Ruth Perou, PhD Child Development Studies Team Division of Human Development and Disability

1. A Public Health Approach to Children’s Behavioral Health at the Center’s for Disease Control and Prevention (CDC) Ruth Perou, PhD Child Development Studies Team Division of Human Development and Disability National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention National Association of County Behavioral Health And Developmental Disabilities Directors Washington DC March 4, 2011 National Center on Birth Defects and Developmental Disabilities Division of Human Development and Disability

2. “One of [our] chief priorities has been to work to ensure that every child has an optimal chance for a healthy start in life…Mental health is fundamental to overall health and well-being. And that is why we must ensure that our health system responds as readily to the needs of children’s mental health as it does to their physical health.” David Satcher, MD, Ph.D, Surgeon General, 1998-2002

3. CDC Mission Collaborating to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. CDC seeks to accomplish its mission by working with partners throughout the nation and the world to Monitor health Detect and investigate health problems Conduct research to enhance prevention Develop and advocate sound public health policies Implement prevention strategies Promote healthy behaviors Foster safe and healthful environments Provide leadership and training

6. Public Health Approach

7. What is Public Health? Population approach Community as client Proactive and preventative Health protection & promotion Research/evaluation, policies, capacity building, and services Multidisciplinary Ecological Holistic

8. The Public Health Model Adapted from Mercy et al. (1993)

9. Around 1 in 5 young people (14-20%) have a current disorder Estimated $247 billion in annual treatment and productivity costs Significant other costs education, justice, health care, social welfare costs to the individual and family Impact of Children’s Behavioral Health From IOM (2009). Preventing Mental, Emotional, and Behavioral Disorders

10. Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies ACE Study: Major Findings Increases in ACE score associated with increased risk for the following health problems:

11. Origins of chronic adult disease are often found among developmental & biological processes occurring during the early years Because brain circuits stabilize over time, the energy costs of altering circuits (and therefore behavior) increase as the brain matures Nurturing, responsive & individualized interactions can buffer toxic stress Children’s Early Brain Development Shapes Lifelong Health

12. Safe Stable Nurturing Relationships (SSNR) Framework Caregiving behaviors are key Nurturing interactions build healthy brain architecture Safe, stable, nurturing environments associated with positive outcomes Promoting SSNRs will Increase positive caregiving behaviors and environments Buffer stress and harm

13. ADHD PLAY Study Pregnancy Risk Assessment Monitoring System Autism & Developmental Disabilities Monitoring Network Early Hearing & Detection Intervention Adverse Childhood Experiences Study (ACE) Childhood Lead Level Surveillance Meta-analysis of Parent Training Programs NCHS PLAYProject to Learn about ADHD in Youth Some Examples of CDC Child/Family Epidemiology

14. Mental Health Surveillance • Behavioral Risk Factor Surveillance System (BRFSS) • Youth Risk Behavior Surveillance System (YRBSS) • Pregnancy Risk Assessment Monitoring System (PRAMS), Division of Reproductive Health • Health-related Quality of Life (HRQOL) • School Health Policies and Programs Study (SHPPS) • National Youth Tobacco Survey (NYTS) • Autism and Developmental Disabilities Monitoring Network (ADDM) • Child and Adolescent Mental Health Metadata website • National Health Interview Survey (NHIS) • National Health and Nutrition Examination Survey (NHANES)

15. Mental Health Surveillance (cont) • National Survey of Children’s Health (NSCH) • Healthy People 2010 • National Ambulatory Medical Care Survey (NAMCS) • National Hospital Ambulatory Medical Care Survey (NHAMCS) • National Survey of Children with Special Healthcare Needs (NS-CSHCN) • National Survey of Early Childhood Health • WISQARS WISQARSTM(Web-based Injury Statistics Query and Reporting System) is an interactive database system that provides customized reports of injury-related data) • National Violent Death Reporting System • School Associated Violent Death Study (CDC/NCIPC and Departments of Education and Justice)

16. National Survey of Children’s Health – Data Resource Center Health Data Interactive (http://www.cdc.gov/nchs/hdi.htm) VitalStats Healthy People Data2010 NCHS Surveys Measures Catalog: Child and Adolescent Mental Health Youth Risk Behavior Surveillance System WISQARS (http://www.cdc.gov/injury/wisqars/index.html) National Violent Death Reporting System (NVDRS) Interactive data access tools on CDC website

19. % of children aged 4-17 years with parent-reported ADHD by state: United States, 2007 14.0%-15.9% 11.0%-13.9% 9.6%-10.9% 8.0%-9.5% 5.6%-7.9% WA ME VT ND MT MI MN OR NH WI ID MA SD NY WY MI RI PA CT IA NE NJ NV OH IL IN DE WV UT MD CA CO VA DC KS MO KY NC TN OK AZ SC AR NM GA MS AL LA TX AK FL HI

20. States with Significant Increases in ADHD Prevalence (ever diagnosed) – US: 2003-2007 = Prevalence significantly increased between 2003 and 2007 = Prevalence remained statistically equivalent between 2003 and 2007 Washington Vermont Maine Montana Minnesota North Dakota Michigan New Hampshire Oregon Wisconsin Massachusetts South Dakota Idaho New York Wyoming Michigan Rhode Island Connecticut Pennsylvania Iowa Nebraska New Jersey Nevada Ohio DC Delaware Indiana Illinois Utah West Virginia Maryland Colorado California Virginia Kansas Missouri Kentucky North Carolina Tennessee Arizona Oklahoma Arkansas South Carolina New Mexico Mississippi Georgia Alabama Texas Louisiana Florida Alaska Hawaii

21. States with Significant (p < .05) Increases in Parent-reported ADHD Diagnosis (2003-2007) Note: There was a statistical trend in the rates in MD, AL, & NE (.05<=p<= .1).

22. SSNR Surveillance National Survey of Children’s Exposure to Violence(NatSCEV) ~70 screener items Broad range of victimizations Caregiver report: age 0-9 yearsYouth self-report: age 10-17 yrs 4,549 participants 34 SSNR items added

23. The Public Health Model Prevention

24. Project Choices Project Connect Learn the Signs. Act Early Legacy for ChildrenTM Sample CDC Child-Family Prevention Programs

25. Learn the Signs. Act Early. • Builds on familiar experiences of parents, such as monitoring their child’s growth • Aims to educate parents, health care professionals, and childcare providers about child development • Encourages early screening and intervention—strategies that hold the most promise for affected children and their families

26. Learn the Signs Resource Kits www.cdc.gov/actearly 26

27. Legacy for ChildrenTM • Improve outcomes for children in poverty by promoting positive parenting • Legacy mechanisms: • Mother-Child Interaction • Enhancing parental self efficacy • Promoting a sense of community • Evaluation • Preliminary analysis are promising • 17% INT children had fewer behavioral challenges • 20% INT children had higher cognitive scores • Longitudinal evaluation in progress • Feasibility study in progress - Collaboration with ACF • Implementation Resources for Communities

28. The Public Health Model Evaluation Feedback throughout process

29. Evaluation feedback at every step Program Evaluation the goal of rigorous evaluation is to rule out alternative explanations (aka “threats to internal validity”) for observed outcomes Technology Enhancements to Parenting Programs Improving Training of Home Visitation Programs Evaluation

30. Triple P: Population-based Approach Everybody All Families in a Specific Setting Families at Risk Media Campaign Brief Consultations in Primary Care Settings Parenting Skills Training Families in Crisis Intensive Counseling

31. Public Health Leadership for the Prevention of Child Maltreatment (PHL) Initiative Supporting state public health agency efforts in primary prevention of child maltreatment

32. PHL Purpose To raise awareness about child maltreatment prevention as a public health issue. To identify ways to support, improve, and expand child maltreatment prevention efforts in public health agencies.

33. Health Department Role

34. Examples of Public Health Relevant Approaches to Child Behavioral Health Across the Social Ecological Model • Examples • Maternity/Paternity Leave • Societal • Community • Relationship • Individual • Examples • Parents Matter Program • School Connectedness • MH Consultation • Examples • Parent Training • Examples • Home visitation • Legacy for ChildrenTM • Project Choices

35. Thank you! Points of Contact: Ruth Perou, PhD rzp4@cdc.gov National Center on Birth Defects and Developmental Disabilities Place Descriptor Here

36. Autism and Developmental Disabilities Monitoring (ADDM) Network Collaborative effort to estimate prevalence of ASDs in multiple areas of US Provide data to Characterize the ASD population Describe variation by subgroups and over time Evaluate methodologic factorswhich may influence estimates Inform hypotheses on potential risk factors

38. UCLA KABC IQ at 3 Years of Age Intervention Comparison Moderate MR Mild MR Borderline IF Moderate MR Mild MR Borderline IF 50% 30% IF = Intellectual Functioning

39. UM DECA: Meeting Referral Criteria at 2 Years • 17% fewer intervention children fell 2 SDs above the mean for behavioral problems • Comparison children had 78% greater odds of meeting referral criteria for behavioral problems

40. % of children aged 4-17 years currently taking medication for ADHD by state: United States, 2007 7.6%-9.5% 5.9%-7.5% 4.7%-5.8% 3.7%-4.7% 1.2%-3.6% WA ME VT ND MT MI MN OR NH WI ID MA SD NY WY MI RI PA CT IA NE NJ NV OH IL IN DE WV UT MD CA CO VA DC KS MO KY NC TN OK AZ SC AR NM GA MS AL LA TX AK FL HI