A Biblioteca Virtual em Sade uma colecao de fontes de informacao cientfica e tcnica em sade organizada e armazenada em formato eletrnico nos pases da Regio Latino-Americana e do Caribe, acessveis de forma universal na Internet de modo compatvel com as bases internacionais. 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. Vulnerability theory recognizes that the human experience of constant vulnerability varies as a result of stages in the life-course, social institutions, and law, which often trace intersecting forms of oppression on the basis of race, gender, sexuality, disability, and class. According to studies, how a human brain is structured shares connections to various subsequent behaviors. Any conflicts have been resolved through a process approved by the Board of Directors. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. Bronfenbrenner's ecological theory of development. Doing so will require all health professionals to address their implicit biases, develop cultural humility, and provide culturally competent recommendations. In the past decade or so, biomedical researchers have proposed an ecobiodevelopmental framework for studying health and disease across the life course . 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. For younger children, these therapies may include attachment and biobehavioral catch-up (ABC),9698 parent-child interaction therapy (PCIT),99102 and child-parent psychotherapy (CPP).103105 For older children, trauma-focused cognitive-behavioral therapy (TF-CBT) may be beneficial.106,107 The effectiveness of these evidence-based therapies may be reduced if targeted interventions are not used to address emerging areas of risk or if universal primary preventions are not applied as well.59,108 A layered public health approach mirrors the concept of proportionate universalism (see the Appendix for a glossary of terms, concepts, and abbreviations), in which the delivery of universal services is at a scale and intensity that is proportionate to the degree of need.109112 For example, if access to healthy foods is a universal objective, a proportionate response would recognize that some families may only need education about which foods are healthy, whereas some may need education about healthy foods and additional financial resources to purchase those healthy foods, and still others may require education about healthy foods, additional financial resources, and access and/or transportation to stores that sell healthy foods. Traumatic and stressful events in early childhood: can treatment help those at highest risk? Transactional Theory 2. These are just a few examples of the many philosophical perspectives that exist on the analysis of society. The examples provided are illustrative and not intended to be comprehensive or exhaustive. The medical home recognizes the family as a constant in a child's life and emphasizes partnership between health care professionals and families (as per the National Resource Center for the Patient/Family-Centered Medical Home at the AAP). Foster strong, trusted, respectful, and supportive relationships with patients and their families to encourage the acceptance of individualized prevention, intervention, and treatment strategies. ancillary support services (interpretation, telemedicine, transportation, etc) enabling youth with special health care needs to access the many layers of support that they frequently require. Bioecological Systems Theory 3. 13, Thinking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health, Resilience to adversity and the early origins of disease, Emotional and behavioural resilience to multiple risk exposure in early life: the role of parenting, A Secure Base: Parent-Child Attachment and Healthy Human Development, Object relations, dependency, and attachment: a theoretical review of the infant-mother relationship, Touchpoints: Birth to 3: Your Childs Emotional and Behavioral Development, Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Relational health, in the form of at least one SSNR, is a universal, biological imperative for children to fulfill their potential; to be healthy and resilient; to be successful academically, economically, and socially; and, perhaps most importantly, to be the caregivers that value and build SSNRs with subsequent generations. Toxic stress responses are known to alter multiple systems that interact in a reciprocal and dynamic manner: genomic function, brain structure and connectivity, metabolism, neuroendocrine-immune function, the inflammatory cascade, and the microbiome.13,14 Toxic stress-induced alterations also influence the adoption of maladaptive coping behaviors decades later.3740. Individual variation in biological sensitivity to context (see the Appendix for a glossary of terms, concepts, and abbreviations) contributes to heterogeneity in both responses to adversity and responses to interventions. Identify and address sources of inequity, isolation, and social discord (poverty and racism). Overview of Lecture - Part 1. Secondary preventions in the toxic stress framework are focused on identifying individuals at high risk for poor outcomes resulting from toxic stress responses by using population-based risk factors (eg, ACE scores) or emerging biomarkers (eg, methylation patterns). 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. Typically, restorative justice allows the victims and the offenders to mediate a restitution agreement that is satisfactory to both parties. To prevent childhood toxic stress responses and support optimal development across the life span, the promotion of relational health needs to become an integral component of pediatric care and a primary objective for pediatric research and advocacy. intel director salary. Toxic stress explains how a wide range of ACEs become biologically embedded and alter life-course trajectories in a negative manner. The toxic stress and its impact on development in the Shonkoff's Ecobiodevelopmental Theorical approach. These additional interventions are supplemental to and do not replace universal primary preventions. They have been proven useful and effective in addressing mental health symptoms in pediatrics across the age spectrum (as per the AAP policy statement on mental health competencies in pediatric care). Realizing the full impact of these principles within primary care practice, however, will also require fundamental changes in medical education and payment models. 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. 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. Drs Garner and Yogman gratefully acknowledge the contributions of Dr Shonkoff to early drafts of this article. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Transactional theory emphasizes that: Infants/toddlers and their parents are constantly affecting each other. Changing all of the potentially salient features of a childs environment cannot be reduced to a single intervention or program, so there will be no singular panacea when it comes to addressing childhood toxic stress responses. Learning Objective: Describe the structure and function of genes. Copyright American Academy of Pediatrics. Bronfenbrenner's theory explains that there are certain cultural and social factors in the immediate environment of a child affect child development and experience. To move forward (to proactively build healthy, resilient children), the pediatric community needs to embrace the concept of relational health.15 Relational health refers to the ability to form and maintain SSNRs, as these are potent antidotes for childhood adversity and toxic stress responses.57,113 Not only do SSNRs buffer adversity and turn potentially toxic stress responses into tolerable or positive responses, but they are also the primary vehicle for building the foundational resilience skills that allow children to cope with future adversity in an adaptive, healthy manner.16,17 These findings highlight the need for multigenerational approaches that support parents and adults as they, in turn, provide the SSNRs that all children need to flourish. Build the therapeutic alliance; employ a common-factors approach; explain behavioral responses to stress; endorse referral resources. The ACE score is the sum of the 10 original categories of ACEs experienced before the 18th birthday. A vertically integrated public health approach acknowledges that universal primary preventions are absolutely necessary yet insufficient to promote relational health. 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. 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. 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. Ecobiodevelopmental theory asserts that: early experiences create the structure of the brain. The Ecobiodevelopmental Theory model of Shonkoff is associated directly to other theoretical models of human development. This emphasis on universal primary preventions is congruent with the fact that more children are mentally and socially well and flourish as adults, regardless of their level of childhood adversity, if they also are afforded positive relational experiences and high family resilience and connection during childhood.59,121 Relational health includes more than nurturing in its traditional, spoken sense (eg, verbal warmth or responsivity); it also includes the activities that support the relationship more broadly (eg, reading aloud and a prescription to play), and research has documented that nurturing words and actions are inextricably linked.137 Although there are both practice-based (eg, Reach Out and Read [ROR],129,138,139 the Video Interaction Project [VIP],66,72 HealthySteps84,85) and community-based programs (eg, positive parenting programs,140,141 home visiting programs,142,143 quality early child care settings69,71) that promote these early positive relational experiences, they are not funded at levels that would make them universally accessible. Adapted with permission from Garner AS, Saul RA. First, last and always. 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. 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. 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. 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 . Dara's parents both work for a corporation that expects them to work for 50 hours a week. 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. A multigenerational perspective is fundamental. An FCPMH is not a building or place; it extends beyond the walls of a clinical practice. 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. Ecological includes experiences in a child's home environment, such as reading, talking, teaching,. This guide asserts In this way, the victims play an active role in communicating with and understanding the offenders, and the offenders have the chance to take responsibility for their actions, identify steps that might prevent offending behaviors in the future, and redeem themselves in the eyes of the victims and community (as per Garner and Saul17). The toxic stress framework may help to define many of our most intractable problems at a biological level, but a relational health framework helps to define the much-needed solutions at the individual, familial, and community levels (see Table 1). For example, expanding family leave policies154 could reduce family stress and promote positive childhood experiences. 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. 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. The capacity to develop and maintain SSNRs with others; relational health is an important predictor of wellness across the life span. Biological sensitivity to context is a theory with emerging evidence that children differ in their susceptibility to environmental influence in a for better and for worse manner, depending on their psychobiologic reactivity to stress. As a consequence, the very characteristics that are often thought of as childrens frailties (eg, high stress reactivity) can also be their strengths, given the right context.*,91,131,134,206. 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. The biological theory asserts that most behaviors are inherited and shaped by adaptation to one's external environment. These techniques come from family therapy, cognitive therapy, motivational interviewing, family engagement, family-focused pediatrics, and solution-focused therapy. For children at higher risk for toxic stress responses, targeted secondary interventions with tiered services (eg, HealthySteps84,85) may be needed. Conversely, a solution-focused approach would focus on relational health15 (see the Appendix for a glossary of terms, concepts, and abbreviations) by promoting the safe, stable, and nurturing relationships (SSNRs) that turn off the bodys stress machinery in a timely manner.1,16,17 Even more importantly, a strengths-based, relational health framework leverages those SSNRs to proactively promote the skills needed to respond to future adversity in a healthy, adaptive manner.16,18,19 The power of relational health is that it not only buffers adversity when it occurs but also proactively promotes future resilience. Promote SSNRs by building 2-generational relational skills. The importance of engaged and attuned adults does not end in the newborn period. Developmental science is only beginning to understand the way relational health buffers adversity and builds resilience, but emerging data suggest that responsive interactions between children and engaged, attuned adults are paramount.1,16,114,115 Not only are infants programmed to connect socially and emotionally with adult caregivers,116 but the brains of parents of newborn infants appear to be reprogrammed to connect with their infants.117 Imaging studies of new parents demonstrate changes in several major brain circuits, including a reward circuit, social information circuit, and emotional regulation circuit.117,118 The reward circuit includes the striatum, ventral tegmental area, anterior cingulated cortex, and prefrontal cortex, where dopamine and rising levels of oxytocin interact to make social interactions more rewarding, thereby encouraging more parental engagement in infant care.118,119 The social information circuit includes structures such as the anterior insula, inferior frontal gyrus, superior temporal gyrus, and supplemental motor area, which support internal representations of what others may be experiencing and more empathic responses to infant behaviors.118,119 Finally, the emotional regulation circuit includes the amygdala, superior temporal sulcus, temporoparietal junction, and prefrontal cortex, which promote social cognition and a downregulation of the stress response.118,119 The convergent conclusion from these preliminary imaging studies of the parental brain is clear: much like the infant brain, the parental brain is programmed to connect. Preventing childhood toxic stress responses, promoting resilience, and optimizing development will require that all children be afforded the SSNRs that buffer a wide range of adversities and build the foundational skills needed to cope with future adversity in an adaptive, health-promoting manner. If properly funded, FCPHMs are well placed to implement the following functions: screening for behavioral and developmental risk factors and diagnoses, including mental health conditions, developmental delays, SDoHs, and family-level risk and resilience factors; care coordination, linking families to community-based supports to address SDoHs, parenting concerns, developmental delays, and behavioral and mental health concerns; integrated behavioral health and family support services through colocated, interdisciplinary teams that include case management, behavioral health services, and positive parenting programs; preventive and dyadic mental health services that do not requiring a psychiatric diagnosis code for payment, thereby enabling the deployment of primary and secondary prevention strategies before the emergence of behavioral or medical disorders; enhanced payment for prolonged medical visits, allowing for more patient-centered communication, interdisciplinary care, and development of therapeutic alliances; and. 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 . Acronym for safe, stable, and nurturing relationships; these allow the child to feel protected, connected, and competent. A public health approach to relational health is built on the SSNRs that buffer adversity and build resilience. (2) Challenge to Dominant Ideology: CRT challenges the claims of neutrality, objectivity, colorblindness, and meritocracy in society. Communication could be further enhanced by cultural humility,164,165 implicit bias training,166171 a more diverse health care team (eg, providing families and patients the opportunity to seeing themselves reflected in the sex, ethnicity, and cultural backgrounds of the team members), and access to professional interpreters. trauma-focused cognitive-behavioral therapy. 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. Thinking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health. 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). Still other techniques keep the discussion focused, practical, and organized. Toxic stress defines the problem. See the Appendix for full descriptions of the abbreviations. Subjective meanings are given primacy because it is believed that people behave based on what they believe and not . It was heralded as a good thing. The Ecobiodevelopmental Model of Health. 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. Neurology also plays a role in the biological perspective of psychology. 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. Provide or support positive parenting classes; participate in ROR, VIP, and other programs that support the dyad. ACEs are common stressful traumatic experiences which affect children's neurodevelopment. 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. Importance: Literacy has been described as an important social determinant of health. Along these lines, the Aspen Institute has created the Social Fabric Project to incentivize local projects that prioritize the building of relationships and community connections over a focus on self-absorption and hyperindividualism.183 Similarly, more attention could be given to the built environment and need for public green spaces, such as parks, to promote social cohesion and a sense of community belonging.184,185. ecobiodevelopmental (EBD) framework to stimulate fresh thinking about the promotion of health and prevention of disease across the lifespan. 3. ROR provides age appropriate books and encourages parents to regularly read to and interact with their children to support school readiness and healthy parent-child relationships. Foster strong, trusted, respectful, and effective collaborations with the community partners who are well-positioned to provide the individualized prevention, intervention, and treatment strategies. Build the therapeutic alliance; promote positive parenting; encourage developmentally appropriate play. Many studies show significant correlations between early neglect and later social, emotional and behavioural difficulties, Life Course Theory. Finally, many of the indicated treatments for children who are symptomatic as a result of toxic stress are programs that focus on repairing strained or compromised relationships (eg, ABC, PCIT, CPP, and TF-CBT). Explain how human development is rooted in biological processes that have evolved to promote adaptation and survival. Someones got to be crazy about that kid. Biological Sensitivity to Context/Adaptive Calibration Model. Relational health defines the solution. 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. 2. Just another site. By continuing to use our website, you are agreeing to, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COUNCIL ON EARLY CHILDHOOD, The Ecobiodevelopmental Model of Disease and Wellness, Components of a Public Health Approach to Toxic Stress, The Emerging Science of Relational Health, Links Between Relational Health and Resilience, A Public Health Approach to Build Relational Health, Vertical Integration to Match Levels of Need With Specific Interventions, Horizontal Integration Across Sectors at the Community Level, The Centrality of Relationships in Pediatric Care, Acknowledging the Role and Toll of Social Isolation, A Renewed Commitment to Science-Based Policy Formation, Application of Science-Based Principles to Strengthen Pediatric Practice, Reduce External Sources of Stress on Families, Glossary of Terms, Concepts, and Abbreviations, Committee on Psychosocial Aspects of Child and Family Health, 20202021, Section on Developmental and Behavioral Pediatrics, 20202021, Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health, http://acestoohigh.com/got-your-ace-score, https://psych.utah.edu/research/labs/biological-sensitivity.php, https://developingchild.harvard.edu/resources/wp1/, https://developingchild.harvard.edu/resources/supportive-relationships-and-active-skill-building-strengthen-the-foundations-of-resilience/, https://developingchild.harvard.edu/resources/wp3/, https://developingchild.harvard.edu/resources/building-the-brains-air-traffic-control-system-how-early-experiences-shape-the-development-of-executive-function/, https://developingchild.harvard.edu/resources/the-timing-and-quality-of-early-experiences-combine-to-shape-brain-architecture/, https://helpmegrownational.org/hmg-system-model/, https://developingchild.harvard.edu/resources/three-early-childhood-development-principles-improve-child-family-outcomes/.
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