Early Childhood Adversity Opportunities to Address Toxic Stress

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions Ohio population 11.5 million 7th most populous state in the US Approximately 20% of households have children under the age of 18 6.2% are under the age of five Nearly one in four children in Ohio live in households with incomes less than the Federal poverty level Close to half live in poverty or near poverty Poverty is the single best predictor of child abuse and neglect

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions Social emotional Children in Single Parent Households Approximately 10 percent of young children suffer from emotional and behavioral challenges that impair their ability to learn The incidence among economically disadvantaged young children is two or three times as high as their more affluent peers In Ohio, almost six in 10 marriages end in divorce leaving 37% of children living in single- family households The proportion of infants born to single mothers is highest among Blacks at 78%, compared with 58% among Hispanics and 33% among Whites demonstrating a racial disparity

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions Child Abuse and Neglect Children in Single Parent Households In 2010, Ohio had 139,079 total referrals for child abuse and neglect among children under 18 833,947 of those children determined victims of abuse or neglect, a rate of 12.5 per 1,000 children Of these children, 47.4% were neglected, 39.2% were physically abused, and 18.5% were sexually abused In Ohio, almost six in 10 marriages end in divorce leaving 37% of children living in single- family households The proportion of infants born to single mothers is highest among Blacks at 78%, compared with 58% among Hispanics and 33% among Whites demonstrating a racial disparity

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions Maternal and Child Health Indicators Ohio’s infant mortality rate was 7.87 infant deaths per 1,000 live births in 2011 compared to national rate of 6.05 Black infant mortality rate was 15.8, more than twice the white rate of 6.3 Ohio ranked #38 among the states for white infant mortality, #47 for overall infant mortality, and #49 for black infant mortality Black babies are more likely to die within the first year of life even when controlling for social and economic factors Metropolitan and Appalachian counties have higher rates of infant mortality Almost one in 10 Ohio children is in foster care, 32% of which are under the age of five Evidence suggests that children in foster care have higher-than- average delinquency rates, teen birth rates, and lower earnings Abuse and neglect is a leading factor in infant and child fatalities U.S. Department of Health and Human Services study found that more than 78% of reported child fatalities resulted from

Adversity attributable to . . . Child or Individual Level Parental or Societal Issues Owing to traumatic experiences Delays in development Disabilities Chronic diseases Temperaments Other unusual physical or personal traits Poverty Divorce/single parenting Poor housing Lack of access to medical or mental health care Threat of violence or terrorism ~ OR ~ Combination of Both

Childhood Physiologic Stress Positive Stress Rare or brief Mild to moderate Social-emotional buffering Builds resilience Tolerable Stress More frequent or sustained Moderate to severe Social-emotional buffering No sustained changes Toxic Stress Frequent or sustained Severe Insufficient buffering Significant changes Potentially permanent changes to the brain

Impaired social-emotional, Potentially permanent changes to the brain Altered Learning Impaired social-emotional, language and cognitive skills Altered Behavior Adaptions to deal with chronic stress Altered Physiology Hyper-responsive or chronically activated stress response Altered developmental outcomes/altered life-course trajectories

Altered developmental outcomes/altered life-course trajectories Fractured Social Networks Divorce/single parenting School failure Poverty Violence/crime/incarceration Homelessness Limited access to physical and/or behavioral healthcare Adoption of Unhealthy Lifestyles Alcohol Tobacco Substance abuse Sex/promiscuity Gambling obesity Changes in immune Function/inflammation Cardiovascular disease Depression Diabetes Cirrohsis COPD Poor health and/or health disparities

Poor health and/or health disparities Non-communicable diseases Economic consequences Intergenerational effect

Home visiting opportunities High levels of recent adversity and distress are the “new normal” If this maternal adversity and distress impairs the mother’s ability to form a safe, stable, and nurturing relationship with her child, the maternal adversity puts the child at risk for toxic stress Home visiting with well-trained specialists is an important opportunity to support the capacity of mothers to develop strong, responsive early relationships with their children The social emotional buffering afforded by these critical early relationships prevents adversity from becoming toxic

Home visiting opportunities Home visits are an important mechanism Intervening early to prevent toxic stress Proactively build the rudiments of resilience Improve the capacity of caregivers to: Promote the safe, stable, and nurturing relationships that buffer toxic stress Encourage the rudimentary but foundational social-emotional, language, and cognitive skills that promote resilience and the adoption of healthy, adaptive coping skills

Home visiting in the future Summary and implications Home visiting specialists, much like pediatric medical homes, cannot address early childhood adversity and toxic stress in isolation Both are integral elements of a desperately needed public health approach to prevent the intergenerational transfer of toxic stress and disparities in health, education, and economic productivity Building the community capacities to support such a public health approach to toxic stress will require unprecedented levels of collaboration and coordination between the healthcare, childcare, early education, early intervention, and home visiting sectors