The First 1000 days: The Importance of Early Brain and Childhood Development

1. The First 1000 days: The Importance ofEarly Brain and Childhood Development Realizing the Potential of the Head Start Colleen Kraft, M.D., F.A.A.P. Professor of Pediatrics Virginia Tech Carilion School of Medicine and Research Institute

2. Learning Objectives Understand the role of toxic stress in the intergenerational transfer of health disparities; Present an organizing, integrated, ecobiodevelopmental framework; Discuss ways Early Childhood Professionals might advocate in translating science into healthier life-courses

3. Critical Concept #1 Childhood Adversity has Lifelong Consequences. Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later.

4. The Adverse Childhood Experiences Study (ACE Study) “In my beginning is my end.” T.S. Eliot, Four Quartets

5. ACE Study Findings • Childhood experiences are powerful determinants of who we become as adults

6. 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

7. 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!

8. The higher the ACE Score, the greater the likelihood of : • 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:

9. Higher ACE Score = significant rise in chronic health conditions: Sexually Transmitted Disease Liver Disease COPD Ischemic Heart Disease Autoimmune Disease Lung Cancer

10. Effect of ACEs on Mortality Age Group 0 ACE 60% live to 65 4 ACE less than 3% live to 65

11. The True Nature of Preventive Medicine Death Birth Early Death Disease & Disability Adoptionof Health-Risk Behaviors ?? Social, Emotional, and Cognitive Impairment Adverse Childhood Experiences Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status Slide modified from V. J. Felitti

12. Current Conceptual Framework Guiding Early Childhood Policy and Practice Significant Adversity Healthy Developmental Trajectory Impaired Health and Development Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

13. Developing a Model of Human Health and Disease How do you begin to define or measure the ecology? What are the mechanisms underlying these well-established associations? Development Learning, Behavior And Health Ecology The social and physical environment Life Course Science Early childhood ecology strongly associates with lifelongdevelopmental outcomes

14. Defining Adversity or Stress How do you define/measure adversity? Huge individual variability Perception of adversity or stress (subjective) Reactionto adversity or stress (objective) National Scientific Council on the Developing Child (Dr. Jack Shonkoff and colleagues) Positive Stress Tolerable Stress ToxicStress Based on the REACTION (objective physiologic responses)

15. 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 preschool The big project in middle school Social-emotional buffersallow 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

16. ToxicStress 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

17. ACEs Impact Multiple Outcomes Relationship Problems Married to an Alcoholic Poor Self-Rated Health Smoking Alcoholism High perceived stress Difficulty in job performance Hallucinations Promiscuity High Perceived Risk of HIV Depression Obesity General Health and Social Functioning Sleep Disturbances Risk Factors for Common Diseases Mental Health Memory Disturbances Poor Perceived Health ACEs Illicit Drugs Anxiety IV Drugs Panic Reactions Prevalent Diseases Sexual Health Multiple Somatic Symptoms Poor Anger Control Cancer Liver Disease Teen Paternity Fetal Death Skeletal Fractures Chronic Lung Disease Teen Pregnancy Unintended Pregnancy Sexually Transmitted Diseases Early Age of First Intercourse Ischemic Heart Disease Sexual Dissatisfaction

18. ProximalCauses of Death: Chronic Disease Acute causes of death are the exception, not the rule

19. Distal Causes of Death: Unhealthy Lifestyles If these unhealthy lifestyles are manifestations of behavioral allostasis, a FUNDAMENTAL cause of death is TOXIC STRESS!

20. 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

21. Developing a Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions Epigenetics Development Learning, Behavior And Health Ecology The social and physical environment Life Course Science Through epigenetic mechanisms, the early childhood ecology becomes biologically embedded, influencing how the genome is utilized

22. 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

23. Maturation 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)

24. Brain Structure (and Function) - The Brake – PFC (with some hippocampal help) Frontal lobes: Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences Parietal Lobe: Integration of sensory data and movement Temporal lobe (outside): Processing sound and language Occipital Lobe: Visual processing Cerebellum: Smooth movements Coordination Limbic System (inside): Emotions and impulsivity + The Gas Pedal + Amygdala Brain Stem & Cranial Nerves: Vital functions Swallowing

25. Out of Balance Prefrontal CortexAmygdala Cold Cognition Hot Cognition JudgmentalEmotional ReflectiveReactive CalculatingImpulsive Think about itJust do it Biological maturity by 24 Biological maturity by 18 Adapted from Ken Winters, Ph.D.

26. Impact of Early Stress TOXIC STRESS CHILDHOOD STRESS Hyper-responsive stress response; calm/coping Chronic “fight or flight;” adrenaline / cortisol Changes in Brain Architecture

27. Development results from an on-going, re-iterative, and cumulative dance between nurture and nature Experience Protective and Personal (versus Insecure and Impersonal) Brain Development Alterations in Brain Structure and Function Epigenetic Changes Alterations in the Way the Genetic Program is Read Behavior Adaptive or Healthy Coping Skills (vs. Maladaptive or Unhealthy Coping Skills)

28. Developing a Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions Neuroscience Epigenetics Development Learning, Behavior And Health Ecology The social and physical environment Life Course Science Declining plasticity in the developing brainresults in potentially permanent alterations in brain functioning anddevelopment

29. Eco-Bio-DevelopmentalModel of Human Health and Disease Biology Physiologic Adaptations and Disruptions The Basic Science of Pediatrics Epigenetics Neuroscience Development Learning, Behavior And Health Ecology The social and physical environment Life Course Science Ecology Becomes biology, And together theydrive development across the lifespan

30. Critical Concept #4 Epigenetics Physiology of Stress Neuroscience The Science of Early Brain and Child Development 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

31. Linking Childhood Experiences and Adult Outcomes Childhood Adversity Poor Adult Outcomes Toxic Stress Epigenetic Modifications Disruptions in Brain Architecture Behavioral Allostasis

32. The BIG Questions are… If TOXIC STRESS is the missing link between ACE exposure and the unhealthy lifestyles and poor outcomes seen as adults, it raises the following BIG questions: 1) Are there ways to treat, mitigate,and/orimmunize againstthe effects of toxic stress? 2) What are the long term costs due to toxic stress versusthe up-front costs to treat, mitigate or immunize?

33. Critical Concept #5 SOCIAL-EMOTIONAL SKILLS… (a.k.a – Affect Regulation, Non-Cognitive Skills) …Are learned(they can be modeled, nurtured, taught, practiced, and reinforced) …Effectively buffer against toxic stress (by helping to turn off the physiologic stress response) …Increase test scores (an average of 11 points by meta-analysis!)

34. Social-Emotional Safety Nets A Public Health Approach to “Toxic Stress” Universal Primary Preventions Anticipatory guidance Consistent messaging No identification No stigma Ceiling effects = Limited evidence base Targeted Interventions (for those “at risk”) Home Visiting Head Start/Early Head Start Early Intervention Less ceiling=More evidence Requires screening Issues with stigma Evidence-Based Treatments (for the symptomatic) PCIT; TB-CBT Treatment works! Screening / stigma / access

35. TheBIGQuestions are… 3) What does this mean for Early Head Start/Head Start?

36. Health-Building Routines in Early Childhood Education Washing hands -Before and after meals Exercise-Playing and moving Nutrition– Fruits and vegetables, water, health choices Safe Environments- playing, eating, sleeping, discipline, social-emotional health RELATIONSHIPS, reciprocal and nurturing – foundation of healthy child development

37. 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

38. Critical Concept #6 • 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 • Head Start is ideally placed to: • Promote this sort of “Purposeful” Parenting • Advocate for a public health approach to address toxic stress

39. 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 ToxicStress

40. Secondary / Targeted Preventions Focused, targeted interventions for those deemed to be “at high risk” Home Visiting Programs Head Start/Early Head Start More likely to be effective; minimize “damage” Requires screening Still issues with stigma, numbersof/access to providers Addressing Toxic Stress

41. Addressing Toxic Stress Treatmentof the consequences TF-CBT and PCITare evidence-based Reactive – some “damage” already done! Very COSTLY Efficacy linked to age and chronicity Due to declining brain plasticity? Insufficient number of / access to providers Persistent STIGMA “Character Flaws”vs“Biological Mal-adaptations”

42. WHAT are we DOING?! 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 Early Head Start/Head Start Mid-level Competencies Evidence-Based Treatments Screening for diagnoses Common factors approach Refer for/advocate for EBT Collaborating/Developing EBT Advanced Competencies

43. Building an Enhanced Theory of Change that Balances Enrichment and Protection New Protective Interventions Significant Adversity Healthy Developmental Trajectory Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

44. APublic HealthDilemma: Do we continue to treat disease, the unhealthy lifestyles that lead to disease, or the TOXIC STRESS that leads to the adoption of unhealthy lifestyles??

45. A Public Health Parable: Man by the river hears someone drowning Being a good swimmer, he rescues the person Before catching his breath, he hears another in need, and another and another… The man, exhausted, begins to walk away Asked where he’s going, he responds…

46. A Public Health Parable: “I’m going upstream to prevent others from falling in!!”

48. SUMMARY • What is Toxic Stress? • A physiologic stress response that is excessive or prolonged (reflects an inability to “turn it off”) • Results in potentially permanent changes in: • Gene expression (epigenetics) • Brain development (neuroscience) • Behavior (allostasis)

49. SUMMARY • Why should I care? • Toxic stress is aMEDIATOR between early childhood adversity and less than optimal outcomes in learning, behavior and health • Understanding the BIOLOGY underlying these well established associations opens up new opportunities for primary prevention and early intervention

50. Linking Childhood Experiences and Adult Outcomes Childhood Adversity Poor Adult Outcomes Health and social services to deal with adverse outcomes (e.g. - efforts to address the behavioral, social, health and economic consequences) Advocacy to minimize childhood adversity (e.g. - efforts to address poverty, food scarcity, domestic violence, parental substance abuse)