1. Community Pediatrics: Presented by: Peter A, Gorski, M.D., M.P.A. Navigating the Intersection of Medicine, Public Health and Social Determinants of Children’s Health

2. Definition The practice of promoting the salutary and integrating the salutary and threatening social, cultural and environmental influences on children’s health and development within a community.

3. Community Pediatrics Includes:  Expanded focus beyond each child to all children  Health and development affected by family, educational, social, cultural, spiritual, economic, environmental and political forces  Synthesis of clinical practice and public health principles – children’s health in context of family, school and community  Collaboration with community partners to provide services and conditions equitably

4. Exemplars  Infant mortality  Preventable infectious diseases  Dental caries  Sedentary lifestyles  Chronic conditions  Obesity/Metabolic syndrome  Other historically adult-onset diseases  Injuries – intentional and unintentional  Violence  Exposure to environmental toxicants  Substance abuse and mental health conditions  Poverty

5. Social Determinants of Health  Life Course Perspective and Early Programming  Epigenetics  Childhood obesity and adult cardiovascular disease  Inadequate calcium and Vitamin D intake in childhood and adult osteoporosis  Childhood maltreatment and adult mental and physical health problems – e.g. depression, high C- reactive protein, inflammation and heart disease  Health care but one of several key influences on children’s health and well-being as children move through other primary systems, services and environments.

6. Brains  Built over time, from bottom up  Genes and experiences together build brain architecture and physiology (function) through “serve and return” process of relationships.  Cognitive, social and emotional development are inextricably intertwined. Therefore programs must work to protect and stimulate all levels.

7. Brain Development  Weight of brain 333 Grams at birth; 999 Grams at 2 years  Born with a finite number of neurons but connection cells (synapses) based on early experiences – e.g. language fluency  1 day old’s breathing patterns decipher and change from Mozart to Stravinsky to Mozart

8. Vulnerability Of The Fetus To Defects During Different Periods Of Development

9. Executive Function  Inhibitory control  Working memory  Cognitive flexibility  Prefrontal cortex fully developed only in early 20’s.

10. Early Evidence of Executive Function  Starts early during toddlerhood  Disruption manifest in:  undercontrolled behavior  low persistence  Inattention  Poor face processing of emotions (differentiating anger, sadness, fear)

11. Stanford Marshmallow Test  1 or 2 marshmallows – 4 minute test of patience  Long-term positive correlation with school performance, earnings, substance dependence, SES and physical health

12. Stress  Mediates development of the immune system as well as the limbic brain system; T cells and brain architecture  Creates susceptibility to infections, cancers and learning disabilities  $55,000/yr for Special Ed vs. $9,000 for reg ed

13. Moshe Szyf, Ph.D.  McGill University, Montreal  Epigenetic changes to DNA are more or less reversible  Epigenetic changes occur only in social animals

14. Michael Murray, McGill  Rat mothers who give low maternal care (licking and feeding) produce pups who are high stress reactors (epigenetic changes on their glucocorticoid receptor genes)  Not genetic  When experimentally split pup litters, proved that behavior inherited from foster mother not biological mother

15.  These epigenetic changes have long- term, even trans-generational effects and durations.  However, they are also always open to change.

16. 1998 ice storm in Quebec  Whole communities lost power and had to adapt for a month – across SES  T-cell function of 15 year olds today correspond with their mother’s stress levels while pregnant during the storm

17. Inequities in Health Status  England has abolished inequalities in access to healthcare.  Still they have gross inequalities in health  Reason: most arise from social inequalities, how they live.  What good does it do to treat people’s illnesses and send them back to conditions that made them sick?!

18. Unequal Life Expectancy  7 year difference between 5 th % and 95% on social gradient  17 year difference in London borough of Westminster  32 year difference in Chicago

19. Essential Foundations for Healthy Development  Fostering healthy relationships in the lives of children (raising social capital)  Promoting high quality learning environments and health literacy (raising educational capital)  Promoting shared prosperity and financial stability for all members of the community (raising economic capital)  Promoting healthy environments and supportive infrastructure (raising environmental capital)

20. Environments  Toxic exposures:  e.g. mold, heavy metals, fluorocarbons  Unsafe housing  Limited play and green spaces  Limited convenient and affordable public transportation  Access for children with special needs

21. All Needs are Equally Important  Physical needs will not be met without education, play, respect and freedom from discrimination  Children’s needs are interdependent

22. Income Inequality  Proxy for more profound inequalities that create unequal sense of worth, efficacy  Income matters more when other primary supports are not equitably provided Healthcare, education, childcare, transportation, workplace environment and security, collective efficacy and social cohesion (epidemiology of depression and smoking)

23. Economic Prosperity  1/3 unqualified to perform manufacturing jobs  U.S. productivity gap mirrors education gap  83% of HS students not proficient in math and reading comprehension  83% of children from low-income families at risk for not graduating, cutting earnings in half ($260,000 per drop out - cost to society) ($320,000 added to economy by every class of 20 kindergarteners who succeed)  30% of Americans hold college degree, need 60% by 2025 to remain globally competitive

24. National Security  75% of 17-24 year olds unfit for military service  Fail Armed Forces Qualification Test of basic knowledge on math, literacy and problem- solving  Overweight and physically unfit  Mentally or emotionally unfit

25. Left Behind By Kindergarten: Children living in poverty average 15 IQ points below their peers. Vocabulary at Age 3 Poor children: 525 words Working class: 749 words Professional: 1,116 words By age 4, the average child in a poor family might have been exposed to 13 million fewer words than child in a working class family and 30 million fewer words than a child in a professional family.

36. Sensitive Periods  Poor living conditions early in life (nutrition, fetal and infant growth, recurrent infections) and increased cardiovascular, respiratory and psychiatric diseases in adulthood.  LBW and risk for heart disease: hypertension, central body fat distribution, insulin resistance, metabolic syndrome and type 2 diabetes.  Dutch famine of 1944 and CHD 50 years later

37. Effects Of Extreme Deprivation Healthy Child Neglected Child Courtesy of Dr. H.T. Chugani from the Children’s Hospital of Michigan, Wayne State University

38. Barker Hypothesis Birth Weight and Coronary Heart Disease Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.

39. Adverse Childhood Experiences Physical, emotional or sexual abuse Emotional or physical neglect Growing up with family members with mental illness, alcoholism or drug problems Family violence Incarcerated family member One or no parents Parental divorce 39 Adverse Childhood Experiences (ACE) Study. Available at www.cdc.gov/ace/index.htm

40. Risk Factors for Adult Substance Abuse are Embedded in Adverse Childhood Experiences Self-Report: Alcoholism Self-Report: Illicit Drugs Self-Report: Alcoholism Self-Report: Illicit Drugs 0 2 4 6 8 10 12 14 16 01234 Source: Dube et al, 2002 Source: Dube et al, 2005 Source: Dube et al, 2002 Source: Dube et al, 2005 % ACEs 0 5 10 15 20 25 30 35 40 012345+

41. Risk Factors for Adult Depression are Embedded in Adverse Childhood Experiences Odds Ratio ACEs 012345+ 1 2 4 3 5 Source: Chapman et al, 2004

42. Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences ACEs Source: Dong et al, 2004 Odds Ratio 012345,67,8 0.5 1 1.5 2 2.5 3 3.5

43. ACE Study Findings Compared with people with no ACES, those with 4 or more ACES were… Twice as likely to smoke, 7x as likely to be alcoholics, 6x as likely to have had sex before age 15, twice as likely to have cancer or heart disease 12x more likely to have attempted suicide Men with 6+ ACEs were 46x more likely to have injected drugs than men with no history of adverse childhood experiences

44. Outcomes Associated With ACE Scores ACEs are highly interrelated. If experienced one ACE, 90% chance for 2 nd category & 70% for 3 rd. Therefore developed ACE score for cumulative stress. Clear dose-response relationship between stressors and adverse health outcomes up to 50 years later. All of the 10 most common causes of death in America. – In other words, should we treat this 70 year old woman as a diabetic and hypertensive? Or, can we conceptualize her problems as childhood sexual abuse, chronic depression, morbid obesity, diabetes, hypertension, & coronary artery disease?

45. ACE Study Findings  For those with 7+ ACEs, even when they didn't smoke or drink & weren't overweight, they still had 360% higher risk of heart disease than those with 0 ACEs.  Somehow the traumatic experiences of early childhood had a negative effect on their health through a pathway that had nothing to do with risky behaviors. Source: Adverse Childhood Experiences (ACE) Study. Available at www.cdc.gov/ace/index.htm

46. Exemplars  Traumatic early childhood events and CAD, CPD, CA, alcoholism, depression, drug abuse.  Child maltreatment, adult depression and inflammation associated with cardiovascular disease  Discrimination, racism, weathering, chronic activation of neuroendocrine stress reactivity - > progressive health disparities with age.

47. Life Course Problems Related to Early Life Experiences

48. The Cumulative Embedding of Experience into our Biology Over Time

49. Racial and Ethnic Disparities in Birth Outcomes: A Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Maternal Child Health J. 2003;7:13-30.

50. Poverty Sickens Strong connections between child health and adult health Between child wealth and adult wealth Between child wealth and adult health – Regardless of child’s health condition – Regardless if social class changes from childhood to adulthood Childhood poverty gets biologically embedded

51. Health by Social Class Marmot MG, Smith GD, Stansfeld S et al.Health inequalities among British civil servants: the Whitehall II study. Lancet 1991;337:1387-1393.

52. 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

53. Normal Stress Response: Allostasis Maintain Stability through Change McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

54. Allostastic Load McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

56. Social Pathogens  Neighborhood violence  Isolation – relationships, transportation  Dysfunctional schools  Child maltreatment  Family chaos  Absent parents  Poverty – Social Gradient/Social Inequalities  Food deserts and energy dense caloric intake  Unequal access to healthcare

57. Racial & Ethnic Disparities Stress and CRH in Pregnancy

58. Genetics?

59. Birth weight distribution of African-born blacks is more closely related to US-born whites than to US-born blacks David RJ, Collins JW. Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997 Oct 23;337(17):1209-14.

60. Behavior?

61. Maternal Smoking? NCHS 2002 Percent of Women Who Reported Smoking During pregnancy 9.3% 13.6%

62. Maternal Smoking? NCHS 2002 13.2 9.2

63. Prenatal Care?

64. Percent of Live Births with First Trimester Prenatal Care 74% 85% 74% 84% NCHS 2002 70%

65. Prenatal Care? NCHS 1999 12.7 5.2

66. Prenatal Care? NCHS 2002 12.7 7.1

67. SES?

68. NCHS 2002 10.2 6.8

69. Prenatal Stress & Programming Of The Brain Prenatal stress (animal model)  Hippocampus  Site of learning & memory formation  Stress down-regulates glucocorticoid receptors  Loss of negative feedback; overactive HPA axis  Amygdala  Site of anxiety and fear  Stress up-regulates glucocorticoid receptors  Accentuated positive feedback; overactive HPA axis Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain. J Neuroendocrinol 2001;13:113-28.

70. Epigenetics

71. Vulnerability or Protection  Early gene-environment interactions may shift from adaptive to maladaptive and pathogenic as environment changes –  e.g. intrauterine under nutrition, energy- sparing metabolic changes may create susceptibility if early childhood environment becomes energy abundant, carbo rich plus sedentary lifestyle

72. Psychophysiological Mechanism  Low self-control, self-efficacy and self-esteem together cause a cascade of toxic stress that destroys brain receptors, ability to fight infection, inflammation and increase all-cause mortality.  Mental health is root of physical health  Social justice affects mental health

73. I matter I belong I can

74. Investment of the State of Florida during difficult stages of childhood

75. Quality Early Care and Education Pays Off: Cost/Benefit Analyses Show Positive Returns $2 $6 $8 $4 $10 $3.23 Abecedarian Project (early care and education aged 0-5) $5.70 Nurse Family Partnership (home visiting prenatal – age 2 for high risk group) Perry Preschool (early education age 3-4) Total Return per $1 Invested Data Sources:Heckman et al. (2009)Karoly et al. (2005) Break-Even Point 0 $9.20 Graph Courtesy: Center on the Developing Child at Harvard University

76. Public Investment in Children by Age

78. Why Target Whole Communities?  Health and well-being of each person depends on condition of all  Cannot predict individual course based on group risk factors without considering the social context  Cost burden of case-finding and treatment too high  Moral weakness of accepting unequal outcomes

79. Post-neonatal Infant Mortality (per 100,000 live births,1986) Wilkinson RG. Income distribution and life expectancy. BMJ. 1992;304:165-168

80. Determinants of Health

81. EcoBioDevelopmental Eco-Bio-Developmental Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions Ecology The social and physical environment Development Learning, Behavior And Health Life Course Science Neuroscience Epigenetics The Science of Development Ecology becomes biology, and together they development drive development across the lifespan

82. Partnering with Public Health  Have always served as beacons for public health dangers  Reporting illness patterns, hazards and risky trends  Reciprocally, pediatricians benefit from population-based information on programs, especially preventive services:  Injury prevention  Child maltreatment prevention  Lead poisoning  Tobacco control  Breastfeeding promotion  Obesity prevention  Asthma  Trauma  Disaster preparedness

83. Advocacy  Pediatricians advocated strongly for passage of ACA and for the needs of children (who do not participate in government)  Legislative advocacy training in Pediatric Residency programs  Need for financing models for accountable care organizations and other practices to bill for attention to social determinants

84. Population Approach to Child Health  Delivers information about early childhood development for all children in community  Moves focus from the individual to the entire community to make a bigger difference  Provides opportunity to “shift the curve” for the whole population  Assesses over time how the community’s cumulative efforts are impacting children’s development

85. Recommendations  Increase use of community data about social determinants (EDI and ECRI)  Partner with public health departments and school districts, child welfare agencies to decrease barriers to health and health care in communities  Disseminate information about effective community programs and resources for children’s health and well-being  Promote preventive health strategies at individual and population levels  Engage with primary settings and resources for children’s health and development

86. Recommendations continued…  Advocate for universal access to medical homes  Advocate for universal access and quality of the social, economic, educational and environmental capital resources for children’s health  Speak out – use the media  Pediatric medical education and continuing medical education should include curricula on community and public health, social determinants of health, health care systems and financing, child advocacy

88. TECCS A National Partnership between UCLA Center for Children, Families and Communities and United Way Worldwide Pioneering a new way of gathering critical information about young children's school readiness, neighborhood by neighborhood, and helping communities use it to advance early childhood system building

89. Early Development Instrument (EDI)

90. Patience, Persistence and the Long View. Planting Date Trees

91. “I’d rather be dead than singing ‘Satisfaction’ when I am 45.” Mick Jagger, DOB 1943

92. All Children Need and Deserve (Emotional Foundation for Healthy Development) To feel connected To feel valued To feel they make a difference Antonovsky (1984). The sense of coherence as a determinant of health. Rutter (1979). Protective factors in children’s responses to stress and disadvantage. Erikson (1959) Growth and crises of the healthy personality.

93. “Few are guilty, but all are responsible.” Rabbi Abraham Heschel