Chapin Hall

Mitigating Toxic Stress: How can systems work together to prevent its effects?

Experiencing and learning how to manage stress is a normal part of child development. But when children experience stress for prolonged periods, without the supportive response of an adult, that stress can be toxic. What we’ve come to know as toxic stress can threaten children’s long-term well-being, with significant costs to our nation’s health and communities.

Pediatric primary care clinics are often the front-line to identifying families and children who may be experiencing toxic stress. In five communities, pediatric clinics employed two innovations to promote family-centered care and better coordination between health care and community-based programs to prevent and mitigate toxic stress.

These innovations are:

• Developmental Understanding and Legal Collaboration for Everyone (DULCE)
• Improving Screening, Connections with families, and Referral Networks (I-SCRN)

Over a three-year period, Chapin Hall investigated the role of these innovations in preventing and mitigating toxic stress among families receiving pediatric health care. We worked with healthcare clinics and early childhood service providers and more than 900 families with young children to capture how family experiences and outcomes are altered by these innovations. We issued the following reports from this study:

• Study Overview, including research methods, study design, methods and data sources, and planned deliverables.
• Implementing DULCE and I-SCRN, perceptions of how implementing these two screening tools has contributed to strengthening family, clinic, and community relations.
• Unlocking the Potential of Electronic Health Records, a look at the challenges and potential of more effective use of electronic health records in pediatric healthcare.
• Integrating Healthcare and Early Childhood Systems, a look at how health care systems and early childhood providers can better work together to mitigate toxic stress.
• Practice Bulletin: Conversations with Families to Recognize Needs, an examination of how providers can help families with young children address health-related needs arising due to COVID-19.
• Practice Bulletin: Community Resources for Patient Referrals, a look at how the COVID-19 crisis uniquely positions pediatric providers to refer families to social supports for food insecurity, housing, and other resources.
• Getting Connected: Referrals for Family Support in Early Childhood, a study of the role of central referral systems in the lives of families with young children.
• Before Crisis Hits: Embedding Legal Support in Preventive Health Care for Families with Young Children, which examines how preventive legal partnering creates new opportunities to positively impact children’s health.

The project staff and their colleagues have also published four journal articles from this study:

• An article in BMC Health Services Research outlined the methodology of this study and its data sources.
• An article published in Children and Youth Services Review investigated the reliability and construct validity of the Functional Impact of Toxic Stress for Parents (FITS-P) measure.
• An article in Prevention Science detailed the results of an examination of how risk and resilience profiles were associated with children’s health status and family unmet needs for social supports 1 year later.
• An article in International Journal of Public Health examined how demographics, neighborhood quality, previous family adversities, and resilience affected caregiver mental health during the COVID-19 pandemic.

The Evaluating Community Approaches to Preventing or Mitigating Toxic Stress study was designed to increase understanding of how to build integrated systems with coordinated services that promote healthy development of young children. We also partnered with Help Me Grow (HMG) to describe how health care practices use community-based early childhood service referral mechanisms to assist families with needed resources.

Our work included deepening our understanding of family experiences of health care and toxic stress through detailed analysis. We matched information collected from families about stressors, protective factors, and risks at three time points, with electronic health records, Medicaid claims, and service delivery registry data. With this information we examined:

• Changes in preventive service use and well-being for families over time
• Improvements to pediatric health care quality using standardized indicators
• Increased value and impact on health care cost through efficient use of prevention services

The study also investigated the five communities’ approaches to embedding and sustaining the innovations over time. The participating pediatric primary care clinics were located in Alameda County, CA; Orange County, CA; Lamoille Valley and Burlington, VT; Los Angeles, CA; and Palm Beach County, FL.

Dr. Julie McCrae, who brings considerable expertise in implementing and studying interventions in community settings, led the work. The Chapin Hall research team also included Dr. Angeline Spain (qualitative lead researcher), Dr. Emma Monahan, and Angela Garza.

Chapin Hall collaborated with NORC, the American Academy of Pediatrics, the Center for the Study of Social Policy, and Help Me Grow National Center to conduct the study, and with the early childhood systems and the pediatric primary care clinics. The JPB Foundation funded the work.

For more information about this initiative, please contact us at ch-toxicstressstudy@chapinhall.org.