Innovation Ecosystem

Toxic stress, where doctors, lawyers, nurses, and brain scientists converge

Understanding how to address the build up of stress hormones in a baby’s brain, and how it can make a profound difference in health, education outcomes

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.

By Richard Asinof
Posted 9/22/14
Rhode Island, a leader in health innovation, is developing new evidence-based tools to identify toxic stress and then refer patients for treatment. The collaborative work effort involves Bradley Hospital, the R.I. Department of Health and the R.I. Chapter of the American Academy of Pediatrics. Brown University is also ahead of the curve in integrating the social determinants of health into its medical school and public health school curricula.
It may sound like a repetitive refrain, but when will there be an initiative to map out health innovation in Rhode Island? The work on toxic stress is exactly the kind of health innovation that needs to be mapped and shared. How much of this work is being coordinated with the neuroscience researchers at Brown Institute for Brain Studies, the Ryan Neurosciences Institute at URI, or the Prince Neurosciences Institute – or, for that matter, with the nursing schools at Rhode Island College and the University of Rhode Island, as part of the Nurse-Family Partnership?
One place where all these conversations will converge is at the Oct. 2 Healthy Early Childhood Development Symposium: Flexibilty, Self Control and Memory. Adele Diamond, a renowned developmental cognitive neuroscientist and expert on the development of executive functions at the University of British Columbia, will present the keynote. The symposium will feature a panel discussion with Rhode Island leaders and practitioners discussing ongoing local efforts to enhance executive function skills among Rhode Island children.

PROVIDENCE – If you were to ask, what is toxic stress in Rhode Island and how can you relieve it, some cynic might be tempted to respond, borrowing an old chestnut about the definition of toxic waste that was once popular in the nation’s capital: “A bus of lawyers [legislators] that goes over a cliff with three empty seats.”

But toxic stress is no laughing matter – and as brain science catches up with the delivery of health care, forging a better understanding of the social determinants of health – there are some fascinating new approaches developing here in Rhode Island.

The gist of the research, as Nicholas Kristof and his wife, Sheryl WuDunn, wrote in “The Way to Beat Poverty” on Sept. 12 in the New York Times, goes like this: A constant bath of cortisol, a stress hormone, as a result of a high-stress infancy, prepares that child for a high-risk environment, a fight-or-flight hair trigger throughout life, according to Jack P. Shonkoff, founder of the Center on the Developing Child at Harvard University.

Shonkoff defines the surge in stress hormones in response to a high-risk environment “toxic stress.” Shonkoff describes it as one way that poverty regenerates, as moms in poverty often live in stressful homes, disproportionately likely to be teenagers, without a partner to help out, according to Kristof and WuDunn.

A baby in such a stress-filled environment is more likely to grow up with a brain bathed in cortisol, according to Kristof and WuDunn. One of the best ways to combat this, they continued, is through a Nurse-Family Partnership – sending nurses to visit low-income, disadvantaged families and offer counseling on child-rearing.

That is something that Rhode Island, with support from Rhode Island Kids Count and federal funds secured with the help of Sen. Jack Reed, has embarked on for the last four years. The program, coordinated by Children’s Friend, enrolls pregnant women expecting their first child and provides regular home visits until the children turns two. All home visitors are nurses, and families must enroll by the 28th week of pregnancy.

The program serves first-time, low-income mothers and their children, targeting Central Falls, Newport, Pawtucket, Providence, West Warwick and Woonsocket. During the visits, nurses work to reinforce good preventive health practices, focused on prenatal care, caring for an infant, and encouraging the emotional, physical and cognitive development of young children. In 2013, the capacity for families to enroll was 225, with 129 enrolled as of September 2013.

Kristof and WuDunn cite the results of randomized controlled trials proving that the program has been “stunningly” effective. A RAND Corporation study found that for each dollar invested in nurse visits to low-income [and often unmarried] mothers, it produced $5.70 in savings.

“We have an anti-poverty program that is cheap, is backed by rigorous evidence, and pays for itself several times over in reduced costs later on,” Kristof and WuDunn wrote. “Yet it has funds to serve only 2 percent to 3 percent of needy families. That’s infuriating.”

Team approach to toxic stress
Another initiative underway, led by Blythe Berger at the R.I. Department of Health and Ronald Seifer, director of research at Bradley Hospital, and coordinated with the Rhode Island Chapter of the American Academy of Pediatrics, or RIAAP, is a statewide effort focused on the developing an evidence-based screening and assessment tool in the treatment and prevention of toxic stress in infants and young children.

The goal of the federally funded project, according to a recent post by RIAAP, “is to mitigate the impact of toxic stress and trauma in infancy and early childhood.” The project defines stress as toxic when it becomes “non-tolerable, prolonged, activating of biological stress responses – with no means to ameliorate the stress response.”

RIAAP, consisting of about 300 pediatricians and pediatric sub-specialists, will serve as a primary conduit to the primary care community where identification of toxic stress and initial response with children and families often occurs.

One of the key outcomes of the project is to develop and administer a curriculum to train primary care providers and their staff to identify and address toxic stress in their patient populations, detailing the impact of toxic stress on early childhood emotional and behavioral regulation, brain development, and family functioning.

“RIAAP is but a small cog in a larger wheel,” said Dr. Ailis Clyne, who is president of the RIAAP [and who recently joined the R.I. Department of Health]. “What the overall goal of the project [seeks to do] is to develop an assessment tool to screen for toxic stress and develop a mechanism for referral,” she told ConvergenceRI.

RIAAP’s role, Clyne continued, is to develop a training program for primary care providers and home visiting staff to screen families of infants and young children for toxic stress.

Clyne called the effort “pioneering” work. “There isn’t an evidence-based, assessment tool for toxic stress. The first step in the project is defining what toxic stress is,” she said.

Brown’s ahead of the curve
Toxic stress is already part of the curriculum being taught by Liz Tobin-Tyler, clinical assistant professor of Family Medicine and Health Services, Policy and Practice at the Warren Alpert Medical School of Brown University and the Brown University School of Public Health.

Tobin-Tyler has been teaching a joint class for law students at Roger Williams University and med students at Brown, focused on a medical-legal partnership that focuses on patient health, integrating lawyers into health care settings, allowing them to address some of the underlying root causes of social determinants of health – such as substandard housing with lead and mold.

“We are teaching health care providers to ask questions about social environments, to talk about patient-centered care and how that is differentiated from medical care,” Tobin-Tyler told ConvergenceRI in a recent interview. “I think one of the worst things that can happen is for a doctor either not to ask a question about social environment, because she doesn’t know the answer, or ask a question and then say, ‘Gosh, I’m sorry, that’s terrible.’”

The idea of the joint classes with lawyers and doctors, she continued, “is that when we bring professionals together that have different skills, then they can work at the top of their licenses.”

Tobin-Tyler also teaches about toxic stress as part of her curriculum, which she said addresses the importance of people being able to lead their lives in the way that they want to – “giving people a sense that they have a voice in their own destiny.”

“When you are talking about changing health behaviors at the individual level,” she said, “you have to talk about the social environment and the stress that it produces.”

When Tobin-Tyler introduces the concept to her students, they find it really fascinating, she continued. Students often ask is about how stress is different in its effects in a vulnerable, low-income community than in a higher-income community, saying: we all have stresses in our lives.

The difference, Tobin-Tyler said, comes back to the question of control and choice. She said she shows the film, “Unnatural Causes,” as part of the class, which details how stress affects low-income people differently, because they have less control over their environments. 

“Stress is different when you feel that you have no control,” Tobin-Tyler said. “People who are high-income, they may have a lot of stress from their work, but they have a choice, a certain degree of control over their lives – what they can afford to buy, their work hours." 

Tobin-Tyler's new class, "Health Systems and Policy," which focuses on the social determinants of health and policies both within and outside of the health care system, is now part of the core curriculum for medical students at Brown, she said.

“Some students are asking: why do I need to know this? The idea is that regardless of what specialty they go into, the health care delivery system is undergoing a major transformation, and we know that social determinants play a key role in both health outcomes and health care costs. The Alpert Medical School at Brown, to its credit, is saying: all of their medical students need to have a better understanding of the policies that affect health care. …Students need to be thinking about population health and not just individual patients.”


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