Treating Toxic Stress with Social Connection
Anita Shah, DO
Maurice Stewart, MS
Brian Calfano, PhD
Maurice Stewart reflects on his life:
Am I going to survive today? Through tomorrow? High school graduation?
Growing up, these were questions I faced constantly, and didn’t necessarily have an answer. I grew up with my mom and two brothers in Cincinnati’s English Woods neighborhood. My family lived in subsidized housing. Food was not always on the table. When it was, nutritious food was a luxury. My father passed away when I was young, bringing quick awareness that some do not make it to a ripe age. My grandfather stepped in to make sure that my family could afford and get to the funeral without navigating the bus. The funeral reminded me that questions about survival would demand an answer eventually.
Have you faced these same questions as Maurice?
Maurice’s situation, unfortunately, is not unique. We live in communities where worry about survival resonates through the lived experiences of some, while others are busy pondering choices about career, education, and recreation—a state that should actually be the norm for all in American society.
Many Cincinnati children and families face the daily struggle to answer their survival question in the affirmative. But doing so is work, and you’re not paid for it. The constant effort to meet basic needs (i.e., access to a safe home, food, or time to sleep, exercise, etc.) does not abate. Kids are the most vulnerable to the struggle. And even when successfully threading the needle of survival, the constant strain leaves a deep mark that can go unnoticed. Fighting for one’s survival constitutes an adverse childhood experience, or ACE.
ACEs can occur in the home or the community. Individual level ACEs may include lack of access to shelter, hygiene, or living with a parent suffering from mental illness (like depression). Community level ACEs can include growing up in poverty, witnessing violence in the community, or even living in a racist society. What’s especially dangerous about ACEs is that they can pose an exacting threat that’s not as immediately terrifying as violence or painful as hunger.
When a child experiences a multitude of ACEs, they may also experience unhealthy levels of stress. This response is coined toxic stress.
Toxic stress is different from our day to day stressors. Everyone experiences a healthy amount of stress that’s just a part of everyday life. For a child, this may be going to the doctor to get shots on their first day of school. The difference between these healthy stressful experiences is that there is usually an adult to help the child cope and learn on how to deal with the stress, and the stress usually resolves. For example, let’s say you are going hiking and run into a bear. Seeing the bear immediately triggers your fight or flight response—your body’s stress response. Cortisol, your stress hormone, is released in these situations and causes your body to increase your heart rate, and you breathe faster. The faster breathing prepares your body to either run from the bear, or if you so choose, fight the bear. But at some point, the bear leaves and your stress response shuts off and you calm down. For a child that bear may be the trip to the doctor, but the proverbial bear leaves once the shot is over and there is a parent to console them.
But toxic stress is different. Imagine, instead, that the bear is with you all of the time. It never leaves you, but is just at your side constantly. Consequently, your cortisol never quite returns to baseline levels, meaning your body is constantly hypervigilant and in this “fight or flight” response. This kind of stress is toxic and can have damaging effects to your body and long-term health. The research is clear that what children experience in their earliest years, both positive and negative, has an impact into adulthood. But the experience, like the constant wonder about the survival question, becomes the norm. You get used to the feeling, which means you don’t suspect there is anything wrong.
Furthermore, as a result of the COVID-19 pandemic, social distancing and stay at home orders compound these adverse experiences by upsetting the existing arrangements one achieved to meet basic needs. This additional layer of uncertainty may increase stress and anxiety, which, in turn, undermines health. Even in the early stages of the pandemic, it is clear that inequities in access to care, including screening and treatment related to COVID-19, are disproportionately burdensome on minority communities. The individual-level uncertainty introduced by macro public health policies only adds to this burden.
So what can help alleviate underlying toxic stress? While it’s admirable to pursue life changes that may enhance food and personal security—and effectively address the survival question— it is also unrealistic to assume those worried about survival have the resources to make these kinds of changes in the immediate term. But addressing toxic stress is an immediate need, so the recommended antidote must be within reach of virtually everyone affected by toxic stress.
Many ACEs are big systemic problems that won’t be fixed overnight. The good news is that kids can bounce forward from compounded adversities with the help of caring adults. Most kids just need one consistent caregiver or parent to buffer the impact of toxic stress by providing a safe, stable nurturing environment. When kids feel loved and protected, their brains don’t need to stay in “fight or flight” mode to survive.
Fortunately, social connection, which is generally within everyone’s control, is one of the strongest antidotes to toxic stress. It’s important to remember that adults are impacted by toxic stress or have many ACEs too! In order to buffer the stress for kids, adults need to take care of themselves and support one another. Think about what got you through tough times? Was it faith in yourself, support of family and friends, a little extra money to get by, a kind word from a coworker, or encouragement from a friend? These are “protective factors” that help adults manage stress and buffer stress for their kids. While social distancing is critically important to limiting the spread of COVID19, wearing a mask, meeting with others while staying 6 feet apart is an excellent way to foster social connection. Online connections also are another great way to connect.
Our region also has organized assistance within reach. Joining Forces for Children is a collective impact group whose mission is to prevent and mitigate the effects of toxic stress in Greater Cincinnati. Its website features resources for community members and service professionals available to leverage social connection and other tools to care for yourselves and others.
But once social connections are strengthened immediate financial concerns may linger as a toxic stressor. An excellent resource for anyone facing concerns with paying rent or utilities, eviction, the Legal Aid of Greater Cincinnati has resources and supports available.
Meanwhile, kids need to stay connected to their education, and worrying about their survival can threaten school progress. Cincinnati Youth Collaborative (CYC) is a local nonprofit that brings together over 1,500 volunteers and over 100 corporate partners and strives for dropout prevention by offering mentoring, college readiness and success, and career preparation. Though there is no single answer for toxic stress and the uncertainties minority communities face, these resources—both social and organizational—can help.
Maurice not only survived, he thrived. He is now on the boards of CYC and Cincinnati College Preparatory Academy, a K-12 public charter school housed in the building where he went to elementary school in the West End. As evidence of the healing power of social connection, Maurice’s teachers. Grandfather, brother, and many others always pushed him to see the positives in himself that led him to his success. He had a group of adults who showed up for him along the way, and sometimes that’s all it takes. Maurice graduated from Jacobs High School and completed both a Bachelor of Arts in Organizational Leadership at the University of Cincinnati and a Master of Science in Organizational Leadership at Southern New Hampshire University. His story is different, and shifted from “Am I going to survive?” to “How can I give back?”
If you would like to give back, follow in Maurice’s footsteps and give back. We all need each other.
Dr. Anita Shah is an assistant professor of Pediatrics in the Divisions of Hospital Medicine and Mayerson Center for Safe and Healthy Children within the UC Department of Pediatrics. She has a strong background in pediatric advocacy and health policy. Dr. Shah is a PEDSnet Scholar through the Agency for Healthcare Research and Quality (AHRQ) which currently supports her research interests. Her research has focused on the association of parental adversity and resilience with outcomes after pediatric discharge. She serves as the lead for the Healthcare Channel within Joining Forces for Children, a collective impact group centered around building child and family resilience in Greater Cincinnati.
Maurice B. Stewart manages the implementation and evaluation of capacity building programs at Interact for Health. Maurice has a background in community advocacy, diversity and inclusion and nonprofit board leadership. Maurice advocates for education around Adverse Childhood Experiences. Maurice is a life coach and a personal trainer. Maurice was selected as the 2019 Outstanding Young Alumnus for the College or Arts and Sciences at the University of Cincinnati.
Brian Calfano is associate professor in the Departments of Political Science and Journalism at the University of Cincinnati. His research focuses on marginalized groups and media coverage of politics.
 Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of C, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246.
 Health ODo. COVID-19 Minority Health Testing. https://coronavirus.ohio.gov/wps/portal/gov/covid-19/families-and-individuals/mhsf/covid-19-minority-health-strike-force. Published 2020. Accessed July 28, 2020.