Measuring Stress & Resilience

Empowering parents, pediatricians, and communities with trusted scientific information to promote well-being in the face of adversity.

Physician sharing information with mother and baby on an ipad in a clinical setting

Over the past decade, a dedicated group of scientists, pediatric clinicians, community leaders, and parents have been working together to develop a battery of measures of stress activation and resilience in young children. Supported by generous funding from The JPB Foundation as a Research Network on Toxic Stress, the goal of this effort from its inception has been to provide credible information for clinicians and parents about the biological effects of significant adversity on the foundations of early development and lifelong health.

Intended for use in primary health care, these measures have been designed to strengthen the capacity of pediatricians to: (1) prevent, reduce, or mitigate biological disruptions of early development and health by identifying children who are experiencing elevated stress responses before overt symptoms appear; (2) evaluate the effectiveness of early interventions and inform enhanced strategies to produce greater impacts; and (3) provide credible reassurance for caregivers when their children are doing well despite experiencing adversity.

Since activation of the stress response is an essential part of healthy development in all children, a broad-based study is currently under way to determine the “typical” range of values and identify the level at which additional evaluation is needed. Once this study has been completed, the JPB battery will be available for use as a validated screening tool to assess individual children during an office visit for primary health care. More recently, the battery is also 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.

Significant early adversity is a widely recognized risk factor for problems in development and health throughout childhood, as well as higher probability of chronic disease in the adult years. That said, the complex interplay among individual differences in sensitivity to context, 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. Without minimizing the importance of group differences (e.g., by parent education, family income, race, or ethnicity) 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.

The need to understand and address differences between groups as well as among individuals 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-group differences in achievement decrease and more attention can be focused on individual variation within each group. Disparities associated with race require interventions that address racism and other structural inequities; disparities associated with individual differences are best addressed through flexible services that are well-matched to the causes of the variation and delivered in the context of responsive relationships.

Working Paper #17 from the National Scientific Council on the Developing Child underscores the critical importance of understanding both kinds of variation. As the biology of adversity, adaptation, and resilience continues to deepen our understanding of how experiencing adversity “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 community or neighborhood level, is an idea whose time has come.

In 2015, the JPB Research Network on Toxic Stress was created as an ambitious project to engage scientists, pediatric clinicians, and community leaders as 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-makers 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 preventive 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 on 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 benefits across sectors.

Building on the scientific progress of the JPB Research Network, an expanded Pediatric Innovation Initiative (PII) was created to test and validate the JPB Battery in pediatric settings. Two rounds of feasibility testing over the past decade have presented numerous opportunities to learn from both successes and challenges, which are being documented by PII working groups. This co-created knowledge base includes insights about health equity that were exacerbated during the Covid-19 pandemic, cultural challenges in collecting certain types of samples (such as hair snippets), and the vital need for transparent processes and communication through all phases of the project. Documentation of lessons learned will be available for public dissemination 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, Associates, and Staff

While the determination of normative values is a critical prerequisite before the JPB Battery can be implemented as an individual-level measure 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 application 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 young children 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 intergenerational poverty, systemic racism, and exposure to violence 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 to reduce excessive stress activation in young children. Use trusted data to help guide decision-making around further interventions, 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.

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 the shared experiences of overcoming challenges and completing successful feasibility testing in pediatric 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 community-based sites across the United States. Initially designed to be conducted during pediatric primary care visits, 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 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.

This distinguished team of researchers from multiple universities brings wide-ranging expertise in pediatric and psychiatric research, neuroscience, genetics, epigenetics and neurogenetics, mental health, neuroinformatics, public health, and epidemiology. Collectively, members of the network have conducted extensive research on the biology of stress that has resulted in hundreds of peer-reviewed papers in top-tier scientific journals. In 2022, the group co-authored a paper laying out the scientific rationale for biological measures of stress and resilience in young children, which was published in Pediatrics, the official journal of the American Academy of Pediatrics.

Jack P. Shonkoff, MD (Chair). Julius B. Richmond FAMRI Professor of Child Health and Development, Harvard T.H. Chan School of Public Health and Harvard Graduate School of Education; Professor of Pediatrics, Harvard Medical School and Boston Children’s Hospital; Founding Director, Center on the Developing Child at Harvard University
Nicole Bush, PhD. Professor, Departments of Psychiatry and Pediatrics, Center for Health and Community; Lisa and John Pritzker Distinguished Professor of Developmental and Behavioral Health; Director, Division of Developmental Medicine, University of California, San Francisco
Megan R. Gunnar, PhD. Regents Professor; Distinguished McKnight University Professor, College of Education and Human Development; University of Minnesota
Takao K. Hensch, PhD. Professor, Molecular and Cellular Biology, Harvard Faculty of Arts and Sciences; Professor, Neurology, Harvard Medical School at Boston Children’s Hospital; Director, Child Brain Development; Director, WPI-IRCN (UTIAS); Director, NIMH Silvio Conte Center for Brain Science, Harvard University
Michael J. Meaney, PhD. Director, Translational Neuroscience Program, Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research; James McGill Professor, Departments of Psychiatry, Neurology & Neurosurgery; Co-Scientific Director, Ludmer Centre for Neuroinformatics & Mental Health and Director, Sackler Program for Epigenetics & Psychobiology, Douglas Research Centre, McGill University
Patrícia Pelufo Silveira, MD, PhD. Associate Professor, Department of Psychiatry, McGill University; Scientific Director, Genetics and Epigenetics Pillar, Ludmer Centre for Neuroinformatics & Mental Health; Associate Director, Integrated Program in Neuroscience (IPN), McGill University; Member of the College of the Royal Society of Canada
Natalie Slopen, ScD. Associate Professor, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health
David R. Williams, PhD, MPH. Florence and Laura Norman Professor of Public Health, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health; Professor of African and African American Studies and of Sociology, Faculty of Arts and Sciences, Harvard University

The active participation of pediatric clinicians in this effort has helped illuminate the realities of the healthcare environment as well as potential obstacles to widespread measurement implementation. From 2018-2021, members of this group participated in a Pediatric Innovation Cluster focused on iterative practice change. During Phases 1 and 2 of the HERO study, members of this group were the first to test the feasibility of collecting these new measures in the context of a primary care visit. Going forward, documentation of lessons learned will be critical to laying the foundation for the beneficial use of the JPB Battery more broadly in pediatric primary care.

Louis Appel, MD, MPH. Chief Medical Officer and Director of Pediatrics, People’s Community Clinic, Austin, TX
Rachel Stein Berman, MD, MPH, FAAP. Division of Academic General Pediatrics, Assistant Professor of Pediatrics, Albert Einstein College of Medicine Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine Family Care Center, Bronx, NY
Kathleen Conroy, MD, MS. Clinical Chief, Boston Children’s Primary Care, Boston Children’s Hospital; Assistant Professor, Harvard Medical School, Boston, MA
Sara del Campo de Gonzalez, MD. Division Chief, General Academic Pediatrics; Associate Program Director. Baylor College of Medicine at San Antonio, Children’s Hospital of San Antonio, San Antonio, TX
Joan Jeung, MD, MPH, FAAP. Clinical Professor of Pediatrics, University of California San Francisco, Department of Pediatrics, Division of Developmental Medicine, San Francisco, CA
Suzanne Roberts, MD. Associate Professor of Clinical Pediatrics, Keck School of Medicine, University of Southern California Division of General Pediatrics; Children’s Hospital Los Angeles, Los Angeles, CA
Michael F. Troy, PhD, LP. Former Medical Director, Mental Health Services; Science Director, Behavioral Health Services, Children’s Hospital of Minnesota, Saint Paul, MN

Measuring Stress & Resilience

Measuring Stress & Resilience

Why This Work Is Important expand_more

History and Focus on Pediatric Primary Care expand_more

An Emerging Opportunity to Develop a Community Health Indicator expand_more

When Will the Battery Be Ready? expand_more

How Can We Ensure Equitable and Ethical Implementation? expand_more

The JPB Research Network expand_more

Pediatric Thought Leaders expand_more

Community and Parent Leadership Council expand_more

Partners, Associates, and Staff expand_more