9UNP1654HD_Dipesh_Navsaria_WordPress

- Welcome, everyone, to Wednesday Nite @ the Lab. I'm Tom Zinnen, I work here at the UW-Madison Biotechnolgy Center. I also work for UW-Extension Cooperative Extension, and on behalf of those folks and our other co-organizers, Wisconsin Public Television, the Wisconsin Alumni Association, and the UW-Madison Science Alliance, thanks again for coming to Wednesday Nite @ the Lab. We do this every Wednesday night, 50 times a year. Tonight it's my pleasure to introduce Dipesh Navsaria in pediatrics. He was born in London, England, and then grew up in New York City. He graduated from high from the Bronx High School of Science, and then went to Boston University where he majored in biology and English literature. Then he got a Master of Public Health at Boston University, and then he went to the University of Illinois and got a Master of Science in library and information science. And as a person who used to work at the Dixon Public Library in high school, it's a very good thing to have a librarian in the house. 

Then he got his master's degree, excuse me, his MD degree at the University of Illinois. He came here in 2006 for his fellowship and, since 2009, has been on the faculty here. Today he's going to talk with us about "Early Experiences Elevate Everything: Early Brain and Child Development." Please join me in welcoming Dipesh Navsaria to Wednesday Nite @ the Lab. 
[applause]

- Good evening. Thank you very much. It's a delight to be here. One of the things that I really enjoy doing is talking about the work out there. 

I will tell you up front that I'm actually a crummy researcher, so why I'm in something with the title "lab" in it is kind of interesting. But I like to take other people's research and really say how can we package this, how can we understand it, and how can we apply it to the world around us so we can use that to drive good programs, good policies, and good advice that we give to folks. I will also answer the question that most people have when they hear my short bio and see all the letters after my name: Yes, I have a lot of student loan debt. 
[laughter]

So I'll get that out of the way there. So in the medical world we always have 
[mumbling on purpose]

 etc., etc. 
[laughter]

 Although, as you will, I'm not sure if the FDA has ever formally approved mouthing as a use of board books. 
[laughter]

 This is actually my son who's now 15 and is highly embarrassed that I show this, so I try to show it as often as I can. So on our short voyage together tonight, we're going to talk about the world of the early brain and the development of children. We're going to talk a bit about the science about it, about what we know out there. The result of what happens when things don't go so well. We'll talk about some principles of solutions and one example of a solution that gets at that. And then, finally, kind of wrap that all together. But now let's talk a bit about the science of the early brain. The American Academy of Pediatrics, which is one of my primary professional homes, has this agenda for children that they lay out. 

And this one's from a few years ago, but still in the middle are some of the central priorities for the Academy. And you can see early brain and child development is still there in that kind of key portion of what the Academy is looking at. And, really, it's something that we've done and worked on and I'm proud to have served on the national leadership group for the Academy on this. Now, over 10 years ago, the National Scientific Council on the Developing Child said let's take all the research that's out there about children and let's see if we can pull these things together into key points, into key points that we can use to guide policies, programs, and the advice that we give because there's a lot of work out there and it's sometimes hard to know, well, should I follow this? Shouldn't I? Is this going to be disproven? What's really the big picture that's out there? And even though this report is over 10 years old, all the principles in it hold true today and in fact have been strengthen by the research since then. So I want to walk us quickly through those items. One, they came out and said child development is a foundation for community and economic development. 

We're not used to talking about children this way, right? We should help children because they're good. Children are worth helping, right? We don't talk about them as part of infrastructure development. But the thing is, the infrastructure of the early brain is as much a part of our future economy and our society as highways and bridges and tunnels and airports and so on. So when we talk about economic development, we shouldn't be talking just about those items, but we should be talking about brain infrastructure as well, because those highways and bridges and tunnels don't mean anything if there's no one left here to use them. Right? If they've all gone elsewhere. So we need to recognize how key that is. Number two, brains are built over time. 

This means that what you do early matters because it affects what happens over time, but it also means that you can't just give up. You can't just say, "Yay, we funded the first year of life." "We did everything you told us to." "We can stop now", right? No. You need to keep going, right? You need to support the gains that were made all the way through and part of adulthood. But that also means if we didn't get it right early on, we still have a chance. Brains are built over time. We have a chance to do it later. 

It's harder. It's more difficult, but it's not impossible. So brains are built over time. There's a three-legged stool for children's development and their trajectory for both development and health. One is the biological stuff that we look at all the time in healthcare. These things are important and they matter. But then we recognized it wasn't just the biology. That the socioeconomic environment that a child is born and brought up in matters. In fact, a child's zip code that they live in matters more than their genetic code when it comes to their outcomes, and a few blocks can make a critical difference. And then we realized it wasn't just the broader socioeconomic environment, that there was something else. 

It was the micro environment around the child. Who's at home? How are they interacting? Who's in their childcare center? Who's in their neighborhood? Those back and forth attachments and relationship patterns matter just as much as the other two things. And that brings me to the third point, that there's two things that affect the wiring of the developing brain. How those neurons are wiring together in those first thousand days of life. And that's your genes and your experiences that you have. And you can't have one without the other. 

Okay? It's like a campfire, you need that wood and you need that spark to get that fire going. Now, you can't change genes so much, I will have no time to talk about that today, but we can change experiences. And how do we talk about experiences? How do we change those experiences? We do it through the advice we give. We do it through programs we set up, and we do it through policies we enact. Those are the levers we can pull. And then if you say, okay, but what is it that's critical? What's the active ingredient that really makes a difference to a child's development and guides how those neurons wire? 

It's how the child's interacting with others. What we call serve and return, like in tennis when that ball is served and your partner volleys it back. Those serve and return interactions. Those loving, nurturing, mutually responsive interactions that happen are what drive development. In fact, they are just about the only thing that drives development. Okay? If you take nothing else away from tonight, what drives development is interactions with other people. There is no toy, there is no app, there is no DVD that does anything that's been proven to children under age two in terms of their development or their learning. I don't care what it says on the box or the web ad or anything like that. As one of my colleagues once said, "There is no app to replace your lap." 

T-shirts available in the lobby. 
[laughter]

 No, okay. But really, parents get anxious, they get worried, they want the best for their children, and they're spending money on these things. They're getting suckered by marketing. Okay? What a child needs is a loving, responsive adult in front of them. And we'll spend some time talking about that. I'm going to play a video for you. I used to work for Ed Tronick, when I was an undergrad. 

He's the director of the Child Development Unit at Children's Hospital in Boston. He created this face-to-face paradigm that he'll explain. You'll see what happens when these back and forth interactions go well, what happens when they don't go so well for a short period of time, and then the recovery that happens when it's short-lived. I'll let him explain. 

- Babies this young are extremely responsive to the emotions and the reactivity and the social interaction that they get from the world around them. This is something that we started studying 30-40 years ago when people didn't think that infants could engage in social interaction. In the still face experiment, what the mother did is she sits down and she's playing with her baby who's about a year of age. And she gives a greeting to the baby. The baby gives a greeting back to her. This baby starts pointing at different places in the world, and the mother's trying to engage her and play with her. 

They're working to coordinate their emotions and their intentions, what they want to do in the world, and that's really what the baby is used to. And then we ask the mother to not respond to the baby. The baby very quickly picks up on this, and then she uses all of her abilities to try and get the mother back. She smiles at the mother. She points because she's used to the mother looking where she points. The baby puts both hands up in front of her and says, "What's happening here?" She makes that screechy sound at the mother. "Like, come on, why aren't we doing this?" Even in this two minutes when they don't get the normal reaction, they react with negative emotions. They turn away. 

They feel the stress of it. They actually may lose control of their posture because of the stress that they're experiencing. 
[baby crying]

- Okay. [baby crying]

I'm here. And what are you doing? Oh, yes. Oh, what a big girl. 

- It's a little like the good, the bad, and the ugly. The good is that normal stuff that goes on that we all do with our kids. The bad is when something bad happens but the infant can overcome it. After all, when you stop the still face, the mother and the baby start to play again. The ugly is when you don't give the child any chance to get back to the good. There's no reparation, and they're stuck in that really ugly situation. 

- So I used to code these videotapes as an undergrad. The hard part was not seeing interactions like that. That was what we expected to see. The hard part was when the mom would go into the still face and the baby wouldn't do anything. 

Just didn't seem bothered by it. Why? Because they weren't used to this back and forth interaction so they didn't feel the loss of it. Now, I want to be very clear about something. I don't believe for a moment that any of the parents in our studies, or any parents anywhere really, don't love their kids, don't care about them, don't want the best for them. You know, it's universal that parents love their children and want the best for them. That no group, socioeconomic, cultural, etc., has cornered the market on loving their kids and wanting, you know, the best for them. The thing is, we think of this back and forth interaction as being automatic and natural and instinctual. It's not. 

It's learned behavior. And we learned it from watching other people around us. Right? How do you know how to do peek-a-boo? That's not hardwired. You saw someone else do peek-a-boo and you saw the baby respond and you tried it yourself and, you know, back and forth and great. But if you're growing up in neighborhoods, environments, cultures, whatever, where interacting with young children doesn't happen routinely, for whatever reason, you don't know that. So here's the thing, we've done a really good job as a society of bridging an information gap, right? We have ads on the bus and billboards and other things that say talk to your child, read to your child, play with your child, sing to your child. Right? 

We've seen a million of those, right? They're all over the place. And no parent that I've worked with, and I've worked with a lot of families that are in underserved populations and so on, I've had no parents in the last five years who, when I say that to them, they look at me in surprise. They've seen the ads. They've seen the brochures. They've seen all this stuff. So we've bridged that information gap. They know it. Here's the problem: we have a skills gap. Right? 

Parent goes home, sits down their six-month-old, starts talking to them. A six-month-old's not going to talk back, right? So you start to feel a little weird. You know, a little stupid, right? What am I doing? And am I saying the right things? Maybe I'm not saying the right things. Oh, you know what? I didn't do so well in school. Maybe I'm the wrong person to be talking to my child. 

Maybe I should put them in front of this learning DVD, right? It's made by educators. That's better for them. I'll mess them up. Right? You see what happens? You get into this cycle where the parent says I'm not going to do this right and I don't even know if I can do it right. So what do we need we need someone to not just bridge the information gap but to bridge the skills gap. And that takes someone saying, "Yeah, modeling it for them, "coaching them, just to simply say yes, you're doing it right. "Yes, that's how you should do that," and so on. 

It's not just about dropping some information on them and handing them a few things and saying, here, go on and do it. You know? Can you imagine if we did that in healthcare? Hey, let's go put a central line in that patient, it's fine. Yeah, you'll be okay, just figure it out. No, that would be terrible. None of us would want that. So why do we expect parents to do this? So we need to think about modeling and coaching and so on. This next point is simple. 

You need simple circuits and skills in order to do more complex things. So when people say things like, why are we putting money, all this money into children just playing? That's what all these daycares are about, right? They're just playing. How expensive can that be? That's a profound misunderstanding of what early childhood education is about. Playing is that child's job because that's how they develop their skills. Play is the work of infancy, as T Berry Brazelton said. So if you want to think of early childhood centers as being early workforce development, be my guest, because that's essentially what it is. This next point we'll spend a few moments on this idea of toxic stress. 

And I'll define that more carefully in just a moment. But toxic stress is associated with persistent effects on the neuroendocrine system and causes lifelong problems, not just in behavior and learning and all, but also in very real measures of physical health that we can show you. So if I put up these two head CT scans, you may not know how to read a CT scan. This is two three-year-old kids and this is a slice through the head kind of looking up. Okay? The child on the left is a typically developing child. Okay? You can see the size of the brain, etc., there. The child on the right is a child who underwent extreme emotional neglect. 

Okay? Not physical neglect. They were bathed, they were clothed, they were fed, but there was very little interaction. This is a child from an eastern European orphanage in the 1980s. Tons of kids, very few staff. Okay? So that made a big difference there. You can see, just without knowing much about a head CT, there's a big difference between these two. That brain on the right is much smaller. That doesn't look as dense with neurons. 

It's kind of shrunken looking, right? I'm giving you an extreme example because if you can see this without a whole lot of training, you can see how profound the effect is. There's more subtle changes that we'll talk about a little bit later that we can see that are in less extreme circumstances. Now, let's talk for a moment about stress in our society. So, first of all, is there anyone here who has absolutely zero stress in their lives? Okay, good. I'm glad no one raised their hand because if you did, I'd have to come over and check for a pulse. 
[laughter]

 Stress is part of being a living being. Okay? 

It's how we cope with changes in our environment. Temperature changes, noise, work stress. You know, family questions, you know, at stressed out times. New skills that we don't know. You know, sound not working on your computer. You know, all those sorts of things. And how we take that stress and how we deal with it changes over time. Even newborn babies have stress, right? They feel hunger. That's a stress and they have a stress response to it and so on. 

This is part of being a living being. If you have zero stress, you have absolutely zero incentive to change. So nothing happens. If you have too much stress, you get overwhelmed and start coping in maladaptive ways, as you'll see. But somewhere in the middle is the sweet spot, right? Where it's just enough stress that, ah, okay, you can cope, you can learn, you adapt, you learn new skills, all those sorts of things. Simplistically, we put out a couple of hormones, epinephrine, cortisol, which is known as the stress hormone, and we often see and use that as a marker for how much stress is happening. So conceptually, we can have three levels of stress. We have positive stress. Little bits of stress hormone. 

This is good. This is how you learn new things. This is how you adapt, etc., etc. This happens every time I get up to give a talk. That's great, right? You don't want me falling asleep up here, forgetting what I'm going to say, so on and so forth. Being able to cope when something happens. So when the sound didn't work, yes, I've had that happen before and I knew exactly where to go and look and fix that quickly. Okay, learned that. 

So small amounts of stress help. Then we have bigger stressors that are tolerable. These are not minor things. Stress levels go up but then they come down after a while because the situation improves, and they're buffered by this idea of supportive relationships. The supportive relationships piece is really, really key, as you'll see, because then you have toxic stress. Toxic stress is not necessarily a single bad stressor. It may not even be a worse stressor than tolerable stress, but it's prolonged. It's there for longer periods of time, and there's few or no of the supportive buffering relationships to get in the way. So in a child's life, what if the things are worse. What if they don't have those good buffering supportive relationships, right? 

And there's that relationships piece again. These are things that sadly happen too often. Child abuse. Parental substance abuse. Homelessness. And these are often prolonged, right? They're not often just these short little snippets and that's it. These are often things that are affecting a child's life over a long period of time. These affect the biology of young children profoundly, and when I say young children, I'm talking about under age five, in different ways. So if you're 11, and everything was fine and then bad stuff happens at 11, I'm not going to say it's great but I'm also going to say guess what, you already have a lot of coping mechanisms and strategies that allow you to deal with it. 

But a young kid? A one-year-old, a two-year-old, a three-year-old? Their brains are still plastic. They haven't developed a lot of those coping strategies yet. So what happens is it affects their brain in such a way that we call it toxic stress because that toxic stress has a profound impact on what happens. So, what's the cycle that happens? They have these childhood stressors that occur. That leads to this fight or flight, right? This cortisol, epinephrine release sort of thing, to become chronic. It wasn't meant to be chronic. 

It was meant to deal with when you're walking in the woods and you suddenly see a bear, right? Mortal danger, safety, all those sorts of things. You release more of these hormones, it causes changes in the brain, in the architecture of the brain, what we'll talk about in just a moment, but the upshot is you get a child who has this hyper-responsive stress response. They're not as calm. They can't cope as well. And this is what we see in our preschools and in our homes and so on. And then that feeds into more stress. So think about this. You take two three-year-olds, you take one three-year-old who had a loving household, good responsive nurturing relationships, very minimal stressors around them and so on, and they go to preschool and they're in story time and the preschool teacher, the kid talks out of turn, the preschool teacher gets a little frown on their face because the kid's talking out of turn. To this child, oh, yeah, frown on the face, when I see that at home, that means I did something I shouldn't, oopsy, you know? 

And they stop talking. No big deal. Then take a child whose home has been filled with witnessing violence, being abused, emotional neglect, so on and so forth. And put them in that same classroom. And that teacher gets that little frown on their face for the same thing, right? Talking out of turn or something. And what happens? To that kid, that doesn't mean oopsy. It means uh-oh, something bad's going to happen. I'm going to get hit. 

Something's going to get thrown. Yelling's going to start. And what do they do? They dive under the table. They run down the hall screaming. They start flailing. They curl up in a ball, you know, and shut down. And everyone says, "What's wrong with this kid?" That's not the right question. The question shouldn't be what's wrong with you, the question should be, what happened to you? 

What happened to you that made that a response that worked for you? That doesn't mean that it's okay for the kid to go running down the hall, right? We still need to maintain safety and orderly classrooms and all that stuff, but it helps us start asking the right questions, to say, hang on, this kid needs some help, and we need to find the right help and really try to make a difference for them by asking the right questions and figuring out what's going on. So what happens to the brain? There's three areas I want to focus on. And this is work that's been down right here on the UW-Madison campus actually by Seth Pollak's lab. The amygdala. The amygdala activates a stress response to fear, to survival, all that sort of stuff. Amygdala lights up. It's larger on MRI scans of kids who've had adversity early in life versus those who haven't. 

Countering the amygdala are two areas. One is the prefrontal cortex, right? This is your logic. You're thinking through things. What we call executive functioning. Planning. Delayed gratification. All that stuff. When you do functional MRI, you see less activity in that part of the brain. There's less neural density and so on. 

And then you have the hippocampus. It plays a big role in memory and mood. The hippocampal volumes are actually smaller, again, in kids who had that early adversity. So there seem to be some qualitative changes in the brain. Now, this is all well and good, but I'm a primary care pediatrician. I do not go order head MRIs, actually on almost none of my patients. A specialist wants one, they can get it. But I do not order these. They're expensive and a pain in the neck to get and, honestly, they are not going to change a lot about what I do. And no parent has come in and said, "Hi, doctor, we're here today to see you because I'm worried that my child's hippocampal volumes are too small." 
[laughter]

 It hasn't happened. It might happen someday, but... Instead, what I hear is parents come in and they say, "I'm worried, school's concerned "because there's some things going on with my child." "They're impulsive." "They can't plan ahead." "They're anxious." "They can't delay gratification." "Their memory's crummy." "Their mood's all over the place." 

So what does this sound a lot like? Well, this sounds a lot like what we often call ADHD. Now, there are kids with classical ADHD. They're trying, school's trying, parents are trying, everyone's trying. Home's supportive, all that stuff. They just can't pay attention. My goodness. Those kids tend to do pretty well, actually, with a relatively small dose of medication. And their grades and performance come up and they take off and fly. Their self-esteem goes up. 

Everyone's happy. Great. Wonderful. That is a minority of the patients that I see typically in the populations I work with. Oh, yeah, we often have them labeled as ADHD and we often are giving the medication and all that, but you know what? They still don't do so well. They still struggle. They're still having behavior problems. And then we look for the right medicine, we adjust doses and all that. We still never get a satisfactory response. 

So what I've learned is when I do my evaluations, I start from the beginning. I say to the parents, "Okay, tell me everything that happened. "Start prenatally and walk me through their life "and tell me what happened and not just what were their APGAR scores "and the birth weight and whether they were hospitalized and surgeries and all that. "Tell me other things. Tell me, were you ever homeless?" "Was there always enough food to eat in your home? "Did your child ever witness domestic violence? "Was your child ever the subject of violence?" And what do I hear? Yes, yes, yes, and yes. 

And I realized that by the time I'm seeing this kid at age six or eight or 13 or whatever, the pileup of these stressors that have happened, and what I'm thinking to myself is, is this really just ADHD or is what I'm seeing the brain changes associated with adversity? It's adversity. Now, here's the problem. I nor anyone else has a magic medication to make this go away. There are evidence-based therapies, but we got to find someone who knows how to do them well, and they do exist. We need to make sure insurance pays for it, and we need, the family has to be able to take advantage of it. Right? I have families that look at me and say, "I would love to go to this therapy "that you're talking about weekly with my child "for the next several months to help them get back on track. "I nearly got fired from my job just to come here today. "I can't commit to weekly. 

"I will lose my job, we will lose our home." It's not that the stressor is magically just lifted from their lives. So if we can prevent this, then we'll see much better outcomes and results over time. So, what happens when this adversity occurs? I talked a little bit about it. There's something called the Adverse Childhood Experiences Study. How many of you have ever heard of this? Yeah, so only a couple of hands, which is why I call this the most important study you've probably never heard of. And even in the medical community, when I do grand rounds and all, I don't get all that many hands even though this came out in the '90s. This was a landmark large study looking at 17,000 adults that had prior histories of abuse and trauma in childhood and looked to see what happened to them across their lives. 

Large cohort, really well done. I want to point out that this is a study of the middle class, having attended college, mostly Caucasian, etc., etc., split between men and women evenly. This is not a study of poor people because people often think, "Oh, it's a study of adversity, This must be a study of underserved populations." No. This is a study of the general population, which makes the results so astounding. They looked at these different categories of abuse and neglect, and there's certainly more that you could add but this is what they went with. The numbers appearing on the right are the prevalence of these things in this population. Just look at these numbers for a moment. 

These are sky high. Okay? 26% said they were physically abused at some point during their childhood. A quarter of middle class people who went to college and all that stuff, right? Even 6%. That's one in 20. These are really, really high numbers. And these numbers are not a fluke. They have repeated the ACEs study over and over. They've done state specific ACEs studies. 

Wisconsin actually has several cohorts work that they've done. And they're finding about the same numbers over and over and over again. I was even at a conference for childhood abuse and trauma, I gave a talk much like this one, and at the break they handed out those little audience response clickers because they're anonymous and did the 10 questions with them, the 10 categories, the numbers for people in the room around us were eerily similar to these. So this is very common. Now, you can't measure intensity, right? How do you say one person's abuse is worse than someone else's? There's not a way you can really quantify that. But you can give them a point for each of these categories, right? You can add up categories. And that's how they came up with something called an ACE score. 

They gave one point for each category listed. And 26% had just one, but four or five or six categories? About one in 20 for each of those. And they found that there was kind of a cumulative effect that happened. So just to show you a couple of things. This is your risk of developmental delay compared to your ACE score. If you had five, six, or seven adverse childhood experiences, you had 75% to nearly 100% chance of having developmental delay in the first three years of life. And developmental delays, tough, right? You got to take all this time to put things together. You know, assess, screen, assess, you know, diagnose, therapy, all those things. 

Okay, so, big difference. Compared to one or two ACEs, almost none. This one blew my mind when I first saw it. This is your risk for adult heart disease. Seven or eight adverse childhood experiences triples, triples your risk for heart disease as an adult compared to someone who had none. Tripling of odds. And I could show you another 50 slides for a variety of conditions, mental health, learning issues, and other medical issues as well. What happens early matters. But if we create the right conditions, coming back to that report, the last point they made was if we create the right conditions for early childhood development, it's more effective and less costly than trying to figure it out later on. So if you think about a child's trajectory from birth to kindergarten entry, you got the kids who are on the healthy trajectory. 

We want them to stay there. You got the kids that we can label as high risk, right? The 26-week preemie. We know they're at high risk. You can say 
[clicks tongue]

 , do stuff for them. And then you got the kids that we can't label so easily who we call at risk. There's many more of them out there and they also won't do so well. Here's the thing: adversity pushes down on all these curves. 

It's not that you're magically immune. So we need good protective interventions to shield children from the effect of the adversity. And that's through those protective relationships and so on. So what are the sorts of things we can do? Well, for healthy kids, good anticipatory guidance, proper reading together, proper discipline, good health services, preschool, etc., or the kids who are at risk, you do all of that plus you can do parental responsiveness training. Right? The parent who doesn't know how to do the face-to-face play? We can model that and do it, and it's not that hard to show it a few times and they get it. They pick it up very quickly. 

Good language stimulation from people not products. They need to hear words from people around them. The TV doesn't count. And good high-quality early childhood education. And then the highest risk kids, all of that plus home visiting, specialized services, and so on. As Jack Shonkoff at the Harvard Center on the Developing Child says, there's a few ways we can really make a difference. One, we need to reduce the emotional and behavioral barriers to learning. This is actually absolutely huge. I have tons of kids I have worked with who are absolutely brilliant. They have fantastic intellect and they are flunking out of school. 

This is a problem not just for that kid or that family or that neighborhood or me or the community, this is a problem for us as a society. Why? Because if that kid had gotten the right conditions, what might that intellect have produced for all of us? Might they have figured out how to cure cancer? Or get us to Mars? Or world peace? Right? Which kid might have figured out Alzheimer's and how to address that? Which might affect us or our kids or our grandkids or whatever. This is like leaving oil in the ground. 

We're just saying forget this natural resource of this powerful intellect there because we can't be bothered to provide the right support. Okay, we all lose out when those kids don't do so well. Number two, children live in families. I know that seems obvious, but people forget. You can't transform the lives of children if you don't transform the lives of their parents. Who am I to tell a parent they should be reading to their child every night when they look at me and say, "I can't. "I'm at my second job because "that's how we make ends meet." Okay? You don't give people a living wage, well this is the fallout. I just talked to a reporter today about family leave and pointed out that family leave is one of those things that helps these strong, supportive relationships build in those first critical thousand days of life that mean we spend less money later on rehab and remediation and so on. 

It actually pays off, but people don't see that. They just see that as, "Oh, you're just at home vacationing with your child. Yes, because parenting is a vacation, right? 
[laughter]

 No it isn't. I have teenagers. It's not a vacation. 
[laughter]

 And then health and well-being is not just medicine's job, it's everyone's job, because as the UW Population Health Institute reminds us, of all the different things, all the different health factors that play into health outcomes, only 20% is clinical care. The rest of health behaviors, it's socioeconomic factors, and it's physical environment. 

So it's much broader than just the health world. So a few numbers to remember. There are 700 new neural connections happening per second in the developing brain. We want those to happen well because brain plasticity is important and brain plasticity changes. We lose cellular plasticity or the beginnings of cellular plasticity by the time the hit kindergarten. Number two, we can measure disparities in vocabulary as early as 18 months. Okay? Three different socioeconomic groups in this graph. The bottom is the age from 10 months to 36 months. The vertical is their cumulative receptive vocabulary, their ability to understand words. 

And you can see right here the richest kids are already pulling away from their less affluent peers. The middle-class kids by two years are pulling away. The achievement gap is not an issue of middle schools not doing their job right. It's not an issue of elementary schools not doing their job right or even preschools. Preschool is off to the right side of this graph. If we can measure it here in toddlerhood, you know darn well those brain changes start in infancy. We will fix the achievement gap when we do serious and substantial investment in the first thousand days of life. This is why I get troubled by the focus sometimes we see on summer slide and all that. Those are important, don't get me wrong. I think we need to do that. 

But we need to look at the roots of why are kids losing their reading across the summers so easily when they don't have a strong foundation in reading early on and so on. Okay, we need to be going early, early, early if we're going to figure this out, because for every dollar we put into early childhood, we're seeing four to nine dollars in returns. Who says that? Folks like James Heckman, who's a Nobel Laureate in economics at the University of Chicago. He's made it his life's work. The Minneapolis Federal Reserve Banks has reports saying similar things as well. And Frederick Douglass told us long before we had MRIs and all that, "It is easier to build strong children "than to repair broken men." Okay, so now that I've depressed everyone thoroughly-- 
[laughter]

 What can we do about all of this? 

I will give you the solution. Well, not really. I'll give you principles of solutions, because this is a complex issue, right? With a lot of moving parts and a lot of different factors that play into it. So what do we need? We need solutions that do a bunch of things. We need to build capabilities. The parent who doesn't know who to do face-to-face play? We can teach them that. We can show them how to do that. 

We need to build capacity. They might say, "Yes, I know how to do all this, "but I'm working my second job." "I can't be there for my child in the evening" or "I'm exhausted because my diabetes is out of control "because I have no health insurance." Fix those things and help lift some of that burden off that parent so they can do the good job of parenting that they want to do and that they know how to do. We need to do things that are based in homes and communities. Don't make them trek across town to campus, right? Do things right where they are because that reduces the burden and load on them that they're already experiencing. I had a parent just this afternoon who showed up a half an hour late. They were the last patient of the day, of course. Half hour late and I said, "Yes, we'll see them," because I know that family. 

I know how much stress that mother's under, and she has to take two or three buses just to get to us. She's doing the best she can. I said, "Yes, we will stay here and we will see you'" because I know that for her to come back would be absolutely massive. We need to address root causes, right? Don't just say, "Yay, we made some test scores change." No. Did you actually make the kid and their family's life better? We need to have long-term effects, use a prevention mindset. We want to leverage those key first thousand days of life. We want to use things that are evidence-guided. 

You notice I don't say evidence-based. If you only do things in pediatrics that are evidence-based, you will do the same 12 things over and over. We don't have as broad a research base as we'd like. So yes, do more research. Yes, build out that evidence base, but funders who insist solely on evidence-based stuff are going to get the same thing repeated over and over and over, and they're going to see no innovation as a result. Okay? So we need to try common sense, try a little, you know, experimentation to see what might work. And then, finally, we need things that are scalable. This is the hard part. We have some great programs that work really well. 

Home visiting, for example. Home visiting is fantastic, has great outcomes, great evidence base. It's expensive per family, so we can't scale it out. So, yes, we should fund home visiting more. I completely agree with that. I've written newspaper columns saying we should do that, right? But we also need to think we're never be able to scale home visiting to reach everyone who needs it. So what can we do also that we can take to scale? So if we want to have good, productive, happy adults who are able to participate fully in society and all, how do we get to that? Well, we need them to be educationally successful. 

Okay, great. So how do we get to that? We need brain circuitry primed for school success, as I've just laid out for you. Okay, so how does that happen? It's through those early experiences we talked about. And how does that happen? It's from those nurturing, responsive interactions when they're young children. Again, all we said. So how do you get that? Well, you need it through adults who can put the skills into action, you know, who have that ability and making sure they have the capability and capacity to do all those things. 

So how do we get to that? Ultimately, it's through the advice, the programs, and the policies we set up. And that ultimately is the chain of things that we're trying to set off here. It's a whole chain of things that will happen and happen well if we get it right early on. So we can do things like home visiting, which are intensive but, because they're expensive, small initiatives. Or we can also do broader but scalable larger initiatives that maybe don't have as much impact but can hit a large amount of the population, in all. So an example of a broader initiative is one that I'm associated with called Reach Out and Read. I showed you that back and forth, parent/child interaction video that was filmed there. Down the hall from where I was working as a research assistant was the primary care clinic at Boston City Hospital, and I heard about this little tiny program where they were giving out books to children and telling them to read at their checkups and telling families to read to their children and so on. That was actually where Reach Out and Read was born. 

It's now in all 50 states, 6,000 clinics, serving six million children, blah, blah, blah. Reach Out and Read is an early literacy program that runs out of clinics, primary care clinics, using the checkup, the regular checkup that people are already coming to and adding in a literacy component to that and advice and all. And here's the thing. We say it's an early literacy program, it's actually not really that. It is kind of that, but it's really a parenting program. Right? We're trying to skill build for parents how can they read effectively with their young child so we can get to those nurturing, responsive interactions and familiarity with books and texts and all that stuff. And if I had to summarize the whole thing in a single graphic, it would be this item here, the prescription to read. I actually hand these out in clinic. I give them at the State Capitol and at the capitol in DC when I do advocacy for Reach Out and Read because I really mean this because of all the stuff I've told you today, this may be the most important prescription I ever hand a family because if this works, so to speak, that child is set on the path for life-long success, and that life-long success means better health, better outcomes, better well-being for them all the way throughout their life, including adulthood. 

So this is really important. I won't dwell on the model, but I want to say it's kind of like, Reach Out and Read and programs like it are like the elephant and the blind man who are all touching and feeling different parts of the elephant. And, you know, because people see different things when it comes to Reach Out and Read. People say, "Oh, you're giving away books to kids in clinic, that's wonderful." I say, "Yes, we're doing that." But, you know what? We're also doing all sorts of other things. Because I walk in with the book in my hand and I give it directly to the child. Me, not the nurse, not the receptionist or anything. Because I want to see what is that child doing with the book? 

How are they manipulating it? How are they interacting? Are they saying words? Are they pointing at things? Do they hold it out to their parent in that "read to me" gesture? Oh, they tell me volumes when they do that because they're saying, "I know what this this is. "This is that thing that if I go up to my parent "and if I hold it out, I trust that they're going "to pull me up into their lap and open it "and we're going to spend some time looking at it together." I know about home life and all those sorts of things. So not only is it a book giveaway, it's an educational intervention, right? Get them familiar with the concepts of texts and so on early on, so we set them off to a good educational path early. 

It's a way for me to look at their development, look for language, fine motor skills, etc., etc., even gross motor skills when they run across the room to grab the book from my hand. I can do all these parts of my job much easier. I can build parental capacity by showing them how to effectively read with their young child at a young age. There's a technique called dialogic reading that we can show parents. We don't call it that because it sounds technical and scary, but we show them how to read to that squirmy toddler because some parents aren't really sure how to do that and they get easily discouraged. It buffers toxic stress, that few moments in the evening of having your child tucked in next to you and being able to just share books together. It's a way to assess relationships in the family, a public health approach, and it's a scalable, evidence-based, there's actually a strong published evidence-based model. So ultimately, programs like Reach Out and Read are not just any one of these things. 

They really are, it's all of these things. And we can do it cheaply and easily through an existing network of clinics that already are doing, that people are bringing their kids to in a near universal, non-stigmatized fashion. And if you want to know more about these various facets of Reach Out and Read, a colleague and I actually wrote a report called "The Elephant in the Clinic." Free download from online. This URL actually might be broken. I need to fix that. But if you go to Google and type in "The Elephant in the Clinic," the page pops right up. Free PDF download. It is a co-publication of Reach Out and Read National Center and Aspen Ascend, which is a two-generation fellows program that I'm in. When I moved here in 2006, there was about 30 clinics in the state doing Reach Out and Read. 

They worked with National Center. There was no statewide coordinating body to kind of help training, technical assistance and so on. I got a few things started here. There was one in Dane County, believe it or not. Only one clinic, which shocked me, right? Madison, come on, you know? By the time we hit 2010, we had gotten up to about 50 clinics. About 10-11 clinics in Dane. And then we founded Reach Out and Read Wisconsin, which is our statewide coordinating body, a program of the Children's Health Alliance of Wisconsin, and boy have we been busy. In that time, we have gone from 55 to-- We're actually at 210 as of this month. 

And so on. Serving almost a quarter of children in the state. Clinics are flocking. I mean, clinics are busy, right? They're not looking for new programs. They are like banging down our doors. I had one colleague actually email me like every two weeks, saying, "So when can you get us set up? When can you get us set up?" Because they're seeing how well this works. So I wanted to share Reach Out and Read as that example. 

It's not merely advice or a book giveaway, it's a process of parental skill-building and support and modeling and saying to them, "You're doing it right," and having them say, "Ah, I get it." And we're using already existing, skilled, trusted professionals to deliver this message. So there's a lot of programs out there that get books to kids. That's great but if the family doesn't really know how to use them effectively, I don't know what the efficacy of those programs are. We need to make sure that they're getting that modeling, that coaching, and so on, and that's really what's critical. And, again, we have an evidence base for that. So, to wrap this all up, thinking about early brain and child development, I like to use this sort of public health model of thinking about how we can build healthy brains. We know kids are going to fall, and we need a net to catch them. The first net is a big net. It's also got some big holes. 

But this is what everyone gets. These are your primary preventions, your guidance, your Reach Out and Reads, your high-quality childcare, etc. The kids who fall through there? We need a net to catch them. This net has smaller holes. This is your screening net, your targeted interventions, your Head Starts, your home visiting, your early intervention, etc., and hopefully we catch most of the kids that do fall through. There's still going to be a few because this isn't a perfect system. For that, you bring out your smallest net. This is an expensive net so you can't do it big. 

But you hope there's only very few kids making it down to the treatment net. All these levels are necessary, none on their own are sufficient. You can't just do the top one or the bottom one alone. You need to have it in this stepwise fashion. I want to close with this quote from the Sutton Trust, which is based in the United Kingdom, but I think it's very apt for us as well: "While schools can do much to raise achievement among "children who initially lag behind their peers, all too "often preschool gaps set in train a pattern of ever "increasing inequality during school years and beyond. "Any drive to improve social mobility must begin with an "effective strategy to nurture the fledgling talent in young "children so often lost before it has had a chance to flourish." This is why I do this work. This is what I see with my patients. This is what I see in communities. That fledgling talent often doesn't have a chance to fly. 

So whatever we can do to support children, support parents in these sorts of roles in important. And I always close with this. This is a picture of my wife reading to my son. I caught them in this moment years ago of being lost in a book together. It reminds me that children are made readers in the laps of their parents, but also that parents are their child's first and best teachers. We need to nurture them in that role, let them see themselves in that role, and support them in that role as much as possible, because that is where we will ultimately see the best payoff overall. Up there, my campus email address, as well as social media that's public-facing. You're welcome to follow me on Facebook, Twitter, etc., post things about child health, advocacy, policy, children's books, etc., etc., 

or feel free to follow along on any of those. So, thank you for your attention tonight, and now I can take questions from folks. Thank you. 
[applause]