Healthy Child Development: An Integrated Policy Approach

1. Healthy Child Development:An Integrated Policy Approach 2011 Governor’s Conference on Public Health Charles Bruner, PhD Debra B. Waldron, MD MPH April 5, 2011

2. Why We’re Here • A mother brings her one-year old in for a check-up and it’s clear that the mom is stressed, if not depressed, and shows little sign of responding to the child’s cues for attention. While the child isn’t “diagnosable” today, if things proceed as the health practitioner expects, in two years there will be significant indicators of development delay and likely social and emotional problems, including a DSM-IV diagnosis. The health practitioner does not want to wait two years to take action and the mom seems receptive to receiving help. At the same time, pointing out problems without offering help could be considered malpractice.

3. Healthy Child Development – A Life Course Approach Protective Factors Risk Factors Children’s Health and Development Improving the trajectory of child health and development involves increasing protective factors and reducing risk factors -- which requires a broad definition of child health services. Age 0 Our Children’s Health: Our Nation’s Wealth

4. Improving Healthy Child Development: Beyond Bio-Medical Care • Fostering resiliency • Strengthening protective factors • Eliminating “toxic stress” • Addressing social determinants of health • Achieving health equity

5. Factors Contributing to Healthy Child Development • Child’s own biological factors/genetics (20%) • Bio-medical care and treatment of physical health conditions (10%) • Child’s social environment and health behaviors (50%) • Child’s physical and economic environment (20%) SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000

6. Health is dependent on • A GOOD START- Genes, food, water, shelter, air, housing, space, safety, transport, behavior and lifestyle • A GOOD FUTURE- Education, skills, work, income, self esteem • GOOD CARE - Life skills, health care, community services, government policy • GOOD SUPPORT - Parents, family, friends, social connections • These influences are known as the determinants of health- social, economic and environmental factors that determine whether or not we enjoy good health and well being.

7. From Neurons to Neighborhoods: The Science of Early Childhood Development CORE CONCEPTS OF DEVELOPMENT 1. Human development is shaped by a dynamic and continuous interaction between biology and experience. 2. Culture influences every aspect of human development and is reflected in childrearing beliefs and practices designed to promote healthy adaptation. 3. The growth of self-regulation is a cornerstone of early childhood development that cuts across all domains of behavior. Jack P. Shonkoff and Deborah A. Phillips, Editors; Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families

8. Epigenetics - definition Changes in gene activity (expression) without affecting the basic structure (code) of the gene Gene stays the same, but doesn’t do what was programmed • Gene can be • silenced - preventing gene expression • enhanced - increase gene expression • changed; transmitted to next generation. Some changes can be reversed

9. Critical Windows In Defining Epigenetic Patterns • Both intrauterine environment & early postnatal life are critical windows in developmental plasticity. • Highly susceptible to adaptation towards its environment whether a response to chemical or social stresses • In a poor intrauterine environment the fetus may enhance postnatal survival by optimizing the growth of key body organs to the detriment of other organs and mechanisms. • Molecular changes that occur as a consequence of early life exposures are thought to be mediated to a greater or lesser extent by persistent changes in gene expression. • Increasing evidence suggests that epigenetic mechanisms are involved in long term programming of gene expression.

10. The Particular Need for Health Equity • Discrimination affects healthy births and child’s constitution • Discrimination affects access to bio-medical care • Discrimination (including institutional racism) affects social supports and contributes to toxic stress • Discrimination affects family environment and availability of resources • Discrimination affects neighborhood safety and exposure to toxins

11. Healthy Development Disparities by Race/Ethnicity: U.S.

12. Select Healthy Development Disparities in Iowa (2008 or 2009) White AfAm Hisp. Low birthweight 6.3% 11.8% 7.0% Late/no prenatal care 24.2% 44.1% 43.9% Teen (15-19) birth rt 2.8% 9.6% 9.0% Children in poverty 13.0% 41.1% 31.6% Single parent fams. 28.2% 71.0% 43.8% Below basic 4th gr. Rd 28% 51% 47% Foster placement/1000 7.3 44.9 10.7 Sources: National Center for Health Statistics; U.S. Department of Health and Human Services. National Center for Educational Statistics; U.S. Census Bureau. Red indicates very significantly higher than national average.

13. The Importance of Health Equity to Iowa’s Children Percent of Iowa Population of Color and/or Hispanic by Age in 2008 Source: United States Census Bureau, 2008 American Community Survey

14. The Role of the Child Health Practitioner in Healthy Child Development Physical health and development • No undetected hearing or vision problem • No chronic health problems without a treatment plan • Immunizations complete for age • No undetected congenital anomalies Emotional, social and cognitive development • No unrecognized or untreated delays Family’s capacity and functioning • Parents knowledgeable about child’s physical health status and needs • No unrecognized maternal depression, family violence, or family substance use • No undetected early warning signs of child abuse or neglect

15. Primary Health Care Practice Implications to Achieving Outcomes • Physical health: Bio-medical care • Parenting information and education: Anticipatory guidance • Developmental surveillance and screening for social determinants • Effective referrals and follow-up services to address medical and trans-medical needs • “Medical home”/”Medical neighborhood”/”Community health system”

16. Exemplary Programs Supporting Healthy Child Development ABCD Assuring Better Child Health & Development Connecticut’s Help Me Grow program

17. Common Framework for Exemplary Programs • Child health practitioner training and support for comprehensive well-child visits with developmental screening/surveillance • Follow-up actions to respond to needs/opportunities through care coordination/case management • Connections to community resources to address needs and connect back with primary care

18. 1. Pediatric Practitioner Training/Developmental Surveillance “Do you have questions about how your child is learning, behaving, or developing?” 2. • Telephone Care Coordination • Schedule Appointments • follow-up assessment • professional services • community supports • Provide Feedback and Follow-up • Community • Child Health Liaison • identify and update resources for care coordination • investigate and follow-up with care coordinator for specific families • develop networks across providers and community resources 3. Part C Child Mental Health Parenting Educa-tion Home Visiting Head Start Domestic Violence Shelter Peer Support Group for Grand-parents Church Family Night Program Parent of Children with ADHD Group Hispanic Resource Center Parents Anony-mous Schematic Representation of Comprehensive Approach

19. The Role of Medicaid (and hawk-i) – Where Children are Served Iowa’s Medicaid and SCHIP Program -Enrollees as Percent of Child Population 40.1% 12.6%

20. Federal Opportunities for Action • Demonstration Initiatives • Community transformation grants • Health innovation zones • Pediatric quality care organizations • CHIPRA outcome demonstration grants • Medicaid • Expanded reimbursement for primary care services • Adult coverage to 133% and new opportunities for improving parental nurturing • Private health coverage • Incorporation of Bright Futures guidelines within all private coverage

21. Iowa Initiatives and Planning Structures on Which to Build • Early ACCESS • EPSDT Outreach Workers • Project LAUNCH • First Five • Health Improvement Partnership and Help Me Grow Planning • Off to a Good Start Coalition • Child Mental Health Reform

22. PI CHI – Partnership to Improve Child Health in Iowa • December 7-8, 2010, Iowa AAP along with Iowa Dept of Education-Early ACCESS, hosted a meeting to discuss the importance of monitoring the overall health of children in Iowa and how Improvement Partnerships can be involved and how they can leverage work already done in other states on many different child health concerns. • Attendees: Diverse group of colleagues from Child Health Specialty Clinics, Early ACCESS, children’s hospitals, state/government agencies, & family advocacy/support groups. • Special guests: • Vermont Child Health Improvement Partnership (VCHIP) • National Improvement Partnership Network (NIPN) • Judith Shaw, EdD, MPH, RN, VCHIP Executive Director • Paula Duncan, MD, FAAP, Youth Health Director, VCHIP, Clinical Professor of Adolescent Medicine, Department of Pediatrics, University of Vermont

23. PI CHI – Partnership to Improve Child Health in Iowa • Discussion on Improvement Partnerships covered why IPs are important to our work of monitoring overall child health and why we need a structure to monitor in Iowa. • Improving the Quality of Health for Iowa’s Late Preterm Infants included presentations and group discussions • Additional topics: EPSDT, Bright Futures and Adolescent Medicine.

24. Next Steps for Iowa • Build upon what we have and know: scale-up/diffuse exemplary practice • Coordinate and collaborate • Take advantage of federal and state opportunities • Track results and reinvest savings • Carpe diem

25. Contact Information Charles Bruner, Director Child and Family Policy Center 505 5th Street, Suite 404 Des Moines, IA 50309 cbruner@cfpciowa.org Relevant reports and publications: The Healthy Child Story Book(www.cfpciowa.org) Federal Health Reform and Children’s Healthy Development (www.buildinitiative.org) Clinical Health Care and Community Building Approaches to Closing Disparities in Child Health (www.cfpciowa.org)

26. Debra B. Waldron, MD, MPH American Academy of Pediatrics, Iowa Chapter, Vice President Iowa Department of Public Health- Division of Health Promotion & Chronic Disease Prevention, Medical Director University of Iowa Carver College of Medicine Clinical Associate Professor Child Health Specialty Clinics, University of Iowa, Iowa City Medical Director

27. Life Course 4 Key Concepts Today’s experiences and exposures influence tomorrow’s health. (Timeline) Health trajectories are particularly affected during critical or sensitive periods. (Timing) The broader community environment–biologic, physical, and social –strongly affects the capacity to be healthy. (Environment) While genetic make-up offers both protective and risk factors for disease conditions, inequality in health reflects more than genetics and personal choice. (Equity)

30. Health Across Lifetimes & Generations

34. Fetal Programing Developmental plasticity enables the organism to change (i.e. re-program) structure and function in response to environmental cues. Adaptive significance is that plasticity enables a range of phenotypes to develop from a single genotype depending on environment factors. Fetus makes adaptations through programming to “prepare” for postnatal environment in response to signals.

35. Plasticity in Developmental Programming