See the Appendix for full descriptions of the abbreviations. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). 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). 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Toxic stress is a deficits-based approach because it is focused on the problem: those biological processes triggered by significant adversity in the absence of SSNRs. Early childhood experiences, both adverse and positive, appear to be biologically embedded and influence both disease and wellness across the life course.30 The ecobiodevelopmental model of disease and wellness explains how the ongoing but cumulative and reciprocal dance between ecology and biology leads to changes at the molecular (eg, methylation patterns), cellular (eg, brain connectivity patterns), and behavioral levels (eg, tobacco, alcohol, or other substance use).2,17 These changes are either adaptive or maladaptive depending on the context, and they are either benefits or risks to future health, academic success, and economic productivity.75. 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. For many resource-poor families and older children, overall relational health is dependent not only on dyadic serve and return interactions with family members but also on trusted, SSNRs with others in the community through interactions at the medical clinic, school, recreation leagues, faith-based and civic organizations, community improvement efforts, and employment opportunities. Executive functions are the cognitive skills needed to control behavior and attain goals. Posted on June 1, 2022 by Other investigators have applied the term ACEs to additional adversities known to affect child health, such as poverty, neighborhood violence, and exposure to racism. Domains, timing, and intensity of chaos were predictive of children's mental and physical health. These perspectives offer different interpretations of the nature of society and the role of . Doing so will require all health professionals to address their implicit biases, develop cultural humility, and provide culturally competent recommendations. University of Utah, Department of Psychology, College of Social & Behavioral Science. Relational health defines the solution. Reciprocal experiences with engaged and attuned adults (like those that occur during developmentally appropriate play) that build SSNRs; they are warm, affirming, and inclusive, and they promote early relational health. 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. 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 the Video Interaction Project; VIP uses video-taped interactions of parent-child dyads to teach parents how to be more engaged, attuned, and responsive to their childs developing behaviors. Public health approaches are vertically integrated when they are founded on universal primary preventions (eg, promoting family resilience and connection and positive childhood experiences), with tiered, targeted interventions (eg, addressing SDoHs) and indicated treatments (eg, PCIT) being layered on this foundation, depending on the specific needs of the particular child, family, or community. 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. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. 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. 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. 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. According to studies, how a human brain is structured shares connections to various subsequent behaviors. Simply put, public policies, social constructs, and societal norms that divide, marginalize, alienate, and isolate are clear threats to the well-being of all children. Acronym for Parent-Child Interaction Therapy; PCIT is an evidence-based intervention to change the patterns of parent-child interactions to improve the parent-child relationship. Foremost on the advocacy agenda will be the need for serious payment reforms that consider the complexity of care attributable to adverse family and community contexts and include financial supports that incentivize families to engage with an FCPMH.204 Payment reforms need to be sufficient to allow FCPMHs to spend more time with families, function as interdisciplinary teams, integrate into their communitys initiatives and services to support children and families (horizontal integration), and anchor medical neighborhoods that not only foster wellness in childhood but promote positive outcomes across the life span. Acute threats to childhood wellness such as abuse need to be taken seriously; similar attention should be given to the social inequities and ongoing, chronic life conditions that similarly imperil a childs biological wellness and life-course trajectory. 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. Childhood trauma can alter developing brain, creates lifetime of risk The 3 principles described above, each of which is grounded in the research literature, provide a science-based framework for developing innovative strategies to promote SSNRs at the dyadic level, family level, and community level. These techniques come from family therapy, cognitive therapy, motivational interviewing, family engagement, family-focused pediatrics, and solution-focused therapy. Dr Garner collaborated in conceptualizing and drafting this document, took the lead in reconciling the numerous edits, comments, and suggestions made by many expert reviewers, and made significant contributions to the manuscript; Dr Yogman collaborated in conceptualizing and drafting this document and made significant contributions to the manuscript; and all authors approved the final manuscript as submitted. 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. 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