Strong foundations, strong society: The case for early child development

1. Strong foundations, strong society: The case for early child development Professor Frank Oberklaid Director, Centre for Community Child Health Israeli Ministry of Health; Jerusalem March 25, 2018

2. Business as usual?

3. We cannot ignore… • Worsening children’s outcomes – obesity, diabetes, child abuse, poor educational achievement • Equity and the social divide – marked differences in outcomes for different segments of society – threatens social cohesion • The evidence about the importance of the early years and the life course

4. Drivers of change • Data – ‘no data, no problem, no solution’ • Equity – social gradient of access, outcomes • Evidence – programs that have been shown to work • Integration – need to address the fragmentation of policies, services and programs • Morbidity – poor match between contemporary morbidity and the way services are delivered • Place – ‘one size does not fit all’ – local solutions to local problems • Relationships – the key to early intervention

5. Fragmentation of public policy Policy delivered mostly in unconnected and poorly coordinated, narrow programmatic silos • Vertical – between central and local governments • Horizontal –between different government departments (health, education, welfare, housing, etc), and within departments • By age – birth to three, preschool, school age • Different targets – child protection, family violence, single parents, children with additional needs, etc

6. Current and Future Healthcare Systems Geared to acute conditions Geared to long-term conditions Hospital centred Embedded in communities Doctor dependent Team based Continuous care Episodic care Disjointed care Integrated care Reactive care Preventive care Patient as recipient Patient as partner Self-care infrequent Self-care encouraged and facilitated Carers undervalued Carers supported as partners Low Tech High Tech

7. The ‘new morbidity’ in paediatrics ‘A group of childhood difficulties that we have termed “the new morbidity” is now gaining attention. Many of these difficulties lie beyond the boundaries of traditional medical care… a major shift in the orientation of training programs is required ….’ - RJ Haggerty, 1975

8. The ‘new’ morbidity • Learning disabilities and school failure • ADHD and behaviour problems • Autism spectrum disorder • Mental health issues • Child abuse and neglect, sexual abuse • Functional health issues – recurrent abdo pain, headache • Chronic disease • Obesity • Sleep problems

9. APRN – 2013 top 10 new diagnoses

10. The importance of ‘community.’ ‘Health is affected by environmental and social processes as well as by sociological factors. The community in which a child lives is a major determinant of his health. Although such statements are widely accepted intellectually today, they are not yet reflected in our health care ….’ - RJ Haggerty, 1975

11. Worsening developmental outcomes Service delivery difficulties Changes in families New knowledge about child development Changes in society New knowledge about early intervention NEED TO CHANGE

12. Worsening developmental outcomes Service delivery difficulties Changes in families New knowledge about child development Changes in society New knowledge about early intervention NEED TO CHANGE

13. ‘Social climate change’ • Rapid social change - conditions under which families are raising children have changed (more complex) • Divorce, single parents, blended families, shared custody arrangements • Both parents working, child care • Working longer hours, part time/shift work, more casual work • Job insecurity, unemployment, homelessness • Increase in poverty/ health inequalities, and increased social gradient • Social media – the ‘digital divide’ - After Moore, CCCH

14. The impact of social climate change on children and families • Well resourced families are better able to meet these challenges. Poorly resourced families can be overwhelmed with challenges of daily life and parenting • Stresses in family functioning are cumulative over time • Increase in number of families with complex needs • More intergenerational disadvantage, underachievement and poor health and developmental outcomes

15. Worsening developmental outcomes Service delivery difficulties Changes in families New knowledge about child development Changes in society New knowledge about early intervention NEED TO CHANGE

16. School Childcare GPs Child protection agency Paediatrician Parenting programs Kindergarten Preschool Disability services Children’s library services Fragmentation of services Family support Early intervention programs

17. Worsening developmental outcomes Service delivery difficulties Changes in families New knowledge about child development Changes in society New knowledge about early intervention NEED TO CHANGE

18. Worsening child outcomes • Physical health – obesity, diabetes • Mental health – anxiety, depression, ADHD, challenging behaviours, eating disorders • Child abuse and neglect • Academic achievement – literacy levels, educational outcomes, school retention rates • Social adjustment – juvenile crime, substance abuse - Stanley, Richardson & Prior Children of the Lucky Country?

19. Prevalence of mental health problems in Australia • Almost one in seven (13.9%) 4-17 year-olds were assessed as having mental disorders in the previous 12 months. • This is equivalent to 560,000 Australian children and adolescents - Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing (August 2015)

20. Worsening developmental outcomes Service delivery difficulties Changes in families New knowledge about child development Changes in society New knowledge about early intervention NEED TO CHANGE

21. Building strong foundations Getting the foundations right is important – healthy brain development is a prerequisite for future health and wellbeing. The early years of a child’s life are critical in impacting on a range of outcomes through the life course.

22. Children’s development • Development is the result of complex, ongoing, dynamic transactions between nature and nurture - a dance between biology and experience • We cannot do much to change biology - but we can change the environment in which young children grow and develop

23. The neuroscience of brain development • Brain architecture and skills are built in a hierarchical ‘bottom-up’ sequence • Foundations important - higher level circuits are built on lower level circuits • Skills beget skills - the development of higher order skills is much more difficult if the lower level circuits are not wired properly • Plasticity of the brain decreases over time and brain circuits stabilise, so it is much harder to alter later • It is biologically and economically more efficient to get things right the first time

24. Adversity Any adversity in the child’s environment has the potential to have a negative impact on brain development in the young child, and therefore acts as a risk factor for the health and development of the child

25. Persistent or ‘toxic’ stress • Strong and prolonged activation of body’s stress response - in absence of buffering protection of adult support • Precipitants include extreme poverty, physical or emotional abuse, chronic neglect, severe maternal depression, substance abuse, family violence • Disrupts developing brain architecture • Leads to lower threshold of activation of stress management systems - can lead to life long problems in learning, behaviour, and both physical and mental health

26. The importance of relationships • Nurturing and responsive relationships build healthy brain architecture that provides a strong foundation for learning, behaviour and health • The relationships a young child has with their caregiver(s) influences the development of neural circuits • When relationships are dysfunctional, levels of stress hormones increase – this interferes with formation of healthy neural circuits, and disrupts brain architecture

27. Disadvantaged environments and dysfunctional parenting in early years • Problems in childhood - child abuse and neglect, developmental delay, school problems, ADHD, mental health problems… • Beginning of pathways to problems later in life • Evidence that many problems in adult life have their origins in pathways that begin in childhood

28. Adult problems with roots in early childhood • Mental health problems • Family violence and anti-social behaviour • Crime • Poor literacy • Chronic unemployment and welfare dependency • Substance abuse • Obesity • Cardiovascular disease • Diabetes

29. Implications for policy • Need for increased government expenditure to address these challenges • But in the long term such policies • Are not sustainable - there will never be sufficient resources • Are often ineffective - treating established problems is difficult (and expensive) • Better to get it right the first time

30. The impact of social inequality Major impact in early years - affects developing brain and establishment of neural circuits Disparities widen as child gets older, and trajectory gets harder to change Chronic stress affects the body’s physiological systems - increasing vulnerability to wide range of diseases and health conditions throughout the life course ‘Double jeopardy’ - have the least access to supports such as consistent health care, quality childcare and preschool, good schools, and family supports

31. Vocabulary growth - first 3 years Vocabulary High SES 1200 Middle SES 600 Low SES 0 12 16 20 24 28 32 36 Age - Months B Hart & T Risley Meaningful Differences in Everyday Experiences of Young American Children 1995

33. School entry

34. Australian Early Development Index (AEDI) • A population based measure which provides information about children’s health and wellbeing • 100+ questions covering 5 development domains considered important for success at school • Teachers complete the AEDI online for each child in their first year of full-time schooling • Results are provided at the postcode, suburb or school level and not interpreted for individual analysis

35. 5 Five AEDI ‘subscales’ • The AEDI measures a child’s development in 5 areas: • physical health and well-being •  social competence •  emotional maturity •  language and cognitive development • communication skills and general knowledge

36. Australian Early Developmental Census (AEDC) Percentage of children developmentally vulnerable (DV)

37. Results: Socio-economic status

38. A comparison of NAPLAN scores for low SES and all students 2017 year 3 NAPLAN Victoria

42. Worsening developmental outcomes Service delivery difficulties Changes in families New knowledge about child development Changes in society New knowledge about early intervention NEED TO CHANGE

43. Challenges – for all of us • No silver bullets – ‘wicked’ problems and complex interventions • Difficulty of evaluation • Prevention/early intervention invisible • Need long term horizon • Framing the issues – getting the language right • Widespread suspicion of government programs

44. ‘For every complex problem there is an answer that is clear, simple, and wrong’. - H.L Mencken

45. ‘Nothing hard is ever easy’ - Don Berwick

46. A different approach • Population focus • Strengthen capacity of universal services • Increased responsibility for communities • Engaging the community • Using data • Working with communities to implement change

47. A different approach • Population focus • Strengthen capacity of universal services • Increased responsibility for communities • Engaging the community • Using data • Working with communities to implement change

48. Tiered service system TERTIARY OR SPECIALIST SERVICES Children with additional needs SECONDARY OR TARGETED SERVICES Vulnerable children UNIVERSAL SERVICES All children

49. Tiered systems of service delivery Targeted high intensity High need Low need Universal low Intensity

50. Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism. - Marmot