Build the therapeutic alliance; surveil for possible barriers to SSNRs; champion screening at practice level; endorse referral resources. Pediatrics August 2021; 148 (2): e2021052582. 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 multigenerational perspective is fundamental. Taken together, these diverse lines of inquiry suggest that it may not actually be the wide spectrum of childhood adversity that drives poor outcomes but the degree to which that adversity drives shame, guilt, anger, alienation, disenfranchisement, and degree of social isolation.181,182 If so, the proposed public health approach toward the promotion of SSNRs is needed, not only to buffer adversity and promote resilience but also to begin bridging political, religious, economic, geographic, identity-based, and ideological divides that increase social isolation, encourage tribalism, diminish empathy, and, ultimately, drive poor outcomes in the medical, educational, social service, and justice systems. In the presence of SSNRs, a limited degree of childhood adversity (eg, normative childhood frustrations and setbacks) can lead to the positive stress responses that build the rudiments of resilience: a set of social and emotional skills that allow children to adapt to future adversity in a healthy manner. Recent research suggests that this dyadic need to connect promotes the development of biobehavioral synchrony between parents and infants.119,120 Feldman119 states, Such coordination is observed across four systems: the matching of nonverbal behavior; the coupling of heart rhythms and autonomic function; the coordination of hormone release [eg, oxytocin following contact with both mothers and fathers]; and brain to brain synchrony [eg, coordinated brain oscillation in alpha and gamma rhythms]. Because the human brain is so immature at birth, the infant is dependent on this biobehavioral synchrony not only for survival but also for laying the foundation for future self-regulation and social-emotional skills. SSNRs not only buffer adversity when it occurs but also proactively build the foundational social and emotional skills that lead to resilience in the face of future adversity. The previous policy statement12 and technical report2 on childhood toxic stress noted the 10 adverse childhood experiences (ACEs) studied in the landmark ACEs Study that began in the 1990s: physical, emotional, or sexual abuse; physical or emotional neglect; problematic parental substance misuse; parental mental illness; parental separation or divorce; intimate partner violence; and an incarcerated house member.23 These adversities are associated with a wide array of negative outcomes in a dose-dependent manner, such that the higher the ACE score (1 point for each category experienced before the age of 18 years), the higher the risk for unhealthy behaviors such as tobacco, alcohol, and other substance use; risky sexual behaviors; and obesity.23,24 Dose-dependent relationships have also been found between ACE scores and several of the leading causes of adult morbidity and mortality,23,24 including cardiovascular disease,25 lung disease,26 liver disease,27 mental illness,28 and cancer.29, These well-established associations between ACEs and poor health outcomes decades later highlight the importance of understanding the biological mechanisms that allow adversity in childhood to get under the skin and to negatively impact life-course trajectories.3036 As discussed in the 2012 AAP technical report,2 toxic stress responses, in which the physiologic stress response to adversity is large, chronic, and unmitigated by social-emotional buffers, are one such mechanism. 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. Communication could be further enhanced by cultural humility,164,165 implicit bias training,166171 a more diverse health care team (eg, providing families and patients the opportunity to seeing themselves reflected in the sex, ethnicity, and cultural backgrounds of the team members), and access to professional interpreters. Chp 2- evolutionary theories Theories of development Theories give a certain perspective Advantages: narrows down way to look at things Negatives: disadvantages to see everything around that one theory (it filters out too many things) Depending on what you are looking at may add different theories NOT JUST 1 5 theories will be seen (removing evolutionary)-Psychoanalytic theories-Humanistic . Biobehavioral synchrony refers to the matching of nonverbal behaviors (eg, eye contact), coupling autonomic functions (eg, heart rate), coordination of hormone release (eg, oxytocin), and alignment of brainwaves between a parent and an infant. These are just a few examples of the many philosophical perspectives that exist on the analysis of society. Three indicators of flourishing are amenable to parental report and are rough markers of executive function: (1) the child shows interest and curiosity in learning new things, (2) the child works to finish tasks he or she starts, and (3) the child stays calm and in control when faced with a challenge.59 In analyses of data from the 20162017 National Survey of Childrens Health, the prevalence of flourishing children increased in a graded fashion with increasing levels of family resilience and connection.59 In fact, a higher percentage of children with high adversity (ACE scores 49) but high family connection and resilience were flourishing (30.5%) than children with low adversity (ACE score of 0) but low family resilience and connection (26.8%).59 Approaches to minimizing toxic stress that only look at measures of adversity (such as ACE scores or biomarkers) will miss out on opportunities to support the relational health that promotes flourishing despite adversity. The ecobiodevelopmental theory has four key components regarding the domains, timing, intensity, and biological vulnerability related to environmental chaos. Emphasizing that the vertical integration of this public health approach or the layering of primary, secondary, and tertiary preventions and/or interventions is necessary because the heterogeneity of responses to adversity seen at the population level will need to be addressed through a menu of programs that are layered and matched to specific levels of individual need (universal preventions, plus targeted interventions for those at risk, plus indicated therapies for those with symptoms or diagnoses). The FCPMH alone cannot leverage significant change within the community context. 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. Approximately 15.5 million children in the United States reside in households in which interpersonal violence is recurrent. Finally, to develop the physician leadership for the FCPMHs of the future, pediatric training programs will need to: Educate residents about the ecobiodevelopmental model and the implications for not only health care but education, juvenile justice, and public policy. Ecological includes experiences in a child's home environment, such as reading, talking, teaching,. An important consideration across many harmed and exploited communities (such as American Indian or Alaska Native populations) is the accumulation of toxic stress responses across generations, sometimes referred to as historical trauma.60 Although higher levels of historical trauma are associated with poorer health outcomes, the science underlying these associations is only now being studied rigorously.61 A detailed discussion of historical trauma and the special needs of these communities is beyond the scope of this policy statement, but the layered, integrated public health approaches presented here to prevent childhood toxic stress and promote relational health might inform efforts to address historical trauma as well. 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. The quoted material in this entry is from Ellis BJ. Relational health 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. Reaffirming an ecobiodevelopmental framework2 because early childhood experiences, both adverse and nurturing, are biologically embedded and influence the development of both disease and wellness later in life. Refers to efforts to repair the harm that occurs with unjust behaviors, as opposed to retributive or punitive justice, which simply punishes those who have acted unjustly. Dara's parents both work for a corporation that expects them to work for 50 hours a week. Proposing that the public health approach also be integrated horizontally across multiple public service sectors (eg, health care, behavioral health, education, social services, justice, and faith communities) because SSNRs are promoted in safe, stable, and nurturing families that have access to safe, stable, and nurturing communities with a wide range of resources and services. 7. The use of trusted, supportive relationships within the FCPMH to promote the relational health of families is an emerging focal point for pediatric clinical research, and pediatric primary care is increasingly seen as a venue for fostering social-emotional health.193,194 These universal primary prevention strategies form the base of the public health pyramid (Fig 1 and Table 2), but additional, layered interventions that recognize and address child-level (eg, delays in development and a biological sensitivity to context), family-level (eg, poverty and parent mental illness), and community-level (eg, racism and violence) barriers to SSNRs may also be required for some families, whereas others will need even more intensive, evidence-based treatments (eg, ABC, PCIT, CPP, TF-CBT) to repair relationships that are already strained or compromised. 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. Explain how human development is rooted in biological processes that have evolved to promote adaptation and survival. Although this term is frequently used to refer to the childs experiences (child ACEs), it has also been applied to the adversities that parents experienced during their own childhoods (parental ACEs). For example, the AAP currently recommends screening parents for postpartum depression90 and food insecurity.87,88 Similarly, when clinical markers for an individual childs biological sensitivity to context9194 (see the Appendix for a glossary of terms, concepts, and abbreviations) are available, children of high (versus low) sensitivity may also benefit from different types of interventions.95 In concordance with a layered public health approach, these various targeted interventions will supplement but not replace the universal primary preventions. Andrew Garner, Michael Yogman; COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, COUNCIL ON EARLY CHILDHOOD, Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health. Learning Objective: Describe the structure and function of genes. 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.