David W. Willis, M.D., FAAP Director, Division of Home Visiting and Early Childhood Systems Maternal and Child Health

1. David W. Willis, M.D., FAAP Director, Division of Home Visiting and Early Childhood Systems Maternal and Child Health Bureau Health Resources and Services Administration Department of Health and Human Services Moving Beyond Adverse Childhood Experiences (ACEs) for our Next Generation: From Collective Vision to ActionFlorida Association for Infant Mental HealthOrlando, FL April 24, 2014 1

2. Take Home Messages • We are now witnessing an unprecedented opportunity for the next generation of children in our nation with the growing attention to and investments in early childhood • The word is out that building health, school readiness and social well-being for the next generation of children requires embracing the one science of early brain and child development, mitigating risk and building resiliency • Early Childhood leaders must embrace the science and a collective impact approach to lead transformation and change 2 2

3. We’re in the “building health and developmental assurance” business… Physical health Developmental health Relational health 3 3

4. A League Table of Child Well-Being Source: UNICEF, 2013 4 4

5. Factors Contributing toHealthy Child Development SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000 5

6. Life Course Drivers of Developmental Trajectories Genetic, Prenatal and Neurodevelop-mental Factors • Neurodevelopmental • Social-economic • Relational Social-economic environment Attachment and Relational Patterns (ACE Scores) Relational Health 6 6

7. An Early Brain and Child Development Focus • BUILDING HEALTH • Promoting the healthy early childhood foundations for life course health • Promoting relational health • Promoting kindergarten readiness • Mitigating toxic stress effects on health and developmental trajectories • Strengthening the systems and community supports to address the social determinants of health 7 7

8. Core Story of EBCD • Child development is the foundation for community and economic development • Brains are built over time – prenatally to young adulthood • Brain architecture is built from bottom up and requires solid foundation for future skills • The interactive influences of genes and experience shape the architecture of the developing brain • Toxic stress on the developing brain has lifelong effects on learning, behavior and health • Creating the right conditions in early childhood is more effective and far-less costly than addressing problems later on 8

9. Eco-Bio-Developmental Model Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions Epigenetics Development Learning, Behavior And Health Ecology The social and physical environment Life Course Science Through epigenetic mechanisms, the early childhood ecology becomes biologically embedded, influencing how the genome is utilized Source: Andy Garner, 2012 9

10. Critical Concepts • Childhood Adversity has Lifelong Effects • Epigenetics • Developmental Neuroscience • The Science of Early Brain and Child Development • Social Emotional Skills are learned and buffer against toxic stress Source: Andy Garner, 2013 10

11. Brain development in the social context of poverty 11

12. Significant Adversity Impairs Development in the First Three Years 100% 80% 60% Children with Developmental Delays 40% 20% 1-2 3 4 5 6 7 Number of Risk Factors Source: Barth, et al. 2008 12

13. Disparities in Early Vocabulary Growth Professional Families 1,116 words Working Class Families 749 words Welfare Families 525 words Source: Hart, B. and Risley, T. R. 2003 13

14. New Protective Interventions Significant Adversity Healthy Developmental Trajectory Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments 14 14 Source: Harvard Center on Developing Child, 2012

15. Adverse Childhood Experiences Are Common Household dysfunction: Substance abuse 27% Parental sep/divorce 23% Mental illness 17% Battered mother 13% Criminal behavior 6% Abuse: Psychological 11% Physical 28% Sexual 21% Neglect: Emotional 15% Physical 10% Source: V. Felitti, 2005 15

16. Adverse Childhood Experiences (ACEs) 16

17. Adverse Childhood Experiences Score Number of categories of adverse childhood experiences are summed … ACE score Prevalence 0 48% 1 25% 2 13% 3 7% 4 or more 7% . Source: V. Felitti, 2005 17

18. ACE Score vs. Smoking and COPD 18

19. Childhood Experiences vs. Adult Alcoholism 4+ 3 2 1 0 Source: V. Felitti, 2005 19

20. Childhood Experiences Underlie Chronic Depression 4+ 3 2 1 0 Source: V. Felitti, 2005 20

21. ACE Score vs. Intravenous Drug Use N = 8,022 p<0.001 Source: V. Felitti, 2005 21

22. Childhood Experiences Underlie Suicide 4+ 3 2 1 0 Source: V. Felitti, 2005 22

23. Childhood Experiences Underlie Chronic Depression Source: V. Felitti, 2005 23

24. Population attributable risk A large portion of many health, safety and prosperity conditions is attributable to Adverse Childhood Experience. ACE reduction reliably predicts a decrease in all of these conditions simultaneously. Source: Family Policy Council, 2012 24

25. ACEs and Head Start Head Start Children (N=50) 60% had violence exposures < 4 yrs. Mean ACE >3 Mean ACE of their Parents is >5 2/3rs of children with Positive ACE screen had one report of social-emotional development concerns (by teacher and parent DECA) Source: C. Blodgett, 2012 25

26. Source: C. Blodgett, 2012 Odds for Academic and Health Problems with Increasing ACEs in Spokane Children 26

27. ACES AMONG ALL CHILDREN 0-5 YEARS-OLD IN HOUSEHOLDS BETWEEN 0%-100% OF FPL Adverse Childhood Experiences*Among Young Children ACES AMONG ALL CHILDREN 0-5 YEARS-OLD SOURCE: National Survey of Children's Health. NSCH 2011/12 27

28. How Early Experience Gets Into the Body A Bio-developmental Framework Lifelong Outcomes Foundations of Healthy Development and Sources of Early Adversity Health-Related Behaviors Cumulative Effects Over Time Environment of Relationships Educational Achievement & Economic Productivity Gene-Environment Interaction Physiological Adaptations & Disruptions Physical, Chemical & Built Environments Nutrition Physical & Mental Health Biological Embedding During Sensitive Periods Source: Shonkoff, et al, 2009 28

29. ACEs have many impacts throughout the lifespan CRITICAL & SENSITIVE DEVELOPMENTAL PERIODS Early childhood, ages 7-9, Pre-puberty, Aging into adulthood Chronic Disease PSYCHIATRIC DISORDERS IMPAIRED COGNITION Work/School Attendance, Behavior, Performance ADVERSE CHILDHOOD EXPERIENCE MORE CATEGORIES – GREATER IMPACT Physical Abuse, Sexual Abuse Emotional Abuse, Neglect Witnessing Domestic Violence Depression/Mental Illness in Home Incarcerated Family Member Substance Abuse in Home Loss of a Parent BRAIN DEVELOPMENT Electrical, Chemical, Cellular Mass ADAPTATION Hard-Wired Into Biology OBESITY ALCOHOL, TOBACCO, DRUGS RISKY SEX GENETICS Including gender – Remember that experience triggers gene expression (Epigenetics) CRIME intergenerational transmission, disparity poverty 29 Source: Family Policy Council, 2012

30. Adversity/Toxic Stress “Social-emotional buffering is the primary factor distinguishing level of stress” Andy Garner, MD, COPACFH • Toxic stress occurs when there is an absence of social-emotional buffering • Metric for adversity is the body’s stress response system • Implications: “Toxic stress is the key intergenerational transmitter of social and health disparities” 30

31. Three Levels of Stress Response 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. Source: Center for Developing Child 2012 31

32. Positive & Tolerable Stress Source: Center on the Developing Child 2012 32

33. Toxic Stress Source: Center on the Developing Child 2012 33

34. Epigenetics Fetal Programming Early Childhood foundations of life course health “Not your parents genome” 34

35. Barker Hypothesis Birth Weight and Hypertension Source: Law CM, et al, 1993 35

36. Barker Hypothesis Birth Weight and Coronary Heart Disease Age Adjusted Relative Risk Source: Rich-Edwards JW, et al, 1997 36

37. The “limbic brain” 37

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39. The emergence of “executive function disorders” Disturbances in: Working memory Self-regulation Attention, organization, impulse control Sequencing and planning Social flexibility 39

40. Maternal DepressionAffects Infants Decreased cognitive stimulation and attachment may cause: Difficulty in developing trusting relationships Impeded growth during first year of life Lower activity level Irritability Irregular sleep and feeding behaviors Increased incidence of depression, anxiety, and attention deficit Lifelong decreased ability to handle stress 40

41. Genetics Orchid-Dandelion Hypothesis “Biological Sensitivity to Context” • Plasticity hypothesis, sensitivity hypothesis, or differential-susceptibility hypothesis • Gene x Environment Interactions • Gene variants (orchid genes) • SERT gene – depression/anxiety – 25% population • Alleles: S/S, S/L, L/L • DRD4 gene – externalizing behaviors and antisocial risk, ADHD, risk – 20% population “Risk becomes possibility” “Vulnerability becomes plasticity and responsiveness” Source: W.T. Boyce, 2008 41

42. Differential Universality On average, disadvantaged children (neighborhoods) have poorer outcomes. However, most vulnerable children are in the populous middle class. Socioeconomic Disadvantage Socioeconomic Advantage Source: C.Hertzman, 2010 42

43. Health and social problems are worse in more unequal countries • Index of: • Life expectancy • Math & Literacy • Infant mortality • Homicides • Imprisonment • Teenage births • Trust • Obesity • Mental illness – incl. drug & alcohol addiction • Social mobility Index of health and social problems 43 Source: Wilkinson & Pickett, The Spirit Level, 2009

44. Relational Health 44 44

45. The Home Visiting Program • Authorized by Title V of the Social Security Act: Maternal, Infant, and Early Childhood Home Visiting Programs (MIECHV) • $1.5 billion over 5 years • $100M FY2010 • $250M FY2011 • $350M FY2012 • $400M FY2013 • $400M FY2014 45 45

46. The Home Visiting Program • In all 50 states, DC, and 5 territories • Formula grants based on child poverty • Competitive grants in 38 states • Development grants • Expansion grants • 3 Nonprofit Organizations in FL, ND, and WY • Tribal programs • 3 percent set-aside • 25 total grants 46

47. Home Visiting Program Goals Provide voluntary, evidence-based home visiting services to improve • Prenatal, maternal, and newborn health • Child health and development, including the prevention of child injuries and maltreatment • Parenting skills • School readiness and child academic achievement • Family economic self-sufficiency • Referrals for and provision of other community resources and supports 47

48. State Selection of Home Visiting Model (April 2013) 48

49. Data Collection on Benchmark Areas • Maternal and newborn health (8 constructs) • Child injuries; child abuse, neglect, or maltreatment; emergency department visits (7) • School readiness and achievement (9) • Crime (2) or domestic violence (3) • Family economic self-sufficiency (3) • Coordination/referrals for other community resources (5) 49

50. Home Visiting Program Innovations • Collaborations and integration across health and early learning • Integrating infant mental health competencies and reflective supervision • Core competencies across models and HV networks • “Crossing the data divide” • Population management • Universal intake and assessment systems • Father engagement in Home Visiting • Early Childhood Public-Private partnerships 50 50