Measuring Stress & Resilience
Measuring Stress & Resilience
Over the past decade, a dedicated group of change agents—including scientists, pediatric health care providers, community leaders, and parents—has been working to develop a battery of measures of stress activation and resilience in young children. The goal of this effort is to provide information in real time about the effects of significant adversity on the biological foundations of early childhood development and lifelong health.
With the information these measures provide, we can: (1) prevent, reduce, or mitigate stress-related challenges to early development and both physical and mental health before overt symptoms appear; (2) evaluate the effectiveness of interventions and inform new strategies to produce greater impacts; and (3) provide credible reassurance when children are doing well despite experiencing adversity. Initially, the group’s focus was on developing a measure of stress activation and resilience that could be used to assess individual children during an office visit for primary health care. More recently, that measure is being explored as a potential community health indicator to assess the effects of place-based interventions on stress in young children across a designated community or neighborhood.
Why This Work Is Important
Significant early adversity is a widely recognized risk factor for problems in development and health throughout childhood, as well as higher probability of a chronic disease in the adult years. That said, the complex interplay among individual genetic differences, the diversity of experiences and exposures (both positive and negative), and age of exposure to external influences leads to significant variation in biological responses to stress.
It is well-documented that social determinants of health (SDOH), adverse childhood experiences (ACEs), and other indicators of increased threat to well-being are highly correlated with early developmental problems, lower educational achievement, and chronic illnesses throughout life at a population level (e.g., groups of people who have histories of specific risk factors such as poverty, systemic racism, child abuse, etc. tend to have a higher prevalence of heart disease or diabetes). Without minimizing the importance of group differences for setting policy priorities, SDOH and ACE scores are not valid predictors of problems at an individual level (e.g., whether a specific child who has experienced adversity will develop health problems later in life). Moreover, not all children respond to the same intervention in the same way.
As the biology of adversity, adaptation, and resilience continues to deepen our understanding of how excessive stress “gets under the skin” and “into the body,” improved capacity to measure variation in stress activation directly in individual children as well as at a population level, is an idea whose time has come.
Working Paper #17 from the National Scientific Council on the Developing Child underscores the critical importance of understanding the difference between two distinctive sources of that variation, particularly for children of color and other minoritized groups. The first, between-group differences, is rooted in social and economic inequities such as intergenerational poverty, systemic racism, and community conditions affecting the availability of opportunities and protective factors. The second, individual variation within groups, comes from each child’s unique biological makeup interacting with the intensity, frequency, and duration of a wide range of experiences and exposures (good and bad) and the age at which they occur, thereby avoiding false stereotypes based on race, ethnicity, or family income.
The need to understand and address both sources of variation is vitally important. For example, racial differences in educational achievement are clearly associated with disparities in access to opportunities and protection from hardships that undermine learning. When these inequities are reduced, racial differences in achievement decrease and more attention can be focused on individual variation within each group. Disparities associated with race require interventions that address structural inequities; disparities associated with individual differences are best addressed through flexible services that are well-matched to the causes of the variation.
History & Focus on Pediatric Primary Care
In 2015, the JPB Research Network on Toxic Stress was created as an ambitious project to engage scientists, pediatric clinicians, and community leaders as full partners in the development of new measures to identify young children who show signs of being more or less sensitive to adversity than others—and thus more or less likely to develop difficulties as well as respond to interventions. This effort evolved into the Pediatric Innovation Initiative, a national network of change agents committed to leveraging cutting-edge science, clinical expertise, and place-based wisdom to strengthen the ability to assess stress activation in pediatric primary care.
The original aims of this enhanced measurement capacity included the following:
- Provide credible data for primary health care providers, working in partnership with families facing significant hardship or trauma, to prevent, reduce, or mitigate negative influences on early health and development—as well as convey reassurance for parents whose children are doing well despite experiencing adversity.
- Supplement parent reports (which are a valuable indicator of what parents observe) and direct assessments of child development (which reflect behaviors that service providers can monitor) with the ability to measure what’s going on “inside the body” to facilitate earlier identification of the need for intervention before outward symptoms appear, as well as assess treatment effects and inform ongoing, individualized care.
- Document the disruptive effects of intergenerational poverty, systemic racism, and interpersonal discrimination on developing biological systems, thereby empowering pediatricians with credible scientific evidence to advocate for more effective policies to reduce the burdens of structural inequities on families with young children.
- Measure the effects of specific interventions in reducing excessive stress activation in young children in a way that can be used to increase their impacts and help secure sustainable healthcare funding for demonstrated evidence of effectiveness across sectors.
Today, the Pediatric Innovation Initiative continues to enroll participants and document lessons learned from its efforts to test and validate the JPB Battery in pediatric settings. This documentation will be available for public review and use in 2025. The current Pediatric Innovation Initiative consists of:
- The JPB Research Network on Toxic Stress
- Pediatric Thought Leaders
- Community and Parent Leadership Council
- Partners and Associates
An Emerging Opportunity to Develop a Community Health Indicator
While the determination of normative values is a critical prerequisite before the JPB Battery is ready for implementation in pediatric primary care practice, several national leaders of place-based initiatives have been asking how the science of ECD 2.0 might help strengthen the front end of their “cradle to career (or college) pipeline” and how they might better measure their impacts on the health and development of young children. As these conversations have continued, a growing interest has emerged in the potential use of the JPB Battery as a community health indicator to assess the effects of place-based interventions on stress activation in young children across a designated community or neighborhood. The proposed benefits of this additional approach include the following:
- Provide credible data for leaders in community investment, anti-poverty and racial equity initiatives, and neighborhood revitalization projects, working in partnership with residents and families with young children, to address adverse community-level influences on early health and development.
- Supplement reliance solely on neighborhood demographics and administrative data with the ability to measure what’s going on inside the bodies of actual residents to facilitate earlier identification of intervention needs, as well as evaluate their effects and inform ongoing community action and decision-making.
- Document within communities the disruptive effects of generational poverty, systemic racism, and personal discrimination on developing biological systems in young children in order to strengthen the power of families, residents, and local leaders to advocate for more effective policies, increased financial resources, and enhanced collaboration across institutions and sectors.
- Measure the ability of community-focused or neighborhood-level investments and interventions to reduce excessive stress activation in young children. Use credible scientific data to help guide decision-making around further investments, contribute to studies of return on investment through future improvements in health, education, and socioeconomic mobility, and catalyze greater financial resources from sources looking for measurable social impact at a community or neighborhood level.
What is the Battery Measuring?
The current version of the JPB Battery comprises 18 biological indicators (including measures of stress hormones, inflammation, and cell wear and tear) that can be assessed in samples of saliva, a cheek swab, and a small snippet of hair; a tablet-based measure of executive function skills (beginning at age 2 ½); and a questionnaire that includes parent reports about the family and neighborhood context in which the child is developing.
A study —known as Health’s Early Roots and Origins (HERO)—is currently under way to determine “normative values” for each component in the battery. Building on two rounds of successful feasibility testing in community-based primary care practices, the HERO Phase 3 study aims to validate and norm the battery in a nationally representative sample of young children between ages four months and five years. This effort is led by JPB Research Network members working in partnership with sites across the United States. Initially designed to be conducted in pediatric office settings, the norming study is expanding to invite families to participate through early learning centers and place-based organizations.
When the norming study has been completed, criteria for defining the boundaries of typical variation in stress activation will be determined by age and sex, and the threshold for an elevated stress response that requires attention will be established. When those criteria have been met, the battery will be ready to use as a validated screening tool for individual assessment in pediatric primary care.
In contrast, the potential value of the battery as a community health indicator lies in its ability to measure change across a resident population after a specific place-based intervention (e.g., housing revitalization, increased availability of well-paying jobs, reduction in community violence) has been implemented. Thus, testing of the battery as a community health indicator is ready to move forward on a faster timeline than for individual-level assessment—and we are currently planning to begin the collection of baseline data with a selected group of community partners.
How Can We Ensure Equitable and Ethical Implementation?
Notwithstanding growing interest in the JPB Battery across sectors, we fully recognize the sensitive nature of collecting biological data to measure stress activation in young children and the critical importance of ensuring ethical implementation and accurate interpretation. This caution is particularly critical for communities of color, given centuries of racist ideologies advanced by the egregious misuse of biology—and deeply embedded racial inequities in the delivery of medical services today.
Guided by this awareness from its inception, the JPB Network was launched as a partnership among scientists, pediatric clinicians, community leaders, and parents primarily from communities of color—and we have worked together to build a firewall of protection against these threats and the understandable distrust they perpetuate. Community co-ownership drives our vigilant attention to both maximizing parent empowerment and preventing potential negative uses of measures of stress effects, such as inappropriate labeling of children or families.
Over the past nine years, under the auspices of the Pediatric Innovation Initiative, we have been inspired by the way an authentic, mutual commitment to partnership has built trust, strengthened parent engagement, honored family strengths, avoided deficit thinking, and enabled continuing hard work hard on the challenges of shared decision-making. This effort has included ongoing engagement of community leaders and parents in all aspects of the work, including study design, consenting procedures, and the information needs of parents as well as clinicians. Active engagement of community leaders in the measurement development process has also highlighted the potential power of mobilizing communities as agents of change.