Making the Case for Early Childhood Brain Development

ROBERT JOHNSON:
This is Public Health Review, I'm Robert Johnson.

On this episode, we're talking about healthy early childhood brain development—

DR. JOHN WIESMAN:
We see a lot of challenges these days with opioid substance use disorders and suicide; and this piece of getting a healthy start on life, supporting this early brain development work, really is a prevention tool for these challenges later in life.

JOHNSON:
—and a call to build on the nation's record of success improving children's health.

DR. AMI KLIN:
We've done so by promoting prenatal care, nutrition, vaccination—all of those approaches have had dramatic impact on the wellbeing of children and their health. We are advocating for the same approach in the case of neurodevelopmental disabilities, which impact 10–12% of the population of children walking into a primary care physician's office.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

This episode, we're talking about the science of early childhood brain development and the public health benefits for children across the nation. Shortly, we'll talk with ASTHO's president, Dr. John Wiesman, about the public health policy aspects of this issue.

But first, a conversation about the science involved with Dr. Ami Klin, director of the Marcus Autism Center at Children's Healthcare of Atlanta and head of the Division of Autism and Related Disorders within the Department of Pediatrics at the Emory University School of Medicine.

For the past 10 years, he's been researching this topic, exploring its value in the battle to improve children's health. Dr. Klin joined us recently to discuss his findings.

KLIN:
We're learning that, in our lifetimes, the greatest changes in the brain happen in the first two years of life. Imagine that by the time we celebrate a baby's first birthday, their brain has doubled in size and the connections in the brain that represent their experiences in learning during this period of time really quadruples. That's one important lesson, that of neuroplasticity—the malleability of the brain—that we need to capitalize on. So, that's the first lesson.

The second lesson is that in regard to many conditions of childhood, from autism through conditions that impact a child's development because of vulnerabilities that they were born with—whether they were genetic or something that happened during birth, or because children are born in a vulnerable environments like in the case of low-income families—that the greatest burdens associated with those conditions are really results of the condition rather than a part of the definition.

In other words, those great burdens are not inevitable; and, by capitalizing on early neuroplasticity—the malleability of the brain—early on via treatments that we now know are effective and also community-viable, we can truly change the developmental trajectories of these children and optimize outcomes to such an extent that they can fulfill that promise.

JOHNSON:
What are some of the problems that we could forestall or even completely eliminate by following this approach?

KLIN:
The most important and lowest hanging fruit in our field is the early identification of those vulnerabilities, increased access to diagnosis, and increased access to early intervention.

I'll give you the example of autism. Even though we know that by intervening early we are really changing the lives of these children forever, in this country the median age of diagnosis of autism is still around four and a half to five years of age. For many children, we wait to diagnose them until they are in school. By that time, we are no longer treating the condition—we are treating the results of the condition, such as the intellectual disability, the language disability, and severe behavioral challenges that our children often experience.

So, this lowest hanging fruit means that were we to engage in a public health campaign that optimizes the conditions for early brain development, we would, in fact, attenuate—if not prevent—those burdens.

JOHNSON:
If a public health practitioner is listening to the very first part of this conversation and thinking that they're in agreement and want to go forward, how should your research inform their work on policies and programs?

How do they use what you're learning to get something done?

KLIN:
There are several ongoing, successful, public health-led campaigns that focus on creating an environment in which children and families are more resilient to those vulnerabilities. One example is a campaign called Talk With Me Baby—a very simple approach, but one that can have very significant impact on the number of children who display the developmental delays—language delays—early on and that eventually will have difficulty acquiring reading skills.

The approach is quite simple; we train trainers to work with vulnerable pregnant mothers in a way that we convey to them the importance of engaging their babies in ways that are going to provide them with what we can call language nutrition—the nutrition that these children need in order for their brains to develop, in order for them to acquire the ability to communicate effectively with others, to learn reading skills and to acquire reading skills, and to succeed in life.

So, this is one example. This program is being implemented in the state of Georgia and is now moving on to several other states like the state of Tennessee, and others.

Other examples have to do with our approach to universal screening for developmental delays. This is something that the American Academy of Pediatrics strongly recommends should happen to every child. And certainly by the time that those well-baby check-up visits happen—at the time that babies are between 18 and 24 months—were we to be able to make those universal screenings translate into greater access to diagnosis and greater access to early treatments, we would really promise a very different future for the next generations of children.

JOHNSON:
Is it as simple as just checking sooner?

KLIN:
Identifying the vulnerabilities, creating optimal conditions for development, are but one step in this process. If we aren't able to convert that early identification into access to services, then we'll be missing an opportunity.

But the kinds of interventions that are available nowadays can be implemented at a population-based fashion. They are cost-effective, they are delivered in the home—it's actually delivered through the parents through parent training programs.

So, I don't want to simplify the matter too much; but the fact is that those solutions are eminently viable and within our reach.

JOHNSON:
We hear so much about early intervention when it comes to cancer and other diseases—heart disease and that sort of thing. It sounds like you're, in some way, making a case for that in this area as well.

KLIN:
Absolutely. I think we have seen that some of the greatest advancements in medicine happen not necessarily by finding the cause of a disease, but by creating a situation in which the organism—in this case, a child—is more resilient to vulnerabilities so that those vulnerabilities don't become diseases.

We've done so by promoting prenatal care, nutrition, vaccination—all of those approaches have had dramatic impact on the wellbeing of children and their health. We are advocating for the same approach in the case of neurodevelopmental disabilities, which impact 10–12% of the population of children walking into a primary care physician's office.

What we've learned is that the burdens associated with those conditions are not inevitable for the vast majority of these children, means that we have a bioethical imperative—really an obligation—to implement the interventions that are going to change the lives of the children. That's the lesson that we have learnt from the past 10 years in the science of early brain development.

JOHNSON:
And would you say that the conditions are not always medical or physical, but sometimes environmental?

KLIN:
We can't forget that the brain not only determines who we're going to be, but the brain also becomes who we are, which means that early experiences matter a great deal. So take, for example, children who are born in environments in which they are not able to benefit from the same level of language nutrition as their more privileged peers. By the time that they are three years of age, they have been exposed to 30 million words less than their peers.

It doesn't take a great deal of sophistication to understand that if that language nutrition is critical for brain development, and if they have been deprived in a way from the adequate stimulation—from the adequate nutrition in terms of language—that they will eventually have delays in language that later in life are going to translate into problems, reading problems, neuropsychiatric problems, and for some of our children, as we know now, they are much more likely to end up in the correctional justice system.

Now, it would be wonderful if we could cure our families from poverty-related challenges—that is going to take maybe a few more generations. What is really exciting is a possibility that we can actually work within that environment while ensuring that the children are going to be resilient and going to achieve a much better outcome; which basically means that their children—the next generation—is going to be at a much more advantageous situation in promoting the wellbeing of their children, and so on.

That's a very exciting a message. It's a message that comes from bringing together developmental brain science together with public health.

JOHNSON:
And we see in countries where poverty is really bad, the adults in the equation don't really have time to spend with their children so the kids are growing up pretty much on their own. Is that what you're talking about here, trying to avoid that?

KLIN:
The great concern that we have is that we tend to underestimate the fact that babies, from the first hours of life ,are active learners. Leaving a child in front of a television, or simply taking care of the child from the standpoint that the child is eating and is clean, is not enough for babies to develop.

Babies don't learn the language from television, or they don't learn a language from simply hearing something coming out of a machine. The way that children acquire the ability to navigate the demands of everyday life—to interact with others, to acquire language, to communicate with others—is by engaging with others. That's the mechanism, and that's as simple as it is engineering, sometimes, for families that—for a whole range of reasons—cannot do that.

JOHNSON:
So, you think then that, obviously, this focus on early brain development as a public health tool is not only exciting, but maybe a little bit overdue?

KLIN:
Yes, I would say that.

As those concerned with the outcome of vulnerable children and families, the concept of early brain development—the knowledge of what it takes to optimize those children's outcomes—those principles have been there for us for the past several years. And it is really exciting for me to see that it resonates so strongly with public health officials. They—more even than academics who sometimes are lost in their science, more than even clinicians who are lost in the world of the individual patients—they realize that they need tools that are going to change the lives of children at a population level. So, this focus on early brain development is an enormous opportunity to all of us and is absolutely overdue.

The equation of cost relative to benefit in the field of neurodevelopmental disorders—children who have an early vulnerability that translates in compromised outcomes associated with brain development—that equation can be turned upside down through investment in early detection, increased access to diagnosis, and community-viable interventions. If we do so, we would have children who are capable of being included in schools, children who not only will not exhibit those results—those burdens in later life—but, in fact, will have an opportunity to make a contribution to society.

JOHNSON:
Dr. John Wiesman is the secretary of health for the state of Washington and the current president of the Association of State and Territorial Health Officials. He explains how his department and others are putting the science into action.

WIESMAN:
Right, so, Healthy Starts is not something particularly new. Although, I will say over the last 5–10 years with some of the research around adverse childhood experiences and their impact on the life course, including chronic disease—that folks who experience childhood adverse childhood experiences have more chronic disease long-term, are more likely to use substances, initiate sex earlier, have unintended pregnancies—has just really, I think, raised the awareness of everyone.

And as we look at what we can do about that and what our role in public health is, has made this a topic of greater interest, I would say, in the last few years. So, it feels like—I think we are feeling of it more acutely.

JOHNSON:
This topic then, I assume, would represent a leadership opportunity for our state and territorial health departments?

WIESMAN:
Yes, absolutely. I think we in public health have leadership opportunities around raising the awareness of the importance of early brain development.

In Healthy Starts, we have a convenor role of pulling together partners from many cross sectors—whether that be early childhood folks, criminal justice, public health, human services—to really take a look at early brain development and how it is we can get ahead of the curve by paying attention to these first prenatal through three years, five years of life; to really support that brain being developed, that the neurons get connected, that the brain pathways are really ignited in a positive, healthy way.

So, that role of convener, of cross-sector around how we come together to support early childhood brain development, is an important role for public health; and to, I think, advocate for policies and programs, the best practices that support this—things like home visiting programs, nursing programs, and other programs that help support the parent in good parenting and the supports that they need for their health and human services.

JOHNSON:
Now, we've got some examples that we can share; but first, let's talk about how your state is tackling this issue.

WIESMAN:
Great. Yeah. Well, one of the things we're doing is we have a coalition of groups, which we call Essentials for Childhood—it's a grant from the Centers for Disease Control, we're one of five states with that—to focus on developing safe, stable, nurturing relationships and environments. We're taking a collective impact approach to that, and we're bringing together government with philanthropy and community organizations to find ways from a systems perspective that we can support these safe, stable, nurturing relationships and environments.

We're sort of taking a three-prong approach to this: whole child, and whole family, and whole community. So, the whole child piece is how do we help enhance parents' capacity to promote healthy child and youth development; and we are using a goal or metric there around increasing kindergarten readiness as our measure of success there. The whole family, we're looking at how we strengthen families and improve economic security, knowing that those are tied very much in terms of social determinants of health; and in that, we are looking at a measure about children having excellent or very good health as reported on the National Survey of Children's Health. And then for the whole community, we're really working on preventing and mitigating the impact of trauma and adversity; and our measure there that we're looking at is that no more than 10% of children would have two or more adverse experiences as reported by the National Survey of Children's Health.

So, we're really coming across sectors, taking this approach of looking at measures that we're focused on, and how each of our sectors can contribute to that.

JOHNSON:
With all of that being under the umbrella of early brain development?

WIESMAN:
Yeah, that's really sort of a big piece of the whole part is the early brain development, a piece of that in supporting—we know that safe, stable, nurturing environments help support the early brain development.

When parents are actively engaging their children in play, for example; providing a safe environment for a child absent of child abuse and neglect; healthy environments where substance use is not occurring; and if there are mental health issues in the family, that they're getting treated. All of those things, we know, really helps support that early learning—that early brain development—in a child.

JOHNSON:
How has it been going in Washington? You've been at this for a while—how long, and what are the results so far?

WIESMAN:
Yeah, that's a great question.

You know, we're really focusing on this systems approach, and we have focused on trying to grow a model called Help Me Grow, which really takes these assets and strengths of local communities and applies a system to this. So, the Help Me Grow approach has a centralized access point where families can essentially go to one place and get linked to services—in our state, Within Reaches is the organization that does that. The second component is doing family and community outreach to make sure that folks know about the services and can be connected to them. The third piece is child health provider outreach, to support the health care providers in this work around early brain development. And then, the last piece is data collection and analysis.

So, we are focusing on helping to grow and spread that across our state. There are a few counties that have it up and running, and we are looking to really take that state-wide. And what I like about this approach, again, it isn't one specific intervention that you do, but rather says, "What's happening in a community, and how do we support that?"

JOHNSON:
When you first began to roll out this concept in the state, was it welcomed?

WIESMAN:
It was, and in part—Washington State was one of those states that was really raising awareness really early on around adverse adverse childhood events, and that sort of primed the pump. And again, I think—as public health leaders—that's one of the things we can do, is prime the pump by raising awareness around the importance of this early first three, five years of life, as well as the concept of adverse childhood experiences and what one can do about it, how one becomes a trauma-informed community and organization.

And, in the simplest words, I think, to put that into is rather than, you know, asking a child when they're acting out or whatever, "What's wrong with you," we really ask, "What happened to you," and try and get at the root causes and address those and provide those sorts of supports and wraparound services for the children and family.

JOHNSON:
Were there any hurdles though? I mean, I imagine there must have been some challenge.

WIESMAN:
For sure—there are always hurdles. Some of those is—it's so large, where do you focus? What outcome measures do we want to specifically rally around? There are a lot of them that one can choose. And so, where one decides to focus is important.

I think another one is helping people understand that their work, which they don't traditionally maybe see as something that supports early brain development, really is connected. Things around play, for example, in childcare centers, you know, or communities.

I lived in the community in Vancouver, Washington that built a new library in the central district, and they incorporated an early learning center into the library, which—it isn't a school, it's a sort of a play center where kids interact with various exhibits, and learn, and play; and it teaches parents that play is actually growing a healthy brain. And so, it's exciting when communities sort of embrace this and see how it is they can support this work.

JOHNSON:
How do you know that this issue of early brain development may be a problem in your state or territory? What are the warning signs?

WIESMAN:
I think, you know, things around child abuse and neglect, mental health issues, you know—frankly, the opioid epidemic I think is one of those. The opiod epidemic is getting a lot of attention, but some of this is about people trying to medicate their pain, whether that be physical pain or psychological pain. And I think this is an opportunity to talk about how we get upstream again in prevention with the opioid epidemic and look at how do we really support those families from the beginning so that our children can be raised in these safe, stable, nurturing environments and have those important first relationships with adults that are healthy so that they can become resilient.

All of us in life are going to have adversity that we need to overcome; and if we can have that healthy brain architecture to start out with, that gives us a really strong starting place to be more resilient.

JOHNSON:
What would you say are the two or three key lessons that you've learned already from your experience as a champion linking early brain development to these health outcomes?

WIESMAN:
I think one is be patient—it takes time to do this work.

The second is you need to be out there talking it up and advocating for it. You have to raise the awareness and help people understand some of the science and the reason for doing this for them to engage.

And then, I think the last is to take the systems approach. This is about all of us coming together—whether we are in law enforcement, childcare, early brain, early learning communities, public health, health and human service sectors—coming together and thinking together around how we prevent adverse childhood experiences and how we support this early brain development. And like I said, it's as simple as helping people understand that play and talking to your child as you're changing their diaper and helping them grow their words is all about early brain development.

JOHNSON:
People listening to this that maybe aren't involved in this project but are thinking, "Hey, you know, we see these problems in our state. We want to tackle them as well," what can they do in the meantime?

Are there resources or places they can go to get more information to inform themselves about the approach, the best way to do this, right out of the box?

WIESMAN:
Oh, sure. You know, the Centers for Disease Control is one of those places in the group that has these a safe, stable, nurturing environments to relationships. The essentials for childhood work is a great place to start.

ASTHO, we'll be developing tool kits in the near future to help people get started and have resources. So, I would encourage folks to look for those later this year.

And working with your partners—if you're in state government, with your early learning agency, your education agencies, health and human services folks—is a great place to start and reach out to people.

Just simply doing an internet search around adverse childhood experiences and educating yourself is one of those ways to get started as well, as well as just searching for early brain development and looking at the science. Harvard has a great resource out there, as well, around the early brain research.

JOHNSON:
The tools Dr. Wiesman mentioned are due online in July. They're being developed by ASTHO with support from the Centers for Disease Control and Prevention through a cooperative agreement with the Office of State, Tribal, Local, and Territorial Support.

They'll include: a searchable database of scientific resources and promising programs and interventions; a how-to guide explaining the steps necessary to implement four different early brain development approaches; a tool to help states and territories assess current efforts against the best practices and programs in the nation; and a series of case studies drawn from current state programs intended to offer cutting-edge examples and inspiration for those looking to inform their own work or get started.

Watch for these exciting resources on ASTHO's website, www.astho.org, coming in July.

Next time on Public Health Review: what Nebraska and the federal government are doing to prevent outbreaks of nightmare bacteria—a discussion about anti-microbial resistance.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you've got comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.