Screening for Early Identification of Toxic Stress Among Young Children: Validation of the Household Strength and Strain Inventory

Background and Purpose: Toxic stress is a physiological response to chronic environmental stress that impacts child neurological and social-emotional development resulting in negative outcomes related to health and well-being throughout the lifespan. Early identification of risk for a toxic stress response to early adversity is critical to ensure prevention and treatment can occur before physiological dysregulation results in long-term disruption to child development, health, and well-being. The purpose of this study was to develop and physiologically validate the Household Strength and Strain Inventory (HSSI) – a non-laboratory screening tool developed for use in early childhood service settings for early identification of toxic stress. Using data collected from children and families receiving Early Head Start (EHS) services, this study examines environmental risk factors and relational protective factors of toxic stress in relation to established measures of child and family functioning, including physiological markers of stress – child cortisol.

Methods: Confirmatory Factor Analysis was conducted to verify the measurement structure of the Household Strength and Strain Inventory developed for the purposes of this study. Structural Equation Modeling was applied to evaluate the convergent and predictive validity of this measure. The sample included EHS-participating families with children under three years of age (N = 67). Study measures included self-report questionnaires, observational measures, and biomarker data. Questionnaires included the HSSI, the Ages and Stages Questionnaire: Social Emotional (ASQ:SE), the North Carolina Family Assessment Scale (NCFAS), the Centers for Epidemiological Studies Depression Scale (CES-D). An observational parent-child play assessment was conducted to assess nurturance. Child cortisol was collected via saliva sampling to assess physiological dysregulation.

Results: The CFA evaluating measurement structure of the HSSI containing latent variables of Economic Hardship, Family Health, Family Relational Risk, and Family Relational Protection revealed mediocre model fit (CFI = .86, TLI = .85, RMSEA = .07). The HSSI was also found to have good internal consistency reliability and some evidence of convergent and predictive validity. The structural model of toxic stress revealed mediocre to acceptable fit (CFI = .88, TLI, .87, RMSEA = .06). The absence of relational protective factors significantly predicted dysregulation of child social-emotional functioning and evening cortisol demonstrating the capacity of this tool to identify contextual environmental factors that predict dysregulated development.

Conclusions and Implications: These results provide promising evidence supporting use of the HSSI as a proxy for cortisol screening in identifying children who are vulnerable to development of physiological and social-emotional disruptions. Validation is an iterative process that must occur across multiple replication studies. However, the results of this study revealed promising support for this tool in terms of reliability, and some evidence of convergent and predictive validity. Therefore, the Household Strength and Strain Inventory may serve to inform social work and other practitioners in the evaluation of young children and families as the first step toward enhanced early childhood screening and promotion of healthy social-emotional development.