David W. Willis, M.D., FAAP Director of the Division of Home Visiting and Early

Childhood Systems (DHVECS)

Maternal and Child Health Bureau

Health Resources and Services Administration

Department of Health and Human Services

Health Equity and Young Children:

Overview of Federal and State Contexts BUILD: Health Equity and Young Children Conference

May 30, 2013

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Take Home Messages

• Building health and health equity are key MCH

strategic priorities

• The emphasis on the Prenatal-to-Three period is

required for building health and education

readiness for the next generation of children

• The ACA and the President’s Early Learning

Agenda have created an unprecedented

opportunity united and coordinated with

unified vision

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A League Table of Child Well-Being

Source: UNICEF, 2013

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Health inequalities can be seen as

an outcome of…

Social Inequalities

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What causes health inequities? “The social determinants of health are mostly responsible

for health inequities - the unfair and avoidable

differences in health status seen within and between

countries. The structural roots of health inequities lie

within education, taxation, labor and housing markets,

urban planning, government regulation, health care

systems, all of which are powerful determinants of

health, and ones over which individuals have little or no

direct personal control but can only be altered through

social and economic policies and political processes.”

WHO Commission on the Social Determinants of Health

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“Social Determinants of Health” Social-Physical-Economic-Services Determinants

• Income & income inequality

• Education

• Race/ethnicity/gender & related discrimination

• Built Environment

• Stress

• Social support

• Early child experiences

• Employment

• Housing

• Transportation

• Food Environment

• Social standing

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Differential Universality On average, disadvantaged children (neighborhoods)

have poorer outcomes. However, most vulnerable

children are in the populous middle class.

Socioeconomic

Disadvantage Socioeconomic

Advantage

Clyde Hertzman, MD

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Genetics:Orchid-Dandelion Hypothesis “Biological Sensitivity to Context”

W. Thomas Boyce, M.D., 2008

• Plasticity hypothesis, sensitivity hypothesis, or

differential-susceptibility hypothesis

• Gene x Environment Interactions

• Gene variants (orchid genes) • SERT gene – depression/anxiety – 25% population

• Alleles:

• S/S, S/L

• L/L

• DRD4 gene – externalizing behaviors and antisocial risk, ADHD, risk –

20% population

“Risk becomes possibility”

“Vulnerability becomes plasticity and responsiveness”

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9 Wilkinson & Pickett, The Spirit Level

Index of: • Life expectancy • Math & Literacy • Infant mortality • Homicides • Imprisonment • Teenage births • Trust • Obesity • Mental illness

– incl. drug & alcohol addiction

• Social mobility

www.equalitytrust.org.uk

Health and social problems are worse in more unequal countries

Inde

x of

hea

lth a

nd s

ocia

l pro

blem

s

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Significant Adversity

Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

Healthy Developmental Trajectory

Impaired Health and Development

Traditional Framework Guiding Early Childhood Policy and Practice

Source: Harvard

Environment of Relationships

Physical, Chemical & Built Environments

Nutrition

Gene-Environment Interaction

Physiological Adaptations & Disruptions

Biological Embedding During Sensitive Periods

Cumulative Effects Over Time

Foundations of Healthy Development and Sources of Early Adversity

Health-Related

Behaviors

Educational Achievement & Economic Productivity

Physical & Mental Health

Lifelong Outcomes

How Early Experience Gets Into the Body

A Biodevelopmental Framework

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A large portion of many health, safety and prosperity conditions is attributable to Adverse Childhood Experience. ACE reduction reliably predicts a decrease in all of these conditions simultaneously.

POPULATION ATTRIBUTABLE

RISK

Social-

economic

environment

Genetic,

Prenatal and

Neurodevelop-

mental Factors

Attachment and

Relational

Patterns

(ACE Scores)

LIFE COURSE Drivers of Developmental Trajectories

• Neurodevelopmental

• Social-economic

• Relational

Relational Health 13

Relational Health

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We’re in the “building health and

developmental assurance”

business…

Physical health

Developmental health

Relational health

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“Innovation lies at the intersection

between early childhood systems and

child health”

Jack Shonkoff, M.D, 2011 Harvard’s Center on the Developing Child

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New Protective Interventions

Building an Enhanced Theory of Change that Balances Enrichment and Protection

Significant Adversity

Healthy Developmental Trajectory

Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

Source: Harvard Center on Developing Child

Pediatric and

OB

Practitioners

CHC’s

Economic

Assistance (TANF,

WIC, Foodstamps)

Child Care

Centers

Head

Start

Family

Resource

Centers

Others

CBO’s

An Early Childhood System

Families

Home

Visiting

Programs

Subsidized

Child Care

Early

Interv.

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Birth

Early Infancy

Late Infancy

Early Toddler

Late Toddler

Early Preschool Late Preschool

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

Dev

elop

men

tal P

rogr

ess

Strategies to Improve

Developmental Trajectories

“At Risk”

Trajectory

“High risk”

Trajectory

“Healthy”

Trajectory

What will push children in red and yellow categories towards green?

Reading to childx

Pre-school Appropriate Discipline

Health Services

Anticipatory Guidance

Parent Responsiveness

Language Stimulation

High quality ECE

Home visiting

Specialized services

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MIECHV Maternal Infant and Early Childhood Home Visiting

• Section 2951 of the Affordable Care Act of 2010

• Amends Title V of the Social Security Act to add Section 511: Maternal, Infant, and Early Childhood Home Visiting Programs (MIECHV)

• A collaboration between MCHB and ACF

• $1.5 billion over 5 years

• Grants to states • 3% set-aside for grants to Tribes & Tribal Organizations

• 3% set-aside for research, evaluation, and TA)

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MIECHV Opportunities

• Advance the field of maternal and early childhood heath and development

• Translate science into policy • Demonstrate a data collection framework to drive

Quality Improvement practices • Impetus for frontier, rural and urban infrastructure • Catalyst for collaboration and partnerships • Systems integration of HV with early intervention

• Early Childhood Comprehensive Systems (ECCS) • Medical home • Early child care and education

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MIECHV Priority Populations • Families in at-risk communities

• Low-income families

• Pregnant women under age 21

• Families with a history of child abuse or neglect

• Families with a history of substance abuse

• Families that have users of tobacco in the home

• Families with children with low student achievement

• Families with children with developmental delays or Disabilities

• Families with individuals who are serving or have served in the Armed

Forces, including those with multiple deployments

continued

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Home Visiting Program Goals

Improvements in:

• Prenatal, maternal, and newborn health

• Child health and development, including the

prevention of child injuries and maltreatment

• Parenting skills

• School readiness and child academic achievement

• Family economic self-sufficiency

• Referrals for and provision of other community

resources and supports

Reductions in crime and/or domestic violence

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AAP Building Bridges Among Health and

Early Childhood Systems Project 2013

Goals • Establish collaborative leadership for EBCD

message carrying

• Emphasize the importance of “First 1000 Days”

across all EC systems

• Establish collaborations that yield linkages

between expanding medical home and EC

activities and programs

• Focus on “crossing the data divide” and

intentionally building health and developmental

capacity

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5 Critical Components

Medical Homes/ Health Care

Early Care and Education

Social-Emotional Development/Mental Health

Family Support Services

Parent Education

ECCS Critical Components

New ECCS Grant Opportunity

• Requires:

• Partnership with Early Childhood System teams

and, preferably, state AAP Chapter

• Strategy choices:

• Mitigation of toxic stress and trauma in infancy

and early childhood

• Coordination of the expansion of developmental

screening activities in EECC settings

• Improvement of state infant/toddler child care

quality initiatives by incorporating 10 or more

Caring for Our Children: National Health and Safety Performance Standards

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Breakthrough Early Childhood Activities

• Project LAUNCH (SAMHSA)

• MIECHV (Maternal Infant and Early Childhood Home Visiting)

• Help Me Grow

• ECCS (Early Childhood Comprehensive Systems)

• Race to the Top States

• TECCS (Transforming Early Childhood Community Systems)

• Place- Based Initiatives

• California: First 5 Alameda County, Magnolia Place

• Children’s Service’s Council Palm Beach County

• Promise Neighborhoods (US Department of Education)

• Magnolia Place

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Project LAUNCH: Dual Focus: Systems Change

Forging partnerships: public,

private, parents

Uniting around a common vision

for young child wellness

Scanning, planning, and

evaluating progress

Improving policies and practices,

smart spending, integrated data

systems and common outcomes

Young Child

Wellness Councils

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New Opportunities for

Collaborative Partners Yields new partners and innovation

• Health Reform

• Trauma informed systems / ACE scoring

• Triple Aim

• Information technology / unified data sets

• ReadyNation – ROI, workforce development

• Early education readiness as health outcome

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The Five Conditions of

Collective Impact Success • Common agenda – shared vision

• Shared Measurement – collecting data and measuring

results consistently

• Mutually Reinforcing Activities – differentiating while

still coordinated

• Continuous Communication – consistent and open

communication

• Backbone Organization – for the entire initiative and

coordinate participating organizations and entities

Source: J. Kania and M. Kramer, 2011 32

It’s all about: • Building health, First 1000 Days

• “Building brains, forging futures!”

• The earliest relationships and their sturdiness

• Breaking the generational transmission of abuse, ACE

transmission and toxic stress mitigation

• Partnerships and shared values of communities of all

agencies that becomes a collective impact approach

• A culture of quality, measurement and accountability

• Population approaches and management upstream

• Driving innovation in all we do

• Proven, wise and sustainable investments for young

children’s future

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Take Home Messages

• Building health and health equity are key MCH

strategic priorities

• The emphasis on the Prenatal-to-Three period is

required for building health and education

readiness for the next generation of children

• The ACA and the President’s Early Learning

Agenda have created an unprecedented

opportunity united and coordinated with

unified vision

34

Contact Information

David W. Willis, MD, FAAP

Director, Division of Home Visiting

and Early Childhood Systems

Maternal and Child Health Bureau, HRSA

301-443-8590

dwillis@hrsa.gov

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