1. Material developed by the American Academy of Pediatrics
Building Better Brains: The Core Story of Early Brain and Child Development (EBCD)
This is the first in five modules about Early Brain and Child Development. During this session, you will gain a broad understanding of early brain development and some of the factors that affect it.
Name of Presenter
Material developed by the American Academy of Pediatrics
Revised: August 2018

2. Objectives Participant will be able to
Define the critical elements of Early Brain and Child Development (EBCD)
Describe factors that shape the developing brain
Identify specific actions to take to promote EBCD
During this session, you will gain a better understanding of what Early Brain and Child Development is as well as what shapes the developing brain and what we can do as professionals to support children and families. Each module after this will offer you a chance to dig deeper into some of the topics we explore during this session.

3. Our Agenda
“Virtually every aspect of early human development, from the brain’s evolving circuitry to the child capacity for empathy, is affected by the environment and experiences that are encountered in a cumulative fashion, beginning in the prenatal period and extending throughout the early childhood years.”
Neurons to Neighborhoods
National Research Council, Institute of Medicine, Committee on Integrating the Science of Early Childhood Development; Shonkoff JP, Phillips DA, editors. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: The National Academies Press; 2000:6
The research on brain development shows that environment and experiences together build to support children’s healthy development, and that the period from conception through the early years is the most impactful.
National Research Council, Institute of Medicine, Committee on Integrating the Science of Early Childhood Development; Shonkoff JP, Phillips DA, editors. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: The National Academies Press; 2000:6

4. Our Agenda
“It’s all about nurturing relationships. Early relationships build their brains and our future.”
Andrew Garner, MD, PhD, FAAP Chair, AAP EBCD Leadership Workgroup ( )
Ultimately, this interplay between experience and environment is impacted by nurturing relationships. As discussed throughout this presentation and all of the modules that follow, the relationships in a child’s life define their development and their future.

5. Why is ECBD Important?
The brain is hard wired for social, emotional, intellectual and developmental trajectories by the age of 5
What happens early affects all aspects of a child’s development
Nurturing relationships in the early years are critical
First 1,000 days have a profound impact
Source: Center on the Developing Child at Harvard University Website. Accessed on July 19, 2018.
Work in neuroscience, molecular biology genomics tells us the following:
The brain is hard wired for social, emotional, intellectual and developmental trajectories by the age of 5
Early relationships, environments, and experiences affect all aspects of a child’s development
Nurturing relationships with parents/caregivers in the early years are critical
The first 1000 days from pregnancy to 2 years is a time period that can have a profound impact on a child’s growth and development
Note to trainer: consider sharing
Center on the Developing Child at Harvard University Website. Accessed on July 19, 2018.

6. Why is ECBD Important?
Executive function supports children’s later success
Toxic stress has a negative impact on a child’s development
Early interventions are critical for optimal life course outcomes
Source: Executive Function & Self-Regulation. Center on the Developing Child at Harvard University Website. Accessed on July 16, 2018.
Executive function is the ability to retain and manage a wide range of information and apply it to multiple or complex tasks while not getting distracted. It is not innate, but the potential to develop it is, so working with families and caregivers to build these skills in children can make a significant impact on their later success.
Toxic stress has a negative impact on a child’s development. Significant adversity can produce physiological disruptions or biological “memories” that can undermine the development of the body’s stress response systems and affect the developing, brain, cardiovascular system, immune system ad metabolic regulatory controls
Early interventions are critical for optimal life course outcomes because these physiological disruptions can persist far into adulthood and lead to lifelong impairments in both physical and mental health
Executive Function & Self-Regulation. Center on the Developing Child at Harvard University Website. Accessed on July 16, 2018.

7. Why Early Experiences Matter
Note to trainer: Depending on the amount of time available, you may remove this slide.
The brain grows rapidly during the first three years of life both in weight, size, and capacity.
Plasticity varies across all brain areas.
IsaacMao. Brain Accessed June 16, 2018.

8. Early Brain Development
Born with lifetime supply of neurons
Synapses form based on early experiences
Mind is fine tuned to the world children inhabit
Birth
3 Years
15 Years
Myelination is important because it increases the speed of conduction and occurs sequentially by region. Motor and sensory development (muscles, vision, etc) begins before birth and is complete by 12 months of age. The prefrontal cortex which includes executive function (attention, organization, and impulse control) is not fully myelinated until early adulthood.
Synaptogenesis or Branching happens when neurons form connections through synapses sequentially and by region.
Synaptic Sculpting occurs at the highest density at 1 year of age. Overproduction leads to pruning. The visual areas of the brain (motor/sensory) peak at 4 months and decline until stable at preschool age. The prefrontal cortex, where control for executive function resides, peaks at 1 year and declines until it stabilizes in adolescence or early adulthood.
As you can see from the brain scan on this slide synaptic sculpting is significant in the first two years. And growth is not as rapid from 24 months to 5 years.
The brain is the ultimate “use it or lose it” machine. More than 1 million new neural connections are formed every second. By the age of 20, pruning reduces the number of neural connections to 500 trillion.
Brain Image Scan :Dean, D.C., O’Muircheartaigh, J., Dirks, H. et al. Brain Struct Funct (2015) 220: Accessed August 28, 2018

9. The Biology of Health
The architecture of the brain depends on the mutual influences of the following:
Genetics
Environment
Experience
Source: National Scientific Council on the Developing Child. The Timing and Quality of Early Experiences Combine to Shape Brain Architecture: Working Paper # Accessed June 16, 2018.
The architecture of the brain depends on the mutual influences of the following:
Genetics: Genetics supply a basic plan for brain development. It provides the structure for the brain’s architecture and supplies the means for interconnecting nerve cells within and across circuits.
Environment: The environment that the brain has to develop in has a profound influence in shaping the capacity of the brain. This begins prenatally with brains needing an abundant supply of nutrients. An adverse prenatal environment can actually alter the genetic plans.
Experience: Experience refers to the interaction the child has with his or her environment. Healthy and stimulating experience results in brain architecture that is able to operate at its full genetic potential.
Persistent adversity, also referred to as toxic stress, leads to week brain architecture with impaired capabilities.
National Scientific Council on the Developing Child. The Timing and Quality of Early Experiences Combine to Shape Brain Architecture: Working Paper # Accessed June 16, 2018.

10. Note to trainer: Depending on the amount of time available, you may remove this slide.
As shown in this graph, The early years are a time when effortless brain development occurs in response to the child’s experiences, but as a child grows and becomes an adult, the amount of effort they need to exert to continue to develop new skills or knowledge and connections in the brain is exceedingly greater.
The brain is constantly changing. It takes less time, intensity, and repetition to organize developing neural systems than to reorganize the developed neural systems. Thinking critically about the earliest years of a child’s life takes advantage of an opportunity to overcome early adversity and build a child’s resiliency.
Source: "The Challenge: The Ability to Change Brains and Behavior Decreases Over Time." Conceptual graph created by Pat Levitt in collaboration with the Center on the Developing Child at Harvard University (2009) and published in From Best Practices to Breakthrough Impacts: A Science-Based Approach to Building a More Promising Future for Young Children and Families (2016). Accessed June 16, 2018.

11. Executive Functioning
Includes:
Working Memory
Mental Flexibility
Self-control
Executive Function & Self-Regulation. Center on the Developing Child at Harvard University Website. Accessed on July 16, 2018.
Impacts:
School readiness
Math and reading competence
Job productivity
Positive relationships
Overall quality of life
Diamond A. Executive functions. Annu Rev of Psychol. 2013; 64: doi: /annurev-psych
While thinking about how the brain functions, it’s important to think about executive function. Some have said that executive function and social and emotional skills are more important for school success than basic cognition. That’s because a child can’t learn if they cannot remember what they are taught, adjust to different learning environments, and exhibit the necessary self-control to participate and engage in lessons.
The Center for the Developing Child uses the metaphor of an air traffic control system for executive functioning. That’s because it is what is required for children to be able to:
Remember and follow instructions
Avoid distractions
Adjust to changes
Be persistent
Manage and organize large amounts of information and apply it over time
Develop good work habits
It involves a child’s working memory, mental flexibility, and self-control. It impacts a child’s school readiness, math and reading competence, job productivity when they are older (including whether they can find and keep a job), positive relationships with others, and overall quality of life.
Executive function is a key part of a child’s resilience. This concept will be discussed in greater depth during the module on the Adverse Childhood Experiences Study.
Note to trainer: consider sharing: (5:35)

12. The Foundations of Health
Stable and responsive environment and relationships
Safe & supportive physical environments
Appropriate nutrition
Source: Lifelong Health. Center on the Developing Child at Harvard University Website. Accessed on July 19, 2018.
The biology of health explains how experiences and environmental influences interact with genetic predispositions which result in various combinations of physiological adaptation and disruption that can affect lifelong health, mental well-being, learning and behaviors. This highlights the importance of understanding and addressing the early childhood origins of lifelong illness and disability.
The foundations of health are three domains that provide a context within which the early roots of physical and mental well-being are nourished. These are:
A stable and responsive environment of relationships
Safe and supportive physical, chemical and built environments
Appropriate nutrition
The first 1000 days, as noted earlier is a window of opportunity that can greatly influence later health and the ability to grow and learn. Helping build a strong foundation in the 1st 1,000 days is key to building better brains and futures.
Now let’s take a deeper dive into these concepts.

13. Stable & Responsive Environments
Provide consistent, nurturing and protective interactions with adults
Positive relationships can serve as social emotional buffers
Source: Center on the Developing Child at Harvard University Website. Accessed on July 19, 2018.
Stable and responsive environment of relationships provide a child with consistent, nurturing and protective interactions with adults that enhance their learning and help them develop adaptive capacities that promote well-regulated stress response. These positive relationships can serve as social/emotional buffers. With sufficient levels of social emotional buffering, the stress response can be either positive (and actually build resilience), or tolerable (and result in no sustained changes).
With insufficient levels of social-emotional buffering, the physiologic stress response is sustained or severe and becomes toxic, resulting in potentially permanent alterations to the epigenome, brain structure, and behavior.

14. Physical Environments
Safe & Supportive
Physical Environments
Safe places to learn
Places free of toxins
Places that nurture and support families
Source: Center on the Developing Child at Harvard University Website. Accessed on July 19, 2018.
Children need safe places to play and learn. They need places that are free from toxins and fears so that they can explore without significant risk of harm. Families need places that support them in raising healthy children. Children need environments where they can be nurtured.
There are sensitive periods of brain development – greatest time of brain plasticity is during the last trimester of pregnancy and the first two years of life.
Note to trainer: consider adding video (9:12)

15. What shapes the developing brain?
Early environments and experiences have an exceptionally strong influence on brain architecture. After most neural circuits in the brain have matured, their genetic plans and architecture can still be modified by experience, but the extent of these modifications tends be far more limited. This means that what happens early has a unique advantage in shaping the architecture of developing brain circuits before they are fully mature and stabilized.
Note to the trainer: This diagram was developed based on a number of sources including:
Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.
Sameroff A. A unified theory of development: a dialectic integration of nature and nurture. Child Dev. 2010;81(1):6–22.
National Research Council, Institute of Medicine, Committee on Integrating the Science of Early Childhood Development; Shonkoff JP, Phillips D, eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington DC, National Academies Press; 2000.
Published in: Shonkoff JP, Garner AS, American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-e246. doi: /peds
Shonkoff JP, Garner AS, American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-e246. doi: /peds

16. How Does Life Course Science
Impact Children?
Life course science looks at an individual’s development over time, considering the various risk factors they face and the protective factors that support them. Essentially, the more children have protective factors to push against risk factors, the more likely they are to have a positive developmental pattern of growth. Therefore genetics and environment work together to set a path for a child’s development and the relationships they have to promote those protective factors can set the stage for important development and growth.
Source: Lu M, Halfon N. Racial and ethnic disparities in birth outcomes: a life course perspective. Matern Child Health J 2003; 7(1):13-30.
Lu M, Halfon N. Racial and ethnic disparities in birth outcomes: a life course perspective. Matern Child Health J 2003; 7(1):13-30.

17. Shaping the Capacity of the Brain
The interactive influences of genes and experiences shape the architecture of the developing brain
Brains are built from the bottom up
Sources: Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.
Sameroff A. A unified theory of development: a dialectic integration of nature and nurture. Child Dev. 2010; 81(1): 6–22. doi: /j x.
National Research Council, Institute of Medicine, Committee on Integrating the Science of Early Childhood Development; Shonkoff JP, Phillips DA, editors. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: The National Academies Press; 2000.
The interactive influences of genes and experience literally shape the architecture of the developing brain and the active ingredient is the “serve and return” nature of children’s engagement in relationships with their parents and other caregivers in their family and community.
We will talk more about serve and return and it’s influence on brain development as we explore the next few modules. Note that it is the interaction between child and the environment which supports brain development; this is particularly relevant for cognition and language development.
Both brain architecture and developing abilities are built from the bottom up with simple circuits and skills providing scaffolding for more advanced circuits and skills over time.
Sources:
Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.
Sameroff A. A unified theory of development: a dialectic integration of nature and nurture. Child Dev. 2010;81(1):6–22.
National Research Council, Institute of Medicine, Committee on Integrating the Science of Early Childhood Development; Shonkoff JP, Phillips D, eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington DC, National Academies Press; 2000.

18. Impact of Early Stress Hyper-responsive stress response; calm/coping
CHILDHOOD STRESS
TOXIC STRESS
Hyper-responsive stress response; calm/coping
Chronic “fight or flight;” cortisol / norepinephrine
Stress is a critical part of life. Without any form of stress, children would not form the capacity to cope with challenges. There are several forms of stress – positive or tolerable stress is the kind of stress that most people endure. A critical component of each are the supports in a child’s life that make the stress manageable. Toxic stress is the form of stress that can have significant, negative impacts on child development.
Toxic stress in early childhood shapes the capacity of the brain. Toxic stress is associated with persistent effects on the nervous system and stress hormone systems that can damage developing brain architecture and lead to lifelong problems in learning, behavior, and physical and mental health.
Changes in Brain Architecture
Garner A, Saul R. Thinking Developmentally. Itasca, IL: American Academy of Pediatrics; 2018.

19. Early Stress
This picture demonstrates how early stress can change brain architecture.
Source: Perry BD. Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture. Brain and Mind 2002; 3(1): doi: /A:

20. Development: Dance Between Nature and Nurture
Development results from an on-going, re-iterative, and cumulative dance between nurture and nature. Creating the right conditions for early childhood development is likely to be more effective and less costly than addressing problems at a later age. Ultimately, the positive, nurturing relationships in a child’s live can impact their developmental progression, and, in turn, impact their opportunities for the future.
From Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 4th ed.: Modified with permission from Garner A, Forkey H, Stirling J, Nalven L, Schilling S; American Academy of Pediatrics, Dave Thomas Foundation for Adoption. Helping Foster and Adoptive Families Cope With Trauma. Elk Grove Village, IL: American Academy of Pediatrics; Accessed July 19, 2018.

21. What Can We Do?
91% of children under 6 had a well-child visit in 2013, up from 83% in 2006.
25.9% of infants, toddlers, and preschoolers re in center-based child care settings, the next most common contact with a formal service system.
In addition to the data presented here, it’s important to be aware of the inequities that exist for young children and families data show that Hispanic children (86%) are less likely than white and black children (92%) to have be current in their well-child visits. The degree of parental education also impacts well child visits – 79% of children of parents with less than a high school degree are current on their well child visits while 96% of children with college degree or higher are current. Children with at least one foreign-born resident parent are also less likely to receive well child visits (86% to 92%).
Younger children are more likely to receive well child visits – 92% children under two are current as compared to 89% of children 4-5 years old.
Child care numbers also indicate differences by race, socioeconomic status, and mother’s education and employment status.
Source: Well-Child Visits. Child Trends Databank Website. Updated October Accessed July 16, 2018.
Child Care. Child Trends. Updated May Accessed July 16, 2018.

22. Review a child’s history,
The AAP’s periodicity schedule for recommended preventive health care services provides several opportunities for primary care pediatricians to promote early brain development as well as assess for development, behavioral, and social-emotional concerns.
This graphic from the American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and Bright Futures Steering Committee’s recommendations for preventive pediatric health care shows some of the EBCD related items that are already taking place. As you can see here, the well child health visit is an opportunity to
Review a child’s history,
Conduct developmental screening and surveillance,
Conduct psychosocial/behavioral assessment,
Screen for lead, and
Use anticipatory guidance to discuss child and family strengths and challenges.
Source: American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and Bright Futures Steering Committee. (2017). Recommendations for preventive pediatric health care. Itasca, IL: Author. Retrieved from:
Recommendations for Preventive Pediatric Health Care. Bright Futures/American Academy of Pediatrics. Updated February Accessed July 16, 2018.

23. Examples for Promoting EBCD
The First 1,000 Days:
Examples for Promoting EBCD
Consistent with
Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, 4th ed.
Explore the Child’s environment
Build relationships/reciprocity
Cultivate development
Develop parenting confidence
The more we do within the first 1,000 days of a child’s life, the more we can support a child’s resilience and ability to develop and grow
Source:
Additional Resource is:
Source: Accessed July 2018

24. First 1000 days are not so much about what to DO …
Take Home Messages
First 1000 days are not so much about what to DO …
Not ordering a specific methylation test
Not giving a specific standardized screen
Not referring to a specific resource
(although all of these may be appropriate)
…More about what to SEE!
It’s really about skilled, intentional observation and information-gathering first and foremost.
Note to trainer: Consider sharing for more information.

25. Developing a Shared “VISION”
Toxic Stress
It’s like a snake!
It’s like a straw fan!
It’s like a tree trunk!
Ultimately, to make sure that we take advantage of those first 1000 days and set the stage for a child’s development throughout the first 5 years of life, we have things upside down and our system needs to change. To try and change things, we need to develop a shared vision.
We can’t do it alone – we need partnerships between pediatricians, health departments, child protective services, early education and child care, and others. However, we need to play a role at each level. How do we bring people together? Maybe this elephant can give us the answer…
There is a proverb about 3 blind men that experience an elephant differently.
Note to the trainer: click on the slide.
The first man says “An elephant is like a straw fan” because he experienced the tail.
The second man says “No, an elephant is like a tree trunk” because he experienced the legs.
The third man says “No, an elephant is like a snake” because he experienced the trunk.
Childhood adversity is like this in that it is interpreted differently. When all of the perspectives come together, they are better able to understand what it is.

26. Take Home Messages
This is not to say that if bad things happen there are necessarily long term negatives.
This is not to say that if bad things happen there are necessarily long term negatives.
Protective interventions such as consistent supportive relationships with caring adults and supportive environments, like high quality childcare and early intervention programs, can serve as buffers and mitigate or lesson the effects of adverse childhood experiences.

27. Take Home Messages
Change the LENS we use to PRIORITIZE how we use our limited time w/ families:
- Use an ecobiodevelopmental framework
- Understand life-course theory and developmental trajectories
- Know the biological threats to healthy life courses
- Identify/address environmental risks early
- Whenever possible, proactively build wellness
We are not asking clinicians to do something dramatically different or extended with the limited time they have with families. Rather, we’re asking to change the “lens” to make the best use of that time to address priorities.

28. Early Childhood Education
Promote the Five R’s of
Early Childhood Education
Reading together as a daily family activity
Rhyming, playing, talking, singing, & cuddling together often
Routines & regular times for meals, play, & sleep, which help child know what they can expect and what is expected of them
Rewards for everyday successes, realizing that praise from those closest to a child is a very potent reward
Relationships that are reciprocal, nurturing & enduring are the foundation of healthy child development
Creating the right conditions for early childhood development is likely to be more effective and less costly at a later age
What can you do? Help promote the Five R’s of early childhood. They may seem simple, but implementing these behaviors and approaches at home can have profound consequences for children’s lives. For example, daily reading together and regular bedtime were two practices found in the most successful families in one study.
Note to the trainer: Consider sharing
Source: American Academy of Pediatrics. Policy Statement– The Pediatrician’s Role in Optimizing School Readiness. Retrieved from pediatrics.aappublications.org/content/138/3/e
Additional Reference for dialing reading and regular bedtime: Kelly, Y., Kelly, J., and Sacker, A. (2013). Time for bed: Associations with Cognitive Performance in 7-year old children: A Longitudinal Population-Based Study. Journal of Epidemiol Community Health. 67. pp
AAP Council on Early Childhood and AAP Council on School Health. The Pediatrician’s Role in Optimizing School Readiness. Pediatrics. 2016;138(3):e doi: /peds

29. It is easier to build strong children than to repair broken men.
Take Home Messages
It is easier to build strong children than to repair broken men.
Frederick Douglass
It’s all about relationships and how we use them to support children while their brains are in the most critical stage of development.

30. Questions?