Pediatric Disaster Behavioral Health (PDBH) Toolbox
3. The Toolbox - Implementation & Tactical Resources
3.9. Primer on Toxic Stress and Neurodevelopmental Considerations
- It is important to distinguish between adverse events that happen to a child as “stressors” and the child’s response to these events as the “toxic stress response.”109
- A number of childhood adversities/stressors can trigger a toxic stress response. This is defined as the prolonged activation of the stress response system that can disrupt brain architecture. Chronic stress can result in epigenetic changes, neurodevelopmental disruption, and the reprogramming of stress and immune regulatory systems. This can change one’s developmental trajectory including increased risk of cognitive deficits, disease, psychopathology, and social problems.110
- Research shows a link between prenatal maternal stress through various mechanisms including physical danger and loss of loved ones and possessions. Prenatal stress can affect the developing fetus.110
- Contextual factors are important in influencing response.109 The following factors should be considered:
- Type of adversity
- Duration of adversity
- Developmental status and critical period timing of adversity/trauma
- Number of adversities and the interactions among them
- Exacerbating factors (e.g., recurrent morbidities, malnutrition, environmental toxins)
- Supportive family environments
- Pre-existing characteristics (vulnerabilities linked to genetic or fetal influences, prematurity, intellectual and developmental disabilities, and children with special health care needs)
- Individual variation (i.e., children have different physiological reactions to the same stressor)
- There can be several impacts of trauma on functioning and behavior. This typically falls under 3 types of symptomatology: Functional symptoms, neurodevelopmental symptoms, and immune function symptoms.
- Functional symptoms (e.g., sleep difficulty, changes in appetite, toileting problems, challenges with school functioning, hyperactivity/impulsivity, inattention)
- Neurodevelopmental symptoms (e.g., rapid reflexive response to stimuli, difficulty tolerating negative mood, aggression, regression, presenting younger than chronological age, attachment challenges, social-emotional and communication challenges)
- Immune function symptoms: (e.g., persistent inflammatory response, headaches, stomachaches, and lethargy).
- Based on age and/or developmental stage, there are differences in common responses to trauma, effects on working memory, inhibitory control, and cognitive flexibility. A summary is provided below:
| Infant / Toddler / Preschooler |
| Common Trauma Responses |
Separation anxiety, inattention, aggressive play, repetitive play, developmental regression |
| Working Memory Impacts |
Difficulty meeting developmental milestones |
| Inhibitory Control Impacts |
Frequent and severe tantrums, increased aggressive behavior |
| Cognitive Flexibility Impacts |
Easily frustrated, difficulty with change and transition |
| School-aged |
| Common Trauma Responses |
Anxiety, hypervigilance, regression |
| Working Memory Impacts |
Filling in missing details/confabulation, difficulty acquiring school-based knowledge |
| Inhibitory Control Impacts |
Increased trouble navigating peer relationships, increased problems at school, increased difficulty with compliance in the home setting |
| Cognitive Flexibility Impacts |
Organizational challenges |
| Adolescent |
| Common Trauma Responses |
Anxiety, depression, hypervigilance, increased engagement in risk-taking behavior |
| Working Memory Impacts |
Difficulty keeping up in school, trouble meeting parent expectations, social challenges |
| Inhibitory Control Impacts |
Impulsive actions |
| Cognitive Flexibility Impacts |
Difficulty assuming tasks associated with increased independence and transition to adulthood |
- The AAP Committee on Psychosocial Aspects of the Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care and Section on Developmental and Behavioral Pediatrics states that “it’s not adversity alone that predicts poor outcomes; it is the absence or insufficiency of protective relationships that reinforce healthy adaptations to stress.”109
- Special considerations may be needed for youth who have been diagnosed with neurodevelopmental disorders. The CDC describes neurodevelopmental disorders as a group of considerations that affect the development of the brain and nervous system leading to various impairments/challenges in areas such as learning, movement, behavior, and social interaction. Neurodevelopmental disorders exist on a continuum and require varying levels of accommodations/modifications. Common examples include autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual disability, learning disabilities, and motor disorders like cerebral palsy. Disasters can potentially exacerbate existing challenges and make new ones. Particular areas for consideration include:
- Sensory sensitivities
- Cognitive rigidity
- Emotional dysregulation
- Dependence on routine
- Communication challenges
- Caregivers of children with neurodevelopmental disorders face increased parental distress in times of uncertainty (such as disasters), there may be strains in the caregivers’ personal relationships, and specialized services may be needed such as accessible shelters, behavioral health care, and respite care.
- Targeted interventions and support systems are needed for children with neurodevelopmental disorders and their families.