Healthy Child Development:An Integrated Policy Approach

2011 Governor’s Conference on Public Health

Charles Bruner, PhDDebra B. Waldron, MD MPH

April 5, 2011

Why We’re Here

A mother brings her one-year old in for a check-up and it’s clear that the mom is stressed, if not depressed, and shows little sign of responding to the child’s cues for attention. While the child isn’t “diagnosable” today, if things proceed as the health practitioner expects, in two years there will be significant indicators of development delay and likely social and emotional problems, including a DSM-IV diagnosis. The health practitioner does not want to wait two years to take action and the mom seems receptive to receiving help. At the same time, pointing out problems without offering help could be considered malpractice.

Healthy Child Development – A Life Course Approach

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Risk FactorsRisk Factors

Protective Protective FactorsFactors

Improving the trajectory of childhealth and development involvesincreasing protective factors and reducing risk factors -- which requiresa broad definition of child health services.

Our Children’s Health: Our Nation’s Wealth

Improving Healthy Child Development: Beyond Bio-Medical Care

Fostering resiliency Strengthening protective factors Eliminating “toxic stress” Addressing social determinants of

health Achieving health equity

Factors Contributing to Healthy Child Development

Child’s own biological factors/genetics (20%)

Bio-medical care and treatment of physical health conditions (10%)

Child’s social environment and health behaviors (50%)

Child’s physical and economic environment (20%)

SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000

Health is dependent on A GOOD START - Genes, food, water, shelter, air,

housing, space, safety, transport, behavior and lifestyle

A GOOD FUTURE - Education, skills, work, income, self esteem

GOOD CARE - Life skills, health care, community services, government policy

GOOD SUPPORT - Parents, family, friends, social connections

These influences are known as the determinants of health- social, economic and environmental factors that determine whether or not we enjoy good health and well being.

CORE CONCEPTS OF DEVELOPMENT

1. Human development is shaped by a dynamic and continuous interaction between biology and experience.

2. Culture influences every aspect of human development and is reflected in childrearing beliefs and practices designed to promote healthy adaptation.

3. The growth of self-regulation is a cornerstone of early childhood development that cuts across all domains of behavior.

From Neurons to Neighborhoods: The Science of Early Childhood Development

Jack P. Shonkoff and Deborah A. Phillips, Editors; Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families

Epigenetics - definition•Changes in gene activity (expression) without affecting the basic structure (code) of the gene

•Gene stays the same, but doesn’t do what was programmed

•Gene can be silenced - preventing gene expression

enhanced - increase gene expression

changed; transmitted to next generation. Some changes can be reversed

Critical Windows In Defining Epigenetic Patterns

Both intrauterine environment & early postnatal life are critical windows in developmental plasticity.

Highly susceptible to adaptation towards its environment whether a response to chemical or social stresses

In a poor intrauterine environment the fetus may enhance postnatal survival by optimizing the growth of key body organs to the detriment of other organs and mechanisms.

Molecular changes that occur as a consequence of early life exposures are thought to be mediated to a greater or lesser extent by persistent changes in gene expression.

Increasing evidence suggests that epigenetic mechanisms are involved in long term programming of gene expression.

The Particular Need for Health Equity Discrimination affects healthy births and

child’s constitution Discrimination affects access to bio-

medical care Discrimination (including institutional

racism) affects social supports and contributes to toxic stress

Discrimination affects family environment and availability of resources

Discrimination affects neighborhood safety and exposure to toxins

Healthy Development Disparities by Race/Ethnicity: U.S.

White Non-Hispanic

Black Non-Hispanic Hispanic

Health Outcomes

Low Birth Weight 7.2% 13.4% 6.8%

Elevated Blood Lead Levels (0-5 year-olds) 2.6% 4.3% 3.1%

6-11 year-olds Overweight 11.8% 19.2% 23.7%

Health Service Access

Lack of Regular Source of Care 3.3% 5.8% 24.1%

Incomplete Immunizations (19-35 month-olds) 16.7% 25.5% 21.3%

Education Outcomes

Below Basic 4th Grade Reading 22% 54% 50%

Below Basic 8th Grade Math 18% 53% 45%

Non-completion of High School 21.4% 48.8% 46.8%

Other Outcomes

Foster Care / 1,000 4.9 15.8 6.5

(20-24 year olds) Male Prison / 1,000 9.5 63.4 24.9

Conditions

Children in Poverty 11% 36% 29%

Children in Single-Parent families 23% 65% 36%

Pop. In High Vulnerability Tracts 1.7% 20.3% 25.3%

Source: Bruner, C., & Schor, E. (2009). Clinical Health Care Practices and Community Building. Des Moines, IA: National Center for Service Integration

Select Healthy Development Disparities in Iowa (2008 or 2009)

White AfAm Hisp.

Low birthweight 6.3% 11.8% 7.0%Late/no prenatal care 24.2% 44.1% 43.9%Teen (15-19) birth rt 2.8% 9.6% 9.0%

Children in poverty 13.0% 41.1% 31.6%Single parent fams. 28.2% 71.0% 43.8%

Below basic 4th gr. Rd 28% 51% 47%Foster placement/1000 7.3 44.9 10.7

Sources: National Center for Health Statistics; U.S. Department of Health and Human Services. National Center for Educational Statistics; U.S. Census Bureau. Red indicates very significantly higher than national average.

The Importance of Health Equity to Iowa’s Children

Percent of Iowa Population of Color and/or Hispanic by Age in 2008

4.1%

3.8%

6.5%

8.8%

5.7%

5.4%

8.3%

8.9%

0.8%

1.9%

0% 5% 10% 15% 20%

Total

65+

18-64

5-17

0-4

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Hispanic non-White (includes Hispanic)

Source: United States Census Bureau, 2008 American Community Survey

The Role of the Child Health Practitioner in Healthy Child Development

Physical health and development No undetected hearing or vision problem No chronic health problems without a treatment plan Immunizations complete for age No undetected congenital anomalies

Emotional, social and cognitive development No unrecognized or untreated delays

Family’s capacity and functioning Parents knowledgeable about child’s physical health status

and needs No unrecognized maternal depression, family violence, or

family substance use No undetected early warning signs of child abuse or

neglect

Primary Health Care Practice Implications to Achieving Outcomes Physical health: Bio-medical care Parenting information and education:

Anticipatory guidance Developmental surveillance and screening

for social determinants Effective referrals and follow-up services to

address medical and trans-medical needs

“Medical home”/”Medical neighborhood”/”Community health system”

Exemplary Programs Supporting Healthy Child Development

Connecticut’s Help Me Grow program

ABCD

Assuring Better Child Health & Development

Common Framework for Exemplary Programs

Child health practitioner training and support for comprehensive well-child visits with developmental screening/surveillance

Follow-up actions to respond to needs/opportunities through care coordination/case management

Connections to community resources to address needs and connect back with primary care

Schematic Representation of Comprehensive Approach

Pediatric Practitioner Training/Developmental

Surveillance

“Do you have questions about how your child is learning, behaving, or developing?”

1.

Community Child Health Liaison

• identify and update resources for care coordination

• investigate and follow-up with care coordinator for specific families

• develop networks across providers and community resources

3.

Part CChild

Mental Health

Parenting Educa-

tion

Home Visiting

Head Start

Domestic

Violence Shelter

Peer Support Group

for Grand-parents

Church Family Night

Program

Parent of Children

with ADHD Group

Hispanic Resource

Center

Parents Anony-mous

Telephone Care Coordination

Schedule Appointments• follow-up assessment• professional services• community supports

Provide Feedback and Follow-up

2.

The Role of Medicaid (and hawk-i) – Where Children are Served

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50,000

100,000

150,000

200,000

250,000

300,000

350,000

Jul-98 Jul-00 Jul-02 Jul-04 Jul-06 Jul-08 Jul-10

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Medicaid Medicaid Expansion hawk-i (SCHIP)

Iowa’s Medicaid and SCHIP Program -Enrollees as Percent of Child Population

12.6%

40.1%

Federal Opportunities for Action Demonstration Initiatives

Community transformation grants Health innovation zones Pediatric quality care organizations CHIPRA outcome demonstration grants

Medicaid Expanded reimbursement for primary care services Adult coverage to 133% and new opportunities for

improving parental nurturing Private health coverage

Incorporation of Bright Futures guidelines within all private coverage

Iowa Initiatives and Planning Structures on Which to Build

Early ACCESS EPSDT Outreach Workers Project LAUNCH First Five

Health Improvement Partnership and Help Me Grow Planning

Off to a Good Start Coalition Child Mental Health Reform

PI CHI – Partnership to Improve Child Health in Iowa

December 7-8, 2010, Iowa AAP along with Iowa Dept of Education-Early ACCESS, hosted a meeting to discuss the importance of monitoring the overall health of children in Iowa and how Improvement Partnerships can be involved and how they can leverage work already done in other states on many different child health concerns.

Attendees: Diverse group of colleagues from Child Health Specialty Clinics, Early ACCESS, children’s hospitals, state/government agencies, & family advocacy/support groups. Special guests:

Vermont Child Health Improvement Partnership (VCHIP) National Improvement Partnership Network (NIPN) Judith Shaw, EdD, MPH, RN, VCHIP Executive Director Paula Duncan, MD, FAAP, Youth Health Director, VCHIP,

Clinical Professor of Adolescent Medicine, Department of Pediatrics, University of Vermont

PI CHI – Partnership to Improve Child Health in Iowa Discussion on Improvement Partnerships

covered why IPs are important to our work of monitoring overall child health and why we need a structure to monitor in Iowa.

Improving the Quality of Health for Iowa’s Late Preterm Infants included presentations and group discussions

Additional topics: EPSDT, Bright Futures and Adolescent Medicine.

Next Steps for Iowa Build upon what we have and know:

scale-up/diffuse exemplary practice Coordinate and collaborate Take advantage of federal and state

opportunities Track results and reinvest savings

Carpe diem

Contact InformationCharles Bruner, DirectorChild and Family Policy Center505 5th Street, Suite 404Des Moines, IA 50309cbruner@cfpciowa.org

Relevant reports and publications:The Healthy Child Story Book (www.cfpciowa.org) Federal Health Reform and Children’s Healthy

Development (www.buildinitiative.org)Clinical Health Care and Community Building

Approaches to Closing Disparities in Child Health (www.cfpciowa.org)

Debra B. Waldron, MD, MPH

American Academy of Pediatrics, Iowa Chapter, Vice President

Iowa Department of Public Health-Division of Health Promotion & Chronic Disease

Prevention, Medical Director

University of Iowa Carver College of MedicineClinical Associate Professor

Child Health Specialty Clinics, University of Iowa, Iowa City

Medical Director

Life Course 4 Key Concepts Today’s experiences and exposures influence

tomorrow’s health. (Timeline) Health trajectories are particularly affected

during critical or sensitive periods. (Timing) The broader community environment–biologic,

physical, and social –strongly affects the capacity to be healthy. (Environment)

While genetic make-up offers both protective and risk factors for disease conditions, inequality in health reflects more than genetics and personal choice.

(Equity)

Health Across Lifetimes & Generations

Fetal Programing Developmental plasticity enables the

organism to change (i.e. re-program) structure and function in response to environmental cues.

Adaptive significance is that plasticity enables a range of phenotypes to develop from a single genotype depending on environment factors.

Fetus makes adaptations through programming to “prepare” for postnatal environment in response to signals.

Plasticity in Developmental Programming