Neil W Boris, MD Irving Harris Training Director, Florida State University Center for Prevention and Early Intervention Policy

Neil W Boris, MD Irving Harris Training Director, Florida State University Center for Prevention and Early Intervention Policy

Professor (Public Health and Medicine), Researcher Focus on Early Childhood and Preventive Intervention Clinician (all ages) but especially <5yo

It is easier to build strong children than to repair broken men. Frederick Douglass

CLINICAL CASE VIDEO CANNOT DISTRIBUTE

Case enrolled at one of our Early Childhood Supports and Services Programs in LA* D. came to us in 2/08 at almost 4.5 years old MaGM was primary caregiver; child protective services had placed him with her At 24 months, D. sustained liver laceration, ruptured spleen, fractured ribs after being kicked by Mo s BF BF sentenced to jail *IT IS AN INCREDIBLE GIFT THAT MOTHER AGREED TO LET ME PRESENT HER STORY

Chief Complaint: he s all over the place ; doesn t listen. Fights, hits and curses others; withdrawn from Head Start because of aggressive behavior In Pre-K was suspended for urinating on another child and impulsive aggression

January 2012 issue of Pediatrics, the American Academy of Pediatrics (AAP) called on "the entire pediatric community to catalyze fundamental change in early childhood policy and services. Greater focus on those interventions and community investments that reduce external threats to healthy brain growth."

Repeated adverse experiences, such as child abuse or neglect, parental substance abuse and maternal depression -- that cause strong, frequent, or prolonged activation of the body s stress response systems in the absence of the buffering protection of a supportive, adult relationship.

https://www.youtube.com/watch?v=l mvwoe1ky8s&spfreload=10

Policy statement: Garner, Andrew S., Shonkoff, Jack P., Siegel, Benjamin S., Dobbins, Mary I., Earls, Marian F., McGuinn, Laura, & Wood, David L. (2012). Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics, 129 (1), 224-231. Technical report: Shonkoff, Jack P., Garner, Andrew S., Siegel, Benjamin S., Dobbins, Mary I., Earls, Marian F., McGuinn, Laura, & Wood, David L. (2012). The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics, 129 (1), 232-246.

The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences over the lifespan. (~18,000 participants) Conducted by a group at Kaiser Permanente led by Vincent Felitti, M.D. https://www.cdc.gov/violenceprevention/ac estudy/

Abuse by Category Psychological (by parent) Physical (by parent) Sexual (by anyone) Household Dysfunction by Category Substance Abuse Mental Illness Mother Treated Violently Imprisoned Household Member

Abuse by Category Prevalence of positive response Psychological (by parent) 11% Physical (by parent) 11% Sexual (anyone) 22% Household Dysfunction by Category Substance Abuse 26% Mental Illness 19% Mother Treated Violently 13% Imprisoned Household Member 3%

Smoking Obesity Physical Inactivity Depression Suicide Attempt Alcoholism Illicit Drug Use Injected Drug Use 5+ Sexual Partners History of STDs Cancer

How does self-reported exposure to adverse childhood experiences relate to major health outcomes?

R e l a t i v e R i s k 14 12 10 8 6 4 2 0 0 1 2 3 4+ ACE SCORE Attempted suicide Injected drug use Alcohol problem Illicit drug use Depressed Chronic bronchitis 50+ sex partners STDs Poor Self-rated health Current Smoker Cancer Severe obesity

Early Death Disease & Disability Adoption of Health Risk Behavior Social, Emotional, & Cognitive Impairment Adverse Childhood Experiences

Burke-Harris, 2009

https://www.ted.com/talks/nadine_burke_har ris_how_childhood_trauma_affects_health_a cross_a_lifetime http://www.newyorker.com/magazine/2011/0 3/21/the-poverty-clinic Paul Tough (2016): Helping Children Succeed: http://paultough.com/helping/

Critical & Sensitive Developmental Periods Chronic Disease Psychiatric Disorders Impaired Cognition Adverse Childhood Experience MORE CATEGORIES GREATER IMPACT Brain Development Electrical, Chemical, Cellular Mass Adaptation Hard-Wired Into Biology Work/School Attendance, Behavior, Performance Obesity Alcohol, Tobacco, Drugs Genetics Experience triggers gene expression (Epigenetics) Source: Family Policy Council, 2012 Intergenerational Transmission, Disparity Poverty Crime Risky Sex

>30-year Follow up of the Carolina Abecedarian Project (ABC) High-Quality Preschool Disadvantaged children randomly assigned to treatment have significantly lower prevalence of risk factors for cardiovascular and metabolic diseases in their mid-30s. The mean systolic blood pressure among the control males is 143 mm Hg, whereas it is only 126 mm Hg among the treated. One in four males in the control group is affected by metabolic syndrome, whereas none in the treatment group are affected.

1. Pediatric Practice 2. Community-based Early Intervention

We re trying to emphasize that much more important than just listening to a baby s heart is listening to a baby s brain, Robert W. Block, M.D., of Tulsa, Okla., past president of AAP 1. Assessing Parent-Child Interactions 2. Uncovering Family Stressors

Lifetime health is more strongly tied to social factors than to unrecognized medical problems. In the 10 minutes I have with the family Does my stethoscope really have a role?

Since the last time I saw you (your child) has anything really scary or upsetting happened to you (your child) or anyone in your family? Screen for family violence, maternal depression, child stress

A 2-question brief screener has similar detection for maternal depression as longer questionnaires During the last 2 weeks have you often been bothered by feeling down, depressed or hopeless? During the last 2 weeks have you been bothered by having little interest or pleasure in activities? Olson, AL et al (2002) Pediatrics. 110 (1169-76)

BEHAVIORAL Aggression Poor regulation of emotions Inattention/hyperactivi ty PHYSICAL Overeating or hoarding food Insomnia Nightmares

Florida State CPEIP: http://floridatrauma.org/trauma-braindevelopment.php AAP: http://www.aap.org/en-us/advocacy-andpolicy/aap-health-initiatives/healthy-fostercare-america/documents/guide.pdf National Child Traumatic Stress Network: http://www.nctsnet.org Harvard Center on the Developing Child: http://developingchild.harvard.edu

Mental Illness Family Violence Substance Abuse Practitioner

https://www.youtube.com/wa tch?v=uru-a_fss5y

PICTURE OF FAMILY CANNOT DISTRIBUTE

Braverman, P & Barclay, C. Health disparities beginning in childhood: A life-course perspective. Pediatrics; 124:S163, 2009. (available free as fulltext online) Campbell et al.,early childhood investments significantly boost adult health, Science, 343 (6178): 1478-1485, March 28, 2014.

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