Translating Translating Developmental Science Developmental Science
into Healthy Lives:into Healthy Lives:
Andrew Garner, M.D., Ph.D., Andrew Garner, M.D., Ph.D., F.A.A.P.F.A.A.P.
University Hospitals Medical Practices, andUniversity Hospitals Medical Practices, andAssociate Clinical Professor of Pediatrics,Associate Clinical Professor of Pediatrics,
Case Western Reserve School of Medicine, Case Western Reserve School of Medicine, andand
Center for Child Health and Policy,Center for Child Health and Policy,Rainbow Babies and Children’s HospitalRainbow Babies and Children’s Hospital
Realizing the PotentialPotential of
PediatricsPediatrics
This presentation is being provided under award #2010-VF-GX-This presentation is being provided under award #2010-VF-GX-K0009, awarded by the Office for Victims of Crimes, Office of K0009, awarded by the Office for Victims of Crimes, Office of Justice Programs, US Department of Justice. The opinions, Justice Programs, US Department of Justice. The opinions, findings, and conclusions or recommendations expressed on this findings, and conclusions or recommendations expressed on this site are those of the contributors and do not necessarily represent site are those of the contributors and do not necessarily represent the official position nor policies of the US Department of Justice. the official position nor policies of the US Department of Justice.
My My 3 Objectives3 Objectives For For TodayToday
• Provide a Provide a generalist’s overviewgeneralist’s overview of of advances in developmental advances in developmental science science
• Present an organizing, integrated, Present an organizing, integrated, ecoecobiobiodevelopmentaldevelopmental framework framework
• Discuss ways Discuss ways pediatricianspediatricians might might assist in assist in translatingtranslating science into science into healthier life-courseshealthier life-courses
Critical Concept #1Critical Concept #1
ChildhoodChildhood Adversity Adversity has has LifelongLifelong
Consequences.Consequences.
Significant adversity in Significant adversity in childhood is childhood is
stronglystrongly associated with associated with unhealthyunhealthy lifestyles and lifestyles and
poor health poor health decadesdecades later. later.
ACE CategoriesWomen Men TotalTotal
• 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
1:41:4!!
1:41:4!!
ACEs
Skeletal Fractures
Relationship Problems
Smoking
General Health and Social Functioning
Prevalent Diseases
Sexual Health
Risk Factors forCommon Diseases
Hallucinations
Mental Health
ACEs Impact Multiple Outcomes
Difficulty in job performance
Married to an Alcoholic
High perceived stress
Alcoholism
Promiscuity
Illicit Drugs
Obesity
Multiple Somatic Symptoms
IV Drugs
High Perceived Risk of HIV
Poor Perceived Health
Ischemic Heart DiseaseSexually
Transmitted Diseases
Cancer Liver Disease
Chronic Lung Disease
Early Age of First
IntercourseSexual Dissatisfaction
Unintended Pregnancy
Teen Pregnancy
Teen Paternity Fetal Death
Depression
Anxiety
Panic Reactions
Sleep Disturbances
Memory Disturbances
Poor Anger Control
Poor Self-Rated Health
Developing a Model of Developing a Model of Human Health and DiseaseHuman Health and Disease
Ecology
The social and physical
environment De
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Life Course Science
Early childhoodEarly childhood ecology ecology strongly associates with strongly associates with
lifelonglifelong developmental developmental outcomes
What are the mechanismsmechanisms
underlying these well-established
associations?
How do you begin to define or
measuremeasure the ecology?
Defining AdversityAdversity or StressStress
• How do you define/measuremeasure adversity?
• Huge individual variabilityindividual variability– PerceptionPerception of adversity or stress
(subjective)– ReactionReaction to adversity or stress (objective)
• National Scientific Council on the Developing Child (Dr. Jack Shonkoff and colleagues)– PositivePositive Stress– TolerableTolerable Stress– ToxicToxic Stress
Based on the REACTIONREACTION (objective physiologic responses)
• PositivePositive 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 buffersSocial-emotional buffers allow a return to baselinebaseline
(responding to non-verbal clues, consolation, reassurance, assistance in planning)
– Builds motivation and resiliencyBuilds motivation and resiliency
– Positive Stress isPositive Stress is NOT NOT the the ABSENCE ABSENCE of stressof stress
Defining AdversityAdversity or StressStress
• ToxicToxic Stress
– Long lasting, frequent, or strong intensity
– More extreme precipitants of childhood stress (ACEsACEs)• Physical, sexual, emotional abuse• Physical, emotional neglect• Household dysfunction
– Insufficient social-emotional bufferingInsufficient social-emotional buffering(Deficient levels of emotion coaching, re-processing, reassurance and support)
– Potentially permanent changes and long-term effects• EpigeneticsEpigenetics (there are life long / intergenerational
changes in how the genetic program is turned ONON or OFFOFF)
• Brain architectureBrain architecture (the mediators of stress impact upon the mechanisms of brain development / connectivityconnectivity))
Defining AdversityAdversity or StressStress
Critical Concept #2Critical Concept #2
Epigenetics:Epigenetics:• WhichWhich genes are turned on/off, genes are turned on/off, whenwhen, and , and wherewhere
• EcologyEcology (environment/experience) influences (environment/experience) influences how the genetic blueprint is read and utilizedhow the genetic blueprint is read and utilized
• Ecological effects at the Ecological effects at the molecular levelmolecular level
• Stress-induced changes in epigenetic markersStress-induced changes in epigenetic markers
““GenesGenes may load the gun, may load the gun,
but the but the environment environment pulls the trigger”pulls the trigger”
BiologyPhysiologic Adaptations
and Disruptions
Ecology
The social and physical
environment De
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Life Course Science
Epig
eneti
cs
Through epigenetic mechanisms, the early childhood ecologyecology becomes
biologically embeddedbiologically embedded, influencing how the genome is utilized
Developing a Model of Developing a Model of Human Health and DiseaseHuman Health and Disease
Critical Concept #3Critical Concept #3Developmental Neuroscience:Developmental Neuroscience:
• SynapseSynapse and and circuitcircuit formation are experience and formation are experience and activity dependentactivity dependent
• EcologyEcology (environment/experience) influences how (environment/experience) influences how brain architecture is formed and remodeledbrain architecture is formed and remodeled
• Early childhood adversity -> Early childhood adversity -> vicious cycle of stressvicious cycle of stress
• Diminishing cellular plasticityDiminishing cellular plasticity limits remediation limits remediation
• Potentially permanentPotentially permanent alterations in brain alterations in brain architecture and functioningarchitecture and functioning
Two Types of Two Types of PlasticityPlasticity
• SSynaptic Plasticityynaptic Plasticity – –
– Variation in the SSTRENGTHTRENGTH of individual connections
– “from a whisper to a shout”– Lifelong (how old dogs learn new tricks)
• CCellular Plasticityellular Plasticity – –
– Variations in the NUMBER (or NUMBER (or CCOUNT)OUNT) of connections
– “ from one person shouting to a stadium shouting”– Declines dramatically with age (waning by age waning by age
55)
MaturationMaturation Progression
• Maturation generally proceeds from the back of the brain to the front.
• Explains in part…
– Preference for physical activity (back of brain)
– More risky, impulsive behaviors (limbic system)
– More moody at times (limbic system)
– Less than optimal planning and judgment (PFC)
– Poor recognition of negative consequences (PFC)
Out of Balance
Prefrontal CortexPrefrontal CortexAmygdalaAmygdalaCold Cognition Hot
Cognition Judgmental Emotional Reflective Reactive Calculating ImpulsiveThink about it Just do
itBiological maturity by 24 Biological maturity by 18 Adapted from Ken Winters, Ph.D.
Impact of Early Stress
TOXIC STRESS
Chronic “fight or flight;”
adrenaline / cortisol
Changes in Brain
Architecture
Hyper-responsive stress response;
calm/coping
CHILDHOOD STRESS
BiologyPhysiologic Adaptations
and Disruptions
Ecology
The social and physical
environment De
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tLe
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And
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Life Course Science
NeuroscienceEpig
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Declining plasticity Declining plasticity in the developing brainin the developing brain results in results in potentially permanent alterations in brain functioning andpotentially permanent alterations in brain functioning and
developmentdevelopment
Developing a Model of Developing a Model of Human Health and DiseaseHuman Health and Disease
EcoEco--BioBio--DevelopmentalDevelopmentalModel of Human Health and Model of Human Health and
DiseaseDiseaseBiology
Physiologic Adaptations and Disruptions
Ecology
The social and physical
environment De
velo
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tLe
arni
ng, B
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And
Heal
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Life Course Science
NeuroscienceEpig
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The Basic
Science ofPediatrics
EcologyEcology BecomesBecomes biology, biology,
And together theyAnd together they drive development development across the lifespan
Critical Concept #4Critical Concept #4
The Science The Science of Early Brain of Early Brain
and Child and Child DevelopmentDevelopment
Epigenetics Physiology of Stress Neuroscience
Education Health Economics
OneOne Science – Science – ManyMany ImplicationsImplicationsThe critical challenge now is to translatetranslate
game-changing advances in developmental developmental sciencescience
into effective policies policies and practicespractices for families w/ children
to improve educationeducation, healthhealth and lifelong lifelong productivityproductivity
Advantages of an EEBBDD Framework
• Though grounded in developmentaldevelopmental science, the simplicity of the EBD framework may promote understandingunderstanding as well as support for translationtranslation
• Psychosocial stressors and other salient features of the ecologyecology are every bit as biologicalbiological as nutrition or lead (no distinction between mental and physical health, just healthy vs. unhealthy developmentdevelopment)
• Emphasizes the dimension of timetime – to reflect the on-going, cumulativeon-going, cumulative nature of benefits and threats to health and wellness
Advantages of an EEBBDD Framework
• Underscores the need to improve the early childhood ecologyecology in order to:– Mitigate the biologicalbiological underpinnings for
educational, health and economic disparitiesdisparities– Improve developmentaldevelopmental/life-course trajectories
• Highlights the pivotal role of toxic toxic stressstress– Not just “step on the gasstep on the gas” or enrichment– But “take off the breaktake off the break” by treating, mitigating
or immunizing against toxic stress
Advantages of an EEBBDD Framework
Models
Maslow’s Hierarchy of Needs America’s Promise Alliance ASCD’s Whole Child Education(Theoretical - 1943) (Evidence-based) (Implementation)
Needs
Self-Actualization Need to know, explore An effective education Each student is activelyand understand engaged in learning
Esteem Need to achieve and Opportunities to contribute Each student has numerous opportunities
be recognized to demonstrate achievement
Love/Belonging Need for friends Caring adults Each student has access to and family qualified, caring adults
Safety/Security Need to feel secure and Safe places Each student learns in a physicallysafe from danger and emotionally safe environment
Physiological Need to satisfy hunger, A healthy start Each student enters schoolthirst, sleep healthy
Reinventing the Wheel -All over again?
Unmet needs are potential sources of STRESSSTRESS!!
Childhood Adversity Poor Adult Outcomes
Toxic StressToxic Stress
Epigenetic Modifications
Disruptions in Brain Architecture
Behavioral Allostasis
Linking Linking Childhood ExperiencesChildhood Experiences and and Adult OutcomesAdult Outcomes
The BIGBIG Questions are…
If TOXIC STRESSTOXIC STRESS is the missing link between ACE exposureACE exposure and the unhealthy lifestyles unhealthy lifestyles and poor outcomespoor outcomes seen as adults, it raises the following BIG questions:
1) Are there ways to treat, mitigate,treat, mitigate, and/or immunize againstimmunize against the effects of toxic stress?
2) What are the long term costslong term costs due to toxic stress versusversus the up-front coststhe up-front costs to treat, mitigate or immunize?
Addressing ToxicToxic Stress
• TreatmentTreatment of the consequences– TF-CBTTF-CBT and PCITPCIT are evidence-based – ReactiveReactive – some “damage” already done!– Very COSTLYCOSTLY– Efficacy linked to age and chronicity
• Declining brain plasticitybrain plasticity?– Insufficient numbernumber of / accessaccess to providers
• Limited reimbursements; carve-outs– Mental Health ParityParity?– Persistent STIGMASTIGMA
• ““Character Flaws”Character Flaws” vs “Biological Mal-“Biological Mal-adaptations”adaptations”
• Secondary / Targeted PreventionsSecondary / Targeted Preventions– Focused, targeted interventions for those
deemed to be “at high risk”“at high risk”– Visiting Nurse Programs (Nurse Family Partner.)– Parenting Programs (Triple-P, Nurturing Parent.)– More likely to be effective; minimize “damage”– Requires screeningscreening– Still issues with stigmastigma, numbersnumbers of/accessaccess to
providers
Addressing ToxicToxic Stress
• Primary / Universal PreventionPrimary / Universal Prevention– Proactive, universal interventions to make stress
positivepositive, instead of tolerable or toxic– Acknowledges that preventing all childhood
adversity is impossibleimpossible and even undesirableundesirable– Actively building resiliencyActively building resiliency (“immunizing”
through positive parenting, 7C’s of resilience, promoting optimism, formalized social-emotional learning)
– SE BuffersSE Buffers allow the physiologic stress response to return to baseline• ParentingParenting skills for younger children• SELSEL skills for older children (www.casel.orgwww.casel.org)
Addressing ToxicToxic Stress
Social-EmotionalSocial-Emotional Skills Can Be Skills Can Be TaughtTaught / / LearnedLearned
Critical Concept #5Critical Concept #5
SOCIAL-EMOTIONAL SOCIAL-EMOTIONAL SKILLS…SKILLS…
(a.k.a – Affect Regulation, Non-Cognitive Skills)(a.k.a – Affect Regulation, Non-Cognitive Skills)
……Are Are learnedlearned (they can be (they can be modeledmodeled, , nurturednurtured, , taughttaught, , practicedpracticed, and , and reinforcedreinforced))
……Effectively Effectively bufferbuffer against against toxic toxic stressstress
(by helping to turn (by helping to turn offoff the physiologic stress response) the physiologic stress response)
……Increase Increase test scorestest scores (an average of(an average of 11 points 11 points by meta-analysis!)by meta-analysis!)
• Promoting Parenting Skills Parenting Skills in the first 1000 days– Parenting is personal – makes pediatricians NERVOUS!– “Positive/Nurturing/Supportive” Parenting– A Poor investment?
• Are parenting skills “teachableteachable?”• Is there a “ceiling effectceiling effect” on returns?
– Or the “Gold Standard?Gold Standard?”• Shouldn’t this be THETHE reference point • (NOT routine, general, or control populations)
• Recent article from Luby et al., PNAS– Maternal supportMaternal support and Depression severityDepression severity at ages 3-5
• “Waiting Test” assessed the dyad (Bright Gift + Parental Surveys)
– Hippocampal volumesHippocampal volumes at school age (7-13)
ParentingParenting as PrimaryPrimary Prevention
What is What is “OK?”“OK?”
YES!!YES!!
Luby et al., 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1118003109
•Early maternal support exerts a positive a positive influence on influence on
hippocampal developmenthippocampal development•The positive effect of maternal support on
hippocampalvolumes was greater in nondepressed greater in nondepressed
childrenchildren
Critical Concept #6Critical Concept #6
For young children, For young children,
parent/caregiver support is criticalparent/caregiver support is critical::
• Turns off physiologic stress response by Turns off physiologic stress response by addressing physiologic addressing physiologic and safety needsand safety needs (Maslow levels 1+2 – (Maslow levels 1+2 – PROTECTPROTECT))
• Turns off the physiologic stress response by Turns off the physiologic stress response by promoting healthy promoting healthy relationships and attachmentrelationships and attachment (Maslow level 3 - (Maslow level 3 - RELATERELATE))
• Notes and encourages Notes and encourages foundational coping skillsfoundational coping skills as they as they emerge (Maslow levels 4+5 - emerge (Maslow levels 4+5 - NURTURENURTURE))
PediatriciansPediatricians are ideally placed to: are ideally placed to:• Promote this sort of “Purposeful” ParentingPromote this sort of “Purposeful” Parenting• Advocate for a Advocate for a public health approachpublic health approach to address toxic stress to address toxic stress
Universal Primary Preventions
Anticipatory guidanceConsistent messaging
No identificationNo identificationNo stigmaNo stigma
Ceiling effects =Ceiling effects =Limited evidence baseLimited evidence base
Targeted Interventions (for those “at risk”)Nursing home visitsParenting programsEarly Intervention
Less ceiling=More evidenceLess ceiling=More evidenceRequires screeningRequires screeningIssues with stigmaIssues with stigma
Evidence-Based Treatments (for the symptomatic)
PCIT; TB-CBTTreatment works!Treatment works!
Screening / stigma / accessScreening / stigma / access
Social-Emotional Safety NetsSocial-Emotional Safety NetsA Public Health Approach to “A Public Health Approach to “Toxic StressToxic Stress””
Universal Primary PreventionsBright Futures
Connected KidsCircle of Security
Relationships as a “vital” signBasic EBCD CompetenciesBasic EBCD Competencies
Targeted Interventions Screening for risks
(assess the ecology)Refer to/advocate for EBI
Collaborating/Developing EBIMid-level CompetenciesMid-level Competencies
Evidence-Based Treatments Screening for diagnoses
Common factors approachRefer for/advocate for EBT
Collaborating/Developing EBTAdvanced CompetenciesAdvanced Competencies
WHATWHAT are we are we DOING?!DOING?!
Public HealthPublic Health Implications
• ACE data provide a working model for understanding and addressing the childhood antecedentschildhood antecedents of adult adult disease.disease.
• Is there a gap between what we dowe doand what we knowwe know?
• What we DODO:– 95% of the trillions of dollars that we
spend on health is on treatmenttreatment and NOT NOT preventionprevention
Public HealthPublic Health Implications
• What we KNOWKNOW:– That 70% of early deaths are70% of early deaths are
preventablepreventable, with…
– 40% due to behavioral patterns 40% due to behavioral patterns (Is this behavioral allostasis?)
– 15% due to social circumstances, and– 10-15% due to shortfalls in medical care
McGinnis, Williams-Russo and Knickman, 2002
A Public HealthPublic Health Dilemma:
Do we continue to treat diseasedisease,
the unhealthy lifestylesunhealthy lifestyles that lead to disease,
or the TOXIC STRESSTOXIC STRESS that leads to the adoption of unhealthy
lifestyles??
CONCLUSION:
It is easier to build strong childrenbuild strong children than to repair broken menrepair broken men.
Frederick Douglass