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The high cost of toxic stress in children

Investing in new tools, solutions to create a healthier Rhode Island

Rhode Island Kids Count

The cover image of the 2013 Rhode Island Home Visitation Annual Report, including the Nurse-Family Partnership program in Rhode Island, one of the programs that helps new parents develop parenting skills.

By Richard Asinof
Posted 2/2/15
The dots are being connected around toxic stress, poverty, primary care interventions, and brain research in Rhode Island.
The link between poverty, chronic stress and adverse changes in early brain development in children has been added as a new factor in measuring the health and well-being of children in Rhode Island, in the latest briefing paper published by Rhode Island Kids Count.
A new screening tool is being developed to identify and diagnose toxic stress in primary care practices in Rhode Island.
Healthy housing has been proposed as a public employee benefit in Providence.
And new research at Butler Hospital has identified biological changes at the cellular level linked to childhood adversity and psychiatric disorders.
When will the Brown School of Public Health convene a conference on toxic stress, bringing together brain researchers, healthy housing advocates, childhood education advocates and primary care providers? What kinds of new collaborative research proposals can be created to support the work underway in Rhode Island? Will Sen. Joshua Miller convene a hearing so that legislators can be briefed on the ongoing efforts to address toxic stress in Rhode Island? Are there specific correlations that can be identified between lead exposure and the incidence of toxic stress? How can the ROI for a green and healthy home public employee benefit be quantified as a way for the city – and the state – to save money?
Much of the work that occurs on toxic stress appears to be done in silos, with little opportunity for common ground. Green and healthy homes advocates, for instance, were not at the table when Rhode Island Kids Count convened its conference to discuss its new brief on child poverty in Rhode Island. At the same time, many primary care providers are unaware of the new screening tools being developed around toxic stress, while the work by researchers at Butler Hospital in identifying biological changes caused by childhood adversity – and its potential relationship to addiction – has not become part of the conversation. A Rhode Island-based conference, hosted by the Brown School of Public Health, might serve as a catalyst for a larger, inclusive conversation.

PROVIDENCE – The Rhode Island Kids Count issue brief, “Child Poverty in Rhode Island” was a front-page news story, above the masthead, in The Providence Journal on Jan. 22, even taking precedence over the growing brouhaha known as DeflateGate.

As such, a copy of the story was dutifully included as a handout in the press kit when the official roundtable was convened later that morning, featuring Elizabeth Burke Byant and Stephanie Geller from Rhode Island Kids Count, and Susan Lusi, superintendent from the Providence Public Schools.

The newspaper story captured the basic fact that Rhode Island’s rate for children living in poverty was the highest in New England, at 21 percent, with some 10 percent of the state’s children living in severe poverty.

Missing, however, was the context: the briefing paper offered a detailed analysis of the growing structural poverty in Rhode Island, undercutting the popular presumption that a strong economy lifts all boats.

There were a lot of families who are not making it in Rhode Island, despite the current economic uptick, as the briefing paper documented.

21.5 percent, or 44,923 of Rhode Island’s 208,700 children under the age of 18, lived below the federal poverty level in 2013, the highest poverty rate for children in New England.

9 percent, or 19,262 of Rhode Island’s children lived in extreme poverty – $9,385 for a family with two children and $11,812 for a family of four with two children.

• More than half [53 percent] of all poor children in Rhode Island were White; more than one-third [38 percent] were ages 5 and younger; and more than three-quarters [76 percent] of poor children lived in single-parent homes.

• Rhode Island’s four core cities – Providence [39.7 percent], Pawtucket [28.9] percent, Central Falls [41 percent] and Woonsocket [42 percent] – had the highest poverty rates for children in Rhode Island.

Toxic stress, brain development and poverty
The Providence Journal story also glanced over the critical connection made by the briefing paper: the link between poverty, stress, children, and adverse changes in early brain development.

For the first time in a Rhode Island Kids Count publication, the issue brief directly connected the negative effects of poverty to chronic, toxic stress, based on research, saying: “Poverty is linked to chronic stress, which adversely alters early brain development that serves as the basis for learning, behavior and health later in life.” Wow!

The Providence Journal’s story briefly touched upon this breakthrough finding. But, when it did, the newspaper changed its tone of voice: all the other information was reported as undisputed fact, but the impact of chronic stress was cast as an assertion: “The agency  asserts [emphasis added] that poverty, and the chronic stress it places on children, often results in adolescent and adult difficulties, including physical and behavioral problems, teen pregnancies and unemployment.”

It wasn’t only The Providence Journal that underplayed the findings on toxic stress. In a seven-minute report, Rhode Island Public Radio failed to mention it, despite specific wording in the advanced, embargoed news release that said: “Poverty is linked to chronic – or toxic – stress, which negatively impacts early brain development that serves as the basis for learning, behavior and health later in life.”

The role that toxic stress plays in children’s health – and in future brain development – is not a new discovery, per se. In the Sept. 22, 2013, story, “Toxic stress, where doctors, lawyers, nurses and brain scientists converge,” ConvergenceRI had connected the dots.

The story detailed the ongoing research, connecting the work being done to develop new guidelines to diagnose and treat toxic stress by Rhode Island pediatricians, the teaching of toxic stress as part of the curriculum at the Brown University Medical School, and new research underway at Butler Hospital. [See link to ConvergenceRI story below.]

What is news is that Rhode Island Kids Count has now added toxic stress as a new metric in its measurement of the health and well-being of Rhode Island’s children, related to brain development.

A significant addition
Bryant, the executive director of Rhode Island Kids Count, acknowledged that the inclusion of toxic stress as a new finding was a significant addition, in an interview with ConvergenceRI on Jan. 21, the day before the issue briefing’s release.

“Research has been very compelling when you look at children’s brain development, and the significant impacts that result from the more stressors in a child’s life [from poverty],” Bryant said. “Children in low-income families are more likely to experience more stress factors over a longer period of time.”

The research shows that such stress influences the brain’s ability to react to stress and to bounce back,” she continued.

In terms of solutions, Bryant pointed to the issue brief’s position that early interventions are more effective than later interventions, and that targeted interventions can improve children’s outcomes and close gaps between low- and higher-income children.

For Bryant, beyond nutrition, childcare and housing assistance, one of the keys is investment in early education.

“In the long view, let’s start right now, and pay attention to education. Education has been the way out of poverty for generations, staring with early childhood education” she said. We need to make sure, she continued, that Rhode Island have “access to high-quality education no matter where they live.”

Assessment tool for toxic stress
A training program for primary care providers and home visiting staff to screen families of infants and young children for toxic stress is now being developed, according to Dr. Ailis Clyne, president of the Rhode Island chapter of the American Academy of Pediatrics, or RIAPP.

The goal, Clyne told ConvergenceRI in an earlier interview, “is to develop an assessment tool to screen for toxic stress and develop a mechanism for referral.”

The pioneering effort puts Rhode Island at the forefront, because there isn’t an evidence-based assessment tool that exists for diagnosing toxic stress, Clyne explained.

The components of the new training program, which will hopefully be finalized later this spring, will feature online self-learning modules as well as in-person workshops, according to Clyne.

The focus of workshops will be a practical, detailed review of the screening tool: how primary care practitioners would incorporate the screening tool as part of an office visit or a well child visit.

A second workshop will focus on communications skills and interactions that may take place as a result of using the screening tool, such as parents talking about adverse childhood experiences. The workshops will also help to train providers about what resources are available depending on what the screening may uncover.

“We are refining the assessment tool,” Clyne said, with a focus on some combination of screening for immediate needs such as food, security and housing as well as “interactional” stressors.

“We are on the forefront,” Clyne continued. “We’re on the cutting edge in creating new ground [in health care]. We hope to come up with a tool that will be effective, useful and user-friendly, both to families and providers.”

Clyne also said that a key buffering factor in mitigating the negative surroundings associated with toxic stress are nurturing and developing relationships with a caring adult or a caring caregiver.

The next step in the process will be recruiting providers who are willing to incorporate the assessment tool as part of their practice, Clyne continued.

Including healthy housing questions as part of the assessment tool
When asked if questions about the health and safety of housing were being considered to become part of the screening tool, Clyne said that it should absolutely be part of the conversation, recognizing that housing can be a real environmental risk for children.

The task will be to figure out, she continued, what are those questions going to look like?

As much as asthma is the number-one health cause of school absenteeism, and the incidence of asthma and high levels of lead in children’s bloodstreams can be mapped by town and legislative district in Rhode Island, the actual number of poor children in Rhode Island who live in unsafe, unhealthy homes has not yet been quantified.

It is not yet part of the Rhode Island Kids Count briefing paper on child poverty in Rhode Island. But Ruth Ann Norton, the president and CEO of the Green & Healthy Homes Initiative, and her new point person in Rhode Island, Betsy Stubblefield-Loucks, have plans to bring the issue to the forefront.

Norton did not have any specific numbers for Rhode Island, but said that nationally, there were more than 9 million families who went to sleep every night in unhealthy, energy inefficient homes. And, that more than 24 million families face serious lead hazards in their homes. “The effects of lead are irreversible and lifelong for children and adults,” Norton said, including neurological damage in children and hypertension and cardiac arrest in adults.

When asked about a proposal to make green and healthy homes an employee benefit in Providence, Norton said she was unaware of any similar program nationally, but responded favorably to the idea.

“This proposal [offers] a good pathway to solving these issues,” Norton said, because inexpensive remediation has a very high, quick return on investment.

“If you have an employee who has to miss five to 20 days a year because of a child’s asthma, you have a less productive workforce,” she said.

“If you have an employee that is paying out higher than needed energy bills because they live in a poorly weatherized home, they will likely move more often and be under greater stress,” Norton continued.

Norton said that by investing in healthier, more energy efficient homes, studies have shown an 88 percent improvement in work attendance as well as increased school attendance and readiness for kids. The cost savings on energy alone, she continued, would help repay any loans.

On the research front
Dr. Audrey Tyrka, the director of research at Butler Hospital, part of the Care New England hospital network, recently published a new study online in Biological Psychiatry, identifying an association between biological changes on the cellular level and both childhood adversity and psychiatric disorders, including early life stress and anxiety and substance abuse disorders.

“Understanding this biology is necessary to move toward better treatment and prevention options for stress-related psychiatric and medical conditions, and may shed light on the aging process itself,” Tyrka said.

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