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Markkula Center for Applied Ethics

The Impact of Toxic Stress and Chronic Health Problems on Children’s Health Outcomes

A girl looking sad and depressed.

A girl looking sad and depressed.

Madison Hoffman ’22

Hieu Van/Pixabay 

Madison Hoffman ’22 is majoring in sociology with minors in public health and philosophy at Santa Clara University and is a 2021-22 health care ethics intern at the Markkula Center for Applied Ethics. Views are her own.

Although technological and medical advancements have allowed children and adolescents to live with conditions that were once fatal, research nevertheless indicates a high rate of chronic illnesses among children, and its projected growth. Defined as a medical condition that “lasts three months or more, affects a child’s normal activities, and requires frequent hospitalizations, home health care, and/or extensive medical care,” epidemiological studies suggest that one out of four U.S. children ages 17 and younger live with a chronic health problem, otherwise translating to about 15 to 18 million children.

However, accurately estimating the scope of chronic illnesses among children and adolescents often proves difficult given the wide range of definitions used. The CDC defines chronic diseases as “health conditions that last a year or more and require ongoing medical attention or limit activities of daily living or both.” While some studies cite that 27% of children in the U.S. suffer from chronic conditions, others, including data from the National Survey of Children’s Health, assert the rate to be more than 40%

Nonetheless, despite differing definitions and incidence rates, there is widespread agreement among experts that the prevalence of chronic conditions in children and adolescents is continuing to rise, and has been for the past 30 years. Specifically, the rates of asthma, obesity, diabetes, and behavior and learning problems like attention-deficit/hyperactivity disorder are rapidly increasing. Furthermore, over 13,000 children annually are diagnosed with cancer and greater numbers of children suffer from depression. Much of this increase corresponds with improvements in medical interventions and mortality rates as well as a better understanding of these conditions and increased rates of diagnosis. 

Research additionally indicates that children living at or below the federal poverty line, publicly rather than privately insured children, children belonging to racial and ethnic minority groups, and children from homes where English is not the primary language are at an increased risk for developing chronic health issues. Children from poor families are not only at a higher risk for developing chronic conditions, but they are also more likely to experience significant barriers to care, lack a usual care source, and are more likely to be uninsured. Furthermore, studies indicate that the prevalence of chronic conditions among Black children is exceptionally higher than among white children and both Black and Hispanic children are more likely than white children to be covered by public insurance or uninsured. Yet despite increasing and disproportionate rates of chronic diseases, research studies have been inadequate in illuminating successful intervention and prevention programs.

As a consequence of chronic illness diagnosis, management, and treatment, children, adolescents, and their caregivers encounter significant sources of stress that can compromise adherence to treatment. Yet, not only is stress a result of chronic illness, but stress can also act to physically and mentally exacerbate illnesses. Chronic or toxic stress is characterized by a prolonged activation of the stress response system in reaction to persistent adversity, particularly in those situations that are both threatening and frightening, like physical or emotional abuse, neglect, exposure to violence, and family hardship. 

This is different from positive stress, which is considered to be “essential for the growth and development of a child.” Positive stress is defined by a normal stress response, one that is short-lived, infrequent, and mild, and can include trying something new. Like positive stress, tolerable stress, which is characterized by responses that are more severe, frequent or sustained, differs from toxic stress in that it is not harmful, as biochemical reactions return to normal after the adversity is removed. 

These stressful or traumatic situations are also called adverse childhood experiences (ACEs). Children exposed to toxic amounts of stress are more likely to suffer from negative behavior, cognitive, and health outcomes as a result of alterations in brain architecture. To be more specific, multiple negative outcomes are associated with chronic stress among children, including asthma, anxiety, depression, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), autoimmune diseases, and cancer. 

Children at heightened risk for toxic stress include those from low-income families as well as children of racial and ethnic minority groups. Thus, low-income, racially and ethnically diverse children are dually and disproportionately compounded by both the burden of chronic stress and chronic illness. In this way, too, a vicious cycle of chronic stress and poor health outcomes seems to emerge: the existence of chronic illness results in heightened stress yet chronic stress simultaneously leads to poorer health outcomes. 

Toxic stress is disproportionately high among Black children as a result of institutionalized racial discrimination, high rates of parental incarceration, as well as housing segregation and concentrated poverty. Discriminatory criminal justice practices like racial profiling, mass incarceration, and police violence as well as differential treatment of Black students in school are likely to contribute to the accumulation of toxic stress. Furthermore, Black families living in low-income, segregated neighborhoods often lack equitable access to high-quality health care, transportation, and employment opportunities which can result in less protection against stressful situations and worsen the negative impacts of toxic stress. 

In effect, the disproportionate rate of toxic stress among low-income children of color can be considered a violation of the ethical principle of justice. While justice demands a fair distribution of society’s advantages and disadvantages, these communities are unduly burdened without the needed resources and support to mitigate against the stress brought on by ACEs. Policy recommendations and interventions must involve providing resources and support to parents, caregivers, and families in order to help mitigate the consequences of toxic stress among children. 

Such an intervention should include home and school visits by community health workers or health care practitioners who can screen for toxic stress in at-risk communities, connect families with resources, and social programs pertaining to their individual needs, and ultimately serve as personal advocates for families in need. The high rates of chronic illness and toxic stress also illuminate the desperate need for additional low-cost, high-quality pediatric primary health clinics in vulnerable communities as well as a reconceptualized, public health-based pediatric training program. 

Pediatric residency programs must include more than the epidemiology of pediatric health issues and should encompass a community and population-based curriculum, including barriers to care and good health for children, advocacy efforts, and the environmental and social determinants of health. Implementing workshops and training programs on toxic stress and its consequences can serve as an opportunity for health care practitioners to build empathy with their patients and challenge their own assumptions. The disproportionate rate of chronic illness and toxic stress among low-income children of color must be addressed. If we truly care about achieving justice and health equity, we must act now to promote and protect the health of our nation’s children.  


May 31, 2022

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