Family Support in Early Childhood

1. Family Support in Early Childhood The case for developing comprehensive and integrated framework for promoting the health and well-being of children birth to five in Kentucky

2. Kentucky Early Childhood Initiatives History • Kentucky Invests in Developing Success = KIDS Now legislation - March 28, 2000: House Bill 706 was unanimously enacted by the Kentucky General Assembly • Goal: All young children in Kentucky are healthy and safe, possess the foundation that will enable school and personal success, and live in strong families that are supported and strengthened within their communities. • Assuring Maternal and Child Health • Strengthening families • Enhancing Early Care and Education • Public Awareness • Funding: 25% of Kentucky’s Phase I Tobacco Settlement • Kidsnow@ky.gov

3. Early Childhood Advisory Council (ECAC) Children Enter Kindergarten Ready High Quality Early Learning Environments Supportive Families Access to Data for Community Planning Common Kindergarten Entry Screener Participation in STARS A great early childhood workforce Families understand child health and developmental needs Data is shared by early childhood programs Scholarships & PD Plans Families are engaged Children have access to appropriate services

4. Our Business ModelEarly Childhood Advisory Council (ECAC) Children Enter Kindergarten Ready High Quality Early Learning Environments Access to Data for Community Planning Supportive Families Common Kindergarten Entry Screener Participation in STARS A great early childhood workforce Families understand and have the skills to addresstheir child’shealth and developmental needs Data is shared by early childhood programs Scholarships & PD Plans Children have access to appropriate services Families are engaged

5. Family Support in Early Childhood Alignment with the Science 1. The Brain is not mature at birth; experiences shape the architecture of the brain 2. Adversity creates stress which can be toxic to the developing brain 3. Adverse childhood experiences have lifelong impacts on health and development

6. Life Course of Health Development Optimal Outcome Poor Outcome Lu and Halfon, 2003

7. Structural Brain Changes due to Early Experiences Healthy Brain Deprivation “The Two Year Window”

8. Neural Circuits are Wired in a Bottom-Up Sequence (700 synapses formed per second in the early years) Language Higher Cognitive Function Sensory Pathways (Vision, Hearing) FIRST FIVE YEARS 1 2 3 4 5 6 7 8 9 10 111 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Years Months Source: C.A. Nelson (2000)

9. Life Course Health Development Critical Period of Brain Development • Social-Emotional development is based on secure attachment and becomes the foundation for cognitive development and sense of self-identity. • Attachment comes from a nurturing relationship with a caregiver that is consistent and caring. Birth – 2 years; critical window for hardwiring the brain for social-emotional development.

10. Implications of Attachment Disorders • Poor coping & problem solving skills • Failure to thrive > Chronic illness • Learning delays / Development delay • Behavior problems • Speech/Language delays • Alienation, Inability to form relationships • Lack of trust, compassion, remorse • Aggression, Violence, Anti-social behavior • Eating disorders (including hording etc.) • Misdiagnosed as bipolar / severe depression • Reactive Attachment Disorder (severe)

11. Life Course Health Development - Environmental interaction and Disparities Poor Nutrition Stress Abuse Tobacco, Alcohol, Drugs Poverty Lack of Access to Health Care Exposure to Toxins Poor Birth Outcome Age 0 5 Puberty Pregnancy Lu and Halfon

12. Three Levels of Stress Positive Brief increases in heart rate, mild elevations in stress hormone levels. Tolerable Serious, temporary stress responses, buffered by supportive relationships. Toxic Prolonged activation of stress response systems in the absence of protective relationships.

13. Stress and Brain Development • Danger • VS • Hypothalamus FIGHT OR FLIGHT RESPONSE Cortisol Epinephrine Norepinephrine Elevated Heart Rate Rapid breathing RUN!!!

14. Allostasis: Maintain Stability through Change McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

15. Multiple Traumatic Events Terror Fear Alarm Vigilance Calm Event #1 Event #3 Event #2 Slide from Dr. David Willis

16. Poor Children Experience Elevated Stress Cortisol Epinephrine Norepinephrine Middle Poverty Middle Poverty Middle Poverty Income Income Income Overnight levels in rural 9-year-old white children Source: Evans, GW and English, K. (2002)

17. The Brain Architecture of Anxiety and Fear

18. The Brain Architecture of Memory and Learning

19. Cognitive, Emotional, and Social Capacities Are Inextricably Intertwined Within the Architecture of the Brain

20. Using Science to Bring About Change • Our growing understanding is of how the over-activation of stress response systems in young children can lead to disruptions in developing brain architecture. When the foundation of that brain architecture is weakened by toxic stress, that creates barriers to learning, as well as the potential for lifelong health problems.

21. The New Science  the New Paradigm American Academy of Pediatrics: The Lifelong Effects of Early Childhood Adversity and Toxic Stress PEDIATRICS 2012 129(1):E232-E246 • The availability of a caring and responsive adult greatly reduces the risk that circumstances will lead to excessive activation of stress response systems that lead to physiologic harm and long-term consequences for health and learning. • The context to establish the early roots of physical and mental well-being include: • A stable and responsive environment of relationships • Safe and supportive physical , chemical, and built environments, and • Sound and appropriate nutrition

22. Adverse Childhood Experiences (ACE) Study • Kaiser study • 1700 middle class enrollees • Categories of trauma experienced in childhood such as: • Physical abuse • Emotional abuse • Domestic violence • Substance abuse in home • Mental illness in parent • Lost parent due to separation or divorce • Household member in jail

23. Adverse Childhood Experiences (ACE) Score Number of individual adverse childhood experiences were summed…… ACE score Prevalence 0 36.4% 1 26.2% 2 15.8% 3 9.5% 4 6.0% 5 3.5% 6 1.6% 7 or more 0.9% 64% reported experiencing one or more 37% reported experiencing two or more

24. Children’s Exposure to Violence – NATIONAL SURVEY (2009) 60% of American Children were exposed to violence, crime, or abuse in their homes, schools, and communities. Almost 40% of American children were direct victims of TWO or more violent acts, and one in 10 were victims of violence five or more times. Almost 1 in 10 American children saw one family member assault another family member, and more than 25% had been exposed to family violence during their lifetime. Exposure to one type of violence increased the likelihood that a child would be exposed to other types of violence and exposed multiple times. Finkelhor, et al “Children’s Exposure to Violence: A Comprehensive National Survey” Juvenile Justice Bulletin, October 2009 [Defending Childhood Initiative]

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

26. Adverse Childhood Experiences And Chronic Depression as an Adult

27. ACE Score and Intravenous Drug Use N = 8,022 p<0.001

28. Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences 3.5 3 2.5 Odds Ratio 2 1.5 1 0.5 0 1 2 3 4 5,6 7,8 ACEs Source: Dong et al, 2004

29. ACE Score and Indicators of Impaired Worker Performance Prevalence of Impaired Performance (%)

30. Adverse childhood experiencesanD ADULT DISEASE: 54% of depression58% of suicide attempts39% of ever smoking26% of current smoking65% of alcoholism50% of drug abuse78% of IV drug abuse48% of promiscuity (>50 partners)are attributable to ACE’s. Dr. V. Felitti. 2011

31. The ACE Study is evidence that….Adverse childhood experiences are the most basic and long lasting causeof : health risk behaviors, mental illness, social malfunction, disease, disability, death, and healthcare costs Dr. V. Felitti. 2011

32. Life Course Health Development - Environmental Interaction and Disparities Cumulative effects of negative experiences depress the trajectory Poor Nutrition Stress Abuse Tobacco, Alcohol, Drugs Poverty Lack of Access to Health Care Exposure to Toxins ADVERSE CHILHOOD EXPERIENCES CHILD ABUSE FAMILY DYSFUNCTION Poor Birth Outcome Age 0 5 Puberty Pregnancy Slide adapted from Lu and Halfon

33. How Risk Reduction and Health Promotion Strategies influence Health Development RR Risk Reduction Strategies Risk Factors HP Health Promotion Strategies Trajectory Without RR and HP Strategies Optimal Trajectory RR HealthDevelopment RR RR HP HP HP Protective Factors 0 20 40 60 80 Age (Years) FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.

34. Life Course Trajectory: A Balance of Risk and Protective Factors Protective Factors Child Family Community School Risk Factors Child Family Community School Positive resilience Negative vulnerability Outcome School Readiness Child Abuse - + Family Skills and Support Slide adapted from Dr. Michael Lu

35. Life Course Trajectory: A Balance of Risk and Protective Factors Secure Relationships Poor Relationships • Strong social-emotional pathways • Cognition, problem solving • Trusting relationships with caring adults • Ability to explore their environment without fear; curiosity • Tolerate disappointments • Stay on task, persevere • Able to form close friendships, networks of support • Poor coping & problem solving skills • Failure to thrive > Chronic illness • Learning delays / Devel. delay • Behavior problems • Speech/Language delays • Alienation, Inability to form relationships • Lack of trust, compassion, remorse • Aggression, Violence, Anti-social behavior • Eating disorders • Misdiagnosed as bipolar / severe depression HARDWIRING OF THE BRAIN for Social-emotional fxn

36. Life Course Trajectory: A Balance of Risk and Protective Factors Executive Function “Amydgala Hijack” • Impaired memory, esp. “working” and contextual memory • Inability to concentrate • Harder to follow directions • Hard to sit still • Constantly on edge • Easily provoked • Impulsive • Ability to problem solve • Self-control • Self confidence • Able to calm self • Follows directions • Persists on task • Adapts to change • Able to manage their tempers when provoked • Able to delay gratification • Able to plan Responses to chronic stress

37. Life Course Trajectory: A Balance of Risk and Protective Factors 0-3 ACE’s More likely: 4 ACE’s High risk for: • Good mental health • Normal growth and development • Less chronic disease • Less tobacco use • Less drug abuse • School readiness & success • Employment • Tobacco Use • Drug abuse • Obesity • Promiscuity, teen pregnancy • Pathologic Gambling • Risk taking behaviors • Lack of social networks • High risk for school failure • Gang membership • Unemployment • Incarceration ACE

38. Family Support in Early Childhood B. Building Resilience 1. All children are born with a natural resilience. Developing resilience is about building on children’s existing strengths. 2. A person may be highly resilient in one aspect of life and need much higher support in others. 3. Parents must have the skills to model resiliency and positive coping strategies.

39. Life Course Trajectory: A Balance of Risk and Protective Factors Protective Factors Child Family Community School Risk Factors Child Family Community School Positive resilience Negative vulnerability Outcome School Readiness Child Abuse + - Family Skills and Support Slide adapted from Dr. Michael Lu

41. Pathways to Resilience • “The great surprise of resilience research is the ordinariness of the phenomena … Resilience does not come from rare and special qualities, but from ordinary everyday magic of ordinary, normative human resources in the minds, brains, and bodies of children, in their families and relationships, and in their communities.” • Ann Masten, 2001

42. The Protective Factors Approach • Benefits ALL families – • All families go thru times of stress and should be able to ask for help without stigma • Every parent should feel supported by their community in their efforts to be a good parent • Builds on family strengths, buffers risk, and promotes better outcomes • Can be implemented through small but significant changes in everyday actions • Builds on and can become part of existing programs, strategies, systems and community opportunities • Is grounded in research, practice and implementation knowledge • Creates a common language and approach among agencies so that communities can meet the diverse needs of their families Slide adapted from NilopherAshan

43. Improved School Readiness CSSP

44. The Protective Factors Framework • Nurturing Relationships • Parental Resilience • Social Connections • Knowledge of Parenting and Child Development • Concrete Support in Times of Need • Social and Emotional Development

45. Nurturing RelationshipsStable, Safe, Responsive Relationships • People of all ages need a safe, stable and nurturing environment- at least one reliable, responsive, caring relationship- which helps to develop adaptive capacities to rise above adversity. This may include family, friends, and community partners. Adapted from CDC

46. Parental ResilienceParents Can Bounce Back • Having the skill, attitude, capacity and ability to withstand and meet stressors and daily challenges; and to be able to solve problems in ways which lead to more positive outcomes for families Kentucky Strengthening Families Leadership Team Title from GA Strengthening Families

47. Social ConnectionsParents Need Friends Title from GA Strengthening Families • An informal network of emotional support provided through an ongoing ability to access positive support and relationships; and the willingness and permission to reach out to others. Kentucky Strengthening Families Leadership Team

48. Knowledge of Parenting & Child DevelopmentParents Know How Children Grow & Learn • Knowing where to go to find out information on essential parenting skills and realistic expectations of child development; what is expected of professionals to know; having the confidence to seek validation for what you’ve been told; and step outside of what you know on parenting. Title from GA Strengthening Families Kentucky Strengthening Families Leadership Team

49. Concrete Support in Times of NeedParents Know Where to Turn for Help • Support must be trusted, reliable and easy access for both emotional and concrete supports like food, shelter, heat; and must include these four components: availability, affordability, acceptability and accessibility. Kentucky Strengthening Families Leadership Team

50. Social & Emotional Competence of ChildrenChildren Learn to Talk About and Handle Feelings • Developing and engaging in self-regulating behaviors; identifying and communicating emotions effectively; interacting positively with others; using words and language skills; delayed gratification skills; persistence; empathy; skills Title from GA Strengthening Families at developmentally appropriate level; and include executive functions like cognitive flexibility, impulse control, and working memory. Kentucky Strengthening Families Leadership Team