Ask the question to all women and men who suffer from Chronic Fatigue Syndrome, Fibromyalgia, and chronic pain about their childhood. How much do you want to bet these disorders/diseases/syndromes are directly related to your topic.

It is frustrating that regulations and restrictions are changing so drastically in the social services venue that abuse is potentially being overlooked MORE frequently due these changes. Shouldn't regulations become more stringent instead of less in order to identify cases of child abuse and neglect?

What can pediatricians and family service providers do to support parents in preventing toxic stress and building resilience with their children?

Mass incarceration, mostly of fathers and increasingly of mothers, means that pre-birth and post-birth a large % of children experience this stress - financial, emotional, physical -- on all family members. Incarceration of a parent appears to have an impact on children's outcomes -- independent of poverty, distressed neighborhoods, and schools. To what extent is parental incarceration relevant to this discussion of early childhood toxic stress? And is it being studied?

Moderate/toxic stress as a result of hospitalizations and medical procedures has to be addressed urgently in the developing world and even in many health facilities of industrialized countries. Child-friendly health care (i.e., safe-guarding of child rights; preparation for medical procedures, including teaching cognitive pain control techniques, medical and recreational play; the presence of significant others during hospitalization and procedures, etc.) are lacking in the developing world. Pain assessment and management is exceedingly poor. Health providers must address this form of stress -- it is not costly, we have evidence that this approach works and reduces stress and need for pain control in children.

(With the Johns Hopkins University Child Life Director, we have assessed the conditions in Serbian pediatric hospitals and developed a Child Life type training approach. Children and parents respond well, and the work of nurses becomes more satisfying).

EDITOR'S NOTE: "ECD" is an acronym for Early Childhood Development. "CEECIS" is an acronym for Central and Eastern Europe Commonwealth of Independent States

What is the research data on children exposed to violence AROUND them, i.e. children who live in areas plagued with a high incidence of gun violence?

What innovative strategies can we develop to help low-income parents head off the effects of some of the toxic stressors of poverty on their children. What is the role of parenting education programs like The Baby College of the Harlem Children's zone in prevention of this type, and how can we convince programs like Medicaid that it would be financially worthwhile to invest in this type of programming up front, rather than paying for the health and mental health costs down the line?

EDITOR'S NOTE: According to the website for the Harlem Children's Zone, The Baby College is a 9-week parenting workshop. See http://www.hcz.org/programs/early-childhood

What do you see as the role of child care in either helping to create the toxic stress in children or to help[ing] alleviate the toxic stress is children? It seems when we had less homes with dual working parents, there was not as much incidence of developmental, behavioral and social concerns with children. In relation to that, how can childcare providers assist in early intervention when the regulations handed down by the Dept. of Health and Human Services are dictating what can and cannot be done in their programs without, in many cases, really knowing any of the information relevant to program development and specifically to individual children. Do you see the strict guidelines put in place to protect children as sometimes preventing the deliverance of needed care and services to those children? Example: When a facility suggests screening for a child in their care, due to repeated observation of developmental delays, behavioral issues, etc. , a parent has the right to refuse the screening, thereby resulting in missed opportunity for early intervention. This is fully supported by Health and Human Services in some of it's rigid regulations regarding confidentiality and practices which allow for overlooking a child's developmental delays, behavioral issues as "developing at their own pace" or "being allowed to develop their own eating/sleeping habits, etc." Where is the line drawn in the distinction between a child "developing at his/her own pace" and recognizing delays which need to be addressed?

Do you know of pediatricians using the ACE [Adverse Childhood Experience] questionnaire or another screening tool to assess for adverse childhood experiences/toxic stress? If yes, who , what tool, how?

Are there models in medicine, faith communities or elsewhere that enable healthy living among vulnerable populations despite environmental risks?

Do children of undocumented immigrants experience specific stressors related to the immigration status of their parents? What are possible impacts of these stressors on health and development?

FORUM WEB EDITOR
QUESTION FROM ONLINE AUDIENCE MEMBER

I am very pleased to see the AAP [American Academy of Pediatrics] issue a significant paper on the effects of early childhood trauma and toxic stress. However, I was a little surprised by the apparent implications that pediatricians should necessarily be front and center in the effort to look at this serious public health issue. Clearly, pediatricians, and, ideally, medical homes, have a significant role to play; however, so do community-based agencies (many of whom have been providing home-based services for decades), early childhood providers, mental health professionals, politicians, policy makers, the entertainment industry (to stop the glorification of violence) and many others. If any issue needs a truly collegial, team-approach, it is this.

Nick Claxton, Children with Special Health Care Needs, Philadelphia Department of Public Health

EDITOR'S NOTE: The AAP "defines the medical home as a model of care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective and is the source of primary care." See http://www.healthychildren.org/English/news/Pages/Medical-Home-Offers-Benefits-for-Children-without-Special-Needs-.aspx

Why are the doctors, teachers and nurses unable to identify those children who have suffered abuse and neglect? Do they not understand depression, sadness and dissociation? What is a community's role if observations [have been made] that a child may be suffering from abuse and neglect at home. It's easier for a community to live in denial. However, there could also be fear and a lack of knowledge of how to address this situation that is amenable to all parties involved if there is fear in coming forward once an observation has made about the lack of a child's well-being. How could that person be protected from harm themselves?

I am interested in the unique stressors experienced by children raised by elderly grandparents, particularly those in poor health.

Can a child's innate resiliency protect against toxic stress?

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Better than not doing anything at all to support babies and families, early intervention and identification is great; what about a prevention model where pediatricians (and the healthcare providers that they are associated,) are in the community raising awareness and providing education on raising kids? What are some exemplar communities (both private and public) who are making changes to health and education policies so that they are doing all three: early intervention and identification and a focus on prevention?

Minh-Trang Do, Vancouver, WA

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With an increase in prevalence in axis II personality disorders......Is the risk of being raised by a parent with a personality disorder being addressed/recognized AND is this likely, in turn, to result in a child at greater risk for developing a personality disorder?

Angela Wagner

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How will pediatricians deal with the cultural diversity they will have to face while trying to focus on the external threats?

Leila Rosario, Department of Health Policy and Management, Harvard School of Public Health

There are obvious faults with the claim, "The woman is biologically programmed to give birth to and care for children..."

Experiments on primates by Harry Harlow (1970's) showed that female monkeys raised in isolaton were unable to adequately care for their own inflants, being either neglectful or abusive: http://muskingum.edu/~psych/psycweb/history/harlow.htm

Education is key. I'm convinced if mothers-to-be understood that the success of their mothering depends upon their having supportive family and friends, there would be less neglect and abuse.

I recall short Canadian commercials that were aired a number of years ago (I think they were government sponsored): "The Zap (I think!) Family". The idea behind these brief and very cute commercials was "proper parenting" and it showed (in different scenarios:the baby was crying and it showed the proper response to calm the child). As a parent myself those commercials reminded me about being a good parent and I know they had a great impact on others too. Surprisingly they were discontinued but I thought they were a brilliant idea.

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I appreciate that the cause of the stress does not matter; however, it seems important to understand the variety of experiences that could create toxic stress. I hope you will speak for a moment to the possibility of parental mental illness contributing to toxic stress, and how this impact might be mediated by others, including pediatricians, involved in the life of the child. Thank you.

Melissa Hidek

1, Your webinar included emphasis on universal screening for social-emotional delay. Are you aware of any existing screening tools that could identify sources of toxic stress for children/families during the pregnancy and infancy stages--before the child becomes delayed/impacted?

2. We are a public health agency exploring ways to utilize this information in our work. Do you have additional recommendations on public health approaches to buffering toxic stress? Some of our goals are: a) local health care providers will recognize the role of Adverse Childhood Experiences (ACES) and/or toxic stress, as a primary determinant of health and social well-being in families; b) implement evidence-based screening tools to identify substance-abuse, perinatal mood disorder, and intimate partner violence, c) strengthen assessment, referral, and case management systems, d) implement parenting programs to improve parents ability to recognize and attend to the needs of their children, including buffering toxic stress.

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Thanks for an interesting forum -- here in New Zealand we had a news release today regarding the stress levels of children in early childcare centres -- which increases over the course of a day. I am interested in the introduction of low-cost, low-risk interventions to reduce stress, such as massage. Has such an approach been considered?

Sharon Erdrich, Department of Nursing, Unitec New Zealand

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Does the phrase toxic stress sound too tame and soft? How can advocates and scientists make clear that this is about an accumulation of severe experiences some children are exposed to in homes where there is frequent violence, mental illness, substance abuse, frequent moves or instability or unsafe communities including those in war zones?

Maria Brown, Vice President of Programs, Virginia Early Childhood Foundation

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What states are changing the conversation?

Irene Surmik, Pittsburgh Child Guidance Foundation

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Is there any research being done on limbic brain health? As a twenty-year youth protection and corrections employee in Denver, limbic therapy is the only effective therapy I've seen.

Kellie Rhodes, Trainer/ Consultant, Limbic Legacy

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During our live chat, a number of participants posted links to resources. Here is a sampling:

3 Videos from Harvard Center on Developing Child
http://bit.ly/oVA46g
http://bit.ly/pz3pdP
http://bit.ly/rnECVR

AAP Children's Mental Health in Primary Care
http://www2.aap.org/commpeds/dochs/mentalhealth/

2012 National Smart Start Conference
http://www.smartstart.org/conference/

NAPNAP Position Statement on the PNP's Role in Supporting Infant and Family Well-Being During the First Year of Life
http://download.journals.elsevierhealth.com/pdfs/journals/0891-5245/PIIS0891524510003159.pdf

Research Connections
http://researchconnections.webs.com/theconsequences.htm

Project Echo
http://echo.unm.edu/

Im wondering if the forum wants to share any information on epigenetics or biological sensitivities in regards to toxic stress. I recently attended the National Zero to Three Institute where I think every presenter mentioned 'Orchid Child ' as compared to the 'dandelion child' within the context of exploring risk and adversity in young children. Any insights would be appreciated. Thank you for a wonderful forum!

Christine Belinda
Early Learning Program Specialist
Penn State Better Kid Care Program

Re: Christine Belinda - Epigenetics & Toxic Stress

Excellent BBC video on this topic:

The Ghost In Your Genes
http://bit.ly/tzDrWA

I think family education and prevention is a better investment than trying to just create programs for children. There needs to be programs to boost parental confidence by teaching them how to be a parent and fitness programs to help improve parent's abilities to be good responsive parents by being healthy. By being able to be healthy, parents can be healthier parents. If a child has toxic stress there are probably family health issues as well . I really think if there is more of a community-approach to health care like the YMCA, and public health, and places of worship it really helps to mitigate some of the problems and provides support to children and families alike. If parents don't have medical insurance, have chronic diseases, and are responsible for raising a couple kids while working full-time, doesn't that add to the toxic stress because the parent is stressed out and physically taxed to the max? So the whole family needs social support, creative outlets, physical activities, and healthy food. Not everyone even has access to health care or adequate food. There should be less money spent on the areas that aren't as effective, and more money spent on what really works and helps the most people.

I am fascinated by this discussion and the varied perspectives made by the people writing in with comments and this will be informing the work that our program does with young parents. I am particularly interested in the discussion of the eco-bio-developmental model as it might relate to programs like Healthy Families, Young Parents Support Programs, et cetera where outreach into homes and communities is one aspect and modality for the work (in addition to linking people to identified services, groups, supports, et cetera). Finding evidence-based ways to partner with children, their young parents, and communities early in development (in their real situations) often allows for a more "real and effective engagement" to happen and produces healthier outcomes, but it feels sometimes like our systems for the poor instantiate alienation and often don't build capacity. I am also reminded of Vygotskian Theory (zones of proximal development; scaffolding development) as it might relate to thinking about parallel processes with adolescent parents (and their developing brains) and their children in "high risk" populations. After working for many years with adults in prisons, in family shelters for the homeless, in adolescent facilities, and in early childhood and parenting programs, I think that we must always be thinking about the parent as being in a parallel process with his/her child's development and that resilience for both must be in our minds as we work. This necessitates a great deal of nuance in the work as intergenerational issues related to toxic stress and development are at play with an incredible degree of complexity in many cases. I would be interested to know more from these researchers related to studies of toxic stress, young parents, brain development and the children of these young parents in high risk communities and effective ways forward when we partner with these families.

In Illinois, we have been serving children and their families following exposure to violence for over 10 years through the Safe From the Start project. With over 3000 participating children, we've found that while children exposed to domestic violence, family substance abuse, and family mental illness show much greater deficits in functioning than children exposed to domestic violence without family mental illness or substance abuse, kids in both types of families improve at the same rate in response to family-based Safe From the Start Services.

Thank you for sharing this remarkably informative discussion about an important and urgent topic. While the focus on the earliest months and years is clearly warranted by the science, I'm also curious about work with older children, in the 7-12 year range. Shonkoff remarked that the most important thing is for the child to sense that she/he is safe and protected. With older children who are highly aware of the dangers and stressors around them even while they are not directly experiencing them, this may require even more work on the part of organizations and individuals seeking to support their resilience.

I work with Palestinian refugee children through Tomorrow's Youth Organization in Nablus. Many of our children suffer from a number of severe stressors at home (including poverty, war, domestic violence, parents in prison, and parents who are young and poorly prepared). The question is, while their home lives are still traumatizing, how much time do those children need to spend away from that toxic environment every day/week/year in order to face those stressors without a toxic response? Nonformal education opportunities give children a chance to explore and encounter their world in new, stress-free ways. But how can we ensure that the time they spend in those activities really prepares them to take on the traumatizing experiences they're sure to have?