Let us state our premise upfront—safe, stable nurturing relationships (SSNRs) are crucial to early childhood development and later adult health. Selective serotonin reuptake inhibitors (SSRIs), commonly prescribed anti-depressant medications, can be very important for children and adults—but they will never be a substitute for the SSNRs that are necessary for adequate, and hopefully far exceeding adequate, nurturing in early childhood. SSNRs are the foundational basis of early brain and child development and crucial to wellness in adulthood. SSRIs can be a lifeline in the teen years or adulthood for mental health considerations but they need to be supplemented by SSNRs. SSNRs cannot successfully be supplanted by SSRIs. Our society cannot rely on SSRIs to fill voids that we failed to fill.
Early brain and child development is a delicate interplay of multiple factors. We do know that these factors will lead to a cumulative experience that will affect adult outcomes. When those experiences are affiliative (associated with parental engagement, quality child care and the opportunity to play; i.e., SSNRs), there is a greater likelihood of healthy lifestyles, academic success and economic stability. When those experiences are adverse (associated with environmental violence, neglect or poverty), there is a greater likelihood of poor health, academic failure and economic hardship. These statements are of course generalizations but now biological science has confirmed the probabilities for these generalizations.
When children have an excess exposure to adverse childhood experiences (ACEs), they are at significant risk for what has now been identified to be toxic stress. Stress in life is always present but when in excess and accompanied by less-than-adequate nurturing, such stress can lead to abnormal brain development, abnormal brain wiring, abnormal brain responses and abnormal genetic expression for certain stress-relieving mechanisms. This stress is therefore called toxic. Toxic stress is not simply identified as one factor. In some ways, it more resembles a soup or a mixture of various factors that in combination will lead to a cumulative negative effect.
An example of a cumulative negative effect can be unequal balance of maladaptive behaviors to adaptive behaviors. Affected children might do well in certain environments (adaptive behaviors) but in other environments exhibit too many maladaptive behaviors. They might do well in gym class but be too disruptive in math class to the point of being sent to the principal’s office or performing poorly on course work. In some ways, the maladaptive behaviors are their compensatory mechanism for dealing with stress and similar situations that their intrinsic biology is not “wired” for.
On top of poor performance in school or various behavior problems in childhood, biology now also tells us that certain adult problems can occur with greater frequency in children exposed to increased toxic stress. Smoking, alcoholism, obesity, promiscuity and substance abuse along with concomitant hypertension, diabetes and heart disease can ensue in individuals with a greater exposure to ACEs. So many disorders in adulthood that we consider adult-onset are actually manifestations in adulthood of ACEs or toxic stress. Therefore, many of the health issues in adulthood are adult-manifestand worthy of our attention much earlier in life.
The temptation in our society is to ask the question “What is wrong with you?” when considering certain health problems. We contend that a much more germane question is “What has happened to you?” as we seek to make positive strides going forward. If we can address the issues in this latter manner, we then can think back to early issues and try to assess our interventions going forward from a developmental standpoint. We can better assess past issues in a non-judgmental manner, establishing trust and nurturing as our tools of assistance.
By thinking developmentally, we seek to assist our neighbors and fellow citizens to diminish negative influences in their lives; we seek to make our community and society a more nurturing environment; and we seek to establish and enhance safe, stable nurturing relationships (SSNRs) in our own families, in our neighbor’s families and in our communities—relationships that are crucial to adult health and well-being.
SSRIs might be necessary to help cope with a variety of life’s stresses—but they will never be a substitute for SSNRs. SSRIs are only an adjunct to health in life. SSNRs are the key.
Robert A. Saul, MD, FAAP, FACMG
Professor of Pediatrics, University of South Carolina School of Medicine-Greenville
Andrew S. Garner, MD, PhD, FAAP
Clinical Professor of Pediatrics, Case Western Reserve University School of Medicine
Authors, THINKING DEVELOPMENTALLY: NURTURING WELLNESS IN CHILDHOOD TO PROMOTE LIFELONG HEALTH, American Academy of Pediatrics, 2018, 175 pages. (ISBN 978-1610021524)