The changing face of child health care
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THE CHANGING FACE OF CHILD HEALTH CARE. DCF Nursing Best Practices Seminar Paul H. Dworkin, MD January 6, 2012 Newington, CT. INTRODUCTION. Goal of Child Health Services. OBJECTIVES. Define the goal of child health services

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The changing face of child health care

THE CHANGING FACE OF CHILD HEALTH CARE

DCF Nursing Best Practices Seminar

Paul H. Dworkin, MD

January 6, 2012

Newington, CT


Introduction

INTRODUCTION

  • Goal of Child Health Services


Objectives

OBJECTIVES

  • Define the goal of child health services

  • Identify key concepts in early brain development that have implications for health services delivery

  • Identify key concepts in early child development that have implications for health services delivery

  • Demonstrate the application of key concepts to program design


1990 s the decade of the brain

1990’s: The Decade of the Brain


The new millennium

The New Millennium


The changing face of child health care

Center on the Developing Childat Harvard Universitywww.developingchild.harvard.edu


Early brain and child development

Early Brain

and Child Development

EARLY BRAIN AND CHILD DEVELOPMENT

  • Proportional brain growth

  • Neural plasticity

  • Critical periods

  • Sequential development

  • Role of experience


Proportional brain growth

Early Brain

and Child Development

PROPORTIONAL BRAIN GROWTH

Courtesy of Bruce Perry, MD, PhD


Neural plasticity

Early Brain

and Child Development

NEURAL PLASTICITY

  • The brain has a great deal of plasticity and can recovery from insults

    • the brain is always changing

    • it takes less time to organize the developing nervous system than to reorganize the developed nervous system

  • “Window of opportunity” during early childhood

    • never permanently closes


Critical periods

CRITICAL PERIODS

From Syllabus, “Brain and Behavior,” Colorado University


Critical periods1

Early Brain

and Child Development

CRITICAL PERIODS

  • Brain development begins before birth; although development continues throughout life, thefirst three years are very important and provide a critical foundation

  • Times in development during which a set of signals must be present for neural systems to differentiate normally

    • e.g., stereoscopic vision


The changing face of child health care

Abstract Thought

Concrete Thought

Neocortex

Affiliation

"Attachment"

Sexual Behavior

Emotional Reactivity

Limbic

Motor Regulation

"Arousal"

Appetite/Satiety

Diencephalon

Sleep

Blood Pressure

Heart Rate

Brainstem

Body Temperature

C

O

M

P

L

E

X

I

T

Y

Courtesy of Bruce Perry, M.D., Ph.D.


Sequential development

Early Brain

and Child Development

SEQUENTIAL DEVELOPMENT

  • The brain develops sequentially

  • Experiences need to be sequential, as well

    • the experiences of the child should match the development of the child

    • provide the “right” experiences in the “right” amounts at the “right” time in the life of a child


Sequential development practical implications

Early Brain

and Child Development

SEQUENTIAL DEVELOPMENTPractical Implications

  • Few infants will benefit from an algebra lecture

  • Few adolescents need to be held and rocked for hours each day

Courtesy of Bruce Perry, MD, PhD


Role of experience

The human brain has the ability to be shaped by experience

Experience, in turn, leads to neural changes in the brain

birth: 50 trillion synapses

1 year: 1,000 trillion

20 years: 500 trillion

The remolded brain facilitates the embrace of new experiences

Early Brain

and Child Development

ROLE OF EXPERIENCE


The changing face of child health care

Early Brain

and Child Development


Health services implications early brain and child development

HEALTH SERVICES IMPLICATIONSEarly Brain and Child Development

  • For optimal effectiveness, stimulation must begin as early as possible

  • Stimulation during the first three years is particularly critical to ensure optimal development

    • “use it or lose it”

    • capacity at any age

  • Stimulation must be aligned with children’s developmental stages and needs


Critical concepts in child development

CRITICAL CONCEPTS IN CHILD DEVELOPMENT

Implications for Child Health Services


The changing face of child health care

Quality ECE

Health services

Appropriate discipline

Early literacy

Parent education

Emotional health

Health literacy

Late Toddler

Late Infancy

Late Preschool

Birth

Early Infancy

Early Preschool

Early Toddler

“School Readiness Trajectories”

Family discord

Inaccessible health services

“Healthy” Trajectory

Poverty

“At Risk” Trajectory

“Ready to Learn”

“Delayed/Disordered ” Trajectory

Age

Prenatal 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs

Graphic Concept Adapted from Neal Halfon , UCLA Center for Healthier Children, Families, and Communities


The changing face of child health care

Chamberlin RW. Preventing low birth weight, child abuse, and school failure: the need for comprehensive, community-wide approaches.Pediatr Rev 1992;13(2):64-71

  • “The most effective long-term strategy appears to be the development of a comprehensive, coordinated, community-wide approach focused on preventing low- and medium-risk families from becoming high-risk, as well as providing intensive services to those who already have reached a high-risk status.”


The changing face of child health care

Universal Curve Shift

Median

Low income

High income

DISABLED

VULNERABLE

Targeted

Interventions

Clinical/Individual Interventions

NUMBER OF CHILDREN

FUNCTION


The productivity argument for investing in young children james j heckman and dimitriy v masterov

The Productivity Argument for Investing in Young ChildrenJames J. Heckman and Dimitriy V. Masterov


Adverse childhood experience study aces

ADVERSE CHILDHOOD EXPERIENCE STUDY (ACES)

  • Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the CDC

  • Decade long.; 17,000 people involved

  • Looked at effects of adverse childhood experiences over the lifespan

  • Largest study ever done on this subject

    The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Lanius & Vermetten, 2009


Adverse childhood experiences

ADVERSE CHILDHOOD EXPERIENCES

  • Sexual abuse

  • Emotional abuse

  • Emotional neglect

  • Physical abuse

  • Physical neglect

  • Substance abuse in home

  • Mental illness in home

  • Incarceration of family member

  • Parental separation or divorce

  • Witness violence against mother


Aces study

ACES STUDY

Individuals with 4 or more of the 10 ACES are:

  • Nearly 2 times more likely to smoke cigarettes

  • 4 ½ times more likely to engage in drug abuse

  • 7 times more likely to suffer from chronic alcoholism

  • 11 times more likely to abuse drugs via injection

  • 19 times more like to have attempted suicide

  • More likely to have health problems that put them at risk of early mortality


Health services imperatives child development concepts

HEALTH SERVICES IMPERATIVESChild Development Concepts

  • Treatment programs and services must be comprehensive, multidisciplinary, and address the multiple factors that facilitate and hinder children’s optimal development

  • Services should address the needs of all children (e.g., the entire population), recognizing that those in greatest need will likely derive the greatest benefits

    • target at-risk children and families

    • perils of exclusive focus on CYSHCN


The changing face of child health care

Child Health Services Building Blocks

Part C (B-to-3)

Title V (CYSHCN)

Links to Preschool Special Ed and

Special Ed (LEA)

Indicated

Service Integration Care Coordination

System Changes

Medical / Surgical Subspecialty Services

Early Childhood Consultation Services

Developmental / Behavioral Health Services

(Mid-level, Comprehensive assessments; Treatment)

Home –based Services

Help Me Grow

Selective

Pay for Performance

Practice Improvement

Reimbursement Reform

(Public & Private)

CT-CHQII

MedicalHome

Developmental/Behavioral Surveillance & Screening

Family Education /Parent & Child Counseling / Anticipatory Guidance

Literacy Promotion

Health Supervision Services

Oral Health/Dental Home

Nutritional Services

Universal

EPIC


Child health services building blocks

Child Health Services Building Blocks

Desired Outcomes for School Readiness

.

Family Capacity and Function

Emotional / Social / Cognitive Development

Physical Health & Development

Early Care and Education

Programs

Family Support

Services

Care Coordination

INDICATED SERVICES

SELECTIVE SERVICES

(Help Me Grow)

Child

Health

Services

UNIVERSAL SERVICES

(Medical Home)


Making the connection help me grow the connecticut experience

"Making the Connection- Help Me Grow The Connecticut Experience"

Centralized Telephone Access Point

Community & Family Outreach

Core Components

Child Health Provider Outreach 

Data Collection & Analysis

Organizing Entity

Continuous Quality Improvement

Statewide

Expansion

Structural Requirements


Summary

SUMMARY

  • Knowledge of early brain development has important implications for promoting children’s optimal development

    • Need for early stimulation

    • Critical importance of first 3 years (“use it or lose it”)

    • Need or alignment with developmental needs

  • Knowledge of early child development has important implications for promoting children’s optimal development

    • Need for comprehensive services

    • Should target entire population of children, especially at-risk


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