Community Pediatrics:

Presented by:Peter A, Gorski, M.D., M.P.A.

Navigating the Intersection of Medicine, Public Health and Social Determinants of Children’s Health

Definition

The practice of promoting the salutary and integrating the salutary and threatening social, cultural and environmental influences on children’s health and development within a community.

Community Pediatrics Includes:

Expanded focus beyond each child to all children

Health and development affected by family, educational, social, cultural, spiritual, economic, environmental and political forces

Synthesis of clinical practice and public health principles – children’s health in context of family, school and community

Collaboration with community partners to provide services and conditions equitably

Exemplars Infant mortality Preventable infectious diseases Dental caries Sedentary lifestyles Chronic conditions Obesity/Metabolic syndrome Other historically adult-onset diseases Injuries – intentional and unintentional Violence Exposure to environmental toxicants Substance abuse and mental health conditions Poverty

Social Determinants of Health Life Course Perspective and Early

Programming Epigenetics Childhood obesity and adult cardiovascular

disease Inadequate calcium and Vitamin D intake in

childhood and adult osteoporosis Childhood maltreatment and adult mental

and physical health problems – e.g. depression, high C-reactive protein, inflammation and heart disease

Health care but one of several key influences on children’s health and well-being as children move through other primary systems, services and environments.

Brains Built over time, from bottom up Genes and experiences together build

brain architecture and physiology (function) through “serve and return” process of relationships.

Cognitive, social and emotional development are inextricably intertwined. Therefore programs must work to protect and stimulate all levels.

Brain Development Weight of brain 333 Grams at birth;

999 Grams at 2 years Born with a finite number of

neurons but connection cells (synapses) based on early experiences – e.g. language fluency

1 day old’s breathing patterns decipher and change from Mozart to Stravinsky to Mozart

Vulnerability Of The Fetus To Defects During Different Periods Of Development

Executive Function Inhibitory control Working memory Cognitive flexibility

Prefrontal cortex fully developed only in early 20’s.

Early Evidence of Executive Function

Starts early during toddlerhood Disruption manifest in:

undercontrolled behavior low persistence Inattention Poor face processing of emotions

(differentiating anger, sadness, fear)

Stanford Marshmallow Test

1 or 2 marshmallows – 4 minute test of patience

Long-term positive correlation with school performance, earnings, substance dependence, SES and physical health

Stress Mediates development of the

immune system as well as the limbic brain system; T cells and brain architecture

Creates susceptibility to infections, cancers and learning disabilities

$55,000/yr for Special Ed vs. $9,000 for reg ed

Moshe Szyf, Ph.D. McGill University, Montreal Epigenetic changes to DNA are

more or less reversible Epigenetic changes occur only in

social animals

Michael Murray, McGill Rat mothers who give low maternal

care (licking and feeding) produce pups who are high stress reactors (epigenetic changes on their glucocorticoid receptor genes)

Not genetic When experimentally split pup litters,

proved that behavior inherited from foster mother not biological mother

These epigenetic changes have long-term, even trans-generational effects and durations.

However, they are also always open to change.

1998 ice storm in Quebec

Whole communities lost power and had to adapt for a month – across SES

T-cell function of 15 year olds today correspond with their mother’s stress levels while pregnant during the storm

Inequities in Health Status

England has abolished inequalities in access to healthcare.

Still they have gross inequalities in health

Reason: most arise from social inequalities, how they live.

What good does it do to treat people’s illnesses and send them back to conditions that made them sick?!

Unequal Life Expectancy

7 year difference between 5th% and 95% on social gradient

17 year difference in London borough of Westminster

32 year difference in Chicago

Essential Foundations for Healthy Development

Fostering healthy relationships in the lives of children (raising social capital)

Promoting high quality learning environments and health literacy (raising educational capital)

Promoting shared prosperity and financial stability for all members of the community (raising economic capital)

Promoting healthy environments and supportive infrastructure (raising environmental capital)

Environments

Toxic exposures:e.g. mold, heavy metals, fluorocarbons

Unsafe housingLimited play and green spacesLimited convenient and affordable public

transportationAccess for children with special needs

All Needs are Equally Important

Physical needs will not be met without education, play, respect and freedom from discrimination

Children’s needs are interdependent

Income Inequality

Proxy for more profound inequalities that create unequal sense of worth, efficacy

Income matters more when other primary supports are not equitably provided

• Healthcare, education, childcare, transportation, workplace environment and security, collective efficacy and social cohesion (epidemiology of depression and smoking)

Economic Prosperity 1/3 unqualified to perform manufacturing jobs U.S. productivity gap mirrors education gap

83% of HS students not proficient in math and reading comprehension

83% of children from low-income families at risk for not graduating, cutting earnings in half ($260,000 per drop out - cost to society) ($320,000 added to economy by every class of 20 kindergarteners who succeed)

30% of Americans hold college degree, need 60% by 2025 to remain globally competitive

National Security75% of 17-24 year olds unfit for military

serviceFail Armed Forces Qualification Test of

basic knowledge on math, literacy and problem-solving

Overweight and physically unfitMentally or emotionally unfit

Left Behind By Kindergarten:Children living in poverty average 15 IQ points below their peers.

Vocabulary at Age 3Poor children: 525 wordsWorking class: 749 wordsProfessional: 1,116 words

By age 4, the average child in a poor family might have been exposed to 13 million fewer words than child in a working class family and 30 million fewer words than a child in a professional family.

An uneven startSES Difference at Start of K

-0.55

-0.22

0

0.25

0.69

-0.47

-0.17

0.27

0.7

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

lowest second third fourth fifth

Income Quintile

Stan

dard

Dev

iatio

n Un

its

Math

Reading

Sensitive Periods

Poor living conditions early in life (nutrition, fetal and infant growth, recurrent infections) and increased cardiovascular, respiratory and psychiatric diseases in adulthood.

LBW and risk for heart disease: hypertension, central body fat distribution, insulin resistance, metabolic syndrome and type 2 diabetes.

Dutch famine of 1944 and CHD 50 years later

Effects Of Extreme Deprivation

Healthy Child Neglected Child

Courtesy of Dr. H.T. Chugani from the Children’s Hospital of Michigan,Wayne State University

Barker HypothesisBirth Weight and Coronary Heart

Disease

Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.

Adverse Childhood Experiences• Physical, emotional or sexual abuse

• Emotional or physical neglect

• Growing up with family members with mental illness, alcoholism or drug problems

• Family violence• Incarcerated family member

• One or no parents• Parental divorce

39Adverse Childhood Experiences (ACE) Study.

Available at www.cdc.gov/ace/index.htm

Risk Factors for Adult Substance Abuse are Embedded in Adverse Childhood Experiences

Self-Report: Alcoholism Self-Report: Illicit Drugs

0

2

4

6

8

10

12

14

16

0 1 2 3 4

Source: Dube et al, 2002 Source: Dube et al, 2005

%

ACEs

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5+

Risk Factors for Adult Depression are Embedded in Adverse Childhood Experiences

Od

ds R

ati

o

ACEs0 1 2 3 4 5+

1

2

4

3

5

Source: Chapman et al, 2004

Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences

ACEs Source: Dong et al, 2004

Od

ds R

ati

o

0 1 2 3 4 5,6 7,8

0.5

1

1.5

2

2.5

3

3.5

ACE Study FindingsCompared with people with no ACES, those with 4 or more ACES were…

• Twice as likely to smoke,

• 7x as likely to be alcoholics,

• 6x as likely to have had sex before age 15, twice as likely to have cancer or heart disease

• 12x more likely to have attempted suicide

• Men with 6+ ACEs were 46x more likely to have injected drugs than men with no history of adverse childhood experiences

Outcomes Associated With ACE Scores

ACEs are highly interrelated.• If experienced one ACE, 90% chance for 2nd category & 70% for

3rd.

• Therefore developed ACE score for cumulative stress.

• Clear dose-response relationship between stressors and adverse health outcomes up to 50 years later.

• All of the 10 most common causes of death in America.

– In other words, should we treat this 70 year old woman as a diabetic and hypertensive? Or, can we conceptualize her problems as childhood sexual abuse, chronic depression, morbid obesity, diabetes, hypertension, & coronary artery disease?

ACE Study Findings

For those with 7+ ACEs, even when they didn't smoke or drink & weren't overweight, they still had 360% higher risk of heart disease than those with 0 ACEs.

Somehow the traumatic experiences of early childhood had a negative effect on their health through a pathway that had nothing to do with risky behaviors.

Source: Adverse Childhood Experiences (ACE) Study. Available at www.cdc.gov/ace/index.htm

ExemplarsTraumatic early childhood events and

CAD, CPD, CA, alcoholism, depression, drug abuse.

Child maltreatment, adult depression and inflammation associated with cardiovascular disease

Discrimination, racism, weathering, chronic activation of neuroendocrine stress reactivity -> progressive health disparities with age.

Life Course Problems Related to Early Life Experiences

The Cumulative Embedding of Experience

into our Biology Over Time

Racial and Ethnic Disparities in Birth Outcomes: A Life Course

Perspective

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Maternal Child Health J. 2003;7:13-30.

Poverty Sickens

• Strong connections between child health and adult health

• Between child wealth and adult wealth• Between child wealth and adult health

– Regardless of child’s health condition – Regardless if social class changes

from childhood to adulthood• Childhood poverty gets biologically

embedded

Health by Social Class

Marmot MG, Smith GD, Stansfeld S et al.Health inequalities among British civil servants: the Whitehall II study. Lancet 1991;337:1387-1393.

Three Levels of Stress

PositiveBrief increases in heart rate, mild elevations in stress hormone levels.

TolerableSerious, temporary stress responses, buffered by supportive relationships

ToxicProlonged activation of stress response systems in the absence of protective relationships

Normal Stress Response: Allostasis

Maintain Stability through Change

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Allostastic Load

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Social Pathogens

Neighborhood violence Isolation – relationships, transportation Dysfunctional schools Child maltreatment Family chaos Absent parents Poverty – Social Gradient/Social Inequalities Food deserts and energy dense caloric

intake Unequal access to healthcare

Racial & Ethnic DisparitiesStress and CRH in Pregnancy

Genetics?

Birth weight distribution of African-born blacks is more closely related to US-born whites than to US-born blacks

David RJ, Collins JW. Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997 Oct 23;337(17):1209-14.

Behavior?

Maternal Smoking?

African American White

NCHS 2002

Percent of Women Who Reported Smoking During pregnancy

9.3%

13.6%

Maternal Smoking?

African American Non-Smokers White American Smokers

Infant Deaths Per 1,000 Live Births

NCHS 2002

13.2

9.2

Prenatal Care?

Prenatal Care?

0

10

20

30

40

50

60

70

80

90

100

AfricanAmerican

NativeAmerican

Hispanic Asian/PI White

Percent of Live Births with First Trimester Prenatal Care

74%

85%

74%

84%

NCHS 2002

70%

Prenatal Care?

African Americans FirstTrimester Prenatal Care

White Americans FirstTrimester Prenatal Care

Infant Deaths Per 1,000 Live Births

NCHS 1999

12.7

5.2

Prenatal Care?

African Americans FirstTrimester Prenatal Care

White Americans PrenatalCare After 1st Trimester or

None

Infant Deaths Per 1,000 Live Births

NCHS 2002

12.7

7.1

SES?

SES?

African Americans 16+ yearsof schooling

White Americans <9 years ofschooling

Infant Deaths Per 1,000 Live Births

NCHS 2002

10.2

6.8

Prenatal Stress &Programming Of The Brain

Prenatal stress (animal model)

Hippocampus

Site of learning & memory formation

Stress down-regulates glucocorticoid receptors

Loss of negative feedback; overactive HPA axis

Amygdala

Site of anxiety and fear

Stress up-regulates glucocorticoid receptors

Accentuated positive feedback; overactive HPA axis

Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.

Epigenetics

Vulnerability or ProtectionEarly gene-environment interactions

may shift from adaptive to maladaptive and pathogenic as environment changes – e.g. intrauterine under nutrition,

energy-sparing metabolic changes may create susceptibility if early childhood environment becomes energy abundant, carbo rich plus sedentary lifestyle

Psychophysiological Mechanism

Low self-control, self-efficacy and self-esteem together cause a cascade of toxic stress that destroys brain receptors, ability to fight infection, inflammation and increase all-cause mortality.

Mental health is root of physical health

Social justice affects mental health

I matter

I belong

I can

Investment of the State of Florida during difficult stages

of childhood

Quality Early Care and Education Pays Off: Cost/Benefit Analyses Show

Positive Returns

$2

$6

$8

$4

$10

$3.23

Abecedarian Project (early care and

education aged 0-5)

$5.70

Nurse Family Partnership

(home visitingprenatal – age 2 for

high risk group)

Perry Preschool(early education age 3-4)

Total Return per $1 Invested

Data Sources: Heckman et al. (2009)Karoly et al. (2005)

Break-Even Point

0

$9.20

Graph Courtesy: Center on the Developing Child at Harvard University

Public Investment in Children by Age

Why Target Whole Communities?

Health and well-being of each person depends on condition of all

Cannot predict individual course based on group risk factors without considering the social context

Cost burden of case-finding and treatment too high

Moral weakness of accepting unequal outcomes

Post-neonatal Infant Mortality

(per 100,000 live births,1986)

0

100

200

300

400

500

600

I II III IV V

England & Wales Sweden

Wilkinson RG. Income distribution and life expectancy. BMJ. 1992;304:165-168

Determinants of Health

Eco-Bio-DevelopmentalModel of Human Health and Disease

BiologyPhysiologic Adaptations

and Disruptions

Ecology

The social and physical

environment De

velo

pmen

tLe

arni

ng, B

ehav

ior

And

Heal

th

Life Course Science

NeuroscienceEpig

eneti

cs

The Science of

Development

Ecology becomes biology, and together they drive development across the lifespan

Partnering with Public Health Have always served as beacons for public health

dangers Reporting illness patterns, hazards and risky

trends Reciprocally, pediatricians benefit from population-

based information on programs, especially preventive services: Injury prevention Child maltreatment prevention Lead poisoning Tobacco control Breastfeeding promotion Obesity prevention Asthma Trauma Disaster preparedness

AdvocacyPediatricians advocated strongly for

passage of ACA and for the needs of children (who do not participate in government)

Legislative advocacy training in Pediatric Residency programs

Need for financing models for accountable care organizations and other practices to bill for attention to social determinants

Population Approach to Child Health

Delivers information about early childhood development for all children in community

Moves focus from the individual to the entire community to make a bigger difference

Provides opportunity to “shift the curve” for the whole population

Assesses over time how the community’s cumulative efforts are impacting children’s development

Recommendations Increase use of community data about social

determinants (EDI and ECRI) Partner with public health departments and

school districts, child welfare agencies to decrease barriers to health and health care in communities

Disseminate information about effective community programs and resources for children’s health and well-being

Promote preventive health strategies at individual and population levels

Engage with primary settings and resources for children’s health and development

Recommendations continued… Advocate for universal access to medical

homes Advocate for universal access and quality of

the social, economic, educational and environmental capital resources for children’s health

Speak out – use the media Pediatric medical education and continuing

medical education should include curricula on community and public health, social determinants of health, health care systems and financing, child advocacy

Children at risk for developmental and

behavioral problems are too often eluding

early detection

Help Me Grow is a system that builds collaboration across sectors, including

child health care, early care and education, and family

support.

TECCS • A National Partnership between UCLA

Center for Children, Families and Communities and United Way Worldwide

• Pioneering a new way of gathering critical information about young children's school readiness, neighborhood by neighborhood, and helping communities use it to advance early childhood system building

Early Development Instrument (EDI)

Patience, Persistence and the Long View

.

Planting Date Trees

“I’d rather be dead than singing ‘Satisfaction’ when I am 45.”

Mick Jagger, DOB 1943

All Children Need and Deserve(Emotional Foundation for Healthy Development)

• To feel connected• To feel valued• To feel they make a difference

Antonovsky (1984). The sense of coherence as a determinant of health. Rutter (1979). Protective factors in children’s

responses to stress and disadvantage. Erikson (1959) Growth and crises of the healthy personality.

“Few are guilty, but all are responsible.”

Rabbi Abraham Heschel