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

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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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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

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And

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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