Toxic Stress in Children: Why the American Academy of Pediatrics Had to Take it On

Betty attached herself to Mrs. Heck the playground monitor like a wad of Bazooka, all the while talking a blue streak. Her short brown hair hung limp beside her pale, oval face; and in the classroom she cried over the least little thing. At any given moment tears pooled in her sad blue eyes and her shoulders slumped inside a dowdy dress. She muttered under her breath, evidently injured by a force unknown to the rest of us. Eventually, her perpetual whines blended into the background, like a sliver of sky in a thousand-piece jig saw puzzle.

We lived only two blocks apart, Betty and I, but I had never seen her running around the neighborhood on a bicycle or roller skates, nor did she sled on Frenchie’s Hill or skate at the lake. I walked her home one day and we said goodbye in front of her house, a run-down place with a long front porch. Once I heard that her father worked at the tire store on the corner, and once I heard someone mention the word “alcoholic.”

After college graduation I worked in a government-funded preschool. Housed in a former barracks, it was not the kind of place a conscientious parent would send a child. Among my class of three-five year olds were a set of twins that everyone called “Los Cuates,” the buddies. Barely verbal, the boys appeared severely malnourished and were behind in every skill imaginable. Their pants sagged over non-existent back sides, secured by too-long belts that flapped when they walked. If a gust of wind had come along, I believe the two might have blown away.

I don’t remember when I first noticed the bruises, but I thought maybe I’d seen some discoloration on their arms even before then. Other employees checked the boys out, too. It was a sensitive issue. No accusations could be made. Someone would visit the mom, they said, but nothing ever happened. At the time I was not aware of a formal reporting system. If I had tried to intervene, I might have lost my job.

Years later, I had little girl named Marissa* in my remedial reading group. Marissa wore paper-thin blouses in winter and hugged her arms for warmth; and every day complained of a stomach ache. Her mother had died, leaving behind five children; and her father was out of work with an injured leg. One day I asked Marissa if she’d eaten breakfast. She said she hadn’t. It seemed Marissa’s older sister forced her to sit still while she braided her hair every morning. The girl took so long that Marissa had no time for to eat. So I marched her to the cafeteria and asked for anything they might have. “We’re only allowed to give milk,” the cafeteria lady said. No exceptions.

That night I made energy bars and the next morning handed one to Marissa. I loaned her my sweater and she wore it like a second skin. She began to smile and then to make progress. She took pride in herself, as though she finally believed she could succeed. I did not know if Marissa’s family had enough food in the fridge; or if they did, whether anyone bothered to cook it. All I knew was that I had a bright child on my hands that could not learn.

Recent advances in science have shown that family secrets harbored by children, the kind Betty and Marissa couldn’t talk about, are dangerous to their cognitive, behavioral, mental and physical health. According to a policy statement published in the January 2012 issue of Pediatrics, the cause is “toxic stress.”

How does it hurt children? “Toxic stress early in life plays a critical role by disrupting brain circuitry and other important systems in ways that continue to influence physiology, behavior, and health decades later.”

It’s a condition that happens in the body due to the release of stress hormones, primarily cortisol; caused by “prolonged or severe exposure to abuse, neglect and economic hardship – exacerbated by a dearth of stable, supportive relationships with adults.”

Despite the policy statement’s long title: “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health,” its message is simple: it’s an urgent call to the pediatric community, asking them play a role in reducing “external threats to healthy brain growth.”

The new scientific framework that addresses these issues encompasses the latest advances in neuroscience, molecular biology, genomics, and social science. It’s called ecobiodevelopmental (EBD). To me, the combination of disciplines is brilliant and nothing short of a miracle.

The move to describe these nonmedical yet very real threats to children began in 1975, when pediatric health care providers began to recognize “noninfectious disease entities” affecting children’s health and well-being, the article said. At the same time they recognized changes in society caused by an increase in single parent households and families with two working parents.

What they were seeing are children like Betty and Marissa, and parents who cannot understand why their children are doing so poorly, why they suffer daily stomach aches or can’t sit still. While well-nurtured kids lap up knowledge like hungry kittens, the fearful Marissas in the classroom have trouble processing new information. The normal learning channels seem to have a “block.”

In her 2004 book, Secrets, Lies, Betrayals: The Body/Mind Connection, author Maggie Scarf quotes analyst and author Joyce McDougall: “The body, like the mind, is subject to the repetition compulsion.”

What this means, writes Scarf, is that emotional experiences such as fear, pain and humiliation exist not only in the mind, but are experienced in the body. They involve a host of neurobiological reactions as well as physical feelings and sensations.
Frightening, stressful experiences, said Scarf, become situated in a person’s body in such a way that they feel completely familiar. The AAP refers to these disruptive physiologic responses as “biological memories” that increase the risk of health-threatening behaviors and frank disease later in life.”

For Betty, anything that even remotely resembled the threat of an attack might have been enough to set her on a crying jag; her body was no doubt familiar with that state of stress. While other kids were busy learning, she was perhaps afraid of receiving more verbal abuse or worse, preparing for a slap or punch. How can a brain on “high alert” think about multiplication or grammar?

The last child I had in private practice for reading remediation was a little boy of six, whom I will call David. His mother had ignored him for the first four years of his life, until “Mimaw” intervened. David perceived everything as an attack and whined and pouted and carried on for no reason. His diagnoses read like the list of ingredients on a package of Twinkies, and Mimaw told me he was on meds for ADHD. I quickly realized what this little boy needed most was love and consistency from a caring adult. He didn’t need remediation; he needed to be taught in the first place, and even that was putting the cart before the horse. The first day of kindergarten David hit another child and wound up on the principal’s bench. That pretty much set the tone for the whole year.

At any point in the lesson David might dissociate, stare off in the distance, eyes fixed for ten or fifteen seconds before “snapping” back. He also pretended to be a velociraptor, a kind of dinosaur, and turned his hands into taut pincers that he snaked in and out above the table. And he wanted to control absolutely everything. This little boy, I told myself, did not feel safe. He had not had an adult in his life to nurture him and be a parent in the truest sense. After nine months of lessons he’d begun to read and was learning to write in cursive. He could sit in his chair for at least 45 minutes, fully engaged in our activities. And then without warning his mother said he could no longer come. He was getting too close to Mimaw, and apparently that had to stop.

Unlike positive or tolerable stress—the kind kids feel when they have to study for a test or try out for baseball— toxic stress, the AAP position paper says, is the excessive or prolonged activation of the physiologic stress response system in the absence of the buffering protection afforded by stable, responsive relationships.

In other words, without nurturing adults to intervene in stressful situations, children cannot regulate themselves; their stress response system stays “turned on,” and is not returned to normal functioning.

The effects of ongoing stress in the home are significant “because they can undermine the development of those adaptive capacities,” the statement said; the kind that make us emotionally stable and resilient human beings. It doesn’t matter whether the stress is caused by alcoholism, poverty, screaming and yelling, or neglect; a child’s brain cannot tell the difference.

People used to think such children should somehow be able to pull themselves up by their bootstraps, and by sheer grit and gumption manage to succeed. Today we know why that is not likely to happen without specific intervention.

Toxic stress affected all of the children I’ve written about here. It damaged their ability to learn, relate, and behave in developmentally appropriate ways. Now, with an unprecedented push for prevention, intervention, and treatment of toxic stress in children, the American Academy of Pediatrics has committed itself to combating one more dangerous “disease.” According to the Policy Statement, “The AAP is committed to leading an invigorated, science-based effort at transforming the way our society invests in the development of all children, particularly those who face significant adversity.” FFG

* Name changed to protect the child’s privacy.

To read the full AAP Policy Statement online go to

To watch a webcast on toxic stress click here: Watch the webcast

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