, such as exposure to racism, poverty, and/or neglect) can lead to toxic stress responses that result in changes at the molecular, cellular, and behavioral levels and negatively impact outcomes in health, education, and economic productivity. Embrace restorative justice and social inclusion (over punitive measures and exclusion). The Healthy Outcomes From Positive Experiences framework promotes relational health through positive childhood experiences, such as being in nurturing, supportive relationships; living, developing, playing, and learning in safe, stable, protective, and equitable environments; having opportunities for constructive social engagement and connectedness; and learning social and emotional competencies.126,127. Educate residents about the many different facets of a fractured early childhood system of care (eg, Medicaid, Individuals with Disabilities Education Act Parts C and B, Child Care and Development Block Grants, Head Start, etc), as there is little collaboration or communication between the systems, funders, and programs that address child health, out-of-home child care, education, special education, protective services, or public health. For example, the AAP currently recommends screening parents for postpartum depression90 and food insecurity.87,88 Similarly, when clinical markers for an individual childs biological sensitivity to context9194 (see the Appendix for a glossary of terms, concepts, and abbreviations) are available, children of high (versus low) sensitivity may also benefit from different types of interventions.95 In concordance with a layered public health approach, these various targeted interventions will supplement but not replace the universal primary preventions. This has important implications for how we nurture and fulfill the potential of all children, not just those who are relatively less sensitive to their contexts and appear to be relatively more resilient despite adversity. According to studies, how a human brain is structured shares connections to various subsequent behaviors. Of the 3 principles, this is the one that aligns most clearly with the core functions of the FCPMH and is, therefore, the primary focus of this policy statement. Similarly, symptomatic children need to be referred to evidence-based treatment programs (eg, ABC, PCIT, CPP, TF-CBT), but these are supplemental to and do not replace either targeted interventions for potential barriers to SSNRs or the aforementioned universal primary preventions. Children with known adversity but no overt symptoms,18 children with parents who experienced significant adversity as a child,86 and families struggling with the social determinants of health (SDoHs) (eg, poverty leading to food or housing insecurity,87,88 language barriers, or acculturation leading to conflicts within immigrant families89) may benefit from an array of interventions that mitigate specific risk factors. Identify and address potential barriers to SSNRs. The strongest factor determining how involved a father is in nurturing and providing physical care, cognitive activities and warmth with an infant is: how important he feels his contribution is Nick's (15 months old) parents often didn't respond when he tried to communicate to them. Although intensive, capacity-building efforts for parents and other caregivers with limited executive function skills is beyond the scope of most pediatric settings, providing information and support around basic child-rearing practices and establishing daily routines is a cornerstone of traditional primary care. By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Other common-factors techniques target feelings of anger, ambivalence, and hopelessness, family conflicts, and barriers to behavior change and help seeking. 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The Ecobiodevelopmental Model of Health. Eco-biodevelopmental models are advocated by the American Academy of Pediatrics, and these models offer insights into the neurobiological processes associated with environmental factors and the ways in which these processes may be addressed to improve outcomes. In doing so, FCPMHs become the anchor for medical neighborhoods,149 in which community resources across multiple sectors (eg, health, education, justice, social services, faith communities, and businesses) collaborate not only to address barriers to SSNRs (such as home visiting programs,142 HealthySteps,150,151 medical-legal partnerships,147 coordinated responses to disasters,152,153 and efforts to promote access to healthy foods, safe housing, potable water, and clean air) but also to advocate for public policies (such as paid parental leave,154,155 income support,87,88 restorative justice,156158 and implementation of the Family First Prevention Services Act) that intentionally and actively foster SSNRs (Table 2).149,159161, Implementing a Public Health Approach to Relational Health Will Require Changes at the Provider, Practice, and Community Levels, as Well as Horizontal Integration Across Sectors. Research done by author Mary Eberstadt shows that the sexual revolution was a Pandora's Box, unleashing many of the ills . Bronfenbrenner's ecological theory of development. Typically, restorative justice allows the victims and the offenders to mediate a restitution agreement that is satisfactory to both parties. But underlying this approach are 2 fundamental assumptions. A public health approach to promoting relational health should also be integrated horizontally (or across sectors) at the local level.81,82,148 SSNRs are easier to form when safe, stable, and nurturing families are able to live in safe, stable, and nurturing communities.124,149,150 The FCPMH is ideally placed to educate families about what a safe, stable, and nurturing family environment looks like for a child, but doing so will require changes at the provider and practice levels (see Table 2). But something happened that few predicted. To promote SSNRs at the practice level, both financial incentives (eg, payment reforms) and enhanced training needs to be provided.162,163 Pediatric providers should be afforded the following: (1) sufficient time with patients and families, (2) the benefit of long-term continuity with patients and families, and (3) opportunities to learn about and practice the interpersonal and communication skills needed to form respectful, trusted, and collaborative therapeutic relationships.162 For parents to trust, pediatric providers need to listen and understand parental concerns and beliefs before making recommendations. An important consideration across many harmed and exploited communities (such as American Indian or Alaska Native populations) is the accumulation of toxic stress responses across generations, sometimes referred to as historical trauma.60 Although higher levels of historical trauma are associated with poorer health outcomes, the science underlying these associations is only now being studied rigorously.61 A detailed discussion of historical trauma and the special needs of these communities is beyond the scope of this policy statement, but the layered, integrated public health approaches presented here to prevent childhood toxic stress and promote relational health might inform efforts to address historical trauma as well. 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