1. Early Childhood Adversity
Opportunities to Address Toxic Stress

2. 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

3. 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

4. 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

5. 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 infant deaths per 1,000 live births in 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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