AAP: Healthy relationships can help offset toxic stress


Toxic stress can have lifelong negative effects. A new policy statement from the American Academy of Pediatrics (AAP) examines how healthy relationships may serve as a buffer.

It isn’t enough to try and prevent traumatic events in childhood. Supporting healthy growth also means helping children identify stable and supportive relationships in their life. These relationships can buffer bad experiences and promote resiliency, according to a recent policy statement from the American Academy of Pediatrics (AAP).

The policy statement updates previous data on the lifelong effects of toxic stress in children with information on the value of a nurturing relationship with at least 1 stable adult.

“Childhood toxic stress is a public health crisis that demands an integrated public health response. With a social isolating pandemic, a widening of disparities, and a reckoning with centuries of systemic racism, the concept of toxic stress has never been more relevant,” said Andrew Garner, MD, PhD, FAAP, a pediatrician from Westlake, Ohio, and clinical professor of pediatrics at Case Western Reserve University in Cleveland.

Garner, a member of the AAP committee that developed the report, explained that toxic stress can permanently remodel a child’s brain at the cellular level, resulting in behavioral changes that become biologically embedded. Addressing these stresses is 1 step to helping children at risk, but Garner said the policy focuses on what pediatricians can do to be proactive.

“Toxic stress is a deficits-based model in that it defines the problem. Toxic stress explains how many of our society’s most intractable problems—disparities in health, education and economic stability—are rooted in our shared biology but divergent experiences and opportunities,” he explained. “Conversely, relational health is a strengths-based model in that it defines the solution. Relational health explains how the individual, family, and community capacities that support the development and maintenance of safe, stable, and nurturing relationships also buffer adversity and build resilience across the life course.”

In 2012, the AAP outlined the dangers of toxic stresses—early childhood experiences that become biologically embedded and impact life-long development—in a policy statement. The recent policy statement updates the lessons from that report, focusing on how relational health can be used to buffer and support growth and resiliency in spite of toxic stress.1

Toxic stress refers to a wide range of childhood experiences that have physical, behavioral, and even cellular impacts on a developing child. Many of these experiences are the result of relationship challenges like the lack of a nurturing support system, and things like homelessness or insecurity over food and housing. These stresses can damage the entire trajectory of a child’s life, according to the policy statement, and may be to blame for some of the most challenging disparities that develop in adulthood.

The statement outlines new research that suggests that positive childhood experiences can have a protective effect against toxic stress, even working to reverse the effects of damaging experiences.

Safe, stable, and nurturing relationships are key to promoting relational health, according to the paper, because they not only buffer toxic stresses but they also help build resiliency. The policy statement therefore advocates for a new focus on not just preventing toxic stress, but also on promoting relational health.

“Promoting relational health and preventing toxic stress are 2 sides of the same coin. Toxic stress is a deficits-based model that describes what goes wrong in the absence of nurturing relationships,” Garner wrote in a summary of the new policy statement for AAP.2 “Conversely, relational health is a strengths-based model that describes what goes right when children are afforded safe, stable, and nurturing relationships and positive early experiences.”

Building relational health is a process that can take at least 2 generations, he added, noting that it takes multiple layers of family and community effort to support a child’s emotional needs. When a child’s support system functions in “survival mode” because of their own stresses, they aren’t able to provide a positive childhood experience or a background of supportive relational health for future generations.

“Understanding that process allows us to see how many ‘adult-onset’ diseases are actually ‘adult-manifest’ diseases with their origins in childhood,” he added.

Addressing these issues, which Garner called a public health crisis, requires both vertically and horizontally integrated efforts. Vertical efforts are rooted in a public health approach that supports stable relationships throughout childhood. Horizontal efforts can include policy and societal changes designed to support families and community health.

Garner said pediatricians are uniquely positioned to universally promote relational health; identify and address potential barriers to relational health; and utilize the common factors approach and refer to evidence-based therapies when relationships are strained. Some examples of universal promotions include educating parents about development, promoting lots of developmentally appropriate play, and supporting emotional intelligence by helping kids tap into their passions when distressed or bored.

“Potential barriers to relational health that the pediatrician might identify and address include: parental adversity as a child; parental mental illness or substance abuse; or the child’s exposure to poverty, violence, or racism,” Garner added. “Attachment and Biobehavioral Catch-up, Parent Child Interaction Therapy, and Child Parent Psychotherapy are all evidence-based interventions to support relational health, and pediatricians are well placed to advocate for the local development of these services.”

According to the report, another challenge is the fact that our society as a whole is moving toward increased division and social isolation, leading to even more barriers to the formation of stable, healthy relationships that can support relational health. AAP is working to develop practices and policies that can help support healthy relationships despite these challenges. A few starting points that have been identifies include:

  • Support nurturing relationships. This is a core function of the family-centered pediatric medical home and a focus of the statement. How to promote relational health in families is a hot topic in pediatric research, and pediatric primary practices may be the perfect place to focus intervention efforts.
  • Reduce external stress on families. Addressing family stressors such as financial circumstances or ill family members—even in adult members who are not normally included in the pediatric care spectrum—can go a long way toward overcoming barriers that increase toxic stress and make it more difficult to promote relational health. Clinicians can suggest programs that could help either ameliorate or solve such stress points.
  • Strengthen core life skills. Offering support for core life skills like executive function and self-regulation is something pediatricians are used to doing for children, but not other members of their families. Including parents and caregivers in these efforts by doing things like providing education on basic child-rearing and the importance of establishing daily routines.

More research is needed to develop best strategies for these efforts, and work is also needed to stress the importance of relational health in physician training programs and residencies. Pediatricians also need to advocate more aggressively to increase community support for programs that foster good relational health—and for payment reforms that will allow clinicians to be reimbursed for the time and effort they need to devote with this level of care.

Creating change when it comes to addressing toxic stress and relational health will require major shifts in the entire pediatric care model, Garner added.

“Most of medicine utilizes a deficits-based framework. It assumes that the patients are ‘broken,’ and that the primary role of the health care professionals is to reactively respond and to fix them. Pediatricians, however, are intuitively strengths-based. We are all about proactively going up-stream and trying to get things right the first time, instead of trying to repair or remediate much larger problems later,” Garner said. “This policy statement is trying to pivot from the deficits-based framework of toxic stress towards the strengths-based framework of relational health. As the policy statement argues, doing so is a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy.”


1. Garner A, Yogman M, Committee on psychosocial aspects of child and family health, section on developmental and behavioral pediatrics, council on early childhood. Preventing childhood toxic stress: partnering with families and communities to promote relational health. Pediatrics. August 2021; 148(2). doi: 10.1542/peds.2021-052582.

2. Garner A. Almost a decade after policy on toxic stress, ‘relational’ health seen as key approach. AAP News. Published July 26, 2021. https://www.aappublications.org/news/2021/07/26/toxicstress072621

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