HOW STRESS AF­FECTS KIDS’ BRAINS

Per­sis­tent ‘flight or flight mode’ can cause health prob­lems later in life

The Hamilton Spectator - - GO - LIND­SEY TAN­NER

ASHEVILLE, N.C. — A quiet, un­smil­ing lit­tle girl with big brown eyes crawls in­side a car­peted cu­bi­cle, hugs a stuffed teddy bear tight, and turns her head away from the noisy class­room.

The safe spa­ces, quiet times and breath­ing ex­er­cises for her and the other preschool­ers at the Verner Cen­ter for Early Learn­ing are de­signed to help kids cope with in­tense stress so they can learn. But ex­perts hope there’s an even big­ger ben­e­fit — pro­tect­ing young bod­ies and brains from stress so per­sis­tent that it be­comes toxic.

It’s no se­cret that grow­ing up in tough cir­cum­stances can be hard on kids and lead to be­hav­iour and learn­ing prob­lems. But re­searchers are dis­cov­er­ing some­thing dif­fer­ent. Many be­lieve that on­go­ing stress dur­ing early child­hood — from grind­ing poverty, ne­glect, par­ents’ sub­stance abuse and other ad­ver­sity — can smoul­der be­neath the skin, harm­ing kids’ brains and other body sys­tems. And re­search sug­gests that can lead to some of the ma­jor causes of death and dis­ease in adult­hood.

“The dam­age that hap­pens to kids from the in­fec­tious dis­ease of toxic stress is as se­vere as the dam­age from menin­gi­tis or po­lio or per­tus­sis,” says Dr. Tina Hahn, a pe­di­a­tri­cian in ru­ral Caro, Michi­gan.

She says her No. 1 goal as a physi­cian is to pre­vent toxic stress. Hahn rou­tinely ques­tions fam­i­lies about stresses at home, ed­u­cates them about the risks and helps them find ways to man­age.

Mount­ing re­search on po­ten­tial bi­o­log­i­cal dan­gers of toxic stress is prompt­ing a new pub­lic health ap­proach to iden­ti­fy­ing and treat­ing the ef­fects of poverty, ne­glect, abuse and other ad­ver­sity. While some in the med­i­cal com­mu­nity dis­pute that re­search, pe­di­a­tri­cians, men­tal health spe­cial­ists, ed­u­ca­tors and com­mu­nity lead­ers are in­creas­ingly adopt­ing what is called “trauma-in­formed” care. The ap­proach starts with the premise that ex­treme stress or trauma can cause brain changes that may in­ter­fere with learn­ing, ex­plain trou­bling be­hav­iour, and en­dan­ger health. The goal is to iden­tify af­fected chil­dren and fam­i­lies and pro­vide ser­vices to treat or pre­vent con­tin­ued stress. This can in­clude par­ent­ing classes, ad­dic­tion treat­ment for par­ents, school and po­lice-based pro­grams and psy­chother­apy.

Many preschool­ers who men­tal health specialist Laura Mar­tin works with at the Verner Cen­ter have been in and out of fos­ter homes or live with par­ents strug­gling to make ends meet or deal­ing with drug and al­co­hol prob­lems, de­pres­sion or do­mes­tic vi­o­lence.

They come to school in “fight or flight” mode, un­fo­cused and with­drawn or ag­gres­sive, some­times kick­ing and scream­ing at their class­mates. In­stead of adding to that stress with ag­gres­sive dis­ci­pline, the goal is to take stress away.

“We know that if they don’t feel safe then they can’t learn,” Mar­tin said. By cre­at­ing a safe space, one goal is to make kids’ bod­ies more re­silient to bi­o­log­i­cal dam­age from toxic stress, she said.

Many of these kids “never know what’s go­ing to come next” at home. But at school, square cards taped at kids’ eye level re­mind them in words and pic­tures that lunch is fol­lowed by quiet time, then a snack, then hand­wash­ing and a nap. Breath­ing ex­er­cises have kids roar like a lion or hiss like a snake to calm them. A peace ta­ble helps an­gry kids work out con­flicts with their class­mates.

The brain and dis­ease-fight­ing im­mune sys­tem are not fully formed at birth and are po­ten­tially vul­ner­a­ble to dam­age from child­hood ad­ver­sity, re­cent stud­ies have shown. The first three years are thought to be the most crit­i­cal, and kids lack­ing nur­tur­ing par­ents or other close rel­a­tives to help them cope are most at risk.

Un­der nor­mal stress sit­u­a­tions — for a young child that could be get­ting a shot or hear­ing a loud thun­der­storm — the stress re­sponse kicks in, briefly rais­ing heart rate and lev­els of cor­ti­sol and other stress hor­mones. When stress is se­vere and on­go­ing, those lev­els may re­main el­e­vated, putting kids in a per­sis­tent “fight or flight” mode, said Har­vard Univer­sity neu­ro­sci­en­tist Charles Nel­son.

Re­cent stud­ies sug­gest that kind of stress changes the body’s me­tab­o­lism and con­trib­utes to in­ter­nal in­flam­ma­tion, which can raise risk for de­vel­op­ing di­a­betes and heart dis­ease. In 2015, Brown Univer­sity re­searchers re­ported find­ing el­e­vated lev­els of in­flam­ma­tory mark­ers in saliva of chil­dren who had ex­pe­ri­enced abuse or other ad­ver­sity.

Ex­per­i­ments in an­i­mals and hu­mans also sug­gest per­sis­tent stress may al­ter brain struc­ture in re­gions af­fect­ing emo­tions and reg­u­lat­ing be­hav­iour. Nel­son and oth­ers have done imag­ing stud­ies show­ing these re­gions are smaller than usual in se­verely trau­ma­tized chil­dren.

Nel­son’s re­search on ne­glected chil­dren in Ro­ma­nian or­phan­ages sug­gests that early in­ter­ven­tion might re­verse dam­age from toxic stress. Or­phans sent to live with nur­tur­ing fos­ter fam­i­lies be­fore age 2 had imag­ing scans sev­eral years later show­ing their brains looked sim­i­lar to those of kids who were never in­sti­tu­tion­al­ized. By con­trast, chil­dren sent to fos­ter care at later ages had less grey mat­ter and their brains looked more like those of chil­dren still in or­phan­ages.

Toxic stress is not the same as post-trau­matic stress dis­or­der. PTSD is a dis­tinct men­tal con­di­tion that can re­sult from an ex­tremely trau­matic event, in­clud­ing com­bat, vi­o­lence or sex­ual abuse. Ex­perts say it can oc­cur in adults and chil­dren who live with per­sis­tent toxic stress, in­clud­ing chil­dren in wartorn coun­tries, ur­ban kids who’ve been shot or live in vi­o­len­ce­plagued neighbourhoods, and those who have been phys­i­cally or sex­u­ally abused.

The toxic stress the­ory has be­come main­stream, but there are skep­tics, in­clud­ing Tu­lane Univer­sity psy­chi­a­trist Dr. Michael Scheeringa, an ex­pert in child­hood PTSD. Scheeringa says stud­ies sup­port­ing the idea are weak, based mostly on ob­ser­va­tions, with­out ev­i­dence of how the brain looked be­fore the trauma.

The Amer­i­can Academy of Pe­di­atrics sup­ports the the­ory and in 2012 is­sued rec­om­men­da­tions urg­ing pe­di­a­tri­cians to ed­u­cate par­ents and the pub­lic about the long-term con­se­quences of toxic stress and to push for new poli­cies and treat­ments to pre­vent it or re­duce its ef­fects.

In a 2016 pol­icy not­ing a link be­tween poverty and toxic stress, the academy urged pe­di­a­tri­cians to rou­tinely screen fam­i­lies for poverty and to help those af­fected find food pantries, home­less shel­ters and other re­sources.

“The sci­ence of how poverty ac­tu­ally gets un­der kids’ skin and im­pacts a child has re­ally been ex­plod­ing,” said Dr. Be­nard Dreyer, a for­mer pres­i­dent of the academy.

Some pe­di­a­tri­cians and schools rou­tinely screen chil­dren and fam­i­lies for toxic stress, but it is not univer­sal, said John Fair­bank, co-di­rec­tor of the Na­tional Cen­ter for Child Trau­matic Stress. “That’s cer­tainly an as­pi­ra­tion. It would be a big step for­ward,” said Fair­bank, a Duke Univer­sity psy­chi­a­try pro­fes­sor.

Much of the re­cent in­ter­est stems from land­mark U.S. gov­ern­men­tled re­search pub­lished in 1998 called the Ad­verse Child­hood Ex­pe­ri­ences study. It found that adults ex­posed to ne­glect, poverty, vi­o­lence, sub­stance abuse, par­ents’ men­tal ill­ness and other do­mes­tic dys­func­tion were more likely than oth­ers to have heart prob­lems, di­a­betes, de­pres­sion and asthma.

A fol­lowup 2009 study found that adults with six or more ad­verse child­hood ex­pe­ri­ences died nearly 20 years ear­lier than those with none.

Some chil­dren seem re­sis­tant to ef­fects from toxic stress. Har­vard’s Nel­son works with a re­search net­work based at Har­vard’s cen­tre on the De­vel­op­ing Child that is seek­ing to find tell­tale biomark­ers in kids who are af­fected — in saliva, blood or hair — that could per­haps be tar­gets for drugs or other treat­ment to pre­vent or re­duce stress-re­lated dam­age.

That re­search is promis­ing but re­sults are likely years off, says Dr. Jack Shonkoff, the cen­tre’s di­rec­tor.

Alvin and Natalie Clarke brought their young grand­chil­dren into their Cass City, Michi­gan home af­ter their par­ents jailed on drug charges. The 6-year-old grand­son hits, yells, breaks toys, mis­be­haves in school. His 4-year-old sis­ter used to have night­mares and re­coil in fear when her baby doll was left alone on the floor — signs her ther­a­pists say sug­gest mem­o­ries of ne­glect.

The Clarkes had never heard the term “toxic stress” when they were granted guardian­ship in 2015. Now it’s a fre­quent topic in a sup­port group they’ve formed for other grand­par­ent-guardians.

Their grand­son’s ther­a­pists say he has PTSD and be­hav­iour prob­lems likely stem­ming from toxic stress. Around strangers he’s some­times quiet and po­lite but the Clarkes say he has fre­quent tantrums at home and school and threat­ens his sis­ter. He gets fright­ened at night and wor­ries peo­ple are com­ing to hurt him, Natalie Clarke said.

Weekly ses­sions with a trauma-fo­cused ther­a­pist have led to small im­prove­ments in the boy. The Clarkes say he needs more help but that treat­ment is costly and his school isn’t equipped to of­fer it.

The lit­tle girl has flour­ished with help from Early Head Start be­hav­iour spe­cial­ists who have worked with her and the Clarkes at home and school. “Thank God she doesn’t re­mem­ber much of it,” Natalie Clarke said. “She’s a happy, lov­ing lit­tle girl now.”

CHUCK BUR­TON, THE AS­SO­CI­ATED PRESS

Amy Band teaches chil­dren how to han­dle con­fronta­tions at the Verner Cen­ter in Asheville, N.C. Safe spa­ces, quiet times and breath­ing ex­er­cises for the preschool­ers are de­signed to help kids cope with in­tense stress.

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