ecobiodevelopmental theory asserts that:

Both genetic and epigenetic factors interact with. 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. Although pediatric and early childhood professionals have long recognized the parent-child relationship as foundational,2022 the elemental nature of relational health is not reflected in much of our current training, research, practice, and advocacy. 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. 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. But these same changes could be considered maladaptive over time because the higher cortisol levels could impair learning, and the infants irritability could impair the formation of a strong parental bond with the infant. 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. Primary preventions in the relational health framework are focused on how to universally promote the development and maintenance of SSNRs. The quoted material in this entry is from Ellis BJ. 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 . Perhaps the most important critique of Kohlberg's theory is that it may describe the moral development of males better than it describes that of females (Jaffee & Hyde, 2000). However, FCPMHs are also called to advocate for policies at the federal, state, and local levels that promote safe, stable, and nurturing communities. 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). The model is separated into three categories: 1) ecological, 2) biological and 3) developmental. A medical home builds partnerships with clinical specialists, families, and community resources. Foster strong, trusted, respectful, and effective collaborations with the community partners who are well-positioned to provide the individualized prevention, intervention, and treatment strategies. 605 PDF Here's a set of five supposedly basic tenets of CRT: (1) Centrality of Race and Racism in Society: CRT asserts that racism is a central component of American life. HealthySteps is an evidence-based, interdisciplinary pediatric primary care program that promotes positive parenting and healthy development for infants and toddlers, with an emphasis on families living in low-income communities. Relational health defines the solution. FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. 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). Transactional theory emphasizes that: Infants/toddlers and their parents are constantly affecting each other. 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. Part 1 - Overview of Developmental Domains, Periods, and Theories a. Domains of Development b. 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). Toxic stress explains how many of our societys most intractable problems (disparities in health, education, and economic stability) are rooted in our shared biology but divergent experiences and opportunities. Copyright American Academy of Pediatrics. 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. Conceptualizing and operationalizing environmental chaos In the immediate vicinity of the child, there are many levels, or systems that can affect and influence the development of children. Arwa Abdulhaq Nasir, MBBS, MSc, MPH, FAAP, Sharon Berry, PhD, LP, ABPP Society of Pediatric Psychology, Edward R. Christophersen, PhD, ABPP, FAAP , Kathleen Hobson Davis, LSW Family Liaison, Norah L. Johnson, PhD, RN, CPNP-BC National Association of Pediatric Nurse Practitioners, Abigail Boden Schlesinger, MD American Academy of Child and Adolescent Psychiatry, Rachel Segal, MD Section on Pediatric Trainees, Amy Starin, PhD, LCSW National Association of Social Workers, Peter J. Smith, MD, MA, FAAP, Chairperson, Carol Cohen Weitzman, MD, FAAP. Provide longitudinal experiences that train residents on how to develop strong, trusted, respectful, and supportive relationships with parents and caregivers. 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. The AAP remains committed to respond when empirical evidence and the latest developmental science shine new light on the issues and trends of the day. Scientists now theorize that toxic stress causes epigenetic changes that allow trauma to be transmitted over the generations. 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. Such an approach will require pediatricians, other pediatric health care professionals, and FCPMHs in general to partner with families and communities in practical and innovative ways to universally promote SSNRs, address potential barriers to SSNRs in a targeted manner, and afford indicated treatments that repair relationships that have been strained or compromised (see Table 2). The ecobiodevelopmental theory has four key components regarding the domains, timing, intensity, and biological vulnerability related to environmental chaos. In the case of toxic stress responses, universal primary prevention means trying to prevent the precipitants of toxic stress responses (eg, advocating to address the spectrum of adversities discussed above) as well as promote healthy, adaptive responses to adversity through the provision of social supports that nurture the development of foundational resilience skills (such as task persistence, curiosity, and self-regulation).16,19,59,83, A public health approach to prevent childhood toxic stress is a public health approach to promote relational health. 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. 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. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Ecobiodevelopmental Theory b. Overview of Domain-Specific Theories. Importance: Literacy has been described as an important social determinant of health. Theories that support a relationship-based framework 1. The mechanism offers an explanation for the historical trauma. 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). Social dominance, school bullying, and child health: what are our ethical obligations to the very young? Understand the relational health framework, which 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 (see Table 1). Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial, A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms, Amygdala response predicts trajectory of symptom reduction during trauma-focused cognitive-behavioral therapy among adolescent girls with PTSD, Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States, Enhancing social-emotional health and wellbeing in the early years (E-SEE): a study protocol of a community-based randomised controlled trial with process and economic evaluations of the incredible years infant and toddler parenting programmes, delivered in a proportionate universal model, Proportionate universalism in practice? 1, Center on the Developing Child at Harvard University, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics, The lifelong effects of early childhood adversity and toxic stress, Associations between early life stress and gene methylation in children, Differential glucocorticoid receptor exon 1(B), 1(C), and 1(H) expression and methylation in suicide completers with a history of childhood abuse, Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse, Annual research review: childhood maltreatment, latent vulnerability and the shift to preventative psychiatry - the contribution of functional brain imaging, Childhood trauma exposure disrupts the automatic regulation of emotional processing, Enhanced amygdala reactivity to emotional faces in adults reporting childhood emotional maltreatment, Childhood maltreatment is associated with increased neural response to ambiguous threatening facial expressions in adulthood: evidence from the late positive potential, Adverse childhood experiences, allostasis, allostatic load, and age-related disease, Child maltreatment and allostatic load: consequences for physical and mental health in children from low-income families, Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health, Genes, environments, and time: the biology of adversity and resilience, Leveraging the biology of adversity and resilience to transform pediatric practice, Building Relationships: Framing Early Relational Health, Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience: Working Paper No. But underlying this approach are 2 fundamental assumptions. Dara's parents both work for a corporation that expects them to work for 50 hours a week. A quasi-experimental study (GoWell) of a UK neighbourhood renewal programmes impact on health inequalities, Towards health equity: a framework for the application of proportionate universalism, University College of London Institute of Health Equity, Safe, stable, nurturing relationships break the intergenerational cycle of abuse: a prospective nationally representative cohort of children in the United Kingdom, Building the Brain's Air Traffic Control System: How Early Experiences Shape the Development of Executive Function: Working Paper No. In the end, the ability of the FCPMH to leverage change within the family context is entirely dependent on the capacity of the pediatric providers to form strong therapeutic relationships with the patients, caregivers, and families. 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. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Acronym for the social determinants of health; SDoHs refer to conditions where people live, learn, work, and play (like socioeconomic status, social capital, or exposure to discrimination or community violence) that are known to affect health outcomes across the life span. Rep. Byron Donalds, R-Fla., said he is co-sponsoring legislation that would prevent federal dollars from being spent on what he labels critical race theory in schools or government offices. To minimize the burden of toxic stress responses at the population level, the entire pediatric community needs to identify and address not only the acute threats to child wellness such as abuse and physical violence but also the ongoing, chronic life conditions such as racism, poverty, and isolation that are rooted in deep-seated social constructs, societal inequities (including those within the health care system), and public policies that inhibit social cohesion, equity, and relational health. 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. Acronym for Trauma-Focused Cognitive Behavioral Therapy; TF-CBT is an evidence-based, manualized, skills-based therapy that allows parents and children to better process emotions and thoughts related to traumatic experiences. 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. Transactional Theory 2. Its components emerge in infancy and are dependent on genetic, medical, and environmental factors. 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). 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. 3. ACE = Events/Incidents which harm social, cognitive, and emotional functioning causing a dramatic upset in the safe, nurturing environments children require to thrive. 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/. This title is accompanied by a complete teaching and learning package. 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 child's environment. 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. Asserting that adults with core life skills are essential, not only to form and maintain SSNRs with children but also to scaffold and develop the basic social and emotional skills that enable children to be resilient and flourish despite adversity. Applying a public health approach to the promotion of relational health (see Fig 1) reveals that many of the universal primary preventions for toxic stress are also effective means of promoting the development of SSNRs (eg, positive parenting styles, developmentally appropriate play with others,66,73,74,128 and shared reading129,130). The FCPMH alone cannot leverage significant change within the community context. 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. Life Course Theory asserts that non-communicable diseases . The text will thoroughly support students' understanding of human behavior theories and research and their applications to social work engagement, assessment, intervention, and evaluation across all levels of practice. First, last and always. The case studies by Chilton and Rabinowich provide poignant and compelling qualitative data that support an ecobiodevelopmental approach towards understanding and addressing both the complex. Any conflicts have been resolved through a process approved by the Board of Directors. Toxic stress defines the problem. 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. 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. 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. : Working Paper No. The second assumption is that the FCPMH will have the capacity to form working relationships with a wide array of community partners. Early childhood behavioral health: can the medical neighborhood move us forward? The biological response to frequent, prolonged, or severe adversities in the absence of at least one safe stable and nurturing relationship; these biological responses might be beneficial or adaptive initially, but they often become health harming or maladaptive or toxic over time or in different contexts. Poverty, food insecurity, housing insecurity, racism, community violence, discrimination, alienation, disenfranchisement, and social isolation are examples that impose significant hardships on families and become potential barriers to developing SSNRs. This policy statement asserts that to move forward (to proactively build not only the healthy, happy children of today but also the well-regulated parents and productive citizens of the future) family-centered pediatric medical homes (FCPMHs) (see the Appendix for a detailed description) need to universally promote relational health. This wide spectrum of adversity underscores the fact that ACE scores and other epidemiologically derived risk factors at the population level are not valid or reliable predictors of outcomes at the individual level.56 Toxic stress, by contrast, refers to an individuals physiologic response to these adversities, and biomarkers of this physiologic response have the potential to be more sensitive and specific measures of experienced adversity at the individual level.37 Validated biomarkers also offer transformational potential as measures of responsiveness to specific interventions.37,57 With these applications in mind, the pediatric research community is hoping to develop clinic-friendly, noninvasive biomarkers for different forms and degrees of adversity. Explain how human development is rooted in biological processes that have evolved to promote adaptation and survival. An ecobiodevelopmental framework sheds new light on the biological basis for persistent disparities in education, poverty, and health. 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). Doing so will require all trainees to address their implicit biases, develop cultural humility, and provide culturally competent recommendations. 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. 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. With almost a century of service to children, families, and communities, the field of pediatrics has made critical contributions at the interface of science and public policy. These perspectives offer different interpretations of the nature of society and the role of . In short, a public health approach to prevent childhood toxic stress is a public health approach to promote relational health. Tertiary preventions in the toxic stress framework are focused on the evidence-based practices that treat toxic stress-related morbidities such as anxiety, depression, oppositional defiant disorder, posttraumatic stress disorder, and substance abuse disorder. 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. Thinking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health. 7. 10.1542/peds.2021-052582. Acronym for Attachment and Biobehavioral Catch-up; ABC is an evidence-based program of interventions to assist foster parents in nurturing children who have experienced disruptions in care. An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. Still other techniques keep the discussion focused, practical, and organized. 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. An FCPMH is not a building or place; it extends beyond the walls of a clinical practice.

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