The Mitigating Toxic Stress study design: approaches to developmental evaluation of pediatric health care innovations addressing social determinants of health and toxic stress

Abstract

Background Health care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress. Because infants’ experiences are inextricably tied to their caregivers, an important target for mitigating “toxic” stress exposure in early childhood is through reducing parents’ experiences of chronic stress in addition to protecting children from direct experiences of harm such as physical or sexual abuse. Conducting screening to identify when children are exposed to early life adversity is a first step; connecting families to needed support services is an essential component to addressing identified challenges. This paper presents the methodology of a three-year study of health care systems innovations designed to engage and support parents of infants to prevent and mitigate children’s toxic stress exposures. Methods Key study features included: 1) multi-component study in five U.S. communities and nine pediatric health care clinics and the families they serve, 2) a developmental evaluation approach to describe how innovations are experienced over time at three levels—community systems, pediatric providers, and families, and 3) rapid cycle feedback conducted with communities, clinics and families to co-interpret data and findings. Data sources included: 1) focus groups and interviews with community stakeholders, clinic staff, and families, 2) electronic health record and Medicaid services data extracted to assess health care quality, utilization, and financial impact, and 3) clinic-recruitment of 908 parents of infants in a longitudinal survey. Results. The sample is briefly characterized based on responses to the enrollment phase of the parent survey. Conclusions We discuss the study design elements’ contribution to generating evidence needed by innovators, communities, and clinics to modify and sustain investments in these innovations to prevent or mitigate the effects of exposure to toxic stress on young children.

Clinically significant depression among parents during the COVID-19 pandemic: Examining the protective role of family relationships.

“…For example, families that are less financially resourced or face other intersecting disadvantages by dint of a lack of social capital (e.g., single-parent status or racial and ethnic backgrounds as people of color) may respond to pandemic-related stress differently within the family. Exposure to heightened stress through inequities in the social determinants of health may constitute toxic stress that is associated with amplified transmission of negative experiences between parents and their children (McCrae et al, 2021). Conversely, resilience may be fostered through developing strong protective factors and adaptive responses over the course of prolonged experiences of disadvantage (Masten & Narayan, 2012).…”

Centering family voice during a public health crisis: Challenge and opportunity for health collaborations and community systems of care.

“…This analysis examines qualitative interview data collected as a part of a mixed-methods rapid cycle study examining the impact of COVID-19 on families with young children. In that study, five counties had engaged in an innovation in early childhood and healthcare to address family access to concrete and social supports (McCrae et al, 2021). The last data collection wave for that study was concluded just as the global COVID-19 pandemic was beginning (Byers et al, 2022).…”

Coordination challenges and promising practices for pediatric healthcare‐community partnerships: A multi‐site study

“…This paper qualitatively examines eight clinics’ experiences implementing DULCE or I‐SCRN between 2017 and 2020. We use data collected as part of a longitudinal, mixed‐methods study of pediatric clinic‐ and community‐based approaches to prevent and mitigate stress among families with young children (McCrae et al, 2021). The study was approved by the University of Chicago Crown Family School of Social Work, Policy, and Practice and Chapin Hall Institutional Review Board.…”

“…Our study examines coordination between pediatric healthcare and community‐based early childhood providers among eight clinics that implemented two different organizational frameworks to address family social needs at well‐child healthcare visits. Clinics are located in five communities in three states and largely serve lower‐income, Medicaid‐insured families (McCrae et al, 2021).…”