Moving Beyond Adverse Childhood
Experiences (ACEs) for our Next Generation:
From Collective Vision to Action
Florida Association for Infant Mental Health
Orlando, FL
April 24, 2014
David W. Willis, M.D., FAAP
Director, Division of Home Visiting and Early Childhood Systems
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
1
Take Home Messages
• We are now witnessing an unprecedented opportunity for
the next generation of children in our nation with the
growing attention to and investments in early childhood
• The word is out that building health, school readiness and
social well-being for the next generation of children
requires embracing the one science of early brain and
child development, mitigating risk and building resiliency
• Early Childhood leaders must embrace the science and a
collective impact approach to lead transformation and
change
22
We’re in the “building health and
developmental assurance” business…
Physical health
Developmental health
Relational health
33
A League Table of Child Well-Being
Source: UNICEF, 2013
44
Factors Contributing to
Healthy Child Development
Medical
Services
10%
Health
Behaviors
50%
Environment
20%
Genetics
20%
SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000
5
Life Course
Drivers of Developmental Trajectories
Genetic,
Prenatal and
Neurodevelopmental Factors
• Neurodevelopmental
• Social-economic
Socialeconomic
environment
Attachment and
Relational
Patterns
(ACE Scores)
• Relational
Relational Health
66
An Early Brain and
Child Development Focus
• BUILDING HEALTH
• Promoting the healthy early childhood
foundations for life course health
• Promoting relational health
• Promoting kindergarten readiness
• Mitigating toxic stress effects on health and
developmental trajectories
• Strengthening the systems and community supports to
address the social determinants of health
77
Core Story of EBCD
• Child development is the foundation for community and
economic development
• Brains are built over time – prenatally to young adulthood
• Brain architecture is built from bottom up and requires solid
foundation for future skills
• The interactive influences of genes and experience shape
the architecture of the developing brain
• Toxic stress on the developing brain has lifelong effects on
learning, behavior and health
• Creating the right conditions in early childhood is more
effective and far-less costly than addressing problems
later on
8
Eco-Bio-Developmental Model
Model of Human Health and Disease
Biology
Physiologic Adaptations
and Disruptions
Life Course
Science
Through epigenetic mechanisms, the early childhood ecology becomes
biologically embedded, influencing how the genome is utilized
Source: Andy Garner, 2012
9
Critical Concepts
Childhood Adversity has Lifelong Effects
Epigenetics
Developmental Neuroscience
The Science of Early Brain and Child
Development
• Social Emotional Skills are learned and
buffer against toxic stress
•
•
•
•
Source: Andy Garner, 2013
10
Brain development in the
social context of poverty
11
Significant Adversity Impairs Development
in the First Three Years
Children with
Developmental Delays
100%
80%
60%
40%
20%
1-2
3
4
5
6
7
Number of Risk Factors
Source: Barth, et al. 2008
12
Disparities in Early
Vocabulary Growth
Professional
Families
1,116 words
1200
Vocabulary Size
1000
Working Class
Families
749 words
800
600
Welfare
Families
525 words
400
200
0
9
12
15
18
21
24
27
30
33
36
Age of child in months
Source: Hart, B. and Risley, T. R. 2003
13
New Protective Interventions
Significant Adversity
Healthy Developmental
Trajectory
Supportive Relationships,
Stimulating Experiences, and
Health-Promoting Environments
Source: Harvard Center on Developing Child, 2012
14
14
Adverse Childhood Experiences
Are Common
Household dysfunction:
Substance abuse
Parental sep/divorce
Mental illness
Battered mother
Criminal behavior
27%
23%
17%
13%
6%
Abuse:
Psychological
Physical
Sexual
11%
28%
21%
Neglect:
Emotional
Physical
15%
10%
Source: V. Felitti, 2005
15
Adverse Childhood Experiences (ACEs)
16
Adverse Childhood Experiences Score
Number of categories of adverse childhood
experiences are summed …
ACE score Prevalence
0
1
2
3
4 or more
48%
25%
13%
7%
7%
.
Source: V. Felitti, 2005
17
ACE Score vs. Smoking and COPD
20
Percent With Problem
18
16
ACE Score:
0
1
2
3
4 or more
14
12
10
8
6
4
2
0
Regular smoking by age 14
COPD
18
Childhood Experiences vs.
Adult Alcoholism
18
16
4+
% Alcoholic
14
12
10
2
3
8
6
1
4
2
0
0
ACE Score
Source: V. Felitti, 2005
19
Childhood Experiences
Underlie Chronic Depression
4+
3
2
1
0
Source: V. Felitti, 2005
20
ACE Score vs. Intravenous Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
ACE Score
3
4 or more
N = 8,022
p<0.001
Source: V. Felitti, 2005
21
Childhood Experiences Underlie Suicide
25
% Attempting Suicide
20
4+
15
10
3
5
2
0
0
1
ACE Score
Source: V. Felitti, 2005
22
% With a Lifetime History of
Depression
Childhood Experiences
Underlie Chronic Depression
80
70
60
50
40
30
20
Women
Men
10
0
0
1
2
3
>=4
ACE Score
Source: V. Felitti, 2005
23
POPULATION
ATTRIBUTABLE
RISK
A large portion of many
health, safety and
prosperity conditions is
attributable to Adverse
Childhood Experience.
ACE reduction reliably
predicts a decrease in
all of these conditions
simultaneously.
Source: Family Policy Council, 2012
24
ACEs and Head Start
• Head Start Children (N=50)
•
•
•
•
60% had violence exposures < 4 yrs.
Mean ACE >3
Mean ACE of their Parents is >5
2/3rs of children with Positive ACE screen
had one report of social-emotional
development concerns (by teacher and
parent DECA)
Source: C. Blodgett, 2012
25
Odds for Academic and Health Problems with
Increasing ACEs in Spokane Children
Academic
Failure
Severe
Attendance
Problems
Severe
School
Behavior
Concerns
Frequent
Reported
Poor
Health
3
5
6
4
Two ACEs
N=213
2.5
2.5
4
2.5
One ACE
N=476
1.5
2
2.5
2
No Known
ACEs =1,164
1.0
1.0
1.0
1.0
Three or More
ACEs N =248
Source: C. Blodgett, 2012
26
Adverse Childhood Experiences*
Among Young Children
ACES AMONG ALL CHILDREN 0-5
YEARS-OLD IN HOUSEHOLDS
BETWEEN 0%-100% OF FPL
ACES AMONG ALL CHILDREN
0-5 YEARS-OLD
100.0%
100%
90.0%
90%
80.0%
80%
70.0%
70%
60.0%
60%
50.0%
2 or more ACEs
40.0%
1 ACE
30.0%
13.3%
32.8%
30%
6.1%
23.0%
40%
22.2%
12.9%
18.0%
20.0%
10.0%
50%
26.0%
20%
23.6%
0.0%
Child less than 2 Child is 2-3 years Child is 4-5 years
years of age
old
old
SOURCE: National Survey of Children's Health. NSCH 2011/12
36.7%
36.9%
31.3%
10%
0%
Child less than 2
years of age
Child is 2-3 years Child is 4-5 years
old
old
27
How Early Experience Gets Into the Body
A Bio-developmental Framework
Lifelong Outcomes
Foundations of Healthy Development and
Sources of Early Adversity
Environment of
Relationships
Physical, Chemical
& Built
Environments
Cumulative Effects
Over Time
GeneEnvironment
Interaction
Physiological
Adaptations &
Disruptions
Nutrition
HealthRelated
Behaviors
Educational
Achievement
& Economic
Productivity
Physical &
Mental Health
Biological Embedding During
Sensitive Periods
Source: Shonkoff, et al, 2009
28
ACEs have many impacts throughout
the lifespan
CHRONIC
DISEASE
CRITICAL
& SENSITIVE
DEVELOPMENTAL
PERIODS
PSYCHIATRIC
DISORDERS
IMPAIRED
COGNITION
Early childhood, ages 7-9,
Pre-puberty,
Aging into adulthood
ADVERSE
CHILDHOOD
EXPERIENCE
MORE CATEGORIES – GREATER
IMPACT
Physical Abuse, Sexual Abuse
Emotional Abuse, Neglect
Witnessing Domestic Violence
Depression/Mental Illness in Home
Incarcerated Family Member
Substance Abuse in Home
Loss of a Parent
WORK/SCHOOL
Attendance,
Behavior,
Performance
BRAIN
DEVELOPMENT
Electrical, Chemical,
Cellular Mass
ADAPTATION
Hard-Wired Into
Biology
Source: Family Policy Council, 2012
ALCOHOL,
TOBACCO, DRUGS
RISKY SEX
GENETICS
Including gender –
Remember that
experience triggers
gene expression
(Epigenetics)
OBESITY
CRIME
INTERGENERATIONAL
TRANSMISSION, DISPARITY
POVERTY
29
Adversity/Toxic Stress
“Social-emotional buffering is the primary
factor distinguishing level of stress”
Andy Garner, MD, COPACFH
• Toxic stress occurs when there is an
absence of social-emotional buffering
• Metric for adversity is the body’s stress
response system
• Implications: “Toxic stress is the key
intergenerational transmitter of social
and health disparities”
30
Three Levels of Stress Response
Positive
Brief increases in heart rate,
mild elevations in stress hormone levels.
Tolerable
Serious, temporary stress responses,
buffered by supportive relationships.
Toxic
Prolonged activation of stress response systems
in the absence of protective relationships.
Source: Center for Developing Child 2012
31
Positive & Tolerable Stress
Source: Center on the Developing Child 2012
32
Toxic Stress
Source: Center on the Developing Child 2012
33
Epigenetics
•
•
•
Fetal Programming
Early Childhood foundations of
life course health
“Not your parents genome”
34
Barker Hypothesis
165
160
155
Systolic Pressure (mmHg)
170
Birth Weight and Hypertension
<=5.5
5.6-6.5
6.6-7.5
7.6-8.5
>8.5
Birthweight (lbs)
Source: Law CM, et al, 1993
35
Barker Hypothesis
Birth Weight and Coronary Heart Disease
1.5
Age Adjusted Relative Risk
1.25
1
0.75
0.5
0.25
0
<5.0
5.0-5.5
5.6-7.0
7.1-8.5
8.6-10.0
>10.0
Birthweight (lbs)
Source: Rich-Edwards JW, et al, 1997
36
The “limbic brain”
37
38
The emergence of “executive
function disorders”
Disturbances in:
•
•
•
•
•
Working memory
Self-regulation
Attention, organization, impulse control
Sequencing and planning
Social flexibility
39
Maternal Depression
Affects Infants
Decreased cognitive stimulation and
attachment may cause:
• Difficulty in developing trusting relationships
• Impeded growth during first year of life
• Lower activity level
• Irritability
• Irregular sleep and feeding behaviors
• Increased incidence of depression, anxiety,
and attention deficit
• Lifelong decreased ability to handle stress
40
Genetics
Orchid-Dandelion Hypothesis
“Biological Sensitivity to Context”
• Plasticity hypothesis, sensitivity hypothesis, or differentialsusceptibility hypothesis
• Gene x Environment Interactions
• Gene variants (orchid genes)
• SERT gene – depression/anxiety – 25% population
• Alleles: S/S, S/L, L/L
• DRD4 gene – externalizing behaviors and antisocial risk,
ADHD, risk – 20% population
“Risk becomes possibility”
“Vulnerability becomes plasticity and responsiveness”
Source: W.T. Boyce, 2008
41
Differential Universality
On average, disadvantaged children (neighborhoods)
have poorer outcomes. However, most vulnerable
children are in the populous middle class.
Socioeconomic
Disadvantage
Source: C.Hertzman, 2010
Socioeconomic
Advantage
42
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness
– incl. drug &
alcohol addiction
• Social mobility
Index of health and social problems
Health and social problems are
worse in more unequal countries
Source: Wilkinson & Pickett, The Spirit Level, 2009
43
Relational Health
44
44
The Home Visiting Program
● Authorized by Title V of the Social Security Act:
Maternal, Infant, and Early Childhood Home
Visiting Programs (MIECHV)
● $1.5 billion over 5 years
 $100M FY2010
 $250M FY2011
 $350M FY2012
 $400M FY2013
 $400M FY2014
45
45
The Home Visiting Program
• In all 50 states, DC, and 5 territories
• Formula grants based on child poverty
• Competitive grants in 38 states
• Development grants
• Expansion grants
• 3 Nonprofit Organizations in FL, ND, and WY
• Tribal programs
• 3 percent set-aside
• 25 total grants
46
Home Visiting Program Goals
Provide voluntary, evidence-based home
visiting services to improve
• Prenatal, maternal, and newborn health
• Child health and development, including the
prevention of child injuries and
maltreatment
• Parenting skills
• School readiness and child academic
achievement
• Family economic self-sufficiency
• Referrals for and provision of other
community resources and supports
47
State Selection of Home Visiting Model
(April 2013)
Evidence Based Model
Number of States
Implementing
Healthy Family America
43
Nurse-Family Partnership
42
Parents as Teachers (PAT)
30
Early Head Start
26
Home Instruction for Parents of
Preschool Youngsters (HIPPY)
8
Healthy Steps
3
Child First
1
Family Check-Up
1
48
Data Collection on Benchmark Areas
1. Maternal and newborn health (8 constructs)
2. Child injuries; child abuse, neglect, or maltreatment;
emergency department visits (7)
3. School readiness and achievement (9)
4. Crime (2) or domestic violence (3)
5. Family economic self-sufficiency (3)
6. Coordination/referrals for other community resources (5)
49
Home Visiting Program Innovations
• Collaborations and integration across health and
early learning
• Integrating infant mental health competencies and
reflective supervision
• Core competencies across models and HV
networks
• “Crossing the data divide”
• Population management
• Universal intake and assessment systems
• Father engagement in Home Visiting
• Early Childhood Public-Private partnerships
50
50
“Innovation lies at the intersection
between early childhood systems
and child health”
Jack Shonkoff, M.D.
Harvard’s Center on the Developing Child
51
51
Three ECCS Strategies
The mitigation toxic stress and trauma
in infancy and early childhood across
two or more early childhood systems.
(25 grantees)
Expanding developmental screening
initiatives. (19 grantees)
Incorporating CFOC Standards – state
infant/toddler child care quality
initiatives. (9 grantees)
52
Together We are Stronger
than the Sum of Our Parts
53
Moving from Individual Programs to
Integrated Systems
Source: Center for Study Social Policy 2013
54
Comprehensive, Integrated
Early Childhood Systems
Key Building Blocks
•
•
•
•
•
Focus on population and place
Whole child, family, community approach
Universal and targeted services /supports
Capacity building
Community change strategies
Source: Amy Fine, 2014
55
Home Visiting Program Innovations
• Collaborations and integration across health and early
learning
• Integrating infant mental health competencies and
reflective supervision
• Core competencies across models and HV networks
• “Crossing the data divide”
• Population management
• Universal intake and assessment systems
• Father engagement in Home Visiting
• Early Childhood Public-Private partnerships
• Collective Impact
56
56
Collaborations across Early
Childhood Systems
ECCS (Early Childhood Comprehensive Systems)
Help Me Grow
Project LAUNCH (SAMHSA)
Child Welfare and Trauma-informed systems
Part C, IDEA
AAP Building Bridges Among Health and Early
Childhood Communities
• Race to the Top - ELC States
• TECCS (Transforming Early Childhood Community
Systems)
• Place- Based Initiatives
•
•
•
•
•
•
57
57
The Five Conditions of
Collective Impact Success
• Common agenda – shared vision
• Shared Measurement – collecting data
and measuring results consistently
• Mutually Reinforcing Activities –
differentiating while still coordinated
• Continuous Communication – consistent
and open communication
• Backbone Organization – for the entire
initiative and coordinate participating
organizations and entities
Source: J. Kania and M. Kramer, 2011
58
59
Promoting Social Networks
•
•
•
•
•
For mothers and babies
For families
For neighborhoods
For communities
For programs and stakeholders
60
Sustainable solutions
1. Knowledge base
2. Political will
3. Social strategy
Dr. Julius Richmond
61
EBCD Public Heath Model
• Universal Primary Preventions
• Anticipatory guidance
• Positive parenting
• Targeted Inventions (at-risk)
• Home Visiting
• Early Intervention
• Evidence-based Treatments
• PCIT, EBHV, CBT
62
It’s all about:
• Building health, First 1000 Days
• The earliest relationships, their sturdiness and supports
• Breaking the generational transmission of abuse, ACE
transmission and toxic stress mitigation
• Partnerships and shared values of communities of all
agencies that becomes a collective impact approach
• A culture of quality, measurement and accountability
• Population, community and place-based approaches
• Driving innovation
• Proven, wise and sustainable investments for young
children’s future
• Promoting Parent Support, Social Capital and Social
Networks
63
Take Home Messages
• We are now witnessing an unprecedented opportunity for
the next generation of children in our nation with the
growing attention to and investments in early childhood
• The word is out that building health, school readiness and
social well-being for the next generation of children
requires embracing the one science of early brain and
child development, mitigating risk and building resiliency
• Early Childhood leaders must embrace the science and a
collective impact approach to lead transformation and
change
64
64
We will know success when……
_____________________________________
…..the lifetime well-being of every American
child is America’s highest priority
Source: R. Dugger, 2007
65
Contact Information
David W. Willis, MD, FAAP
Director, Division of Home Visiting
and Early Childhood Systems
Maternal and Child Health Bureau, HRSA
301-443-8590
dwillis@hrsa.gov
66
66