This is a committee for pediatricians to become involved in advocacy/policy around literacy, parenting, child care, preschool, and early brain and child development. As a committee of the Washington Chapter of the American Academy of Pediatrics (WCAAP), we work in an advisory capacity to the Board of Trustees and to the programs of the Chapter. We provide guidance, expertise, and linkages around early childhood policy, practices, and system improvements that will guide Chapter activities and priorities. Membership in the Early Learning Committee is open to all WCAAP members interested in forwarding this important work.
Early Childhood Interventions
Linkages for pediatricians from the Promoting First Relationships presentation by Drs. Danette Glassy and Maxine Hayes, January 2014. Download
Zero to Three
Child Care Aware of Washington
National Resource Center For Health and Safety in Child Care and Early Education
Early Childhood Education and Assistance Program
Washington State Department of Early Learning
Thrive by Five Washington
Building Brains, Forging Futures
Childhood Adversity has Lifelong Consequences
This newsletter series is adapted from a presentation by Dr. Andrew Garner reviewing developmental science, explaining the ecobiodevelopmental framework affecting outcomes for children, and for the first time, explaining how pediatricians can help translate the science into healthier lives for our patients.Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later. The relationship is documented in the Adverse Childhood Experiences (ACE) work. The significant adversity linked to poor outcomes includes:
- Emotional, physical, and sexual abuse
- Household dysfunction such as domestic violence, household substance abuse, household mental illness, parental separation/divorce, or incarcerated household member
- Emotional/physical neglect
The ACE Study uses the ACE Score, which is a count of the total number of ACEs that respondents reported. As the number of ACE increases, the risk for health problems increases in a strong and graded fashion. The linked health problems and unhealthy lifestyles include:
- Chronic obstructive pulmonary disease
- Depression and other mental health problems
- Fetal death
- Ischemic heart disease
- Liver disease
- Risk for intimate partner violence
- Sexually transmitted diseases
- Suicide attempts
- Alcoholism and alcohol abuse
- Illicit drug use
- Multiple sexual partners and early initiation of sexual activity
- Unintended and adolescent pregnancy
The opportunity here is that if we reduce or mitigate these Adverse Childhood Experiences, then there will be less disease in later life.
For more information click below for a short preview of a PBS documentary, Raising of America.
Emotional Buffers Mitigate the Effects of Toxic Stress
Adverse Childhood Experiences (ACEs) are experiences, not events, because there is huge individual variability in the perception of what is stressful. One child finds a barking dog engaging, while another is terrified for months. This variability suggests that the measure of stress cannot really be the occasion of the stressor, but the individual’s physiologic response or REACTIVITY to those stressors.
The National Scientific Council on the Developing Child has proposed the following categories of stress based on the measurable, physiologic response to the stress:
- Positive – brief, infrequent, mild to moderate intensity. Most normative childhood stress falls within this category such as the inability of the 15 month old to express their desires, beginning school or child care, that big middle school project. Positive stress is not the absence of stress. It builds motivation and resiliency.
- Tolerable – no physiologic response.
- Toxic – long lasting, frequent, or strong intensity. More extreme precipitants of stress (ACEs) such as physical, sexual, emotional abuse; physical, emotional neglect; household dysfunction. This can potentially cause permanent changes in the brain with long-lasting effects.
But it is the physiologic response to that stress that can make it tolerable or toxic. Social-Emotional buffers allow a return to baseline or reduce the long lasting effects of toxic stress. The social-emotional buffers are when caregivers respond to the child’s non-verbal cues, offer consolation, reassurance, or assistance in planning. The hallmark of toxic stress is the inability to return to baseline due to insufficient Social-Emotional buffering.
To read more about a pediatrician addressing ACEs to improve her patient’s health see The Poverty Clinic.
Toxic stress occurs when there is a negative event that is intense, recurrent or long-lasting, and when there is insufficient social-emotional buffering from parents/caregivers (deficient levels of emotion coaching, re-processing, reassurance and support). The importance of toxic stress is that it affects brain connectivity and functioning, potentially permanently. Toxic stress also alters the way the genetic program is turned on and off.
Epigenetics is the concept that some genes are turned on or off in the event of certain environments or experiences. Thus, ecology influences how the genetic blueprint is read and utilized. These ecological effects occur at the molecular level and can be inherited or passed to subsequent generations.
Unfortunately stress-induced changes in epigenetic switches can cause permanent changes in gene expression. Genes may load the gun, but the environment pulls the trigger.
Through epigenetic mechanisms, the early childhood ecology becomes biologically embedded, influencing how the genome is utilized. This begins to explain how an early adverse event can affect how body functions can be altered throughout life and even passed to the next generation.
To learn more about epigenetics and early childhood development see this article and click below to watch a NOVA episode about epigenetics.
It is now known that brain architecture is experience dependent. Both individual connections or synapses and complex circuits of connections are dependent upon activity. The young child’s environment and experience or ecology influences how brain architecture is formed and how it is remodeled. This is the plasticity that allows learning. Unfortunately, with time, there is diminishing cellular plasticity and this limits remediation. Early childhood adversity, with vicious cycles of stress, causes potentially permanent alterations in brain architecture and functioning.
There are two types of brain plasticity:
- Synaptic – variation in the strength of individual connections that is a lifelong process. This is how old dogs learn new tricks.
- Cellular variation in the number or count of connections. This type of variation dramatically declines with age, waning by 5 years. This is like an increase of one person shouting to a stadium shouting.
In addition, different parts of the brain mature at different times. Two areas to consider are the amygdala and the prefrontal cortex. The amygdala is the seat of HOT cognition: emotional, reactive, impulsive, “just do it”. The prefrontal cortex is the seat of COLD cognition: judgmental, reflective, calculating, “think about it”. The amygdala is the gas pedal and the prefrontal cortex is the brake. The amygdala matures first, and is fully mature by 18 years. The prefrontal cortex is not fully mature until 24 years. Early childhood stress increases stress hormones like cortisol and norepinephrine. These stress chemicals interfere with the development of cellular connections so the amygdala is hyper responsive, leaving a person with less brain capacity for calm coping with stressful events in the future. Toxic stress can interfere with the actual connections or architecture of the developing brain’s connections, and interfere with important parts of the brain like the amygdala and prefrontal cortex.
To learn more about developmental neuroscience click below to see a short video from the Center on the Developing Child: Three Core Concepts in Early Development.
Translating Developmental Science into Effective Policies and Practices
The environment a young child experiences becomes biology, and together they drive development across his or her lifespan. The critical challenge is to translate game-changing advances in developmental science into effective policies and practices to improve education, health and lifelong productivity.
The science of Early Brain and Child Development (EBD) underscores the need to improve early childhood ecology to 1) mitigate the biological underpinnings for educational, health and economic disparities, and 2) improve developmental trajectories. EBD also highlights the pivotal role of toxic stress.
If toxic stress is the missing link between Adverse Childhood Experiences (ACE) exposure and poor adult outcomes, are there ways to treat, mitigate and/or immunize against the effects of toxic stress?
Treatment: Evidence-based treatments such as cognitive behavioral therapy and Parent Child Interaction Therapy can be somewhat effective, but are reactive, costly, not universally available, and of declining benefit the later it is started.
Secondary/Targeted Prevention: These interventions are focused and targeted for those at high risk. The most effective include some home visiting programs and parenting programs. Prevention always is preferable to treatment, so these programs are more likely to be effective and minimize the damage from toxic stress. Unfortunately, the screening step is not perfect, and these programs are not universally available.
Primary/Universal Prevention: These interventions help families mitigate stress to make it positive instead of tolerable or toxic. The approach acknowledges that preventing all childhood adversity is impossible and even undesirable. It is like immunizing through actively building resiliency. Some of the interventions improve parent/caregiver skills, and some are formalized social-emotional learning for children.
For more information, see: Building Adult Capabilities to Improve Child Outcomes: A Theory of Change.