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Expanding How We Think About and Treat Toxic Stress

December 2, 2022

In this Perspectives article being early released by Pediatrics, Gilgoff et al (10.1542/peds.2021-055591) make the case that primary care providers should consider implementing secondary (early detection) and tertiary (disease management) preventative approaches when addressing toxic stress in our patients. Such an approach, they argue, should not necessarily replace primary preventative approaches but are more of a recognition that the primary approaches have been insufficient in addressing identified levels of stress. This is based on data they obtained from California’s Adverse Childhood Experiences (ACEs) awareness initiative coupled with salient factors (e.g., pandemics and a possible economic recession) over which we providers have little control.

The authors site examples of such secondary and tertiary approaches that they term “trauma-specific mental health interventions” (including improving sleep/diet/exercise and having supportive relationships) for which they delineate population-level data supportive of such approaches. In addressing the ‘how’ of implementation, they recommend incorporation of such approaches into patients’ treatment plans in consultation with patients and families regarding which approach is most feasible. 

While the main goal of implementing such an approach is to reduce toxic stress, the authors posit a secondary goal of determining which interventions work best in certain sub-populations given the relative dearth of such granular data.

Interestingly, the authors end by asking us to shift our thinking about toxic stress from a deficit model (focusing on what is wrong with a patient and/or their circumstances) to more of a resilience model (what is working well for the patient). It is quite a paradigm shift but may help to buttress the self-efficacy needed to address some of the challenges faced by patients and their families.  Finally, they outline 8 specific actions (ranging from individual- to population-based targeting) providers can consider taking to better address toxic stress when it occurs in their patients.

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