Before age one, there is rapid and extensive dendritic growth and complex neurological development. Brain development is very vulnerable to environmental influences.The influence of early environment is long lasting. There is scientific evidence for the negative impact of early stress on brain function.Patterns are established for long-term family cohesion and communication.
Epigenetics: Personalized chemical signatureEpigenetics is any process that can alter gene expression temporarily or permanently without changing the DNA sequence (Mellor, Dudek &Clynes, 2008).The environmental experiences in the early childhood period act as stimuli that is carried into the brain as an electric signal.A biochemical cascade is created that can trigger structural and chemical changes on the genes, affecting the ability of the genes to switch on or off.The epigenome resembles the software in an computer, which determines the ‘dos’ and don’ts of the genetic hardware (structural genome).
An emerging multidisciplinary science of development supports an EBD framework for understanding the evolution of human health and disease across the life span. In recent decades, epidemiology, developmental psychology and longitudinal studies of early childhood interventions have demonstrated significant associations between the ecology of childhood and a wide range of developmental outcomes and life course trajectories. Concurrently, advances in the biological sciences, particularly in developmental science and epigenetics have made parallel progress in beginning to elucidate the biological mechanisms underlying these important associations. The convergence of these diverse disciplines defines a promising new basic science of pediatrics.Ecobiodevelopmental (EBD) framework for understanding the promotion of health and prevention of disease across the life span that builds on advances in neuroscience, molecular biology, genomics, and the social sciences.Together, these diverse fields provide a remarkably convergent perspective on the inextricable interactions among the personal experiences, environmental influences and genetic predispositions that affect learning, behavior and mental health across the life span
Parental deathAbusive parent steps in and is unable to provide the response the baby needsMother experiences abuse with no supportParents emotionally unavailable- no one else to respond Child exhibits behvioural symptoms
One parent is an abuserSecond parent removes child and her/himself from the situationParent accesses supportParental deathOther non abusive family members step in and provide the response the baby needs
Slide 7: Children need nurturing, loving environments for healthy developmentThis is a graph that was illustrated by the National Scientific council on the Developing child. As you can see, the horizontal line shows the number of risks a child may have, from 1 risk, to the red bar of 7+ risks. The vertical line shows the percentage of children with developmental delays. As you can see, the more risk factors a child may have, the greater risk of having developmental delays. For example, a child with 1 or 2 risk factors only has about 10% or less of a risk for developmental delays – opposite is true for a child who has more than 7 risk factors. Of course, this is a general overview, and there is no “cut off” of risk factors.. It varies from child to child. So, the aim of protective factors is to diminish as many effects of risk factors as possible.
The ALPHA ProjectEndorsed byThe Canadian Pediatric AssociationThe Canadian Psychiatric AssociationThe College of Family Physicians of CanadaThe Ontario Association of MidwivesThe Ontario Medical AssociationThe Royal College of Physicians and Surgeons of CanadaThe Society of Obstetricians and Gynecologists of CanadaFinancial SupportThe Lawson FoundationThe Ontario Medical AssociationThe PEI Reproductive Care CommitteeThe Women’s Health Bureau, Ontario Ministry of Health Women’s Health Program, The Toronto HospitalAdministrative SupportThe Family Healthcare Research Unit, DFCM, Faculty of Medicine, U of T
The ALPHA History1989ALPHA Group is formed1992Survey of Family Physicians in Ontario; need for an assessment form identified 1994Critical Review of the Literature revealed 15 antenatal factors associated with adverse postpartum outcomes of: woman abuse ( WA)child abuse ( CA) couple dysfunction (CD) postpartum depression (PD)increased childhood physical illness (PI)1995AntenatalPsychosocial Health Assessment Form, provider version (35 questions relating to15 antenatal factors) developed from review of the research literature. Piloted in Ontario; focus groups held and form modified by feedback from obstetricians, family physicians, midwives, nurses, social workers, childbirth educators ALPHA highly rated by pregnant women in the pilot//Provider’s Guide and video developedSelf-report ALPHA developed, tested on PEI: no differences in satisfaction, utility, yield 1998ALPHACARE- Community and Residency Education Expert panel convened in Ontario; Provider’s Guide and video revamped 2000 Care in Pregnancy Project RCT in Ontario of obstetricians, family physicians, midwives - domestic violence identified in self report form and utility of use revealed (43 questions with ranking 1-5 or yes/no /room for comments) ALPHA form integrated into Ontario Antenatal Record as tick boxesASSURE: ALPHA Screening and Substance Use Reliability Evaluation The self-report ALPHA tested with substance-using pregnant women2004 AIRS: ALPHA Inter-rater Reliability Study - good correlation from various practitioners observing use of ALPHA in 3 distinct case presentations
The Role of Family Medicine in Screening for Domestic Violence
ONTARIO COLLEGE OF FAMILY PHYSICIANSHEALTHY CHILD DEVELOPMENT:IMPROVING THE ODDSInterpersonal Personal Violence Screening inPregnancy and Creating Opportunities In PrimaryCare: Impact on Infant Mental Health and OptimizingChild Developmental Outcomes
The Early Years InterventionOpportunities to intervene Early Years Biological Environment Birth Genetic Conception Social / Ecological Environment
AAP Technical Report on the lifelong effects of early childhood adversity and toxic stress (Pediatrics Vol. 129 No. 1 January 1, 2012 pp. e232 -e246 )
Hyper arousal arousal Disrupts Dysregulated CNSSympathetic HPA axis CatecholamineNervous system HPA system Pathway Hyper vigilant Suppressed Hyper-reactive immune system “survival mode”
What is infant mental health?• Infant mental health is the social, emotional & cognitive well being of infants and toddlers • An infant’s mental health begins at conception • An infant can have serious mental health and emotional problems • Poor mental health of an infant and/or toddler is sometimes about the absence of “normal experiences, interactions or reactions” • An infant who experiences poor mental health this early in life, will be vulnerable for poor mental health throughout life• Infant mental health = healthy social & emotional development that includes the infant’s capacity to: • Experience, regulate, & express emotions • Form close interpersonal relationships • Explore the environment & learn
Developmental Consequences for Trauma Exposure• Sleep problems • Anxiety• Eating problems “Re- • PTSD experiencing” or playing out • Relationship problems – memories of the event including poor attachment or• Toileting problems attachment disorders• Withdrawal • Depression• Increased • Dysregulation of stress system clinginess/separation • Low self-esteem• Unresponsive • Preoccupation with the• Verbal or language difficulties traumatic event such as• Developmental regression bringing up the episode• Onset of new fears repeatedly or uncontrollably• Aggressive outbursts or increased activity level
Traumatic events/experiences Limited Protective Factors Baby or Toddler unable to recover from traumaInfant or Toddler suffering from poor mental health
Traumatic events/experiencesProtective Factors that maymitigate or minimize impact Baby or Toddler who has recovered from traumatic experience/event
Trauma Stress Brain Overalldevelopment Overall Relationship/ health development attachment
Children need nurturing, loving environments for healthy development… Source: National Scientific Council on the Developing Child (2004)
We Need to Move Beyond Surveillance and Beyond the PhysicalTypical Well Child Visit: Monitoring of physical growth and development• Counseling about development, safety, nutrition and community resources• Providing immunization and other preventive care In IPV: Review safety concerns for the child• Think about, discuss, and together identify any risks/problems for action• Consider referral to consultants, and community resources to support the child’s needsConsider Child Protection Referral if required for supervised access visitsNEW: Assess parent-child interactions and look at the emotional needs of theinfant. Interpersonal violence can cause major impact to the mental health ofthe child. Providing community support for the mother can be a supportivefactor that can buffer risk factors. Provide early intervention by screening atwell child visits.
Early Action for Suspected Infant Developmental / Mental Health Concerns when IPV is present• Family assessment in depth- identify supports and strengths• Refer to Public Health for Home Visiting and for family support• Consider whether Child Protection Services ( CPS) are required• Provide information about shelters and emergency agencies• Further assessment / monitoring of child’s developmental status• e.g. Hearing assessment / vision assessment Speech, language, motor assessment Psychological assessment /evaluate attachment concerns Full socio-emotional assessment Parenting Capacity assessment – role of supervised access visits• Early infant / child intervention programs• Family centers, play groups, child care centers• Respite care if required – includes Shelters in IPV• Social work referral for financial or housing issues
Comprehensive Assessment• Consider screening for intimate partner violence at all well woman visits and especially during pregnancy and the post partum period when risks are higher – ALPHA (Antenatal Psychosocial Health Assessment) – Three key questions: • Have you ever experienced abuse? • Are you or have you ever been afraid of your partner? • Are you safe? ALPHA: http://dfcm19.med.utoronto.ca/research/alpha ALPHA Video illustrates interviewing techniques
The ALPHA Forms Antenatal Psychosocial Health Assessment The ALPHA Forms are a reliable, valid, user-friendly tools to be used byobstetrical care providers for the systematic assessment of the psychosocial health of pregnant women.Suggestions for Use•Complete after 20 weeks gestation•Can be completed in 1 visit (20 mins) or over several regular prenatal visits•Give the self-report out for completion in the office –avoid sending home ifworries about woman abuse•Can bill for counseling/psychotherapy when appropriate•Be sensitive to cultural issues; use non-family interpreters•Discuss with the woman before sharing information (ie CPS concerns) ;maintain confidentialityRemember that associations do not imply causality!
The ALPHA Forms / Antenatal Factors1) Family Factors - Social Support (CA, WA, PD ) Recent Stressful Life Events (CA, WA, PD, PI ) Couple’s Relationship ( CD, PD, WA, CA )2) Maternal Factors - Prenatal Care ( Late onset ) (WA) Prenatal education ( refusal or quit) ( CA) Feelings towards pregnancy after 20 weeks ( CA , WA ) Relationship with parents in childhood ( CA) Self-esteem (CA, WA ) History of psychiatric/emotional problems (CA , WA , PD) Depression in this pregnancy (PD)3) Substance Use - Alcohol and Drug Abuse ( WA, CA ) CAGE utilized ( Cut down, Annoyed, Guilty, Eye opener)4) Family Violence - Woman or partner experienced or witnessed abuse (physical, emotional, sexual ) ( CA, WA) Current or past woman abuse (WA, CA, PD) Previous child abuse by woman or partner (CA) Child discipline (CA) Critical Review of the Literature 15 antenatal factors associated with adverse postpartum outcomes of: woman abuse (WA) child abuse (CA) couple dysfunction ( CD) postpartum depression ( PD) increased childhood physical illness (PI)
FAMILY FACTORSSocial support (CA, WA, PD) How does your partner/family feel about your pregnancy? Who will be helping you when you go home with your baby?Recent stressful life events (CA, WA, PD, PI) What life changes have you experienced this year? What changes are you planning during this pregnancy?Couple’s relationship (CD, PD, WA, CA) How would you describe your relationship with your partner? What do you think your relationship will be like after the birth?
MATERNAL FACTORSPrenatal care (late onset) (WA) First prenatal visit in third trimester?Prenatal education (refusal or quit) (CA) What are your plans for prenatal classes?Feelings toward pregnancy after 20 weeks (CA, WA) How did you feel when you just found out you were pregnant? How do you feel about it now?Relationship with parents in childhood (CA) How did you get along with your parents? Did you feel loved by your parents?Self esteem (CA, WA) What concerns do you have about becoming/being a mother?History of psychiatric/emotional problems (CA, WA, PD) Have you ever had emotional problems? Have you ever seen a psychiatrist/therapist?Depression in this pregnancy (PD) How has your mood been this pregnancy?
SUBSTANCE USEAlcohol/drug abuse (WA, CA) How many drinks of alcohol do you have per week? Are there times when you drink more than that? Do you or your partner use recreational drugs? Do you or your partner have a problem with alcohol or drugs?CAGE:1. Have you tried to Cut down?2. Do you feel Annoyed if someone mentions your drinking?3. Do you feel Guilty for drinking?4. Do you ever need a drink in the morning to get going?, Eye-opener)OR T-ACE (Tolerance, Annoyed, Cut-down, Eye opener)
FAMILY VIOLENCEWoman/partner experienced or witnessed abuse(physical, emotional, sexual) (CA, WA) What was your parents’ relationship like? Did your father ever scare or hurt your mother? Did your parents ever scare or hurt you? Were you ever sexually abused as a child?Current or past woman abuse (WA, CA, PD) How do you and your partner solve arguments? Do you ever feel frightened by what your partner says or does? Have you ever been hit/pushed/slapped by a partner? Has your partner ever humiliated you or psychologically abused you in other ways? Have you ever been forced to have sex against your will?Child discipline (CA) How were you disciplined as a child? How do you think you will discipline your child? How do you deal with your kids when they misbehave?
Setting the Context within Primary Care Practice• You are the health care professionals who see many women and children at regular intervals• You can provide women exposed to Intimate Partner Violence with insight into the impact on her child• You can be the broker for her to obtain support• You are able to observe the family “in action” including moments of distress for the child (ie immunization, illness).• There are questions you can ask as a Family Health Team member (physician/nurse/ midwife/ social worker) about many of the determinants of health including risk factors
Risk Factors Normal Child Child with CNS insult Nurturant Dysfunctional Nurturant Caring dysfunctional Dysfunctional IPV Caring Environment IPV Environment At risk Opportunity High To thrive riskFor Child: Interactions & Relationships with Caregivers are the most crucial elements in the Environment EPIGENTICS Nature and Nurture continuously Interacting