Disclaimer Social and Cultural Determinants This material was - PowerPoint PPT Presentation

3/3/2017 Disclaimer Social and Cultural Determinants • This material was supported by the American Academy of of Developmental Disabilities Pediatrics (AAP) and funded (in part) by the cooperative agreement FAIN: 1U61TS000237-03 from the Agency for Toxic Substances and Disease Registry (ATSDR). • Acknowledgement: The U.S. Environmental Protection Agency Leslie Rubin MD Morehouse School of Medicine (EPA) supports the PEHSU by providing partial funding to Developmental Pediatric Specialists ATSDR under Inter-Agency Agreement number DW-75- Innovative Solutions for Disadvantage and Disability 95877701. Neither EPA nor ATSDR endorse the purchase of Southeast Pediatric Environmental Health Specialty Unit at Emory University any commercial products or services mentioned in PEHSU publications Hughes Spalding Social Determinants of Health Cerebral Palsy Clinic • The social determinants of health are the • The Inner City Population of Atlanta in the 1990’s circumstances in which people – are born, grow up, live, work, and age, & was low income, predominantly minority and – the systems in place to deal with illness. decidedly underserved • These circumstances are, in turn, shaped by a • In 1998 we started an interdisciplinary clinic for children with Cerebral Palsy wider set of forces: – economics, social policies, and politics 1

3/3/2017 Hughes Spalding Cerebral Palsy Clinic • In 2002 we surveyed the records of 260 children who had attended the clinic since its inception • We found a complex set of medical, developmental and social complications Percentage of Patients Whose Mothers Used Demographic and Etiological Findings Substances during Pregnancy, per Gestational Age Group 50.00% • A high rate of mothers using substances during 40.00% pregnancy particularly in the lower birth weights Percentage 30.00% 25.58% and gestational age 19.64% 18.18% 20.00% 14.29% • Most children live in single parent families with 8.89% 10.00% Mother 0.00% <28 28-32 33-35 36-40 41+ Gestational Age in Weeks 2

3/3/2017 The Child lives with… Poverty Disparities 70 64 60 58 • Race : 50 – 12.3% of white children 40 – 31.9% of Hispanic children 32 30 21 – 37.1% of black children 20 18 13 <28-35 • Education: 17 10 9 Weeks – some college education, 13% are poor 0 2 3 – less than a high school degree, 57% are poor 36-41+ M other • Employment: Grandparent(s) Weeks Foster/Adopt... Father Both biologic.. – 1 parent works full-time, 9% are poor – no parent works full-time, 48% are poor Mediators of Child Poverty Pascoe et al Pediatrics April 2016 Childhood Disability: Poverty Disparities Maternal Age and Education • The absence of fathers in the home is associated with a fourfold risk of poverty. – 42% of single female-headed families are poor – 12% for 2-parent families • Children of single mothers are at greater risk for: – infant mortality – child maltreatment – failure to graduate from high school – incarceration Mediators of Child Poverty Pascoe et al Pediatrics April 2016 3

3/3/2017 Built Environment in Poor Communities • Unsafe Neighborhoods due to: Traffic, Crime, Litter & Trash, Food Desert, Limited Green Space – 61% more likely to be Obese • Older Houses in Poor Condition – 3.5x more likely to have lead toxicity • Older Schools in Poor Condition – 50% less likely to graduate high school – 2x more likely to be unemployed Poverty Effects on Cognitive and Educational Function Smoking Prevalence and Education • 5.6 percent with a graduate degree Indicator Children Who Are Poor Children Who Are Not Poor Developmental delay 5.00% 3.80% Learning disability 8.30% 6.10% • 9.1 percent with a college education Grade retention 28.80% 14.10% Ever expelled or suspended 12.10% 6.10% High school dropout rate in 1994 21.00% 9.60% • 24.2 percent who do not graduate Not employed or in school at age 24 15.90% 8.30% from high school David Wood Pediatrics 2003;112:707–711; CDC, MMWR, 63(No. 47):1108-1112, November 28, 2014 4

3/3/2017 Long-Term Consequences of Fetal and Neonatal Nicotine Exposure • Studies suggest that nicotine may be a key chemical responsible for many long-term effects associated with maternal cigarette smoking on the offspring, such as – hypertension – type 2 diabetes, obesity – respiratory dysfunction – neurobehavioral defects – impaired fertility Bruin et al Toxicological Sciences 116: 364-374 2010 Children at most risk for adverse health and developmental outcomes Stressed Poverty • The Lifelong Effects of Early Childhood Adversity Single Mother and Toxic Stress Lead & other Experiencing toxins Violence Exposure to Insecurity • Volume 129, Number 1, January 2012 Tobacco & Anxiety Smoke Unsafe Limited neighborhood Access to Healthcare 19 Health Equity and Children's Rights Pediatrics ; March 29, 2010; 5

3/3/2017 Toxic Stress Outcomes Toxic Stress • Strong, frequent, or prolonged activation of the • Disorders of learning, memory and body’s stress response systems executive function • Without the buffering protection of a supportive, • Impaired decision-making adult relationship. • Behavioral self-regulation • Resulting in persistently elevated levels of stress • Mood and impulse control hormones • Which can disrupt its developing brain • Risk-taking behaviors architecture Pediatrics Volume 129, Number 1, January 2012 Pediatrics Volume 129, Number 1, January 2012 Poor Health Outcomes Long Term Outcomes • School failure • Chronic stress alters immune • Unemployment function and measurably • Being single parents increases inflammatory • Homelessness markers, increasing risk for: • Substance abuse – obesity – diabetes • Gang membership – hypertension • Violent crime – stroke • Incarceration – early death • Poverty Pediatrics Volume 129, Number 1, January 2012 Pediatrics Volume 129, Number 1, January 2012 6

3/3/2017 Can we make a Difference? • Absolutely!!!!! • Positively!!!!!! SE PEHSU Project SE PEHSU Project Nat Rev Neurosci. 2009 June; 10(6): 446–457. 7

3/3/2017 Home-Based Early Intervention The Perry Preschool Program • Impact of EI on children of high resource (HR) & low • Poor children with low IQ resource (LR) families • Beginning at age 3 and lasting 2 years: • LR children displayed greater improvement with – 2.5-hour preschool program weekdays during the school year, EI than HR children – supplemented by weekly home visits by teachers • LR children receiving EI • Follow-up at ages 15, 19, 27, and 40 did not differ significantly from HR children NBER Working Paper Series. Heckman et al 2010 Early Intervention and Cognitive Development PEDIATRICS 137:4 ,April 2016 The Perry Preschool Program Summary • Infants and children who grow up under adverse social and economic circumstances have a greater likelihood of neurodevelopmental disorders • In addition, there is a limited access to appropriate education and health care compounding the problem • Our responsibility is to identify at-risk children as early as possible and provide appropriate and intensive early support and intervention • And to assure access to good educational opportunities and quality health care NBER Working Paper Series. Heckman et al 2010 8

3/3/2017 Conclusion Thank You….. • Although these are issues invoke the realms of public health and public policy • We each have the responsibility to improve the lives of children and families Leslie Rubin MD with whom we come into contact Developmental Pediatric Specialists • If you save the life of a single child it is as Research Associate Professor Morehouse School of Medicine President Institute for the Study of Disadvantage and Disability Southeast Pediatric Environmental Heath Specialty Unit at Emory if you are saving the entire world! 9