Three Messages for Policymakers About Leveraging Science to Strengthen the Foundations of Lifelong Health JACK P. SHONKOFF, M.D. Julius B. Richmond FAMRI Professor of Child Health and Development, Harvard T.H. Chan School of Public Health and Harvard Graduate School of Education. Professor of Pediatrics, Harvard Medical School and Boston Children’s Hospital. Director, Center on the Developing Child at Harvard University. Keynote Address | ASTHO Policy Summit and Annual Meeting Washington, D.C.| September 21, 2017 @HarvardCenter
Setting the Context: Adult Diseases Associated With Childhood Adversity Dominate U.S. Health Care Costs Four of Top Ten Most Costly Diagnoses = $274 billion $100 billion Cancer $81 billion $107 $80 billion billion Annual Cost $60 billion $73 billion $40 billion $51 $43 billion billon $20 billion Heart Diabetes Mental Hypertension Conditions #7 Disorders #8 #1 #4 Source: Agency for Healthcare Research and Quality (2010)
The Persistent Challenge of Racial and Ethnic Disparities in Infant Mortality 20 18 16 Deaths per 1,000 14 Black non-Hispanic live births 12 10 American Indian or Alaska Native 8 Hispanic 6 White non-Hispanic 4 Asian or Pacific Islander 2 Source: National Center for Health Statistics, America ’ s Children: Key National Indicators of Well-Being (2011)
The Persistent Challenge of Racial and Ethnic Disparities in Death Rates from Heart Disease 500 Deaths per 100,000 resident population (age-adjusted) 400 Black or African American 300 White Hispanic or Latino 200 American Indian or Alaska Native Asian or Pacific Islander 100 1980 1990 2000 2007 2008 Source: National Center for Health Statistics (2011)
1 The architecture of the developing brain is built and shaped by continuous interactions among genes and environmental influences — beginning before birth — with lifelong effects on learning, behavior, and both physical and mental health.
The Opportunity: Greater Understanding About the Impact of Early Experience on Brain Development
The Cumulative Pile Up of Adversity Impairs Development in the First Three Years Developmental Delays 100% Children with 80% 60% 40% 20% 1-2 3 4 5 6 7 Number of Risk Factors Source: Barth, et al. (2008)
Risk Factors for Adult Depression are Embedded in Adverse Childhood Experiences 5 4 Odds Ratio 3 2 1 0 1 2 3 4 5+ Adverse Experiences Source: Chapman et al, 2004
Biological “ Memories ” Link Maltreatment in Childhood to Greater Risk of Adult Heart Disease 50% Percent of adults 40% with elevated C-reactive protein 30% 20% 10 % Control Depression Maltreated Depression (age 32) (as a child) (age 32) + Maltreated (as a child) Source: Danese, et al. (2008)
The Threat: Toxic Stress Disrupts Brain Architecture and Other Biological Systems
Early Life Experiences Are Built Into Our Bodies (For Better or For Worse) Stable and supportive relationships, language-rich environments, and mutually responsive, “ serve and return ” interactions with adults promote healthy brain architecture, adaptive regulatory systems, and building blocks of resilience. Excessive or prolonged activation of stress response systems, and reduced availability of the buffering protection of supportive relationships, can weaken brain architecture, stimulate excessive inflammation, produce insulin resistance, and disrupt multiple metabolic functions.
2 Achieving much better outcomes at scale for children facing adversity requires that we support the adults who care for them to build their own core capabilities and to strengthen the communities in which they live.
Capabilities that Promote Effective Parenting and Other Aspects of Successful Adult Functioning are Built on Foundational Skills in Executive Function and Self-Regulation These core dimensions of development include the ability to: Error Processing focus and sustain attention • Behavioral set goals, make plans, and Reaction • Control and Working monitor actions Use of Responses Memory Rules make decisions and solve • Risk/Reward problems Decisions Emotions follow rules, control impulses, • and delay gratification
The Development of Executive Function Skills Begins in Early Childhood and Extends Into the Early Adult Years Skill proficiency Birth 3 5 10 15 25 30 50 70 80 Weintraub, et al. (2011) Age (Years)
Higher Childhood Self-Control Predicts Fewer Adult Health Problems 0.4 More Substance Dependence Index Poor Physical Health Index 0.2 Adult Health 0 Problems -0.2 Fewer -0.4 1 2 4 5 3 Low High Childhood Self-Control Source: Moffitt, et al. (2011)
3 Current best practices in multiple contexts and systems that affect the health and development of young children clearly make a difference but they should be viewed as a starting point, not a final destination.
Leveraging Science to Strengthen Current Programs & Policies and Drive Innovation to Produce Larger Impacts Children Adults Healthy Development & Responsive Caregiving & Educational Achievement Economic Stability Support Strengthen Responsive Core Life Skills Relationships Reduce Sources of Stress
Achieving Greater Impact at Scale Requires Rethinking the Criteria for Defining Evidence-Based Investments What We Should Ask Why did this work so well for these children and families? Current Approach Significant mean effect earns evidence-based status 0 Why did this work so poorly for these children and families?
Achieving Greater Impact at Scale Requires Rethinking the Criteria for Defining Evidence-Based Investments Scale effective strategies for similar subgroups Build a suite of programs and policies across sectors that matches different strategies to different resources, needs, and outcomes Design and test new approaches for these subgroups
The Frontiers of 20 th -Century Science Provide a Wealth of New Discoveries Waiting to Be Leveraged New insights about the dynamics of brain plasticity and critical periods in development can catalyze fresh thinking about the timing and nature of interventions across the life cycle. Research on how stress affects individuals differently can inform the design of a diverse portfolio of more effective strategies and assessment of differential impacts of specific policies and program. The emerging availability of measures of biological and behavioral effects of significant stress in young children that are acceptable to parents and modifiable by interventions will have game- changing implications.
If We Use This Knowledge Well … 2 1 3 x x = Building GXE Driving Adult Science-based Interaction Capabilities Innovation …we will generate a multiplier effect that will increase the impacts of effective policies and practices across multiple agencies and systems, including public health, medical care, education, child welfare, economic development, housing, juvenile justice, and public safety, among others.
www.developingchild.harvard.edu @HarvardCenter
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