““All Children deserve the right of full participation in community life” Dr Dan Offord Dr Fraser Mustard “Investing in expectant mothers and their young children is a powerful equalizer and a key tool for economic and social stability.”

Why are some people healthy and others not?

“Poor social policies, unfair economics and bad politics are killing people on a grand scale.” Sir Michael Marmot

Families or Society 5

National Scientific Council on the Developing Child (2010). Early Experiences Can Alter Gene Expression and Affect Long-Term Development: Working Paper No. 10. Retrieved from September 28, 2010.

Graphic courtesy of Center on the Developing Child at Harvard University. Originally published in Nelson, C.A. (1999) Change and continuity in neurobehavioral development: lessons from the study of neurobiology and neural plasticity. Infant Behavior and Development, Volume 22(4) Cited in InBrief: The Science of Early Childhood Development, presentation summary from the National Symposium on Early Childhood Science and Policy, Cambridge, MA, June 2008.

From Aitken and Trevarthen Sound Vision Smell Touch Proprioception Taste SERVE AND RETURN Concept also from Centre on the Developing Child at Harvard University 10

High SES Medium SES Low SES Words Million Age of child in months Estimated Cumulative Difference in Language Exposure by 3 Years of Age B. Hart & T. Risley, Meaningful Differences in Everyday Experiences of Young American Children, 1995

Disparities in Early Vocabulary Growth 16 mos.24 mos.36 mos. Cumulative Vocabulary (Words) Child’s Age (Months) College Educated Parents Working Class Parents Welfare Parents B. Hart & T. Risley, Meaningful Differences in Everyday Experiences of Young American Children, 1995

Sensitive Periods in Early Brain Development Vision High Low Years Habitual ways of responding Emotional control Symbol Peer social skills Numbers Hearing Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.) Pre-school yearsSchool years Language

Cradle to Prison Pipeline The burden of mental health problems and early criminality will be driven by the level of vulnerability in social-emotional development in the early years. Thus, our strategy should focus on reducing vulnerability early in life.

Life Course Problems Related to Early Life 2 nd Decade 3 rd /4 th Decade 5 th /6 th Decade Old Age School Failure Teen Pregnancy Criminality Obesity Elevated Blood Pressure Depression Coronary Heart Disease Diabetes Premature Aging Memory Loss

Trends in Fair/Poor Self-Rated Health by Sex, 1991–2011 (Grades 7, 9, 11 only)

Self-Esteem Items (% Agree) by Sex, 2011 OSDUHS (Grades 7–12)

GHQ12 Symptoms Experienced Over the Past Few Weeks by Sex, 2011 OSDUHS (Grades 7–12)

The ACE Study is perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life. 18,000 participants! The majority of participants were 50+ (62%), were white (77%), and had attended college (72%).

Differences in stress reactivity of adult rats are determined by maternal licking and grooming (LG) during infancy HIGH LG LOW LG Development of Stress Reactivity Modest Stress Reactivity Reduced Risk for Poor Development & Disease Increased Stress Reactivity Increased Risk for Heart Disease, Type II Diabetes, Alcoholism, Affective Disorders, Brain Aging, etc. M. Szyf

Gene Transcription: Maternal Behaviour in the Rat (Meaney, M., Szyf, M. et al ) Gene Transcription: Maternal Behaviour in the Rat (Meaney, M., Szyf, M. et al ) Pregnancy DNA methylation at GR promoter Regulation to subordinate roles Low maternal licking and grooming Epigenetic expression of GR Behavioral Inhibition Upregulation of HPA reactivity

Methylation Dr R Gibb U of Lethbridge Epigenetics Is any process that can alter gene activity without changing the DNA sequence.

The Influence of Environment The influence of the early environment is long lasting... …a child’s experience during the ‘early years’ affects their health, learning, and behaviour for their lifetime.

Vulnerability to School Readiness Question: What percentage of Ontario senior kindergarten students (without special needs) have vulnerabilities with regard to school readiness to learn? Answer: Based on the Early Development Instrument (EDI), almost 30% of Ontario non-special needs students score below the 10th percentile on at least one readiness to learn domain (i.e. physical health and well-being, social competence, emotional maturity, language and cognitive development, or communication skills and general knowledge). 14% are low on at least two readiness to learn domains. Source: The Offord Centre for Child Studies, McMaster University, Early Development Instrument: School Readiness to Learn Ontario SK Cycle 2 Results based on the Early Development Instrument Data Collection for Senior Kindergarten Students in Ontario, 2010

WHAT DOES THE EDI MEASURE?

HAMILTON EDI SCORES

SUDBURY EDI SCORES Low on 1 or more domain reflects the prevalence of vulnerability

Did You Know? Question: What percentage of Ontario children aged 0-23 months made more than 50% of their primary care visits to a GP/FP or Paediatrician? Answer: 96% of children in Ontario made more than 50% of their visits to a GP/FP (69%) or Paediatrician (27%). Source: Jaakkimainen L, Upshur R, Klein-Geltink J, Leong A, Maaten S, Schultz S, Wang L., Institute for Clinical Evaluative Sciences (ICES), Primary care in Ontario, November 2006, electronic version of the report posted June 3, 2009, accessed September 15, 2010,

Role of Primary Healthcare Providers Role of Primary Healthcare Providers Enhanced 18- Month Well-Baby Visit A consistent, focused, developmental review and evaluation completed by a primary healthcare provider in collaboration with parents. The use of standardized assessment tools: Nipissing District Developmental Screen (NDDS) TM Rourke Baby Record (RBR) Promotion & Risk Reduction Education and anticipatory guidance Identification of developmental concerns Promotion of development Risk reduction and prevention by identification of risk factors Early assessment and intervention Monitoring & Follow Up Collaborate with community providers Follow up: progress, results, intervention, outcomes

Preparing Parents for the Enhanced Visit

Rourke Baby Record

OHIP Schedule of Benefits Fee Changes OHIP Schedule of Benefits Fee Changes New OHIP Fee Code Enhanced 18-month well baby assessment fee of $62.20 (GP/FP – A002; Pediatrics – A268) Use of the Enhanced Fee The new fee can be used when rendering a well baby assessment on a child between the ages of months Requirements of Fee Code 1.A review with the caregiver of a brief standardized tool (completed by the caregiver) - Example: Nipissing District Developmental Screen and 2.An 18 month age appropriate developmental screen - Example: Rourke Baby Record

Figure 1: Claims for enhanced well-baby visits over time, by physician specialty, in Ontario, October 2009 to December 2010

Figure 2: Proportion of children months of age with an enhanced well-baby visit, by Local Health Integration Network, in Ontario, 2010 The overall proportion of eligible children receiving the enhanced screening is 38.2%

Determinant of Health Lens Figure 3: Proportion of children months of age with an enhanced well-baby visit, by income quintile, in Ontario, 2010 As income quintile increases, the proportion of children receiving an enhanced 18-month well-baby visit increases.

Supporting Provincial Implementation Education and information strategies for primary care New Enhanced 18-Month Well-Baby Assessment Fee Interactive NDDS TM guide for parents Public education portal Health care provider central web portal Incorporating the NDDS TM and RBR into the electronic medical record Pictorial Version of NDDS TM Future directions…

Acknowledgements Jodie Bousfield, instructional technologies John Bousfield, web programming Marie Levesque, instructional technologies James Monkman, graphic design Program Development Team Jean Clinton, MD, FRCPC, Offord Centre for Child Studies, Project Lead Anthony J Levinson, MD, FRCPC, McMaster University, Project Lead Peggy Carter-Arrowsmith, RN(EC), NP, MNSc Umberto Cellupica, MD, FRCPC Lisa Colizza, MEd., BA (Psych), BEd, McMaster University Linda Comley, MD, CCFP, FCFP, PG Cert. Adl Psychotherapy, Ontario College of Family Physicians Sarah Garside, MD, PhD, FRCPC, McMaster University Jan Kasperski, RN, CEO Ontario College of Family Physicians Patricia Mousmanis, MD, CCFP, Ontario College of Family Physicians Technical Development Team, Division of e-Learning Innovation, McMaster University