Transcript TAKE UP OF SOCIAL BENEFITS Conference

Healthy Child Development:
An Integrated Policy Approach
2011 Governor’s Conference
on Public Health
Charles Bruner, PhD
Debra B. Waldron, MD MPH
April 5, 2011
Why We’re Here

A mother brings her one-year old in for a checkup 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
Children’s Health and
Development
Protective
Factors
0
Risk Factors
Improving the trajectory of child
health and development involves
increasing protective factors and
reducing risk factors -- which requires
a broad definition of child health
services.
Age
Our Children’s Health: Our Nation’s Wealth
Improving Healthy Child Development:
Beyond Bio-Medical Care
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Fostering resiliency
Strengthening protective factors
Eliminating “toxic stress”
Addressing social determinants of
health
Achieving health equity
Factors Contributing to Healthy
Child Development
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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%)
Medical
Services
10%
Health
Behaviors
50%
Environment
20%
Genetics
20%
SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000
Health is dependent on
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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.
From Neurons to Neighborhoods:
The Science of Early Childhood
Development
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.
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
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Both intrauterine environment & early postnatal life
are critical windows in developmental plasticity.
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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
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Discrimination affects healthy births
and child’s constitution
Discrimination affects access to biomedical 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 NonHispanic
Black NonHispanic
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%
11.8%
19.2%
23.7%
3.3%
5.8%
24.1%
16.7%
25.5%
21.3%
Below Basic 4th Grade Reading
22%
54%
50%
Below Basic 8th Grade Math
18%
53%
45%
21.4%
48.8%
46.8%
Foster Care / 1,000
4.9
15.8
6.5
(20-24 year olds) Male Prison / 1,000
9.5
63.4
24.9
Children in Poverty
11%
36%
29%
Children in Single-Parent families
23%
65%
36%
1.7%
20.3%
25.3%
6-11 year-olds Overweight
Health Service Access
Lack of Regular Source of Care
Incomplete Immunizations (19-35 month-olds)
Education Outcomes
Non-completion of High School
Other Outcomes
Conditions
Pop. In High Vulnerability Tracts
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
Late/no prenatal care
Teen (15-19) birth rt
6.3%
24.2%
2.8%
11.8%
44.1%
9.6%
7.0%
43.9%
9.0%
Children in poverty
Single parent fams.
13.0%
28.2%
41.1%
71.0%
31.6%
43.8%
Below basic 4th gr. Rd
Foster placement/1000
28%
7.3
51%
44.9
47%
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
0-4
8.8%
Age
5-17
8.9%
6.5%
18-64
8.3%
3.8%
5.4%
0.8%
65+
1.9%
Total
4.1%
0%
Hispanic
5.7%
5%
10%
15%
non-White (includes Hispanic)
Source: United States Census Bureau, 2008 American Community Survey
20%
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
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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
ABCD
Connecticut’s
Help Me Grow
program
Assuring Better Child
Health & Development
Common Framework for Exemplary
Programs
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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
1.
2.
Pediatric Practitioner
Training/Developmental
Surveillance
“Do you have questions about how
your child is learning, behaving, or
developing?”
3.
Peer
Support
Group
for
Grandparents
• follow-up assessment
• professional services
• community supports
Provide Feedback and
Follow-up
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
Child
Mental
Health
Part C
Telephone Care
Coordination
Schedule Appointments
Parentin
g Education
Church
Family
Night
Program
Home
Visiting
Parent of
Children
with
ADHD
Group
Domesti
c
Violence
Shelter
Head
Start
Hispanic
Resource
Center
Parents
Anonymous
The Role of Medicaid (and hawk-i) –
Where Children are Served
Iowa’s Medicaid and SCHIP Program Enrollees as Percent of Child Population
350,000
40.1%
Number of Children
300,000
250,000
200,000
150,000
12.6%
100,000
50,000
0
Jul-98
Medicaid
Jul-00
Jul-02
Jul-04
Medicaid Expansion
Jul-06
Jul-08
Jul-10
hawk-i (SCHIP)
Federal Opportunities for Action
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Demonstration Initiatives
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Medicaid
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Community transformation grants
Health innovation zones
Pediatric quality care organizations
CHIPRA outcome demonstration grants
Expanded reimbursement for primary care
services
Adult coverage to 133% and new
opportunities for improving parental
nurturing
Private health coverage
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Incorporation of Bright Futures guidelines
within all private coverage
Iowa Initiatives and Planning
Structures on Which to Build
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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
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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
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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
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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
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Carpe diem
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Contact Information
Charles Bruner, Director
Child and Family Policy Center
505 5th Street, Suite 404
Des Moines, IA 50309
[email protected]
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 HealthDivision of Health Promotion & Chronic Disease
Prevention, Medical Director
University of Iowa Carver College of Medicine
Clinical Associate Professor
Child Health Specialty Clinics,
University of Iowa, Iowa City
Medical Director
Life Course 4 Key Concepts
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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)
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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
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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