Three Dramatic Advances

1. Three Dramatic Advances Life-Course Science Epigenetics Developmental Neuroscience

2. Dramatic Advance #1 Life-Course Science Experiences in childhood (both good and bad) are strongly associated with behaviors, health and economic productivity … … DECADES LATER!

3. 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!

4. 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

5. Linking Childhood Experiences and Adult Outcomes Childhood Adversity Poor Adult Outcomes Toxic Stress Epigenetic Modifications Disruptions in Brain Architecture Behavioral Allostasis Maladaptive behaviors Non-communicable Diseases Improve caregiver/community capacity to promote healthy, adaptive coping skills (e.g. - efforts to encourage rudimentary but foundational SE, language, and cognitive skills ) Improve caregiver/community capacity to prevent or minimize toxic stress (e.g. – efforts to promote the safe, stable and nurturing relationships that turn off the physiologic stress response)

6. Dramatic Advance #2 EPIGENETICS • “Above the genome” • Change in gene expression/no change in DNA sequence • Larger revolution in genomic science • OLD VIEW = STATIC; NEW VIEW = PLASTIC (environ. input) • Complex set of SWITCHES • Some are: Master; Dynamic; Programmed Early and Stabile • “Epigenetics: NOT your parents’ genome!”

7. Impact of Early Stress TOXIC STRESS MATERNAL STRESS NEWBORN HPA reactivity and salivary cortisol levels methylation of the FETAL glucocorticoid (GC) receptor gene brain expression of the GC receptor

8. SE Buffers • Yin/Yang of Childhood: • PROTECT the Brain • BUILDNew Skills Toxic Stress Protect the Brain Build New Skills Maladaptive Skills Adaptive Skills

9. Dramatic Advance #3 Developmental Neuroscience • Brain Architecture is experience dependent (individual connections or “synapses” and complex circuits of connections or “pathways” are both dependent upon activity) • Ecology (environment/experience) influences how brain architecture is formed and remodeled(plasticity) • Diminishing cellular plasticity limits remediation • Differential Maturation + Significant Adversity -> Vicious Cycle of Stress • Early Experiences create potentially permanent alterations in brain architecture and functioning

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

11. 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

12. 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

13. Advantages of an EBD Framework Though grounded indevelopmental science, the simplicity of the EBD framework may promote understanding as well as support for translation (early investments are the right thing to do biologically) Psychosocial stressors and other salient features of the ecology are every bit as biological as nutrition or lead (no distinction between mental and physical health, just healthy vs. unhealthy development) Emphasizes the dimension of time – to reflect the on-going, cumulative nature of benefits and threats to health, educational success, and economic productivity Advantages of an EBD Framework

14. Development results from an on-going, 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) Adapted from: Helping Foster and Adoptive Families Cope with Trauma

15. Underscores the need to improve the early childhood ecology in order to: Mitigate the biological underpinnings for educational, health and economic disparities Improve developmental/life-course trajectories Changing the early childhood ecology will require a PUBLIC HEALTH approach … and collaboration!! Highlights the pivotal role of toxic stress Not just “step on the gas” / enrichment But “take off the brake” by treating, mitigating or immunizing against toxic stress (all are necessary!) Advantages of an EBD Framework

16. Addressing Adversity, Toxic Stress, and Resilience in Pediatrics Development of a National Center Annual Leadership Forum – March 13, 2014

17. How did we get here?

18. A Brief History

19. Strategic Priorities

20. Academy Groups

21. Other AAP Initiatives Addressing Adversity, Toxic Stress, and Resilience • Bright Futures • Head Start National Center on Health • Healthy Child Care America • Medical Homes for Children Exposed to Violence • National Center on Medical Home Implementation

22. Efforts at the Federal Level Numerous Federal partners are addressing these issues, as well. The AAP hosted a meeting with many of those listed here in October 2013 to begin discussing how we might all work together more closely to address these critically important issues.

23. Robert Wood Johnson FoundationCommission to Build a Healthier America In January 2014, the Commission released a report entitled “Time to Act: Investing in the Health of Our Children and Communities.” In the report, the RWJF Commission identified 3 requirements if we are to improve the health of all Americans: • Invest in the foundations of lifelong physical and mental well-being in our youngest children • Create communities that foster health-promoting behaviors • Broaden health care to promote health outside of the medical system

24. Public Interest – the Media • Discussion of adversity, toxic stress, and resilience in high visibility media outlets • New Yorker • Huffington Post • New York Times • Strong media attention on the publication of the AAP policy statement and technical report on toxic stress • Ecobiodevelopmental model gaining attention and momentum

25. Something is profoundly wrong when we can point to 2-year-olds in this country and make a plausible bet about their long-term outcomes – not based on their brains and capabilities, but on their ZIP codes.

26. the vision & goals

27. The VisionLead a national, multidisciplinary response to:

28. The Goal

29. The National Center

30. Current Status

31. Brand Discovery Goal To garner core insights that will shape a credible and distinct brand positioning, which will become the basis for the Center’s brand, messaging, and all communications. Background • Assessed the landscape of 10 organizations addressing childhood adversity and resiliency, looking at brand positioning and visibility. • Conducted interviews with 7 influencers to learn their perspectives on the issue and how AAP can drive it forward on the national level.

32. Organizations ReviewedThought Leadership Organizations to Service Providers

33. Additional Organizations Reviewed(Informally) Definition of medical home When children have a medical home, all aspects of pediatric care can be managed by one consistent pediatrician who knows a child’s family and their medical history. This includes well-child visits; immunizations; screenings and assessments; patient and parent counseling about health, nutrition, safety, and mental health; and supervision of care. In addition, when appropriate, a pediatrician can also refer a child to specialized health care providers and early intervention services while coordinating care with other programs and services. The AAP has identified seven desirable characteristics of a medical home: accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. Please see www. medicalhomeinfo.org for more information.

34. Stakeholders Interviewed Research Community • Robert Anda, MD, PhD, Principal Investigator of ACEs Study • Arthur Rolnick, PhD, Senior Fellow & Co-Director of Human Capital Research Collaborative, Humphrey School of Public Affairs, University of Minnesota • Jack Shonkoff, MD,Director, Harvard Center on the Developing Child; Co-author of AAP Policy Statement and Technical Report on Toxic Stress Nonprofit • Ann O’Leary, VP & Director of the Children & Families Program, Next Generation (Too Small to Fail) • Kristin Schubert, Team Director & Senior Program Officer, Vulnerable Populations, Robert Wood Johnson Foundation Pediatricians • RJ Gillespie, MD, The Children’s Clinic Media • Richard Besser, MD, Senior Health and Medical Editor, ABC News (media and pediatric perspective)

35. Near Future

36. Learn More • More on ACEs • ACEs study: www.cdc.gov/ace • ACEs blog & discussion groups: http://acestoohigh.com/ • More on early brain development and toxic stress • Our own EBCD leadership work group, including their policy statement, technical report, and more: www.aap.org/ebcd • Harvard Center on the Developing Child: http://developingchild.harvard.edu/ • More on working with children exposed to violence: www.aap.org/medhomecev • More on resilience (http://resiliencetrumpsaces.org/) and protective factors (http://www.cssp.org/reform/strengthening-families)