THE CHANGING FACE OF CHILD HEALTH CARE

1. THE CHANGING FACE OF CHILD HEALTH CARE DCF Nursing Best Practices Seminar Paul H. Dworkin, MD January 6, 2012 Newington, CT

2. INTRODUCTION • Goal of Child Health Services

4. OBJECTIVES • Define the goal of child health services • Identify key concepts in early brain development that have implications for health services delivery • Identify key concepts in early child development that have implications for health services delivery • Demonstrate the application of key concepts to program design

5. 1990’s: The Decade of the Brain

6. The New Millennium

8. Center on the Developing Childat Harvard Universitywww.developingchild.harvard.edu

10. Early Brain and Child Development EARLY BRAIN AND CHILD DEVELOPMENT • Proportional brain growth • Neural plasticity • Critical periods • Sequential development • Role of experience

11. Early Brain and Child Development PROPORTIONAL BRAIN GROWTH Courtesy of Bruce Perry, MD, PhD

13. Early Brain and Child Development NEURAL PLASTICITY • The brain has a great deal of plasticity and can recovery from insults • the brain is always changing • it takes less time to organize the developing nervous system than to reorganize the developed nervous system • “Window of opportunity” during early childhood • never permanently closes

14. CRITICAL PERIODS From Syllabus, “Brain and Behavior,” Colorado University

15. Early Brain and Child Development CRITICAL PERIODS • Brain development begins before birth; although development continues throughout life, thefirst three years are very important and provide a critical foundation • Times in development during which a set of signals must be present for neural systems to differentiate normally • e.g., stereoscopic vision

16. Abstract Thought Concrete Thought Neocortex Affiliation "Attachment" Sexual Behavior Emotional Reactivity Limbic Motor Regulation "Arousal" Appetite/Satiety Diencephalon Sleep Blood Pressure Heart Rate Brainstem Body Temperature C O M P L E X I T Y Courtesy of Bruce Perry, M.D., Ph.D.

17. Early Brain and Child Development SEQUENTIAL DEVELOPMENT • The brain develops sequentially • Experiences need to be sequential, as well • the experiences of the child should match the development of the child • provide the “right” experiences in the “right” amounts at the “right” time in the life of a child

18. Early Brain and Child Development SEQUENTIAL DEVELOPMENTPractical Implications • Few infants will benefit from an algebra lecture • Few adolescents need to be held and rocked for hours each day Courtesy of Bruce Perry, MD, PhD

19. The human brain has the ability to be shaped by experience Experience, in turn, leads to neural changes in the brain birth: 50 trillion synapses 1 year: 1,000 trillion 20 years: 500 trillion The remolded brain facilitates the embrace of new experiences Early Brain and Child Development ROLE OF EXPERIENCE

20. Early Brain and Child Development

21. HEALTH SERVICES IMPLICATIONSEarly Brain and Child Development • For optimal effectiveness, stimulation must begin as early as possible • Stimulation during the first three years is particularly critical to ensure optimal development • “use it or lose it” • capacity at any age • Stimulation must be aligned with children’s developmental stages and needs

22. CRITICAL CONCEPTS IN CHILD DEVELOPMENT Implications for Child Health Services

23. Quality ECE Health services Appropriate discipline Early literacy Parent education Emotional health Health literacy Late Toddler Late Infancy Late Preschool Birth Early Infancy Early Preschool Early Toddler “School Readiness Trajectories” Family discord Inaccessible health services “Healthy” Trajectory Poverty “At Risk” Trajectory “Ready to Learn” “Delayed/Disordered ” Trajectory Age Prenatal 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs Graphic Concept Adapted from Neal Halfon , UCLA Center for Healthier Children, Families, and Communities

24. Chamberlin RW. Preventing low birth weight, child abuse, and school failure: the need for comprehensive, community-wide approaches.Pediatr Rev 1992;13(2):64-71 • “The most effective long-term strategy appears to be the development of a comprehensive, coordinated, community-wide approach focused on preventing low- and medium-risk families from becoming high-risk, as well as providing intensive services to those who already have reached a high-risk status.”

25. Universal Curve Shift Median Low income High income DISABLED VULNERABLE Targeted Interventions Clinical/Individual Interventions NUMBER OF CHILDREN FUNCTION

26. The Productivity Argument for Investing in Young ChildrenJames J. Heckman and Dimitriy V. Masterov

27. ADVERSE CHILDHOOD EXPERIENCE STUDY (ACES) • Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the CDC • Decade long.; 17,000 people involved • Looked at effects of adverse childhood experiences over the lifespan • Largest study ever done on this subject The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Lanius & Vermetten, 2009

28. ADVERSE CHILDHOOD EXPERIENCES • Sexual abuse • Emotional abuse • Emotional neglect • Physical abuse • Physical neglect • Substance abuse in home • Mental illness in home • Incarceration of family member • Parental separation or divorce • Witness violence against mother

29. ACES STUDY Individuals with 4 or more of the 10 ACES are: • Nearly 2 times more likely to smoke cigarettes • 4 ½ times more likely to engage in drug abuse • 7 times more likely to suffer from chronic alcoholism • 11 times more likely to abuse drugs via injection • 19 times more like to have attempted suicide • More likely to have health problems that put them at risk of early mortality

30. HEALTH SERVICES IMPERATIVESChild Development Concepts • Treatment programs and services must be comprehensive, multidisciplinary, and address the multiple factors that facilitate and hinder children’s optimal development • Services should address the needs of all children (e.g., the entire population), recognizing that those in greatest need will likely derive the greatest benefits • target at-risk children and families • perils of exclusive focus on CYSHCN

31. Child Health Services Building Blocks Part C (B-to-3) Title V (CYSHCN) Links to Preschool Special Ed and Special Ed (LEA) Indicated Service Integration Care Coordination System Changes Medical / Surgical Subspecialty Services Early Childhood Consultation Services Developmental / Behavioral Health Services (Mid-level, Comprehensive assessments; Treatment) Home –based Services Help Me Grow Selective Pay for Performance Practice Improvement Reimbursement Reform (Public & Private) CT-CHQII MedicalHome Developmental/Behavioral Surveillance & Screening Family Education /Parent & Child Counseling / Anticipatory Guidance Literacy Promotion Health Supervision Services Oral Health/Dental Home Nutritional Services Universal EPIC

32. Child Health Services Building Blocks Desired Outcomes for School Readiness . Family Capacity and Function Emotional / Social / Cognitive Development Physical Health & Development Early Care and Education Programs Family Support Services Care Coordination INDICATED SERVICES SELECTIVE SERVICES (Help Me Grow) Child Health Services UNIVERSAL SERVICES (Medical Home)

33. "Making the Connection- Help Me Grow The Connecticut Experience" Centralized Telephone Access Point Community & Family Outreach Core Components Child Health Provider Outreach  Data Collection & Analysis Organizing Entity Continuous Quality Improvement Statewide Expansion Structural Requirements

34. SUMMARY • Knowledge of early brain development has important implications for promoting children’s optimal development • Need for early stimulation • Critical importance of first 3 years (“use it or lose it”) • Need or alignment with developmental needs • Knowledge of early child development has important implications for promoting children’s optimal development • Need for comprehensive services • Should target entire population of children, especially at-risk