1 The First 1000 days: The Importance of Early Brain and Childhood Development Colleen Kraft, M.D., F.A.A.P. Professor of Pediatrics Virginia Tech Carilion School of Medicine and Research Institute Realizing the Potential of Pediatrics Disclosures • Senior Medical Officer for MajestaCare, a Medicaid Managed Care ACO • Merck Vaccines, speaker and Advisory Board • Expert Panel, Text4Baby Learning Objectives • Understand the role of toxic stress in the intergenerational transfer of health disparities; • Present an organizing, integrated, ecobiodevelopmental framework; • Discuss ways pediatricians might advocate in translating science into healthier life-courses
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The First 1000 days: The Importance of
Early Brain and Childhood Development
Colleen Kraft, M.D., F.A.A.P.
Professor of Pediatrics
Virginia Tech Carilion School of Medicine and Research Institute
– Parental Separation or Divorce 24.5% 21.8% 23.3%
– Incarcerated Household Member 5.2% 4.1% 4.7%
• Neglect*
– Emotional 16.7% 12.4% 14.8%
– Physical 9.2% 10.7% 9.9%
* Wave 2 data only (n=8,667) Data from www.cdc.gov/nccdphp/ace/demographics
1:4!
1:4!
• Severe and persistent emotional problems
• Health risk behaviors
• Serious social problems
• Adult disease and disability
• High health, behavioral health, correctional and social service costs
• Poor life expectancy
For example:
The higher the ACE Score, the greater the likelihood of :
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• Sexually Transmitted Disease
• Liver Disease
• COPD
• Ischemic Heart Disease
• Autoimmune Disease
• Lung Cancer
Higher ACE Score = significant rise in
chronic health conditions:
Effect of ACEs on Mortality
0
10
20
30
40
50
60
Pe
rce
nt
in A
ge
Gro
up
0 2 4
ACE Score
19-34
35-49
50-64
>=65
Age Group
0 ACE 60% live to 65 4 ACE less than 3% live to 65
CORE Predictive Modeling from Aetna
Mbrs who are
Top 1%
Mbrs who are
High Risk ED
Mbrs who are
Medium/High
Risk IP
A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups…
Members who are Top 1% AND high risk for an ED visit next 12 mos.
Members who are Top 1% , high risk for an ED visit, AND medium/high risk for IP admit next 12 mos.
Members who are top 1% general risk AND medium/high risk for IP admit next 12 mos.
Members who are high risk for an ED visit AND medium/high risk for IP admit next 12 mos.
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Personalize the Profile for Medical Homes Increasing Medical and Behavioral Complexity
Group 3:
•Ave age 33
•72% female
•PMPM $962
•5 ED visits, 0.2 admits
•32% asthma prevalence; 25% med adherence (asthma)
•85% MH prevalence
•58% co-occurring mental health and substance abuse
•52% with 5+ Rx classes
•5 Specialist visits
•10 PCP visits
Group 4:
•Ave age 49
•PMPM $3908
•2.6 admits
•12 IP bed days
•7 ED visits
•51% diabetes prevalence
•73% MH prevalence
•87% with 5+ Rx classes
•20 Specialist visits
•10 PCP visits
Group 6:
•Ave age 43
•PMPM $2425
•1.6 admits
•7 IP bed days
•6 ED visits
•Low medical disease prevalence
•85% MH prevalence
•62% co-occurring MH and SA
•12 Specialist visits
•9 PCP visits
3
6 4
Group 5:
•Ave age 53
•PMPM $3202
•2 ED visits
•2 admits
•10 IP bed days
•56% diabetes prevalence
•41% MH prevalence
•84% with 5+ Rx classes
•19 Specialist Visits
•7 PCP visits
5
ED Risk Only
ED Risk/IP Risk Only Top 1%/
ED Risk/IP Risk Top 1%/ IP Risk Only
Significant Adversity
Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments
Healthy Developmental Trajectory
Impaired Health and Development
Current Conceptual Framework Guiding Early Childhood Policy and Practice
Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status
Adverse Childhood Experiences
Social, Emotional, and
Cognitive Impairment
Adoption of
Health-Risk Behaviors
Disease & Disability
Early Death
Death
Birth
The True Nature of Preventive Medicine
Slide modified from V. J. Felitti
??
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Developing a Model of
Human Health and Disease
Life Course Science
Early childhood ecology
strongly associates with
lifelong developmental outcomes
What are the
mechanisms
underlying these
well-established
associations?
How do you
begin to define
or measure the
ecology?
Defining Adversity or Stress
• How do you define/measure adversity?
• Huge individual variability
– Perception of adversity or stress (subjective)
– Reaction to adversity or stress (objective)
• National Scientific Council on the Developing Child (Dr. Jack Shonkoff and colleagues)
– Positive Stress
– Tolerable Stress
– Toxic Stress
Based on the REACTION
(objective physiologic responses)
• Positive Stress
– Brief, infrequent, mild to moderate intensity
– Most normative childhood stress
• Inability of the 15 month old to express their desires
• The 2 year old who stumbles while running
• Beginning school or daycare
• The big project in middle school
– Social-emotional buffers allow a return to baseline
(responding to non-verbal clues, consolation, reassurance, assistance in planning)
– Builds motivation and resiliency
– Positive Stress is NOT the ABSENCE of stress
Defining Adversity or Stress
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• Toxic Stress
– Long lasting, frequent, or strong intensity
– More extreme precipitants of childhood stress (ACEs)
• Physical, sexual, emotional abuse
• Physical, emotional neglect
• Household dysfunction
– Insufficient social-emotional buffering (Deficient levels of emotion coaching, re-processing, reassurance and support)
– Potentially permanent changes and long-term effects
• Epigenetics (there are life long / intergenerational changes in how the genetic program is turned ON or OFF)
• Brain architecture (the mediators of stress impact upon the mechanisms of brain development / connectivity)
Defining Adversity or Stress
Critical Concept #2
Epigenetics:
• Which genes are turned on/off, when, and where
• Ecology (environment/experience) influences
how the genetic blueprint is read and utilized
• Ecological effects at the molecular level
• Stress-induced changes in epigenetic markers
Biology Physiologic Adaptations
and Disruptions
Life Course Science
Through epigenetic mechanisms,
the early childhood ecology becomes
biologically embedded, influencing how the genome is utilized
Developing a Model of
Human Health and Disease
8
Critical Concept #3
Developmental Neuroscience:
• Synapse and circuit formation are experience and
activity dependent
• Ecology (environment/experience) influences how
brain architecture is formed and remodeled
• Early childhood adversity -> vicious cycle of stress