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The First 1000 days: The Importance of

Early Brain and Childhood Development

Colleen Kraft, M.D., F.A.A.P.

Professor of Pediatrics

Virginia Tech Carilion School of Medicine and Research Institute

Realizing the

Potential of

Pediatrics

Disclosures

• Senior Medical Officer for MajestaCare, a

Medicaid Managed Care ACO

• Merck Vaccines, speaker and Advisory Board

• Expert Panel, Text4Baby

Learning Objectives

• Understand the role of toxic stress in

the intergenerational transfer of

health disparities;

• Present an organizing, integrated,

ecobiodevelopmental framework;

• Discuss ways pediatricians might

advocate in translating science into

healthier life-courses

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Critical Concept #1

Childhood Adversity has Lifelong Consequences.

Significant adversity in childhood is

strongly associated with

unhealthy lifestyles and

poor health decades later.

The Adverse Childhood

Experiences Study

(ACE Study)

“In my beginning is my end.”

T.S. Eliot, Four Quartets

ACE Study Findings

• Childhood experiences are powerful

determinants of who we become as adults

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HMO Members in ACE Study

• 80% White,

including Hispanic

• 10% Black

• 10% Asian

• About 50% men,

50% women

• 74% had attended

college

• 62% age 50 or older

ACE Categories

Women Men Total

• Abuse (n=9,367) (n=7,970) (17,337)

– Emotional 13.1% 7.6% 10.6%

– Physical 27.0% 29.9% 28.3%

– Sexual 24.7% 16.0% 20.7%

• Household Dysfunction

– Mother Treated Violently 13.7% 11.5% 12.7%

– Household Substance Abuse 29.5% 23.8% 26.9%

– Household Mental Illness 23.3% 14.8% 19.4%

– Parental Separation or Divorce 24.5% 21.8% 23.3%

– Incarcerated Household Member 5.2% 4.1% 4.7%

• Neglect*

– Emotional 16.7% 12.4% 14.8%

– Physical 9.2% 10.7% 9.9%

* Wave 2 data only (n=8,667) Data from www.cdc.gov/nccdphp/ace/demographics

1:4!

1:4!

• Severe and persistent emotional problems

• Health risk behaviors

• Serious social problems

• Adult disease and disability

• High health, behavioral health, correctional and social service costs

• Poor life expectancy

For example:

The higher the ACE Score, the greater the likelihood of :

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• Sexually Transmitted Disease

• Liver Disease

• COPD

• Ischemic Heart Disease

• Autoimmune Disease

• Lung Cancer

Higher ACE Score = significant rise in

chronic health conditions:

Effect of ACEs on Mortality

0

10

20

30

40

50

60

Pe

rce

nt

in A

ge

Gro

up

0 2 4

ACE Score

19-34

35-49

50-64

>=65

Age Group

0 ACE 60% live to 65 4 ACE less than 3% live to 65

CORE Predictive Modeling from Aetna

Mbrs who are

Top 1%

Mbrs who are

High Risk ED

Mbrs who are

Medium/High

Risk IP

A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups…

Members who are Top 1% AND high risk for an ED visit next 12 mos.

Members who are Top 1% , high risk for an ED visit, AND medium/high risk for IP admit next 12 mos.

Members who are top 1% general risk AND medium/high risk for IP admit next 12 mos.

Members who are high risk for an ED visit AND medium/high risk for IP admit next 12 mos.

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Personalize the Profile for Medical Homes Increasing Medical and Behavioral Complexity

Group 3:

•Ave age 33

•72% female

•PMPM $962

•5 ED visits, 0.2 admits

•32% asthma prevalence; 25% med adherence (asthma)

•85% MH prevalence

•58% co-occurring mental health and substance abuse

•52% with 5+ Rx classes

•5 Specialist visits

•10 PCP visits

Group 4:

•Ave age 49

•PMPM $3908

•2.6 admits

•12 IP bed days

•7 ED visits

•51% diabetes prevalence

•73% MH prevalence

•87% with 5+ Rx classes

•20 Specialist visits

•10 PCP visits

Group 6:

•Ave age 43

•PMPM $2425

•1.6 admits

•7 IP bed days

•6 ED visits

•Low medical disease prevalence

•85% MH prevalence

•62% co-occurring MH and SA

•12 Specialist visits

•9 PCP visits

3

6 4

Group 5:

•Ave age 53

•PMPM $3202

•2 ED visits

•2 admits

•10 IP bed days

•56% diabetes prevalence

•41% MH prevalence

•84% with 5+ Rx classes

•19 Specialist Visits

•7 PCP visits

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ED Risk Only

ED Risk/IP Risk Only Top 1%/

ED Risk/IP Risk Top 1%/ IP Risk Only

Significant Adversity

Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

Healthy Developmental Trajectory

Impaired Health and Development

Current Conceptual Framework Guiding Early Childhood Policy and Practice

Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status

Adverse Childhood Experiences

Social, Emotional, and

Cognitive Impairment

Adoption of

Health-Risk Behaviors

Disease & Disability

Early Death

Death

Birth

The True Nature of Preventive Medicine

Slide modified from V. J. Felitti

??

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Developing a Model of

Human Health and Disease

Life Course Science

Early childhood ecology

strongly associates with

lifelong developmental outcomes

What are the

mechanisms

underlying these

well-established

associations?

How do you

begin to define

or measure the

ecology?

Defining Adversity or Stress

• How do you define/measure adversity?

• Huge individual variability

– Perception of adversity or stress (subjective)

– Reaction to adversity or stress (objective)

• National Scientific Council on the Developing Child (Dr. Jack Shonkoff and colleagues)

– Positive Stress

– Tolerable Stress

– Toxic Stress

Based on the REACTION

(objective physiologic responses)

• Positive Stress

– Brief, infrequent, mild to moderate intensity

– Most normative childhood stress

• Inability of the 15 month old to express their desires

• The 2 year old who stumbles while running

• Beginning school or daycare

• The big project in middle school

– Social-emotional buffers allow a return to baseline

(responding to non-verbal clues, consolation, reassurance, assistance in planning)

– Builds motivation and resiliency

– Positive Stress is NOT the ABSENCE of stress

Defining Adversity or Stress

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• Toxic Stress

– Long lasting, frequent, or strong intensity

– More extreme precipitants of childhood stress (ACEs)

• Physical, sexual, emotional abuse

• Physical, emotional neglect

• Household dysfunction

– Insufficient social-emotional buffering (Deficient levels of emotion coaching, re-processing, reassurance and support)

– Potentially permanent changes and long-term effects

• Epigenetics (there are life long / intergenerational changes in how the genetic program is turned ON or OFF)

• Brain architecture (the mediators of stress impact upon the mechanisms of brain development / connectivity)

Defining Adversity or Stress

Critical Concept #2

Epigenetics:

• Which genes are turned on/off, when, and where

• Ecology (environment/experience) influences

how the genetic blueprint is read and utilized

• Ecological effects at the molecular level

• Stress-induced changes in epigenetic markers

Biology Physiologic Adaptations

and Disruptions

Life Course Science

Through epigenetic mechanisms,

the early childhood ecology becomes

biologically embedded, influencing how the genome is utilized

Developing a Model of

Human Health and Disease

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Critical Concept #3

Developmental Neuroscience:

• Synapse and circuit formation are experience and

activity dependent

• Ecology (environment/experience) influences how

brain architecture is formed and remodeled

• Early childhood adversity -> vicious cycle of stress

• Diminishing cellular plasticity limits remediation

• Potentially permanent alterations in brain

architecture and functioning

Two Types of Plasticity

• Synaptic Plasticity –

– Variation in the STRENGTH of individual connections

– “from a whisper to a shout”

– Lifelong (how old dogs learn new tricks)

• Cellular Plasticity –

– Variations in the NUMBER (or COUNT) of connections

– “ from one person shouting to a stadium shouting”

– Declines dramatically with age (waning by age 5)

Brain Stem & Cranial Nerves:

Vital functions Swallowing

Cerebellum:

Smooth movements Coordination

Occipital Lobe:

Visual processing

Parietal Lobe:

Integration of sensory data and movement

Temporal lobe (outside):

Processing sound and language

Limbic System (inside):

Emotions and impulsivity

Frontal lobes:

Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences

Brain Structure (and Function)

+ The Gas Pedal +

Amygdala

- The Brake – PFC (with some hippocampal help)

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Impact of Early Stress

TOXIC STRESS

Chronic “fight or flight;” adrenaline / cortisol

Changes in Brain Architecture

Hyper-responsive stress response; calm/coping

CHILDHOOD STRESS

Development results from an on-

going, re-iterative, and cumulative

dance between nurture and nature

Brain Development

Alterations in Brain

Structure and Function

Experience

Protective and Personal

(versus Insecure and Impersonal)

Epigenetic Changes

Alterations in the Way the

Genetic Program is Read

Behavior

Adaptive or Healthy Coping Skills

(vs. Maladaptive or Unhealthy Coping Skills)

Biology Physiologic Adaptations

and Disruptions

Life Course Science

Declining plasticity in the developing brain results in potentially permanent

alterations in brain functioning and development

Developing a Model of

Human Health and Disease

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Eco-Bio-Developmental

Model of Human Health and Disease

Biology Physiologic Adaptations

and Disruptions

Life Course Science

The Basic

Science of Pediatrics

Ecology

Becomes biology,

And together they drive development across the lifespan

Critical Concept #4

The Science of

Early Brain and

Child Development

Epigenetics Physiology of Stress Neuroscience

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

Childhood Adversity Poor Adult Outcomes

Toxic Stress

Epigenetic Modifications

Disruptions in Brain Architecture

Behavioral Allostasis

Linking Childhood Experiences and

Adult Outcomes

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It’s

Health

Equity

It’s early

brain &

child dev

It’s epi-

genetics

It’s

foster

care It’s

mental

health

It’s

obesity

Toxic Stress

…it’s a little like the blindfolded man feeling the

elephant

The Problems of Children And Families that We Focus on: Are Parts of the Elephant

It’s problems

of immigrant

children

It’s food

insecurity

It’s low

immuniz.

rates

It’s poor

oral

health

It’s

poverty

The BIG Questions are…

3) What does this mean for pediatrics

– particularly for primary care?

Critical Concept

For young children,

parent/caregiver support is critical:

• Turns 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

Pediatricians are ideally placed to:

• Promote this sort of “Purposeful” Parenting

• Advocate for a public health approach to address toxic stress

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• 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, 7C’s of resilience, promoting optimism, formalized social-emotional learning)

– SE Buffers allow the physiologic stress response to return to baseline

•Parenting skills for younger children

•SEL skills for older children (www.casel.org)

Addressing Toxic Stress

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 – PRAISE is

a powerful reward

• RELATIONSHIPS, reciprocal and nurturing –

foundation of healthy child development

• Secondary / Targeted Preventions

– Focused, targeted interventions for those deemed to be

“at high risk”

– Visiting Nurse Programs (Nurse Family Partner.)

– Parenting Programs (Triple-P, Nurturing Parent.)

– More likely to be effective; minimize “damage”

– Requires screening

Addressing Toxic Stress

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Addressing Toxic Stress

• Treatment of the consequences – TF-CBT and PCIT are evidence-based

– Reactive – some “damage” already done!

– Very COSTLY

– Efficacy linked to age and chronicity

•Declining brain plasticity?

– Insufficient number of / access to providers

– Persistent STIGMA

•“Character Flaws” vs “Biological Mal-adaptations”

Universal Primary Preventions

Bright Futures

Connected Kids

Circle of Security

Relationships as a “vital” sign

Basic EBCD Competencies

Targeted Interventions

Screening for risks

(assess the ecology)

Refer to/advocate for EBI

Collaborating/Developing EBI

Mid-level Competencies

Evidence-Based Treatments

Screening for diagnoses

Common factors approach

Refer for/advocate for EBT

Collaborating/Developing EBT

Advanced Competencies

WHAT are we DOING?!

New Protective Interventions

Building an Enhanced Theory of Change that Balances Enrichment and Protection

Significant Adversity

Healthy Developmental Trajectory

Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

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Public Investment in Children

by Age

Quality Early Care and Education

Pays Off: Cost/Benefit Analyses

Show Positive Returns

41

$2

$6

$8

$4

$10

$3.23

Abecedarian Project (early care and

education aged 0-5)

$5.70

Nurse Family Partnership

(home visiting prenatal – age 2 for

high risk group)

Perry Preschool (early education age 3-4)

Total Return per $1 Invested

Data Sources: Heckman et al. (2009) Karoly et al. (2005)

Break-Even Point

0

$9.20

Graph Courtesy: Center on the Developing Child at Harvard University

State Network Business leader organizations in many states have

started supporting proven investments in early childhood. ReadyNation has sponsored business

leader summits and provided other types of assistance

to support business leader engagement in over half

the states. There are also many other business groups

in the states working in early childhood. Click on the map to find out more about business

organizations promoting early childhood policy in that

state.

Learn more about our National Network of business

organizations.

The States at a Glance Looking for data on your state that illustrates both the

status of children and the power of early investment? We recommend the following:

http://www.readynation.org/state-

network/

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We’re in the “building

health and developmental

assurance” business…..

Physical health

Developmental health

Relational health

Key Drivers of EBCD

• Pediatricians carrying the urgent message

– Core Story of EBCD/ toxic stress

– “Building health for education readiness and our economic

future”

• Collaborative intentional partnerships with shared

vision at all levels – national, state and local

• Calling out Building Health in child health reform

• Calling for population health and outcome trajectory

data from health and EC investment

• Promoting innovation at the intersections of EC

communities and medical home

CONCLUSION:

It is easier to build strong children

than to repair broken men.

Frederick Douglass