TUNE My Life: Lessons We’re Learning about Life Course Planning

1. TUNE My Life: Lessons We’re Learning about Life Course Planning Kathy Karsting, RN, MPH Program Manager Maternal Child Adolescent Health Nebraska DHHS Division of Public Health

2. Objectives • Identify the function of life course planning in promoting preconception health among adolescents and young adults • Describe the evolution of Nebraska’s approaches to life course planning • Discuss the role of life course planning in engaging youth in reflection, introspection, expression, sequential and longitudinal thinking, delayed gratification, and executive function

3. Objectives • Identify the function of life course planning in promoting preconception health among adolescents and young adults • Describe the evolution of Nebraska’s approaches to life course planning • Discuss the role of life course planning in engaging youth in reflection, introspection, expression, sequential and longitudinal thinking, delayed gratification, and executive function

4. Outline – • Where we are • Definition and Scope • Key Messages • Adolescent Brain Development • Where we’ve been • TUNE My Life 1.1 and 1.2 • Where we’re going • TUNE My Life 2.0 • Strategic planning

5. Maternal Child Adolescent Health (MCAH) As a team, we support holistic life course development, pregnancy through young adulthood.  Health is developmental.

6. Laying the Foundation #1 LIFE COURSE HEALTH DEVELOPMENT?

7. Life Course Development Theory • Our life course is a trajectory • punctuated by critical and sensitive periods • Height of the trajectory represents functional development/capacity • Length of the trajectory represents life span • Influenced negatively by risk factors and positively by protective factors • Influenced by economic, social, and environmental factors

8. RR Risk Reduction Strategies Risk Factors Risk Factors HP Health Promotion Strategies Trajectory Without RR and HP Strategies Optimal Trajectory RR RR RR RR HealthDevelopment RR RR HP HP HP HP HP HP Protective Factors Protective Factors 0 20 40 60 80 Age (Years) How Risk Reduction and Health Promotion Strategies Influence Health Development 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. 8

9. Life Course Development Theory – The Effects of Stress • Stress is cumulative and creates genetic and biological wear and tear (the allostatic load) • Stress is psychosocial, physiological, and/or environmental in nature • “Toxic stress” (Shonkoff) impacts neurochemical development of the brain and relates to Chronic Inflammation, Adaptability, Resilience, Adoption of Risk Behaviors, and Poor Health and Social Outcomes • Particularly telling in pregnancy and birth outcomes; infancy

10. A Life Course Perspective for Maternal Health • Powerful influences shape pregnancy outcomes long before conception • Pregnancy outcomes are shaped by social, psychological , behavioral, environmental and biologic factors • Preconception care has traditionally focused on factors a few weeks or months prior to conception by women planning pregnancy. • Nearly 1/3 of pregnancies are unintended • The influence of many factors, such as nutritional status, begins in childhood.

11. Life Course Development and Health Disparities • Disparities in birth outcomes result from differential developmental trajectories over the life course. • While race as a biological concept may have little scientific meaning, as a social construct it may have profound health consequences. • The effect of race on birth outcome is likely mediated in part through (the) weathering of racism and racial discrimination over the life course. • Lu and Halfon (2003)

13. Resources: Life Course Implications of Health at Birth • Abundant evidence emphasizing the significance of health at birth and early childhood • Number of prenatal care visits may not have an effect on a child’s birth outcomes (Or, it takes more than 9 months to make a healthy baby) • Health disparities begin at birth (Or, the future of civilization is in the health of our girls) • Address health disparities by improving management of chronic disease and overweight; substance use; stress; mental health; environments; poverty… well before pregnancy Preconception Health and Health Care and Early Childhood Comprehensive Systems: Opportunities for Collaboration. National Center for Children in Poverty http://nccp.org/publications/pub_1063.html

14. Recommended Resources – Life Course Development and Maternal Health • Misra, Dawn. 2006. Racial disparities in perinatal health; a multiple determinants perinatal framework with a lifespan approach. Harvard Health Policy Review. 7(1): 72 -90. • Grason, Holly and Dawn Misra. 2006. Application of a lifecourse and multiple determinants framework to improve maternal health. Baltimore MD. Womens’ and Children’s Health Policy Center. Johns Hopkins Bloomberg School of Public Health. http://www.jhsph.edu/research/centers-and-institutes/womens-and-childrens-health-policy-center/publications/Lifecourse_and_Mult_Determinats_Frmwk_brief.pdf • Lu M, Halfon N. Racial and ethnic disparities in birth outcomes: a life course perspective. Maternal and Child Health Journal 2003:7(1):13-30. • Contra Costa Health Dept. 2010. A 12-point plan to close the black-white gap in birth outcomes http://cchealth.org/lifecourse/pdf/12_point_plan_fact_sheet.pdf

15. What is … Preconception Health ?

16. Working Definition of Preconception Health Preconception Health encompasses the key health skills and behaviors for youth* aged 12-19 years, necessary to promote optimal life course outcomes for self and offspring during (future) reproductive years. * Female and Male

17. The Purpose of Preconception Health Promotion To prepare youth to be physically, emotionally, and mentally healthy, and to be empowered with information and resources before the onset of sexual activity.

18. Our Vision of Preconception Health We address preconception health as a holistic approach to support young people growing up in the adolescent years: embracing behaviors contributing to healthy relationships, healthy pregnancy, healthy parenting, and success for both parent and child.

19. Look to the Future Key message development Resources Evaluation by Youth

20. Look to the Future • Preconception Fact Sheets • The “vehicle” for development of Key Messages • Resource Page • Evaluation questions, convenience sample

21. Evaluation Findings • Toxic exposures • Support your partner • Dental care • Living with violence • Folic Acid

22. Resources - CDC • http://www.cdc.gov/preconception/index.html • http://www.cdc.gov/preconception/documents/reproductivelifeplan-worksheet.pdf • http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf

23. Resources – ACOG Feb. 2012 • Preconception = Preparing for Pregnancy • Weight • Vitamins and supplements • Exercise • Substance Abuse • Environment – toxins and violence • Chronic conditions • Medications, Herbals, Supplements • Infections • Past Pregnancies • Family Health History • Pregnancy AP056 Good Health Before Pregnancy: Preconception Health

24. Resources – Preconception Health and Health Care Reform • Increase the number of women covered by Medicaid • Improve preventive care • Address health disparities through improved pregnancy outcomes • Improve knowledge, attitudes and behaviors of men and women related to preconception health Association of Maternal and Child Health Programs (AMCHP) Opportunities and Strategies for Improving Preconception Health through Health Care Reform Jan. 8, 2013

25. Resources – AMCHP • Family Planning counseling and use of reproductive life plan • Physical activity • Nutrition • Nutrient Intake • Immunizations • Infectious Disease • Parental Exposures to drugs and alcohol Association of Maternal and Child Health Programs (AMCHP) Opportunities and Strategies for Improving Preconception Health through Health Care Reform Jan. 8, 2013

26. Social Marketing – Short-term Communication Goals • Increase awareness of preconception health behaviors • Increase awareness that there is a preconception time period • Increase awareness that what happens pre-pregnancy (maternal and paternal) can affect health of baby • Increase awareness about where to find more information http://www.cdc.gov/preconception/showyourlove/index.html

27. Outline – • Where we are • Definition and Scope • Life Course Health Development • Key Messages • Adolescent Brain Development

28. The Adolescent Brain and Life Course Planning • The science of brain development • The impacts of adversity on brain development • The reality of Executive Function • Can we help make it happen?

29. The Adolescent Brain – • Anterior cortex • Sequential development to higher levels of integration of information • The impact of role models, or lack thereof • The connection between health and executive function • The role of education and learning

30. Executive Function • A neuropsychological concept referring to the high level cognitive processes required to plan and direct activities, including task initiation and follow-through, working memory, sustained attention, performance monitoring, inhibition of impulses, and goal-directed persistence. • Self-regulation

31. Four Executive Functions related to Life Course Planning • Planning/Prioritization – The ability to create a roadmap to reach a goal or to complete a task. (PL) • Time Management – the capacity to estimate how much time one has, how to allocate it, and how to stay within time limits and deadlines. How to monitor progress and stay on schedule. (TM)

32. Four Executive Functions related to Life Course Planning • Goal-Directed Persistence – the capacity to have a goal, follow through to the completion of the goal, and not be put off or distracted by competing interests (GDP) • Metacognition – The ability to stand back and take a bird’s eye view of oneself in a situation, the ability to self-monitor and self-evaluate (M)

33. Examples of Strategies to Model and Train Executive Function • Break long-term projects into clearly defined subtasks and give each a time frame (PL) • Use an analogy of a roadmap. Identify the destination. Visualize the path needed to reach the destination (PL) • When making a plan, include the amount of time involved for each step (TM). • Identify likely distractors, diversions, and roadblocks and how they may impact schedule and time estimates (TM).

34. Examples of Strategies to Model and Train Executive Function • If a young person is unable to establish goals, offer a menu of choices for what they might want to work toward (GDP) • Make the goal real and visible as possible with images or experiences (GDP) • Make measures of progress visible (GDP) • Embed questions designed to elicit self-evaluation or self-assessment (M) • Ask, “How did you solve that problem?” and “Can you think of another way of doing that?” (M)

35. Examples of Strategies to Model and Train Executive Function • Make tasks short • Make steps explicit • Make tasks closed-ended • Build in variety or choice

36. The Adolescent Brain – and Adverse Childhood Experiences • Reframing child – and parent – wellbeing • Trauma-informed care • Call to Action: Addressing Toxic Stress and Health Disparities across the Lifespan

37. Recommended Resources - Brain Development • Harvard University Center on the Developing Child http://developingchild.harvard.edu/

38. Recommended Resources – Learning Executive Function • Dawson, Peg and Richard Guare. 2010. Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention 2nd Ed. Guilford Press: New York.

39. Where We’ve Been • TUNE My Life 1.0 • Observations • If adults love it… ask yourself if you’re on the right track • If adults review and critique it… ask yourself if kids will accept it • If adults direct action from it… ask yourself if anybody is still in the room

40. TUNE My Life 2.0 • Key Messages • Multiple Choices • Guided Self-interpretation • Resources • Incorporate Health Literacy • Demonstrate Cultural and Linguistic Intelligence and Sensitivity

41. Reproductive Life Plans

42. Where We’re Going: Project LIFECOURSE • Brain Development + TUNE My Life = Executive Function • Look to the Future: Implementing the Key Messages as program activities • Steering Committee • Reaching Youth, Improving Life Course Outcomes

43. Where Will YOU Go?

44. Where Will YOU Go? • Is there something about this session you will apply? • Is there something you will research or think about further? • Are you interested in joining a steering committee?

45. THANK YOU! • kathy.karsting@nebraska.gov