TECHNICAL REPORT The Lifelong Effects of Early Childhood ...

1 TECHNICAL REPORT . The Lifelong Effects of Early Childhood Adversity and Toxic Stress abstract Jack P. Shonkoff, MD, Andrew S. Garner, MD, PhD, and THE. COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND. FAMILY HEALTH, COMMITTEE ON Early Childhood , Advances in elds of inquiry as diverse as neuroscience, molecular ADOPTION, AND DEPENDENT CARE, AND SECTION ON. biology, genomics, developmental psychology, epidemiology, sociology, DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS. and economics are catalyzing an important paradigm shift in our un- KEY WORDS. derstanding of health and disease across the lifespan. This converging, ecobiodevelopmental framework, new morbidity, toxic stress, multidisciplinary science of human development has profound impli- social inequalities, health disparities, health promotion, disease cations for our ability to enhance the life prospects of children and to prevention, advocacy, brain development, human capital development, pediatric basic science strengthen the social and economic fabric of society.

2 Drawing on these ABBREVIATIONS. multiple streams of investigation, this REPORT presents an ecobiodeve- ACE adverse Childhood experiences lopmental framework that illustrates how Early experiences and envi- CRH corticotropin-releasing hormone ronmental in uences can leave a lasting signature on the genetic EBD ecobiodevelopmental PFC prefrontal cortex predispositions that affect emerging brain architecture and long-term health. The REPORT also examines extensive evidence of the disruptive This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors impacts of toxic stress, offering intriguing insights into causal mech- have led con ict of interest statements with the American anisms that link Early adversity to later impairments in learning, be- Academy of Pediatrics. Any con icts have been resolved through havior, and both physical and mental well-being.

3 The implications of a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any this framework for the practice of medicine, in general, and pediatrics, commercial involvement in the development of the content of speci cally, are potentially transformational. They suggest that many this publication. adult diseases should be viewed as developmental disorders that begin The guidance in this REPORT does not indicate an exclusive Early in life and that persistent health disparities associated with pov- course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be erty, discrimination, or maltreatment could be reduced by the allevi- appropriate. ation of toxic stress in Childhood . An ecobiodevelopmental framework All TECHNICAL reports from the American Academy of Pediatrics also underscores the need for new thinking about the focus and bound- automatically expire 5 years after publication unless reaf rmed, aries of pediatric practice.

4 It calls for pediatricians to serve as both revised, or retired at or before that time. front-line guardians of healthy child development and strategically po- sitioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and Lifelong health. Pediatrics 2012;129:e232 e246. INTRODUCTION. Of a good beginning cometh a good end. John Heywood, Proverbs (1546). The United States, like all nations of the world, is facing a number of social and economic challenges that must be met to secure a promising future. Central to this task is the need to produce a well- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). educated and healthy adult population that is suf ciently skilled to Copyright 2012 by the American Academy of Pediatrics participate effectively in a global economy and to become responsible stakeholders in a productive society.

5 As concerns continue to grow about the quality of public education and its capacity to prepare the nation's future workforce, increasing investments are being made in e232 FROM THE AMERICAN ACADEMY OF PEDIATRICS. Downloaded from by guest on October 12, 2019. FROM THE AMERICAN ACADEMY OF PEDIATRICS. the preschool years to promote the the 20th century, as effective vaccines, ecobiodevelopmental (EBD) framework foundations of learning. Although antibiotics, hygiene, and other public to stimulate fresh thinking about the debates about Early Childhood policy health measures confronted the in- promotion of health and prevention of focus almost entirely on educational fectious etiologies of Childhood illness, disease across the lifespan. Second, it objectives, science indicates that a variety of developmental, behavioral, applies this EBD framework to better sound investments in interventions and family dif culties became known understand the complex relationships that reduce adversity are also likely to as the new morbidities.

6 8 By the end among adverse Childhood circum- strengthen the foundations of physical of the century, mood disorders, pa- stances, toxic stress, brain architec- and mental health, which would gen- rental substance abuse, and exposure ture, and poor physical and mental erate even larger returns to all of to violence, among other conditions, health well into adulthood. Third, it ,2 This growing scienti c un- began to receive increasing attention proposes a new role for pediatricians derstanding about the common roots in the pediatric clinical setting and to promote the development and im- of health, learning, and behavior in became known as the newer mor- plementation of science-based strate- the Early years of life presents a po- bidities. 9 Most recently, increasingly gies to reduce toxic stress in Early tentially transformational opportunity complex mental health concerns; the Childhood as a means of preventing for the future of pediatrics.

7 Adverse Effects of television viewing; or reducing many of society's most Identifying the origins of adult disease the in uence of new technologies; ep- complex and enduring problems, and addressing them Early in life are idemic increases in obesity; and per- which are frequently associated with critical steps toward changing our sistent economic, racial, and ethnic disparities in learning, behavior, and current health care system from a disparities in health status have been health. The magnitude of this latter sick-care to a well-care 5 called the millennial morbidities. 10 challenge cannot be overstated. A re- Although new discoveries in basic Advances in the biological, develop- cent TECHNICAL REPORT from the Amer- science, clinical subspecialties, and mental, and social sciences now offer ican Academy of Pediatrics reviewed high-technology medical interventions tools to write the next important 58 years of published studies and continue to advance our capacity to chapter.

8 The overlapping and syner- characterized racial and ethnic dis- treat patients who are ill, there is gistic characteristics of the most parities in children's health to be ex- growing appreciation that a success- prevalent conditions and threats to tensive, pervasive, persistent, and, in ful well-care system must expand its child well-being combined with the some cases, Moreover, scope beyond the traditional realm of remarkable pace of new discoveries the REPORT found only 2 studies that individualized, clinical practice to ad- in developmental neuroscience, ge- evaluated interventions designed to dress the complex social, economic, nomics, and the behavioral and social reduce disparities in children's health cultural, environmental, and devel- sciences present an opportunity to status and health care that also com- opmental in uences that lead to confront a number of important ques- pared the minority group to a white population-based health disparities tions with fresh information and a group, and none used a randomized and unsustainable medical care ex- new perspective.

9 What are the bi- controlled trial design. ,6,7 The science of Early ological mechanisms that explain the The causal sequences of risk that Childhood development has much to well-documented association between contribute to demographic differences offer in the realization of this vision, Childhood adversity and adult health in educational achievement and physi- and the well-being of young children impairment? As these causal mecha- cal well-being threaten our country's and their families is emerging as a nisms are better elucidated, what can democratic ideals by undermining the promising focus for creative invest- the medical eld, speci cally, and so- national credo of equal opportunity. ment. ciety, more generally, do to reduce or Unhealthy communities with too many The history of pediatrics conveys a rich mitigate the Effects of disruptive fast food franchises and liquor stores, narrative of empirical investigation Early -life in uences on the origins of yet far too few fresh food outlets and pragmatic problem solving.

10 Its Lifelong disease? When is the optimal and opportunities for physical activity, emergence as a specialized domain time for those interventions to be contribute to an unhealthy population. of clinical medicine in the late 19th implemented? Unemployment and forced mobility century was dominated by concerns This TECHNICAL REPORT addresses these disrupt the social networks that sta- about nutrition, infectious disease, and important questions in 3 ways. First, bilize communities and families and, premature death. In the middle of it presents a scienti cally grounded, thereby, lead to higher rates of violence PEDIATRICS Volume 129, Number 1, January 2012 e233. Downloaded from by guest on October 12, 2019. and school dropout. The purpose of has been demonstrated to be passed this TECHNICAL REPORT is to leverage new on to the next 22 This knowledge from the biological and burgeoning area of research is chal- social sciences to help achieve the lenging us to look beyond genetic positive life outcomes that could be predispositions to examine how envi- accrued to all of society if more effec- ronmental in uences and Early expe- tive strategies were developed to re- riences affect when, how, and to what duce the exposure of young children degree different genes are actually to signi cant adversity.