1. Beal, Judy A. DNSc, RN, FNAP, FAAN

Article Content

The recent controversy over the policy on immigration and subsequent treatment of immigrant children has resurfaced concerns about toxic stress in children. Toxic stress is defined as "the extreme, frequent, or extended activation of the stress response that causes distress for the child and may lead to negative psychological and physical health outcomes" (Johnson, Riley, Granger, & Riis, 2013, p. 320). The concept of toxic stress in children, specifically its relationship to exposure to trauma, was significantly advanced by publication of the Adverse Childhood Experiences Study (ACE) (Felitti et al., 1998). The ACE study explored relationships between adverse childhood events including exposures to emotional, physical, and/or sexual abuse; emotional and/or physical neglect; domestic violence; familial substance abuse and mental illness; parental marital problems; and household criminality (Felitti et al.). Two thirds of the ACE participants reported exposure to at least one of these traumatic events and of those 86.75% reported at least one additional event and 52% reported at least three additional adverse events during childhood (Dong et al., 2004).


The American Academy of Pediatrics (AAP) reported on the science of early life toxic stress and concluded that "young children who experience toxic stress are at high risk for a number of health outcomes in adulthood, including cardiovascular disease, cancers, asthma, and depression" (Johnson et al., 2013, p. 319). A year earlier, AAP (2012) issued a policy statement Early Childhood Adversity, Toxic Stress and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health in which they endorsed and promoted the importance of pediatricians taking a leadership role to leverage research evidence to inform the development of innovative strategies to prevent adverse childhood events and to mitigate the lifelong negative effects.


Nurses can play a pivotal role in addressing this major public health problem. Hornor (2015) discussed the role of the pediatric nurse practitioner in identifying exposure to childhood trauma and toxic stress. Appropriate interventions for prevention and mitigation are outlined in detail as are the relationship between trauma and toxic stress, descriptions of the physiology and outcomes of toxic stress, examples of screening questions and helpful checklists to be used during well-child visits, and models for trauma exposure intervention (Hornor). Screening questions are given for domestic violence, sexual abuse, discipline/corporal punishment, neglect as well as for general age-related trauma. Hornor makes a strong argument for the importance of enhancing resiliency for all children exposed to trauma. Nurses can be instrumental in building resiliency by: encouraging healthy and supportive parent-child interactions, providing parental guidance on appropriate developmental behavioral expectations and responses and use of nonphysical forms of discipline, referral and use of community-based programs such as Big Brothers/Big Sisters as well as other models of mental health treatments. These include but are not limited to parent-child interactive therapy, child and parent psychotherapy, stress intervention therapy for both parents and children, and risk reduction family therapy. The key take-away is that "for children to truly heal from trauma exposure their exposure to trauma must be eliminated or greatly reduced" (Hornor, p. 196). In today's world this may be easier said than done, but nurses can and must make a difference.




American Academy of Pediatrics. (2012). Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics, 129(1), e224-e231. doi:10.1542/peds.2011-2662 [Context Link]


Dong M., Anda R. F., Felitti V. J., Dube S. R., Williamson D. F., Thompson T. J., ..., Giles W. H. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse and Neglect, 28(7), 771-784. doi:10.1016/j.chiabu.2004.01.008 [Context Link]


Felitti V. J., Anda R. F., Nordenberg D., Williamson D. F., Spitz A. M., Edwards V., ..., Marks J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-248. doi:10.1016/S0749-3797(98)00017-8 [Context Link]


Hornor G. (2015). Childhood trauma exposure and toxic stress: What the PNP needs to know. Journal of Pediatric Health Care, 29(2), 191-198. doi:10.1016/j.pedhc.2014.09.006 [Context Link]


Johnson S. B., Riley A. W., Granger D. A., Riis J. (2013). The science of early life toxic stress for pediatric practice and advocacy. Pediatrics, 131(2), 319-327. doi:10.1542/peds.2012-0469 [Context Link]