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«Toxic Stress, Behavioral Health, and the Next Major Era in Public Health Andrea K. Blanch, Ph.D., David L. Shern, Ph.D., and Sarah M. Steverman, ...»

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Toxic Stress, Behavioral Health,

and the Next Major Era in

Public Health

Andrea K. Blanch, Ph.D.,

David L. Shern, Ph.D., and

Sarah M. Steverman, Ph.D., M.S.W.

Next Era in Public Health Page 1

Toxic Stress, Behavioral Health, and the

Next Major Era in Public Health

Andrea K. Blanch, Ph.D., David L. Shern, Ph.D. & Sarah M. Steverman, Ph.D., M.S.W

September 17, 2014

Next Era in Public Health Page 2

Executive Summary

America’s health and well-being are dangerously in decline. Our longevity has dropped from 28th to 36th in the world since 1990. Compared to 16 similar high income countries, the U.S. consistently has the worst health outcomes. Our academic achievement is lagging, with U.S. scores on reading, science, and math dropping during the last 15 years to near the bottom of the Organization for Economic Cooperation and Development (OECD) nations. Among comparable nations we score poorly on 25 of 54 indicators of well-being, including primary and secondary school enrollment and inequality of educational attainment. We have the highest incarceration rate in the world, and the highest rate of diagnosed mental illnesses. Relative to our wealth and international prominence, we appear to be in the midst of a public health crisis.

At one time epidemics of infectious illness were the greatest threat to the public’s health. This changed with the broad adoption of the germ theory of disease. Although fully implementing the germ theory required massive investments in public health infrastructure (water and sewage systems, mass vaccinations, new treatments, policy and standard setting), the strong science that supported the germ theory provided a compelling rationale for these investments. In this paper we argue that the science regarding our current public health crisis is as convincing as the germ theory was when the public hygiene movement began. This paper details the rationale for an action agenda to usher in a new era of public health that focuses on reducing the impact of toxic stress and trauma on our health, productivity and well-being.

We argue that behavioral health is the linchpin for the next era in public health. The argument is based, in part, on our increasing understanding of the role of toxic stress and trauma, in combination with genetic vulnerability, as antecedents to our declining health and well-being. A review of relevant literature demonstrates the pathways through which these problems develop by mapping the effects of stress and trauma on neural, endocrine and immunological systems. These effects, in turn, cause problems in cognition and executive and emotional control which lead to further developmental problems. A subsequent cascade of consequences ultimately results in increased rates of chronic illnesses and disability.

Behavioral health problems, whether initially displayed in childhood or adulthood, are often the first visible consequences of stress and trauma. Without identification and treatment, children who are exposed to toxic stress and trauma are at increased risk for mental and addictive disorders as well as learning deficits, which in turn predict academic failure, compromised occupational achievement, lower socioeconomic status, and health problems. Adults who experience violence and trauma are also at increased risk for a variety of poor health and social outcomes. Without effective support and intervention, the risk increases for inter-generational exposure to toxic stress and trauma, creating a ‘vicious circle’ of self-reinforcing mechanisms that undermine population health and well-being.

Although the exposure to toxic stress and trauma is nearly universal, not everyone exposed is adversely affected.

Resilience is key to understanding this differential response. Resilience is a characteristic of both people and environments that can be purposely developed. Many prevention and promotion strategies strengthen resilience and reduce environmental risk factors. Child abuse and neglect, for example, are powerful predictors of later life difficulties. The Triple P program and the Nurse Family Partnership both demonstrate significant reductions in child maltreatment and produce positive behavioral and social outcomes. Other programs increase personal skills and social supports associated with resilience.

A public health approach to reducing toxic stress will include strategies for preventing or reducing extreme stress and trauma, building resilience, and providing effective care and treatment. Just as the sanitarians needed infrastructure to reduce and treat infectious illness, we need infrastructure to realize the promise of our science.

Infrastructure needs to be developed at the individual/family, community and societal levels. Public education targeted to individuals and families can help to create safer, healthier environments, address the impact of toxic stress and trauma on overall health, and present effective strategies for building resilience. Parental education Next Era in Public Health Page 3 and support can increase skills-based parenting and create a sense of urgency regarding children’s well-being.

Interventions that reduce abuse and neglect need to be universally available, as well as other parental support mechanisms including treatment for mental health and substance abuse problems. Clearly, early identification and treatment of problems for all age groups is essential. Safer, less toxic communities are environments in which stress and trauma are prevented whenever possible, risk factors are identified and addressed, and people who are affected receive immediate support and treatment. It is ‘on the ground’ in communities where existing resources in education, housing, health, juvenile justice, child welfare, etc. can be coordinated and focused on common goals. Community coalitions are an essential ingredient, and can provide a platform for evaluating the effectiveness of preventive and treatment interventions and monitoring overall community health. Several communities have found that using the trauma and developmental lens discussed here greatly helps to identify common interests across divergent sectors, and provides a template for community action.

At the societal level, state and national leadership is critical. Current service systems can be reshaped to emphasize public health goals and functions. Policy interventions like criminalizing domestic abuse and increasing alcohol taxes can reduce exposure to the toxic stress and trauma. Developing common language can facilitate greater coordination among sectors. Collaborative workgroups can help to inform processes such as the Healthy People national public health goals. Population based measurement systems can help us to track progress over time. Federal legislation enabling greater coordination and accountability for population health and well-being could further facilitate progress. A national action agenda is needed to usher in this next great era in public health. The agenda will operationalize the elements of public health infrastructure needed to address these issues. Perhaps most importantly, it will create broad-based coalitions across the public, private and voluntary sectors that can help create the political will required at local, state and national levels. Given the centrality of behavioral health, SAMHSA has a unique opportunity to provide strategic leadership to the field by facilitating the interaction of the various government components and systematically implementing a change strategy informed by research and past public health successes.

As a nation, we are confronted with serious challenges to our health, well-being and competitiveness. These challenges are not broadly understood or appreciated by the nation’s population. Individuals were once resigned to early mortality and morbidity from infectious illnesses. After understanding the germ theory and building public health infrastructure, expectations changed. The resignation changed to action. We now must address our contemporary resignation to the inevitability of the effects of toxic stress and trauma and mobilize for action. We have the opportunity to usher in a new era in public health. The need is compelling. The role of behavioral health is central. While more science will be developed and our insights enhanced, our knowledge is clearly adequate for action. It is in our enlightened self-interest to act now.

Next Era in Public Health Page 4


The U.S. population is sick, and we are only now beginning to recognize it. We are the most obese population in the world. We have the highest rates of mental illness in the world. Our life expectancy is decreasing relative to other developed nations. All of this is in the context of the wealthiest nation and most expensive medical care system in the world. What’s wrong?

While our health was once threatened primarily by infectious illnesses, our contemporary public health challenges have different causes. As with infectious illnesses, it is the interaction of our biological vulnerabilities with environmental toxins that undermines our health. The contemporary toxins, however, are not microorganisms but the effects of toxic stress and trauma. 1 1 Just like John Snow’s careful study led to a cholera control strategy prior to the full elaboration of the germ theory, we now have compelling evidence for the long term impact of toxic stress and trauma on the development of behavioral and general health problems. In fact, our knowledge of the mechanisms that undermine our health is much better than what Snow had available.

We also know a lot about what can be done to address these effects – both by reducing exposure and by increasing resilience. Addressing these problems is not easy, but it is not an impossible task. When the early sanitarians proposed installing pipes in every household to bring in clean water and separate pipes to remove waste, it must have seemed impossibly complex and expensive. However, armed with a convincing theory about epidemic infections, the infrastructure was conceptualized and implemented. Fully implementing the proposed public health infrastructure will also be a challenge. However, many individual interventions are already in place, and we have the knowledge necessary to implement others. We already have a sufficient platform to build a coordinated strategy and approach. It is our hope that the data and integrative theory presented here will create the political will to develop a coordinated public health infrastructure to address these contemporary challenges. From our perspective, this is the next great challenge in public health.

Today’s Public Health Crises - Indicators of Health and Wellbeing

Despite the common belief that U.S. citizens enjoy the best health and living conditions in the world, we lag behind other nations on many measures of health and wellbeing. In 2012, the U.S. ranked 36th out of 194 countries in life expectancy, dropping from 28th in 1990. 2 The U.S. ranks 38th in disability adjusted life years. The Institute of Medicine (IOM) recently compared the U.S. to 16 similar high income countries. The U.S. consistently has the worst health outcomes, with the highest 0-5 child mortality rate, maternal mortality rate, and rate of obesity. The U.S. has the second highest rates of death due to coronary heart disease, lung disease, and noncommunicable diseases. 3 Moreover, U.S. health is deteriorating, with increasing rates of multiple chronic illnesses during the last decade. 4 Diabetes rates nearly doubled between 1997 and 2013. 5 The U.S. consistently has the most expensive and poorest performing health care system - ranked last among 11 comparable nations in each year since 2004, and 9th on measures of access. 6 The U.S. has the highest rates of mental illnesses and second highest rate of substance abuse problems in the world. 7 Almost half of Americans, 47.4%, will develop a mental health or addiction condition in their lifetime. 8 Individuals who migrate to the U.S. from Mexico have rates of mental illness like the Mexican general population.

However, over 13 years these immigrants’ rates increase to equal those of the U.S. population 9 10. Compared to 16 similar countries, the U.S. has the highest rate of death by violence, almost three times higher than the next country. 11 The U.S. accounts for 80 percent of all firearm deaths among the Organization for Economic Cooperation and Development (OECD) nations – which greatly exceeds our proportion of the OECD population. 12 We incarcerate far more individuals than any other country, with a rate of 707/100,000 population, dramatically higher than similar nations (e.g., Canada’s rate is 118/100,000). 13 Many American children end up in the child welfare system, victims of child abuse and neglect. In 2012, 678,810 children were abused or neglected, a rate of 9.2/1,000. Children under 1 year of age had the highest rate of abuse, at 21.9/1,000. Child abuse impacts healthy development, and also resulted in 1,640 deaths in 2012. Over 70% of these were of children under the Not to minimize other chemical environmental toxins, which are important but not the focus of this work.

Next Era in Public Health Page 5 age of 3. Eighty percent of the fatalities were caused by one or both parents. 14 We have the second highest rate of intentional child death of the OECD nations exceeded only by Brazil. 15 More U.S. teenage girls become pregnant than those in the 16 comparable countries. Our teen pregnancy rate is almost 10 times higher than that of Switzerland, the country with the lowest rate. 16 The U.S. lags other countries in the economic health of the population. Of the 34 OECD countries, the U.S. had the sixth highest child poverty rate (21.8%). 17 18 In 2012, 15.0% of the population lived in poverty, 19 significantly higher than 12.2% in 2000. 20 The U.S. has the highest rates of income inequality of comparable OECD countries. 21 Lagging academic performance helps to limit mobility and exacerbates inequality. We rank 20th in reading, down from 10th in 2009; 30th in math, compared with 24th in 2009; and 23rd in science, slipping from 19th in 2009. 22 In 2011, the World Economic Forum ranked the U.S.'s education system 26th in its ability to prepare students for a competitive economy. 23 Several measures have been developed to assess overall performance in health, opportunity, and sustainability.

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