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Journal of Child and Adolescent Psychiatric Nursing
ISSN 1073-6077
Commentary
A Call to Action: Reducing Toxic Stress During Pregnancy and Early Childhood
Since the 1990s, Vincent Felitti’s team has published results of research on Adverse Childhood Experiences, illuminating the relationship between adverse events in childhood and a lifetime of physical and mental health disparities (Felitti et al., 1998). The National Research Council and Institute of Medicine (2000) report, “From Neurons to Neighborhoods: The Science of Early Childhood Development,” set forth a national agenda to reduce health disparities through early childhood intervention. Subsequent research has revealed the impact of adversity and toxic stress at even earlier stages of fetal development (Bock, Rether, Groger, Xie, & Braun, 2014; Gluckman, Hanson, Cooper, & Thornberg, 2008; Shonkoff, Boyce, & McEwen, 2009). The importance of addressing toxic stress during pregnancy and early childhood is gaining national attention and momentum. In 2014, the American Academy of Nursing identified toxic stress in childhood as a top priority for improving the health of populations (Mason & Cox, 2014). Nurses are called to action to safeguard the health and potential of children through the reduction of toxic stress exposures for mothers and children. Why is this body of research important to psychiatric nurses, and how can we contribute to this national effort? The aim of this column is to review key research findings that call psychiatric nurses to action to prevent, recognize, and intervene early to reduce the devastating effects of toxic stress. The National Scientific Council on the Developing Child (NSCDC, 2005/2014) has defined toxic stress as “strong, frequent, or prolonged activation of the body’s stress management system” (p. 2). Maternal exposures to toxic stress during pregnancy impact the developing brain of the fetus, altering the architecture of brain circuits and regions responsible for executive functions and emotional/behavioral regulation. The pregnant mother and her fetus are a biological system. Fetal development actively adapts to the physical state and health of the mother (Gluckman et al., 2008). The adaptive response of the maternal-fetal system prioritizes essential functions for maternal survival. Under high levels of stress, adaptive responses of the neuroendocrine, autonomic, and immunological systems assure the survival of the mother but can exert a toll on fetal development and growth. A consequence of these systemic adaptive responses to toxic maternal stress is the development of a fetal brain that is biologically doi: 10.1111/jcap.12106
70
wired for stress reactivity, impulsivity, and prolonged activation of survival mechanisms (NSCDC, 2005/2014; Shonkoff et al., 2009). The impact on child development can include “functional scars” in brain regions necessary for emotional regulation, attention, problem solving, and learning (Bock et al., 2014). Pregnant women who are exposed to toxic levels of stress through impoverished living conditions, inadequate food and shelter, domestic violence, and unsafe homes and neighborhoods unknowingly contribute to the “biological embedding” of health risks in their children (Shonkoff et al., 2009). An infant born into this stressful environment sustains further risks through the continuation of toxic stress exposures during his or her first years of life (Gluckman et al., 2008). Unmitigated adverse childhood experiences are associated with a host of poor mental health outcomes, including depression, suicidality, anxiety disorders, personality disorders, and substance use disorders (Chapman, Dube, & Anda, 2007). With the accumulation of four or more adverse exposures during childhood, the risk for depression increases fourto five-fold and the risk for suicidality increases 12-fold (Burke-Harris, 2014). The developing brain is especially malleable to the effects of risk and protective factors during infancy and the first 5 years of life (NSCDC, 2005/2014; Shonkoff et al., 2009). Animal research conducted by Michael Meaney (2001, 2010) and colleagues identified the effects of responsive maternal behaviors on hippocampal resilience of offspring exposed to stress. Human studies have followed. A study by Luby et al. (2013) used neuroimaging to detect reduced hippocampal volumes in children exposed to early stressful environments. In Luby’s study, parental nurturance buffered the detrimental effects of stressful environments on hippocampal development in children. The buffering effects of early protective relationships are essential to support healthy brain development and ameliorate the effects of toxic stress exposures for infants and young children. The first 5 years of a child’s life is a period of rapid brain development, and a time of unique opportunity for interventions that reduce or moderate the effects of toxic stress exposures.Reducing the toxic stress of pregnant mothers and intervening early to engender nurturing parenting practices has the potential for multigenerational effects,improving the life course of parents, children, and future generations. The Nurse Family Partnership and the Chicago Parent Program are examples of programs that have demonstrated Journal of Child and Adolescent Psychiatric Nursing 28 (2015) 70–71 © 2015 Wiley Periodicals, Inc.
Commentary
the positive effects of early parenting interventions on child outcomes (Breitenstein et al., 2012; Kitzman et al., 2010). Nurses and healthcare providers have an opportunity and a responsibility to assess and intervene to reduce adverse events and toxic stress exposures in pregnant women and young children. An assessment of even one adverse event increases the likelihood of multiple toxic stress exposures, and should “serve as a signal” to health professionals that intervention is needed (Anda et al., 2006, p. 363). Psychiatric nurses encounter pregnant mothers, infants, and young children in multiple settings and have an important role in public education, primary prevention, early intervention, referral, and advocacy to assure healthy environments for women and children, thereby influencing the future potential, mental and physical health, and quality of life for generations of individuals and families who may come within our care. Janiece DeSocio, PhD, RN, PMHNP-BC, FAAN Professor College of Nursing Seattle University Seattle, WA, USA Author contact: [email protected], with a copy to the Editor: [email protected] References Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–186. Bock, J., Rether, K., Groger, N., Xie, L., & Braun, K. (2014). Perinatal programming of emotional brain circuits: An integrative view from systems to molecules. Frontiers in Neuroscience, 8(11), 1–16. Breitenstein, S. M., Gross, D., Fogg, L., Ridge, A., Garvey, C., Julion, W., & Tucker, S. (2012). The Chicago Parent Program: Comparing 1-year outcomes for African American and Latino parents of young children. Research in Nursing & Health, 35, 475–489. Burke-Harris, N. (2014). How childhood trauma effects health across a lifetime. TED Talk. Retrieved from http://www.ted .com/talks/nadine_burke_harris_how_childhood_trauma_ affects_health_across_a_lifetime
Journal of Child and Adolescent Psychiatric Nursing 28 (2015) 70–71 © 2015 Wiley Periodicals, Inc.
Chapman, D. P., Dube, S. R., & Anda, R. F. (2007). Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals, 37(5), 359–364. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Sapitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. Gluckman, P. D., Hanson, M. A., Cooper, C., & Thornberg, K. L. (2008). Effect of in utero and early-life conditions on adult health and disease. New England Journal of Medicine, 359(1), 61–73. Kitzman, H. J., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., & Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children. Archives of Pediatric and Adolescent Medicine, 164(5), 412–418. Luby, J., Belden, A., Botteron, K., Marrus, N., Harms, M. P., Babb, C., . . . Barch, D. (2013). The effects of poverty on childhood brain development: The mediating effect of caregiving and stressful life events. JAMA Pediatrics, 167(12), 1135–1142. Mason, D. J., & Cox, K. (2014). Toxic stress in childhood: Why we all should be concerned. Nursing Outlook, 62(2014), 382–383. Meaney, M. J. (2001). Maternal care, gene expression, and the transmission of individual differences in stress reactivity across generations. Annual Review of Neuroscience, 24, 1161–1192. Meaney, M. J. (2010). Epigenetics and the biological definition of gene × environment interactions. Child Development, 81(1), 41–79. National Research Council and Institute of Medicine. (2000). J. P. Shonkoff & D. A. Phillips (Eds.), From neurons to neighborhoods: The science of early child development. Washington, DC: National Academy Press. Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. National Scientific Council on the Developing Child. (2005/2014). Excessive stress disrupts the architecture of the developing brain: Working paper 3. Retrieved from http://www.developingchild.harvard.edu Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252–2259.
71
Copyright of Journal of Child & Adolescent Psychiatric Nursing is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Journal of Child and Adolescent Psychiatric Nursing
ISSN 1073-6077
Commentary
A Call to Action: Reducing Toxic Stress During Pregnancy and Early Childhood
Since the 1990s, Vincent Felitti’s team has published results of research on Adverse Childhood Experiences, illuminating the relationship between adverse events in childhood and a lifetime of physical and mental health disparities (Felitti et al., 1998). The National Research Council and Institute of Medicine (2000) report, “From Neurons to Neighborhoods: The Science of Early Childhood Development,” set forth a national agenda to reduce health disparities through early childhood intervention. Subsequent research has revealed the impact of adversity and toxic stress at even earlier stages of fetal development (Bock, Rether, Groger, Xie, & Braun, 2014; Gluckman, Hanson, Cooper, & Thornberg, 2008; Shonkoff, Boyce, & McEwen, 2009). The importance of addressing toxic stress during pregnancy and early childhood is gaining national attention and momentum. In 2014, the American Academy of Nursing identified toxic stress in childhood as a top priority for improving the health of populations (Mason & Cox, 2014). Nurses are called to action to safeguard the health and potential of children through the reduction of toxic stress exposures for mothers and children. Why is this body of research important to psychiatric nurses, and how can we contribute to this national effort? The aim of this column is to review key research findings that call psychiatric nurses to action to prevent, recognize, and intervene early to reduce the devastating effects of toxic stress. The National Scientific Council on the Developing Child (NSCDC, 2005/2014) has defined toxic stress as “strong, frequent, or prolonged activation of the body’s stress management system” (p. 2). Maternal exposures to toxic stress during pregnancy impact the developing brain of the fetus, altering the architecture of brain circuits and regions responsible for executive functions and emotional/behavioral regulation. The pregnant mother and her fetus are a biological system. Fetal development actively adapts to the physical state and health of the mother (Gluckman et al., 2008). The adaptive response of the maternal-fetal system prioritizes essential functions for maternal survival. Under high levels of stress, adaptive responses of the neuroendocrine, autonomic, and immunological systems assure the survival of the mother but can exert a toll on fetal development and growth. A consequence of these systemic adaptive responses to toxic maternal stress is the development of a fetal brain that is biologically doi: 10.1111/jcap.12106
70
wired for stress reactivity, impulsivity, and prolonged activation of survival mechanisms (NSCDC, 2005/2014; Shonkoff et al., 2009). The impact on child development can include “functional scars” in brain regions necessary for emotional regulation, attention, problem solving, and learning (Bock et al., 2014). Pregnant women who are exposed to toxic levels of stress through impoverished living conditions, inadequate food and shelter, domestic violence, and unsafe homes and neighborhoods unknowingly contribute to the “biological embedding” of health risks in their children (Shonkoff et al., 2009). An infant born into this stressful environment sustains further risks through the continuation of toxic stress exposures during his or her first years of life (Gluckman et al., 2008). Unmitigated adverse childhood experiences are associated with a host of poor mental health outcomes, including depression, suicidality, anxiety disorders, personality disorders, and substance use disorders (Chapman, Dube, & Anda, 2007). With the accumulation of four or more adverse exposures during childhood, the risk for depression increases fourto five-fold and the risk for suicidality increases 12-fold (Burke-Harris, 2014). The developing brain is especially malleable to the effects of risk and protective factors during infancy and the first 5 years of life (NSCDC, 2005/2014; Shonkoff et al., 2009). Animal research conducted by Michael Meaney (2001, 2010) and colleagues identified the effects of responsive maternal behaviors on hippocampal resilience of offspring exposed to stress. Human studies have followed. A study by Luby et al. (2013) used neuroimaging to detect reduced hippocampal volumes in children exposed to early stressful environments. In Luby’s study, parental nurturance buffered the detrimental effects of stressful environments on hippocampal development in children. The buffering effects of early protective relationships are essential to support healthy brain development and ameliorate the effects of toxic stress exposures for infants and young children. The first 5 years of a child’s life is a period of rapid brain development, and a time of unique opportunity for interventions that reduce or moderate the effects of toxic stress exposures.Reducing the toxic stress of pregnant mothers and intervening early to engender nurturing parenting practices has the potential for multigenerational effects,improving the life course of parents, children, and future generations. The Nurse Family Partnership and the Chicago Parent Program are examples of programs that have demonstrated Journal of Child and Adolescent Psychiatric Nursing 28 (2015) 70–71 © 2015 Wiley Periodicals, Inc.
Commentary
the positive effects of early parenting interventions on child outcomes (Breitenstein et al., 2012; Kitzman et al., 2010). Nurses and healthcare providers have an opportunity and a responsibility to assess and intervene to reduce adverse events and toxic stress exposures in pregnant women and young children. An assessment of even one adverse event increases the likelihood of multiple toxic stress exposures, and should “serve as a signal” to health professionals that intervention is needed (Anda et al., 2006, p. 363). Psychiatric nurses encounter pregnant mothers, infants, and young children in multiple settings and have an important role in public education, primary prevention, early intervention, referral, and advocacy to assure healthy environments for women and children, thereby influencing the future potential, mental and physical health, and quality of life for generations of individuals and families who may come within our care. Janiece DeSocio, PhD, RN, PMHNP-BC, FAAN Professor College of Nursing Seattle University Seattle, WA, USA Author contact: [email protected], with a copy to the Editor: [email protected] References Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–186. Bock, J., Rether, K., Groger, N., Xie, L., & Braun, K. (2014). Perinatal programming of emotional brain circuits: An integrative view from systems to molecules. Frontiers in Neuroscience, 8(11), 1–16. Breitenstein, S. M., Gross, D., Fogg, L., Ridge, A., Garvey, C., Julion, W., & Tucker, S. (2012). The Chicago Parent Program: Comparing 1-year outcomes for African American and Latino parents of young children. Research in Nursing & Health, 35, 475–489. Burke-Harris, N. (2014). How childhood trauma effects health across a lifetime. TED Talk. Retrieved from http://www.ted .com/talks/nadine_burke_harris_how_childhood_trauma_ affects_health_across_a_lifetime
Journal of Child and Adolescent Psychiatric Nursing 28 (2015) 70–71 © 2015 Wiley Periodicals, Inc.
Chapman, D. P., Dube, S. R., & Anda, R. F. (2007). Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals, 37(5), 359–364. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Sapitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. Gluckman, P. D., Hanson, M. A., Cooper, C., & Thornberg, K. L. (2008). Effect of in utero and early-life conditions on adult health and disease. New England Journal of Medicine, 359(1), 61–73. Kitzman, H. J., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., & Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children. Archives of Pediatric and Adolescent Medicine, 164(5), 412–418. Luby, J., Belden, A., Botteron, K., Marrus, N., Harms, M. P., Babb, C., . . . Barch, D. (2013). The effects of poverty on childhood brain development: The mediating effect of caregiving and stressful life events. JAMA Pediatrics, 167(12), 1135–1142. Mason, D. J., & Cox, K. (2014). Toxic stress in childhood: Why we all should be concerned. Nursing Outlook, 62(2014), 382–383. Meaney, M. J. (2001). Maternal care, gene expression, and the transmission of individual differences in stress reactivity across generations. Annual Review of Neuroscience, 24, 1161–1192. Meaney, M. J. (2010). Epigenetics and the biological definition of gene × environment interactions. Child Development, 81(1), 41–79. National Research Council and Institute of Medicine. (2000). J. P. Shonkoff & D. A. Phillips (Eds.), From neurons to neighborhoods: The science of early child development. Washington, DC: National Academy Press. Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education. National Scientific Council on the Developing Child. (2005/2014). Excessive stress disrupts the architecture of the developing brain: Working paper 3. Retrieved from http://www.developingchild.harvard.edu Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252–2259.
71
Copyright of Journal of Child & Adolescent Psychiatric Nursing is the property of WileyBlackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
