ecobiodevelopmental theory asserts that:

An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. 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. Adapted with permission from Garner AS, Saul RA. 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. 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. Trainees need to understand all of these many facets so they are prepared to be effective advocates for their patients and families. Conceptualizing and operationalizing environmental chaos Periods of Development 1. In short, a public health approach to prevent childhood toxic stress is a public health approach to promote relational health. The common factors are communication skills that help to build a therapeutic alliance (the bond felt between the clinician and patient and/or family, a powerful factor in facilitating emotional and psychological healing), which, in turn, increases the patient and/or familys optimism, feelings of well-being, and willingness to work toward improved health. A Comparison of the Toxic Stress and Relational Health Frameworks. Many studies show significant correlations between early neglect and later social, emotional and behavioural difficulties, Life Course Theory. Relational health explains how the individual, family, and community capacities that support the development and maintenance of SSNRs also buffer adversity and build resilience across the life course. Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. Doing so will require all trainees to address their implicit biases, develop cultural humility, and provide culturally competent recommendations. Bronfenbrenner's ecological theory of development. Bronfenbrenner's theory explains that there are certain cultural and social factors in the immediate environment of a child affect child development and experience. 2. 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. 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 . Be it child labor laws, federal grants to states to promote maternal-child health, support for paid parental leave after childbirth, required immunizations to attend school, the use of car safety seats, the adoption of children by same-sex parents, the harms of corporal punishment, the safe storage of firearms, the care of immigrant children in federal custody, the negative effect of toxins and global warming on child health, or the importance of nutrition and income support for healthy families, pediatric professionals have been a powerful force for bringing a scientifically grounded, evidence-based perspective to public debates. Symbolic interactionism theory asserts that society is composed of symbols and can be understood and analyzed by addressing the subjective meanings that people attach to objects, events, and behaviors that they consider as symbols. 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. Reaffirming an ecobiodevelopmental framework2 because early childhood experiences, both adverse and nurturing, are biologically embedded and influence the development of both disease and wellness later in life. Transactional Theory 2. FCPMHs could work to reduce these barriers by partnering with their AAP chapter, local organizations (such as schools, businesses, and faith-based organizations), and other community assets (including parents, extended family, child care providers, community health workers, and patients) to form medical neighborhoods149,159,161 that work collaboratively to address the SDoHs while also advocating for policies that support safe, stable, and nurturing families and communities. The term toxic stress refers to a wide array of biological changes that occur at the molecular, cellular, and behavioral levels when there is prolonged or significant adversity in the absence of mitigating social-emotional buffers.2 Whether those adversity-induced changes are considered adaptive and health-promoting or maladaptive and toxic depends on the context. Research done by author Mary Eberstadt shows that the sexual revolution was a Pandora's Box, unleashing many of the ills . Ecobiodevelopmental theory asserts that: early experiences create the structure of the brain. But underlying this approach are 2 fundamental assumptions. FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. A multigenerational perspective is fundamental. apartments for rent on north avenue. See the Appendix for full descriptions of the abbreviations. Rather, an integrated public health approach (see Fig 1) is needed to support all children, including those with delays in development and special health care needs.8082 The foundation for any public health approach is universal primary prevention. 11, The Timing and Quality of Early Experiences Combine to Shape Brain Architecture. Both genetic and epigenetic factors interact with. Three indicators of flourishing are amenable to parental report and are rough markers of executive function: (1) the child shows interest and curiosity in learning new things, (2) the child works to finish tasks he or she starts, and (3) the child stays calm and in control when faced with a challenge.59 In analyses of data from the 20162017 National Survey of Childrens Health, the prevalence of flourishing children increased in a graded fashion with increasing levels of family resilience and connection.59 In fact, a higher percentage of children with high adversity (ACE scores 49) but high family connection and resilience were flourishing (30.5%) than children with low adversity (ACE score of 0) but low family resilience and connection (26.8%).59 Approaches to minimizing toxic stress that only look at measures of adversity (such as ACE scores or biomarkers) will miss out on opportunities to support the relational health that promotes flourishing despite adversity. Acronym for safe, stable, and nurturing relationships; these allow the child to feel protected, connected, and competent. The HMG Model System Model, Healthy Steps: a case study of innovation in pediatric practice, HealthySteps: transforming the promise of pediatric care, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, Ensuring the health of children in disasters, DISASTER PREPAREDNESS ADVISORY COUNCIL AND COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, Providing psychosocial support to children and families in the aftermath of disasters and crises, Paid parental leave and family wellbeing in the sustainable development era, Time off to care for a sick child--why family-leave policies matter, Support for restorative justice in a sample of U.S. university students, A neighborhood-based approach to population health in the pediatric medical home, Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health, From medical home to health neighborhood: transforming the medical home into a community-based health neighborhood, Implementing a trauma-informed approach in pediatric health care networks, Cross-cultural interactions and shared decision-making, The relationship between physician humility, physician-patient communication, and patient health, The impact of racism on child and adolescent health, Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: challenges, solutions, and future directions for provider communication training, Implicit bias: what every pediatrician should know about the effect of bias on health and future directions, Tackling implicit and explicit bias through objective structured teaching exercises for faculty, A systematic review of the impact of physician implicit racial bias on clinical decision making, Comparison of physician implicit racial bias toward adults versus children, Translating developmental science to address childhood adversity, Social: Why Our Brains Are Wired to Connect, The Spirit Level: Why Greater Equality Makes Societies Stronger, Bowling Alone: the Collapse and Revival of American Community, The Crisis of Connection: Roots, Consequences, and Solutions, Social isolation: a predictor of mortality comparable to traditional clinical risk factors, Social deprivation and the HPA axis in early development, Prolonged institutional rearing is associated with atypically large amygdala volume and difficulties in emotion regulation, Subjective social status and inflammatory gene expression, The potential protective effect of friendship on the association between childhood adversity and psychological distress in adulthood: a retrospective, preliminary, three-wave population-based study, The Relationship between social cohesion and urban green space: an avenue for health promotion, Exposure to natural space, sense of community belonging, and adverse mental health outcomes across an urban region, Sigmund Freud Collection (Library of Congress). Early childhood behavioral health: can the medical neighborhood move us forward? 5, Attachment and the regulation of the right brain, The adaptive human parental brain: implications for childrens social development, Two Open Windows: Infant and Parent Neurobiological Change, The neurobiology of mammalian parenting and the biosocial context of human caregiving, Positive childhood experiences and adult mental and relational health in a statewide sample: associations across adverse childhood experiences levels, Childhood adversity and parent perceptions of child resilience, A systematic review of amenable resilience factors that moderate and/or mediate the relationship between childhood adversity and mental health in young people, A new framework for addressing adverse childhood and community experiences: the building community resilience model, Responding to ACEs with HOPE: Health Outcomes From Positive Experiences, Balancing Adverse Childhood Experiences with HOPE: New Insights Into the Role of Positive Experience on Child And Family Development, Sit down and play: a preventive primary care-based program to enhance parenting practices, Books and reading: evidence-based standard of care whose time has come, Effectiveness of a primary care intervention to support reading aloud: a multicenter evaluation, Differential susceptibility to the environment: toward an understanding of sensitivity to developmental experiences and context, Stress and the development of self-regulation in context, Biological sensitivity to context: II. In the past decade or so, biomedical researchers have proposed an ecobiodevelopmental framework for studying health and disease across the life course . Integrated behavioral health services as part of the FCPMH team might be the next layer for parents who need additional assistance (eg, parental depression), and the need for more intensive skill building (eg, PCIT) for some parents becomes yet another focus for collaboration with key services within the community (eg, ABC, PCIT, CPP, and TF-CBT). For example, significant adversity in the last trimester of pregnancy is associated with methylation of the childs glucocorticoid receptor gene.76 In adults, the methylation of this gene is associated with the expression of fewer glucocorticoid receptors in the brain.5 Because cortisol downregulates its own production via negative feedback loops in the brain that use glucocorticoid receptors, children with fewer glucocorticoid receptors would be expected to have higher cortisol levels and be more irritable and harder to console.77 These changes could be considered adaptive and beneficial in the short-term because they might prepare the newborn infant for a stressful world in which the infant may need to be more vocal to have his or her needs met. trauma-focused cognitive-behavioral therapy. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. Someones got to be crazy about that kid. Provide or support positive parenting classes; participate in ROR, VIP, and other programs that support the dyad. The commitment of the AAP to the well-being of all children requires that it not only address a wide spectrum of adversities but, also, that it speak against public policies, social constructs, and societal norms that perpetuate the ongoing, chronic precipitants of toxic stress responses such as poverty87,88 and racism166 and for public policies that promote relational health, inclusion, and equity.111,188191. These are just a few examples of the many philosophical perspectives that exist on the analysis of society. 3, Early childhood social disadvantage is associated with poor health behaviours in adulthood, Beyond residential mobility: A broader conceptualization of instability and its impact on victimization risk among children, Adversity and children experiencing family homelessness: implications for health, The association between familial homelessness, aggression, and victimization among children, Links between childhood exposure to violent contexts and risky adolescent health behaviors, Community violence exposure in early adolescence: longitudinal associations with hippocampal and amygdala volume and resting state connectivity, Associations of neighborhood disorganization and maternal spanking with childrens aggression: a fixed-effects regression analysis, Community-level adverse experiences and emotional regulation in children and adolescents, Factors that influence trajectories of delinquency throughout adolescence, Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population, Bullying victimization in childhood predicts inflammation and obesity at mid-life: a five-decade birth cohort study. Contact your SAGE representative to request a demo. Just another site. 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. Feminist theory asserts that gender is a social construct and that the unequal treatment of women is a result of patriarchal norms and values. culturally effective: the family and child's culture, language, beliefs, and traditions are recognized, valued, and respected. Many of the components of a public health approach to prevent, mitigate, and treat toxic stress responses (see examples) are also components of a public health approach to promote, identify barriers to, and repair SSNRs. To usher in these fundamental reforms, more pediatricians will need to assume leadership positions outside the realm of clinical care.202,203 In addition, pediatric training programs will need to educate residents about the ecobiodevelopmental model, train them on how to develop strong therapeutic relationships with parents and caregivers, teach them how to model nurturing and affirming interactions with children of all ages, train them how to encourage caregivers to have positive relational experiences with children of all ages, prepare them to work as part of interdisciplinary teams144,150 (eg, integrated with behavioral health and social service professionals), educate them on how to develop collaborative partnerships with community referral resources, and encourage them to become vocal advocates for public policies that promote safe, stable, and nurturing families and communities. The examples provided are illustrative and not intended to be comprehensive or exhaustive. Traumatic and stressful events in early childhood: can treatment help those at highest risk? 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. Dara's parents both work for a corporation that expects them to work for 50 hours a week. Simply put, successfully implementing a public health approach that prevents childhood toxic stress and promotes SSNRs will require FCPMHs to put relational health at the center of everything they do.172, There is an emerging evidence base that social isolation is on the rise and detrimental to both individual173 and community health.174 Social scientists have documented the fragmentation of society at the community level175 as well as its negative impact on how communities view their collective stewardship of their most treasured resource: their children.176 Psychologists have decried a crisis of connection and point to a culture that values the self over relationships and individual successes over the general welfare, leading to declining levels of empathy and trust.177 Epidemiologists have demonstrated that an individuals degree of social isolation is a powerful predictor of mortality, much like traditional clinical risk factors (eg, obesity or hypertension) or ACE scores.178 Both epidemiologists and economists have pointed to increasing levels of inequity as correlating with poorer levels of overall health for both the impoverished and the wealthy.174 Finally, physiologists have long known that social deprivation in childhood alters the programming of the bodys stress response.179,180. Neurology also plays a role in the biological perspective of psychology. The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner. These perspectives offer different interpretations of the nature of society and the role of . 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 . The ecobiodevelopmental model suggests that, to improve the likelihood of positive developmental outcomes across the life span, efforts should be made to improve the salient features of the childs environment. Although this term is frequently used to refer to the childs experiences (child ACEs), it has also been applied to the adversities that parents experienced during their own childhoods (parental ACEs). Extends the concept of the FCPMH into the local community; in a medical neighborhood, the FCPMH or health system anchors and supports cross-sector efforts to address family needs (eg, the SDoH), promote population level wellness, and collectively advocate for needed funding and policy changes. Typically, restorative justice allows the victims and the offenders to mediate a restitution agreement that is satisfactory to both parties. Primary preventions in the toxic stress framework are focused on how to prevent the wide array of adversities that might precipitate a toxic stress response. An integrated, biodevelopmental framework is offered to promote greater understanding of the antecedents and causal pathways that lead to disparities in health, learning, and behavior in order to inform the development of enhanced theories of change to drive innovation in policies and programs. Pediatrics August 2021; 148 (2): e2021052582. Part 1 - Overview of Developmental Domains, Periods, and Theories a. Domains of Development b. See the Appendix for full descriptions of the abbreviations. Embrace an ecobiodevelopmental model for understanding how both adverse and positive relational experiences in childhood become biologically embedded and impact both negative and positive outcomes across the life course. Based on the EBD model, The Ecobiodevelopmental Theory model of toxic stress experiences provoke these memories, Shonkoff is associated directly to other theoretical which are essentially created by interactions models of human development. 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. 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