Once again, the American Academy of Pediatrics is demonstrating its clinical leadership. Two recent, groundbreaking reports -- "The Lifelong Effects of Early Childhood Adversity and Toxic Stress" and "Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health" -- by the Academy boldly declare what has been known but too hidden from sight: Namely, that brain and emotional development is profoundly disrupted by childhood adversity and trauma.
The pediatric academy quotes Frederick Douglass who said "It is easier to build strong children than to repair broken men."
Toxic stress, or early environmental trauma, has been proven to disrupt normal brain development and trigger genetically predisposed diseases. The tragic results include impairments in the ability to regulate emotions and learn, to adapt socially with others and produce, in adolescence and adulthood, lifelong physical and mental disorders, including heart disease, asthma, arthritis, obesity, diabetes, cancer, depression, substance abuse and PTSD. Trouble staying and succeeding in school are also common, as are brushes with the law.
Adverse Childhood Events, or ACEs, were initially studied by Kaiser Health of Southern California and then by the World Health Organization (WHO) World Mental Health Survey Initiative. ACEs include:
1. Direct psychological abuse
2. Direct sexual abuse
3. Direct physical abuse
4. Substance abuse in household
5. Mental illness in household
6. Mother treated violently
7. Criminal behavior in household
The greater the number of ACEs, the greater the risk of developing a chronic disease,
or multiple chronic diseases. From post traumatic disorder research we know the greater the
severity and frequency of the trauma the more like it will burn itself into the brains neural circuitry.
The mechanisms by which early childhood adversity lays its toxic roots are numerous and complex. The manifestations are as specific as youth engaging in impulsive and dangerous behaviors (well beyond normal adolescent risk taking), including reckless (and drunk) driving and unprotected sexual behaviors, which can result in sexually transmitted diseases and teenage pregnancies. The mechanisms are as fundamental as the unregulated and ongoing release of stress hormones, including cortisol and adrenaline, which weaken body defenses (compromising the immune system's ability to protect from infection and cancer or to turn our immune systems against us in the form of autoimmune diseases), raise blood pressure, promote plaque formation in arteries, and are linked, neurologically, to depressive and post-traumatic stress illnesses.
The specialty of pediatrics was first to develop "medical homes" (popularized today with federal enabling legislation) designed initially for the young with serious and chronic illnesses whose proper care needs to be monitored and clinically managed by one responsible (accountable) doctor and clinic. Pediatricians have long used screening tools to track childhood development and more recently many have introduced depression screening (and treatment paths) as basic tenets of good care. Their declaration, through these recent reports, of the impact of childhood trauma is a rallying call for what heretofore was another example of "don't ask, don't tell."
There are many proven approaches to these problems. Among them are:
- Home visits by nurses to mothers identified as being at high risk for emotional problems (e.g., Dr. David Olds' Nurse Home Visiting Program)
- Primary care screening and early intervention for depression in moms
- Pediatric screening and early intervention for depression and addictive disorders in youth
- Parental skills training programs (e.g., Positive Parenting, The Incredible Years, Bright Futures, About Our Kids)
- Youth support programs (e.g., Big Sister, Big Brother, after school programs)
- Pediatric medical homes that holistically support child development and deliver health, mental health and wellness services
- Trauma-focused mental health programs (for youth already affected)
The health of our youth, today and into their futures, can be protected. We can prevent the diseases and disabilities that result from childhood adversity and trauma. State and national budgets can be protected from decades of preventable health, correctional and social welfare expenditures. By following the wise counsel of the American Academy of Pediatrics, and other professional and policy groups, early experience need not be destiny for countless children, their families and their communities.
Committee on Psychosocial Aspects of Child and Family Health, Committee on
Early Childhood, Adoption, and Dependent Care, and Section on Developmental and
Behavioral Pediatrics, Garner AS, Shonkoff JP, Siegel BS, Dobbins MI, Earls MF,
Garner AS, McGuinn L, Pascoe J, Wood DL: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health.
Pediatrics. 2012 Jan;129(1):e224-31. Epub 2011 Dec 26. PubMed PMID: 22201148.
Shonkoff JP, Garner AS, Siegel BS, Dobbins MI, Earls MF, Garner AS, McGuinn L, Pascoe J, Wood DL. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. 2012 Jan;129(1):e232-e246. Epub 2011 Dec 26. PubMed PMID: 22201156.
Association of Childhood Adversities and Early-Onset Mental Disorders With Adult-Onset
Chronic Physical Conditions: Scott,KM, Korff, M, ScD; Angermeyer,MC Benjet,C, Bruffaerts,R, de Girolamo,G, Haro, JM, Le´pine,J-P, Ormel, J, Posada-Villa, J, Tachimori, H, Kessler, RC, Archives of General Psychiatry Volume 68, August 2011
Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report, Volume 59, December 17, 2010.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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