In a recently released article in Pediatrics, Dr. Amanda Jichlinski from Children’s National Medical Center in Washington, DC
continues an ongoing discussion about the development and management of toxic stress
(10.1542/peds.2017-2869). Her article, which won second place in the Section of Pediatric Trainee’s First
Annual Advocacy Essay Competition, provides a comprehensive overview of the topic
and outlines a stepwise approach to combat toxic stress. We have known for some time
that the long term effects of adverse childhood events (ACEs) such as exposure to
abuse and severe household dysfunction are intimately linked to some of the leading
causes of deaths in adults (Felitti et al Am J Prev Med. 1998). We also now understand that the key to limiting the effects of toxic stress
is the development of resilience. Yet we are still working to successfully translate
this understanding into our daily, clinical practice in a way that allows us to effectively
intervene in this devastating cycle.
Dr. Jichlinski suggests that we must follow three steps: 1) Enhance provider awareness
so we can more effectively identify those patients at risk of toxic stress; 2) Create
a network of support through integration of social workers and other support services
into a single medical home; and 3) Work with the local community to foster discussions
from multiple perspectives that can aid in the development of resilience.
Unfortunately, it has been shown that only 4% of pediatricians routinely screen for
ACEs, which reflects the fact that only 11% of pediatricians have reported familiarity
with the 7 identified ACEs (Kerker et al Acad Pediatr. 2016). The reasons for this are multifactorial, but increasing provider awareness
and education needs to remain a key focus within high priority pediatric initiatives.
This is especially true given that intervention during a child’s developing years
may significantly and positively alter their adult health(Garner et al Pediatrics2012). With help from social support services, pediatricians are uniquely positioned
to connect families with additional services that mitigate toxic stress such as legal
aid, housing referrals or food pantries, and counselling. Furthermore, as Dr. Jichlinski
points out, involvement of the local community is fundamental in the development of
childhood resilience, since kids spend far more of their time with parents, teachers,
counselors and coaches than with physicians.
Dr. Jichlinski’s article opens with a well-known quote by Mahatma Gandhi: “Strength
does not come from physical capacity. It comes from an indomitable will.” Long before
research could support his claim, Gandhi understood the power of resilience. As physicians
and advocates, we must focus more of our attention on the identification of ACEs and
reach out to our local communities to better address toxic stress. Only then, as an
interdisciplinary team, can we help our young patients develop the indomitable will
that may prove to be critical in their overcoming the toxic stress and ACEs that can
prevent them from achieving optimal physical and mental health as they grow up.
Felitti, Vincent J, et al. “Relationship of Childhood Abuse and Household Dysfunction
to Many of the Leading Causes of Death in Adults.” American Journal of Preventive Medicine, vol. 14, no. 4, 1998, pp. 245–258., doi:10.1016/s0749-3797(98)00017-8.
Kerker, Bonnie D., et al. “Do Pediatricians Ask About Adverse Childhood Experiences
in Pediatric Primary Care?” Academic Pediatrics, vol. 16, no. 2, 2016, pp. 154–160., doi:10.1016/j.acap.2015.08.002.
Shonkoff, J. P., et al. “The Lifelong Effects of Early Childhood Adversity and Toxic
Stress.”Pediatrics, vol. 129, no. 1, 2011, doi:10.1542/peds.2011-2663.