THE CHANGING FACE OF CHILD HEALTH CARE

DCF Nursing Best Practices SeminarPaul H. Dworkin, MD

January 6, 2012Newington, CT

INTRODUCTION

• Goal of Child Health Services

OBJECTIVES

• Define the goal of child health services• Identify key concepts in early brain

development that have implications for health services delivery

• Identify key concepts in early child development that have implications for health services delivery

• Demonstrate the application of key concepts to program design

1990’s: The Decade of the Brain

The New Millennium

Center on the Developing Childat Harvard Universitywww.developingchild.harvard.edu

EARLY BRAIN AND CHILD DEVELOPMENT

•Proportional brain growth

•Neural plasticity•Critical periods•Sequential

development•Role of experience

Early Brainand Child Development

Courtesy of Bruce Perry, MD, PhD

PROPORTIONAL BRAIN GROWTH

Early Brainand Child Development

NEURAL PLASTICITY• The brain has a great deal of plasticity and

can recovery from insults– the brain is always changing– it takes less time to organize the

developing nervous system than to reorganize the developed nervous system

• “Window of opportunity” during early childhood– never permanently closes

Early Brainand Child Development

From Syllabus, “Brain and Behavior,” Colorado University

CRITICAL PERIODS

CRITICAL PERIODS

• Brain development begins before birth; although development continues throughout life, the first three years are very important and provide a critical foundation

• Times in development during which a set of signals must be present for neural systems to differentiate normally

– e.g., stereoscopic vision

Early Brainand Child Development

Neocortex

Limbic

Diencephalon

Brainstem

Abstract Thought

Concrete Thought

Affiliation

"Attachment"

Sexual Behavior

Emotional Reactivity

"Arousal"

Appetite/Satiety

Blood Pressure

Heart Rate

Body Temperature

Sleep

Motor Regulation

C

O

M

P

L

E

X

I

T

Y

Courtesy of Bruce Perry, M.D., Ph.D.

SEQUENTIAL DEVELOPMENT• The brain develops sequentially

• Experiences need to be sequential, as well

– the experiences of the child should match the development of the child

– provide the “right” experiences in the “right” amounts at the “right” time in the life of a child

Early Brainand Child Development

Courtesy of Bruce Perry, MD, PhD

SEQUENTIAL DEVELOPMENTPractical Implications

• Few infants will benefit from an algebra lecture

• Few adolescents need to be held and rocked for hours each day

Early Brainand Child Development

ROLE OF EXPERIENCE• The human brain has the ability

to be shaped by experience

• Experience, in turn, leads to neural changes in the brain

– birth: 50 trillion synapses

– 1 year: 1,000 trillion

– 20 years: 500 trillion

• The remolded brain facilitates the embrace of new experiences

Early Brainand Child Development

Early Brainand Child Development

HEALTH SERVICES IMPLICATIONSEarly Brain and Child Development

• For optimal effectiveness, stimulation must begin as early as possible

• Stimulation during the first three years is particularly critical to ensure optimal development– “use it or lose it”– capacity at any age

• Stimulation must be aligned with children’s developmental stages and needs

CRITICAL CONCEPTS IN CHILD DEVELOPMENT

Implications for Child Health Services

Birth

Early Infancy

Late Infancy

Early Toddler

Late Toddler

Early Preschool

Late Preschool

AgePrenatal 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs

“Re

ad

y t

o L

ea

rn”

“School Readiness Trajectories”

“At Risk” Trajectory

“Delayed/Disordered ” Trajectory

“Healthy” Trajectory

Parent educationEmotional healthHealth literacy

Early literacy

Quality ECE

Appropriate discipline

Poverty

Inaccessible health services

Family discord

Graphic Concept Adapted from Neal Halfon , UCLA Center for Healthier Children, Families, and Communities

Health services

Chamberlin RW. Preventing low birth weight, child abuse, and school failure: the need for comprehensive, community-wide approaches.Pediatr Rev 1992;13(2):64-71

• “The most effective long-term strategy appears to be the development of a comprehensive, coordinated, community-wide approach focused on preventing low- and medium-risk families from becoming high-risk, as well as providing intensive services to those who already have reached a high-risk status.”

Targeted Interventions

NU

MB

ER

OF

CH

ILD

RE

N

FUNCTION

Median

High income

Low income

VULNERABLE

Universal Curve Shift

DISABLED

Clinical/Individual Interventions

The Productivity Argument for Investing in Young ChildrenJames J. Heckman and Dimitriy V. Masterov

ADVERSE CHILDHOOD EXPERIENCE STUDY (ACES)

• Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the CDC

• Decade long.; 17,000 people involved

• Looked at effects of adverse childhood experiences over the lifespan

• Largest study ever done on this subject

The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Lanius & Vermetten, 2009

ADVERSE CHILDHOOD EXPERIENCES

• Sexual abuse• Emotional abuse• Emotional neglect• Physical abuse• Physical neglect• Substance abuse in home• Mental illness in home• Incarceration of family member• Parental separation or divorce• Witness violence against mother

ACES STUDY

Individuals with 4 or more of the 10 ACES are:• Nearly 2 times more likely to smoke cigarettes• 4 ½ times more likely to engage in drug abuse• 7 times more likely to suffer from chronic alcoholism • 11 times more likely to abuse drugs via injection• 19 times more like to have attempted suicide• More likely to have health problems that put them at

risk of early mortality

HEALTH SERVICES IMPERATIVESChild Development Concepts

• Treatment programs and services must be comprehensive, multidisciplinary, and address the multiple factors that facilitate and hinder children’s optimal development

• Services should address the needs of all children (e.g., the entire population), recognizing that those in greatest need will likely derive the greatest benefits– target at-risk children and families– perils of exclusive focus on CYSHCN

Child Health Services Building Blocks

Univ

ersa

l

Sele

ctiv

e

Indi

cate

d

Service Integration Care Coordination

Medical Home

Part C (B-to-3)Title V (CYSHCN)

Links to Preschool Special Ed and

Special Ed (LEA)

Developmental/Behavioral Surveillance & Screening

Family Education /Parent & Child Counseling / Anticipatory Guidance

Literacy Promotion

Health Supervision Services

Oral Health/Dental Home

Nutritional Services

Medical / Surgical Subspecialty ServicesEarly Childhood Consultation Services

Developmental / Behavioral Health Services(Mid-level, Comprehensive assessments;

Treatment)Home –based Services

Help Me Grow

Practice Improvement

System Changes

Pay for Performance

Reimbursement Reform

(Public & Private)CT-CHQII

EPIC

Child Health Services Building Blocks

Family SupportServices

Care Coordination

UNIVERSAL SERVICES(Medical Home)

ChildHealth

Services

SELECTIVE SERVICES(Help Me Grow)

INDICATED SERVICES

Desired Outcomes for School ReadinessFamily Capacity and

FunctionEmotional / Social /

Cognitive Development Physical Health & Development

.

Early Care and EducationPrograms

33

Core

Com

pone

nts

Structural Requirements

Centralized Telephone Access Point

Centralized Telephone Access Point

Community & Family Outreach

Community & Family Outreach

Child Health Provider Outreach

Child Health Provider Outreach Data Collection & Analysis Data Collection & Analysis

Organizing EntityOrganizing Entity Statewide ExpansionStatewide Expansion

Continuous Quality

Improvement

Continuous Quality

Improvement

"Making the Connection- Help Me Grow The Connecticut Experience"

SUMMARY• Knowledge of early brain development has

important implications for promoting children’s optimal development– Need for early stimulation– Critical importance of first 3 years (“use it or lose it”)– Need or alignment with developmental needs

• Knowledge of early child development has important implications for promoting children’s optimal development– Need for comprehensive services– Should target entire population of children, especially

at-risk