Aboriginal primary health care, Early Childhood and the Nurse Family Partnership and Abecedarian programs Donna Ah Chee, CEO

Introduction 1.Central Australian Aboriginal Congress 2.Aboriginal Health Status in the NT and early childhood development 3.Early Childhood: the evidence base 4.The Nurse Family Partnership Program 5.The Abecedarian Educational Day care Program and the Congress pre-school program

Children’s Services Health Education & Training CAACAC Board CEO Deputy CEO Alukura Childcare Ingkintja Services Social & Emotional Heath Lowitja AMSANT Remote Health NACCHO CARHDS Directorate Public Health headspace

Congress Urban Unique Clients: Health Service Area and Visitors

Congress Episodes of Health Care (all)

Aboriginal Health Status in the NT and Early Childhood

COAG Reform Council report. Healthcare : Comparing performance across Australia. May 2013

COAG Target 1: Life expectancy Life expectancy at birth, by Indigenous status, sex and selected state/territory, 2005–2007

COAG Target 1: Life expectancy Main causes of Indigenous mortality, NSW, Qld, WA, SA and NT,

Australian Early Development Index

NAPLAN Year 3 Reading

Early Childhood: The Evidence base

“Babies are born with 25 per cent of their brains developed, and there is then a rapid period of development so that by the age of 3 their brains are 80 per cent developed.” Ref: Allen G. Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government. HM Government, UK. Jan

“A child’s development score at just 22 months can serve as an accurate predictor of educational outcomes at 26 years.” Ref: Allen G. Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government. HM Government, UK. Jan

Evidence is clear that nutrition and experiences in the early years of a child’s life influence the infant’s brain development.

“In the brain, the ability to hold onto and work with information, focus thinking, filter distractions, and switch gears is like an airport having a highly effective air traffic control system to manage the arrivals and departures of dozens of planes on multiple runways. Scientists refer to these capacities as executive function and self-regulation—a set of skills that relies on three types of brain function: working memory, mental flexibility, and self-control. Children aren’t born with these skills—they are born with the potential to develop them”.

Regulation needed by other Capacity for regulation by self Regulation needed by other Capacity for regulation by self Development Healthy development Child has experiences in early life that enable development of regulation. Child becomes less dependant of external figure (ie parent) to regular emotions and is able to manage challenges without emotional breakdown or physical outburst Unhealthy development Child does not have experiences in early life that enable self regulation in adult life. Functioning is never developed to the extend that emotions and impulses can be managed. Individuals who do not have regulation display problems in later life such as alcohol abuse, mental health problems, impulse control that require control by external systems including legislation and agencies such as police and mental health services

Major longitudinal study Followed a cohort of 1000 children from birth to age 32 96% retention, Dunedin, New Zealand

The California Adverse Childhood Experiences Study Links between childhood maltreatment and later life health and well-being. 17,000 participants. Adults who had adverse childhoods showed higher levels of violence and antisocial behaviour, adult mental health problems, school underperformance and lower IQs, economic underperformance and poor physical health. The scientific rationale for Early Intervention is overwhelming Anda RF, Felitti VJ, Walker J, Whitfield CL, Bremner JD,Perry BD, Dube SR, Giles WH (2006) The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience 256(3): 174–86.

Negative experiences in the early years have long- lasting effects that can be difficult to overcome later. Ref. McCain MN, Mustard JF. Reversing the real brain drain: Early Years Study- Final Report. Ontario Children’s Secretariat pp25-26

Hart and Risley in Shenk, D, the Genius in All of Us, Doubleday, 2010 “The differences were astounding. Children in professionals' homes were exposed to an average of more than fifteen hundred more spoken words per hour than children in welfare homes. Over one year, that amounted to a difference of nearly 8 million words, which, by age four, amounted to a total gap of 32 million words. They also found a substantial gap in tone and in the complexity of words being used “ In addition there were more positive affirmations in the professional households compared with more negative affirmations in the welfare households

Mothers’ Speech and Infant Vocabulary Ref: Huttenlocher et al, Developmental Psychology, (1991)

Audible television is associated with decreased exposure to discernible human adult speech and decreased child vocalizations. These results may explain the association between infant television exposure and delayed language development. Ref: Christaki DA et al. Audible television and decreased adult words, infant vocalizations, and conversational turns. Arch Pediatr Adolesc Med. 2009;163(6):

“What parents do is more important than who they are. Especially in a child’s earliest years, the right kind of parenting is a bigger influence on their future than wealth, class, education or any other common social factor.” Ref: Allen G. Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government. HM Government, UK. Jan

Key Initiatives For Health Improvement Immunisation Smoking Prevention/ Cessation Home VisitingSchool Connectedness Breastfeeding Early Educational Infant Day-care Maternal Education Advocacy - enhance social, political, economic and physical environment; legislation (eg. seatbelts), structural changes (eg housing design) ConceptionBirth2 years5 years 12 years 18 years Community Development Population Parenting Programs

NURSE FAMILY PARTNERSHIP’S THREE GOALS 1.Improve pregnancy outcomes 2.Improve child health and development 3.Improve parents’ economic self-sufficiency

TRIALS OF PROGRAM Low-income whites Semi-rural Low-income blacks Urban Large portion of Hispanics Nurse versus paraprofessional visitors Elmira, NY 1977 N = 400 Memphis, TN 1987 N = 1,138 Denver, CO 1994 N = 735

CONSISTENT RESULTS ACROSS TRIALS  Improvements in women’s prenatal health and dramatic reduction in arrests, convictions and jail  Reductions in child abuse, mortality and children’s injuries  Fewer subsequent pregnancies and greater intervals between births  Increases in fathers’ involvement  Increases in employment and reductions in welfare dependency  Improvements in school outcomes  Less addictions, sexual partners and a healthier lifestyle at age 15

NFP at Congress 6 nurse home visitors and 3 Aboriginal community workers Recruitment has not been a problem Need to present prior to 28 weeks 140 births per year 70% acceptance rate higher for first time mothers Increasing early presentations Reduction in smoking and enhanced language development in children

The Home Visit / Domains Mother is visited by the same Nurse Home Visitor and throughout the program (therapeutic relationship, linked to outcomes). Frequency is between weekly and bi-weekly (potentially over 60 visits) Content of visits is prescribed (Pregnancy, Infancy and Toddler NFP guidelines) The 6 program domains: 1. Personal Health (e.g. access to ANC, substance use, nutrition, mental health) 2. Environmental Health (e.g. safety around the home) 3. Life Course Development (e.g. resume schooling) 4. Maternal Role (e.g. physical and emotional care of baby, parenting) 5. Family and Friends (e.g. building strong net works) 6. Health and Human Services (e.g. housing)

Congress Nurse Family Partnership 38

NFP: Outcomes for 213 accepted clients 39

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Washington State Institute for Public Policy Economic Analysis Nurse Family Partnership produced large return on investment: – Implementation costs $9, 118 – Benefits $26, 298 – Return on investment$17, 180 *Benefits and Costs of Prevention and Early Intervention Programs for Youth, S. Aos, et al.. Washington State Institute for Public Policy: Olympia, WA, 2004.

Learning Games: Teachers daily engage in short interactive sessions (adult/child interaction games) with individual children or very small groups (e.g., 2 children). Learning Games: Teachers daily engage in short interactive sessions (adult/child interaction games) with individual children or very small groups (e.g., 2 children). Conversational Reading: Teachers use a 3S strategy to read a book individually every day to every child. Conversational Reading: Teachers use a 3S strategy to read a book individually every day to every child. Language Priority: Teachers use a 3N strategy to surround spontaneous events with adult language. Language Priority: Teachers use a 3N strategy to surround spontaneous events with adult language. Enriched Caregiving: Teachers encourage children to practice skills (e.g., cooperating, listening, counting, colour recognition) during care routines. Enriched Caregiving: Teachers encourage children to practice skills (e.g., cooperating, listening, counting, colour recognition) during care routines. The Abecedarian Approach All 4 elements of the Abecedarian Approach are shared with parents through home visits and through carers in day care Centre's from 1 to 3 years

Abecedarian studies

Long-term Health Results for at risk Children with Abecedarian Fewer risky behaviors at age 18 (p<.05) Fewer symptoms of depression (p<.03) at age 21 if there was a medicine that produced this odds ratio all children would be on it! Healthier life styles. The odds of reporting an active lifestyle in young adulthood were 3.92 times greater compared to the control group: if there was a medicine that produced this odds ratio all children would be on it! McCormick, et al Pediatrics. McLaughlin Child Development. Campbell et al., Early Childhood Research Quarterly.

% of children in Normal IQ Range (>84) by Age (longitudinal analysis) Martin, Ramey, & Ramey American Journal of Public Health

Stanford-Binet X Maternal Education Ramey & Ramey Preventive Medicine..

Educational Attainment: Percent College Attendance Campbell et al., Applied Developmental Science. At age 21, almost three times as many individuals in the treated group (39.5%) compared to the control group (13.7%) had attended, or were still attending, a 4-year university. χ2(1, N = 104) = 6.78, p <.01

Post-High School Education for Teen Mothers Whose Children Were in the Abecedarian Program Ramey et al Applied Developmental Science Percent of Group

Outcome for vulnerable children with 7 week Abecedarian pre-school intervention

Once enrolled children stay enrolled

Ref: Early Learning & Development - The first five years determine a lifetime. Children Now pment/

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