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Infant Mental Health RoundsInfant Mental Health RoundsSocial Pediatrics Social Pediatrics

-- The History, The FutureThe History, The Futureyy

Feb. 2, 2010,TorontoFeb. 2, 2010,TorontoElizabeth Lee Ford-JonesProfessor of PediatricsThe Hospital for Sick ChildrenUniversity of Toronto

Declaration of DisclosureDeclaration of Disclosure

I have no actual or potential conflict of I have no actual or potential conflict of interest with this program. interest with this program.

I also assume responsibility for ensuring the I also assume responsibility for ensuring the scientific validity, objectivity, and scientific validity, objectivity, and completeness of the content of my completeness of the content of my presentation. presentation.

Learning ObjectivesLearning Objectives

1. Summarize over1. Summarize over--representation of disadvantaged families representation of disadvantaged families in our disease management system.in our disease management system.

2. Summarize child poverty data/ranking in international 2. Summarize child poverty data/ranking in international comparisonscomparisonscomparisonscomparisons

3. Indicate how social pediatrics is embedded in the SDOH and 3. Indicate how social pediatrics is embedded in the SDOH and informed by new neuroscience of EB3D and Right to Healthinformed by new neuroscience of EB3D and Right to Health

4. Reflect on the intersection of early child learning and care 4. Reflect on the intersection of early child learning and care with health equity. with health equity.

1. History of Social Medicine2. Current rationale3 F k3. Framework4. At the crossroads

Recognition of Social Context fundamental to pediatric care

since inception…

Abraham Jacobi (1830-1919)

Father of Pediatrics1st Professor of Diseases of Children (Columbia)1st President of American Pediatric Society, AMA sectionFocal Point of all pediatric thought and teaching

( b il d) ’s milk h i t m ts i k ts- raw (unboiled) cow’s milk, hygiene, tenements, rickets- did hundreds of tracheostomies for diphtheria

Father of Pediatric Social Medicine

“ It is not enough to work at the individual bedside in the hospital…(influence) school boards, health department, legislature, advisor to judge and jury, seat in council.”

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Father of Pathology was also the Father of Social Medicine Father of Social Medicine …

History of Social MedicineHistory of Social MedicineVirchow (1821-1902)

Father of PathologyCell theory (every cell originates from a like cell)First to reco nize leukemiaFirst to recognize leukemiaNode - Large left SC node early sign of GI

malignancyTriad - Mechanism of pulmonary embolism

Father of Social MedicineAs politician, worked to improve health of Berlinersincluding water and sewage systems

“Disease never purely biological, often socially derived”

Pediatric Training in the 1970’s…

Home visits with Pediatricians in the community- with Pediatricians in the community

- as part of Home Care rotations - aboriginal communities

QUESTION: Have any of you been Housing like this?

Homeless Children in TorontoHomeless Children in TorontoAnnually > 3000 Toronto children in shelters- homeless WCFV- motel strip (commonly without kitchen…) Impact…e.g. School

Absent ++ prior to shelter Transfer of school records limited. Limited school support

… AND elevated cortisol and EB3D!

Decter, Kidbuilders Report, October, 2007

All medicine is inescapably social…

Leon Eisenberg, Urban Health, 1999

”need a community-side manner…”

Holtz, PLoS, 2006

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And appreciation for difficulty of lives comes from lived experience…

But in 2005, 75% of U.S. medical students ,from the top two quintiles Jolly P. Diversity of U.S. medical students by parental income. . Association of 

American Medical Colleges website, http://www.aamc.org/data/aib/aibissues/aibvol8_no1.pdf. accessed Dec. 17, 2008.

Sickkids Pediatrician-in-Chief Dr. Denis Daneman

Type I Diabetics Type I Diabetics with HbAIC > 10

Refractory to traditional and research interventions

Health outcomes intimately involved with reality: Health outcomes intimately involved with reality: -- macromacro--environment environment societalsocietal, , communitycommunity, and , and institutionalinstitutional-- micromicro--environment environment intraintra and and interpersonalinterpersonal

Other SickKids Specialists note:Admissions to the ICU

Asthma- lack of recognition of early signs, supervision of meds, (both parents work, has variable care givers); $$ for meds Diabetic Ketoacidosis- not receiving insulin; mother deceased, dad working

Issues for our Kidney Specialists- ability to get to clinic appointments (no TTC fare etc.) ability to get to clinic appointments (no TTC fare etc.) - ability to pay for meds, monitoring e.g. urine dipsticks, BP, special diet (salt, protein)

Issues for our Advisory Neurologist - delay to diagnosis- access to medications often on LT anticonvulsants- access to early intervention services

- in theory, should be equal access regardless of SES- in practice, parents of higher SES get treatment faster

GETTING BACK TO CLINIC APPOINTMENTS IS BIG PROBLEM… no work, no pay

We are“hitting the wall in our treatment”

of medical conditionsof medical conditions

Sick Kids findings are based on a comparison of the red and blue areas (i.e., ‘high poverty’ neighbourhoods)

with the white and yellow areas.

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Summary for SickKids PatientsChildren, families from high poverty neighbourhoods constitute:

56% of Admissions62% of Total Length of Stay

extra 1.6 day LOS (7.6 vs 6.0)63% of Total Weighted Cases63% of Total Weighted Cases

extra 0.5 case intensity (2.0 vs 1.5 Resource Intensity Weighting)52% of Clinic, Emergency and Day Treatment Visits56 -64% of unplanned readmissions 60% of missed clinic visits

From only ¼ of Toronto neighbourhoods, the high poverty ones..Ted McNeill PhD

Majority of inpatients from low income neighbourhoods

- where the population growth is…

58% of Toronto children live in high poverty neighbourhoods

(defined as > 26% of families falling below the Stats Canada Low Income Cut-off Line)

Ted McNeill PhD

MostResponsibleProviderServiceDesc CasesTotal LOS

Totol Weight ALOS

Avg. RIW Cases

Total LOS

TotalWeight ALOS

Avg RIW

Adolescent Medicine 11 647 64 58.8 5.9 20 916 79 45.8 3.9

Pediatrics 1025 5862 1303 5.7 1.3 758 3824 815 5.0 1.1

Pediatric Cardiology 222 2084 801 9.4 3.6 146 1073 382 7.3 2.6

Pediatric Endocrinology and Metabolism 31 102 22 3.3 0.7 19 62 12 3.3 0.6

Pediatric Gastro-Enterology 72 1467 382 20.4 5.3 56 506 91 9.0 1.6

Pediatric Nephrology 61 592 113 9.7 1.9 60 362 72 6.0 1.2

Pediatric Neurology 81 453 100 5.6 1.2 63 204 40 3.2 0.6

Pediatric Respirology 59 608 175 10.3 3.0 51 391 76 7.7 1.5

Pediatric Rheumatology 28 203 34 7.3 1.2 18 119 33 6.6 1.8

Pediatric General Surgery 332 3538 790 10.7 2.4 328 2003 497 6.1 1.5

High Poverty Neighbourhood (120)26 – 50% Poverty

Toronto Other Neighbourhoods (380)0 – 25.9 % Poverty

Pediatric Cardiac Surgery 11 216 57 19.6 5.2 9 20 8 2.2 0.9

Pediatric Neurosurgery 119 762 246 6.4 2.1 105 693 197 6.6 1.9

Pediatric Orthopedic Surgery 290 1006 339 3.5 1.2 235 693 254 2.9 1.1

Pediatric Plastic Surgery 180 850 229 4.7 1.3 167 645 174 3.9 1.0

Pediatric Urology 79 181 74 2.3 0.9 70 174 55 2.5 0.8

Obstetrics And Gynecology 15 20 11 1.3 0.7 9 18 7 2.0 0.8

Pediatric Otolaryngology 270 568 215 2.1 0.8 238 433 160 1.8 0.7

Pediatric Ophthalmology 23 41 12 1.8 0.5 - - - - -

Pediatric Psychiatry 19 629 63 33.1 3.3 20 395 48 19.8 2.4

Pediatric Hematology 311 3354 838 10.8 2.7 193 2079 555 10.8 2.9

Neonatal-Perinatal Medicine 149 2720 838 18.3 5.6 81 1242 336 15.3 4.1

Critical Care 20 147 48 7.4 2.4 14 75 23 5.4 1.7

Grand Total 3408 26050 6753 7.6 2.0 2660 15927 3913 6.0 1.5

56% 62% 63% 44% 38% 37%

Medical Complications of PovertyBirth Outcomes

Infant mortality rate:Toronto: 70% increased risk (1996-1998)

Lowest income neighbourhoods: 7.3/ 1000Highest income neighbourhoods: 4.2/ 1000

L bi th i ht 40% (7% 4 9%)Low birth weight: 40% (7% vs 4.9%)Asthma Overweight and obesity

NLSCY (1998-99) 25% 2-11 yr olds vs 16%NLSCY (2000-01) 35% 5-17 yr olds vs 24%

Injuries intentional and unintentional2.5 X risk of injury and 4.5 X risk of death due to injury

Gupta, Paed Child Health Oct. 2007

Med Complications contMed Complications cont’’ddChildren’s Mental Health

Aggression: NLSCY age 4-11 40% vs 25%Emotional disorder-anxiety 12% vs 7%High hyperactivity scores: 20% vs 12%***Deep Poverty (> 75% below median): highest rates conduct disorders, hyperactivity and emotional disorders

Functional Health low functional health 4-11 yr. 2.5 Xrisk; also extra financial pressures in special needs children exacerbate needs

Gupta, Paed Child Health Oct. 2007

…… Low Adult Life Trajectory Poorest 1/5 vs richest 1/5 of Canadians have:

more than 2X the rate of diabetes and heart diseasenearly 2X the rate of arthritis or rheumatismmore than 3X the rate of bronchitis

358% higher rate of disability128% more mental and behavioural disorders95% more ulcers

Poverty is Making Us Sick, Wellesley Institute, Dec. 2008

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Facts about Newcomers and Child Poverty in Ontario

Overall, 1 in 3 Toronto children live in poverty(“down the mineshaft” – June Callwood)

Ontario white/Euro poverty 28%but racialized poverty 361% (1980-2000).

Poverty rates for visible minority/immigrant/aboriginal2X average rate in Canada.

Child poverty rate for newcomers is 39%

Recent ROOTS OF VIOLENCE REPORT

Roy McMurtry, Former Chief Justice of OntarioAlvin Curling December 2008-Alvin Curling, December 2008

#1 Social Exclusion#2 Racism#3 Poverty

The 3rd Era of Medicine The 3rd Era of Medicine –– Represents an Epidemiological TransitionRepresents an Epidemiological Transition

The First Era(1750-1950)

The Second Era(1950-present)

The Third Era(NOW)

Focused on acute and infectious diseaseInfectious diseases

High infant mortality rates

Increasing focus on chronic disease

But in 1980’s also Disorders ofPoor nutrition

Few cures for chronic disease

Epidemics (eg, influenza, polio)

Diseases of overcrowding

ut 980 s a so

Family dysfunction

Learning disabilities

Emotional disorder

Functional distress

Educational needs

In 1980-s-2000

Social disarray

Political ennui

New epidemics (eg, violence, HIV, crack cocaine, homelessness)

Increased survivorship

High-technology care

Disorders of Bioenvironmental InterfaceSocioeconomic influences on health, including poverty

Health disparities

Technological influences on health

Overweight and obesity

Increasing mental health concerns

Halfon and Pediatrics, 2005

Dr. D’s initiation of Dr. D’s initiation of SickKids Social Pediatrics…….SickKids Social Pediatrics…….

1. Medical student elective (20091. Medical student elective (2009--))2.Expansion of opportunities for Residents2.Expansion of opportunities for Residents

Defining Social Pediatrics…Defining Social Pediatrics…

Dr. Denis Daneman: “Care for disadvantaged”

Sweden (L Kohler): Conditions with social causes and social consequences and social consequences require special consideration

“Seeing the patient from the other side.”

Policy for Health (vs Health Policy)

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ACTION is a key element.

Changing conditionsto elevate life trajectories of socially excluded.

John Snow not known for studies of cholerabut for taking the handle off the Broad Street pump and ending epidemic cholera.

Changing conditionsto elevate life trajectories of socially excluded.

BY ACTING ON THE SOCIAL DETERMINANTS OF HEALTH

BECAUSE THEY DRIVE BRAIN DEVELOPMENT

BY THE EXPERIENCES THEY CREATE…

COHERENCE IS CRITICAL

Apply knowledge base, skill set …

*** to elevate the Life Trajectory

*** informed by EB3D, SDOH , Right to Health

- in models context-sensitive - to improve health outcomes- with recognition of gradients, universality

Poverty and socio-economic inequality (urban, rural) including young mothers“Apartment block kids” (where the population growth is) Homeless, in shelters

Aboriginal/First NationsRefugees and immigrants

In protective care i.e. foster care, group home, youth

Those taking on a caring role for parents with health problemsThose taking on a caring role for parents with health problems(psychiatric, alcohol) ± Generational Poverty

Abuse (physical, mental, sexual,neglect)Victims of violence (relatives, witnesses) Witnesses of abuse and violenceIncarcerated and children of the incarceratedSex trade workers, transgenderedGang-involved, drug using

Developmentally and/or physically delayed

New Neuroscience!New Neuroscience!

ExperienceExperience Based Brain and Based Brain and ExperienceExperience--Based Brain and Based Brain and Biologic Development (EBBiologic Development (EB33D) D)

”Neuroscience has caught up with Social Epidemiology”

Experience‐based Brain Development

from from FathersFathers to to Judges in the CourtroomJudges in the Courtroom

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The long reach of early childhood

NOT NATURE VS NURTURE

BUT NATURE AND NURTURE!

= epigenetics

Early environment powerfully influences gene expression

Skills and abilities are created…

newborn brain cells not specializedrequire specific sensory input experiences to activate genes

cause neurons to form connections, pathwayspruning and sculpting occurs “use it or lose it”

Children in fearful environments: develop vigilance parts; reset setpoints of HPA axis Children in nurturing environments: develop more pathways, synapses, dendrites

Brain development is time sensitive Brain development is time sensitive Suture kittens eyes relatively briefly

Never see

Suture adult cats eyes for same timeN blNo problem

Babies with cataracts require immediate removal in order to have visual stimuli to activate genes.

`Sensitive periods’ in early human brain development

High

LanguageConceptualization

Peer social skills`Numbers

“Pre‐school” years School years

Vision

0 1 2 3 7654Low

Years

Habitual ways of responding

Language

Emotional control

p

Hearing

Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.) 

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Synaptic (Connection) Density – experience-based

At Birth 6 Years Old 14 Years Old

Rethinking the Brain, Families and Work Institute, Rima Shore, 1997. From: Founders’ Network, slide 03-012

Your neuroscience is for everyone…1. Basic brain development, time sensitive2. Set-points for how we react3. Cortisol damages the brain

• brain is environmentally sensitive organ like lung, others

• nature + nurture/what epigenetics means

Skills and abilities are created…Children in nurturing environments

develop more pathwaysdevelop more synapsesdevelop more dendritesp

Children in fearful environmentsdevelop vigilance partsreset setpoints of HPA axis Good if you are living in the wilderness….!!

Teen Brain also under construction…

SUCCESS TO 24 YEARS (+ by 6 yr.)

Prefrontal CortexPrefrontal Cortex-- executive functionexecutive functionAnterior Cingulate Gyrus Anterior Cingulate Gyrus -- attentionattentionAmygdala and Hippocampus Amygdala and Hippocampus –– fear/flight responsefear/flight response

J. ClintonJ. Clinton

ERIC LAMAZE OLYMPIC GOLD 2008

Intrauterine/neonatal cocaineUnknown fatherRaised by alcoholic grandmother; M h I/O j ilMother I/O jailTeenage substance abuseSchool D/O in Gr. 7

"It's a long journey…you need great friends. Great people that believe in you. People that push you to come back, a 2nd or 3rd

chance to the struggling”

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ERIC LAMAZE OLYMPIC GOLD 2008

Social Skills and MentoringJob trainingJob training

"It's a long journey…you need great friends. Great people that believe in you. People that push you to come back, a 2nd or 3rd

chance to the struggling”

Social Determinants of HealthSocial Determinants of HealthHow to remember these..

“ITHELLPS”Income and foodTransportationHousingEducationLiteracyLegal needsPersonal safetySupport

Adapted from Zimmerman, Sept. 2007Pediatrics; Newacheck, Pediatrics, August, 2008

% poor health by #social risk factors i.e.low mat’l

mental health,family conflict,unsafe neighbourhood

Copyright ©2008 American Academy of PediatricsLarson, K. et al. Pediatrics 2008;121:337-344

Good response to Civil Rights, Women’s Rights, Gay Rights (GLBT)..

“RIGHT TO HEALTH”

““Right to HealthRight to Health””and 20and 20thth Anniversary Anniversary

of UNCRC signing Nov. 20,2009of UNCRC signing Nov. 20,2009(a) Comment 14 - British Medical Association(b) U.N. Convention on the Rights of the Child

24 H lth24 Health27 Standard of Living 28 Education

Canada reports every 5 years(c) Special Rapporteur e.g. Guantonamo Bay(d) Child-conscious decisions

Applying “Right to Health”, U.N Conv on Rights of the Child

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"Child Friendly City is local system of good "Child Friendly City is local system of good governance governance committedcommitted to fulfilling rights“to fulfilling rights“

(UNICEF)(UNICEF)Influence decisions about their city Express their opinion on the city they want Participate in family, community and social life R i b i i h h lth d d tiReceive basic services such as health care and educationDrink safe water and have access to proper sanitation Be protected from exploitation, violence and abuseWalk safely in the streets on their ownMeet friends and play Have green spaces for plants and animals Live in an unpolluted environment Participate in cultural and social events Be an equal citizen of their city with access to every service,regardless of ethnic origin, religion, income, gender or disability

Detractor #2 Detractor #2 LACK OF SUPPORT and LACK OF SUPPORT and DEPRESSIONDEPRESSION -- on Trajectoryon Trajectory

The Child,Youth Life TrajectoryThe Child,Youth Life Trajectory

We know that Canada is not doing well in ginternational rankings of well-being

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Child well-being (OECD) and social expenditure as % GDP 2001 Bradshaw 2006

130

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Total socialexpenditure as % GDP

40302010

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red

over

all 110

100

90

80

USAUK

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POVERTY LARGELY BEATEN IN SENIORS In 1970’s, 20% of seniors age ≥ 65 yr. in poverty

Guaranteed annual supplement to old-age-pension

By 2000 to 4%! (vs 25% in U.S.) “NORDIC SENIORS POLICY!”

CHILD POVERTY IMPROVING IN QUEBEC1998 23.8%2005 9.6%

Child Poverty in Canada

QUESTION: What is difference between Sweden and Canada?

CHILD POVERTY IS A POLITICAL DECISION

Campaign 2000, Report Card on Child and Family Poverty in Canada (2007) Innocentii, 2000

AND THE RESULT OF PROVIDING INCOME TO FAMILIES… …..REDUCED CONDUCT DISORDERS!American Indian Popn

- income intervention of opening casinoreduced child disruptive behaviour- reduced child disruptive behaviour

- parental supervision of children- parental engagement

conduct/oppositional disorders by poverty

Heckman, Ann NY Acad Sci 2008; 1136:307Costello, JAMA 2003; 290:2023

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Per Capita Health Care Spending in Various Countries in 2006, According to the Country's Relative Wealth

Iglehart J. N Engl J Med 2009;10.1056/NEJMp0901927

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Education has not been h lthe great equalizer.

What % of Ontario children are failing What % of Ontario children are failing standardized Gr. 3 literacy testing? standardized Gr. 3 literacy testing?

…roughly …roughly 47%

Failing Gr. 3 Literacy Failing Gr. 3 Literacy –– what does this mean? what does this mean?

Poor preschool/kindergarten readiness (EDI)Parents/supportEarly education and learning (EEL)Early education and learning (EEL)

High school completion20 (-50)% of local youth not completing

Future Prison Cell needs… U.S. Cities using Gr. 3 Literacy.

03‐085

How to measure Kindergarten readiness Early Development Instrument (EDI)

Physical health and well-beingSocial knowledge and competence

Communication skills, general knowledge

Emotional health/maturityLanguage and cognitive development

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EDI Results – Vancouver Districts

District Income EDI Results$ % scoring in bottom 10%

06‐030

1 12,000-24,000 34.5

2 24,000-37,000 27.53 37,000-49,000 21.54 49,000-62,000 15.05 62,000-74,000 8.5

Readiness To Learn .Senior Kindergarten Children Not Ready to Learn at School, by Health Planning Area, Toronto, 2004/05

WORDS IN AND WORDS OUT BY SESSome mothers live with so much pressure and stress they do not have the energy to talk to their children (Jody Heymann).

SES Words in(age 48 mo.)(million)

Words out (age 36 mo.)

Hi h 45 1100ch ldren (Jody Heymann).Hart, Rsisey, 1995

Question: What could be on a mother’s mind other than her children?

High 45 1100

Middle 26 700

Low 13 500

DOCTORS MAKE A DIFFERENCE!DOCTORS MAKE A DIFFERENCE!““Speak, Sing, Read/talk about picturesSpeak, Sing, Read/talk about pictures””

at office visits - books to take home- community volunteers read in

iti waiting room → book reading at home → reading in early school yrs

Zuckerman Contemp Peds 19:51 2001

Preschool Programs Preschool Programs

Age 2-5 yearsIncludes

play groups h l hild H d Snursery school, child care centres, Head Start

child development programsRecognize good preschool is one of smartest investmentsgovernments can make (economists, neuroscientists,

educators, developmental psychologists)BUT need Quality, maximizing learning and development

Why prisons instead of preschool?Why prisons instead of preschool?“Early Education instead of Prison” (prison $80,000/yr.)

Chicago Longitudinal Study Perry School/Headstart• Low income students age 3-4 yr.; 12 hr. /wk.• Follow-up at age 24 yr.

- More high school grads (71% vs 64 % p=.01)More high school grads (71% vs 64 % p .01)- More attend 4-yr. college- More employed FT (43% vs 36% p=.04)- Less serious crime (17% vs 21% p=.02), incarceration- Less depressionEmotionally nurturing environments produce more capable learners

Arch Pediatr Adol Med 2007; 161:809Arch Pediatr Adol Med 2007; 161:809

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SCHOOL IS NOT THE GREAT EQUALIZER FOR CHILDREN

Unless there is Quality preschool education and learningNutrition (breakfast, lunch)Addi i l S i l Skill liAdditional Social Skills, numeracy, literacy

Extended school day Extended school year

Sports, arts, music, dance, drama

WITH PARENTAL RESPECT AND INVOVEMENT

PROVINCIAL INTERVENTIONSACROSS THE AGES AND STAGES

Early Learning Advisory Report (Pascal)Early Learning Advisory Report (Pascal)Roots of Violence (McMurtry Curling)Our Youth Matter! (Lankin, McMurtry)

Middle Childhood Matters Coalition

Video Clip – City Hall, Toronto October, 2007

Jim Dunn, PhD CIHR Chair Applied Public HealthCIHR Chair, Applied Public Health

Need new ways of seeing and actingNeed Coherence in our endeavours…

- follow IMP lead! (Neuroscience+++)– elevate Child Life Trajectory L f r j ry- pop’n based interventions

- shift thinking upstream to SDOH

- it is about rights, not charity (Swedish Model)- “sectors without silos” approach

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NEW CONVERSATION (“A JOLT”)

return of academic medicine to historic roots

improving health of public

Ramsey, Miller. A single mission for academic medicine ‐ improving health JAMA 2009;301:1475‐76.

Solutions lie outside of the individual’s office..

but remember Kipling’s Law of the Jungle”but remember Kipling s Law of the Jungle“..the strength of the pack is the wolf….the strength of the wolf is the pack..”