SLIDE 1 Three Messages for Policymakers About Leveraging Science to Strengthen the Foundations of Lifelong Health
Keynote Address | ASTHO Policy Summit and Annual Meeting Washington, D.C.| September 21, 2017 @HarvardCenter 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.
SLIDE 2 Setting the Context: Adult Diseases Associated With Childhood Adversity Dominate U.S. Health Care Costs
Source: Agency for Healthcare Research and Quality (2010)
Annual Cost
$20 billion $40 billion $60 billion $80 billion $100 billion
Diabetes #7 Mental Disorders #4 Hypertension #8 Heart Conditions #1
Four of Top Ten Most Costly Diagnoses = $274 billion
Cancer $81 billion $73 billion $43 billon $51 billion $107 billion
SLIDE 3 2 20 4 6 8 10 12 14 16 18
Deaths per 1,000 live births
Asian or Pacific Islander White non-Hispanic Hispanic American Indian or Alaska Native Black non-Hispanic 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 Infant Mortality
SLIDE 4 Deaths per 100,000 resident population (age-adjusted)
The Persistent Challenge of Racial and Ethnic Disparities in Death Rates from Heart Disease
Source: National Center for Health Statistics (2011) Asian or Pacific Islander White Hispanic or Latino American Indian or Alaska Native Black or African American
100
1980
200 300 400 500
1990 2000 2007 2008
SLIDE 5
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.
SLIDE 6
The Opportunity: Greater Understanding About the Impact of Early Experience on Brain Development
SLIDE 7 Number of Risk Factors
Source: Barth, et al. (2008)
Children with Developmental Delays
1-2 3 5 4 6 7 20% 40% 60% 80% 100%
The Cumulative Pile Up of Adversity Impairs Development in the First Three Years
SLIDE 8 Risk Factors for Adult Depression are Embedded in Adverse Childhood Experiences
Odds Ratio Adverse Experiences
Source: Chapman et al, 2004
1 2 3 4 5+ 1 2 4 3 5
SLIDE 9 Biological “Memories” Link Maltreatment in Childhood to Greater Risk of Adult Heart Disease
Percent of adults with elevated C-reactive protein
Source: Danese, et al. (2008)
Control 10 % 20% 40% 30% 50% Depression (age 32) Depression (age 32) + Maltreated (as a child) Maltreated (as a child)
SLIDE 10
The Threat: Toxic Stress Disrupts Brain Architecture and Other Biological Systems
SLIDE 11 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
- f supportive relationships, can weaken brain architecture,
stimulate excessive inflammation, produce insulin resistance, and disrupt multiple metabolic functions.
SLIDE 12
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.
SLIDE 13 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:
- focus and sustain attention
- set goals, make plans, and
monitor actions
problems
- follow rules, control impulses,
and delay gratification
Emotions Error Processing Reaction and Responses Use of Rules Risk/Reward Decisions Behavioral Control Working Memory
SLIDE 14 The Development of Executive Function Skills Begins in Early Childhood and Extends Into the Early Adult Years
Weintraub, et al. (2011)
Birth
Age (Years)
50 70 80
Skill proficiency
3 5 15 25 30 10
SLIDE 15 Higher Childhood Self-Control Predicts Fewer Adult Health Problems
0.4 0.2
Adult Health Problems Childhood Self-Control 5 4 3 2 1 High Low
Source: Moffitt, et al. (2011)
Poor Physical Health Index Substance Dependence Index More Fewer
SLIDE 16
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.
SLIDE 17
Leveraging Science to Strengthen Current Programs & Policies and Drive Innovation to Produce Larger Impacts
Reduce Sources of Stress Strengthen Core Life Skills Support Responsive Relationships Children Healthy Development & Educational Achievement Adults Responsive Caregiving & Economic Stability
SLIDE 18
Achieving Greater Impact at Scale Requires Rethinking the Criteria for Defining Evidence-Based Investments
Current Approach Significant mean effect earns evidence-based status What We Should Ask Why did this work so well for these children and families? Why did this work so poorly for these children and families?
SLIDE 19
Achieving Greater Impact at Scale Requires Rethinking the Criteria for Defining Evidence-Based Investments
Scale effective strategies for similar subgroups Design and test new approaches for these subgroups
Build a suite of programs and policies across sectors that matches different strategies to different resources, needs, and outcomes
SLIDE 20
The Frontiers of 20th-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.
SLIDE 21 Driving Science-based Innovation
3
Building Adult Capabilities
2
GXE Interaction
1
…we will generate a multiplier effect that will increase the impacts
- f 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.
If We Use This Knowledge Well…
x x =
SLIDE 22 www.developingchild.harvard.edu
@HarvardCenter
