the changing face of child health care dcf nursing best practices seminar paul h. dworkin, md...
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THE CHANGING FACE OF CHILD HEALTH CARE
DCF Nursing Best Practices SeminarPaul H. Dworkin, MD
January 6, 2012Newington, CT
INTRODUCTION
• Goal of Child Health Services
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
The New Millennium
Center on the Developing Childat Harvard Universitywww.developingchild.harvard.edu
EARLY BRAIN AND CHILD DEVELOPMENT
•Proportional brain growth
•Neural plasticity•Critical periods•Sequential
development•Role of experience
Early Brainand Child Development
Courtesy of Bruce Perry, MD, PhD
PROPORTIONAL BRAIN GROWTH
Early Brainand 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
Early Brainand Child Development
From Syllabus, “Brain and Behavior,” Colorado University
CRITICAL PERIODS
CRITICAL PERIODS
• Brain development begins before birth; although development continues throughout life, the first 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
Early Brainand Child Development
Neocortex
Limbic
Diencephalon
Brainstem
Abstract Thought
Concrete Thought
Affiliation
"Attachment"
Sexual Behavior
Emotional Reactivity
"Arousal"
Appetite/Satiety
Blood Pressure
Heart Rate
Body Temperature
Sleep
Motor Regulation
C
O
M
P
L
E
X
I
T
Y
Courtesy of Bruce Perry, M.D., Ph.D.
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
Early Brainand Child Development
Courtesy of Bruce Perry, MD, PhD
SEQUENTIAL DEVELOPMENTPractical Implications
• Few infants will benefit from an algebra lecture
• Few adolescents need to be held and rocked for hours each day
Early Brainand Child Development
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 Brainand Child Development
Early Brainand 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
Implications for Child Health Services
Birth
Early Infancy
Late Infancy
Early Toddler
Late Toddler
Early Preschool
Late Preschool
AgePrenatal 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs
“Re
ad
y t
o L
ea
rn”
“School Readiness Trajectories”
“At Risk” Trajectory
“Delayed/Disordered ” Trajectory
“Healthy” Trajectory
Parent educationEmotional healthHealth literacy
Early literacy
Quality ECE
Appropriate discipline
Poverty
Inaccessible health services
Family discord
Graphic Concept Adapted from Neal Halfon , UCLA Center for Healthier Children, Families, and Communities
Health services
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.”
Targeted Interventions
NU
MB
ER
OF
CH
ILD
RE
N
FUNCTION
Median
High income
Low income
VULNERABLE
Universal Curve Shift
DISABLED
Clinical/Individual Interventions
The Productivity Argument for Investing in Young ChildrenJames J. Heckman and Dimitriy V. Masterov
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
• 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
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 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
Child Health Services Building Blocks
Univ
ersa
l
Sele
ctiv
e
Indi
cate
d
Service Integration Care Coordination
Medical Home
Part C (B-to-3)Title V (CYSHCN)
Links to Preschool Special Ed and
Special Ed (LEA)
Developmental/Behavioral Surveillance & Screening
Family Education /Parent & Child Counseling / Anticipatory Guidance
Literacy Promotion
Health Supervision Services
Oral Health/Dental Home
Nutritional Services
Medical / Surgical Subspecialty ServicesEarly Childhood Consultation Services
Developmental / Behavioral Health Services(Mid-level, Comprehensive assessments;
Treatment)Home –based Services
Help Me Grow
Practice Improvement
System Changes
Pay for Performance
Reimbursement Reform
(Public & Private)CT-CHQII
EPIC
Child Health Services Building Blocks
Family SupportServices
Care Coordination
UNIVERSAL SERVICES(Medical Home)
ChildHealth
Services
SELECTIVE SERVICES(Help Me Grow)
INDICATED SERVICES
Desired Outcomes for School ReadinessFamily Capacity and
FunctionEmotional / Social /
Cognitive Development Physical Health & Development
.
Early Care and EducationPrograms
33
Core
Com
pone
nts
Structural Requirements
Centralized Telephone Access Point
Centralized Telephone Access Point
Community & Family Outreach
Community & Family Outreach
Child Health Provider Outreach
Child Health Provider Outreach Data Collection & Analysis Data Collection & Analysis
Organizing EntityOrganizing Entity Statewide ExpansionStatewide Expansion
Continuous Quality
Improvement
Continuous Quality
Improvement
"Making the Connection- Help Me Grow The Connecticut Experience"
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