The Editorial Board of the Section on Pediatric Trainees Monthly Feature is proud to feature an article by Dr Kavitha Selvaraj, who suggests that the effects of toxic stress can be combated through the development of physician–teacher partnerships. Her article concluded our series of featured essays on the Advocacy Campaign for 2016–2017.

Catherine Spaulding, MD, Editor, Pediatrics, SOPT Monthly Feature

I first learned about toxic stress the day my student “J” punched me in the face.

As a seventh-grade biology and health teacher in an underserved neighborhood, I hoped to inspire the next generation of scientists. Unfortunately, the 5-week teachers’ boot camp left me woefully underprepared for the students’ constant behavioral outbursts, so little time was actually spent teaching. The most memorable incident started when I heard voices in the hallway yelling, “Fight! Fight! Fight!” and found my students, “J” and “N,” throwing punches. I positioned myself between the sparring students and yelled at them to stop.

N backed away immediately, but J kept swinging with full force. His pupils were dilated, his face was sweaty, his respirations were fast and shallow. I implored him to stop, but instead, he stared at me blankly and punched me square in the face. Within moments, security guards arrived to escort J and N to the dean’s office, and the crowd dispersed. I stood there a moment longer, my cheek throbbing and my ego even more wounded, in shock at what had just occurred.

After finding an ice pack for my swollen face, I dialed the number for J’s mother. To my surprise, the call was answered by a substance abuse rehabilitation facility. After hearing about the morning’s events, she mumbled, “So what?” and hung up the phone. I was instantly worried. Who was taking care of J while his mother was in rehabilitation? Why did his mother not care about him fighting? Sadly, I never learned the answers to these questions.

After J’s punch, I came close to quitting. However, the discovery of J’s tumultuous social situation kept me from leaving that day, much to the surprise of my students. Once the students realized that I was staying, they began to trust me. Over time, my classroom became a space for students to spend free time before school, during recess, and after school. Occasionally, they disclosed something serious. One child admitted to me that he had difficulty concentrating because of constant hunger. A different student confided that he was afflicted by nightmares that had started after witnessing a fatal neighborhood shooting. Another student passed me a note that said she was being sexually abused by her stepbrother. These disclosures were handled with food pantry referrals, conferences with parents and school counselors, and calls to the Department of Child and Family Services. The term toxic stress was unfamiliar to me at the time, but I felt its impact on my students every day. Although I do not recommend getting punched in the face to help children thrive, the chain of events that unraveled after J’s fight showed me that as a teacher and a caring adult figure, I was in a unique position to limit the long-term effects of toxic stress by cultivating resilience in my students and myself.

Adverse childhood experiences (ACEs) and early exposure to poverty contribute to the development of child toxic stress,1,2 which can lead to negative health outcomes across the life span.3,4 Challenging home environments may lead to behavioral and emotional problems in early childhood, so toxic stress symptoms are often first noticed by teachers.5 As my students’ social contexts became more familiar, it was clear that there was usually a reason a child would lash out or withdraw. Sometimes, the right question to ask was not, “Why are you behaving this way?” but rather, “What is happening to you?” Positive student–teacher relationships are associated with higher levels of student wellbeing,6 and indeed, my students’ behavior and academic performance improved once they began to trust me. They engaged in class discussions, submitted assignments, and excelled on assessments. Within months, they transformed from the lowest-performing into the highest-performing students in the school.

Pediatricians and teachers have a complementary understanding of how children thrive; accordingly, my students’ stories inform the questions I ask in my clinic and in my research as a fellow in academic general pediatrics. In the clinic, I have only 15 minutes with each family to address toxic stress in addition to health maintenance, acute illness, and chronic conditions. I cannot help but remember that as a teacher, I spent at least an hour per day with my students. I knew my students in a way that I cannot know my patients. Children with toxic stress have complex educational, behavioral, and medical needs that cannot be managed by a single sector.

Historically, the physician–school collaboration has had a track record of success in improving the lives of children with developmental disorders, attention-deficit/hyperactivity disorder, undernutrition, obesity, food allergies, and asthma.7,12 It is time to add toxic stress to this list. Besides families, teachers spend the most time with children and are therefore invaluable partners in identifying toxic stress and building child resilience.13 However, a pediatrician–teacher partnership to address child resilience must also address teacher resilience to break the cycle of teacher stress and student stress. This relationship is a well-described phenomenon; difficult classrooms lead to burnout and high teacher turnover,14 which in turn only make the student experience more chaotic.15 After hearing similar experiences from many other teachers, my colleagues and I worked together to develop stress management strategies for the students and ourselves. Our collective efforts helped to break the cycle of student stress and teacher stress, and this professional support network became invaluable to me during my 2 years in the classroom.

Pediatricians often talk with parents about positive parenting16; similarly, we can work with schools to promote positive teaching. This could include teacher training to manage behavior in children with high ACE scores, deescalate charged situations, and build teacher capacity.17 Physicians, researchers, and educators can conduct dissemination and implementation studies to help schools screen for ACEs, identify the socioemotional symptoms of toxic stress, and promote the 7 C’s of resilience (competence, confidence, connection, character, contribution, coping, and control).18,20 Emotional self-regulation strategies, such as meditation and mindfulness, can be reinforced across the classroom and clinic settings.21 Pediatricians and teachers can communicate regularly to discuss progress in at-risk children, as we do for children with attention-deficit/hyperactivity disorder. At a systems level, we can advocate for smaller student-to-teacher ratios and trauma-informed mental health services in schools.

If we aspire to raise happy and healthy children, we must move beyond the concept of the trauma-informed medical home or the trauma-informed school. Instead, we must work together with our teachers and schools to build trauma-informed communities.19,22 As for J, I wish I could tell you that I got him the help he needed to process his own traumas. Unfortunately, I never saw him again. After the report to the Department of Child and Family Services, he was moved out of state to live with extended family, and I was not provided contact information for him. I hope he is thriving wherever he is now. Maybe someday I can tell him about how he inspired me to spend my life helping kids like him, although I was unable to help him.

     
  • ACE

    adverse childhood experience

Dr Selvaraj conceptualized, drafted, revised the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects of the work.

FUNDING: No external funding.

I thank my fellowship mentors for their feedback on this article: Helen Binns, MD, MPH; Adolfo Ariza, MD; Barbara Bayldon, MD; and Matthew Davis, MD, MAPP.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.