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Land Acknowledgement

Our chapter territory spans from the northern border of California to the southern border of Monterey, Kings, Tulare and Inyo counties. This land was once the home for Native Americans from over 40 different tribes. Native Americans from these territories still live in California and have strong, vibrant communities and cultures. We’d like to acknowledge those tribes and respect the history of the land that we now inhabit.

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�

Screening for ACEs: The Missing Link

in Fostering Early Childhood Development

Renee C. Wachtel MD FAAP

Developmental Behavioral Pediatrician

Clinical Professor of Pediatrics, UCSF School of Medicine

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��No one involved in the planning or presentation of this activity has any relevant financial relationships with a commercial interest to disclose.�

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Objectives

To understand the ACEs Aware Mission
To increase awareness of the difference between ACEs, Stress, Toxic Stress, Trauma, and Post Traumatic Stress Disorder
To review the science of behind ACEs including allostatic load and toxic stress, and its relationship to health and early childhood development
To understand the role of resilience in counteracting the impact of ACEs
To help pediatricians develop strategies that promote prevention and early intervention to ameliorate the impact of ACES on early life.

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What are ACEs and why are they important? �The ACEs Aware Initiative in California

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ACEs Aware: Background and Mission

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ACEs Aware Mission

To change and save lives by helping providers understand the importance of screening for Adverse Childhood Experiences and training providers to respond with trauma-informed care to mitigate the health impacts of toxic stress.

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Common Definitions

Stressor- is a physical, mental, or emotional factor that causes bodily or mental tension.
Stressors can be external (from the environment, psychological, or social situations) or internal (illness, or from a medical procedure). Stressors can initiate the "fight or flight" response, a complex reaction of neurologic and endocrinologic systems.
Stress – is the physiologic process in response to a stressor

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Common Definitions

Childhood adversity- negative conditions that diminish quality of life and may increase the risk for the toxic stress response

Trauma- an event experienced as real or threatened death, serious injury, or sexual violence that leads to lasting effects

Adverse Childhood Experiences (ACEs)-10 categories of adversity that have been correlated with the toxic stress response and health outcomes

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10 Categories of Adverse Childhood Experiences That Are Associated with the Toxic Stress Response

Notes:

The term Adverse Childhood Experiences (ACEs) come from the landmark 1998 study conducted among more than 17,000 adult patients by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. The term ACEs specifically refers to the 10 categories of adversities in three domains experienced by age 18 years that were evaluated in the study.

Abuse: Physical, emotional, or sexual
Neglect: Physical or emotional
Household challenges Growing up in a household with parental incarceration, mental illness, substance dependence, absence due to separation or divorce, or intimate partner violence (initially queried as violence towards the mother or stepmother)

One of the pieces that's really important is to recognize that the 10 ACEs identified in the landmark CDC/Kaiser Permanente study are certainly not the only risk factors for toxic stress. Other factors such as racial discrimination, separation from a parent or a caregiver for other reasons like deportation or migration or even a medical trauma may also be risk factors for toxic stress.

BACKGROUND NOTES:

Why we don’t add additional questions to the ACE screener or change the scoring to include other types of adversity:

When it comes to the traditional 10 ACEs, we have very large, robust population level data sets about relative risk of health conditions. So for example, with the traditional ACEs, we know that if an individual has four or more ACEs, their relative risk of, for example, ischemic heart disease is 220% (Felitti et al, 1998)

When you add in other risk factors for toxic stress like discrimination or like being a victim of violence in the community or elsewhere, we don't have the same reference ranges for those datasets. And that's why we score those differently. It's not that they aren't all risk factors for toxic stress, but when it comes to the integrity of the data around the relative

risk of different health conditions, we have to compare apples to apples. And that's why they're separated in that way.

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Prevalence of ACEs in California

Sources: California Department of Public Health, Injury and Violence Prevention Branch (CDPH/IVPB), University of California, Davis, Violence Prevention Research Program, California Behavioral Risk Factor Surveillance System (BRFSS), 2011-2017.

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Prevalence of ACEs

The most commonly reported ACEs in California are verbal or emotional abuse (30.4%) and household substance use (28.2%).
Among Medi-Cal enrollees, 68.7% have experienced at least one ACE, and 22.8% have experienced four or more ACEs

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. (p. xxiv)

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Social Determinants of Health (SDOH)

“Social Determinants of Health (SDOH) are conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

SDOH include:

Education
Employment
Health systems and services
Housing
Income and wealth
Physical environment
Public safety
Social environment (including

structures, institutions, and policies),

and transportation”*

Source: The Catalyst Center Supplemental Training

*Center on the Developing Child at Harvard University, n.d. cited in NASEM, 2019

Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N. Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General's Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812

Social Determinants Of Health:

Foster unmet social needs that often co-occur with ACEs
Contribute to the prevalence of ACEs
Can exacerbate the impact of ACEs and increase the likelihood they will lead to toxic stress
Some may directly lead to toxic stress
May reduce availability of safe, stable, and nurturing relationships and environments due to cumulative dose of adversity

SDOH, ACEs, and Toxic Stress

Live

Learn

Work

Play

Worship

Age

Let’s take a moment to quickly define the Social Determinants of Health and how these additional adversities are risk factors for toxic stress.

According to the Center for the Developing Child at Harvard University, “Social determinants of health are conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. The social determinants of health are: education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment (including structures, institutions, and policies), and transportation”*
While validated odds ratios are available in large, population-based studies using the 10 standardized ACE criteria, the strengths of association between other experiences/social determinants of health and health outcomes have not been similarly standardized.
Recognizing these additional risks is important since they often co-occur with ACEs, contribute to their prevalence, and can exacerbate their impacts. It is also crucial to understand and address the ways in which these factors may compound the cumulative dose of adversity and reduce caregivers’ ability to provide safe, stable, and nurturing relationships and environments, particularly given the disproportionate burden of ACEs in systemically marginalized communities.

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Post Traumatic Stress Disorder

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PTSD in young children under 6 years of age�

The following are the specific criteria outlined in the DSM-5 for those six years or younger.

Criterion A

Children under the age 6 have been exposed to an event involving real or threatened death, serious injury, or sexual violence, with symptoms that have lasted at least one month and result in considerable distress

Criterion B

The presence of intrusive symptoms that are associated with the traumatic event and began after the event occurred such as recurring, spontaneous, and intrusive upsetting memories, dreams, flashbacks, emotional distress or strong physical reactions to reminders of the traumatic event, which can be expressed through play

Criterion C

The child exhibits at least one of the following avoidance symptoms or changes in his or her thoughts and mood. These include more frequent negative emotional states, such as fear, shame, or sadness, lack of interest in activities that used to be meaningful or fun, social withdrawal, reduced expression of positive emotions

Criterion D

The child experiences increased irritable behavior or angry outbursts, (which may include extreme temper tantrums), hypervigilance, exaggerated startle response, difficulties concentrating, problems with sleeping

Diagnostic and Statistical Manual of Mental Disorders (DSM-5), APA, 2013.

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What contributes to the hand you are dealt?

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The Science behind ACEs

Stress and Toxic Stress

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Mc Ewen (2020)-Revisiting the Stress Concept: Allostatic load/overload��

The biology of stress has led to the concept of allostasis and allostatic load/overload
Allostasis refers to the active process of adapting and maintaining stability (or homeostasis) through the production of mediators, like cortisol, that promote adaptation.
However, if the perturbations in the environment are unrelenting, the equilibrium set point needs to be altered to a “new normal,” and this can be costly to the organism.
“Allostatic load refers to the price the body pays for being forced to adapt to adverse psychosocial or physical situations”.
The brain is a vulnerable organ that can be damaged by toxic stress, but it is also capable of adaptive plasticity and resilience. This plasticity exists throughout life, with critical periods such as early life and adolescence when it is particularly evident.

Bruce S. McEwen and Huda Akil Revisiting the Stress Concept: Implications for Affective Disorders�Journal of Neuroscience 2 January 2020, 40 (1) 12-21; DOI: https://doi.org/10.1523/JNEUROSCI.0733-19.2019

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Three general types of stress

Positive stress is characterized by moderate, short-lived increases in heart rate, blood pressure, and stress hormone levels.
Precipitants include the challenges of dealing with frustration, receiving an injected immunization, and other normative experiences.
The essential nature of positive stress is that it is an important aspect of healthy development that is experienced in the context of stable and supportive relationships that facilitate adaptive responses, which, in turn, restore the stress response system to baseline status.

National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Updated Edition. Retrieved from www.developingchild.harvard.edu.

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Three general types of stress

Tolerable stress refers to a physiological state that could potentially disrupt brain architecture (eg, through cortisol- induced disruption of neural circuits or neuronal death in the hippocampus) but is buffered by supportive relationships that facilitate adaptive coping.
Precipitants include the death or serious illness of a loved one, homelessness, or a natural disaster. The defining characteristic of tolerable stress is that it occurs within a time-limited period.

National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Updated Edition. Retrieved from www.developingchild.harvard.edu.

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Three general types of stress�

Toxic stress refers to strong, frequent, and/or prolonged activation of the body’s stress-response systems in the absence of the buffering protection of adult support. Major risk factors include recurrent physical and/or emotional abuse, chronic neglect, severe maternal depression, parental sub- stance abuse, and family violence.
The defining characteristic of toxic stress is that it disrupts brain architecture, affects other organ systems, and leads to stress-management systems that establish relatively lower thresholds for responsiveness that persist throughout life,
This increases the risk of stress- related disease and cognitive impairment well into the adult years. �

National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Updated Edition. Retrieved from www.developingchild.harvard.edu.

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Key elements of the limbic HPA. Glucocorticoids feed back to the brain to restrain the stress response.

Bruce S. McEwen, and Huda Akil J. Neurosci. 2020;40:12-21

This is to demonstrate the underpinning physiology that gives rise to the impacts on the ENTIRE BODY as we will see in subsequent slides manifesting in potential ACE Associated Health Conditions.

Key elements of the limbic and HPA. Glucocorticoids feed back to the brain to restrain the stress response. They produce their actions via GRs and MRs, which are generally classified as ligand-dependent transcription factors that are expressed in multiple brain regions, especially the hippocampus. Glucocorticoid effects in the brain involve not only direct and indirect genomic actions, but also direct stimulation of glutamate release and stimulation of endocannabinoid production, which then feed back on glutamate and GABA release and actions in mitochondria to affect Ca²⁺ buffering and free radical formation. BDNF, in the presence of glucocorticoids, phosphorylates the GR at sites that facilitate its translocation to the cell nucleus for transcriptional actions; this effect is synergistic with the ability of glucocorticoids to promote the phosphorylation of the TrkB receptor independently of BDNF. Table 1 refers to mechanistic studies of mediators and cellular processes that are involved in the remodeling of neurons in hippocampus, amygdala, and prefrontal cortex.

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What does stress do to neurotransmitters in the brain? Popoli et al (2012)

Mounting evidence suggests that acute and chronic stress, especially the stress-induced release of glucocorticoids, induces changes in glutamate neurotransmission in the prefrontal cortex and the hippocampus, thereby influencing some aspects of cognitive processing.

Dysfunction of glutamatergic neurotransmission is increasingly considered to be a core feature of stress-related mental illnesses.

Dysregulation of cortisol is increasingly considered to be a core feature of toxic stress, related physical illness and disease.

Maurizio Popoli et al, The stressed synapse: the impact of stress and glucocorticoids on glutamate transmission Nature Reviews Neuroscience volume 13, pages22–37(2012)

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The brain is a primary organ that perceives and responds to what is stressful to an individual.

Bruce S. McEwen, and Huda Akil J. Neurosci. 2020;40:12-21

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ACE- Associated Health Conditions

ADHD

Aggression/fighting

Alcohol/Drug Use

Anxiety

Depression

Developmental Delay

Enuresis

Encopresis

Headaches

Learning Problems

Pain

PTSD

Cardiovascular Disease

Diabetes

Failure to Thrive

Hepatitis

Late menarche

Overweight

Obesity

Stroke

Allergies

Arthritis

Asthma

COPD

Eczema

Increased infections

Urticaria

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. (p. 12-32)

Here is another way to look a this…

At the Center for Youth Wellness in San Francisco, ACE-Associated Health Conditions were organized into the categories of Neuro, Endo/Metabolic and Immune as a way to help assess for signs of NEI dysregulation.

While ACEs are known to be associated with elevated risk for poor physical health even in childhood (e.g. failure to thrive, asthma, obesity), in practice it may be difficult to see beyond the behavioral and mental health issues and symptoms (e.g. ADHD, oppositional behavior, school problems, drug use, depression, anxiety, violence). The hope is that grouping health conditions by NEI can support providers in linking what may seem to be

disparate medical conditions (both mental and physical health issues) with the underlying toxic stress a child may be experiencing. ACE screening plus the ACE-Associated Health Conditions may point to a change in diagnosis.

For example, while there are potentially many causes for ADHD, Autism or Oppositional Defiance Disorder including a spectrum of normal neurodiversity, ACE screening and further assessment, including the assessing for health conditions may identify which symptoms are manifestations of a trauma reaction, leading to a diagnosis of Developmental Trauma Disorder.

This checklist can aid providers in assessing which symptoms may be indicative of a toxic stress response in the presence of exposure to ACEs, consider differential diagnostic approaches as well as treatment and follow-up plans, and better determine whether a dysregulated neuroendocrine-immune system is at the root of the medical problem.

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. (p. 12-32)

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Genetic influences in toxic stress responses�Zannas et al (2013)

As noted by Zannas (2013): environmental exposures both differ and have varying effects among individuals with different genetic backgrounds.
In other words, environmental exposures may occur and exert their effects only in the presence of predisposing genetic factors.
These limitations highlight the importance of examining the effects of specific environmental exposures on specific genetic polymorphisms with the study of gene–environment interactions (GxEs).
Replicated GxEs have been reported for mood and anxiety disorders

Zannas et al. Genes, Brain and Behavior, Volume: 13, Issue: 1, Pages: 25-37, November 2013, DOI: (10.1111/gbb.12104)

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Relationship between genes and stress response: Zannas et al (2013)�Lujik et al (2010)

For example , Zannas et al investigated the polymorphisms in a gene encoding the FK506 binding protein 51 (FKBP5) that among other functions regulates the sensitivity of the glucocorticoid receptor.
The C allele is protective, whereas the T allele is less common and has been associated with glucocorticoid receptor resistance in carriers of the T‐allele.
Since all individuals have 2 alleles, possibilities include CC, CT or TT combinations.
Healthy adult T‐allele carriers have been shown to have a prolonged cortisol response even to minor stressors.

Zannas et al. Genes, Brain and Behavior, Volume: 13, Issue: 1, Pages: 25-37, November 2013, DOI: (10.1111/gbb.12104)

Lujik MP et al.(2010) Psychoneuroendocrinolgy 35, 1454-1461.

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Relationship between genes and stress response: �Zannas et al (2013)�Lujik et al (2010)

Infants who had the T‐allele exhibited prolonged increases in salivary cortisol following exposure to the Strange Situation Procedure, a paradigm that is designed to evoke mild stress in the infant by exposure to the lab environment and a female stranger, coupled with brief separation from the parent.
This relationship was further influenced by the infant’s attachment pattern, with T‐allele carrying infants having resistant maternal attachment showing the highest cortisol reactivity.

Zannas et al. Genes, Brain and Behavior, Volume: 13, Issue: 1, Pages: 25-37, November 2013, DOI: (10.1111/gbb.12104)

Lujik MP et all.(2010) Psychoneuroendocrinolgy 35, 1454-1461.

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Gene–environment interactions at the FKBP5 locus: sensitive periods, mechanisms and pleiotropism

Genes, Brain and Behavior, Volume: 13, Issue: 1, Pages: 25-37, 12 November 2013, DOI: (10.1111/gbb.12104)

*FKBP5/NF-kB are not the only pathway toward the physical health impacts of early life trauma

*

Simplified model of the pleiotropy of GxEs at the FKBP5 locus via the intracellular crosstalk of FKBP5 with other molecules. Solid arrows denote phenotypes (or endophenotypes) that have evidence for GxE, whereas dotted lines are used for phenotypes without current evidence and which could be explored in future research studies. References for existing evidence are provided in parentheses. AR, adrenal receptor; CaN, calcineurin; GR, glucocorticoid receptor; HPA, hypothalamic‐pituitary‐adrenal axis; Hsp90, heat shock protein 90; NF‐κB, nuclear factor kappa‐light‐chain‐enhancer of activated B cells; PTSD, post‐traumatic stress disorder.

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Epigenetics in relation to stress responses

Epigenetics refers to the mechanisms that regulate genomic information by dynamically changing the patterns of transcription and translation of genes.
Epigenetic mechanisms include methylation, histone acylation, or binding of noncoding RNAs to DNA sequences
Mounting evidence from preclinical rodent and clinical population studies strongly support that epigenetic modifications can occur in response to trauma and chronic stress.

Zannas et al. Genes, Brain and Behavior, Volume: 13, Issue: 1, Pages: 25-37, November 2013, DOI: (10.1111/gbb.12104)

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These are ACEs

Toxic stress is a physiological response

Clinical implications lead to ACE-Associated Health Conditions

Please listen to the recording for talking points on this slide.

Notes:

One of the things about ACE screening that's really important to recognize, is that the purpose of ACE screening is not specifically to identify the ACEs per se, but a recognition that Adverse Childhood Experiences are risk factors for development of the toxic stress response. And we understand that the toxic stress response is a repeated exposure to adversity, leads to changes in neuro development, in the development of the immune system, in the development of our hormonal systems and even the way DNA is read and transcribed. And all of these together, this dysregulated stress response with neuro-endocrine immune and genetic regulatory disruption is what is now known as the toxic stress response. And this is what leads to health problems from behavioral to physical.

One of the pieces that's really important to recognize is that while there's research underway to identify clinical diagnostic criteria and biomarkers for the toxic stress response, currently that doesn't exist. And so, the best indicator of whether a patient is at risk for toxic stress response and potentially experiencing a toxic stress physiology is cumulative adversity. That's what the science shows us. Cumulative adversity is the greatest risk factor for development of the toxic stress response. And so that is the reason why we screen for ACEs.

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The Science Behind ACEs

Maternal Depression

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Effects of maternal depression: Kingston et al (2018)

1983 Participants in Canada completed six questionnaires at the following time points:

1) before 25 weeks of pregnancy; 2) between 34 and 36 weeks of pregnancy; 3) at four months postpartum; 4) at one year postpartum; 5) at two years postpartum; and 6) at three years postpartum.

These comprehensive questionnaires asked about socio-demographics, pregnancy, health service utilization, maternal mental and psychosocial health, obstetric and birth outcomes, child health, child development, and parenting.

The questionnaires include both standardized scales and investigator-derived questions created specifically for the study when standardized measures were not available.

Kingston D et al. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at 3 years. PLOS One 2018

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Fig 1. Estimated means of the EPDS for the four trajectories of maternal depressive symptoms from pregnancy to one year postpartum.

Kingston D, Kehler H, Austin MP, Mughal MK, Wajid A, et al. (2018) Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PLOS ONE 13(4): e0195365. https://doi.org/10.1371/journal.pone.0195365

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Effects of maternal depression

Kingston D, Kehler H, Austin MP, Mughal MK, Wajid A, et al. (2018) Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PLOS ONE 13(4): e0195365. https://doi.org/10.1371/journal.pone.0195365

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Effects of maternal depression: Results �Kingston et al (2018)

Children with elevated behavior symptoms at age 3 was highest for children whose mothers had persistent high depressive symptoms

After accounting for demographic, child and psychosocial factors, the relationships between depression trajectories and child hyperactivity/inattention, and separation anxiety symptoms remained significant.

Conclusion: Women with elevated depressive symptoms need to be identified, provided with evidence-based treatment, and monitored with repeat screening to improve maternal mental health outcomes and reduce the risk of associated negative outcomes on children’s early social-emotional and behavior development.

Kingston D et al. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at 3 years. PLOS One 2018

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Relationship between Maternal Depression, Parental ACEs and Parenting Stress: Lange et al (2019)

Study by Lange et al 2019: 81 mothers (most 25-45 years, 71% Black, 43% college education in New Haven CT) with depression were studied prior to a Stress Management course
Maternal ACEs were compared to parental distress, parent-child dysfunctional interactions and parent perceptions of a “difficult child”
66.7% of mothers self- identified ACEs, of which 35% identified sexual abuse, 34% identified emotional abuse, and 27% had a family member imprisoned.
Parental distress, difficult child and total parenting stress scores (on the Parenting Stress Index) were increased with each additional maternal ACE in a dose response manner.

Lange BC etal. (2019) Community Mental Health Journal, 55:651-662

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Maternal depression and child brain development: �Hay et al (2020)

Understanding how prenatal maternal depression impacts child behavior is critical for appropriately treating prenatal maternal mental health problems and improving child outcomes.
In a study by Hay et al, 54 mother child pairs were followed during pregnancy until the child was 4-6 years of age. Mothers completed the Edinburg Depression Scale during the second and third trimesters and at 3 months postpartum. Children had MRIs at mean age of 4.1 years and a Child Behavior Checklist by the parent at that time.
Children of mothers with worse depressive symptoms had weaker white matter connectivity between areas related to emotional processing.
This is shown in figure B in the next slide

Amygdala-Prefrontal Structural Connectivity Mediates the Relationship between Prenatal Depression and Behavior in Preschool Boys.Hay RE, Reynolds JE, Grohs MN, Paniukov D, Giesbrecht GF, Letourneau N, Dewey D, Lebel C.J Neurosci. 2020 Sep 2;40(36):6969-6977. doi: 10.1523/JNEUROSCI.0481-20.2020. Epub 2020

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White matter tracts examined in this study.

Rebecca E. Hay et al. J. Neurosci. 2020;40:6969-6977

Figure 1. White matter tracts examined in this study. A, Cingulum. B, Amygdala pathway. C, Fornix. D, Uncinate fasciculus. Tracts did not overlap.

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Maternal depression and child brain development: �Hay et al (2020)

In this study, the connectivity between the amygdala and prefrontal cortex mediated the relationship between maternal depressive symptoms and externalizing behavior in boys.
This shows that altered brain structure is a possible mechanism via which maternal prenatal depression impacts children's behavior.
This provides important information for understanding why children of depressed mothers may be more vulnerable to depression themselves and may help shape future guidelines on maternal prenatal care.

Amygdala-Prefrontal Structural Connectivity Mediates the Relationship between Prenatal Depression and Behavior in Preschool Boys.Hay RE, Reynolds JE, Grohs MN, Paniukov D, Giesbrecht GF, Letourneau N, Dewey D, Lebel C.J Neurosci. 2020 Sep 2;40(36):6969-6977. doi: 10.1523/JNEUROSCI.0481-20.2020. Epub 2020

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Mean diffusivity (MD) of the right amygdala pathway significantly mediated the relationship between third trimester depressive symptoms and externalizing behavior in males.

Rebecca E. Hay et al. J. Neurosci. 2020;40:6969-6977

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Effects of maternal ACEs upon newborn brains: intergenerational effects. Moog et al (2018)

Results—Maternal CM exposure was associated with lower child intracranial volume (F1,70=6.84, p=.011), which was primarily due to a global difference in cortical gray matter (F1,70=9.10, p=.004).
The effect was independent of potential confounding variables, including maternal SES, obstetric complications, obesity, recent interpersonal violence, pre- and early postpartum stress, gestational age at birth, infant sex, and postnatal age at MRI scan.

Moog, et al. Biol Psychiatry. 2018 Jan 15; 83(2): 120–127.

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Effects of maternal ACEs upon newborn brains: intergenerational effects. Moog et al (2018)

Childhood maltreatment (CM) confers deleterious long-term consequences, and growing evidence suggests some of these effects may be transmitted across generations.
Moog et al (2018) examined the intergenerational effect of maternal child maltreatment on her child’s brain structure and also addressed the hypothesis that this effect may start during the child’s intrauterine period of life.
This was a prospective longitudinal study was conducted in a clinical sample of 80 mother-child dyads. Maternal CM exposure was assessed using the Childhood Trauma Questionnaire.
CM exposure was reported by 35% of the women.
Structural magnetic resonance imaging (MRI) was employed to characterize newborn global and regional brain (tissue) volumes near the time of birth.

Moog, et al. Biol Psychiatry. 2018 Jan 15; 83(2): 120–127.

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Reduced Cortical Gray Matter Volume in Neonates born to Mothers with Child Maltreatment. �

Moog, etal. Biol Psychiatry. 2018 Jan 15; 83(2): 120–127.

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.��

Note. The statistical map is overlaid on a typical neonatal T1-weighted image in radiologic convention and thresholded at p_adj < 0.05 with hot colors representing a more significant finding. The most significant reduction of GM volume was observed in the right occipital cortex and cerebellum, as well as the left parietal and prefrontal cortex. MOOG et al Biol Psychiatry. 2018 Jan 15; 83(2): 120–127

MRI Regions with reduced Cortical Grey Matter volume in newborns of mothers exposed to Child Maltreatment

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The Science Behind ACEs

ACEs and Maternal Behavior

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Unpredictable patterns of maternal behavior and its effects on brain development��Granger et al (2021)

Across species in animal models, unpredictable patterns of maternal behavior alters brain circuit maturation and cognitive and emotional outcomes later in life.
In study by Granger et al 2021, human neurobiological mechanisms were studied in 69 maternal infant dyads (at 6 and 12 months of age) using diffusion imaging in children followed up to 9-11 years of age.

Granger et al 2021 J Neuroscience 41 (6) 1242-1250.

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Unpredictable patterns of maternal behavior and its effects on brain development��Granger et al (2021)

They found that higher maternal unpredictability of maternal signals to infants was associated with differences in a specific brain tract.
This tract, the uncinate fasciculus- FIGURE D in the next slide, connects the amygdala to the orbito- frontal cortex
These results suggested that unbalanced maturation of the corticolimbic circuits is a mechanism by which early unpredictable maternal behavior is associated with compromised memory function.

Granger et al 2021 J Neuroscience 41 (6) 1242-1250.

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White matter tracts examined in this study.

Rebecca E. Hay et al. J. Neurosci. 2020;40:6969-6977

Figure 1. White matter tracts examined in this study. A, Cingulum. B, Amygdala pathway. C, Fornix. D, Uncinate fasciculus. Tracts did not overlap.

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The Science Behind ACEs

ACEs and Parental Discipline

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How might child’s genes, and parenting behavior interact to affect child behavior? Noroña et al (2018)

Individual differences in emotion regulation are central to social, academic, occupational, and psychological development. Emotion dysregulation (ED) in childhood is a risk factor for numerous developmental outcomes.
Norona et al (2018) studied child serotonin transporter polymorphisms, emotional dysregulation and parenting interactions
The goal of the study was to examine the effects of serotonin transporter genotype (G), positive and negative parenting behaviors (E), and GxE on initial levels of child Emotional Dysregulation (ED) and change in ED over time, in 99 children from ages 3-6 years.
Child ED and early parenting were coded from parent-child laboratory interactions.

Developmental patterns of child emotion dysregulation as predicted by serotonin transporter genotype and parenting Amanda N. Noroña ,et al J Clin Child Adolesc Psychol. 2018 ; 47(SUP1): S354–S368. doi:10.1080/15374416.2017.1326120.

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How might genes, and parenting behavior interact to affect child behavior? Noroña et al (2018)

Results: AGE 3- Negative parenting emerged as the only predictor of initial levels of ED in the expected direction, such that higher negative parenting scores were associated with higher ED at age 3.

They observed separate (genotype x positive) and (genotype x negative) parenting behavior interactions in the predictions of ED growth curves from ages 3-6 years. Genotypes could be either SS, SL or LL.

Developmental patterns of child emotion dysregulation as predicted by serotonin transporter genotype and parenting Amanda N. Noroña ,et al J Clin Child Adolesc Psychol. 2018 ; 47(SUP1): S354–S368. doi:10.1080/15374416.2017.1326120.

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Child serotonin transporter polymorphisms, emotional dysregulation and parenting interactions.�Noroña et al (2018)

Children with the SL/LL genotype had ED trajectories that were minimally related to positive and negative parenting behavior.
However, for children with the SS genotype, negative and positive parenting behaviors predicted change in ED over this developmental period
ED decreased precipitously among children with the SS genotype when exposed to low negative parenting or high positive parenting.

Developmental patterns of child emotion dysregulation as predicted by serotonin transporter genotype and parenting Amanda N. Noroña ,et al J Clin Child Adolesc Psychol. 2018 ; 47(SUP1): S354–S368. doi:10.1080/15374416.2017.1326120.

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CONCLUSIONS: They concluded that there is evidence for an interaction between child genotype and parenting which affects emotional dysregulation in children ages 3-6.
Specifically, children with the SS genotype improved in emotional dysregulation best with high levels of positive parenting and/or low levels of negative parenting. High negative parenting did not allow them to improve in emotional dysregulation.

Developmental patterns of child emotion dysregulation as predicted by serotonin transporter genotype and parenting Amanda N. Noroña ,et al J Clin Child Adolesc Psychol. 2018 ; 47(SUP1): S354–S368. doi:10.1080/15374416.2017.1326120.

Child serotonin transporter polymorphisms, emotional dysregulation and parenting interactions.�Noroña et al (2018)

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How does the parent genetic profile affect parent caregiving? Morgan et al (2018)

The serotonin transporter-linked polymorphic region (5-HTTLPR) is associated with caregiving in nonhuman animals and with affective and cognitive correlates of human parenting
Morgan et al (2018) studied the effects of the parent serotonin transporter polymorphisms, interacting with parenting behavior, upon stress response and child behavior
One hundred and sixty-two parents (86% mothers) and their 6- to 9-year-old children with and without attention-deficit/hyperactivity disorder were studied using multiple methods including structured interviews, rating scales, and observed parent-child interaction
Parental polymorphisms in the serotonin transporter 5-HTTLPR genotype were determined (either SS/SL/ LL)

Parental Serotonin Transporter Polymorphism (5-HTTLPR) Moderates Associations of Stress and Child Behavior With Parenting Behavior. Morgan, JE et al. J Clin Child Adolesc Psychol 2018;47(sup1):S76-S87

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How does the parent genetic profile affect parent caregiving? Morgan et al (2018)

The study controlled for multiple youth-level (e.g., sex, 5-HTTLPR genotype, disruptive behavior) and parent-level (e.g., demographics, depression, attention-deficit/hyperactivity disorder) factors
RESULTS: Parents with an S allele exhibited significantly less observed positive parenting than those with the LL genotype.
Observed disruptive child behavior was positively associated with parental negativity for both genotypes, but the effect was strongest in SS/SL parents.
The findings suggest that parental 5-HTTLPR is uniquely associated with positive and negative parenting behavior, with more specific patterns according to child-related stress and disruptive child behavior

Parental Serotonin Transporter Polymorphism (5-HTTLPR) Moderates Associations of Stress and Child Behavior With Parenting Behavior. Morgan, JE et al. J Clin Child Adolesc Psychol 2018;47(sup1):S76-S87

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The Science behind ACEs

Resilience

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Resilience �American Academy of Pediatrics: Adverse Childhood Experiences and the Lifelong Consequences of Trauma 2014

Adverse events and protective factors experienced together have the potential to foster resilience.
Our knowledge about what constitutes resilience in children is evolving
We know that several factors are positively related to such protection, including cognitive capacity, healthy attachment relationships (especially with parents and caregivers), the motivation and ability to learn and engage with the environment, the ability to regulate emotions and behavior, and supportive environmental systems.

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Resilience

The ability to withstand or recover from stressors, and results from a combination of intrinsic factors and extrinsic factors (like safe, stable, and nurturing relationships with family members and others) as well as pre-disposing biological susceptibility.

Of note, with scientific advances in the understanding of the impact of stress on neuro-endocrine-immune and genetic regulatory health, we must advance our understanding of resilience as also having neuro-endocrine-immune and genetic regulatory domains.

Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. p xxiv

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Resilience

These relationships are obviously complex, but indicate the interactive effects of parental well-being, perceived quality of life and childhood health.

In a study by Tully et al (2019), they found that parental mood and resilience was directly related to their child’s asthma free days in a group of 217 families with children on Medicaid who had persistent asthma.

Tully C et al. Fam Syst Health 2019 Jun;37(2):167-172.

Relationship between parent mood and resilience and child health outcomes in pediatric asthma

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Family Protective Factors: Bethell et al (2016)

Bethell et al (2016) using the US National Survey of Children’s Health 2011/2012 found that exposure to ACEs is 71% for all US children in fair or poor health.
Additionally, US children exposed to ACEs are substantially and significantly more likely to repeat a grade in school and lack resilience, such as usually or always being able to stay calm and in control when faced with a challenge
The study looked at specific family focused protective factors and their relationship to child emotional, behavioral and mental health conditions (EBM) for children ages 2-17.
Compared with children with no adverse childhood experiences (ACEs),the prevalence of emotional, mental, or behavioral conditions (EMB) is 1.65 to 4.46 times higher across ACEs levels.

Bethell et al Child Adolesc Psychiatr Clin N Am2016 Apr;25(2):139-56.

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Family Protective Factors: Bethell et al (2016)

The prevalence of EMB is 1.45 to 3.62 times higher when the following five family-focused protective factors assessed are missing:
(1) parent-child share ideas and discuss things that matter (rate ratio: 1.92);
(2) parent has met most or all of child's friends and usually or always participates in child's events (rate ratio: 1.45);
(3) parent manages stress and aggravation with parenting (rate ratio: 3.62);
(4) parent copes well with parenting (rate ratio: 1.92); and/or
(5) mother's mental health is excellent or very good (rate ratio: 1.82).
Across all five family-focused protective factors, children with EMB are 1.23 to 1.44 times less likely to live in homes where the five family-focused protective factors exist compared to children without EMB.
Bethell et al Child Adolesc Psychiatr Clin N Am2016 Apr;25(2):139-56.

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Family Protective Factors: Bethell et al (2016)

• Those without resilience and multiple ACEs have nearly 11 times greater adjusted odds of having an EMB compared with children with resilience and no ACEs.

• With resilience, children with EMB and multiple ACEs have 1.85 times higher rates of school engagement and are 1.32 times less likely to miss 2 or more school weeks.

• Resilience is nearly 2 times greater among children with EMB and multiple ACEs when their parents report less parenting stress and more engagement in their child’s lives.

Bethell et al Child Adolesc Psychiatr Clin N Am2016 Apr;25(2):139-56.

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Positive Parenting: Cprek et al (2015)

Cprek et al (2015) used the same survey data (n=21,527) to examine parenting practices and developmental risk in children 1-5 years, controlling for parental education and poverty
Results: Three positive parenting practices that correlate with decreased risk of childhood developmental, social or behavioral delays:

Reading to children
Engaging in storytelling or singing
Eating family meals together
Each was independently correlated, with a dose response relationship, as was total score of all three.

Cprek S etal (2015) Matern Child Health J:19(11): 2403-2411.

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Positive Parenting Matters�Yamaoka et al (2019)

A recent study by Yamaoka et al (2019) used data from 29,997 children ages 0-5 years in the National Survey of Children’s Health 2011/2012
More than a third of the children had at least one ACE.
RESULTS: The number of ACEs was associated with both social-emotional deficits and developmental delay risks BUT positive parenting practices demonstrated robust protective effects (13-17%) independent of the number of ACEs.
This evidence supports promotion of positive parenting practices in the home, especially for children exposed to high levels of adversity.
Yamaoka et al (Am J Prev Med 2019, 56(4):530-539)

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How can we increase positive parenting practices? The role of home visiting programs

Reflective Home Visiting Program: What is that?
These programs support mothers in recognizing their infants' physical and internal states, being themselves a model in their interaction with the mothers and their children.
The Home Visitor, for instance, may try to give voice to the child's mental states, starting from the observation of the here and now interaction between the infant and her/his mother, facilitating wondering and eliciting affects.
In parallel, the Home Visitor addresses the mother's mental states in relation to her caregiving role, her child's characteristics and their relationship.

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Does reflective home visiting make difference? �Vismara et al (2020)

Vismara et al (2020) aimed to investigate the effects of a reflective parenting home visiting program in first time-mothers at risk for depression, anxiety, and parenting stress, from three to 12 months after their child's birth.
The sample was composed by 77 first-time mothers and their healthy babies (53% boys and 47% girls). Mothers filled out the Edinburgh Postnatal Depression Scale, the State-Trait Anxiety Inventory, and the Parenting Stress Index-SF at 3, 6 and 12 months of the child.
Thirty-six mothers were assigned to the experimental group and received the reflective parenting home-visiting program, the other 36 constituted the control group.
Results showed a significant higher reduction in the level of depression, anxiety and parenting stress among mothers belonging to the experimental group, compared to the control group.

Vismara et al (2020) Heliyon Jul 4;6(7):e04292.

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Effects of COVID 19: protective factors�Glynn (2021)

A recent study looked at 169 families of preschool children ages 2-6 years (mean age 4.1 years) in Southern CA, during the stay at home order in 2020.
61% had incomes below the living wage, 46% of the mothers were Latina, and 50% had at least one parent that was an essential workers
Mothers completed the Preschool Feelings Checklist, a 16 item screening tool for depression and other child behavior problems
Parents were asked about family routines, maternal stress and depression, and food insecurity

Glynn et al 2021. Neurobiology of Stress 14, 100291

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Effects of COVID 19: protective factors �Glynn (2021)

Results showed that child behavior issues increased in 64% of the children compared to pre-COVID as reported by the parents
In families employing more routines, rates of child depressive symptoms were lower, and increases in conduct problems during the pandemic less likely
Children who exhibited an increase in conduct problems since the start of the pandemic were more likely to have families exercising fewer routines, even adjusting for family sociodemographic factors and maternal depression/stress.
Glynn et al 2021. Neurobiology of Stress 14, 100291

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Prevention and Early Intervention: The Pediatrician’s Role

Integration of Screening Tools
Observation
Treatment

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The Message:

The attenuating effects of child resilience, parental stress management, and parental engagement suggest promotion of these protective factors by pediatricians.

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Modifiable factors in a pediatric practice to improve outcomes: Traub et al (2017)

Traub et al (2017) suggests 10 evidence based practices for pediatricians:

Train all pediatric clinical staff in the principles of trauma informed care
Screen pediatric practices for screening for ACEs, resilience, parental ACEs
Employ non-MDs to screen and offer family education
Create a medical home for children with ACEs
Integrate Behavioral and Physical Health Care in the office
Offer group based parenting education
Offer peer based group education to children with ACEs
Customize pediatric care to family needs
Familiarize staff with community resources
Be aware of barriers to engaging families of children with ACEs
Modifiable Resilience Factors to Childhood Adversity for Clinical Pediatric Practice.Traub F, Boynton-Jarrett R, Pediatrics. 2017 May;139(5):e20162569. doi: 10.1542/peds.2016-2569.

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Screening for ACEs & Risk of Toxic Stress & Providing Evidence-Based Treatment

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What can we do as pediatricians?�

Screen for child ACEs with Part 1 of the PEARLS and for SDOH with Part 2 of the PEARLS starting at 1 year of age
Use the ACEs clinical algorithm and ACEs provider toolkit for the appropriate clinical response
Screen for parental ACEs and maternal depression within the first few months of life
Screen children for developmental progress including social-emotional development using the ASQ-3 at well child visits, including 9, 18 and 30 months of age
Utilize the opportunity to advise parents about stress, stress “busters” and effects of the toxic stress response upon both child health and development
Utilize the services provided by First 5/Help Me Grow, the Medical Home Project, Family Resource Navigators the Regional Center and other community supports for Prevention and Early Intervention

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Pediatric ACEs and Related Life-events Screener (PEARLS) – Child ��Part 1 as shown here is the de-identified version for ACEs and Part 2 is the identified version for other adversities that may be risk factors for toxic stress.

Talking points:

This is the de-identified version of the PEARLS tool.

The caregiver counts the number of ACE categories on the screening tool that their child has experienced and indicates only the total score — without identifying which ACE(s) their child experienced. This focuses on how many ACEs the patient has experienced in order to assess level of risk of toxic stress, and does NOT focus on the ACE categories experienced.

Only Part 1/Top section of questions is used to calculate the ACE score (10 ACE categories).

Part 2/Bottom section of questions asks about history of other adversities that may be risk factors for toxic stress, including some social determinants of health (SDOH) such as exposure to violence, discrimination, and housing & food insecurity, and other potential risk factors for toxic stress, such as separation from or death of a parent or caregiver, or living with a parent or caregiver with serious illness or disability.

Note that Part 2 asks about a history of these potential risk factors to help assess level of risk for toxic stress, but they do not ask about current needs related to SDOHs. However, there may be follow up conversation between the provider and patient about their score on this section to inform additional follow-up.

Source:

27. “Screening Tools, PEARLS in English.” ACEs Aware, 16, Nov. 2020, www.acesaware.org/wp-content/uploads/2019/12/PEARLS-Tool-Child-Parent-Caregiver-Report-De-Identified-English.pdf

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ACEs and Toxic Stress Risk Assessment Algorithm – Pediatrics

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Full algorithm is available at: ACEsAware.org/clinical-assessment

This is here as a reminder that the ACEs and Toxic Stress Risk Assessment involves the “triad”

ACE screen
Assessment for ACE associated health conditions
Assessment of protective factors

“A complete ACE screen involves assessing for the triad of adversity (ACE score), clinical manifestations of toxic stress (ACE- Associated Health Conditions, AAHCs), and protective factors. The first two components are used in assessing clinical risk for toxic stress and all three help to guide effective responses.”

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812 (p. 79).

This clinical algorithm provides guidance to clinicians about using the score on the PEARLS, then assessing for ACE Associated Health conditions, and using your physical exam and clinical assessment to develop the appropriate response. This will include education about ACEs and toxic stress and resilience, identifying protective factors, and referral to support services as appropriate and of course, follow up.

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Clinical Response Overview

Clinical response to identification of ACEs and increased risk of toxic stress should include:

Validating existing strengths and protective factors
Referrals to patient resources or interventions, such as educational materials, social work, school agencies, care coordination or patient navigation, and community health workers
Follow up as necessary, using the presenting ACE-Associated Health Condition(s) �as indicators of treatment progress

For information on the clinical response to ACEs and toxic stress, �visit ACEsAware.org/assessment-and-treatment

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. (p. 79-80)

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Clinical Response Overview

Clinical response to identification of ACEs and increased risk of toxic stress should include:

Applying principles of trauma-informed care, such as establishing trust, safety, and collaborative decision-making
Supplementing usual care for ACE-Associated Health Conditions by providing patient education on toxic stress and offering strategies to regulate the stress response, including:

Supportive relationships, including with caregivers (for children), other family members, and peers
High-quality, sufficient sleep
Balanced nutrition
Regular physical activity
Mindfulness and meditation
Experiencing nature
Mental health care, including psychotherapy or psychiatric care, and substance use disorder treatment, when indicated

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. (p. 79-80)

We recognize that for the supplemental trainings you may be doing a deeper dive into a piece of the clinical response. Our request is that you frame your work to reflect how it fits into the larger ACEs picture.

So for example, if your training will be on healthy relationships – then having a slide such as this one in the beginning where you can highlight that there are a number of ways to buffer and treat toxic stress and that your training will primarily focus on 2a – supportive relationships.

Source: Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812. (p. 79-80)

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Three guiding principles for prevention strategies: Shonkoff et al (2021)

Number 1: Support responsive relationships:

promoting “safe, stable, and nurturing relationships” including managing perinatal depression, and fostering male caregiver engagement,
encouraging developmentally appropriate play, discouraging screen time and promoting shared book reading
encouraging “serve and return” interactions between young children and the adults who care for them
When caregivers have difficulties interacting with their children, relationship-focused coaching can make an important difference, including partnering with home visiting programs and Early Childhood Mental Health programs

Shonkoff etal, Pediatrics 2021:147(2), e20193845

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Three guiding principles for prevention strategies: Shonkoff et al (2021)

Number 2. Reduce sources of stress:

Interventions that lessen economic, psychosocial, and health burdens on families, many of which are associated with structural inequities that are beyond the capacity of pediatricians to address directly, increase adult bandwidth for providing positive caregiving.
Financial supports to help meet basic needs (eg, rent, food, diapers) and interventions that reduce more proximal stressors on neurobiological, immune, and metabolic systems (eg, poor nutrition, environmental toxicants, chronic microbial exposures) all contribute to promoting the healthy development of young children.
through linkages to resources and coordination of needed services with community partners such as Help Me Grow

Shonkoff etal, Pediatrics 2021:147(2), e20193845

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Three guiding principles for prevention strategies: Shonkoff et al (2021)

Number 3. Strengthen core skills to provide a well-regulated caregiving environment:

The development of the brain and other biological systems is facilitated by regularized daily routines (eg, mealtime, sleep time, play) scaffolded by caregivers with the skills needed to provide an environment of stability and predictability.
The capacities of parents and other primary caregivers to set and meet goals and manage their own behavior and emotions can be strengthened through coaching and practice.
Integrated behavioral health services offer a variety of models and strategies for providing such interventions within the medical home

Shonkoff etal, Pediatrics 2021:147(2), e20193845

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What have we learned today?

Figure legend as talking points: "This figure presents a transdisciplinary model that describes “stress” as a set of interactive and emergent processes. The figure illustrates that stressors are experienced within the context of a person’s life, represented by the contextual factors in the blue triangle. These contextual factors include individual-level characteristics such as personality and demographic factors, the environment in which one lives, current and past stressor exposures, and protective factors; all of which combine to determine the baseline allostatic state of physiological regulation, and the lens through which stressors are perceived and assigned meaning. Contextual factors and habitual processes together influence psychological and physiological responses to acute and daily stressors. These responses, if dysregulated, are thought to lead to allostatic load and ultimately biological aging and early disease."

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Resources:

ACESaware.org-Provider Toolkit and Roadmap to Resilience
American Academy of Pediatrics aap.org- Trauma Toolkit
My contact information: drrwachtel@aol.com

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Questions????

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