Reducing toxic stress experienced by children living in poverty

Abstract

In my last President's Message I shared the five policy areas set by the Academy Board of Directors. They are:•Reproductive Rights•Environmental Health•Violence Prevention•Opioid Addiction•Toxic Stress in Children In this message I will focus on toxic stress in children. What is toxic stress and why does it matter? First, toxic stress is the result of exposure to Adverse Childhood Events (ACEs). These events include physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, intimate partner violence, mother treated violently, substance misuse within the household, potential separation or divorce, mental illness within the household, and incarcerated household member. And there is a dose response. The higher the number of ACEs, the higher the likelihood a child will experience significant episodes of toxic stress. This exposure to toxic stress has powerful and lifelong effects on physical and mental health. Revealed in a seminal study in 1998 (Felitti et al, 1998Felitti V.J. Anda R.F. Nordenberg D. Williamson D.F. Spitz A.M. Edwards V. Marks J.S. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study.Am J Prev Med. 1998; 14: 245-258Abstract Full Text Full Text PDF PubMed Scopus (9683) Google Scholar), those who had four or more ACEs were at increased risk for alcoholism, drug abuse, suicide attempt, smoking, more than 50 sexual partners, depression, heart disease, obesity, and liver disease. We now know that prolonged exposure to toxic stress actually changes the brain architecture (Luby, 2015Luby J.L. Poverty's most insidious damage: The developing brain.JAMA Pediatr. 2015; 169: 810-811Crossref PubMed Scopus (43) Google Scholar). These changes can impact higher level functioning and decrease decision-making capacity. Framing this as the biologic impact of diversity helps to shift the conversation away from blaming individuals for making bad choices toward implementing system level changes that decrease exposure to toxic stress. Poverty is one major root cause. Although all children can experience ACEs, those with means are more likely to access more resources to mitigate the impact. The fact that 41% of children in the United States live in poverty or near poverty underscores the significance of ACEs and vulnerability to exposure to toxic stress (Koball, Jiang, 2018Koball H. Jiang Y. Basic Facts about Low-income Children: Children under 18 Years, 2016.2018Google Scholar). Further, less than 9% of the Federal Budget is appropriated for children's programs. When you consider that children are our future, you can understand how evidence-based policy strategies to reduce childhood poverty has the potential for a significant financial return on investment of taxpayer's dollars, improved quality of life for children and their families, and the enhanced economic development of our communities. The National Academy of Medicine is near completion of a white paper entitled, “Building an Agenda to Reduce the Number of Children in Poverty in Half in 10 Years.” The Academy will review the recommendations with interest as we work on our policy agenda to reduce toxic stress. The American Academy of Nursing convened a Critical Conversation on “Toxic Stress in Children Living in Poverty” last October. An invitation-only meeting, the Critical Conversation was launched in response to the Robert Wood Johnson Foundation's Culture of Health working group that met in 2016, resulting in a focus on eliminating Childhood Poverty. Among the approximately 100 participants who assembled at the National Press Club in Washington, DC represented 33 organizations and 15 universities. The result of this Critical Conversation laid the groundwork for developing and promoting policies that are bundled, addressing several social determinants of care as well as the concept of “warm handoffs” among agencies and professionals working with children and their families. In addition to the Critical Conversation, several expert panels have focused on toxic stress. Mahatma Gandhi said, “The true measure of any society can be found in how it treats its most vulnerable members.” Let us work to improve the lives of children for now and for the future.