THE CHANGING FACE OF CHILD HEALTH CARE DCF Nursing Best Practices Seminar Paul H. Dworkin, MD January 6, 2012 Newington, CT

INTRODUCTION Goal of Child Health Services

OBJECTIVES Define the goal of child health services Identify key concepts in early brain development that have implications for health services delivery Identify key concepts in early child development that have implications for health services delivery Demonstrate the application of key concepts to program design

1990’s: The Decade of the Brain

The New Millennium

Center on the Developing Child at Harvard University

EARLY BRAIN AND CHILD DEVELOPMENT Proportional brain growth Neural plasticity Critical periods Sequential development Role of experience Early Brain and Child Development

Courtesy of Bruce Perry, MD, PhD PROPORTIONAL BRAIN GROWTH Early Brain and Child Development

NEURAL PLASTICITY The brain has a great deal of plasticity and can recovery from insults – the brain is always changing – it takes less time to organize the developing nervous system than to reorganize the developed nervous system “Window of opportunity” during early childhood – never permanently closes Early Brain and Child Development

From Syllabus, “Brain and Behavior,” Colorado University CRITICAL PERIODS

Brain development begins before birth; although development continues throughout life, the first three years are very important and provide a critical foundation Times in development during which a set of signals must be present for neural systems to differentiate normally – e.g., stereoscopic vision Early Brain and Child Development

Neocortex Limbic Diencephalon Brainstem Abstract Thought Concrete Thought Affiliation "Attachment" Sexual Behavior Emotional Reactivity "Arousal" Appetite/Satiety Blood Pressure Heart Rate Body Temperature Sleep Motor Regulation COMPLEXITYCOMPLEXITY Courtesy of Bruce Perry, M.D., Ph.D.

SEQUENTIAL DEVELOPMENT The brain develops sequentially Experiences need to be sequential, as well – the experiences of the child should match the development of the child – provide the “right” experiences in the “right” amounts at the “right” time in the life of a child Early Brain and Child Development

Courtesy of Bruce Perry, MD, PhD SEQUENTIAL DEVELOPMENT Practical Implications Few infants will benefit from an algebra lecture Few adolescents need to be held and rocked for hours each day Early Brain and Child Development

ROLE OF EXPERIENCE The human brain has the ability to be shaped by experience Experience, in turn, leads to neural changes in the brain – birth: 50 trillion synapses – 1 year: 1,000 trillion – 20 years: 500 trillion The remolded brain facilitates the embrace of new experiences Early Brain and Child Development

Early Brain and Child Development

HEALTH SERVICES IMPLICATIONS Early Brain and Child Development For optimal effectiveness, stimulation must begin as early as possible Stimulation during the first three years is particularly critical to ensure optimal development – “use it or lose it” – capacity at any age Stimulation must be aligned with children’s developmental stages and needs

CRITICAL CONCEPTS IN CHILD DEVELOPMENT Implications for Child Health Services

Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool Age Prenatal 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs “Ready to Learn” “School Readiness Trajectories” “At Risk” Trajectory “Delayed/Disordered ” Trajectory “Healthy” Trajectory Parent education Emotional health Health literacy Early literacy Quality ECE Appropriate discipline Poverty Inaccessible health services Family discord Graphic Concept Adapted from Neal Halfon, UCLA Center for Healthier Children, Families, and Communities Health services

Chamberlin RW. Preventing low birth weight, child abuse, and school failure: the need for comprehensive, community-wide approaches. Pediatr Rev 1992;13(2):64-71 “The most effective long-term strategy appears to be the development of a comprehensive, coordinated, community- wide approach focused on preventing low- and medium-risk families from becoming high- risk, as well as providing intensive services to those who already have reached a high-risk status.”

TargetedInterventions NUMBER OF CHILDREN FUNCTION Median High income Low income VULNERABLE Universal Curve Shift DISABLED Clinical/Individual Interventions

The Productivity Argument for Investing in Young Children James J. Heckman and Dimitriy V. Masterov

ADVERSE CHILDHOOD EXPERIENCE STUDY (ACES) Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the CDC Decade long.; 17,000 people involved Looked at effects of adverse childhood experiences over the lifespan Largest study ever done on this subject The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Lanius & Vermetten, 2009

ADVERSE CHILDHOOD EXPERIENCES Sexual abuse Emotional abuse Emotional neglect Physical abuse Physical neglect Substance abuse in home Mental illness in home Incarceration of family member Parental separation or divorce Witness violence against mother

ACES STUDY Individuals with 4 or more of the 10 ACES are: Nearly 2 times more likely to smoke cigarettes 4 ½ times more likely to engage in drug abuse 7 times more likely to suffer from chronic alcoholism 11 times more likely to abuse drugs via injection 19 times more like to have attempted suicide More likely to have health problems that put them at risk of early mortality

HEALTH SERVICES IMPERATIVES Child Development Concepts Treatment programs and services must be comprehensive, multidisciplinary, and address the multiple factors that facilitate and hinder children’s optimal development Services should address the needs of all children (e.g., the entire population), recognizing that those in greatest need will likely derive the greatest benefits – target at-risk children and families – perils of exclusive focus on CYSHCN

Child Health Services Building Blocks Universal Selective Indicated Service Integration Care Coordination Medical Home Part C (B-to-3) Title V (CYSHCN) Links to Preschool Special Ed and Special Ed (LEA) Developmental/Behavioral Surveillance & Screening Family Education /Parent & Child Counseling / Anticipatory Guidance Literacy Promotion Health Supervision Services Oral Health/Dental Home Nutritional Services Medical / Surgical Subspecialty Services Early Childhood Consultation Services Developmental / Behavioral Health Services (Mid-level, Comprehensive assessments; Treatment) Home –based Services Help Me Grow Practice Improvement System Changes Pay for Performance Reimbursement Reform (Public & Private) CT-CHQII EPIC

Child Health Services Building Blocks Family Support Services Care Coordination UNIVERSAL SERVICES (Medical Home) Child Health Services SELECTIVE SERVICES (Help Me Grow) INDICATED SERVICES Desired Outcomes for School Readiness Family Capacity and Function Emotional / Social / Cognitive Development Physical Health & Development. Early Care and Education Programs

33 Core Components Structural Requirements Centralized Telephone Access Point Community & Family Outreach Child Health Provider Outreach Data Collection & Analysis Organizing Entity Statewide Expansion Statewide Expansion Continuous Quality Improvement "Making the Connection- Help Me Grow The Connecticut Experience"

SUMMARY Knowledge of early brain development has important implications for promoting children’s optimal development – Need for early stimulation – Critical importance of first 3 years (“use it or lose it”) – Need or alignment with developmental needs Knowledge of early child development has important implications for promoting children’s optimal development – Need for comprehensive services – Should target entire population of children, especially at-risk