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How early childhood experience determines our health

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People in Glasgow are more likely than other UK citizens to die prematurely, even when socio-economic deprivation is taken into account. This excess mortality is largely due to problem substance use, suicide and violence: the 'Glasgow Effect'.

There are compelling reasons to believe that experiences in utero and early childhood largely explain the Glasgow Effect through programming of the hypothalamo-pituitary-adrenal axis, through learned patterns of attachment to caregivers and through other learned behaviours. Several early indicators of vulnerability can now be identified and doctors should pay attention to them in the same way as they pay attention to blood pressure readings.

Lecture given to the Glasgow Southern Medical Society on Thursday 8th November 2012 by Prof. Phil Wilson, Professor of Primary Care and Rural Health, University of Aberdeen.

http://www.gsms.org.uk

Published in: Health & Medicine
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How early childhood experience determines our health

  1. 1. How early childhood experience determines our health Phil Wilson Centre for Rural Health University of Aberdeen
  2. 2. Overview • Childhood deprivation and health • Adverse childhood experiences • The “Glasgow effect” • Some possible mechanisms • Critical/sensitive periods • HPA axis • Parenting, social learning and attachment • Early identification of vulnerability • Glasgow maps • Future plans
  3. 3. • Low childhood SES associated with increased cortisol production regardless of current SES• Genome-wide transcription profiling: • Up-regulation of pro-inflammatory mechanisms • Down-regulation of glucocorticoid receptor-related mechanismsPNAS 2009, 106: 14716-21
  4. 4. 18 5118 -18 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 55 5318 -18 59 5718 -18 63 6118 -18 67 6518 -18 71 6918 -18 75 7318 -18 Scotland 79 7718 -18 83 8118 -18 87 8518 -18 91 8918 -18 95 9318 -18 99 9719 -19 03 0119 -19 07 0519 -19 11 0919 -19 15 1319 -19 19 1719 -19 23 21 Life expectancy trends19 -19 27 2519 -19 31 2919 -19 35 3319 -19 39 3719 -19 43 4119 -19 47 45 Source: Human Mortality Database19 -19 51 4919 -19 55 5319 -19 59 5719 -19 63 6119 -19 67 65 Portugal19 -19 71 6919 -19 75 7319 -19 79 77 Life expectancy: Scotland & other Western European Countries, 1851-200519 -19 83 8119 -19 87 8519 -19 91 8919 -19 95 9319 -19 99 9720 -20 03 01 -2 00 5
  5. 5. Comparing health outcomes in Glasgow with those ofalmost identically deprived cities Liverpool andManchester: premature deaths in Glasgow are over 30% higher, excess mortality found across men and women, all ages except the very young, both deprived and non-deprived neighbourhoods.
  6. 6. Standardised mortality rates by cause,all ages: Glasgow relative to Liverpool& Manchester All ages, both sexes: cause-specific standardised mortality ratios 2003-07, Glasgow relative to Liverpool & Manchester, standardised by age, sex and deprivation decile Calculated from various sources 350 300 248.5 229.5 250 Standardised mortality ratio 200 168.0 150 131.7 126.7 112.2 111.9 100 50 0 All cancers Circulatory system Lung cancer External causes Suicide (inc. Alcohol Drugs-related (malignant undetermined intent) poisonings neoplasms)Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010
  7. 7. UNICEF domains of childwellbeing • Material Deprivation – Relative Income, Households without jobs • Health & Safety – Infant Mortality, Immunisations • Educational Well-being – School Achievement, Post- 15 Education • Relationships – Family Structure, Peer Relationships • Behaviours & Risks – Health Behaviours, Experience of Violence • Subjective Well-being – Self-assessed indicators.
  8. 8. UNICEF comparisons Average Material Health & Educational Behaviours & Subjective Ranking Deprivation Safety Well-Being Relationships Risks Well-being Netherlands 4.2 10 2 6 3 3 1 Sweden 5.0 1 1 5 15 1 7 Denmark 7.2 4 4 8 9 6 12 Finland 7.5 3 3 4 17 7 11 Spain 8.0 12 6 15 8 5 2 Switzerland 8.3 5 9 14 4 12 6 Norway 8.7 2 8 11 10 13 8 Italy 10.0 14 5 20 1 10 10 Ireland 10.2 19 19 7 7 4 5 Belgium 10.7 7 16 1 5 19 16 Germany 11.2 13 11 10 13 11 9 Canada 11.8 6 13 2 18 17 15 Greece 11.8 15 18 16 11 8 3 Poland 12.3 21 15 3 14 2 19 Czech Republic 12.5 11 10 9 19 9 17 France 13.0 9 7 18 12 14 18 Portugal 13.7 16 14 21 2 15 14 Austria 13.8 8 20 19 16 16 4 Hungary 14.5 20 17 13 6 18 13 United States 18.0 17 21 12 20 20 N/A UK 18.2 18 12 17 21 21 20
  9. 9. Adverse ChildhoodExperiences study – 17,000Kaiser Permanente patients • Abuse • emotional – recurrent threats, humiliation (11%) • physical—beating, not spanking (28%) • contact sexual abuse (28% women, 16% men; 22% overall) • Household dysfunction • mother treated violently (13%) • household member was alcoholic or drug user (27%) • household member was imprisoned (6%) • household member was chronically depressed, suicidal, mentally ill, or in psychiatric hospital (17%) • not raised by both biological parents (23%) • Neglect • physical (10%) • emotional (15%)
  10. 10. A C E S c o r e v s In t r a v e n o u s D r u g U s e 3 .5 3 % H a v e In je c te d D r u g s 2 .5 2 1 .5 1 0 .5 0 0 1 2 3 4 o r m o re A C E S c o re p < 0 .0 0 1Felitti & Anda in: R. Lanius & E. Vermetten eds. 2010
  11. 11. Adverse childhood events and risk of alcoholism Hillis et al 2011
  12. 12. ACE and physical morbidity The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice) A C E S c o re v s . C O P D 20 18 16 Percent (%) 14 P e r c e n t W ith P r o b le m 12 10 8 6 4 2 0 ACE Score COPD Felitti & Anda in: R. Lanius & E. Vermetten eds. 2010
  13. 13. ACE and cardiovascular disease A C E s In c r e a s e L ik e lih o o d o f H e a r t D is e a s e * ¥ E m o tio n a l a b u s e 1 .7 x ¥ P h y s ica l a b u s e 1 .5 x ¥ S ex u al a bu se 1 .4 x ¥ D o m e s tic v io le n c e 1 .4 x ¥ M e n t a l il ln e s s 1 .4 x ¥ S u b s ta n c e a b u s e 1 .3 x ¥ H o u s e h o ld c r i m i n a l 1 .7 x ¥ E m o tio n a l n e g le c t 1 .3 x ¥ P h y s ica l n eg lect 1 .4 x • After correction for smoking, lipids, diabetes
  14. 14. Harsh parenting andconduct disorder • Strong association between erratic, coercive or punitive parenting and conduct disorder or other forms of aggression • The earlier the exposure, the greater the risk of CD • CD much more common in boys • Great variability between individuals in response to harsh parenting
  15. 15. Harsh parenting andconduct disorder • Dunedin cohort study: • MAO A gene – lower MAO A activity shown in animal studies to be linked to aggression • MAO A gene lies on X chromosome • Caspi et al (2002) looked at the link between MAO A genotypes and conduct disorder • High MAO A activity protects against the tendency of abuse to lead to violence
  16. 16. Child psychopathologyand later health • Few robust longitudinal studies • Selective attrition of children with problems • Lack of funding • But good evidence of, for example: • Strong associations between ADHD or conduct disorder and problem substance use • Strong associations between conduct disorder and later psychopathology • Substantial excess premature mortality with conduct disorder (RR>9)
  17. 17. What happens duringearly brain development? • Physical growth • Neuron numbers • Basic structure: cell migration ends by sixth month of gestation • Synaptogenesis and myelination
  18. 18. What happens duringearly brain development? Reprinted with permission – Prof Peter Seeman
  19. 19. Critical and sensitiveperiods • The visual system • Cataracts, hypermetropia and amblyopia • Amblyopia represents the selective pruning of synapses in the visual system as a result of lack of ‘through traffic’ • Partially preventable through patching • Children under 4 need less patching than older children, and probably pointless beyond age 7-8. • Is emotional, social and cognitive development like visual development?
  20. 20. Sensitive Periods in EarlyBrain DevelopmentHigh Pre-school years School years Numbers Peer social skills Symbol Language Habitual ways of responding Emotional control Vision Hearing Low 0 1 2 3 4 5 6 7 YearsGraph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.)
  21. 21. Early stress andthe HPA axis Hunter, Minnis, Wilson. Altered stress responses in children exposed to early adversity: A systematic review of salivary cortisol studies. Stress, 2011
  22. 22. Sandman et al. IJP 2011, # 837596.
  23. 23. Severe emotional deprivation • Long term outcomes in institutionalised Romanian orphans: • mild cognitive impairment • Impulsivity • Attention deficits • Social deficits • Abnormalities of HPA function
  24. 24. 00-046The Founders’ NetworkEvening Cortisol Levels Increase with Months of Orphanage Rearing * -0.2 -0.4 -0.6 -0.8 -1 *linear trendline -1.2 0 10 20 30 40 50 Months of Orphanage Rearing
  25. 25. Severe emotional deprivation • Chugani et al (2001): ‘Glass brain’ • 10 orphans (mean age 9, in orphanages from 5 weeks old for mean 3 years) and 24 controls • PET scans
  26. 26. Epigenetic mechanisms
  27. 27. Early identification –GUS* • Looking for predictors of persisting conduct problems at 3, 4 and 5 years • Used Strengths & Difficulties Questionnaire • 2070 children born in 2003 with SDQ data at all time points • Comparing: • 90 children with conduct problems at all 3 times • And 1557 who never had conduct problems *Wilson, Bradshaw, Tipping, Henderson, Minnis, JECH 2012 in press
  28. 28. Early identification -GUS Adjusted odds, C.I. and P value No. of natural parents in household Two One or none 2.10 (1.28, 3.44) <0.01 Child’s general health Very good or good Fair, bad or very bad 3.32 (1.35, 8.19) 0.01 Child had some difficulty being understood No Yes 1.93 (1.08, 3.44) 0.03 Maternal smoking during pregnancy No Yes 2.35 (1.32, 4.19) <0.01 Agree that smacking is sometimes the only thing that will work No Yes 2.07 (1.13, 3.79) 0.02 Frequency child taken to visit other people with children Fortnightly or more often Less often or never 2.16 (1.14, 4.09) 0.02 Frequency child is read to Daily Less often 1.86 (0.98, 3.52) 0.06
  29. 29. Early identification -ALSPAC • Avon Longitudinal Study of Parents and Children – 14,000 pregnancies • Videos (not very good!) of 10% sample of children aged one year and their parents, in 1992/3 • Psychiatric assessment at age 7.5 years (DAWBA)
  30. 30. Early identification -ALSPAC• 60 (6%) children had a psychiatric diagnosis: • 27 Conduct/oppositional disorder (CD, ODD, DBD NOS) • 6 Pervasive developmental disorder (autism) • 16 ADHD • 28 Emotional problems (anxiety, depression, phobias etc) • 12 with more than one diagnosis• Compared with 120 children with no diagnosis
  31. 31. ALSPAC findings sofar... • (Specialist) clinicians failed to predict psychopathology1 • Infant motor activity not associated with later ADHD2 1 Allely et al , RIDD 2012 in press 2 Johnson et al, IJMPR 2012 in press
  32. 32. Motion tracking
  33. 33. ALSPAC findings so far... • Increased infant vocalisation associated with later diagnosis of disruptive behaviour disorders (ADHD/CD) • MATERNAL hypoactivity is associated with later ADHD, CD/ODD and anxiety disorders* • Low levels of MATERNAL vocalisation are associated with later ADHD and CD/ODD* • Positive parenting behaviours associated with reduced risk of conduct disorder • Reduced mutual gaze and shared attention in conduct disorder ...even when adjusted for maternal depression *Marwick et al 2012, RIDD, in press
  34. 34. The Glasgow parenting supportframework evaluation • Three year project – 2011 to 2013 • Led by team at Glasgow University, in collaboration with NHSGGC – Public Health Resource Unit • Funded by Scottish Government and Fairer Scotland Fund • Multiple strands of data collection: • Triple P monitoring data • Population level data - assessing social, emotional and behavioural problems at various stages • Looking for population and individual changes • Qualitative interviews with parents and practitioners
  35. 35. The Strengths and Difficulties Questionnaire (www.sdqinfo.org)• A brief behavioural screening questionnaire for 3-16 year olds.• 2 versions – 3-4 years, 4-16 years• Can be teacher, parent or self-complete• Used extensively as before- and after- measure for range of parenting and family intervention studies as well as a population measure of children’s wellbeing e.g. GUS• NOT a diagnostic tool
  36. 36. The Strengths and Difficulties Questionnaire• 25 questions in 5 domains: • Emotional problems • Conduct problems • Inattention/hyperactivity problems • Peer-relationship problems • Prosocial behaviour• First four domains summed to give total difficulties score.
  37. 37. The SDQ in Glasgow
  38. 38. 30 month results80% eligible children received visit• ~20% had some language or SDQ problem identified• More than half the children with likely SDQ or language difficulties had been considered to be at low risk• 2/3 children with language delay also had ‘abnormal’ SDQ score
  39. 39. Pre-school results • Data from 2010-12 • About 10,500 children • Linear mixed effects modelling • Scores higher among boys, in looked-after children and in areas of higher deprivation
  40. 40. Where are we now?
  41. 41. Where next? • Analysis of local determinants of social/emotional development problems • Using data linkage to identify determinants of ‘good’ or ‘bad’ trajectories • A new birth cohort?
  42. 42. Acknowledgements • Carolyn Wilson and the SG Child and Maternal Health Division • Lucy Thompson, Louise Marryat, Kim Jones, Kelly Chung, Elsa Ekevall, Jane White • Chris Gillberg, Christine Puckering, Helen Marwick, Clare Allely • John Butcher, Amanda Kerr, Michele McClung, Morag Gunion and City of Glasgow Education Services • Margaret McGranachan and colleagues in PHRU • Sarah Barry, Alex McConnachie, Paul Johnson • Scottish Government produced the socio-economic data and Scottish Neighbourhood Statistics provided the datazone information.

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