Translating Developmental Science into Healthy Lives

Transcription

1 The First 1000 days: The Importance of Early Brain and Childhood Development Translating Developmental Science into Healthy Lives Colleen Kraft, M.D., F.A.A.P. Medical Director, Health Network at Cincinnati Children s Hospital

2 Learning Objectives Understand the role of toxic stress in the intergenerational transfer of health disparities; Present an organizing, integrated, ecobiodevelopmental framework; Discuss ways early childhood professionals might advocate in translating science into healthier lifecourses

3 Dramatic Advances in Developmental Science Life-Course Science Epigenetics Developmental Neuroscience

4 Current Conceptual Framework Guiding Early Childhood Policy and Practice Significant Adversity Healthy Developmental Trajectory Impaired Health and Development Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

5 The True Nature of Preventive Medicine Death Early Death Disease & Disability Adoption of Health-Risk Behaviors Social, Emotional, and Cognitive Impairment?? Birth Adverse Childhood Experiences Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status Slide modified from V. J. Felitti

6 Impact of Early Stress MATERNAL TOXIC STRESS NEWBORN HPA reactivity and salivary cortisol levels methylation of the FETAL glucocorticoid (GC) receptor gene brain expression of the GC receptor

7 Dramatic Advance #3 Developmental Neuroscience Brain Architecture is experience dependent (individual connections or synapses and complex circuits of connections or pathways are both dependent upon activity) Ecology (environment/experience) influences how brain architecture is formed and remodeled (plasticity) Diminishing cellular plasticity limits remediation Differential Maturation + Significant Adversity -> Vicious Cycle of Stress Early Experiences create potentially permanent alterations in brain architecture and functioning

8 Early Experiences are Crucial By age 3, 80% of synaptic connections are already made By the second decade of life growth levels off and pruning begins Increased experiences define the wiring of an infant s brain

9 Two Types of Plasticity Synaptic Plasticity Variation in the STRENGTH of individual connections Development of long term and working memory Dysfunction results in working memory deficits Cellular Plasticity Variations in the NUMBER (or COUNT) of connections Billions of connections made, many redundant Pruning of connections after age 5-6

10 10 5 Days 2 Months 1 Year 28 Years

11 Human Brain at Birth 6 Years Old 14 Years Old 11

12 Brain Structure (and Function) - The Brake PFC (with some hippocampal help) Frontal lobes: Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences Parietal Lobe: Integration of sensory data and movement Temporal lobe (outside): Processing sound and language Occipital Lobe: Visual processing Limbic System (inside): Emotions and impulsivity + The Gas Pedal + Amygdala Brain Stem & Cranial Nerves: Vital functions Swallowing Cerebellum: Smooth movements Coordination

13 Impact of Early Stress CHILDHOOD TOXIC STRESS Hyper-responsive stress response; calm/coping Chronic fight or flight; cortisol / norepinephrine Changes in Brain Architecture

14 Eco-Bio-Developmental Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions The Basic Science of Pediatrics Life Course Science Ecology Becomes biology, And together they drive development across the lifespan

15 Critical Concept Epigenetics Physiology of Stress Neuroscience The Science of Early Brain and Child Development Education Health Economics One Science Many Implications The critical challenge now is to translate game-changing advances in developmental science into effective policies and practices for families w/ children to improve education, health and lifelong productivity

16 SE Buffers Toxic Stress Critical Concept Protect the Brain Yin/Yang of Early Childhood: Build New Skills - PROTECT the Brain Maladaptive Skills Adaptive Skills - BUILD New Skills

17 Critical Concept For young children, Caregivers create the environment for brain development! Caregivers can turn off physiologic stress response by addressing physiologic and safety needs Turns off the physiologic stress response by promoting healthy relationships and attachment Notes and encourages foundational coping skills as they emerge Early Childhood professionals are ideally placed! Promote this sort of Purposeful Parenting Advocate for a public health approach to address toxic stress

18 Addressing Toxic Stress Primary / Universal Prevention Proactive, universal interventions to make stress positive, instead of tolerable or toxic Acknowledges that preventing all childhood adversity is impossible and even undesirable Actively building resiliency ( immunizing through positive parenting, One Minute socialemotional learning) SE Buffers for caregivers allow the physiologic stress response to return to baseline

19 Primary Care innovation to reduce toxic stress Comprehensive approach to hardships PCMH 3.0? Community system of partnerships Perfect connections - Birth hospital to PCMH

20 What A Well-Trained Clinic Will Detect Maslow s Hierarchy of Needs DRAFT Potential Collaborations Unemployment; lack of high school degree; ex-offender reentry issues Achieving potential Overwhelmed new parents; lack of parenting role models Esteem & Respect Domestic violence; mental health issues; inadequate education services Hunger; homelessness; denial or delay of benefits; utility shut offs Belonging Safety Basic Human Needs A. Henize (2013)

21 Using EMR to drive social history screening Benefits Housing Depression Domestic Violence All others

22 # of referrals/1000 Well Child Visits Connecting to Community Services Child HeLP Referrals per 1000 Well Child Visits PPC Fairfield Hopple May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14

23 Preventive services use among children receiving free formula (KIND) vs. who did not (Klein) KIND (%) No KIND (%) P Lead complete <.01 ASQ complete <.01 5 well visits in first 14 months <.01 Social risks identified Food insecurity <.01 Parental depression 11 5 <.01 Housing issues 15 6 <.01 Benefit issues <.01 Domestic violence issues 5 2 <.01 Referrals to social work <.01 Referrals to MLP 15 6 <.01

24 Receipt: 1 st Newborn Connection to PCMH Brown *babies born 37 weeks

25 Promoting the Five R s of Early Childhood Education READING together - daily RHYMING, playing and cuddling ROUTINES help children know what to expect of us - what is expected of them REWARDS for everyday successes a powerful reward PRAISE is RELATIONSHIPS, reciprocal and nurturing foundation of healthy child development

26 Strategies Identify roles of all Home Visitors and connection to OB practices; Consider using the prevention bundle as a chronic condition for PCMH; Resources for PCMH: consider how practices link to HV, parent play/support, HNCC if they are in our network

27 Addressing Toxic Stress Secondary / Targeted Preventions Focused, targeted interventions for those deemed to be at high risk Home Visiting Parenting Play/Support Programs More likely to be effective; minimize damage

28 Care Management Design Home Visiting Contract High Touch, in-person, in-home Prenatal Early Childhood Asthma Case Management Behavioral Health Case Management Oral Health Screening/Dental Varnish

29 Home Visiting Intervention Pilot

30 Home Visiting = In-Home Prenatal Care Management IDEA Poverty is a risk factor for poor maternal and newborn outcomes. What if every mother with Medicaid had a Home Visitor to provide support, education, transportation? How would this impact health of the next generation? AIM STATEMENT Reduce the number of infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as inhome case managers.

31 Team Huddles, CQI Driver Diagram Outcomes Primary Drivers Secondary Drivers Reduced numbers of premature and low birth weight infants Improved maternal physical and behavioral health Reduced cost of care (due to reduced NICU days) Access to prenatal care Health insurance Transportation Access to behavioral health Emotional support Healthy nutrition Smoking Cessation CONNECTION Home Visitors connect with pregnant moms; incentives; depression screening, referral, treatment RELATIONSHIP Emotional support, healthy nutrition, smoking cessation, parenting readiness, pregnancy health and when to call SYSTEMS Screening and enrollment for health insurance, In home data collection

32 National Benchmark=March of Dimes Virginia C grade for premature birth Total prematurity = 11.3% Late preterm (34-36 wk) = 8% Uninsured = 17.2% Maternal smoking = 15.2% Roanoke/Allegheny Metrics worse for this region Prematurity = 12.2% Late preterm (34-36 wk) = 10.1% Uninsured =15.6% Maternal smoking = 24.4%

33 Measures Measure Percent of infants born at > 37 weeks gestation Percent of infants born between 34 and 36 weeks gestation (late preterm) Birth weight Percent of infants <2500 grams Percent of Pregnant Moms participants who smoke that stopped smoking Percent of Pregnant Moms participants who start prenatal care in the first trimester Percent of Pregnant Moms participants who attend all the recommended prenatal visits Percent of Pregnant Moms participants who are uninsured Percent of Pregnant Moms participants identified with depression Percent of Pregnant Moms participants connected to treatment for depression Cost of Care Health Care Cost O O O O P P P P P C

34 1 st Trimester Goal =90% Percent Goal = 90%

35 All Visits-Goal = 60% Percent Goal = 60%

36 Reduce Maternal Smoking by 1/3 Percent Goal = 16%

37 Perinatal Depression

38 Reduce Percentage of Infants born <37 weeks by 30% <37wk wk Goal

39 Reduce Percentage of Term Infants born < 2500g by 30%

40 Note: One premature infant March 19-May 10 Cost of Care

41 Family-Centered Medical Home Parenting Support Early Intervention Home-visiting network Developmental Services Prevention, Building Health Developmental Services Vulnerable children and families Child and Family Medically Complex Children Lactation Support Acute Care Chronic Care Early Child Mental Health Services Early HeadStart & HeadStart Child Care Resource & Referral Agency

42 Medical Home: Pediatric Extensive Care Oral Health Ed, Fluoride, dev scr Anticipatory Guidance reinforced inhome Shared Inbasket with EHR Child and Family CYSHCN, refer to CCC, Special Families Health Concierge; Screening, risk id Medical or social needs, refer to CHIP

43 Who are the Home Visitors? Team Care Each team has one RN Three family intervention specialists AAS trained Trained in Evidence-based model (Parents As Teachers) Often from community being served 43

44 Routine Medical/Social Screening Screening, Risk Stratification, Communication Personnel dedicated to this position (health concierge) Ability to connect more important than education Could be a family partner Becomes a point of contact for the practice Can sign up families for text4baby and healthychild.org push notifications, select blogs, Facebook groups Can facilitate appointments or point-of-care referral 44

45 Early Childhood support/guidance Parents as Teachers Parent/Child curriculum Frequent Developmental Screening Safety Sleeping Car seats Home safety Anticipatory Guidance Relevance in home setting

46 Oral Health and Fluoride Varnish Begin with a Grin!

47 Asthma Case Management Assess environment, modifications Smoking cessation Observe inhaler use Asthma control assessment Asthma action plan and education Transportation to visit

48 Behavioral Health Prenatal to age 7 Perinatal/postpartum depression screening Connection to services for parents and children at-risk and diagnosed Transportation to visits

49 Results 100% families receive early childhood education 90% 2yr olds UTD on well visits and immunizations 100% children are screened for lead, Hgb, development 100% children have a Dental Home 66% of children have had a dental visit by age 3 97% have had an oral health assessment and fluoride varnish 145 children in program % well controlled 84% minimal inhaler use 90% decrease in ED visits 82% decrease in school absence due to asthma

50 Next Steps Expansion to a private practice Social-emotional and school outcomes Expanded Behavioral Health through MIECHV Assess HEDIS measures Compliance with Asthma guidelines, ER and hospital admissions, missed school and work days Co-locate HV teams in OB and Pediatric practices Development and school readiness of birth cohort

51 SUMMARY What can I do? Understand the ecobiodevelopmental framework (advocate for a collaborative, public health approach to address toxic stress) Help children figure out how to turn off their stress response (parent/child skills) Recognize the relationship as a vital sign

52 SUMMARY What can I do? Develop purposeful partnerships with Pediatric healthcare providers Incorporate practice process to screen, refer, and follow all children Intervene early for those children who appear unable to turn off their stress response (secondary and tertiary prevention)

53 SUMMARY What can I do? Provide parents information on Adverse Childhood Experiences Understand and learn about parents adverse childhood experiences Refer parents for resources to help them address their own stress and health concerns.

54 Next Steps Expansion to a private practice Social-emotional and school outcomes Expanded Behavioral Health through MIECHV Assess HEDIS measures Compliance with Asthma guidelines, ER and hospital admissions, missed school and work days Co-locate HV teams in OB and Pediatric practices Development and school readiness of birth cohort

55 Building an Enhanced Theory of Change that Balances Enrichment and Protection Significant Adversity New Protective Interventions Healthy Developmental Trajectory Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

56 CONCLUSIONS Advances in developmental science are: - forcing us to reconsider the early childhood origins of lifelong health & disease - challenging us to get it right the first time - beckoning for community based programs to protect the brain and build new skills

57 CONCLUSION: It is easier to build strong children than to repair broken men. Frederick Douglass