'From anatomy to policy ;how advancing neuroscience helped shape policy shift in the Early

Years in Scotland '

Dr Kate McKay

Senior Medical Officer

Scottish Government

Aim of Presentation

• Context of Child Health Services in Scotland• Changing Epidemiology• Understanding neurodevelopment in children• Epigenetics of maltreatment• Policy development in Scotland and

Improvement Science• Interventions in Early Years

Child Health Epidemiology

• Patterns of disease • Social determinants• Effects of poverty• Increasing parental expectations and public

consultation• Inter-relationship with other agencies• Reducing variability in service provision and

access

OUTCOME MEASURES -Health

• Infant Mortality rates• Child Death rates• ‘Survival rates ‘• Hospital admission and discharge

numbers• Attainment

http://www.economist.com/news

Child Deaths

• Child deaths due to injury in four UK countries 1980 to 2010

• P. Hardelid1, J. Davey1, N. Dattani1, R. Gilbert1 on behalf of the Working Group of the Research and Policy Directorate of the Royal College of Paediatrics and Child Health*

To examine trends in child deaths due to injury England, Scotland, Wales and

Northern Ireland between 1980 and 2010.

Whilst child deaths from injury have declined in all four UK countries, substantial

differences in mortality rates remain between countries, particularly for older

boys. This group stands to gain most from policy interventions to reduce deaths from

injury and poisoning in children.

OUTCOMES and QUALITY• Data• Data• Data• Data• Data

Early BRAIN DEVELOPMENT

In the first few years of life, 700 new neural connections are formed every second. After this

period of rapid proliferation, connections are reduced through a process called pruning.

Connections proliferate and prune in a prescribed order, with later,

more complex brain circuits built upon earlier, simpler circuits.

The molecular biology of a cuddle

Child Development –nature and nurture

• First 1000 days critical – prenatal and postnatal enviroment

• Effects of maltreatment on development persist across the life course

• New genetics suggest certain genotypes are a risk factor in adversity , but also confer resilience

Epigenetics• DNA alone cannot explain all inherited

biological traits• Histones act as spools around which the

DNA is wound and control whether or not particular genes are switched on

• This may explain why enviromental conditions such as stress or diet can influence the function of genes passed onto offspring

Cicchetti,Rogosch and Toth (2011)

Serotonin Transporter gene -5HTTLPR s/s genotype a risk factor in face of

adversity but a protective factor under supportive conditions

Genetic heterogeneity

Age ,socio-economic status ,racial/ethnic diversity all influence range of gene expression

Methylation of DNA

Differential Susceptability

HPA AXIS Dysregulation

Gunnar and Quevedo (2007 )

Hypothalamic-pituitary-adrenal (HPA ) axis

In Infants the developing HPA axis are particularly vulnerable to chronic stress especially in child maltreatment

Further reading

Relational interventions for child maltreatment; Past, Present, and Future

perspectives

Toth, Gravener-Davis,Guild,Cicchetti Dev Psychpathology Nov 2013

Triple Risk Model

ENVIRONMENT INFANT FACTORS

Critical period of

development

Interventions

Should be matched to genotype ?

How do genes affect intervention at a particular time to alter developmental process ?

• Relationships that are reciprocal, nurturing, purposeful, and enduring, are the foundation of a healthy early brain and child development.

Pediatrics Vol. 134 No. 2 August 1, 2014 pp. 404 -409 (doi: 10.1542/peds.2014-1384)

DESIGN DESIGN DESIGN DESIGN APPROVE

Conference Room

Real World

IMPLEMENT

The Typical Approach…

DESIGN

TEST & MODIFY

TEST & MODIFY

APPROVEIF NECESSARY

Conference Room

Real World TEST &

MODIFY

The Quality Improvement Approach

START TO IMPLEMENT

Quality Improvement Methodology

• Support, inspirational leadership, non-hierarchal, sharing, confidence to broach QI

• Enriching and empowering , learning reliance and success but from support networks locally and wider. Plan and prepare ...strategies for clinician engagement - what was in it for them and for patients and families to get a shared ownership .

Evidence based interventions

• Family Nurse Partnership• ‘Before Words ‘• Play Talk Read• Psychology of Parenting• Early Years Collaborative• Nurture Classes

Early Years – Shared Vision

To make Scotland the best place in the world to grow up in by improving outcomes and

reducing inequalities for all babies, children, mothers, fathers and families across Scotland, to ensure that all children have the best start in life

and are ready to succeed.

Early Years Collaborative

• Global Aim :Scotland is the best place to grow up and the best place in the world to bring up children

• First ever national , multi agency Quality Improvement Programme led by Community Planning Partnerships

Stretch Aims

• To ensure women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths(from 4.9 per 1000 births in 2010 to 4.3 per 1000 in 2015)

• And reduction of infant mortality from 3.7 per 1000 live births in 2010 to 3.1 per 1000 live births in 2015

EVIDENCE BASED IMPLEMENTATION

• STAFF CAPACITY• COMPETENCY• FIDELITY TO PROGRAMMES• DATA COLLECTION• MANAGERIAL BUY IN AND SUPPORT

This journey representsthe core services offeredto families from thehealth visiting service

Introductory antenatal visit 32 -

34 weeks New birth visit

11-14 daysTwo visits before 6 weeks

(at 3 and 4 weeks)

Health Visitor assessment 6-8 weeksHealth Visitor

visit at 12 weeks (3 months)

Health Visitorassessment/visit

4 months

Confirmation of HPI

6 months

Integrated Child/Family

Health Review4½-5 yrs

Family/ChildHealth Review

13–15 months

Note: At any time throughout this journey, additional programmes of care will be offered to children and families if required.

Family/ChildHealth Review

27-30months

Health Visitorvisit at

8 months

Transfer of informationFrom Named Midwife toNamed Health Visitor

Transfer of information fromNamed Health Visitor toNamed Person (Education)

47

Com

pete

ncy

Dri

vers

Com

pete

ncy

Dri

vers

Organization D

rivers

Organization D

rivers

LeadershipLeadership

Improved Outcomes

Sustainable

evidence-based

parenting programmes

High

fidelity

• Standardised core training

• Checklist and video-based self-monitoring of fidelity

• Authorised supervision and consultation

accreditation data-driven decision-making

• Intelligent targeting

• Proactive parent recruitment and retention strategies

• Data management

• “Fit-for-purpose” resources

• Dedicated staff time and nurturing managerial systems

• Long-term sustainability planning

PoPP implementation

framework

• Peer practice and learning systems

• Strength-based communication skills training

With acknowledgement to the National Implementation Research Network

Progress of PoPP roll-out across Scotland

Wave Preparation phase began

Groups start date

Implementation complete and still running groups

CPP

1 April 2013 August 2013 August 2014 Falkirk

August 2014 West Lothian

2 Sept 2013 Feb 2014 Fife

Stirling & Clackmannanshire

3 March 2014 August 2014 Argyll & Bute

4a Aug 2014 Jan- Feb 2015 Edinburgh City

Highland

Perth & Kinross

Scottish Borders

4b Dec 2014 May 2015 East Lothian

5 Jan 2015 Sept 2015 North Ayrshire

% of families enrolled in PoPP groups according to postcode DEPCAT scores

34%

33%

16%

11%

7%

1 (most deprived)2345 (least deprived)

19%

24%

20%

19%

18%

1 (most deprived)2345 (least deprived)

% of families enrolled in PoPP groups by deprivation category

Overall residential Postcode DepCat for 3-4 year olds in PoPP sites

54

OutcomesLevels of improvement for children ( for whom we have pre and post measures) who had initial SDQ scores in clinical range (N=244)

Number %

Moved out of clinical range 149 61%

Moved out of clinical range to normal range

109 46%

National Outcomes• Our children have the best start in life and are ready

to succeed.

• We have improved the life chances for children, young people and families at risk.

• Our young people are successful learners, confident individuals, effective contributors and responsible citizens.

Alfie

• ‘I like my bedtime story because it helps me to dream’

http://playtalkread.org/laughter-benefits