Disclosure 8/11/2014. Tales of Early Brain and Child Development, Toxic Stress, and Marshmallows

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1 Tales of Early Brain and Child Development, Toxic Stress, and Marshmallows KAAP Fall CME Meeting; September 12 th, 2014 Kathryn Ellerbeck, MD, MPH, FAAP Center for Child Health & Development Disclosure I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of any commercial product/device in my presentation. 3 1

2 Brain Hero! watch?v=s31hdbebgg4 Policy Statement January 1, 2012 Orientation Use the 2012 Policy Statement to unpack the pizza boxes - AAP s Child Health Priorities Do two quick class activities Explore the Baby Buffer Website 2

3 Overview Epigenetics David Barker and Michael Meaney Early Brain and Child Development ACE study, Toxic stress, the EBD Framework Poverty and Child Health Translating the Science Children, Adolescents and the Media HP2020 Social Media Grant Objectives Be able to define toxic stress and describe two mechanisms for how toxic stress damages the developing brain. Discuss the health and public policy implications of the Adverse Childhood Experiences (ACE) study. State at least 3 recommendations to the pediatric community from the 2012 AAP Policy Report on Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician. Developmental Outcomes of Health and Disease (DOHaD) Barker Hypothesis Programming refers to process (often epigenetic) by which early environmental stimuli (e.g. nutrition, excess fetal glucocorticoid exposure) alter how genes are expressed throughout the lifetime. Best described in fetal period with effect of prenatal nutrition=> adult cardiovascular health (Barker hypothesis) Besides nutrition, high levels of stress hormones and maternal exposure to social stressors associate with poverty known to play a role in adult chronic disease. 3

4 Allostatic Load Stress and the Individual Mechanisms Leading to Disease Bruce McEwan, PhD, Eliot Stellar, PhD. Arch Int Med., 1993 Allostatic load is defined as the cost of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or chronic environmental challenge that an individual reacts to as being particularly stressful. Michael Meaney Stress and Epigenetics Showed that differences in rats mothering style results in behavioral and biologic differences in adult rats. Demonstrated reversible, early life epigenetic modifications of genes by DNA methylation leading to behavioral characteristics in response to stressors. The Adverse Childhood Experiences (ACE) Study Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study Vincent J. Felitti, MD, FACP, Robert D. Anda, MD, MS, Dale Nordenberg, MD, David F. Williamson, MS, PhD, Alison M. Spitz, MS, MPH, Valerie Edwards, BA, Mary P. Koss, PhD, James S. Marks, MD, MPH Am J. Preventive Medicine 1998: 14 (4) 4

5 Activity Find your ACE Score Instructions: Please calculate your ACE score *Not to be shared ACE Study Almost 2/3 of study participants had at least 1 ACE; of those 87% had experienced > 2 types. More than 1/5 study participants reported > 3 ACE. 1/6 people had an ACE score of > 4. 1/9 people had an ACE score of > 5. Lifespan Perspective The ACE Study Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy Felitti,et al. Am J Prev Med,1998 5

6 Molecular Scars Epigenetics Mechanisms BDNF,TrkB,Polyamines,5-HTT HPA axis malfunction SCIENCE NEWS, Nov 3, 2012 Poverty and ACEs Evans G, English K. The Environment Of Poverty: Multiple Stressor Exposure, Psychophysiological Stress, and Socioemotional Adjustment. Child Development, 73, 4 (2002) Number of Multiple Stressors Poverty n (%) Middle-income n (%) 0 5 (3) 15 (13) 1 30 (18) 58 (69) 2 44 (25) 28 (24) 3 32 (19) 5 (5) 4 31 (19) 10 (7) 5 20 (12) 2 (2) 6 6 (4) 0 (0) Mean level of multiple stressors The Early Catastrophe: The 30 Million Word Gap by age 3 by age three, the professors children had heard thirty million more words (total words, not unique words) than the children growing up in poverty. 6

7 Poverty and Brain Development Luby J, et al. The effects of poverty on childhood brain development: The mediating effects of caregiving and stressful life events. JAMA Pediat 2013 Dec 1: 167 (12): Poverty has been well established in research to be linked to developmental delays in young children, but the biomedical connection has not been clear. Left hippocampal volume may be mediated by supportive parenting and reduced stressful life events. While reducing poverty might be the best way to reduce povertyrelated developmental problems, it is not as feasible as intervening early in supportive ways for vulnerable children. Stress and Brain Architecture There are abundant GC receptors in the amygdala, hippocampus and PFC. Exposure to high level of stress shown to alter size and neuronal architecture of these areas. Chronic stress results in hypertrophy and over activity of amygdala and loss top-down control as result of PFC atrophy as well as impaired memory and mood control as a consequence of hippocampal reduction. Summary: Critical Concepts Developmental Neuroscience Brain architecture is experience dependent Ecology (environment/experience) influences how brain architecture is formed and remodeled. Decreased cellular remodeling (plasticity) limits remediation. Early childhood adversity -> vicious cycle of stress. Stress can cause potentially permanent changes to brain architecture and function. Source: Andrew Garner, MD. Chair, AAP Leadership Workgroup on Early Brain and Child Development 7

8 Summary: Critical Concepts Epigenetics Epigenetics refers to which genes are turn on and off and when and where. Ecology influences how the genetic blueprint is read and utilized. Stress induces changes in gene expression. Genes may load the gun, but the environment pulls the trigger. Source: Andrew Garner, MD. Chair, AAP Leadership Workgroup on Early Brain and Child Development What s a Pediatrician To Do? Pediatric providers are uniquely qualified and placed to assist in translating recent advances in developmental science into effective interventions for the home, the clinic, and the community It is essential that innovative and practical strategies continue to be developed that strengthen the capacity of the medical home to reduce sources of toxic stress and mitigate their impact on the lives of young children. Policy Statement: Recommendations Recommendation #1: Adopt the Ecobiodevelopmental Model Recommendation #2: Teach the science of toxic stress Recommendation #3: Adopt more proactive role in educating public Recommendation #4: Advocate for new evidence-based interventions Recommendation #5: Strengthen the medical home re: toxic stress 8

9 The Ecobiodevelopmental Model Ecobiodevelopmental Model Toxic Stress National Scientific Council on the Developing Child has proposed a conceptual taxonomy of 3 distinct types of stress responses on the bases of differences in their potential to cause enduring physiologic disruptions. EdzLis&list=PLyJcqMAI9Y msueaa938u UzNsVHkq1Ob 9

10 Social-Emotional Buffering: Attachment Refers to the bond that forms in time between an infant and a caregiver Becoming attached is the core work of infancy The toddler seeking autonomy relies on secure parental ties a secure base. Experimental paradigm: The Strange Situation Disorders of attachment may result from inconsistent caregiving, and occur more often in stressed families Social-Emotional Buffering: Executive Function EF refers to higher order cognitive processes that underlie flexible goal-directed behaviors Includes: Inhibitory control, working memory, and set shifting The parent child relationship appears to play an important role in children s developing selfregulatory capacities/ef Bernier, Whipple & Carlson,

11 Activity The marshmallow test Instructions: Take one marshmallow You can either wait or eat it now If you wait until we get through part of this talk, you will get another marshmallow The Marshmallow Test What do marshmallows have to do with it? A Lifespan perspective What do marshmallows have to do with it? 11

12 Focus on education and economics James J. Heckman is the Henry Schultz Distinguished Service Professor of Economics at The University of Chicago, a Nobel Memorial Prize winner in Economics, and an expert in the economics of human development. Needed: Focus on ACE and health outcomes Andrew Garner, MD 95% of the trillions of dollars that we spend on health is on treatment and NOT prevention Science Does Not Speak for Itself: Translating Child Development Research Assumption that science has a role to play in advising policymakers on crafting responses to complex social problems, including those affecting children. Child development professionals and scientists often reluctant to participate and not good at communicating science Need to build a rigorous science of knowledge translation and practices for knowledge transfer from research to policy Need to focus on not just economic outcomes, health outcome and burden of chronic disease. 12

13 Technical Report: January 1, 2012 The Lifelong Effects of Early Childhood Adversity and Toxic Stress WHERE TO START? Number and complexity of threats to child health associated with toxic stress is daunting. Call for bold, creative leadership and the selection of strategic priorities for focused attention Science suggests that 2 areas are particularly ripe for fresh thinking: the child welfare system and the treatment of maternal depression. Social Media Technology and brain development D. Christakis, MD, MPH Seattle Children s Research Institute Text4Baby Cellular phone-enhanced Home Visitation/Parenting Program Judith Carta, PhD, et al. KU Juniper Gardens Children s Project AAP HP2020 Baby Buffer Project Objectives: Healthy People 2020 Grant Health Communication and Social Media 1. Educate pediatricians about toxic stress 2. Develop materials to help practices recruit parents of young children into the Baby Buffer Program 3. Develop age appropriate messages to push out to parents weekly 4. Develop content (blog, reading library) for parents with specific tools for positive parenting 5. Evaluate the Program and its potential for wider dissemination 13

14 How is Baby Buffer different? 1. There is some evidence that social media may be effective in reaching even high risk populations. 2. As your child s trusted provider your prescription of and willingness to talk about positive parenting practices can be powerful. 3. There will be emphasis on the why based on brain science. 4. There will be emphasis on the how to based on evidence-based positive parenting practices. Collaborative Partners/Potential Funders Community Collaborators: Barbara and Bob Unell / Daniel Brenner Family Education Center Digital Evolution Group Addington Designs, Inc. Potential Funders: DEMDACO Foundation Ewing Marion Kauffman Foundation Hall Family Foundation Regnier Family Foundation Content/Health Literacy Cathy Smith, Ph.D. Rene Jamison, Ph.D. Barbara/Bob Unell Kathy Ellerbeck, M.D. Mel Hudelson 14

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