Early Brain and Child Development The Public Health

Early Brain and Child Development: The Public Health Perspective Name of Presenter Material developed by the American Academy of Pediatrics August 2018

Objectives • Describe the importance of early brain and child development in public health • Define strategies for addressing early brain development • Identify mechanisms to make a difference

Why Early Experiences Matter Isaac. Mao. Brain. 2005. https: //www. flickr. com/photos/isaacmao/19245594/in/album 72057594061652307/. Accessed June 16, 2018.

Source: "The Challenge: The Ability to Change Brains and Behavior Decreases Over Time. " Conceptual graph created by Pat Levitt in collaboration with the Center on the Developing Child at Harvard University (2009) and published in From Best Practices to Breakthrough Impacts: A Science-Based Approach to Building a More Promising Future for Young Children and Families (2016). Accessed June 16, 2018.

Executive Functioning Includes: • Working Memory • Mental Flexibility • Self-control Executive Function & Self-Regulation. Center on the Developing Child at Harvard University Website. https: //developingchild. harvard. edu/science/keyconcepts/executive-function/. Accessed on July 16, 2018. Impacts: • School readiness • Math and reading competence • Job productivity • Positive relationships • Overall quality of life Diamond A. Executive functions. Annu Rev of Psychol. 2013; 64: 135 -168. doi: 10. 1146/annurev-psych 113011 -143750.

What shapes the developing brain? Shonkoff JP, Garner AS, American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012; 129(1): e 232 -e 246. doi: 10. 1542/peds. 2011 -2663.

Development: Dance Between Nature and Nurture From Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 4 th ed. : Modified with permission from Garner A, Forkey H, Stirling J, Nalven L, Schilling S; American Academy of Pediatrics, Dave Thomas Foundation for Adoption. Helping Foster and Adoptive Families Cope With Trauma. Elk Grove Village, IL: American Academy of Pediatrics; 2015. https: //www. aap. org/traumaguide. Accessed July 19, 2018.

Stable & Responsive Environments • Provide consistent, nurturing and protective interactions with adults • Positive relationships can serve as social emotional buffers Source: Center on the Developing Child at Harvard University Website. https: //developingchild. harvard. edu/. Accessed on July 19, 2018.

Safe & Supportive Physical Environments • Safe places to learn • Places free of toxins • Places that nurture and support families Source: Center on the Developing Child at Harvard University Website. https: //developingchild. harvard. edu/. Accessed on July 19, 2018.

Desired Protective Factors For Families Concrete support in times of need Social connections Knowledge of parenting and child development Personal resilience The ability to enhance social and emotional competence in children • The ability to foster nurturing and attachment • • • Strengthening Families: A Protective Factors Framework. Center for the Study of Social Policy. https: //www. cssp. org/young-children-their-families/strengtheningfamilies/about#protective-factors-framework. Accessed July 26, 2018.

Desired Protective Factors For Communities Safe neighborhoods Safe, high quality schools Stable and safe housing Access to nutritious food Access to job opportunities Access to medical care (including behavioral health and wellness care) • Access to transportation • Access to safe, high quality, affordable child care • Inclusion and equity related to race, ethnicity, and disability • • • Strengthening Families: A Protective Factors Framework. Center for the Study of Social Policy. https: //www. cssp. org/young-childrentheir-families/strengtheningfamilies/about#protective-factors-framework. Accessed July 26, 2018.

Impact of Early Stress CHILDHOOD STRESS TOXIC STRESS Hyper-responsive stress response; calm/coping Chronic “fight or flight; ” cortisol / norepinephrine Changes in Brain Architecture Garner A, Saul R. Thinking Developmentally. Itasca, IL: American Academy of Pediatrics; 2018.

Precipitants and Consequences of Stress in Childhood Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 4 th ed. : Reproduced with permission from Garner A, Forkey H, Stirling J, Nalven L, Schilling S; American Academy of Pediatrics, Dave Thomas Foundation for Adoption. Helping Foster and Adoptive Families Cope With Trauma. Elk Grove Village, IL: American Academy of Pediatrics; 2015. https: //www. aap. org/traumaguide. Accessed July 2018.

“The perception of adversity is subjective, but the reaction is not” - Drs. Andrew Garner and Robert Saul, Thinking Developmentally Source: Garner, A. and Saul, R. (2018) Thinking Developmentally. Itasca, IL: American Academy of Pediatrics, pg. 16

What is the Adverse Childhood Experiences (ACE) Study? Study participants were middle-class Americans from San Diego, 75% white, 75% attended college, average of 57, split evenly between men and women. NOTE: Not an impoverished or “at-risk population” About the CDC-Kaiser ACE Study. Centers for Disease Control and Prevention Website. https: //www. cdc. gov/violenceprevention/acestudy/about. html. Updated June 14, 2016. Accessed July 17, 2018.

We know that: Early Adverse Experiences (ACEs) contribute directly to the risk for long-term physical and mental health. Source: U. S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2016. Published 2018. https: //www. acf. hhs. gov/sites/default/files/cb/cm 2016. pdf. Accessed July 17, 2018.

Prevalence of Adverse Childhood Experiences (1995 -97 Data) (1 point for each category listed) Physical, sexual or emotional abuse Physical or emotional neglect Household mental illness Living in a household with substance abuse • Having a parent/caregiver divorce or separate • Exposure to domestic violence • Living in a household where a member was or has been incarcerated • • ACE Score Women Men 0 35% 38% 1 25% 28% 2 16% 3 10% 9% 4 or more 15% 9% About the CDC-Kaiser ACE Study. Centers for Disease Control and Prevention Website. https: //www. cdc. gov/violenceprevention/acestudy/about. html. Updated June 14, 2016. Accessed July 17, 2018.

As the ACE Score increases, the risk of the following health problems increases Health Problems • Alcoholism/alcohol abuse • Sexually Transmitted Diseases • Chronic Obstructive Pulmonary • • • Disease Depression Fetal death Health related Quality of Life Liver disease Smoking Unintended pregnancy Suicide attempts Intimate partner violence Ischemic heart disea ACE Score Prevalence in Study (1995 -97 data) 0 36% 1 26% 2 16% 3 10% 4 or more 13% About the CDC-Kaiser ACE Study. Centers for Disease Control and Prevention Website. https: //www. cdc. gov/violenceprevention/acestudy/about. html. Updated June 14, 2016. Accessed July 17, 2018.

Impact of Childhood Experiences on Brain Architecture Luby J L et al. PNAS 2012; 109: 2854 -2859 © 2012 by National Academy of Sciences Hippocampus Volume by Preschool Depression Severity and Maternal Support Luby JL, Barch DM, Belden A, et al. Maternal support in early childhood predicts larger hippocampal volumes at school age. PNAS. 2012; 109(8): 2854 -2859. doi: 10. 1073/pnas. 1118003109

Poverty and the Brain • Children in poverty have reduced gray matter volumes – Reduced gray matter accounts for between 15 – 20% of income-related achievement gap – Reductions impact executive function • Chronic stressors related to poverty impact brain development – Raised levels of cortisol and other stress markers Source: Blair C, Raver C. Poverty, Stress, and Brain Development: New Directions for Prevention and Intervention. Academic Pediatrics. 2016; 16(3): S 30 -S 36. https: //doi. org/10. 1016/j. acap. 2016. 010. .

Resilience • Supportive relationships and opportunities for skill building • Dynamic interaction between internal predispositions and external experiences • Learning to cope with manageable threats • Extreme responses to experiences • Earlier is better, but can happen anytime Source: Resilience. Center on the Developing Child at Harvard University Website. https: //developingchild. harvard. edu/science/keyconcepts/resilience/. Accessed on July 17, 2018.

Strategies to Improve Developmental Trajectories E V I S T N C E TIO T O PR RVEN E T N I Anticipatory Guidance Additional Strategies for ‘At Risk’ Families • High Quality ECE • Language Stimulation • Parent Responsiveness Additional Strategies for ‘Poor Health’ Families • Home visiting • Specialized Services Source: Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse Health Development: Past, Present and Future. Matern Child Health J. 2014; 18(2): 344 -365. doi: 10. 1007/s 10995 -013 -1346 -2.

Brain Plasticity Declines With Age • Get “brain wiring” right the first time • Share the message that children are vulnerable • Address toxic stress by: – Using a “common messaging” – Making sure everyone is screened – Helping connect families to community resources Garner A, Saul R. Thinking Developmentally. Itasca, IL: American Academy of Pediatrics; 2018.

What Determines Health? Building Adult Capabilities to Improve Child Outcomes: A Theory of Change http: //developingchild. harvard. edu/resources/multimedia/ videos/theory_of_change/ Building Adult Capabilities to Improve Child Outcomes. Center on the Developing Child at Harvard University Website. https: //developingchild. harvard. edu/resources/building-adult-capabilities-toimprove-child-outcomes-a-theory-of-change/. Accessed on July 18, 2018.

The First 1000 Days: Examples for Promoting EBCD Consistent with Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 4 th ed • • Explore the Child’s environment Build relationships/reciprocity Cultivate development Develop parenting confidence The First 1000 Days: Examples for Promoting EBCD Consistent with Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 4 th ed. https: //www. aap. org/en-us/advocacy-andpolicy/aap-health-initiatives/EBCD/Documents/EBCD_Well_Child_Grid. pdf , Accessed August 28, 2018

Chronosystems= Changes over time, history Bronfenbrenner’s Socioecological Model Macrosystem = societal and cultural values Exosystem = society/indirect environment Mesosytem = Community Microsystems = Relationships Individual Child Adapted from: Bronfenbrenner, U. (1994). Ecological models of human development. Readings on the Development of Children, 2(1), 37 -43. Macrosystem: Economic system, laws, history, culture, social conditions, attitudes Exosystem: Extended family, parents work environment, social services, mass media, local politics Mesosytems: Relationships between those in microsystem Microsystems: Family, peers, child care, neighborhood Child: age, health, behaviors

”Development, it turns out, occurs through this process of progressively more complex exchange between a child and somebody else – especially somebody who’s crazy about that child” - Urie Bronfenbrenner. Quoted in Childhood, Robert H. Wozniak (1991). A viewer's guide produced in collaboration with Thirteen WNET.

What Determines Health? Source: University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2018. www. countyhealthrankings. org. . Accessed July 18, 2018.

Definitions Population health is: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group. ” - Institute of Medicine, 2012, Pg. 19 Public health is: “fulfilling society’s interest in assuring conditions in which people can be healthy. ” - Institute of Medicine, 2003, pg. 411 Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press; 2012: 19. https: //doi. org/10. 17226/13381. Accessed July 18, 2018. Institute of Medicine. The Future of the Public's Health in the 21 st Century. Washington, DC: The National Academies Press; 2003: 411. https: //doi. org/10. 17226/10548. Accessed July 18, 2018.

Returns on Dollars Invested in Early Childhood Source: The Heckman Equation, downloadable toolkit: Social Media Content: Early Investments and Return on Investment for ECE/Childcare https: //heckmanequation. org/resource/social-posts-earlyinvestments-and-return-on-investment-for-ece-childcare/, Accessed August 28, 2018

How Early Experience Gets Into the Body: A Biodevelopmental Framework Foundations for Healthy Development • Gene-environment Lifelong Outcomes • Health Related interaction Behaviors • Relationships • Cumulative effects • Physical, Chemical • Biological embedding • Physical & Mental Health and Built • Physical adaptations • Educational & disruptions Environment Achievement • Nutrition • Economic Productivity • Positive early influences = typically healthy and adaptive • Adverse early influences = dysfunctional, maladaptive, poor health Adapted from: Shonkoff, J. Building a New Biodevelopmental Framework to Guide the Future of Early Childhood Policy. Child Development, January/February 2010, Volume 81, Number 1, Pages 357– 367 https: //steinhardt. nyu. edu/scms. Admin/media/users/eez 206/srb_conference/Building_a_New_Biodevelopment al_Framework_-_J__Shonkoff. pdf. Accessed August 28, 2018

Conceptual Framework Guiding Early Childhood Policy and Practice Healthy Developmental Trajectory Significant Adversity er t un o c n rsity a C ve ad • Supportive Relationships • Stimulating Experiences • Health-Promoting Environments Impaired Health and Development Adapted from: Shonkoff JP. Translating the Biology of Adversity Into More Effective Policy and Practice. Presented at Pediatric Academic Societies Annual Meeting; May 6, 2013; Washington, DC. https: //www. aap. org/en-us/advocacy-and-policy/aap-healthinitiatives/EBCD/Documents/Shonkoff_PAS_Plenary. pdf Accessed August 28, 2018

10 Essential Public Health Services The Public Health System & the 10 Essential Public Health Services. Centers for Disease Control and Prevention Website. https: //www. cdc. gov/stltpublichealth/publichealthservices/essentialhealthservices. html. Updated September 20, 2017. Accessed July 18, 2018.

What You Can Do… • Client interactions provide opportunities to – deliver services – conduct information-gathering – Identifying and fostering strengths – identify additional needs – make referrals to community partners Institute of Medicine Committee on Educating Public Health Professionals for the 21 st Century; Gebbie K, Rosenstock L, Hernandez LM, editors. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21 st Century. Washington, DC: National Academies Press; 2003. https: //www. ncbi. nlm. nih. gov/books/NBK 221185/. Accessed July 13, 2018.

What You Can Do… Leadership at the local and state level offer opportunities to – Partner with other systems to assess population health including the social determinants of health – Examine and evaluate evidence based policies to determine their effectiveness in meeting desired outcomes – Build partnerships with hospitals, non-profit agencies, home visiting programs, schools, child care, etc. – Ensure effective laws, regulations, and implementation such as through law enforcement, social services, court systems, and legislative advocacy – research insights and innovations for personal and population health services Institute of Medicine Committee on Educating Public Health Professionals for the 21 st Century; Gebbie K, Rosenstock L, Hernandez LM, editors. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21 st Century. Washington, DC: National Academies Press; 2003. https: //www. ncbi. nlm. nih. gov/books/NBK 221185/. Accessed July 13, 2018

The Public Health System & the 10 Essential Public Health Services. Centers for Disease Control and Prevention Website. https: //www. cdc. gov/stltpublichealth/publichealthservices/essentialhealthservices. html. Updated September 20, 2017. Accessed July 18, 2018.

Connections Between Public Health and the Medical Home – One Example • Started in 2015 • Administrated through Children’s National Health System • Close collaboration across Project Team, Working Group and Community Advisory Board. • Public-private partnership • Representation from over 25 child-serving organizations, parents and community groups. Source: DC Collaborative for Mental Health in Pediatric Primary Care. DC MAP Mental Health Access in Pediatrics Website. http: //www. dcmap. org/about/dc-collaborative-for-mental-health-in-pediatric-primary-care/overview/. Accessed July 18, 2018.

Partnerships Between Pediatricians & Public Health Current Collaborations • Epidemic response and emergency preparedness • Immunization endeavors, including education, administration, and tracking through registries • Lead poisoning prevention • Newborn screening • Perinatal hepatitis B prevention Kuo AA, Thomas PA, Chilton LA, Mascola L, Council on Community Pediatrics, Section on Epidemiology, Public Health, and Evidence. Pediatricians and Public Health: Optimizing the Health and Well-Being of the Nation's Children. Pediatrics. 2018; 141(2): e 20173848. doi: 10. 1542/peds. 2017 -3848.

Partnerships Between Pediatricians & Public Health Current collaborations • Promotion and adoption of healthy lifestyle behaviors • Protecting the health of travelers • Recognition of the health needs of children who are immigrants, refugees, and migrants • Recognition and reporting of new illness and outbreaks by pediatricians • Substance use prevention and reduction, including tobacco, alcohol, and illicit drugs Kuo AA, Thomas PA, Chilton LA, Mascola L, Council on Community Pediatrics, Section on Epidemiology, Public Health, and Evidence. Pediatricians and Public Health: Optimizing the Health and Well-Being of the Nation's Children. Pediatrics. 2018; 141(2): e 20173848. doi: 10. 1542/peds. 2017 -3848.

Partnerships Between Pediatricians & Public Health Threats that Require Collaborations • Environmental health concerns, including climate disruption, air quality, water safety, environmental toxins, and natural disasters • Food safety • Vaccine hesitancy and/or refusal • Communicable diseases • Obesity epidemic • Supports for immigrant, refugee, and migrant families • Children with special health care needs • Health epidemics (for example, Zika) Kuo AA, Thomas PA, Chilton LA, Mascola L, Council on Community Pediatrics, Section on Epidemiology, Public Health, and Evidence. Pediatricians and Public Health: Optimizing the Health and Well-Being of the Nation's Children. Pediatrics. 2018; 141(2): e 20173848. doi: 10. 1542/peds. 2017 -3848.

Partnerships Between Pediatricians & Public Health Threats that Require Collaborations • Adverse childhood experiences resulting in toxic stress, including poverty, social isolation, immigration, and violence • Health care access, especially for underserved groups (eg, children of undocumented immigrants) • Injury prevention (including gun violence), education, regulation, and anticipatory guidance • Substance use and addiction (including tobacco use, opioids, alcohol, and prescription and illicit drugs) Kuo AA, Thomas PA, Chilton LA, Mascola L, Council on Community Pediatrics, Section on Epidemiology, Public Health, and Evidence. Pediatricians and Public Health: Optimizing the Health and Well-Being of the Nation's Children. Pediatrics. 2018; 141(2): e 20173848. doi: 10. 1542/peds. 2017 -3848.

Resources to Share

Exemplary Programs Supporting Healthy Child Development – and Many More!

Connections Between Public Health and the Medical Home "We are all pieces of the population health puzzle, " she said. "Collaboration is essential to solve the puzzle, create effective solutions to the challenges we collectively face, and optimize the health of our children and our communities. " Lillianne Lewis, MD, MPH, FAAP Prevention and Public Health Special Interest Group, co-chair (2018) AAP Section on Epidemiology, Public Health and Evidence

Advocacy in Action: Flint, MI https: //www. tedmed. com/talks/show? id=627338 Hanna-Attisha M. Mona Hanna-Attisha: Flint's fight for America's children. Presented at TEDMED 2016; November 30, 2016; Palm Springs, California. https: //www. tedmed. com/talks/show? id=627338. Accessed July 18, 2018.

Colorado’s Two-Generation (2 Gen) Approach • 2 Gen concept integrated across 10 state programs • Interdisciplinary approach to improve health outcomes for children and families • Better communication systems to work across departments and streamline services • Developed strategic plans to close achievement gaps and use whole child/whole family approaches Colorado Department of Human Services website. The Two-Generation (2 Gen) Approach. https: //colorado. gov/pacific/cdhs/two-generation-approach, Accessed August 28, 2018

What are We Building? ies t i n u mm o C g Hea lthy tron S Eco nom y Successful Parenting of Next Generation Educational Achievement Economic Productivity Responsible Citizenship Lifelong Health HEALTHY CHILD DEVELOPMENT Graphic adapted from: Three Core Concepts in Early Development. Center on the Developing Child at Harvard University. https: //developingchild. harvard. edu/resources/three-core-concepts-in-earlydevelopment/. Accessed July 26, 2018.

Questions?