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
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
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.
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
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
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.
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.
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
Executive Function Inhibitory control Working memory Cognitive flexibility
Prefrontal cortex fully developed only in early 20’s.
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)
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
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
Moshe Szyf, Ph.D. McGill University, Montreal Epigenetic changes to DNA are
more or less reversible Epigenetic changes occur only in
social animals
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
These epigenetic changes have long-term, even trans-generational effects and durations.
However, they are also always open to change.
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
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?!
Unequal Life Expectancy
7 year difference between 5th% and 95% on social gradient
17 year difference in London borough of Westminster
32 year difference in Chicago
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)
Environments
Toxic exposures:e.g. mold, heavy metals, fluorocarbons
Unsafe housingLimited play and green spacesLimited convenient and affordable public
transportationAccess for children with special needs
All Needs are Equally Important
Physical needs will not be met without education, play, respect and freedom from discrimination
Children’s needs are interdependent
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)
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
National Security75% of 17-24 year olds unfit for military
serviceFail Armed Forces Qualification Test of
basic knowledge on math, literacy and problem-solving
Overweight and physically unfitMentally or emotionally unfit
Left Behind By Kindergarten:Children living in poverty average 15 IQ points below their peers.
Vocabulary at Age 3Poor children: 525 wordsWorking class: 749 wordsProfessional: 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.
An uneven startSES Difference at Start of K
-0.55
-0.22
0
0.25
0.69
-0.47
-0.17
0.27
0.7
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
lowest second third fourth fifth
Income Quintile
Stan
dard
Dev
iatio
n Un
its
Math
Reading
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
Effects Of Extreme Deprivation
Healthy Child Neglected Child
Courtesy of Dr. H.T. Chugani from the Children’s Hospital of Michigan,Wayne State University
Barker HypothesisBirth 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.
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
39Adverse Childhood Experiences (ACE) Study.
Available at www.cdc.gov/ace/index.htm
Risk Factors for Adult Substance Abuse are Embedded in Adverse Childhood Experiences
Self-Report: Alcoholism Self-Report: Illicit Drugs
0
2
4
6
8
10
12
14
16
0 1 2 3 4
Source: Dube et al, 2002 Source: Dube et al, 2005
%
ACEs
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5+
Risk Factors for Adult Depression are Embedded in Adverse Childhood Experiences
Od
ds R
ati
o
ACEs0 1 2 3 4 5+
1
2
4
3
5
Source: Chapman et al, 2004
Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences
ACEs Source: Dong et al, 2004
Od
ds R
ati
o
0 1 2 3 4 5,6 7,8
0.5
1
1.5
2
2.5
3
3.5
ACE Study FindingsCompared 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
Outcomes Associated With ACE Scores
ACEs are highly interrelated.• If experienced one ACE, 90% chance for 2nd category & 70% for
3rd.
• 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?
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
ExemplarsTraumatic 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.
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.
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
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.
Three Levels of Stress
PositiveBrief increases in heart rate, mild elevations in stress hormone levels.
TolerableSerious, temporary stress responses, buffered by supportive relationships
ToxicProlonged activation of stress response systems in the absence of protective relationships
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.
Allostastic Load
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
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
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.
Maternal Smoking?
African American White
NCHS 2002
Percent of Women Who Reported Smoking During pregnancy
9.3%
13.6%
Maternal Smoking?
African American Non-Smokers White American Smokers
Infant Deaths Per 1,000 Live Births
NCHS 2002
13.2
9.2
Prenatal Care?
0
10
20
30
40
50
60
70
80
90
100
AfricanAmerican
NativeAmerican
Hispanic Asian/PI White
Percent of Live Births with First Trimester Prenatal Care
74%
85%
74%
84%
NCHS 2002
70%
Prenatal Care?
African Americans FirstTrimester Prenatal Care
White Americans FirstTrimester Prenatal Care
Infant Deaths Per 1,000 Live Births
NCHS 1999
12.7
5.2
Prenatal Care?
African Americans FirstTrimester Prenatal Care
White Americans PrenatalCare After 1st Trimester or
None
Infant Deaths Per 1,000 Live Births
NCHS 2002
12.7
7.1
SES?
African Americans 16+ yearsof schooling
White Americans <9 years ofschooling
Infant Deaths Per 1,000 Live Births
NCHS 2002
10.2
6.8
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.
Vulnerability or ProtectionEarly 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
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
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 visitingprenatal – 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
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
Post-neonatal Infant Mortality
(per 100,000 live births,1986)
0
100
200
300
400
500
600
I II III IV V
England & Wales Sweden
Wilkinson RG. Income distribution and life expectancy. BMJ. 1992;304:165-168
Eco-Bio-DevelopmentalModel of Human Health and Disease
BiologyPhysiologic Adaptations
and Disruptions
Ecology
The social and physical
environment De
velo
pmen
tLe
arni
ng, B
ehav
ior
And
Heal
th
Life Course Science
NeuroscienceEpig
eneti
cs
The Science of
Development
Ecology becomes biology, and together they drive development across the lifespan
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
AdvocacyPediatricians 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
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
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
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
Children at risk for developmental and
behavioral problems are too often eluding
early detection
Help Me Grow is a system that builds collaboration across sectors, including
child health care, early care and education, and family
support.
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
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.