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Healthy development in the early years provides the building blocks for educational achievement, economic productivity, responsible citizenship, strong communities, and successful parenting of the next generation. By improving children’s environments, relationships, and experiences early in life, society can address many costly problems, including incarceration, homelessness, and the failure to complete high school. But if you’re a parent, caregiver, teacher, or someone who works with children every day, you may be wondering, “Where do I start?!” From brain architecture to toxic stress to serve and return, The Brain Architects, a new podcast from the Center on the Developing Child at Harvard University will explore what we can do during this incredibly important period to ensure that all children have a strong foundation for future development.
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In June, we hosted a webinar about our latest Working Paper, Place Matters: The Environment We Create Shapes the Foundations of Healthy Development, which examines how a wide range of conditions in the places where children live, grow, play, and learn can shape how children develop. The paper examines the many ways in which the built and natural environment surrounding a child can affect their development, emphasizes how the latest science can help deepen our understanding, and points towards promising opportunities to re-design environments so that all children can grow up in homes and neighborhoods free of hazards and rich with opportunity. Corey Zimmerman, our Chief Program Officer, moderated a discussion around these themes between Dr. Lindsey Burghardt (Chief Science Officer) and Dr. Dominique Lightsey-Joseph (Director of Equity, Diversity, Inclusion and Belonging Strategy) which has been adapted for this episode of the Brain Architects podcast.
Tassy Warren: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m Tassy Warren, the Center’s Deputy Director and Chief Strategy Officer. Our Center believes that advances in the science of child development provide a powerful source of new ideas that can improve outcomes for children and their caregivers. By sharing the latest science from the field, we hope to help you make that science actionable and apply it in your work in ways that can increase your impact.
In June, we hosted a webinar about our latest Working Paper, Place Matters: The Environment We Create Shapes the Foundations of Healthy Development, which examines how a wide range of conditions in the places where children live, grow, play, and learn can shape how childre
During the webinar, Corey Zimmerman, our Chief Program Officer, moderated a discussion around these themes between Dr. Lindsey Burghardt (Chief Science Officer) and Dr. Dominique Lightsey-Joseph (Director of Equity, Diversity, Inclusion and Belonging Strategy) which we’re happy to share with you all on today’s episode. To access the full Working Paper and related publications, please visit our website at developingchild.harvard.edu.
Now, without further ado, here’s Corey Zimmerman.
Corey Zimmerman: Hi, everybody. Welcome. I’m Corey Zimmerman. I’m the Chief Program Officer here at the Center on the Developing Child, and today we’re going to be discussing a paper, the name of it is Place Matters: The Environment We Create Shapes the Foundation of Healthy Development. This paper was written by our National Scientific Council on Developing Child and was released earlier this year in March.
We see this webinar as an opportunity to begin to understand a broader frame for thinking about what influences early childhood development, the role that inequity plays in influencing the environment children are in, and third, some early thoughts on new actors or sectors that might be called upon given this broader frame, to be able to join us in our collective effort to improve outcomes for all children and their families.
Okay. With that, let’s get started. It is my pleasure to introduce you to my two colleagues, Dr. Lindsey Burghardt, who is the Chief Science Officer here at the Center on the Developing Child. And then second, Dr. Dominique Lightsey-Joseph, who is our Director of Equity, Diversity, Inclusion and Belonging Strategy here at the Center. Okay. So we’re going to start with a brief overview of the Working Paper, Place Matters from Dr. Burghardt.
Lindsey Burghardt: Thank you again, Corey, for that introduction. And thanks to all of you today who took time out of your day to join us and to hear about this new working paper from the National Scientific Council. So the overall focus of this paper is really to broaden the frame of how we’re talking about early childhood development and health. And we’re going to look upstream today and consider all the different factors that influence how kids develop.
So we all experience this continuous influx and flow of influences from our environments, and they begin before birth right in the earliest days of the prenatal period, and they continue throughout our lives. And these influences include the environments of relationships and those environments–that environment of relationships–is just as important as it’s ever been. And children also experience exposures and influences from the physical environment that surrounds them and their caregivers.
So particularly the built and natural environments. And there are a really wide range of conditions in places where children live, learn, play and grow, and all these conditions have the ability to get under the skin and affect the developing brain and also other biological systems. So the immune system, the microbiome and the metabolic system, among others. And beginning before birth, these environmental conditions are shaping how children develop and that, in turn, has the ability to shape their lifelong physical and mental health.
So the built and natural environments and the systemic factors that shape them, like policies that influence where people are able to live and how resources are distributed, interact with each other and they interact with a child’s social environment in really deeply interconnected ways. So this is really what we mean when we say that place matters. So every environment is infused with a combination of influences, and these influences can have positive or negative effects on health and development.
And it’s also really important to recognize that level of exposure to risk and access to opportunity for children are not distributed equally. So in 2004, the National Scientific Council on the Developing Child described the effects of early life experiences on the developing brain and its first working paper called Young Children Develop in an Environment of Relationships. And over the two decades that followed, this concept really helped to make the case for caregiver-child relationships is sort of the active ingredient in how environments can influence the architecture of the developing brain. So the environment of relationships includes the presence of responsive relationships, the presence of significant stress and adversity, caregiver well-being, social connectedness, community support, faith and cultural traditions. And so more recently as our understanding of how early the early origins of health and disease have advanced, we’ve also really started to understand how early experiences affect multiple developing biological systems beyond the brain. So thinking about the immune system, the metabolic system, the respiratory system, and actually how these systems are interacting with each other and shaping each other as well as the brain. So the environment of relationships again, is just as important as it’s ever been, but these environments–that environment or relationship–it doesn’t exist in isolation; it exists in the context of is much broader environments that include the built and natural environments that surround children.
Exposures from the natural and the built environments also directly shape the development of biological systems inside the body, and they interact with adult-child relationships in a really deeply interconnected way. And these exposures can be positive or negative, and they can include things like air quality and temperature that children breathe, the purity and availability of their water supply, their ability to access safe green space and healthy housing and whether or not they’re exposed to things like environmental toxicants.
So we can take the example of lead is one that many people are familiar with. So lead is one factor in the built environment that connects to safe and healthy housing, connects to clean water supply and to exposure to toxicants. And we’ve known now for a really long time that lead is harmful to children’s development, particularly in the prenatal period and in the earliest years. And lead is still a challenge for a lot of families that today that are still dealing with this and the ongoing situations in Flint and in Jackson speak really clearly to this issue. So the presence of lead in children’s drinking water directly influences and affects their development, and it also shapes the environment that their caregivers are in with the burden and stress that it puts on them. So if there’s lead in the water supply, caregivers often have to seek out alternatives, and it’s typically at a cost, they may need to find in time for additional doctor’s visits and follow up. And all this can cause stress on them, and that can impact their ability to be in a caregiving relationship. So when we look at an environment, one that provides lots of positive influences is more likely to support children’s healthy development, and just as an environment that provides or imposes more negative influences is going to be more likely to result in disease and in poor health outcomes.
So let’s widen the frame one level further, because there’s also these really broad systemic influences that play quite a powerful role in shaping the environments our children live. So these systemic influences are going to shape children’s development directly and they’re going to shape them indirectly through their influence on a child’s environment of relationships and their built and natural environments. And these influences include things like current and historic public policies, systemic racism and intergenerational poverty, among others. So it’s really important to acknowledge that conditions in our built and natural environments are not experienced equally among children. They vary widely and the adverse effects of systemic racism in particular have deep historical roots whose impacts continue to the present day and many present-day policies continue to perpetuate these inequities and their ongoing effects. So there’s an example that we’re going to dive deeper into a little bit later on in redlining. And redlining strongly influences where many children of color live today. And although this practice is now illegal, it has modern day implications like the home appraisal process that continues to shape the environment where young children grow. So increasingly, data that has been provided that shows deep analysis of these differences at the community level. And there’s one that’s provided by the Childhood Opportunity Index, or COI, that’s cited in the working paper. And then we’ll again talk in more detail later on. But the COI demonstrates that in the United States, neighborhood opportunity is highly segregated by race with black and Hispanic children having access to significantly less neighborhood opportunity than white children.
So let’s shift a little bit now to talk about the timing, which is so important. Well, it’s really clear now that it’s not just our genetics and it’s not just our environment, that influence health and development. It’s both. And the influence that our genes and our environment have on our health is also really depends on the time during which we have certain experiences or exposures. And people differ in their sensitivity to influences from their environment at different points throughout their life course. And children’s biological systems in particular have different periods when they’re really sensitive and more sensitive to various environmental exposures and influences, even within the same biological system. So one example is the developing microbiome in our gut, which is very sensitive to influence from the built and natural environments around the time of birth and in the first few years of life.
So in general, the sensitivity of the brain and the other biological systems that we’ve talked about is typically greater in the prenatal period than it is in early childhood. And in general, young children are more sensitive to influences from their environment than older children who are in turn more sensitive than adolescents. And in general, adolescence will be more sensitive than adults to many environmental exposures, and this is really important when we consider the importance and the impact of environmental exposures because of a greater sensitivity in early childhood.
When an exposure happens during a fetal development or in early childhood, it’s going to have a very different impact and potential effects than if that same exposure happened later in life. So when we think about it, actually the first place where a child’s development is affected by place is the intrauterine environment during pregnancy. And during fetal development,immature biological systems are developing a very, extremely fast pace and their development is powerfully shaped by the environment around them. And these systems read the conditions in the womb as predictors of what they’re going to encounter after birth, and they sort of adapt accordingly. And so because these systems are still differentiating, they’re still becoming specialized and figuring out what they’re going to be, the exposures can result in really different outcomes depending on the time during development when they occur.
And we can take a look here at the example of air pollution. So air pollutants can be absorbed in a variety of ways and can cause problems in developing organs and entire organ systems. But the nature and the severity of any potential effects will be different depending on the time during childhood and during development when the exposure occurs.
So, for example, in the prenatal period, exposure to air pollution is associated with things like adverse birth outcomes in prematurity and in low birth weight. And in early childhood exposure to air pollution is a known risk factor for a variety of health effects, including asthma and children who are exposed to higher rates of outdoor air pollution during the first year of life may have diminished functional lung capacity as teenagers. So this is only one example of how the nature and the extent of an exposure that occurs very early in life may not even be fully apparent for years or even decades later.
So let’s talk a little bit about climate. So climate and our changing climate is a really important factor in how children experience place. So we’ve talk today about how environment shape development and health, and we’ve discussed that what surrounds us quite literally shapes us.
So let’s go back to thinking really broadly about what’s surrounding and shaping children in their environment. We talked about the quality and the temperature of the air that they breathe, the purity and availability of their water supply, their ability to access safe and healthy housing, their ability to access nutritious foods and the quality and density of the buildings in their neighborhoods. So climate is modifying the environment where these kids are living in a number of ways, it’s increasing the temperature of the air that’s surrounding them and making that air less pure. And it’s altering the availability and purity of the water supply, and that’s making housing less predictable through displaced men and through increasing energy costs. And it’s making nutritious foods for many children around the world even more scarce.
So climate is changing children’s environment and it’s doing it unequally across groups. Let’s just take a moment to look at heat as an example. So higher temperatures actually lead to a really wide variety of negative outcomes on development and health, including adverse birth outcomes like prematurity and low birth weight. It can have impacts when it’s experienced even in early childhood on academic achievement that can persist for many years later and heat increases the effect of air pollutants which are known to worsen conditions like asthma. So more heat will intensify the effects of air pollution and we’ll see more problems with asthma as a result. And heat is increasing in all children’s environments all over the world, but it’s not increasing equally among communities. So urban areas that already have a higher density of buildings, already are experiencing higher temperatures and have less green space, are going to be more impacted than suburban or rural areas. And the disparities then, in exposure to heat and the intensified effects of air pollution are going to be different depending on where you live and how you’re experiencing our changing climate. And as a result, we’re going to see a disparate impact in the contribution to disparities in rates of diseases like asthma that are already based on where children live.
So we feel that the implications of this really rapidly growing science on this front are clear. Understanding the really powerful effects that the natural and built environments have on the early foundations of health and development is calling for increased attention to really important influences that fall well beyond what we all consider the traditional boundaries of the early childhood field. So this demands that we have to incorporate a more intentional early childhood perspective within the current concerns of things like urban planning, rural development, environmental protection, climate change, anti-discrimination policies, many others. And doing this requires that a much broader range of policy domains must work together to address racist and other discriminatory policies, and we have to achieve greater equity.
All communities have aspects of their built and natural environments that have been designed through intentional decisions made over time, and they can be redesigned to support healthy development. And supporting healthy development is still very much about encouraging and supporting caregiver-child relationships, and it’s also about bringing communities, businesses and governments to work together to assure a supportive and healthy environment for all young children with particular attention to the built and natural environments that are currently falling far short of that goal.
So working together across various policy domains beyond the early childhood field and sector, we can reshape environmental influences with a science informed lens and a shared goal of achieving fairness of place so that all children can grow up in homes and neighborhood that are free of hazards and rich with opportunity.
Corey Zimmerman: All right. Thank you, Dr. Burghardt, for that overview of the paper. So many rich insights. I’m actually really excited to dive into this more now with you and Dr. Lightsey-Joseph. Thank you. All right. That was a great overview. And now we’re going to shift into the panel part. So, Dr. Burghardt, this first question is going to be for you.
You mentioned that every environment is infused with a combination of influences and that those influences can impact children in positive and negative ways. And I was wondering, can you give us an example of an environmental influence that has an important impact on children and families? But maybe that’s not something that we typically think of as related to early childhood development.
Like, help us dimensionalize a little bit. What would be an example?
Lindsey Burghardt: Yeah, thanks for the question, Corey. So one of my favorite examples here is green space. So our knowledge of the health effects of green space is really increasing as we’re learning more and more of the science behind how green space exposure affects health and development in children. And we have a growing body of science that’s demonstrating that the benefits of access to safe green space around the prenatal period has a variety of benefits and a variety of health outcomes in children.
So later on, benefits to the immune system and benefits really on children’s mental health in a number of ways. And there’s also a really growing and exciting deepening knowledge about how green space can offset some of the more negative environmental exposures that I spoke about, like heat and air pollution. So, you know, as we talked about earlier, children are experiencing the built and natural environment really differently based on where they live. And right now, children’s opportunity to access green space is not equal. But I think that given the robustness and the rapidly growing science in this area, around the really wide range of benefits, this kind of disparity of place is one that really demands greater attention. And in particular when when it pertains to green space. There’s also, I think, really interesting and significant what we call co-benefits when we think about bringing together in conversation and action children’s health and their environments.
So, for example, if we’re decreasing concentrations of air pollution, including through ways like increasing green space, then we can improve the air quality that children are breathing and potentially make problems like asthma less likely to occur. And these types of interventions, as we spoke about earlier, they’re really needed most in communities that have the lowest concentrations of green space right now and also the highest rates of asthma.
Corey Zimmerman: So many thoughts. That’ sparking so many different ideas, and that’s an example that’s close to my heart as well. So I really appreciate that one. Dr. Lightsey-Joseph, I want to bring you in. I want to ask about this concept of fairness of place that Dr. Burghardt mentioned. And I was curious if you could tell us a little bit more about the social history that’s led to this unequal distribution of environmental influences.
Dominique Lightsey-Joseph: Sure. Thank you for having me today, Corey. And good to see you, Dr. Burghardt. Yeah, sure. I can answer that question for you. I think in understanding the unequal distribution of environmental influences, we have to name the historical practice of redlining in the U.S., which is a policy in the thirties by the Federal Home Owners loan Corporation, in which neighborhoods, particularly those that were populated by Black residents, were color-coded based on perceived financial risks or real estate investments. And those areas that were color coded red were seen as the riskiest and the most undesirable neighborhoods. And this process resulted in these communities being systematically denied vital services and opportunities for economic advancement in this country. And despite the Civil Rights Act of 1964, the Fair Housing Act of 1968, which officially outlawed redlining, the economic disparities that resulted from these discriminatory practices persist.
An example of this would be, there was a 2020 report that was conducted by the National Community Reinvestment Coalition, which found that 74% of neighborhoods initially redlined in the ‘30s remain economically disadvantaged today. And this is characterized by lowered home values, higher rates of poverty and things of that nature. And I’d be remiss if I didn’t say that the impact of redlining, it doesn’t just end at financial implications. They stretch deep into the health and environmental qualities, too. And as Dr. Burghardt mentioned earlier, we can take Flint, Michigan, for instance, which is discussed in the paper, and the city’s water crisis, which subjected a predominantly Black community to dangerous levels of lead exposure has roots in the long term consequences of redlining. It was that facilitated segregation of that city all of those years ago that resulted in this higher concentration of poverty and exposure to these environmental hazards.
In comparison to, you know, other neighbor of neighboring areas in the state. So to really answer that question, Corey, I think the influence of redlining has pervasively shaped the socioeconomic and environmental contours of our neighborhoods, and consequently, it has defined the environments where kids are raised and the opportunities or lack thereof, they have to grow up healthy.
Corey Zimmerman: Thank you for sharing that. And I want to pull it forward now and ask you a follow up question, Dr. Lightsey-Joseph, around the Child Opportunity Index that Dr. Burghardt mentioned earlier and is in the paper, I think that’s a way of kind of quantifying also some of the ongoing pieces that you’re talking about. So, the Index lays bare the many ways in which disparity of place continue to exist across communities today. And I was curious about what this powerful dataset has to offer us as we think about how to create health promoting environments for all children. So I was curious your thoughts about that.
Dominique Lightsey-Joseph: Yes, the Child Opportunity Index, or the COI, it really does lay bare the fact that these disparities across communities exist. And I think it quantifies it to your point in a way that there’s that felt anecdotal knowledge of it, but to see it in the form of the COI, I think is invaluable. So it’s a tool that really does help us to understand these disparities across communities. And it uses a range of indicators, as Dr. Burghardt said earlier, within the educational, health and environmental domains, that really examines the conditions that are vital for children’s healthy development across neighborhoods in the U.S. And one of the most significant insights by the COI is that the substantial disparities in child opportunity are often racialized in nature between different neighborhoods, cities and regions. And for example, in the 100 largest U.S. metropolitan areas , a turn of the decade analysis of the COI, found that Black children are 7.6 times more likely than white children to live in neighborhoods with substantially lower opportunity to grow up healthy. And Latine children are about 5.3 times more likely to live in neighborhoods with lower opportunity. And so the COI beyond that, right, it allows us to identify these environmental disparities across neighborhoods within the same city as well.
So as you both know, I’m a transplant from California, has deep roots out there. And there’s a neighborhood in West Fresno that has consistently been ranked as one of the neighborhoods most burdened by population in the state of California. And subsequently it ranks really low on the COI as well, due to the high air pollution and the limited green spaces. But in contrast to that, neighborhoods with a higher ranking within the same city, literally across the tracks, right, often have less pollution and more parks and playgrounds. And I think the data that is offered by the COI is really this powerful resource, right? That not only allows us to identify these spaces, but it also allows us to address these disparities so that they can inform where these targeted interventions and resource allocations in neighborhoods that require more attention to infrastructure and investment is necessary.
And I would say that it’s important to note that neighborhoods in Flint, like we mentioned a few times and Fresno, are still impacted by being redlined all those years ago, the environments in which our kids live, grow, play and learn, they were not fixed, and these outcomes are not inevitable. They are the products of decisions that have been made over time and they can be reimagined and restructured.
And so I think it’s the responsibility of us, like researchers, government officials, advocacy groups, policymakers, just to name a few. But it’s our responsibility to really work collectively with community leaders to invest and restructure these built environments. I think we have to work together. That’s the only way that we’re going to be able to support healthy development for kids, regardless of their race, their ethnicity, or their socioeconomic status.
Corey Zimmerman: I love that. This is a product of decisions that have been made over time and we have an opportunity to redesign. And I find such power in that. There’s such agency actually in that this is changeable. We can do this differently. And so, Dr. Burghardt, I want to actually ask you, with that lens in mind, there is an opportunity to redesign neighborhoods in communities to support healthy development. And I was curious, can you say more about your you had a last point in your presentation that was around the extended role for actors in other sectors outside the traditional early childhood field. So I wondered if you could expand on that a bit.
Lindsey Burghardt: Yes, absolutely. Thanks, Corey. And I think I’m going to +1 what Dr. Lightsey-Joseph just said. And that I think for me, like the thing about the COI that really stands out is her point that she made about the geographic proximity and the starkness of difference. Like I feel that we can’t emphasize that point enough. If you look at cities like Milwaukee, I think is a good example of one where literally adjacent to each other some of the highest levels of opportunity in the state and the lowest opportunities in the country right next to each other. And I think that it just highlights that that intentional decision making of where to allocate and distribute resources is a really stark example. And if you check out the, if anyone’s interested, you can go to the website actually and learn a lot about the COI in your particular area. And you can it kind of translates, I think, to what we experience and know from our own experiences. So I’m not adding anything more eloquent than what Dr. Lightsey-Joseph said, but I think just a really, really valuable tool when we’re thinking about where we can invest and where we can focus on health promoting environments.
So, to get back to your question, Corey you know, in the beginning of our time together, I talked about broadening this list of policies that we’re thinking about as affecting the foundations of early childhood development and lifelong physical health and mental health. And the list I gave is by no means exclusive. But I think that looking at things like environmental protection, climate change policies, in particular, mitigation, housing, urban planning, zoning requirements, which helps to redress things like redlining, economic development, criminal legal reform and the criminal justice system and anti-discrimination policies. We can bring decision makers from all these different sectors to the table, even though they haven’t traditionally considered their work perhaps as impacting childhood development and lifelong health. We can again think about how all of the decisions we’re making–literally, every one–is affecting childhood health and development, and I think many people who are here today are already doing that in their work. But it’s thinking about who else can we bring in and who else can we share this messaging with, because we can make a child assessment, you know, impact assessment in every policy and program that we do. We should be looking at every single decision we make, even the ones that on the surface you think, well, there’s no way that that could affect children. Most people here could explain how it, in fact, would. So everything from minimum wage laws to zoning laws, they will affect children’s development, they will shape those environments and those environments will shape children’s health and development. And we really need to demand that kids are considered and that the impact on them is considered when all of these decisions are made.
Corey Zimmerman: Okay, so we have reached the point in the session, I feel like I should readjust my chair somehow, like we’re going to switch into the Q&A session now. So we’re going to switch over from the questions that we have sort of prepared and now respond to questions that have come in through the through our social media channels, through registration links. So a big thank you to Dr. Lightsey-Joseph and Dr. Burghardt for your responses so far and for your upcoming now next set of thoughtful responses also. Alright, the first one I’m going to start with is this one. It’s for you, Dr. Lightsey-Joseph, given what we’ve been talking about. And the question is, can you talk more about how and connect this to how does this align with protective factors and resiliency? Curious your thoughts about that.
Dominique Lightsey-Joseph: I love that question. So in these neighborhoods, right, there, there are these strong community-based organizations and social support structures that already exist, and they have long been providing emotional support, the practical help, the collective strength and resilience, which in turn nurtures the well-being and empowerment for the kids and families residing in these respective communities. And I think acknowledging these protective factors is important because they are invaluable for sure. I also think it doesn’t negate the need to confront and address the systemic injustices that have resulted in such disparities and made resilience so necessary in the first place. So these protective factors are present and they, to me, serve as a really good starting point from which we might begin to foster a healthier and more equitable environments for these kids. And so I think, to Dr. Burghardt’s point earlier about, you know, approaching this from a holistic perspective and looking at all of these other sectors, that we have to come together and work collectively to restructure these environments, but the approach in how we do that should be guided by the insights and the experiences of those within the communities and not merely outside speculations, assumptions or perceptions of the challenges.
So while we might use data to help us identify where these areas are, I think pairing that information with an approach to the wider systemic challenges and keeping it community-led and community-guided can really give us a real shot at transforming these opportunities that are available to kids on a national scale.
Corey Zimmerman: All right. I’m going to keep this going. Dr. Burghardt, this next question is for you. And you touched on this a bit earlier, but I think this is an opportunity for us to go deeper. And this is a topic that I care a lot about, and I swear I didn’t plant this question. Somebody else actually submitted it. And so the question is, how does the impact of climate change on the built in natural environments shape the foundations of development? And I’m excited to see this question, too, because I think there’s a lot of energy in this space right now. So I’m curious for you to add a little more thoughts from what you did earlier.
Lindsey Burghardt: Yeah, thanks, Corey. I appreciate the chance to come back to this topic and to talk more about it. You know that I share this passion with you, but I also think it’s a real opportunity for those of us in the early childhood field who kind of understand how there’s all these different influences, how they affect children’s health and development, to bring to conversations into the same space that maybe aren’t happening as much as they could right now. So climate change and children’s health are two things that I think once we can kind of explain the connections between the two make a lot of sense, but aren’t necessarily intuitive, especially for some of those sectors that I mentioned before, that kind of sit outside of what we consider the traditional scope of the early childhood field. So when we think about how we can tell the story, we’ve discussed today how children’s environments shape their development and health, and we know that environments affect development and that climate change affects each of the environments that we talked about today and that it does so unevenly across these different groups. So climate change, again, is modifying in many, many ways, both the built and the natural environments where children are living. And heat is one example that we discussed, but there are many others. So if we think about the availability of a pure water supply and access to nutritious foods as other examples of things that are impacted by climate change. So if nutritious foods are less available, for example, this can directly affect children’s developing biological systems, especially in the prenatal period and early childhood. So when we take what science has already demonstrated and what we already know about the importance of nutrition or lack thereof in the prenatal period in early childhood, and then we think about how that’s modified and changed by climate, it becomes a really clear and compelling story about why this is a really important issue that’s going to affect–and is affecting today–children’s development and health. And then things like natural disasters and flooding are going to increase the number of families who are displaced from where they live, and that’s going to significantly alter the physical environment that surrounds those children and it’s going to directly affect their developing biological systems as well. And so while climate change is an urgent issue that’s affecting how children are experiencing place, there’s also in this space a really wide solutions space that’s already available to us now at every level from high, broad, reaching goals also to more immediate things that many of us may have a potential to act on fairly quickly. And there’s actually a really big, what we call co-benefit that exist when we look at climate change and early children’s development and health in the same space. Because many of the solutions that we all know about that promote early childhood development, healthy development, are also climate promoting policies and programs like access to green space and decreasing air pollution by decreasing fossil fuel combustion. All of these things are really good for children and they’re really good for our climate. There’s a strong financial case that we can make here too, so there’s good research that’s demonstrated that for every dollar we put into decreasing greenhouse gas emissions, for example, we see up to almost at least $6 gained in child related outcomes. So that’s pretty compelling and maybe something we can take out into the field when we have these conversations.
Corey Zimmerman: So much richness there. I really love the like as we think about place matters and then how climate modifies place and why that is such are and see and attention and this idea of co-benefits that there are solutions that are good for the planet and good for helping us reduce the effects as well as are good for children and their outcomes.
So we can spend another hour there. But that’s not what this webinar is for. Okay, let me keep going in questions. Dr. Lightsey-Joseph, this one is for you. This is a theme we’ve been touching on throughout and it’s sort of expanding beyond early childhood. But this one is particularly about how can government agencies and nonprofits reach influential leaders like business to advocate for young children?
Dominique Lightsey-Joseph: So I think this in the same vein as Dr. Burghardt’s presentation earlier, at the time of our start together, I think the key to reaching influential leaders like those in business is to first recognize that there is this intersectionality of children’s lives, and so the environments that they are growing up in are influenced by so many sectors outside of just the early childhood arena. So really anybody, everybody can contribute from their respective domains and it’s going to take that kind of a holistic approach—there’s that term again–to you know, to make this change happen. And I think to answer this question more directly, I might use what we do at the Center as an example. So we have the knowledgebase on early child development as it relates to the brain, and we do the work to turn that scientific information into practical action, and we develop partnerships to engage with leaders–some within ECD and some outside–and we address what we bring to the table to their respective contexts. And then that enables those leaders to go out and advocate for and restructure programs and policies that favor children and families within their own unique contexts.
And so from my perspective, I see advocacy being more about more than just persuading others to act. It’s equally about investing that time into empowering one another to act. And I think the aim of government agencies and nonprofits should be to provide open access to our insights and our resources, develop outreach tactics that are content-specific and relevant. And I think we need to partner with leaders with respect for their unique contexts. And when we approach these leaders, we need to make sure we’re not approaching them merely as benefactors of our resources. They are our partners in doing this important work.
Corey Zimmerman: I love that, there’s so much–like it’s a two way interaction here—like, what do we bring and how do we engage together in this world. There’s so much. I think it connects actually in some ways to this next question that we have. The next question is for you, Dr. Burghardt, and it’s asking about what are possible changes that schools can make? So now coming at it from kind of a different lens and different set of partners. What are possible changes that schools can make to have a positive impact on healthy development? And maybe there are some particular calling out of early care and education centers to within that. But the question asked first about schools.
Lindsey Burghardt: Yeah, it’s a good question and it’s tough because, you know, most schools are already taking on like really substantial, really difficult efforts to meet the basic needs of a lot of students and teachers. So how we think about talking about adding in and layering in things like place-based support in those spaces, I think really has to be done in alignment with the needs and the priorities of people who have been working and are working in that space for a really long time to make schools the health promoting environments that they are. And I think, as in any program or policy domain, it’s really important to call out what Dr. Lightsey-Joseph said, and involving and working with the community who is there and affected and in those schools to understand what the needs are and what their priorities are, whether it’s related to air quality in schools, to high temperatures in classrooms, or to access to clean drinking water. And one resource that I do refer to that I think is useful for some concrete tools is the Environmental Protection Agency has a website they created with Office of Children’s Health Protection and it has really specific recommendations about how to pursue, and different options for pursuing, health promoting environments and specific categories within schools. It even has a list, I think it’s called Top Ten Ways to Make Your Schools Healthier, and it has a really specific breakdown of each item in the list that contains action steps and kind of a guide for how to approach these things that can seem very kind of large and overwhelming to tackle on an individual level. And the list has things like, you know, items that are indoor and outdoor air quality, radon, you know, lead in drinking water and how to approach–if you’re interested–you know, each of these different factors. I think we can also think about on green space the issues that we talked about earlier and thinking about if there’s local context or opportunity to bring green space to children’s learning environments even, and especially the early care and education environments too. You know, we know that there’s benefits to having children access green space. And if they’re able to do that locally in their school environment, I think that’s really potentially powerful.
Corey Zimmerman: Thank you. And I think there’s so many creative solutions out there right now, too, around how to schools and that outdoor learning environments and what they’re being able to do and it’s a great resource. Thanks for sharing about the EPA one. I think we have time, I think for two, maybe three questions we’ll see here. So the next question, Dr. Lightsey-Joseph, is kind of touching a little bit on what we’ve talked about earlier, but how might we use data better to identify neighborhoods for higher investment and what needs are most prevalent so we know where? I’m curious on your thoughts.
Dr. Lightsey-Joseph: One: yes, data critical. It’s a critical role in informing policy decisions and identifying neighborhoods in need for that higher investment. And we’ve been talking about it, as you said, with the COI being one example, which we’ve been discussing. But I want to pick up too on what Dr. Burghardt was saying, in terms of looking at the data on environmental conditions of neighborhoods, I think that has a really rich–it’s a really rich data source that we can tap into as well. And that could include looking at the data on pollution levels, access to green spaces, quality of housing, just to name a few. And we know from these studies, right, that children growing up in these areas with high levels of pollution or limited access to green spaces are more likely to suffer from health related issues like asthma and have lower levels of physical activity. We can also look at access to health resources such as primary care providers, nutritious food options, because those are critical to children’s physical development and overall well-being. And I think there’s also data out there on social determinants of health, such as poverty rates or employment opportunities, that that can also be critical in understanding the challenges faced by neighborhoods. And I think cross-referencing all of these data points on top of one another might be the way that we can identify those neighborhoods that are most in need of investment. A neighborhood that might run low all of those indicators I mentioned would be a prime candidate for some form of or community-based participatory intervention. And I know that’s a mouthful: community-based participatory intervention. But I say that because it goes back to what I said earlier. It’s not just about identifying where these neighborhoods are. Any interventions would need to involve and partner with the communities and the local organizations who are already doing this work to really understand those specific needs and strengths within the context of the neighborhood.
Corey Zimmerman: I love that. So many pieces that are connecting to what we’ve been talking about. I want to draw out–this question’s for you, Dr. Burghardt–and just one particular dimension actually, of what we’ve been talking about, about where there’s inequity and actually and there’s a lot of data. I was wondering if you could talk about–So this is a question that had come in and it was curious about can you address the unequal exposure to air pollution and talk some more about that?
Lindsey Burghardt: Yeah, I think it does. It’s a nice question too. I think it ties together some of the points that Dr. Lightsey-Joseph was just making. I’ll put out there first, you know, we use the term air pollution a lot. Air pollution really means a bunch of different things that are put out into the environment that are harmful for human health and development. But it’s generally a mixture that comes largely from fossil fuel combustion. So we can think about things like cars, busses like manufacturing sites and the amount of air pollution that a child is exposed to depends on where they live. So children who live closer to highways or roadways, closer to transportation depots or near manufacturing or combustion facilities are going to be exposed to higher rates of air pollution than children who live further from these sources. And we’ve discussed throughout the hour that where children live is impacted by historical policies like redlining and modern-day policies that kind of perpetuate where people are able to live and what type of neighborhood opportunity they’re able to access. But in neighborhoods that were previously redlined, and Dr. Lightsey-Joseph explained this very well earlier, there was an inability of the residents who live there to accumulate wealth by getting favorable mortgages or access to high paying jobs. And through that inability to accumulate wealth, they were therefore unable to gain as much political power to oppose the building of things like highways and transportation hubs, manufacturing sites in their neighborhoods. And so many of these air pollution producing factors are more commonly situated in neighborhoods that were previously redlined. And so, as a result, children who live in these areas are exposed to more air pollution than children who live farther from highways, manufacturing sites, transportation terminals. And that translates to a difference in the rates of things like asthma and other diseases that are caused by–or can be influenced by–exposure to air pollution. And we see higher rates of asthma in children who live and previously redlined neighborhoods than children who have access to neighborhoods with lower rates of air pollution. So it’s very clearly influenced by where you live.
Corey Zimmerman: There’s some sobering facts in there, just sort of pieces you were sharing and lots of reactions. All right. So last question. I’m going to squeeze one last one in here. This one’s for you, Dr. Lightsey-Joseph. It’s a question around how do you–how do we think about promoting change and do that in a way that keeps in mind people’s cultural norms, whether those are regional or local, but just thinking about how to promote change while keeping in mind those cultural norms.
Dominique Lightsey-Joseph: That is such an important question, Corey, for so many reasons. I think was sticking out for me is is important is an important question because there are so many well-meaning institutions that do run the risk of perpetuating a savior complex if their solutions aren’t representative of the communities that we’re trying to serve. And so what is being asked speaks to that importance of respect and understanding that change should never mean dismissing the ways people have lived for generations, but rather promoting change should involve working within those cultural frameworks to improve conditions in ways that really do resonate within the community.
And I think for sustainable change we’ve been talking about, you know, throughout our time today, we need to first understand and respect the context of these communities we’re engaging with. And this can be achieved in a number of ways, whether it’s active listening, engaging in learning opportunities of community-building relationships, collaborating with our communities, our members across different events. It’s really about amplifying those voices and insights rather than imposing our own. I think we also need to recognize that there is not a one-size fits-all approach to problem-solving solutions that work in one context or in one neighborhood might not work in another. So we have to really develop these framework targeted strategies that align with the specific realities of a respective community. And then I think the last thing I would say is it’s really about building capacity and empowering communities too, by providing access to the knowledge that we have. So the goal is to make sure we’re respectful of the cultural aspects in these communities while promoting and supporting programs, conditions. And I think to achieve this, our approach has to be rooted in empathy, respect and most importantly, not most importantly, but also very important is partnership.
Corey Zimmerman: What a great note to end on. All right, I’m pulling forward the theme that there are these universal concerns and ways we can use data that really having an approach that’s rooted in empathy and respect and partnership. And with that, thank you. A nd we wish you the best in your continued work supporting children and families.
Thank you for all that you’re doing. I’m really thrilled to be on this journey with you. Thank you.
Tassy Warren: The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we will post any resources that were discussed in this episode. You can find us on Twitter @HarvardCenter, Facebook at Center Developing Child, and Instagram @DevelopingChildHarvard. Our music is from freemusicarchive.org.
Contents
Podcast
Panelists
Additional Resources
Transcript
In April, we hosted a webinar about the recently released IDEAS Impact Framework Toolkit—a free online resource designed to help innovators in the field of early childhood build improved programs and products that are positioned to achieve greater impact in their communities. During the webinar, we provided an overview of the site and had the opportunity to hear from two organizations in the field about how they leveraged the toolkit and its resources to shape their work: Valley Settlement and Raising a Reader. This episode of the Brain Architects podcast features highlights from the webinar. If you’re interested in hearing a full walk through of the toolkit by the Director of our Pediatric Innovation Initiative, Dr. Melanie Berry, please head over to our YouTube channel to view the full webinar recording.
Corey Zimmerman: Welcome to the Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m Corey Zimmerman, the Center’s Chief Program Officer. Our Center believes that advances in the science of child development provide a powerful source of new ideas that can improve outcomes for children and their caregivers. By sharing the latest science from the field, we hope to help you make that science actionable, and apply it in your work in ways that can increase your impact.
With that goal in mind, the Center recently released the IDEAS Impact Framework Toolkit—a free online resource designed to help innovators in the field of early childhood build improved programs and products that are positioned to achieve greater impact in their communities. The Toolkit is self-guided, self-paced, and provides a structured and flexible approach that facilitates program development, evaluation, and fast-cycle iteration, including resources to help teams develop and investigate a clear and precise Theory of Change.
In April, we hosted a webinar about the toolkit, where we provided an overview of the site and had the opportunity to hear from teams at several organizations in the field about how they leveraged the toolkit and its resources to shape their work. We’re excited to share those discussions with you here on this episode of the Brain Architects podcast. If you’re interested in hearing a full walk through of the toolkit, by the Director of our Pediatric Innovation Initiative, Dr. Melanie Berry, please head over to our YouTube channel to view the full webinar recording. You’ll also hear from Dr. Melanie Berry during the Q&A portion.
The full IDEAS toolkit we’ll be talking about today can be found at ideas.developingchild.harvard.edu. And now, without further ado, here’s Dr. Aeshna Badruzzaman, the Center’s Senior Project Manager for Instructional Design and the moderator for our panel discussion.
Aeshna Badruzzaman: Hello, everyone. Welcome. My name is Dr. Aeshna Badruzzaman. I am a Senior Project Manager for Instructional Design at the Center on the Developing Child at Harvard University or HCDC, and I’m part of the development team of the IDEAS Impact Framework Toolkit. And today, I’ll be your host. So, you may hear me come off mute, and help guide presenters, and I’ll be facilitating our question and answer period. So, we are so pleased to be talking to you today about this resource. The IDEAS Impact Framework was born out of more than a decade of the Frontiers of Innovation Initiative or FOI. And some of you may have been partners in that effort. So, while our team no longer offers live training on the framework, we are so excited to be introducing it to you as a free open access resource. And we really hope that this format is going to help make IDEAS accessible to innovators in the field of early childhood development moving forward. The framework was developed in partnership with the University of Washington College of Education, and the University of Oregon Center for Translational Neuroscience. With support from the Gates Foundation, The Lego Foundation, Porticus and the Hemera Foundation. I encourage you to check out our history and acknowledgments page of the toolkit for more information about our various collaborations and supporters throughout time as well.
Now I’ll go ahead and introduce our first set of speakers from folks at Valley Settlement. We have with us Karla Reyes, who is the program manager of the El Busesito mobile preschool program at Valley Settlement, which is a nonprofit that works to create opportunities for the Latino community in the Aspen to Parachute region of Colorado. Karla joined Valley Settlement in March 2015, as a preschool teacher for El Busesito until June 2021 when she took on a leadership role. And we also have Sally Boughton who is the Director of Development and Communications at Valley Settlement, a nonprofit again, serving the rural Aspen to Parachute region Colorado with six to generation programs designed by and for local Latina immigrant families. And Sally has been with Valley Settlement for over five years and began managing the organization’s evaluation function in 2021. Thank you so much Karla and Sally look forward to hearing from you.
Karla Reyes: Good afternoon, everyone. Thank you for inviting us to share our work with you all and how we have used the framework. I’m going to talk a little bit about it, we’ll see the program and how I kind of started. The idea that it will succeed though began in 2011. We had two bilingual and bicultural community organizers, who met one on one with about 300 families from the Aspen to Parachute region of Colorado. And they learned about their lives and the barriers that they faced within our community. One of the findings from the initial listening tour was that only 1% of Latino children in our community were enrolled in preschool. We also learned that three of the biggest barriers for families to participate in preschool programs were language, cost and transportation resulting in lack of access. Now we have all this information. And we started thinking creatively of different ways that we could bring more access to preschool education to our community. I have also seen those one of the first two generation programs that we launched in Valley Settlement to address the needs of preschool education. And throughout the years Valley Settlement has continued to learn, evolve and co-design programming to respond to community needs. Now, our program has four mobile preschool buses that have been retrofitted into small preschool classrooms. We have two teachers on the bus, and we serve eight children at a time, we provide families with about five to 10 hours of free preschool education. We have about 96 children that we serve annually between 40 to 50 children graduating at the end of the school year and moving on to kindergarten. And currently right now we serve different five different neighborhoods within our community. And we strive to build close relationships with families. So, our program really is designed to meet families at where they are, are at and start breaking down those barriers. We host family nights; we have home visits with our families. We have parent teacher conferences; we have different ways that families can volunteer within our program. We provide a lot of materials for families to use that home so that they can do home activities and homework packets with their students. And we really try to engage with the families. So, each one of our teachers speak Spanish, is bilingual and bicultural. So, this really allows that bond and that relationship to build with each one of our families. I’m going to hand it off to Sally Boughton, and she’s going to talk a little bit more about how we’ve used the framework.
Sally Boughton: Thanks, Karla. So, several years ago, we started working with the team at Frontiers of Innovation to refine and evolve our evaluation practices. This work included creating theories of change for each of our programs, researching and recommending observational assessments to measure participant progress towards our program targets and outcomes, and creating implementation guides for our programs to detail the critical components of our work and ensure that future staff can implement programs with fidelity, while still continuing to listen to and evolve alongside families. Since the early days of our programming, Valley Settlement has invested in evaluation to measure understand and strengthen the changes that children and families create in their lives through our programming. Working with the team at FOI really brought this to the next level. Over the last few years, we’ve been working to be more inclusive and participatory in our evaluation process. So now our entire staff gathers for three days every summer, in what I call an evaluation retreat, where we review our annual program data as a team and then try to answer those questions ¿qué? ¿por qué? ¿Y ahora qué? or as the toolkit outlines: What does the data say? Why? Why might the data say this? Or what does that mean? And finally, now what do we do to tweak or change in our evaluation approach or in our programming, based on what we see in the data? Our teams then create action plans to outline those changes that they want to make. We’re usually tweaking one or more program components for the upcoming year. On day two of the retreat, teams then go in and refine and evolve their theories of change. So, we really see that theory of change as a living document that breathes and grows alongside our programming. They identify what targets and outcomes they’re interested in measuring for the coming program year. And then after that evaluation retreat, we work together with our evaluation consultant to refine our measurement tools. And then I always try to call out and highlight that I am in the minority of Valley Settlements. Our staff are largely of the community that we work with. Most of our staff are immigrants or children of immigrants, many have grown up in this community, or immigrated to the community as adults with young children. And so, they have those shared lived experiences with the participants in our programs. And many of our staff have actually been former participants in our programs. Having the entire team participate in this process is incredibly valuable. It really places the experts in the work our staff in the evaluator seat, and we gained so much more by having that inclusive, participatory process. And we’re really so grateful to have our work shared in the online toolkit because, you know, I am not an expert in the IDEAS framework by any means. And that’s kind of the whole point is that it’s very usable, you can go in, you can click through this toolkit, you can see how it all is structured and works. And it just makes for a really kind of manageable, useful process that you can engage in. Thanks so much.
Aeshna: Thank you, Karla, and Sally, really appreciate you taking the time to share your experiences with us. Now we’ll hear from folks from Raising a Reader. So Raising A Reader supports families to build, practice and grow reading routines at home. Their award-winning evidence-based program helps caring adults set their children up for success by creating shared reading routines, fostering social emotional learning, healthy family relationships and learning skills needed to thrive in school and beyond. And first, we’ll hear from Michelle Sioson Hyman, who is Senior Vice President, program and partnerships. And in her role, Michelle is responsible for overseeing program development, growth and impact. And then we’ll hear from Andres Garcia Lopez, who is a Senior Project Manager at the Center on the Developing Child. And in his role, he’s coached many early childhood development entrepreneurs, including Raising a Reader in developing strategies to maintain their science-based impact, while scaling their ventures. Welcome Michelle and Andreas.
Michelle Sioson Hyman: Thank you so much for having me. I’ll start with a brief overview of Raising a Reader and how we’ve used the framework and then fundraising, engaging some conversation. So Raising a Reader is a national family engagement and early literacy organization through our network of affiliates and partners across 34 states and both rural and urban communities. We engage and support parents and the other caring adults in children’s lives help strengthen the bonds with their children, while building critical early reading and social emotional skills. So along with our award winning multicultural and multilingual book collection, we provide easy to use materials and guides that are really designed to make the most of that shared reading time in the home. So our work really does begin though, with partnering with local agencies who become members of our affiliate network, a community of practice in which we can share best practices and build connections. And we provide professional development, technical assistance and capacity building support to this network of affiliates and partners, who really work across the intersection of systems, supporting children and families at the various points throughout their educational and developmental journey. So that’s, you know, in ECD, K, 12, Health and Human Services. And we’re really able to meet families in the spaces and places where they are involved in how the framework has really impacted our work was that we were introduced to Andres. And the framework is a really critical inflection point in our history. So we’re over 23 years old and Raising a Reader had 39 independent evaluation that prove the success of our Classic Red Bookbag Program and its impact on improving and sustaining home literacy environments. But one thing that we realized through our work with Andres was that there were critical aspects to our work that we weren’t capturing in our theory of change. And just maybe I’ll stop there, and then we can chat. Does that work?
Andres Garcia Lopez: Sounds good. That works. Michelle. Thanks so much for that overview. And I’m so excited to be part of this panel, and it’s an honor to share it with you, Michelle, and with the Valley Settlement team. So I’ll just add a few things. I was working with Michelle as part of a fellowship that the Center partners with the Promise Venture Studio. And as was mentioned before, the theory of change on the IDEAS framework really helps you think about what are the key ingredients that my organization in my program works on or provides to families and
or maybe two partners that get to the targets that that move the needle towards my outcomes. One thing that was different about Raising a Reader was that they weren’t with partners. So I wanted to mention that sometimes the IDEAS framework can be, and the theory of change could be flexible, and adaptable to meet your needs. Originally, there are three columns in the theory of change. But we’re working with Michelle, we thought we should have an extra column because they wanted to look at how working with partners and affiliate organizations, what their strategy is that was doing racing, a reader was getting into the targets in partners and affiliates and how that was getting to the outcomes with families. And that was a key component on identifying precisely the actions that get to the targets and the outcomes. And I’ll pause there so that Michelle can share more about the specifics of what some of those strategies were and how that helped the organization.
Michelle: Thanks, Andres. Yeah, so one of the things including that additional column that Andres was talking about, it really helped us think through, how are we really building that educator capacity? And how are we really providing professional development around early childhood development. And another aspect to it is that we knew we did it all the time. And we had stories about how we did it all the time. But using the theory of change, the framework to really make it much more precise, is really helping us think through how we are doing it. And so, it also helped us think about how our program is impacting early relational health through strengthening healthy family bonds. And so, it really has made us to be better poised to effectively test and evaluate how we are doing this work and what isn’t what is not working.
Andres: Thank you, Michelle. And one comment that I add, as we have about 90% of the participants that are now in the webinar are new to the to the framework, sometimes you may use the framework as a program developer, or somebody who’s implementing a program like your shell, but you could also use it to help other organizations like the way I have used it as part of the center in the developing child, or as promised venture studio has also used it with social entrepreneurs in their organization, the framework is really helpful in helping you think through your impact strategy. I mentioned a brief comment, if you’re familiar with other frameworks that innovators use, like the lean startup or business model canvas or other ones, it these helps you think through in a very clear way, in a simplified way, what are your strategies and how I am I get into the outcomes. And because of its it’s simple, and it can fit in one page, it also facilitates communication, communicating internally and externally, with the families you work with, with their funders, potential funders and with potential partners. But I’ll pause there.
Michelle: One more thing I just wanted to add about the framework is how it really helped us think about our innovations and new programming to into our theory of change and help facilitate that fast cycle iteration. Because it’s over the last few years, we’ve developed to new programs and explored how we were success and exploring how we can integrate technology into our programming. And we didn’t have that we didn’t have that in our previous theory of change. And so being able to build that into a using the framework to build that into our theory of change, thinking about the evaluation, how do we get that feedback loop? It was really beneficial and helpful for us as we’re continuing to innovate and develop new programs to
Andres: Thank you, Michelle.
Aeshna: Thank you so much for sharing your experiences. And we’re going to go ahead and pull some questions from the chat. And we will start with kind of a somewhat broad question. And that came from Aaron Soto. Is that are there any prerequisites for an organization to implement the ideas framework? And it was Melanie, you might want to speak to this?
Melanie Berry: Sure. I would say there aren’t necessarily any standard prerequisites. But I do think having worked with a lot of different organizations around this framework, there are some conditions that set you up to be more or less successful or effective using the framework. One thing I would say is it’s important to have all the right people at the table. So, I mentioned that one of the principles of the framework is co creation and this idea that, you know, bringing together a group of people who have multiple perspectives on the program can be really valuable and that might include leadership, people who are responsible for developing or implementing the program, people who will lead on the evaluation or research efforts, but equally, importantly, you might invite people to contribute who have a role in actually delivering the service working directly with kids, families and caregivers. And better yet invite a representative from the community that you serve to be part of this process. So that’s the first piece is just having the right people at the table. And then the second thing I would say is timing can be important. So this framework is really designed to help you prepare for a fast cycle iteration process. So to prepare for a round of collecting data, reviewing that data, interpreting and analyzing it and making sense of it, and putting what you learn into practice. So the timing there can be important, you know, are you set up and prepared to actually put this plan into action? Do you have the resources you need? Is everyone bought in? Etc? Yeah, and having the authority to put what you learn into practice. So if you’re implementing a program that was developed by someone else, do you have sort of the leeway to make changes to how you’re implementing that program based on what you learned? Or are there kind of more strict parameters around how you implement that program?
Aeshna: Thanks, Melanie. The next question we have came from Nicolas, and it says a question for Miss Reyes from El Busesito. Were there any outcomes or benefits that happened unexpectedly from developing this program? i.e. unintended consequences that happened, which you did not expect, yet?
Karla: Yes. So there, it’s that’s definitely been a learning curve, we’ve definitely had to modify and just evolve the program. One of the biggest changes that we’ve made just recently is changing the program from a five-hour week model, where children receive two and a half hours of preschool twice a week, to offering five hours of preschool twice a week. So in total, they’re receiving 10 hours a week. And this really came from listening and taking the time to listen to parents and hear what their needs were, for years, or parents had been asking for more time on the bus, we’re really trying to make an impact on how many children we served. And like I said, we have, we have the capacity to serve 96 children in our valley. So that’s 96 children that otherwise wouldn’t be receiving preschool, you know, in a traditional preschool setting. And we’ve noticed recently, we’ve had a decrease in our enrollment. So it’s been a little bit harder to enroll children into our shorter classes. And I think that has now impacted our school district and our other centers that have grown their capacity in their centers, which was the ultimate goal to get more children into preschool and enrolled. So we’ve now looked at how we can because we’re mobile, we can now take our program and start serving communities that don’t have that access. So it’s, it’s been playing out lately, that we’ve noticed these trends.
Aeshna: Thank you. And actually, I just realized that this question is, the way it got segmented in the question answer section, I didn’t realize that the Nicholas who asked the question has the same question for folks at Raising a Reader. So were there any outcomes or benefits that happened unexpectedly from developing the program?
Michelle: Sure. So I’ll say that we have had 39 independent evaluation that showed, then we knew that Raising Reader helped improve home literacy environments, and which is like increased shared reading time, increased duration, and frequency, improve the number of books in the home. But one thing that we were hearing from folks was, oh, well, it’s helping me build confidence and supporting my child’s early learning in the home. It’s really providing a sense of comfort and support for our families, this daily really reading routine. And so creating a new theory of change, with coaching support from Andres, to really make a much more precise, we were able to build those kinds of things into our theory of change, which then led us to improving our measurement tools, so asking specific questions so that we could actually get some more data around, While their stories are great,it’s also helpful to have our surveys also reflect some of that more quantitatively as well.
Aeshna: Thank you, Michelle. And we have one question here. This asks if someone could speak to how this theory of change framework can inform logic model use and development, ensuring that the information is complimentary and not duplicative for programs who choose to create both types of resources.
Melanie: I’m happy to field that; I get asked that question a lot. From what I understand. Those two terms theory of change and logic model are often used actually interchangeably in the field. And there really isn’t solid consensus on how the two are similar and different. The best guidance on that that I’ve found is that logic models tend to be more standardized, they often include inputs, activities, outputs, and then short term and long-term outcomes are variations on that theme. And they’re really, their descriptive theories of change, are a bit less standardized. So if you Google the term theory of change, you’ll find many, many, many different approaches to theory of change. But in general, they’re intended to be causal models that really explain how and why the expected changes come about. That’s one way of thinking about that, then logic models are more descriptive and theories of change are really intended to be explanatory causal models. Honestly, in practice, I find that they’re, you know, when someone asks you for a logic model or a theory of change, you really have to follow up to ask what they mean, specifically what they’re looking for there. Because I think expectations vary widely. Our approach to theory of change is really, it zooms in on the point of service delivery, or the point of contact with kids, families, caregivers, and follows that through to the ultimate outcomes that you’re hoping to see, which are typically child level in the field of early childhood. And it can be really helpful to set you up to make a plan for gathering data to better understand whether you’re having the impact that you’re hoping to achieve. I hope that’s helpful. Sally, do you want to add to that?
Sally: Yeah, so I actually have a real-life example of how we’ve used both at the same time. So we recently worked with the team at Mathematica to create a Two Gen logic model, they did a project with different to join organizations across the country. And so we have been using theories of change for years in our programs and our six different programs to really identify, you know, what is the what are our strategies? What are the targets? What are the outcomes we’re trying to have in each of our programs, so it’s kind of granular, and then we worked with the team at Mathematica to create this, like, what is our whole organization do? And what is the whole change we’re trying to make in the community in in children and families. And so having that overarching logic model, that our theories of change then kind of feed up into, you can see how they, how they interact, how they’re incorporated in that larger logic model has been just really interesting, but we’re not duplicating. So we don’t have like a logic model and a theory of change for each of our programs.
Aeshna: Does anybody else want to speak to that before I move to the next question? Okay. So we have a question here from Eric Marlowe and asks, In your experience, I think this could be open to anyone here. How long are the typical iteration cycles? How long do you recommend evaluating and adapting elements of a given program so that changes are made neither too soon? nor too late?
Melanie: I can take a first pass that then I’d be curious to hear from our colleagues at Raising a Reader and Valley Settlement, if I understood correctly. So that was the question. Like, how often or how long does it take? Or maybe a little bit of both?
Aeshna: My interpretation was a little bit of both.
Melanie: Okay. I think so the way this question gets asked to us often is how fast is fast cycle? Like, are we talking something you can do in days, weeks, months, years? And the answer there, I think is unfortunately, it depends. It really depends on the nature of the program, or service or product that you’re looking to evaluate and improve. If it’s, let’s say, a 10 week parenting group, then a single cycle could take, you know, you’d want a couple of months to plan and prepare, to identify to develop your theory of change to identify your questions to figure out your study design, figure out the tools you want to use prepare for data collection, then obviously, you need the 10 weeks to go by where you’re actually delivering the program to kids and families. And then you’ll need some time afterwards to analyze interpret and make sense of that data.
But that timeframe is obviously going to be really different if it’s a program that’s implemented on a school year calendar, for instance, or if you develop something like an app or a website that families can engage with, as they choose, and maybe dosage and engagement looks really different from parents or parents. So there’s no right answer for how long a cycle can take, you really just need to be thoughtful about what you’re hoping to learn. And then in terms of how often, I think that really varies, again, from organization to organization, and what the appetite and bandwidth is to engage in this kind of iterative learning. I know that valley settlement, for instance, has really built this into your kind of culture and your routines as an organization. And it seems like you’ve developed a really nice kind of annual rhythm. So maybe I could pass the baton to Sally and, Karla, to talk more about that.
Sally: Yeah, so as you say, Melanie, we really do our evaluation on an annual basis. So we most of our programs happen during the school year. We do pre and post surveys, we also do pre mid and post TS GOLD assessments for Busesito preschool. And then we really we do the bulk of data analysis in June and July. And then every July, we gather and do that evaluation retreat with our entire team. And then in August, we’re kind of refining our evaluation and planning the next evaluation cycle. But what I will say is that when we’re piloting new initiatives, we are trying to be a little more like eyes on as the as the initiative is happening. So for example, we worked a few years ago to implement a Child Development Associate course, for family, friends and neighbors, providers, and also for high school students who are Spanish speaking. And we were we were doing little pre and post assessments throughout at the beginning and end of kind of each section of the quarter module. Just to understand like, was our approach working? How could we pivot and adjust. So as we’re piloting new things, we do try to be a little more rapid, if you will, I would just echo the same thing that we do have an annual, like an annual cycle, I guess, where we do an annual evaluation, annual check in with our affiliates is what we call it. And then we do have a couple of pilots right now where we are calling them mini learning phases. After each learning phase, then we’ll take a look at the feedback and then see what tweaks or what modifications we need to do to improve the program. And then we have our second learning phase, and things like that.
Aeshna: A quick follow up from Nicolas to this question was so does that mean that the theory of change is different with each iteration?
Sally: So we definitely like we can evolve our theory of change every year, we go in as a team and look at the strategies and say like, you know, are you are you still doing these things? How are you doing them? You know, we definitely change and evolve in our programming, we’re not doing the same thing every year, because programs, neighborhoods, communities change and evolve. And we learn new things every year. So we do go in and tweak our theory of change every year.
Michelle: And I’ll say we just revised ours so we haven’t changed it. But one thing I think it is helping us think about though, as we are developing our program, how to stay focused on what it is that we really want to do. Because there are so many needs, and we serve so many different communities that have different needs. How do we stay true to this theory of change that for our mission, and things like that, so it really helps us identify are clearly like, where is our most unique impact and helps us stay there and not kind of stray just because there might be a funding source over there or something like that.
Melanie: I’ll just add that. It’s a great question. And it gives us the chance to underscore that. Absolutely. A Theory of Change can and should evolve over time, as you learn. So we call them living documents, right? It’s not a one-time exercise that you do, and you make a PDF of it. And it’s done. It’s a living document that you come back to after every round of learning. And you say, you know, what did we learn? How can we refine our theory of change? How can we refine our actual program or product or service? And how could we refine how we’re gathering data and learning going forward?
Aeshna: Thank you. So now we have a question from Megan Crystal, asking if we have any examples if we know of any state level policy or programs that have used this framework.
Melanie: I have a couple that come to mind. So a while back as part of the Frontiers of Innovation Initiative that Aeshna mentioned, there was a project team who implemented a video coaching program to support childcare and early learning professionals. And that project was done in partnership with the State Department of Early Learning. And this framework was used to sort of articulate theory of change for that approach, and to actually work with partners at the University of Washington to craft the evaluation plan. So that’s one example. And then another more recent example that comes to mind is our Center worked with partners at the Massachusetts Department of Early Education and Care to create an initiative wide theory of change, actually, similarly for an effort underway to bring early care and support organizations to build the capacity of actually childcare directors across the state. So we worked with them to create an initiative wide theory of change. And then each organization who was providing that service, use that initiative, wide theory of change as a template and kind of tailored it for their particular approach. And I think that’s still being used right now, as the initiative continues to kind of facilitate learning and improvement over time. There might be other examples, but those are two that come to mind.
Aeshna: Thanks, Melanie. Does anybody else-
Melanie: Can I squeeze in one more just in case folks are looking for examples. We worked with an organization called TOPS, which is based in the Netherlands. And they provide if I’m remembering correctly, services to families with newborn children. And I think that’s actually like a nationwide program that’s used ideas to drive towards greater impact. And there are resources or references about the tops program in the resources section of the toolkit. I think there’s a research article there that talks about their experience.
Aeshna: Alright. Great. Thanks, everyone. I was hoping we might have time for one more question, but actually see that we’re pretty close to the end there. So I just wanted to thank you all for joining us. thank our panelists for sharing your experiences and your learning, we really appreciate it. And thank you all so much for joining, we really, really hope that this resource is useful for you all, and we wish you the best in your continued work, supporting kids and families.
Corey: The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter @HarvardCenter, Facebook at Center Developing Child, and Instagram @DevelopingChildHarvard. Our music is Brain Power by Mela from freemusicarchive.org.
Contents
Podcast
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Transcript
These days, resilience is needed more than ever, and one simple, underrecognized way of supporting healthy and resilient child development is as old as humanity itself: play. Far from frivolous, play contributes to sturdy brain architecture, the foundations of lifelong health, and the building blocks of resilience, yet its importance is often overlooked. In this podcast, Dr. Jack Shonkoff explains the role of play in supporting resilience and five experts share their ideas and personal stories about applying the science of play in homes, communities, and crisis environments around the world.
Sally Pfitzer, host: Welcome to the Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Our Center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children and take what you’re hearing from our experts and panels and apply it to your everyday work.
So in today’s episode, we’re going to get serious about the topic of play. For children, play is a fundamental building block of child development, but its role in supporting resilience is often overlooked. And after the past few years, we surely need resilience now more than ever! For me, as a former preschool teacher, I’m especially excited about this episode and speaking with today’s experts, because I’ve seen first-hand how important play is for young children’s development. But what can science tell us about it? And what can be done to support more play in everyday life, even in crisis contexts? In this podcast, we’ll dive into the science of play and resilience, and then we’ll explore how people are using that knowledge to support child development around the world. To explain the science, we’ll start with Dr. Jack Shonkoff, Professor of Child Health and Development and the Director of the Center on the Developing Child at Harvard University. So Jack, what do we mean by resilience and what do we know about how people develop it?
Jack Shonkoff: What we mean by resilience is that we’re talking about the ability to do well, the ability to cope, the ability to overcome hardship, or adversity, or threat to your well-being. So the key about resilience is it doesn’t occur in a vacuum.
Resilience is something that you actively build, and you build it in the context of relationships in an environment that helps you learn how to cope with challenges, cope with stress, cope with hardships. And it starts very early. It starts in infancy. And infants need to have some sense of participation in that.
But also, you don’t do it totally on your own. You need the support and the security, when you’re a baby, of adults who basically help provide a manageable environment in which you can learn resilience. So, if stresses and threats are overwhelming, they can overwhelm the system. And you don’t really get a chance to build resilience. If every time something happens that challenges you, somebody jumps in to protect you, that’s not good for you either because you have to build that yourself.
So the environment has a lot to do with how you develop resilience and skills, but so does your own activity on the environment, your own sense of being a player rather than just a receiver.
But no two children are the same, even children in the same family, growing up in the same environment. From birth, children differ in how adaptable they are. If you go into a newborn nursery in a hospital, the nurses who work there can tell you about how those babies are all different from each other. Some kids are just more easygoing, constitutionally. Some kids roll with the flow, a little bit easier than others. So in a sense, we don’t all start off with the same way of reacting to stress or hardship.
Sally: That’s great. And thinking about how resilience is built, are there specific building blocks that you need to think about? In this case, could you talk a little bit more about how play might support those building blocks?
Jack: Play, by definition, is an interactive process or a kind of self-directed process. It’s not by chance that all children, regardless of where they live in the history of the species, use play as a way to develop skills. It’s the way children learn to master their environment. And they learn to try things out. They test things. They test limits. It’s driven by curiosity, and it’s driven by an inborn drive to master the environment.
And if you think about what resilience is all about, resilience is mastering your environment. It’s building the skills to be able to cope, building the skills to have strategies, to deal with your own reactions, be able to have some control over what’s going on around you. And none of that would develop as well as it does if you depended on just being taught how to be resilient. No. Your ability, your natural ability to play, is one of the most important strategies that we have developmentally to build resilience in the face of adversity.
Sally: So, what is the science that underlines this connection between healthy development and how play supports it?
Jack: God, there are mountains of science that help us to understand the process of development. And three principles, three concepts, just continue to stand out among all of the research, evidence, and knowledge we have about development. And they are the keys to healthy development.
The first is the importance of supportive relationships. Children develop in an environment of relationships. So, supportive relationships are critically important for healthy development. The second is the need to reduce significant sources of stress—not eliminate stress, but reduce stress, so it’s manageable. And then the third is building core skills, the kinds of skills that are needed for just about anything that we’re expected to do at any point in our life. So these are the core skills that are the building blocks of learning, and behavior, and good health.
And if we put those three things together—supportive relationships, reducing sources of stress, and building core skills—they are essential for us to understand not only how resilience develops over time, but also what an important role play occupies in that process. Particularly in a young child, there is this sense of trying to figure out what the world is all about. So core skill development, which is essential for building resilience, is very much tied into the ability to learn actively through play and through interaction with others.
There has been so much research done on resilience in a variety of circumstances, trying to understand what is it that explains how some children overcome adversity and do well in spite of hardship and threats. The one thing that comes out in just about every single study is whenever there’s evidence of resilience, you can always identify at least one very important relationship that was critical to the development of resilience. Very often, it’s a parent. It doesn’t have to be a parent. It can be another member of the family. It doesn’t have to be a family member. It could be a neighbor. It could be a preschool teacher. It could be a child care provider. It could be a coach. It doesn’t really matter who it is. It certainly doesn’t have to be a blood relative, but there has to be at least one relationship that basically provides a scaffold in which children develop the skills to be able to cope themselves.
That’s the ultimate answer to the question of, can you build your own resilience? The answer is for all the studies that have ever been done, no, you can’t. You can’t become resilient yourself. You can’t will yourself to be resilient. You have to be able to be supported by at least one nurturing relationship.
If we look across the incredible range of experiences and conditions that children grow up in, the principles remain the same. Children are all busy actively mastering their environment, regardless of what that environment is. The challenge is to understand what’s individually different about each child and what is the nature of the environment in which the child is living. And everything else is just figuring that out based on basic principles of what science tells us about development.
Sally: So Jack, you spoke earlier about how play helps build resilience. I’m wondering if you could you give us an example of what that might look like at different ages—for example, what would it look like for an infant?
Jack: What play is about is early on, beginning in the earliest of infancy, really, shortly after birth, is if you think about what babies do, and once babies become attuned to the people who are caring for them, it’s the kind of thing that gets everybody all excited—the eye contact, the beginning of a smile, the cooing, and the vocalizations, and all that stuff that elicits back and forth, serve and return interaction between very young infants and adults. The vocalizing back and forth, the smiling, the looking around and then looking at the same thing, and then handing something, and grabbing it, and giving it back. And, all of those very simple interactions early on are playful interactions.
And then, as you move out of the very earliest of infancy and get into the second half of the first year, when babies become more mobile, and they’re rolling over, and then they’re crawling, being able to reach for things, and grab things. You find the right balance between allowing the child some room to do things in a protected environment and also initiating some things with you. So you initiate interactions. You respond to interactions. You let a child move around. You put stuff out on the floor for a child to play with. And sometimes, hopefully, you leave the child alone in a safe place and let the child explore.
All of this, a lot of people may not think of that as play. They may think of play as more organized kinds of activities. But that is the beginning of play. It’s the beginning of active learning, discovery, curiosity, trying things, learning from what happens when you do something, action and reaction, all that stuff. And then, as you get older and you start to play more organized games, play peekaboo, play Simon Says with a child that’s a little bit older, play all these kinds of games that have rules attached to them, rules about taking turns, rules about following instructions, all of this, board games as kids get older, and then as they get into the school age years, organized games, sports, more challenging board games, again, now most people would say, oh, yeah, that’s like play. That’s what play is all about. But it started much earlier, and it started with the foundation that was all about discovery, creativity, exploration, learning.
In the best of all worlds, play doesn’t end until you die, because play is a way of thinking and engaging with the world. Play is one of the most important vehicles for having some sense of mastery and control over the world that you live in, which is getting us very close to the definition of what resilience is all about. It’s not being able to just deal with predictable things that you’re expecting and you’re prepared to cope with, but being able to deal with anything that life sends your way.
Sally: Could you talk a little bit more about how play might actually support health? What are we learning from our current research?
Jack: This is a really important question and a really important expansion of how we think about play. It’s easy to understand that most of the conversation and most of the thinking about play for the last, let’s say, last 20 years as we’ve been learning more and more about the science of early development is it naturally connects to learning and behavior. It was very brain-focused.
But it’s not just the brain that’s developing. It’s the immune system and metabolic systems. Just like the brain is experience-dependent, the immune system is experience-dependent. It’s learning about different bacteria and viruses that are out there and it’s exposed to. And as a result of that, the immune system is building resistance to those infections early on and preparing you for better physical health. And the same thing with metabolic systems. A well-regulated environment every day is affecting all of these systems. And a dysregulated environment or a highly stressed environment, as it affects the immune system, can cause increased inflammation, which is part of the stress response.
And early behavioral regulation, it leads to more health-promoting adult behaviors, less likely to engage in risk-taking behaviors, less likely to engage in addictive behaviors, problems with smoking, problems with alcohol, problems with risky physical activities that get you into trouble.
So the link with play—there’s no question that somewhere down the road over the next 10 to 20 years, we will all have an understanding that playful learning and the role of play in building resilience is as much about physical and mental health as it is about early learning and school achievement.
Sally: You’ve given us so much to think about, as always, Jack! Thanks so much for your time and being here with us today. When we come back, our panel is going to give us some examples of how they’re putting that science into action.
Musical interlude
Sally: Okay, so we’ve learned a bit about how play affects our biology. Let’s bring it out of the lab now, and into our daily lives. Most of us think about play happening in child care and on playgrounds, but play can honestly happen anywhere! In our next segment, I’m so excited to talk to our panel members, who have lots of examples to share. Joining us on today’s podcast, we have Andres Bustamante, who is an assistant professor in human development in context at the University of California Irvine. Thanks for being here today.
Andres Bustamente: Thank you, Sally. It’s such a pleasure to be here.
Sally: Also on today’s podcast, we have Lynneth Solis, who’s a researcher and lecturer at the Harvard Graduate School of Education. It’s so nice to talk to you today, Lynneth.
Lynneth Solis: Thank you, Sally. It’s a pleasure to be here.
Sally: And also on today’s podcast, we have Laura Huerta Migus, who is the deputy director of the Office of Museum Services at the Institute of Museum and Library Services. Nice to see you today.
Laura Huerta Migus: So happy to be here, Sally.
Sally: Lynneth, I know you’ve looked at research on play and how it helps to build resilience in a lot of different places and contexts. How might opportunities for play look different in some of these different contexts?
Lynneth: The interesting thing is that we see play supporting children’s coping with stress and developing resilience in all kinds of contexts. So you may find it in a simple drop-off at preschool. So that can be really stressful for a child. What we have seen is that children that are allowed a few minutes between drop-off and the start of the day to play on their own or with peers, depending on their choice, actually show reduced levels of stress, both behaviorally and biologically.
But we also can think about other settings with children being exposed to prolonged adversity, like war or being in a refugee setting, where having the opportunity to play, for example, in play groups with caregivers or with other children gives the children an opportunity to create bonds with their caregivers and with other children. And it gives them opportunities to practice some of the coping skills to deal with the difficult emotions and effects of prolonged stress.
We’ve also seen it in situations where children have hospital stays or hospital interventions, which, again, can be very foreign for children, can be very stress-producing. And when health care staff use play to introduce to children what the procedures might be, to give them some space between the introduction of these procedures and the actual medical intervention, what we see is that children show reduced levels of stress prior to the medical intervention but also post the medical intervention.
So their ability to reduce the stress after coming out of that experience also seems to allow them to regulate their stress levels more quickly and more effectively. And so what we see is that both cross-culturally but also in different types of settings, play can be very beneficial for children and for the adults and caregivers in their lives.
Sally: That was the perfect tee-up, Lynneth. Thank you. Laura, what are some examples you’ve seen that encourage play that were created by museums and libraries? I think that’s a really interesting place to be thinking about how play is happening.
Laura: Yeah. Thanks for that, Sally. So it actually builds quite a lot on what Lynneth was telling us about the evidence. So the practice of children’s libraries and children’s areas being interactive, sometimes looking like mini children’s museums for example, having “making spaces” or craft spaces is a relatively new pursuit that is now pretty mainstream practice in library design.
You’ll see the same in museums. Obviously, we have children’s galleries. We have children’s programming, even children’s tours in mainstream museums. And, of course, we take it to the extreme in museums. We actually have children’s museums, right, the entire museum that’s designed with the child’s needs and development in mind.
We also think about playful experiences, like story times. And story times that are starting for the youngest families and the youngest children to help build that sense of playfulness but also helping parents build great relationships with their babies from day one in enriched environments. And then we’re helping to be part of really a public education effort in helping to teach caregivers—so not just parents, but any adult caregiver, which could also include educators—about the value of play as learning and how important it is for child development.
Sally: Laura, I was really struck by that phrase, you said it was a public education effort. And that was making me think, Andres, of your work, thinking about engaging community. And I was wondering if you could tell us a bit more about how you engage community members authentically to help devise playful learning opportunities.
Andres: Yeah, absolutely. So I’m part of a larger project called the Playful Learning Landscapes Initiative, which was started by Kathy Hirsh-Pasek and Roberta Golinkoff—who are my mentors and close collaborators. And that project is all about designing everyday spaces, spaces where children and families naturally go and naturally spend time. You can think bus stops, parks, grocery stores, doctors’ offices, laundromats, anywhere where families go in their everyday routine, and trying to enrich those spaces with play and learning value. Because, like our other guests Lynneth and Laura have shared with us, that has so much value. Those interactions and that play time is so enriching for kids.
We are partnering with a local community organization called SAELI. SAELI stands for the Santa Ana Early Learning Initiative. And we’re partnering with SAELI in order to design public spaces so not only that they have the learning value and stay true to what developmental science tells us about what creates high-quality learning situations, but also so that they reflect the community’s values and goals and strength and culture.
And this is really important because it can have a big impact on the way that families interact and engage with the sites and really build a sense of ownership, which can really increase learning value and also longevity and usability of these sites in the community. And so SAELI has over 200 members, and it’s local parents, it’s teachers, it’s school administrators, it’s local politicians, it’s community organizing and nonprofit organizations.
And so all people coming together to promote enrichment activities and supports for families with kids 0 to 9. And so through this partnership with SAELI, we’ve held design sessions where we have about 40 mothers from Santa Ana come in and just share their vision for their community. So we have them tell stories about their childhood and their experiences growing up, sometimes in other countries or sometimes here in Santa Ana, and what they did in those spaces. What did they do at the bus stop? Or what did they do at the park? Or how was it going to the market or the grocery store? And then from those stories, we’re able to distill themes and commonalities across families’ experiences and then try to represent those experiences in the designs that we create. And then we actually have families build stuff, so we’ll bring arts and crafts kits and have them actually build out a bus stop or a game for the park.
And so families end up sharing these really special stories and games that they played as kids and that now they want to play with their kids and show other people in their community. And these games are so rich with learning value. And so it becomes this situation where we accomplish all the goals that we wanted to from a science perspective about making learning situations that create these high-quality caregiver-child interactions, but are deeply embedded in the community’s lived experiences.
Many of our families are from Mexico, and they talked about how the abacus was a really common tool for them to learn math. And so we’re going to make a bus stop that has a giant abacus. And so kids can count things and engage in math conversation while they wait for the bus. And it’s a way that we’re really building on families’ strengths and experiences of like, this is how they learned math, and so they’re really equipped to communicate math and engage in this activity with their kids.
Another game, another bus stop idea was a Loteria bus stop. So Loteria is a really popular local game. It’s kind of like bingo. You spin a wheel and then you get a symbol. And then we’re going to make a bus stop that has a big version of Loteria. And then when you get a symbol, you flip it, and there’s different activities that kids and families can engage in that are play-oriented but have a learning value. I think that there’s going to be a real deep sense of ownership, because the families are the ones who really created these designs.
Laura: I just wanted to respond, Andres, to something really important about those examples that you gave. And that often when we’re talking about children and children’s learning and play, we talk about children as if they are isolated and they’re experiencing these activities on their own or in a child-only environment.
And we know how important play can be for strengthening or building really positive adult-child relationships and what you’re talking about here in terms of identity development and cultural identity building and generational transmission of knowledge. And I just think that that’s really important, at least also think about play as not just for the child but for the child and everything around and everyone around the child. It’s good for everybody.
Sally: Very true, and it seems to me that we all need play now more than ever, especially given the past couple of years!
Laura: Families have gone through trauma on a large scale over the last two years. And I think there’s a really important moment right now where, as a country, we have the opportunity to say we know what is important for our children’s well-being and for their recovery.
Lynneth: Play allows children to deal with uncertainty. So what it allows children to do is to pivot, to adapt, to follow different paths, depending on what’s happening right in front of them. So it’s an iterative process. And those skills that are developed over time are the building blocks of those coping mechanisms that are important when children are exposed to uncertain situations, like a pandemic, et cetera. And the interesting thing is that this is also true for adults.
Laura: Some of the most impacted families and children in the pandemic were our youngest children, so pre-academic years, children 0 to 4 or 5 years old, whose parents and caregivers were essential workers, and who tended to also be in our lower socioeconomic strata. Those families and children lost access to most of their learning and care supports and were very isolated in their homes. So many of us were, but you think about a restaurant or service worker with a two-year-old and what that first year of the pandemic looked like. Virtual learning doesn’t work for a three-year-old.
One of the innovations that we saw, in the children’s museum world in particular, was the development of learning kits—very simple sets of materials, tangible materials, that were focused around fun and playful activities. Quite often, they were just small prompts to elicit pretend play and guided play between adult and child.
What we heard from hundreds and thousands of parents was that they wanted these kits. They needed materials to engage their children away from screen time and in ways that were meaningful and that gave the parents confidence and power to engage their children in something joyful in a time of incredible stress. Hundreds of thousands of these kits have been disseminated by hundreds of libraries and museums. And the need is still there, and the want is still there. And so I think that tells us something about how families feel like play is a critical part of their toolkit, their resilience toolkit.
Sally: Thank you for those thoughts; they’re so important. We’ve talked a lot about the connection between resilience and play as it relates to learning. I’m wondering, though, are there also connections between play and other kinds of development? For example, we’ve been thinking a lot about health and social-emotional skills..
Lynneth: Something that is important to understand about the connections between play and all sorts of developmental outcomes for children is that not every single play experience leads to all the outcomes. So what do I mean? That there are certain types of play that are particularly supportive of health outcomes, for example. So you might think about more physically active play that might have children practicing both fine and gross motor skills or games that might have them be, again, physically active, may help reduce stress, which is also associated to biological responses to stress that can be harmful to the body.
On the other hand, if you think about social-emotional skills, dramatic play, pretend play, storytelling are types of play that can be associated with outcomes that are about understanding emotions, knowing how to name emotions, knowing how to respond to others and their emotions, regulating how to interact with others in a positive way.
So it’s not that children should only be engaging with object play and building and learning mathematical skills or that they should only be engaged in dramatic play and developing language and social-emotional skills. But that, actually, it’s sort of the toolbox of opportunities for children to engage in different types of playful interactions with peers, with friends, but also adults, as we’ve heard from the other panelists.
Laura: I really would like to “yes, and” what Lynneth said about the different kinds of play. Especially as you’re thinking about yourself as a parent or an educator or a policymaker, there’s often wanting the answer of, what kind of play is the best? And so I think emphasizing the notion that all kinds of play is the best is so important.
And also acknowledging why different communities are going to take different approaches, because the needs are going to be different. The affordances, what’s available, what matters is going to be different from family to family, community to community. And that’s a kind of diversity and flexibility I think it’s important for us to also embrace.
Lynneth: A question we often hear is, should this be free play or guided play? Which one is the most beneficial? And I think going along with this idea of all kinds of play for different types of outcomes is the idea that free play, children being able to play uninterrupted, being able to focus, being able to set up their own challenges and figure out problem-solving strategies is incredibly important for children.
And, as we’ve also discussed in the podcast, that the interaction with others—so the added support, the added scaffolding from educators, from parents, from other adults in children’s lives—can also help expand the types of opportunities that children have to learn and to develop skills through their play. So it’s important to know that adults helping to shape play is not necessarily a negative thing.
And it’s always in relationship to what is the interaction, how are we making these interactions with children the most valuable to both allow them to take risks and build autonomy and independence while also feeling supported in their environment?
Andres: I absolutely love this conversation about different kinds of play. And I really appreciated something that Laura said, which is that in each community, this might look different. And I think that’s the beauty in this idea of designing with the people who are going to be, at the end, using the space.
And so, for example, in our work in Santa Ana, a huge theme that came through from all of our families is this idea of transmission of culture intergenerationally. You know, whether it’s their language or their culture or their customs or their childhood games, they feel like their kids are not always getting their full experience of their community.
That might not actually be a top priority for every community. But I think that’s why if you design with the people who are going to be in the space, it’s so powerful. And you end up tapping into these really valuable ideas that are really going to motivate people to use these play spaces and create the kind of rich learning that we really want to see between kids and families.
Lynneth: I love what Andres and Laura have shared about working with communities. When I think about involving communities and creating playful experiences for children, there’s three questions that I like to think about. One is, what is working here? What’s already good? And what’s most meaningful?
Both Andres and Laura have shared examples of this. How do we work with communities to say, when we think about play, we don’t want to impose an already packaged program or set of activities. What we want to learn is, what’s already working for you? What’s already meaningful for you? And how does this continue to celebrate your history, your family relationships, community relationships, and the values that you have for the children in your community? So I really, really appreciate this conversation.
Sally: Thank you all so much, this was honestly such a treat – I love hearing all of your perspectives. So thank you!
Musical interlude
Sally: So next up, we have an expert on one really important kind of setting that’s all too often overlooked: humanitarian settings for refugees. There are millions of children in these settings worldwide and they need playful experiences as much as any child. Well, fortunately, there are some very committed people working on just that, and today I’m delighted to have a chance to speak with one of them. Her name is Erum Mariam and she’s with the BRAC Institute of Educational Development. I’m so looking forward to our conversation today, Erum.
Erum Mariam: Thank you, Sally. Looking forward to this conversation with you today.
Sally: So I know that you and the BRAC Institute, as well as your partners from Sesame Workshop and other organizations, have done a lot of work bringing play to humanitarian or refugee settings. Could you tell me a little bit more about what you mean by humanitarian settings?
Erum: Sure. I’ll be speaking from my experience of the Rohingya context today. Rohingya started coming in in 2017. There were thousands and thousands of Rohingya who were coming over from Myanmar and coming to Bangladesh to a place named Cox’s Bazaar. It’s the largest refugee camp in the world, and with about almost a million people.
So I will be talking about people who have been displaced from their own country. And in this case, it’s really very, very sad because they came away after the genocide in Myanmar. And there were women with infants and toddlers. They came with the most essential belongings, their families. And then they went into shelters, which were absolutely very temporary, with bamboo and then plastic sheets on top. And then after that, they moved more into what looked like housing. But these houses are of two, three rooms and made of bamboo as well as sheets. And that’s the humanitarian setting.
Sally: Wow. Could you give me a sense of how many children in particular are in this kind of setting worldwide, and maybe give us a glimpse into what that situation might look like for a child in particular?
Erum: I think, worldwide, the amount of displaced population is somewhere around 82 million. And out of that, believe it or not, it’s thought that about 42% are children. That’s around 34 million children we are talking about. It’s a really big number of children.
And what it’s like for children, I mean, one day, I saw this, I observed this, and it has really stayed with me. That there was a child who was about two years old, and she was with the mother. And the mother was given some—they were getting relief materials, and the mother got biscuits. And I saw that the mother took a piece of stone and the packet, and she was crushing the biscuits. As she crushed the biscuits, and it became powder, and she took the powder, and she was feeding the child. And then she was taking some for herself. Because you know, there were days that they wouldn’t get meals. And so even in the extremely difficult situation, I saw that mothers and parents tried their best for the children.
After that, when I observed that they got some kind of housing, we could see parents trying so hard to get a sense of normalcy, to give a sense of normalcy to their children in a very, very difficult situation. So I would see moms and dads getting water, moms cooking, dads getting bamboo to make the house stronger, parents drying their chilis and other things on the rooftop. And so just to give that sense of normalcy to everyday life in a very, very difficult situation.
Sally: I can imagine in these moments, where people are struggling to have access to food and water, that play might be something that’s lost. And in some cases, rightfully so, right? You need to make sure you’re treating these more immediate needs. Could you tell us a little bit more about why play should still be considered important in these settings?
Erum: Sure. Play does have this power of creating a very nurturing environment. And play of course has so much to do with relationships, because when children play, there is a relationship there. There is a caregiver or even their older siblings also in that space. When there are these situations of real deprivation, of so much of trauma, and if we can have these situations where there is nurturing and there is stimulation, I think that’s really fantastic for the children, that there are these opportunities for child development.
Sally: Erum, I love that you highlighted that responsive relationship with an adult or sibling. I think that’s really critical in terms of developing resilience. Could you give me an example of how these playful approaches might be integrated into these settings?
Erum: Yes, absolutely. In 2017, when we were there in the camp, and one day we were at a center. It was a child-friendly space, and the children were there. And we went in and we said, what do you want to show us? Show us anything that you really want to show and you’re proud of. And the children all got up and they were chanting a rhyme.
And believe it or not, Sally, when the children were chanting, we found that community members, they came and they surrounded the center. And they surrounded the center because with the chanting and with the children clapping and chanting, there was a connection with the community.
So we started exploring the Rohingya culture. We asked the children, what did you do when you were in Myanmar? And they showed us the most fascinating physical play. We asked the children, what do you like drawing? And they showed us motifs which were different. Children even as young as age two were able to hold the crayon. And they had really good fine motor skills. And so they were showing us the motifs of art.
We explored, we were exploring with the caregivers. We asked what is it that they had that belongs to the Rohingya culture. They showed us designs of cloth that they used to have in every household that would hang under the ceiling. The caregivers, the community members, they told us stories which were very much about the Rohingya culture and history.
As we developed this content, we spoke to child therapists. And the child therapists, they told us that, don’t you see what you have done. What you have done is you’ve been working on learning through play, but what you have really done here is healing through play.
And so they said that the two elements that you have been able to bring out is you have given so much emphasis on the children’s voices that they could say—they could tell you that this is what we did, this is what we like, this is what we play, and things like that. And the second was that we respected the Rohingya culture. And the Rohingya have beautiful play. And their play is really about coordination and balance. And they were bringing that to us and to the world.
Sally: Incredible. I really loved it when you were talking about both respect for the culture and how they play, as well as respect for children as autonomous and humans that have their own beliefs and ideas and creative thinking, too. I think that’s a really powerful mix. I’m wondering if you could tell us a little bit more about how this pandemic that we’re experiencing has affected your work with the Rohingya?
Erum: Once there was the lockdown and there was restricted mobility, parents of course had to step up. And that meant that every child’s home had to be, had to have an environment which was so very stimulating for the child.
So every week we would call the mother for 20 minutes. For the first 10 minutes, we would speak about her mental health issues. Was she having any kind of difficulty? How were the days? Is there anything that she wanted to speak to us about? And the next 10 minutes was about the playful approaches with the child. And so the child and the mom and the facilitator who was calling on the phone. And so this was, the next 10 minutes was about the chanting, the rhymes that the children love doing, and also some physical play that would be possible under those circumstances.
This was something that was totally emerged from COVID. And what we have found is when we looked at all the data and the results of the 20-minute phone call, we found that this has shown so much of improvement in the children’s communication and language, in children’s social-emotional development and cognitive development. So those are results that we’re extremely excited about. And so we look forward to much more.
Sally: That’s thrilling. And I feel like this thread that’s gone throughout this interview is around listening and how important that’s been for you and your organization, and how that’s meant that the resources you provide are so much more targeted. And that’s beautiful.
I have one last question for you. The needs for international refugees seem really huge and daunting. And we were wondering if you could share a little bit more around how might listeners of the podcast take action, or any feelings you have around hope that you’d like us to end on.
Erum: Yeah. My experiences with working with the refugees have shown that those who are displaced, their experiences are so hard. And so they live under such harsh realities. But what I have found is that their spirit is so—they have so much resilience. And there’s so much spirit for them to go on.
Because at the end of the day, we go back to our lives. But the people who are living in these conditions, they go on, and they find normalcy. They find aspirations. They find dreams. They find—under the most difficult of conditions. So the best we can do is just keep on supporting. Whatever opportunity we get. Whenever there’s a chance for any kind of resources, contribute there. So any opportunity to be there to amplify the cause and be a part of the solutions for the humanitarian settings.
Sally: Thank you so much for your time, Erum, I really enjoyed our conversation. And for listeners, we’ll post resources and information relating to the support for children in humanitarian settings on our website, which is developingchild.harvard.edu. When we come back, we’ll wrap up with a pediatrician’s important prescription for parents.
Musical interlude
Sally: And we’re back! After so much emphasis on what societies and communities can do, we wanted to close with something really practical that everyone could do. Joining us on today’s podcast, we have Dr. Michael Yogman who’s a pediatrician and faculty at Harvard Medical School and Cambridge Hospital. It’s so nice to talk to you today, Dr. Yogman.
Michael Yogman: Thank you so much for inviting me.
Sally: One thing I didn’t say in my introduction is that you are actually the founder and driver of an initiative of the American Academy of Pediatrics; it’s called Prescription for Play. The idea is to encourage pediatricians to actively prescribe play for children to support their healthy development, and then to give them some tools and resources for the kinds of playful interactions they might suggest to parents. Could you tell me a little bit more about what the Prescription for Play initiative is, and where did it come from?
Michael: I spent about six years as chairman of the board of the Boston Children’s Museum. I was also chairing a committee of the American Academy of Pediatrics and had agreed to write a clinical report on play in early childhood. It occurred to me that pediatricians often considered play frivolous, parents often considered play frivolous. And there had been an increasing movement about taking the focus on learning standards, and third grade, and literacy, and moving that kind of No Child Left Behind testing standard back into preschool and early child care. And I interviewed a teacher who was weeping because her director said that she should remove the blocks from her child care center. And I said, you know what? That’s nuts!
It started a notion that we could point out to pediatricians that just like any other medicine, they could write a “prescription for play” at all well visits, and that it would convey a message that play was not frivolous, that it was brain-building. We realized the role that play could play in promoting safe, stable, nurturing relationships, which were critical to resilience. And pediatricians could play an important role in incentivizing parents to value play.
I think the pandemic and its ensuing stresses, this child mental health emergency that we’re now seeing, never has it been more important for kids to be able to play. The notion that we’re going to make up for the learning loss through remote learning, by hammering kids with more stressful academic pressure is only compounding the stresses of child mental health. Play has a really important role in buffering the stress that is really preventive.
Sally: Do you have any sense of how many pediatricians are participating in this?
Michael: So it’s an uphill battle. I think just as I think we really were making headway, lo and behold, the pandemic hit. Pediatricians are very supportive of this concept. I think that any changes have been a little bit put on the back burner as they’ve just tried to get kids immunized, move away from virtual visits toward in-person visits. And I think we’ll get back to an emphasis on play. So I think it’s been picked up actually in hospitals in Denmark, and in Salt Lake City, and by the LEGO Foundation. I’ve gotten lots of inquiries on trying to transform pediatric waiting rooms, hospital waiting rooms to really promulgate a lot of these ideas. And part of the purpose is to enable parents to realize the value in observing what their kids are doing during play rather than sitting on their iPhones during the waiting room.
Sally: It’s exciting to hear, and I can only imagine how frustrating that was to feel like you were getting traction and then have this pandemic hit.
Michael: Unbelievable.
Sally: So could you give our listeners three ideas or maybe three tips that represent how pediatricians might guide parents to support healthy child development through play?
Michael: I think that acknowledging when really young infants have that brief period of quiet alertness and they’re cooing, to realize those are meaningful moments, and parents want to be responsive and engaged. Even if it’s brief. It’s important. So that’s number one. When they coo and you coo back at them, they’re really learning about turn-taking. That’s an important skill for the pragmatics of language development, which evolves later on.
Number two, the power of letting kids explore. There’s some wonderful research by Alison Gopnik that if parents were too pushy, you gave them a toy with multiple aspects of it, if parents were too pushy at demonstrating all the things, the kids weren’t interested. If you let the children explore it on their own, they did much more active exploration and were much more joyful about discovering things on their own.
And the third one is just to emphasize the importance of reading, and singing, and letting kids even play. You don’t need to buy expensive toys, playing with wooden spoons and plastic Tupperware that are just around the house. Since parents are using those objects, kids are really excited to pretend that they’re adults and exploring those objects just as the adults are using them.
Sally: It’s funny, they’re all ready to grow up and turn into adults, and here we are as adults sometimes wishing we could be kids again, right?
Michael: Exactly. And I think for parents to, the final advice is as adults, I love George Bernard Shaw’s quote: “We don’t stop playing because we grow old, we grow old because we stop playing.” Probably a good note to end on.
Sally: Perfect. I really have enjoyed talking with you.
Musical interlude
Sally: So that concludes our look at how play builds resilience and what we can do to support it. I’d like to thank all of our guests, those conversations were so much fun, I really learned so much on today’s episode. And thank you for sharing your personal experiences and your stories. I’m your host, Sally Pfitzer, and we hope you’ll join us next time!
The Brain Architects is a product of the Center on the Developing Child at Harvard University. Harold Shawn of Levelsoundz Productions was our audio editor for this episode and Lauren Osgood was our production assistant. Our music is “Brain Power” by Mela from freemusicarchive.org. You can find much more on the science of child development at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter (@HarvardCenter), Facebook (@centerdevelopingchild), Instagram (@developingchildharvard), and LinkedIn (Center on the Developing Child at Harvard University).
The devastating toll of the pandemic has underscored the critical importance of connecting what science is telling us to the lived experiences of people and communities. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. Now, a year later, we wanted to continue these conversations and discuss what we’ve learned, what needs to change, and where we go from here.
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Transcript
In the final episode in this special series, host Sally Pfitzer speaks with Dr. Nancy Rotter, a pediatric psychologist and the Director of Psychology in Child and Adolescent Psychiatry, Ambulatory Care Division at Massachusetts General Hospital. They discuss how the pandemic changed conversations around mental health, why we need to integrate mental health into the context of overall health, and what caregivers can do to help children prepare for the lessening of restrictions and the return to school.
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Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. You may remember we discussed the importance of self-care for caregivers, and the importance of physical distancing, not social distancing. And now a year later, we wanted to continue those conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Joining us on today’s podcast, we have Dr. Nancy Rotter. She’s a pediatric psychologist and the Director of Psychology in Child and Adolescent Psychiatry, Ambulatory Care Division, at Mass General Hospital. Thanks so much for being with us today, Nancy.
Dr. Rotter: Thanks for having me, Sally.
Sally: So, the pandemic has made conversations about mental health more common and perhaps even less stigmatized. How do we make sure that this perspective and these conversations continue even as vaccines become available and restrictions are lessened?
Dr. Rotter: You know, I agree that there has been some shifting over time in terms of awareness and acknowledgement about mental health and specifically children’s mental health. I think the pandemic has really raised these conversations to a higher level. I think that there’s certainly been comfort in talking about heightened distress that people have experienced due to the pandemic secondary to the many stressors that families have experienced. I think about things like loss of typical childcare support, like daycare, in-person school, or even grandparents caring for children, unemployment or shifts to having to work at home, social isolation. And I think all of these things are widely understood as contributing to how people are coping and to mental health. I think sometimes people find it easier to describe experiences of anxiety and depression in the context of stress and the stress perhaps experienced by the pandemic. You might not hear those words as much. You might hear things that sound less stigmatizing—that people might talk a lot about stress or isolation or fatigue, rather than referring to specific mental health conditions themselves.
I do think that it might be a good direction to go in to think about how we can acknowledge mental health conditions as an aspect of overall health so that we can increasingly talk about things like depression or anxiety or substance use disorders in the same way that we speak about diabetes or heart disease. Shifting towards a more specific and accurate language for mental health conditions can really make a difference. because I think if we do so we can really add clarity for diagnoses, which then result in leading to more effective evidence-based treatments to treat these illnesses. Again, thinking about these like we do other health conditions.
I think the continued progress, to kind of get to the other part of your question, towards the de-stigmatization of mental health conditions will really require increased and ongoing discussions about emotional health, and to have this happen in schools, in the media, within families, and certainly when children go to see their pediatrician. I think that pediatricians more and more are providing mental health screenings at routine exams, asking developmentally based questions to both parents and children or adolescents to screen for things that are concerning—anxiety, depression, suicidality, substance use disorders. And I kind of like the idea of thinking of that type of screening as mental health vital signs. And for me, that fits with the concept that when you go to your pediatrician or you go to your doctor, there’s always vital signs. They take your heart rate and your blood pressure, and it seems to me that using that kind of language really is helpful and is something that’s understandable to everyone and can help to really de-stigmatize the concept of mental health. And I do hope that we continue to work in the direction of integration of mental health into the context of overall health.
Sally: Yeah, absolutely. So many important points, and I especially love that idea of the vital signs. Nancy, from your perspective, has the pandemic exposed any weaknesses in our mental health care systems, particularly for young children? And how should we take those into consideration as we move forward?
Dr. Rotter: I would describe the primary challenges in our mental health care system for young children as twofold. The first relates to access to mental health care and the second is for increased need for prevention and early intervention services. While thinking about the importance of mental health care for children, I think it’s really important to be aware of some of the prevalence rates. For example, 50% of all life-time mental illness begins by age 14 and 75% begins by age 24. So, it’s very clear that making sure that we are keeping an eye on and assessing children and adolescents is key.
I have to say that the pandemic has impacted access to mental health care in somewhat of a complicated way. On the one hand, unfortunately, there’s been an increased need for mental health services for everyone, and specifically for children, and the need has really outstripped the availability of services. This has occurred in the setting of overall improved ability to access care via telehealth. Telehealth, through both the use of video and telephone visits has improved access in many ways. Families who struggle with transportation, that don’t have the time, that have financial limitations—it’s allowed them to access behavioral health care more readily. However, this is further complicated as telehealth access has not been equitable. Black, Latino, and non-English speaking patients, and patients living in communities hardest hit by the pandemic demonstrate consistently lower rates of use and access to video-enabled technology.
And while overall access to care has been a problem during the pandemic and it’s not easily solved, there’s been some hopeful news in Massachusetts. Effective January 1st of this year, the state legislature passed a bill requiring insurers to pay for services conducted by either telephone or by video technology at the same rate of reimbursement that they cover in-person visits. And I do think that’s really going to make a difference. That isn’t going to solve our immediate problem of access during the pandemic, but hopefully that knowing that that’s going to be an option down the road that that will allow for additional ways that we can help people.
In terms of prevention and early intervention, I think addressing the mental health needs of young children when they present with mild symptoms—like sleep or feeding, or toileting, anxiety or behavioral issues—sometimes might not get identified until they reach a level that really requires urgent intervention. However, preventative and early intervention when the initial or the mild symptom becomes apparent can be extremely useful, and my thinking is that it can be improved by having mental health professionals in the clinic, with the pediatricians so that there’s behavioral health care integration. And that way, making services available in the context of the yearly pediatric checkup, which families typically come to, that there would be screening and opportunity for intervention when families are coming every year or even for other visits.
In my work at MGH, in pediatric behavioral medicine, we’ve been very successful at embedding psychologists in specialty medical clinics like gastroenterology and diabetes and food allergy, which is where I work. Sometimes, for example in food allergy, I will meet with a family where a child is very anxious about having a blood test. And so, I can—at a minimum—meet with the child then and if they’re not ready to do a blood test that day with intervention, that now they know me and they can come back a couple of times to see me and I can help prepare them for that. And so, catching families where they’re going to get their medical care and being able to help them in that context is really important and really useful. This is something that has been established in many primary care clinics and hospitals across the country. The idea is to really think about a variety of services that might best meet the needs of the family by offering some in-clinic consultation, some brief treatment, access to parenting groups, and potentially digital health interventions in addition to the more traditional therapy and medication treatments that we all know about.
Sally: I really love this idea of integration. In particular, at the Center, we talk a lot about the need for responsive relationships and I hear a lot of what you’re saying there is that if you’re able to build those responsive relationships early with kids, you have a better chance at allowing them to benefit from your services if they know you better.
Dr. Rotter: Absolutely. And you know, one of the other statistics that I think is so powerful is that when referrals are made by anyone—by physicians or pediatricians—to a mental health professional, approximately 50% of those do not follow through. And so, by having someone actually live in the clinic to meet the family—sometimes even what we call as a warm hand-off—where they just are introduced, they get to see a face and a name, and there’s a connection that can really reduce the gap we have sometimes when they’re referrals that don’t make it to the referral source.
Sally: So, in a Q&A for Mass General Hospital on preparing children for when their parents return to work, you said, and I’ll quote you here, “Parents may experience their own anxiety about having children return to daycare due to the worries about COVID and may inadvertently send signals to children about their own anxiety.” Could you give us some ideas on how we can support caregivers during this adjustment period?
Dr. Rotter: Absolutely, in supporting parents and caregivers, it’s important to be aware that they may have their own mental health needs and perhaps had mental health issues prior to the pandemic. The toll that the pandemic has had on caregivers and parents has been tremendous. Caregivers have been required to step into roles that they were neither trained to do nor prepared for, such as becoming teachers to their children, providing full-time childcare while at the same time working a full-time job or perhaps coping with stress of unemployment or the loss of loved ones.
Self-care strategies can range from taking a few minutes to read an email from a friend, a section of the paper. Additionally, self-care can come in the form of family activities, creating scavenger hunts or obstacle courses for children, or even coming up with healthy cooking projects can combine self-care with family time. And I think that sometimes there are things that we might do that are really self-care that we may not consider self-care. They might be small, or they might be small and done every day and even that sense of routine can provide a break, can provide some comfort, and can provide some predictability. I think we’ve all been dealing with the lack of predictability in quite a profound way during the pandemic. And I’m not sure that’s going to change quickly as things open up in different pieces and in different ways.
Sally: I really appreciate that lens on the caregiver, and I wonder if you could talk a little bit more about how caregivers can ease their children back into normal life, while at the same time remaining cognizant of the stressors of this past year. And if you could speak specifically to infants and toddlers, I think their fears are sometimes a little less obvious to us.
Dr. Rotter: Absolutely, young children may exhibit distress through behavioral changes or shifts in their typical functioning, which can include sleep, eating, toileting, anxiety, tantrums, or increased irritability. And it’s hard to know when that happens what that could be a function of. It’s really important that if there are changes—abrupt changes or unusual changes in a child’s functioning—it’s really important to seek out consultation from your child’s pediatrician in order to rule out any underlying medical issues as a first step. And if at that point in conversation with the pediatrician, the belief is that perhaps what is being experienced by the child are indicators of stress or anxiety, that’s a time where a referral to a mental health professional from your pediatrician can be very helpful.
Many children and families are currently adjusting to the increased amount of time children are spending in-school and/or activities that were not happening during the pandemic restrictions. It’s typical and expected for infants and toddlers to experience discomfort when separating from their parents or caregivers, and this may in fact be exacerbated by the extended period of time they spent at home during the pandemic with parents or caregivers. So, it’s helpful to have a plan in mind. For older children, maybe toddlers, talking with them about familiar school activities that they may remember from when they were in school in the past, such as things that they played with or listening to stories, can help them prepare for their new schedules. But it’s also useful to think about what might be different, like the teacher will be wearing a mask, and there might be new hand-washing rules. They might tell their child, “we’ll wake up in the morning and have breakfast together and then you’ll go off to school, where you’re playing with your friends and you’ll be with your teachers and have lunch with them. And then you’ll return when it’s about time for dinner, we’ll all have dinner together.”
Additionally, for older children, sometimes the process of rehearsing going to school through play with dolls or figures can help reduce the stress. Reading books about returning to school can be useful as well. When possible, even for very young children, doing a short visit to school or daycare to acquaint or reacquaint the child with the classroom and the teacher can ease the transition as well. Even starting back in a more gradual manner can be helpful if that’s an option—going for a couple of hours the first few days and then working up to longer periods of time at the daycare center or preschool. Parents might also find talking with their children in the direct, but simple way about the coronavirus and how their child’s school or daycare has rules to make sure everyone is safe and healthy. For example, they may tell their children that their school is listening to the things that the doctors and the scientists are saying about going to school safely, and those are the things that they’re doing at school.
Sally: I know a lot of kids have been really isolated the last year, some maybe have only one friend or no younger children that they see. So, could you talk a little bit more about that social isolation or maybe potential anxiety that might be resulting from that?
Dr. Rotter: Yeah, I think social anxiety is a concern that many caregivers and parents have and some children have. I think for children who are naturally slightly more shy or anxious, particularly in new situations, that reentering social environments can be quite challenging. I would think a lot with the family about ideas such as previewing what to expect. Sometimes for young children looking at pictures of someone they maybe haven’t seen in a while, thinking about things they did before with that child that might have been fun or interesting when we’re thinking of young children.
Another thing that I talk a lot about with families when children have some anxiety about social situations is the structured play date. I think the idea of having a very specific plan in mind for an activity that’s really time based, so it’s not a long unstructured period of time, but it might be that a child comes over for lawn bowling and cookies and lemonade. And then that’s the end of that particular playdate. Or a specific arts or crafts activity or something along those lines, but that everyone knows what the expectation it, that there’s it’s something else to focus on, and sometimes that really helps to sort of build things. And often, what we’ll find is in those situations, that once children are comfortable with each other or reconnect in the case of they haven’t seen each other in a while that they can sort of take it from there. But some children need more, more structured play dates to help build in that comfort in a social setting.
Sally: There’s so many people, who I think will be comforted by your examples, because you gave really clear ideas on how to move things forward. So really, we’re really delighted.
I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, Instagram @DevelopingChildHarvard and LinkedIn, Center on the Developing Child at Harvard University. Brandi Thomas is our producer. Dominic Mathurin is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. This podcast was recorded at my dining room table.
The devastating toll of the pandemic has underscored the critical importance of connecting what science is telling us to the lived experiences of people and communities. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. Now, a year later, we wanted to continue these conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Contents
Podcast
Speakers
Additional Resources
Transcript
In the third episode in this 4-part special series, host Sally Pfitzer speaks with Dr. Renée Boynton-Jarrett, the founding Director of Vital Village Networks at Boston Medical Center and an Associate Professor of Pediatrics at Boston University School of Medicine. They discuss the cost of failing to address structural inequities with sustainable and comprehensive policy changes, the vital role community leaders played during the pandemic, and why health care systems need to demonstrate trustworthiness.
The next and final episode of this special podcast series will focus on the pandemic’s impact on the mental health system.
Subscribe below via your podcast platform of choice to receive all new episodes as soon as they’re released.
Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. You may remember we discussed the importance of self-care for caregivers, and the importance of physical distancing, not social distancing. And now a year later, we wanted to continue those conversations and discuss what we’ve learned, what needs to change, and where we go from here.
On today’s podcast, we have Dr. Renée Boynton-Jarrett, who is the founding Director of Vital Village Networks at Boston Medical Center and an Associate Professor of Pediatrics at Boston University School of Medicine. So good to have you with us, Renée.
Dr. Boynton-Jarrett: Delighted to be here. Thank you, Sally.
Sally: Renée, in March of 2020, we spoke with Dr. David Williams, who explained that many of the disparities that we saw in the early stages of the pandemic were predictable and the result of longstanding social policies and systemic racism. From your perspective, as an expert in the field, in the past year, what have we learned about these disparities?
Dr. Boynton-Jarrett: I think what Dr. Williams shared is absolutely correct. What we saw happen with the COVID-19 pandemic is it took advantage of the existing inequities and just widened those. So actually, our existing structural racism created a broader opportunity for the pandemic to disparately impact the lives, the well-being, and the health of communities of color and communities that are disproportionately impacted by structural racism. And so, I think one of the things that we have learned or relearned is the tremendous cost of failing to truly address structural inequities with sustainable and comprehensive policy changes.
And as importantly, because we know structural racism is around these interconnected systems and institutions, but there are also these ideologies, mindsets, ways of thinking and being. And if we think about it, those ideologies and mindsets about who’s okay just to remain at risk, to not have the luxury of physical distancing, to not have the luxury of having water to wash hands and do the hygienic practices. We’ve learned that we also have mindsets that truly impact the way in which we view humanity and human dignity and human rights, and that this pandemic has completely taken advantage of the ways in which those mindsets, ideologies, and systems create structures of inequities.
Sally: Could you give us some examples of what changes you think need to happen in the field, particularly how communities and neighborhoods could help?
Dr. Boynton-Jarrett: Yeah. I think your question actually hits on where I see the biggest opportunity for change. So, one of the things we saw happen over and over during the pandemic is in the absence of plans. Strategic plans and responses are being created in real time, and often those decisions—whether they were decisions being made about how vaccines would roll out, whether they were decisions being made about what economic supports and resources will come to families, or what will happen with early care and education, childcare, school—we saw time and time again decisions being made that were not being made with true engagement. Not just engagement of communities, but engagement of community leadership. So really, in partnership with, in conversation with. Those who were closest to the inequities—experiencing them most directly—were not being engaged or brought to the table.
And time and time again, we also saw that the ideas, the wisdom, the strategies that were actually happening within communities were thoughtful, were creative, were real-time responsive. And actually, when we begin to get behind them, we see more protection happening for communities. So, we also saw tremendous community leadership, and in the absence of that leadership, I think that we would have all fared much worse in this pandemic.
Sally: Just anecdotally, I’ve seen that even in some of the work we’ve done at the Center too, and often finding that bringing in members of the community actively from the beginning of projects has been the thing that has made those projects so much more successful. Could you tell us more about your work at Vital Village Networks?
Dr. Boynton-Jarrett: So, Vital Village Networks is based at Boston Medical Center. We promote child well-being and address structural and systemic inequities and systems of care and education in early childhood by doing a couple of things. We really work around establishing sustainable, authentic, and equitable partnerships between caregivers, parents, and community residents and community-based organizations and cross sector institutions—health care, education, advocacy, social service. In this work, we all really focus on expanding leadership trajectories and pathways for community leaders, and that can be through trainings and certifications and expanded opportunities. But we also really think about how do we work to build capacity and enhance existing community-driven solutions? So, how do we build capacity within a community to promote well-being? And often, that involves helping institutions and organizations within the community work with community leaders in a different way and we use a model called co-design. So, how do we create and design things together?
We really work to think about what builds equitable partnerships. What creates a table for truly equitable participation? A lot of approaches to community engagement and community work begin with the deficit lens. They begin with the idea that there’s a problem in the community, and we have a solution, we want to bring the solution. Well, that starting point actually makes it very hard to partner equitably with communities. Because if you think about—even if you were going to pick someone for a team, would you pick someone or something that you had only framed in terms of their weaknesses? Parents don’t do that with their children, right? We all have our strengths and weaknesses. Parents are really good at framing the strengths and uplifting the strengths and building upon the strengths of their children, but we don’t do that with community engagement. We often view a problem and that’s our primary way of understanding a community, and that really creates an imbalance in power from the very beginning. Also, who gets to ask the questions? Who gets to design the evaluation? What type of technology do you need to participate virtually? So, all of these things create barriers for equitable partnerships.
With co-design, we really begin first by understanding that there are solutions that already exist within communities and if we’re not aware of those solutions, it’s because we’re not seeing them, not because they don’t exist. So really beginning by recognizing, appreciating, and valuing the strengths and the wisdom and solutions within communities, which creates a much more level playing field for partnership. The second piece is how do we plan? How do we design together? So, how can we disrupt tools and strategies that bias someone based on their training or education? And how do we create opportunities to design things together that are centered around the diversity of people in the room? And that’s also a particular invitation that no one is at the table only as an expert, but everyone is at the table, both with their expertise and their gifts, as well as as learners. And so, creating that mutuality, that ability for us to be in both roles, all of those factors really lead to the ability to partner with communities and not on behalf of.
Sally: Why do you think there’s a disconnect between health systems and the families they’re supposed to serve? I’m thinking particularly here about the COVID vaccine in relation to this.
Dr. Boynton-Jarrett: What I would share is I think we’ve had a disproportionate focus on distrust about the vaccine. So, when we think about it, when we actually look at the real data that we have, actually the vast majority of people who have been surveyed or interviewed in communities of color are along a continuum of interest in the vaccine, and/or very interested in getting the vaccine or have already received it. So, a very, very small percentage that has said, you know an absolute no. So, that is a strong signal that people are seeking an opportunity to have their questions answered, to have a conversation, and to engage around the vaccine.
Also, what I think we haven’t focused on enough is how do health care institutions demonstrate trustworthiness? So, we want people to trust the vaccine, and that it’s good for their health. And we have like this, I think an overemphasis or an over expectation that what we’re hearing from people is that they don’t trust the vaccine. What we may be hearing from people that we haven’t focused on enough is how do institutions demonstrate that they are trustworthy—that they’re going to share updated information about concerns, or warnings, or emerging complications, or side effects? That they are going to offer the vaccine in settings where you will be able to get your questions answered. That you will have opportunities to hear from other people who have received the vaccine.
And so, what I think that we need to really focus on is also taking a hard look from a lot of current and historical lessons at the ways in which, you know, despite what might be well intentioned efforts, systemic racism truly exists within our institutions, including our health care institution. And how that is experienced for people is sometimes that the institution does not appear to be trustworthy, because time and time again needs are not being heard or listened to or responded to with dignity.
If we are expecting that we can change people’s minds to make them do what it is we’d like them to do, again, that only serves to reinforce, “I’m not wanting to hear your concern. I’m wanting you to follow my guidance, my advice in a system that you have not been invited to help design what this experience would look like.” So, that’s why we’re seeing so much success of vaccines that are being administered at faith-based institutions in partnerships with the faith-based community. That’s why we’re seeing so much success with providers of color that are creating safe and brave spaces for people to learn about, talk about, and discuss the vaccine. And in our work with Vital Village Networks, we’ve had what I would just consider—led by community members—we’ve had love conversations. Conversations that aren’t so much about all of the details, but are just creating a space for people to be honest about any fears they may have, or anxieties that they may have. And time and time again, they connect to what you have learned throughout your life around untrustworthy medical institutions that have demonstrated that time and time again. So, we must do a better job and a different job of demonstrating trustworthiness.
Sally: I really appreciate that response.
I’m your host Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, Instagram @developingchildharvard, and LinkedIn: Center on the Developing Child at Harvard University. Brandi Thomas is our producer. Dominic Mathurin is our audio editor. Our music is Brain Power by Mila from freemusicarchive.org. This podcast was recorded at my dining room table.
The devastating toll of the pandemic has underscored the critical importance of connecting what science is telling us to the lived experiences of people and communities. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. Now, a year later, we wanted to continue these conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Contents
Podcast
Speakers
Additional Resources
Transcript
In the second episode in this 4-part special series, host Sally Pfitzer speaks with Dr. Rahil Briggs, National Director of ZERO TO THREE’s HealthySteps program. They discuss the potential impact of the pandemic on infant and toddler development, how an overstressed pediatric health care system responded, and the importance of overcoming equity challenges and public fears to resume well-child visits.
Upcoming episodes of this series will feature expert speakers reflecting on the longstanding social policies and systemic racism that resulted in the pandemic disparately impacting communities of color, and the pandemic’s impact on the mental health system. The experts will discuss how we can take what we learned over the past year and make meaningful changes that will improve outcomes for children and families. Listen to the first episode of this series, where Center Director, Jack P. Shonkoff, M.D. discusses what COVID-19 revealed about the needs of caregivers with young children or during pregnancy.
Subscribe below via your podcast platform of choice to receive all new episodes as soon as they’re released.
Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. You may remember we discussed the importance of self-care for caregivers, and the importance of physical distancing, not social distancing. And now a year later, we wanted to continue those conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Joining us on today’s podcast is Dr. Rahil Briggs, National Director of ZERO TO THREE’s HealthySteps program. Rahil, thanks so much for being here with us today and just for timing, I’m going to jump right into our first question. What can we tell parents and caregivers about the potential effects the pandemic lifestyle changes could have on development, particularly on infants and toddlers?
Dr. Briggs: Thank you Sally, and thanks for having me. I know this question is on a lot of people’s minds. We’re a year into this and what’s been the effect? For some of these kids, it’s half of their life that they’ve lived within the COVID pandemic. But for parents of babies and toddlers, I think we mostly have really good news. Because they are learning through serve and return interactions, it doesn’t need to occur in one particular kind of learning environment or even a specific variety of environments for them to continuously be learning. So, parents can rest assured that babies and toddlers who are having that regular interaction with their primary caregivers in loving, supportive, nurturing ways with all sorts of serve and return moments all day long are still learning a lot. So, reading books, singing, playing music, just observing what’s going on around them. We often talk about—you know nobody expects that you’re going to put your life on hold and read 20 books to your kids every hour, but can you just comment on what you’re doing as you’re cooking dinner? Now I’m putting the water in the pot, and now I’m putting the rice in, and let’s watch it boil—and just really narrating or sportscasting that day.
I’ll say it again and again and again, you know, it’s about really taking care of oneself—avoiding toxic stress, bringing in mindfulness if you can. And I don’t mean that we all become yogis and meditate every day. That is not realistic right now. We’re trying to juggle 12 different things every minute.
It’s about self-care of adults. Self-care is not selfish as we’ve discussed before. Reducing that caregiver stress will reduce baby and toddler stress, and when babies and toddlers are less stressed, they learn better just like us, right? We learn better when we’re less stressed and it’s exactly the same for them. And of course, if there’s one thing we’ve all learned in this last year, it’s that stress can’t be avoided per se, but it’s about regulating. And so, for parents and caregivers it’s about self-regulating or asking for help. And when you do those things, either self-regulate or ask for help, you model really important social-emotional skill that babies will eventually learn through that example.
Sally: Rahil, I really appreciate that connection you just made between the health of caregivers and the health of children. I think it’s something that can easily be overlooked, especially with everything going on. And I’m wondering, are there concrete examples of things that caregivers should look out for? Something that might indicate that their child has been negatively impacted by the uncertainty and chaos surrounding the pandemic?
Dr. Briggs: Sure, so we know that the difference between a one-year-old and a two-year-old say in developmental terms is pretty remarkable. It’s quite different than the difference between a 33-year-old and a 34-year-old, for example. And so, developmental regression is something that you might look at and you might look for. So, is a child who used to be toilet-trained now going back to having accidents or asking for diapers? Or a child who used to be, you know, fully weaned from a bottle, or breastfeeding or a pacifier, suddenly going back in that direction? Those can be signs of them just saying like “Hey, this is all a bit overwhelming for me right now and I want to go back to a place where things are a little bit easier, and I get a lot more soothing and a lot more care.”
From some of the wonderful work of people like Joan Luby and others, we know that preschool age children can be unfortunately depressed. They can be reliably diagnosed with depression, meaning that a number of different professionals would agree: “yes, this looks like depression.” And not too unlike ourselves in the adult phase of life, you know. It could be impacting sleep, diet, interest in everyday things. So, I would say that’s a great time to really reach out to your pediatrician and say, “This is what I’m seeing. Does this feel like the new normal and just what I should expect because of how we’ve all been? Or does this feel like something that needs a little bit more attention?” And so, any prolonged or substantial changes might be something to bring to a pediatrician.
We know that lots of families have been worried about going to the pediatrician. I saw just this week, the American Academy of Pediatrics has put out a new call that parents are superheroes when they bring their children to the pediatrician to get up to date on vaccinations, but it’s also those times to ask those questions and really double-check like is this okay? Is this something to be expected? Or is this something to be worried about?
Sally: So, the pediatric system, like many had to adapt rapidly to the pandemic. What do you think has worked well and what has not worked well?
Dr. Briggs: So, talk about superheroes. When I think about my colleagues in pediatric care at Montefiore and around the country and all through healthcare, the lengths to which people have gone to support families is remarkable. We’ve heard about just pediatric practices, sort of turning themselves inside out and becoming one-stop-shops for families—diapers, formula, and the like. So, just gratitude to everyone in pediatric healthcare. They’ve been stressed, to say the least, and so that pediatric system has had to get retooled to serve adult patients. There have been some children’s hospitals where full floors have become adult-focused out of need, and of course, as people have gotten sick or been less available, we’ve seen that as well.
So, the pediatric system was stressed to say the least. We saw and we continue to see dips in well-child visits. We see dips in vaccinations—not COVID, but all those other diseases that we have these wonderfully evidence-based vaccinations for—and it’s around the country. We’ve also heard about pediatric practices closing, just not being able to stay open for business because the volume was down or because the workforce issues. There’s been a slow rebound on all of these points, but I’d say we’re not quite back yet to pre-pandemic levels and so that means that families are missing out. They’re missing out on that really important care that happens at the pediatric office.
If we don’t reverse this and quickly, that will be concerning. I think about it, especially from an equity lens. When all babies and toddlers have a strong start, and when they can get that start through a partnership through a high performing pediatric practice, the entire country is better, right? Pediatric primary care is like the only setting we have in this country that almost universally reaches all babies, all toddlers, and their families no matter what your income is, no matter, you know where you’re living.
So, I’d say some of the transitions we saw, you know, as folks got to recognize that this new normal was going to be around for a lot longer than they had anticipated. We saw our HealthySteps practices really adhere to the guidance that was put out by the American Academy of Pediatrics and by the CDC. And so, for many practices that meant postponing visits for older kids and only seeing kids birth to age 2 in person. That was some early American Academy of Pediatrics guidance. Some practices experimented with drive through vaccinations, others went fully remote and started seeing families virtually. Telehealth in pediatrics is not quite as seamless as it may be for us in the adult world, right? That was a really big adjustment for people. I think it’ll be here to stay in some form, but lest you think it’s easy, try to imagine a baby or a toddler on the other side of that telehealth visit and telling them, “please sit there for the next three minutes and don’t move and show me the inside of your wrist.” Right? It’s like “uhh no.” So, not always the most compliant.
You know, but for a lot of folks, for families and providers, seeing their patients virtually was better than not seeing them at all. Again, though, I think about equity here. And so many of those inequities that we saw pre-COVID are still relevant. Perhaps more relevant than ever, and they really come to light when we think about telehealth and folks who don’t have multiple computers in the home and the one that they do have is needed for the school-age child to do online schooling. They don’t have unlimited Internet access or cell phone data. And then, when we close the public spaces, previous options like using a computer at the library or the like aren’t really feasible. We’ve heard from our practices in rural areas that broadband access is a huge issue. This was again pre-COVID, and that affects telehealth and of course, remote learning for older children and work.
As we become vaccinated, many of us, you know, practices are mostly back to in-person with the safety precautions that they need, which is really promising. And I would say we’ve all learned a lot. We’ve learned we are more flexible than we knew we could be, and we have been reminded about the inequities that existed pre-COVID because they have been magnified. My real hope is that we renew a focus on changes that really last for families—committed to health, well-being, school readiness of all babies and toddlers. Our work at HealthySteps continues with I’d say even more urgency than we had earlier. And hopefully, the world and the community at large can join us with really that mission to give all babies and all toddlers that incredibly strong start.
Sally: Yeah, you started talking about this a little bit, but I’m curious when families are really stressed and they’re starting to say like, “Well, a well-child visit might be something that I can skip because there’s so much going on and I’m worried about exposure.” What would you say to those families and how would you kind of help them think through what that might mean?
Dr. Briggs: It’s a great question. In terms of skipping well-child visits, we have data that suggests that there are negative outcomes when you skip well-child visits. So, what are some things that can happen? Well, developmental delays can go undiagnosed, and we all know that the earlier we catch those developmental delays and the earlier that we provide evidence-based treatment, the better the outcome for children, sometimes erasing what was a delay in only just a year.
We also know about the incredibly lifesaving importance of vaccinations. We all are pretty well, you know, the number of people who can talk about what an mRNA vaccination does these days is remarkable and hopefully they remember that we’ve got vaccinations for lots of other really life-threatening diseases, and it’s critical—early childhood is the moment when you’re getting vaccinated, right? Almost every visit there’s some combination of vaccinations. They’re just so important.
Growth is an obvious one. Not everybody has a perfect infant scale at home, and so being able to make sure that babies are gaining back that early birth weight and then gaining weight at the rate we would expect really has significant implications for development and well-being overall. So, it’s really one of those visits that feels pretty darn worth it to mask up, to call ahead about safety protocols, and to know that each and every one of those health care providers is going in there every day just as worried about their own health and well-being and that of their families and wouldn’t do anything to put their patients in danger.
Sally: You always make me feel better when I talk to you, Rahil. I love those concrete examples too, I think that’ll be really helpful.
I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, Instagram @developingchildharvard, and LinkedIn: Center on the Developing Child at Harvard University. Brandi Thomas is our producer. Dominic Mathurin is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. This podcast was recorded at my dining room table.
The devastating toll of the pandemic has underscored the critical importance of connecting what science is telling us to the lived experiences of people and communities. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. Now, a year later, we wanted to continue these conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Contents
Podcast
Speakers
Additional Resources
Transcript
The first guest in this 4-part special series is Center Director Jack P. Shonkoff, M.D. He and host Sally Pfitzer discuss what COVID-19 revealed about the needs of caregivers with young children or during pregnancy, what we learned about the importance of science over the course of the pandemic, and how we can make changes going forward.
Upcoming episodes of this series will feature expert speakers reflecting on the pandemic’s impact on pediatric and mental health systems, and the longstanding social policies and systemic racism that resulted in the pandemic disparately impacting communities of color. The experts will discuss how we can take what we learned over the past year and make meaningful changes that will improve outcomes for children and families. Subscribe below via your podcast platform of choice to receive all new episodes as soon as they’re released.
Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. You may remember we discussed the importance of self-care for caregivers, and the importance of physical distancing, not social distancing. And now a year later, we wanted to continue those conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Joining us today is Dr. Jack Shonkoff, Director of the Center on the Developing Child. Jack, we really appreciate you being here, and I know we have a lot to cover, so let’s jump right in. Could you tell us what COVID-19 has revealed about the needs of young children, families and people who are pregnant?
Dr. Shonkoff: So immediately, we saw the difference between people who had access to resources that helped them get through and those who before the pandemic were always at the edge and that this put families over the edge in terms of meeting basic needs—food, clothing, housing. But then, there’s the other universal experience of the critical importance of supportive relationships—the critical importance of extended family, neighbors, friends—and the extent to which every parent, regardless of your circumstances, cannot parent a child alone. And the social isolation that so many people felt, from the poorest to the wealthiest.
And so, I think if there’s anything good to take out of this past year, it’s a recognition of the universal needs that all families have to provide a healthy environment for their children, but the tremendous inequalities in resources and buffers and supports that we could all turn to when we are faced with really unusual hardships. So, it’s this balance between kind of universal experience and highly unequal consequences that I think are the lessons from the past year.
Sally: Could you tell us what we’ve learned about science over the course of this pandemic? And especially, how that science relates to what children need.
Dr. Shonkoff: Our work has been deeply grounded in the importance and the value of bringing credible, trusted, scientific knowledge to the table in addressing all of the challenges and opportunities that face families with young children, especially families who are dealing with excessive adversity or burdens. And this past year, has been a real eye-opening experience I think for all of us about both the critical importance of trusted, credible science in the face of threats to our health and well-being and the very significant limitations on how that science can provide direction or guidance about how to move forward.
We certainly learned this past year, not only that science doesn’t always have all of the answers—and especially at the beginning of problem—but that science doesn’t stand still, and that we depend upon science to keep moving forward. And we also have to learn how to make decisions based on incomplete science and based on the best science we have. And in many ways, we’ve always known that. We know that there aren’t answers to every problem. But I think one of the really very complex and and sobering lessons we learned this past year is how science has to be aligned with the lived experiences and the values and beliefs of the population. Because when it isn’t aligned, people can choose to not only not believe in the science, but to adopt alternative perspectives that try to delegitimize science.
So, for me personally, and certainly for the work of our center, this is a real time to just step back and try to figure out how we can maximize the contributions of science and we can leverage cutting-edge science that has solutions—or partial solutions—to our problem, without expecting that science will have all the answers. And certainly, for those of us at the Center on the Developing Child, kind of recognize both the limitations of the science at any time and the power of the science to guide us in more effective approaches to deal with any of the challenges we’re facing.
Sally: Looking forward, what can we do? How can we make changes?
Dr. Shonkoff: We’ve all learned a lot about how much the health of any society depends upon a sense of shared responsibility for each other. To get through this together. Whether it be people caring about their communities, decision leaders caring about the well-being of the country. I think we’ve learned simultaneously that we are all in this together and we all have shared vested interests and we are not all in this with equal resources and equal assets. And this has not just been about the pandemic. We have had the converging crises of an infection out of control, of a massive economic disruption that did not have an equal impact on all parts of the population, and then, of course, we have the dramatically increased consciousness about something that is not a new problem, but the dramatic increase in understanding the unbelievable threat and hardship of systemic racism and structural inequities imposes on families of color and other groups that are disadvantaged in ways that are kind of embedded in our society.
So going forward, I think the health of our society depends upon the extent to which we see all of us as having a shared investment in the well-being of each other. So, this is still politically extraordinarily complicated, but I think one lesson we might take from this is shared interest in everybody doing well. We do know a lot about the kinds of conditions in which young children grow up that increase the likelihood of a healthy, productive outcome: supportive relationships, manageable levels of stress, basic needs met, major opportunities for learning, and buffering and protection from excessive stress activation.
So what do we do going forward? We start with the fact that in a society like ours with our political traditions, there’s a mix of self-reliance and kind of shared responsibility. And no family gets by by itself. So, the question is: Do you pay for it yourself or do we share the responsibility of paying for it for everyone else? Whether it be health care, child care—child care, there’s an interesting tension. Is child care something we need so that parents can go to work or is child care something we need to make sure that children have kind of optimal environments, for their development while their parents are working; because we have learned how the economy cannot move without child care to take care of children while their parents work. So, we could go down the slippery slope of seeing child care as basically something we need to promote parent employment and set very low standards and just say: make sure kids don’t fall our windows or run out in the street and we’re okay. Or we could say we need it for the economy to work, but we also need to build a strong foundation for the next generation. We have to just recognize that at the end of the day, going forward is some combination of making sure that we find some way to support families to meet their children’s needs and promote their children’s health and development. And then thinking about as a country, what kind of resources do we need for population health? But let’s just remember at the end of the day, governments do not raise children. Parents, families, caregivers, raise children. But how they’re able to kind of provide for their children’s needs and their own needs, depends a lot on communities, depends a lot on government, and depends a lot on resources. A lot.
And so, I think going forward for the early childhood system, I would say there are a couple of things that involve more than just how do we rebuild what’s broken down. Because, what we learned from this past year is how fragile the infrastructure is for many essential early childhood services, whether it be child care, early education, early intervention programs, family support programs. It’s a fragile infrastructure. It’s not permanently supported, and its funding is always up in the air. So going forward, I think the big challenges for the early childhood field come in two categories. One is how do we rebuild and re-envision early childhood services so that they are able to have a more stable infrastructure and more predictable funding , so that all of the energies could go into providing supports for families instead of half of the energies going into trying to keep the money flowing. That’s a huge problem. But there’s another part of the early childhood world that hasn’t traditionally been thought of as the early childhood world, but I think is one of the most important messages just coming out of the past year. Which is that for families experiencing structural inequities—the families who are from generation to generation dealing with the way certain structures and policies in our country disadvantage some groups over others , with racism being at the top of the list—the question is how are we going to deal with that and break down those hardships and threats that are critical to the early childhood system.
So, let me be very specific about this. Right now, in the early childhood world, most of our resources, most of our energy is focused on children, their families, and adults who work in programs that provide essential services—and there is a lot that can be done to improve life prospects for children. But, at some point, we’ve got to think about how we go upstream and how do we prevent the things that are causing the problems rather than just figuring out how better and better to kind of treat or help people cope with things that ultimately have to be prevented. So, it’s like this is not just about rebuilding what was lost during the pandemic. It’s not just about trying to reopen child-care centers . It’s taking the best of what we have, but not just trying to kind of rebuild and replenish, but try to re-envision what an early childhood field will look like. And it’s got to be more of a balanced combination. To do what we know how to do to promote responsive relationships and health-promoting environments, but also start to pay more attention to going upstream and at a macro level, at a society level, dealing with what is imposing very unequal hardships and burdens and threats on families raising young children.
Sally: That’s such an important point, Jack. There’s clearly a lot of work that needs to be done. Thanks so much for your time again today.
I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, Instagram @developingchildharvard, and LinkedIn: Center on the Developing Child at Harvard University. Brandi Thomas is our producer. Our music is Brain Power by Mela from freemusicarchive.org. This podcast was recorded at my dining room table.
How do we use the science of early childhood development to implement practical strategies and overcome longstanding barriers in the early childhood field? How can we ensure that families’ voices are heard when we create policies or programs?
Contents
Podcast
Panelists
Additional Resources
Transcript
To kick off this episode, Center Director Dr. Jack Shonkoff describes what the science means for policymakers, system leaders, care providers, and caregivers.
This is followed by a discussion among a distinguished panel of experts, including Cindy Mann (Manatt Health), Dr. Aaliyah Samuel (Northwest Evaluation Association), and Jane Witowski (Help Me Grow). The panelists discuss how we can break down the silos in the early childhood field, policies affecting prenatal-three, and how policies can change to address the stressors inflicted by poverty, community violence, and racism.
Sally: Welcome to the Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Our Center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children and take what you’re hearing from our experts and panels and apply it to your everyday work.
Today, we’ll discuss how the science we shared in our previous episode, on the early years and lifelong health, can change the way we think about early childhood policy and practice, and what this shift means for policymakers, practitioners, and caregivers. So, I’d like to welcome back Dr. Jack Shonkoff, Professor of Child Health and Development and the Director of the Center on the Developing Child at Harvard University. Hi, Jack. Welcome back.
Jack: Hey, Sally.
Sally: So we talked in the last episode about how the brain is connected to the rest of the body, and especially how the early years really matter when it comes to lifelong health. What does this science mean for policymakers, system leaders, or even caregivers?
Jack: That’s a really important question, Sally. From the beginning of the early childhood field, it’s always been focused on early learning and improving children’s readiness to succeed in school. In the policy world, it’s in education policy, comes out of the education budget. For people who work in early childhood programs, and for parents, it’s about programs that encourage and provide rich learning opportunities for children to develop early literacy competencies.
But the mindset shift here is that it’s not just about early learning in school—it‘s about the foundations of physical and mental health. It’s not just about improving outcomes for greater economic productivity—better educational achievement. It’s also about decreasing the likelihood that you’ll develop heart disease or hypertension, or diabetes, or a wide range of the most common chronic illnesses in society. It’s not just a matter of return on investment—asking “So, how much more economically productive will the population be? How much will we save in incarceration?” It’s also how much will we save in the cost of health care.
Sally: We’ve previously discussed the coronavirus pandemic, as well as the national reckoning regarding systemic racism, and the impact that this current climate has on children and families. Could you talk about how both of those issues are playing out in the context of policy and systems change?
Jack: From a science point of view, disparities in health outcomes is not a new discovery. But from a public understanding point of view, the COVID-19 epidemic and its gross inequalities in exposure and in infection and in complications and in deaths has really put front and center the incredibly important impact of systemic racism and interpersonal discrimination as it affects health. We know that more people of color, particularly African Americans—but also Latino and Indigenous populations—have greater exposure to the infection because of working in jobs that cannot be done at home, more reliance on public transportation, tighter housing circumstances—all of which make it more difficult to be protected from exposure to the infection.
But what’s getting less attention is not just rates of exposure and infection, but also rates of complications. We do know that of those people who are infected, people with underlying medical conditions are more likely to be sicker, and in many cases, more likely to die from the infection. And those underlying conditions are not equally distributed across the population. And they are particularly a higher prevalence in populations of color and in people who have grown up in poverty.
And here, what this new science is telling us is: this is not about adult exposure. These diseases have their roots early in childhood. They have their origins in excessive stress activation—excessive adversity—related to poverty, related to racism, related to exposure to violence, related to unstable housing, and related to food insecurity, all of which present tremendous burdens for families raising young children that increase the risk for excessive stress activation, which early on in life—doesn‘t always affect—but can affect brain development, the development of the immune system, development of metabolic systems.
On the one hand, the impacts of racism belong on the list of a lot of other sources of stress for families. But on the other hand, there are burdens and hardships that are unique to experiencing racism that we have to start to come to grips with in a very different way. If we don’t protect children from that, if we don’t provide the support for families to be able to help protect their children from the stresses in the environments in which they live, then what we see is over time, not only influences on early learning affecting readiness to succeed in school, but greater likelihood to have many of these chronic diseases later in life. And this is a rude awakening and an opportunity for the early childhood field to focus much more not just on early learning and school readiness, but to focus on the early origins of lifelong health problems, both physically and mentally.
Sally: I completely agree with that Jack. And I’d also say that it’s so important that people at the policy and systems level work directly with families who are experiencing these stressors just to make sure they really understand their perspectives and their needs. And up next, Jack’s going to answer a question that’s been submitted by one of our listeners.
Musical interlude
Sally: And we’re back! For this segment, we asked audience members who listened to the podcast to send in any questions they may have for Jack. Today’s question involves the role of significant stress on our abilities to use core life skills—the skills that help us manage information, make decisions, and plan ahead to make healthier long-term choices or avoid impulsive risks, reduce stress, and ultimately improve health. Today’s question comes from a listener named Abbi Wright.
Abbi: My name is Abbi Wright, and I’m a first–year graduate student at Oklahoma State University studying speech language pathology. And my question for Dr. Shonkoff is: how does strengthening core life skills in children affect lifelong health? How can we strengthen those skills in families that are especially vulnerable because of immigration status or racism?
Jack: So that’s a really important question, Abbi. Let me try to answer in the following way. Building core skills is part of a strong foundation of resilience that will help you deal with stresses and engage in more health promoting behavior over your life course and further decrease the risk for disease. For young children, strengthening those skills helps to build coping capacities. That helps bring the stress response down so that when these systems are developing very early on, they’re not being disrupted. One of the things that we are beginning to understand in a much clearer way is that reducing excessive stress activation in the early childhood period helps to protect all these developing biological systems that not only affect learning, but also affect physical and mental health.
Part of the way that we reduce stress activation in young children is by the adults who care for them to provide a sense of safety and security and buffer children from the stresses that are present in the lives of their caregivers. Families are experiencing significant stress. The pressures are greater to be able to provide that sense of safety for children—help them build their own coping skills. We know that some groups are particularly at risk, not for their ability to be good parents, but for the level of threat and hardship and burden that is imposed on families because of structural inequities in our society. Systemic racism is one obvious example. Immigrant families in the United States right now are another good example of families who are dealing with more than the usual amount of stress because even for immigrants whose legal status is not in question, there is an atmosphere of anxiety and threat and concern about the discrimination experienced by many immigrant families. So, the basic biology is the same regardless of your life circumstances. The level of threat—the level of hardship—varies based less on parents’ abilities to help build skills in their children, but more in terms of how much of an external burden of hardship and threat is imposed on families in their everyday lives raising their young children.
Sally: Thanks, Jack. And thank you, Abbi, for that thought provoking question. Up next, our panel will talk more about the implications of this new science for people across the early childhood field.
Musical interlude
Sally: So, on today’s podcast, we have with us Dr. Aaliyah Samuel. She’s the Executive Vice President of Government Affairs and Partnerships at Northwest Evaluation Association, and a Senior Fellow at the Center on the Developing Child. Thanks for being here today, Aaliyah.
Aaliyah: Thanks so much, Sally, for having me. I’m really looking forward to the conversation today.
Sally: Also joining us on today’s podcast, we have Cindy Mann, partner at Manatt Health and former Deputy Administrator at the Centers for Medicare and Medicaid Services, and former Director of the Center for Medicaid and CHIP services. Hi, Cindy, great to have you with us.
Cindy: It’s a pleasure. Thanks so much for including me.
Sally: And also, on today’s podcast, we have Jane Witowski. State Director of Help Me Grow South Carolina. Thanks for joining us, Jane.
Jane: Thanks so much. I’m happy to join the group today for this very important conversation.
Sally: My first question is for you, Aaliyah. Could you discuss the policy silos in state and federal government? What mindsets have shaped the current policy landscape?
Aaliyah: I will say one of the fundamental challenges is really the cross and inter-agency communication. It’s just really important both at the federal level and as well as the state and local level, that we get individuals that represent multiple systems to come to the table and have conversations. That is how we can start to really think about how to blend and braid funding to ensure that we get the maximum number of families—children—getting access to these programs.
We have seen the evolution over really the last I would say five to 10 years, where it has moved from early childhood being a woman’s issue to a workforce issue and a non-partisan issue. When I was Director at the National Governors Association of the Education Division, we watched the 2018 gubernatorial campaigns very closely. And of the 36 governors that were running at the time, there was not one that did not make a reference to early childhood and its importance to some degree. So, I can say that early childhood and this issue around childcare, families, our youngest citizens, is truly a non-partisan issue, which I think is important to underscore because it creates a recognition that it doesn’t matter what side of the aisle you’re on, this is an important issue.
I think too as we talk about some of the mindsets or even the current policy landscape, I will say, one of the things COVID has really done is exposed the inequities that were hidden in plain sight. We can’t ignore the data, we can’t ignore the disparities, we can’t ignore the communities and individuals and families that have been hit the hardest, and who have historically been hit the hardest, and will also have the most challenges recovering from the pandemic and all that’s come with it. I think, ultimately, what is really lacking is the voice of those who are impacted the most. I heard a quote once, that I really do believe, which says, don’t do anything for us without us. I think as we start to really think about reshaping the policy landscape to address some of these inequities, we need to make sure that there is diversity at the table of decision makers, but also those who will be impacted the most, and making sure that we’re underscoring their voices.
Sally: Yeah, that’s such a great point, and leads into my next question for you, Cindy. Can you speak about the policies affecting prenatal to three?
Cindy: Let me just start by underscoring a point, which is that the country is moving in this direction. I’m seeing all across the country, movements in pediatric practice, in health care, in Medicaid programs, in state government, in local communities along these paths. So, I really do think these are all achievable.
Everybody has to have access to health care coverage. Start there. That is not the case now. And while children are more likely to be covered than other groups, the rate of insurance for children has been dropping in the last couple of years. And mostly, they’ve been dropped off in Medicaid and not picked up elsewhere, and there’s a lot of different reasons for that. There’s also groups of children who because of their immigration status are just not eligible for coverage. Also, one of the I think really important tenets of good pediatric practice is to make sure that parents’ needs are met as well. We also have a number of states that have not extended Medicaid to low-income parents, and that really disenfranchises the family in terms of being able to access the kind of care that families need to make kids strong and healthy.
Some of the other policy issues that need to happen are, is to really begin to integrate behavioral health and physical health. Those two worlds have lived often in very separate silos. That’s not how kids live, that’s not how families live. We need attention to the social and economic needs of families as a very integrated way of addressing those issues in the practice of the provision of health care coverage. A real focus on equity throughout all of the policies that we’re moving forward. As Aaliyah said, there’s no secret to the fact that we have significant structural racism and disparities based on race, and COVID has laid bare and put that, again, in our face, and we need to do something about it. And it really does take a very intentional focus on trying to address disparities to deal with it.
We also have a financing issue. So much of the recent investments around social determinants—help with homelessness, help with hunger—have been driven by this perception of a return on investment to the healthcare sector. Well, that mostly leaves kids out, because while there is a market return on investment if you invest in young children’s health care, that return doesn’t always happen in a very short period of time, and that return also sometimes happens to other parts of our system. To our education system, to our juvenile justice system, to our child welfare system. So, we need a way of really having cross-sector collaboration in the design and in the financing of the full range of services for kids.
Sally: And Jane, I’m wondering if you could speak to us from the healthcare and community service perspective, how do the families you work with feel about the policies in early childhood? Is there a sense that change is needed?
Jane: Sure. I would characterize the mindset as hopeful and encouraged. And what I’ve experienced is a real desire to work together across sector, and was pleased to hear Cindy bring that up as one of her last points in that cross-sector collaboration how necessary it is. And I’ve seen that at the local level and at the state level. However, it’s accompanied by a real frustration about how to go about it. There’s still a lot of confusion, and also barriers. When providers are faced with funding restrictions, staff capacity, regulatory mandates, and still this mindset of needing to stay in your lane. One of the reasons that I’m hopeful is the Help Me Grow system, which 20 years ago was seen as an innovation and an opportunity to bring together those service providers with the common goal of meeting family’s needs. And so, I’ve seen how it can allow service providers to break down those barriers, and to help make connections that are really meaningful for families.
Aaliyah: Sally, can I just chime in here? Jane, when you said the flexibility, particularly in the regulations and staff capacity that is so spot on. I do a lot of advocacy work both at the federal and state level. One of the things we are advocating hard on is allowing for flexibility in the regulation so that at the community level, the funds can be used in the way that best fits the community needs. We fundamentally have to take a step back and stop being so prescriptive on what we think communities need, and create the funding structure to then package it to a community to make the changes and provide the supports that they need.
And also, it’s ironic when you mentioned the innovation piece or staff capacity. It’s so hard to be innovative when you’re pumping out reports, when you’re seeing families one after another. And so, we have to think about how do we create the place and space for innovation to happen. And that takes time, that takes time to plan, it takes time to collaborate across systems. We can’t keep expecting do what you’re doing with no additional funds or support, and then be innovative on top of that. It just doesn’t happen that way. And you can have the most well-intended people who have the passion and the ideas to innovate, but if they don’t have the capacity it’s not going to happen.
Cindy: I’d love to jump in on this part of the conversation as well. Another important point is to build the infrastructure in the community to be able to help connect people—health care sector—to community-based organizations and other resources. You can’t expect that a pediatrician is going to figure out where to send their families if they’re homeless or if they’re hungry. Or maybe you can send them, but you can’t necessarily do the follow up that’s needed to make sure that those needs get met. So, increasingly different communities are coming up with and states coming up with integrator organizations. They can be Accountable Communities of Health, is what Washington state calls them. North Carolina is planning to set up lead entities to help coordinate community–based organizations in certain regions and connect them to the healthcare sector.
So, we absolutely can’t do this just on the fly. We’ve got to create systems—systems of financing and systems of working together—that are adequately funded so that this can work. And let me just also underscore a point made before that I neglected to raise, which I so firmly believe in the importance of families being not only at the table, but really in leadership to really figure out what those priorities are, and whether the system is working well, and whether the system is not working well. So, both at the policy table, and then as real time monitors of how well the system is working for kids.
Sally: How can policies change to address the stressors inflicted by poverty, community violence, and racism?
Aaliyah: First, we have to acknowledge that they exist. That has to be step one. The stressors, the impacts of racism, bias, violence. What is real to someone who exists and has to exist in those communities, versus those who only have a perception based off of what their realities are, what their community is. It creates that disconnect. And the realities of families at all levels are different, and we have to acknowledge that. We can’t turn a blind eye, we can’t say, well, I’ve never seen it, so, I don’t think that that’s true. I will say—I‘ll give a personal example. I have two sons, but my youngest son has some really significant health care needs. I didn’t understand the challenges of being a mom with a child with special healthcare needs until I had one. I was an educator, I have a master’s degree in special education. But it’s very different when it’s your child and you’re trying to navigate the education system, the health care system, and advocate for your child who is struggling.
There’s two parts. One, policymakers have to be more intentional in bringing in the voices of the people most proximate to these issues. And really include their voices, not just into the considerations, but into the actual decision making. I also think from the community aspect, we really have to hone in and recognize that policymakers work for us. They work for us. And it is okay as a community to stand up and require our policymakers to not only adhere to their campaign promises or challenges within the community, but recognizing that in their role, it is their fundamental obligation to hear from the constituents. And so, whether that is writing a letter, whether it’s writing an email, whether it’s having a phone call, all of those small actions at a community and individual level do matter. The more active we are at the local level and really elevating our voices and the needs, it makes policymakers pay attention. We have to recognize that not addressing racism, stress, poverty, has a multi-generational effect. It doesn’t only affect the adults right now, but it affects the children and even the children’s children. And so, if we really want to start breaking these cycles of poverty and racism, we have to start addressing them now.
And so, I think holistically, it’s just time to take a step back and think about how do we really ensure access to these support programs, to health care, and what that means so that we can really start to address and see the changes around improving wealth outcomes for families, health outcomes for families, and really educational outcomes as well.
Sally: To follow up on that, I have a pretty big question for this panel, which is, what does an ideal future look like from your perspective in this cross-policy system space?
Cindy: That is a big question. So, let’s imagine a world where first of all, everybody has a source of payment for their healthcare needs. That seems to be basic, it’s true in most westernized countries, it is not true in the United States. So, let’s start with that. And then, let’s go to the narrow world of healthcare, and let’s break down those lanes—those silos. I think it was Jane that mentioned everybody’s in their lane and it’s hard to break out. Well, children and families, they don’t live in lanes. They live in the community, they live in their homes, they live in their real life, and we need to meet them where they are. So, let’s start with having an integrated healthcare delivery system where we treat the whole family and the whole child. And then, let’s go beyond the healthcare system. Let’s look at all of the agencies and departments and entities that are really in very close regular contact with kids, and think about how they can work together with the healthcare sector. That’s schools, that’s child care, that’s the juvenile justice system, that’s parks and recreation. What do we need to keep kids and families healthy? So, beginning to work together.
And then working—as I mentioned before—with community-based organizations, who really do have a lot of expertise on how to address homelessness and hunger. They may not have all the resources they need for sure, but they need to be working together in concert both to deliver the services and to have everybody advocate for more resources to the extent that more resources are needed.
We need to have a very intentional equity lens as we go about these collaborations in the delivery of services and the thinking about where the financing should be prioritized. And we need to have all of this with the construct of families in the lead. And particularly, communities of color, given the health disparities. I’ve had the occasion of working with community-based organizations that are led by the community, and I’m taken by Aaliyah’s reference. I never learned more about the system as when I’m talking to parents of kids with special health care needs. They are so expert not just on what their kid needs, but on what works and what doesn’t in the health care system.
So, if you’re really wondering how to get smart on all of this, sit down with some families that have really been trying to navigate the struggle, whether it’s because they’re homeless and they’re trying to get care for their kids, or whether their kid has special health care needs. They are the experts and they really need to guide us as we go forward.
Sally: I really love this thread and I feel like it’s been followed through our entire conversation today. Really just making sure you have the right voices at the table—not for them to just for react to something that’s already been created, but to be there to actually create these things, and I think that’s extremely important. And Jane, I’m wondering if you could talk a bit more from your perspective about how these silos that everyone’s been referring to throughout the conversation truly impact families and communities.
Jane: I would like to tell you the story about a family we worked with, a lower income family who identified themselves as Latino. Dad worked in construction, mom was home with four children. The older children were in school. And she had reached out to Help Me Grow because she had some real concerns about her youngest child—lack of language skills primarily, but also some behavior issues, which may have been associated with those communication challenges.
The family lives in a rural part of our state, which while services are available in a nearby city, transportation is not available. And the mom and the child were connected with our early intervention to have an evaluation. But when we did some follow up with them, we understood they missed the appointment. Why? Because the car that they were using broke down, and the family had no money to get the car fixed. So, the story could have ended right there with the child in need, a frustrated parent, and a frustrated service provider not truly understanding what was going on. But it didn’t thank goodness, and I think that shows the resiliency that this mom had in understanding that she really had a child who had some needs and she wanted to get help for her child. And a care coordinator at Help Me Grow, who really understood the social and environmental challenges that that family was facing, and who came up with some innovative solutions to make sure that the child and the mom could get to the appointment. So, we ended up with a child who was evaluated and qualified and is still receiving early intervention services. And I just feel like that’s an example of how we can work together in a coordinated fashion to have a positive impact on outcomes for children.
Imagine a community where children and families could access services without any restrictions. A community where every individual member shared a common goal of improving outcomes for all children, and where programs and resources and services that families might need, such as the health care, early learning experiences, healthy nutrition, would work together as a coordinated system. I do see one challenge, and I’d love to hear some thoughts that Cindy might have around this, is that historically, child health care providers haven’t been viewed as full participants in this community network. And yet, ironically, they are the very first service providers for children, and really continue to see the majority of children on a regular basis throughout their earliest years.
And so, I think one of our goals should also be to intentionally embed child healthcare practitioners seamlessly into this network of community providers. Think about this provider network as an electrical power grid. So, when the grid is really functioning well, there’s this reliable flow of resources, and families can access them and plug in whenever it is that they need to. Help to keep children healthy and really provide opportunities for them to be successful, and for their families to be well. There’s work to be done on building and maintaining such a strong grid because it’s complex and it often requires some work to untangle pieces of the grid so that there is a guarantee that we won’t experiences any outages.
But I think that that is an opportunity for us, if you think about how we can provide access to multiple resources and have a reliable flow of resources for families so that we can have some influence on that lifelong healthy trajectory that we want children to begin with.
Aaliyah: Sally, if I could just build on that. Jane, I so see the same future and community that you just outlined. That is the world that I not only want to exist in, but I want for my sons as well. For those who would say, well, you know what, I don’t have kids, why should this matter? And for people who respond in that way or have that question, my response is, we are all connected in some way, shape, or form. None of us exists in isolation. We all have a mother, a brother, a sister, an aunt, a cousin, a coworker, somebody that we care about. And our communities are all interconnected. We have to think about not only the health and well–being and safety for those in our immediate concentric circles, but thinking about how those concentric circles are nestled within others. And if we don’t really think about the support of all, that as a whole, as a community, as a state, as a nation, we are not going to be able to succeed.
Cindy: I want to jump in too at Jane’s invitation to talk a little bit about the issue she raised, which is our children’s health care providers not really given the resources and the voice that is commensurate with the importance of the work that they do. We really do need to build the mechanisms to hear from those pediatric providers, to support those pediatric providers, and to bring the families, again, into the discussion and into the dialogue. We’ve got the future of the nation and children in our hands, and we’re being very short-sighted by not devoting the kind of resources that’s needed.
Now, there are a lot of advances in this area. We’re really seeing some additional investments put into those practices. Extra dollars to help with care coordination. Extra dollars to make sure there’s family navigators, child navigators, to really help families make their way through the health care system, but also beyond the health care system. If they need to apply for SNAP, if they need to have assistance in terms of housing subsidies. So, the design is not a mystery. Help Me Grow has that design, other pediatric practice innovations have that design. We need to value it and to put our resources in it.
Aaliyah: When you mentioned the care coordination, that was the game changer for us with our youngest son. Between the age of nine months and three, he had over eight specialists in two different states. And I was a working mom, I had a four-year-old, and I was trying to consistently figure out which specialist, track medications, give the referral. I mean, it was a true nightmare. And finally, at the age of three, we finally got a care coordinator who managed all five of the primary specialists that my son was seeing at the time. That was when I could finally take a step back and breathe because I had someone helping me navigate this complex health system.
Cindy: Thank you for sharing that. We need to really have a much more family-centered system of care management, where the alliance of that care manager is to the child and the family, not to a particular institution, not to a hospital or a rehab center or a specialty practice. But I am here for the child, I am here for the family. We also need to not just put all the burden on the families, we also need people in power positions to align with those families’ voices, and to say, yes, it is time to put a different balance in our investments in this country. And that’s healthcare sector leaders, that’s business leaders as well really stepping up to the plate and saying we’ve got to do things differently.
Many, many years ago, I was working with a pediatric clinic in Boston Medical Center. And they were seeing a system—a lot of no shows as they call them, in terms of people not coming for their appointments. And they did a survey. They reached out and asked their patients, what’s going on in your lives? Why aren’t you able to make appointments? In a non-judgmental way, really trying to find out what was happening. And of course, not surprisingly, the two issues were, I didn’t have childcare and I didn’t have transportation. I was desperately trying to come into the appointment. It was really high priority, it’s not that it wasn’t a priority for families, but they had very concrete barriers of lack of transportation and lack of childcare. And then the institution said, fine, we’ll develop some shuttle buses. And they developed their own system of transportation. It couldn’t solve everybody’s problem, it wasn’t perfect, but it was a really important step forward in the community. And they also set up childcare in the clinic so that a mom could come and bring her other children and not worry that they weren’t going to be attended to or that they would be bored or otherwise get into trouble. And so, it really became a family center.
So, it really goes to the point of listening on a one-on–one basis to the family, and also soliciting their advice and respecting that they very much want to be full partners in the system, and mostly care so much about the well–being of their children. Instead, entities have imposed copayments, saying, well, people don’t appreciate care unless they pay money. Well, that will be a barrier to care. So, listen to what people want and construct your policies accordingly.
Jane: As a service provider, we have to be not just engaging parents, but really listening to parents. And include them in the work we do, the plans that we make. Too many times, I think parent engagement is looked at sort of as a have to, check the box, we do it. But, that’s not enough. So, I would definitely put that out there as an opportunity and sort of a mandate, a challenge to all of us who are not truly in a meaningful way, including that voice at the table.
Aaliyah: I think the only thing I would say is as we continue to move towards equitable outcomes, we have to really understand that moving towards equitable outcomes is not going to confirm equity. There are two different things. By trying to make sure everyone has access, that doesn’t mean we’ll get the outcomes that we need. There are some that are resting back and kind of sitting back and saying, well, they could access that program if they wanted to. But if we don’t really unpack it, like the perfect example that Cindy just gave, then we’re not going to get to the outcomes that we’re really trying to drive towards.
Sally: Thank you all so much for joining us. I really enjoyed this conversation, and especially, the different perspectives that you each brought to the table. When we come back, Dr. Shonkoff and I will be discussing another common misconception about early childhood development and lifelong health.
Musical Interlude
Sally: I’m joined again by Dr. Jack Shonkoff, who’s going to help clear up another myth that exists in the early child development field. So Jack, we’ve talked a lot about how interactions between genes and environment shape human development and lifelong health. And yet, when some people talk about adult diseases, the conversation can turn to being about whether the disease that person has or this person has is a result of genetics or if it’s a result of their lifestyle choices.
Jack: The reason why that’s a myth is that it’s basically telling us that if you develop a chronic disease as an adult, particularly the most common chronic diseases like heart disease and hypertension, diabetes, addictions, depression, that it’s either genetic or it’s because you are not living a healthy lifestyle. And that kind of setup is a really important myth to burst. Because what we do know is that all health outcomes are a mix of differences in genetic predispositions, and whether we’re living health promoting or health disrupting lifestyles. Not to say that it doesn’t matter how well you exercise or how well you eat. It’s also not true to say that there’s no genetic contribution to the greater risk to have a particular health impairment.
Very, very few, and none of these common chronic conditions are primarily genetically determined. And many of these conditions that are found to be associated with not very healthy lifestyles, you don’t exercise, you eat poorly, you’re overweight, your blood pressure’s up and you have a heart attack, people can look at that and say, well, yeah, that’s your own fault because of the way you live. What we’re missing is that the relatively higher risk or protection against these diseases starts very early in life. It starts prenatally and the first few years after birth. And that’s why it is so important that we try to protect children from excessive adversity, and why we want to help bring down excessive stress activation because it affects these developing systems very early in life, when they are relatively immature, that can have an effect on the greater likelihood of good health or the greater likelihood of being at risk for many common diseases.
Musical Interlude
Sally: And we’re back with Dr. Jack Shonkoff to wrap up today’s episode. Jack, we’ve talked a lot about changes that need to happen at the policy level, the systems level, and even the program level. What would you say to parents or caregivers who are hearing this information and thinking, well, I can’t wait for these changes to happen, I need to help my child now. Why should this new science make our listeners more hopeful that these changes can occur, and what can we be doing in the meantime?
Jack: Let me answer first by saying that not being hopeful is never an alternative. Ever. If we’re talking about the health and wellbeing of young children, both our own children, if we’re looking at it from a family perspective, or all of our own children, if we’re looking at it from a community or societal perspective, there’s no room for hopelessness.
I think the most important message for parents about this new mindset is that all of the things that you have been doing right to provide an environment for your young child that promotes early learning, healthy social and emotional development, and prepares your child to come to school ready to succeed, you don’t have to do anything differently to build a strong foundation for your child’s physical and mental health. A lot of attention has been directed in the early childhood field to the importance of responsive relationships, the need for serve and return interaction between young children and the adults who care for them. The importance of buffering children from stresses in the lives of families who work really hard to help build their children’s ability to be able to adapt to the stresses of everyday life. The importance of building skills to help to deal with stresses and hardships. The importance of building resilience that then transforms into being able to cope with adversity and to learn effectively and do well in school. That same resilience, those same kinds of coping skills, not only protect the developing brain, they protect the developing immune system. They protect developing metabolic systems. All of the wonderful things that parents do for their children. It used to be done in the service of early learning without even thinking about you doing the same thing to protect your child’s health now and in the future.
The reason to be more hopeful about this is that we have a very strong science-based explanation for why what happens early in life influences all of the things that make for a healthy, productive, successful, engaged population for society. It’s very hopeful to think that if that science message gets out with the credibility that it deserves, that a broader part of the population will understand what a terrible missed opportunity is to not invest very early in the lives of children whose families are facing significant adversity and to understand that we will all benefit at the end of the day. Doesn’t mean that there isn’t a lot of hard work to be done at the policy level, a lot of hard work to be done at the service delivery level. A lot of hard work to be done to help families with young children across the population to be empowered, to advocate for what families need to kind of raise healthy and competent children. All of that to me presents a lot of hope. It doesn’t underestimate the struggle to change policies, but we have more information and knowledge to work with.
Sally: Absolutely. There’s clearly a lot of work that needs to be done. But hearing your perspective as well as the voices of our panelists earlier in the call definitely makes me feel optimistic that change is possible. I’d like to once again thank our guests, Cindy Mann, Dr. Aaliyah Samuel, Jane Witowski, and Dr. Jack Shonkoff. And thanks to Abbi Wright for your question. I’m your host, Sally Pfitzer, and we’ll see you next time.
The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter @Harvardcenter, Facebook at Center Developing Child, Instagram @developingchildharvard, and LinkedIn Center on the Developing Child at Harvard University. Brandi Thomas and Charley Gibney are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org.
How do our biological systems work together to respond to chronic stress? What do these responses mean for early learning and lifelong health? And when we say that early experiences matter, what do we mean by early? This episode of The Brain Architects podcast addresses all these questions and more!
Contents
Podcast
Panelists
Additional Resources
Transcript
To kick off this episode, Center Director Dr. Jack Shonkoff describes the body’s stress response system, how our biological systems act as a team when responding to chronic stress, and the effects chronic stress can have on lifelong health.
This is followed by a discussion among a panel of scientists including Dr. Nicki Bush (University of California-San Francisco), Dr. Damien Fair (University of Minnesota), and Dr. Fernando Martinez (University of Arizona). The panelists discuss how our bodies respond to adversity, inflammation’s role in the stress response system, the effects of stress during the prenatal period and first few years after birth, and how we can use this science to prevent long-term impacts on our health.
Articles
Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. Our center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children and take what you’re hearing from our experts and panels and apply it to your everyday work.
In today’s episode, we’ll discuss how early experiences, especially during the prenatal period and first few years after a baby is born, get inside the body and can have long–term impacts on lifelong health. Here to help us dig into that science around the early years and lifelong health is Dr. Jack Shonkoff who is the Professor of Child Health and Development, and the Director of the Center on the Developing Child at Harvard University. Hi Jack. It’s really great to have you back.
Jack: Hi Sally. Great to be with you. Thanks very much.
Sally: Let’s dive right in. In previous podcasts, we’ve discussed the impacts of stress and specifically you referred to this term of toxic stress, but we never really went too much into the detail about the body’s stress response system. I’m wondering if you could explain how the body responds to stressors or adverse experiences and environments.
Jack: Yeah. That’s a really good question. For starters, the fact that we have a stress response system is really good. It’s protective for us. It actually can be lifesaving. It’s built into our body because this is how we deal with threat or challenges or hardships. This is the basis of the fight or flight response. So, what’s going on inside our body? Well, when we are stressed, a number of systems in the body get activated. Stress hormone levels are elevated and distributed all through the body. Our heart rate goes up, our blood pressure goes up. This is controlled by signals from the brain to the heart and the cardiovascular system. Our immune system is activated and there’s an inflammatory response. Our metabolic systems are activated to produce more energy for our body—more energy for our muscles, if we have to run or if we have to fight or more energy to think more clearly.
The important message here is that the stress response is not just in our brain, it’s in all of the biological systems in our body that are constantly communicating with each other. They’re all reading the environment, they’re getting feedback, they’re communicating with each other. And this is what allows us to deal with challenges, to deal with an acute threat. The best way to think about this is to think about your brain and your immune system and your metabolic system and your cardiovascular system as all different members of a team. Success as a team depends upon each member of the team having a specific contribution to make. And a successful team depends upon interaction and alignment with each other. If any one part is not pulling its own weight, that affects the whole team.
The immune system is another one of those team players. It is our body’s defense against infection. It’s our body’s ability to respond to injuries that require wound repair, and also helps us to be protected against other kinds of toxic exposures that might come in. Inflammation is the first response of the immune system to the threat of let’s say infection, or let’s say a wound like a cut. Think of it as the mobilization of the kind of first responders of our biological system. Now, everybody knows what inflammation looks like outside the body. When you have a cut or some kind of an injury that’s bleeding, and as it starts to heal, you notice that the area around the cut is red, it can be warm in the beginning, it may be particularly sensitive or painful. That’s the inflammatory response that is actually fighting against germs coming in. It’s kind of cleaning out body tissue that may have been injured by bacteria or viruses or trauma, physical trauma and it is beginning to initiate the healing process. And then over time the redness goes away and it’s less painful and the wound is healed.
Well, that inflammation also can happen internally in the body. Now, in the beginning in a stressful situation, inflammation is very helpful internally. It mobilizes your body’s defenses against infection, and it’s meant to then deal with that acute injury or threat and suppress it. But what happens if the stress continues? This is what we refer to as toxic stress. So, in the beginning, it’s protective, but over time, that inflammation can then start to have a wear and tear effect on the body. It can actually start to disrupt organ systems. Here’s one or two examples. We know that inflammation accelerates atherosclerosis, kind of forming plaques that can clog up your arteries around your heart. Inflammation can also affect metabolic systems leading to insulin resistance internally and increasing the risk for diabetes. Individuals who have severe depression have elevated inflammatory markers in their body, evidence of elevated inflammation.
We know that chronic inflammation internally doesn’t automatically mean you’ll get any of the diseases that I just mentioned, but it means that it increases your risk, which is now beginning to help us understand what is it about chronic severe stress that makes people more likely to develop chronic diseases, not just mental health problems, but physical health problems.
Sally: That’s really interesting. And hearing you talk about how early experiences of chronic stress can have more of a long–term impact, I’m imagining that these impacts are not likely evenly distributed. Right? And I’m wondering if you can talk a little bit more about that.
Jack: We have a very serious problem certainly in this country of unequal access to healthcare and unequal treatment in the health care system. And those are very important and clearly need a lot of work. But that’s not the whole story about disparities in health outcomes. Before we get to issues about healthcare, how does it happen that we have inequalities in the prevalence of many stress-related diseases like heart disease and hypertension and stroke? The new science is helping us get inside the body and say what is it about chronic stress and chronic hardship that leads to health problems? How does that happen? Some of this we’ve talked about already, which is the chronic activation of multiple parts of the stress response system that can have a wear and tear effect on different organs and biological systems leading to the most common and the most expensive chronic diseases in adult life.
So, when we think about that problem of chronic adversity, and we know there are some very consistent and predictable differences in terms of racial and ethnic disparities in health outcomes, starting with prematurity and low birth weight, and then extending all the way up to obesity and heart disease and type 2 diabetes and a variety of other chronic disorders. So how do we understand this? Well, here is some of the things that are very important for all of us to focus on. Number one, the differences by race and ethnicity are not genetic. There may be for some individuals, a greater risk for some diseases related to genetics, but from a population basis, certainly for race, race is a social construct, there’s no biological basis for race and certainly not when we’re talking about illnesses.
This gets us back to the discussion that we’ve been having about how chronic stress and chronic stress activation lays the foundation for greater risk for health problems later in life. Often, we make a list of sources of chronic adversity. We talk about poverty, we talk about racism, we talk about exposure to violence, we talk about a serious mental illness in a family, a young child living alone with a mother with severe depression who loves her child as much as any mother does but can’t be consistently responsive because of depression which is an illness. The body’s stress system and its response is the same regardless of the source of the stress.
There’s something about systemic racism and the kind of interpersonal discrimination that’s part of the daily lives of people who are subjected to structural inequities, things that are built into society, that really requires us to take a careful look and say on the one hand, racism is a source of stress like many other sources of stress, but on the other hand, systemic racism and being constantly subjected to the indignities of discrimination raises a different question, which is: what do we do about that? How do we protect young children from the racism that their families and other caregivers have to deal with?
The real solution to this is to go upstream and to deal at the source with the hardships and the threats of systemic racism that are bearing down on families, rather than focusing on helping families to cope with that racism. This is prevention in its true sense, which is not just to kind of put a band–aid on things, but to go to the source. I think the increased consciousness that we have in our society right now about systemic racism in a way that has always been known to families of color, but has sometimes been invisible—many times been invisible to families who do not know what it’s like to be victimized by chronic racism presents a really important opportunity for us to be much smarter and much more effective about how we think about this issue.
Sally: You brought up some really important points. And we’re actually going to be getting more into the policy and system solutions in the next episode, so stay tuned. But can you tell us a little bit more about why early in childhood development is so important? So, I know we say early a lot, but what does that actually mean?
Jack: Yeah. This is a really important question about what we mean by early and this is one of the real game changers about connecting the brain to the rest of the body. There’s an increasing public understanding that chronic stress activation can affect the development of the brain and ultimately affect your readiness to come to school prepared to succeed. But what this new science is telling us as we connect the brain to the rest of the body, is it’s not just about early learning, it’s also about the foundations of lifelong health.
And if you think about the way we approach early childhood policies and early childhood programs, we have over the years realized that kindergarten is a nice time to start school, but actually it’d be better to start school earlier especially for children who are living under difficult circumstances. We have been increasing our investment in preschool for three and four-year-olds. Makes a lot of sense, good decision in terms of public policy. But for the children who are experiencing the most severe stress, that’s not early because the effects of this serious adversity begin very early.
In fact, they begin even before you’re born. A pregnant woman who is in an environment where there’s very little support, where there’s constant stress activation, and also may be problems with inadequate nutrition, exposure to pollutants in the environment, these kinds of stressors and adversities can actually affect the development of the fetus before a baby is born. And certainly, in early infancy in an environment that is constantly stressed, this can really affect the environment of relationships in which very young children grow up.
When we start to talk about health and not just learning, and we think about how all of these biological systems are responding to the environment, the science is sending us a very clear message. In the face of significant chronic adversity, we need to begin way before age three and four, in terms of providing an environment that’s more supportive of healthy development to reduce those sources of external stress. Metabolic systems and the immune system begin to show effects that may be more difficult to change later as early as the prenatal period and certainly in the first two years after birth.
And so, that’s the important message of this new science for the early childhood period. It’s about health as well as about learning. And early in the face of severe adversity means prenatal and the first two or three years after birth. The bottom line for all of this is we are now learning that what happens early on prenatally and in the first couple of years sets you on a pathway to be either more at risk for some problems or more protected for some problems. But it’s not an absolute prediction. It’s never too late to make things better, but in the long run, you’re always better off by having the best health-promoting experiences as early as possible.
Sally: Yeah. I’ve often heard you use that phrase that early is better, but it’s never too late. And I’m really glad to hear that continue to come up in our podcast because it’s such an important message for listeners to take home. When we come back, we’re going to have Jack answer a question that was submitted by a listener, and we’re going to dive into that question together.
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Sally: And we’re back, and now we’re going to answer a question from one of our listeners. I know how much I enjoy getting a chance to ask you questions, Jack. And this time we thought we’d ask the audience. Here’s one from Sid Gardner.
Sid: Hello. I’m Sid Gardner, President of Children and Family Futures. And my question for Dr. Shonkoff is the impact of prenatal substance exposure is mentioned briefly as one item in the list of toxic effects. How does this affect physical and mental health and what can we do about it?
Jack: Sid, that’s a really important question and I really appreciate it. There’s a very well-described phenomenon of fetal alcohol effects or fetal alcohol syndrome that exposure to alcohol at different times during pregnancy can have significant effects on brain development and also physical features that are very noticeable after a baby is born.
We have lots of examples of how certain exposures to substances that are particularly disruptive to different organ systems based on where they are in their development before birth can have significant consequences after birth. This is about sensitive periods in development, which by definition are periods when that particular organ or that particular function is optimally responsive to environmental influences, even the environment in the uterus. And so, positive experiences promote healthy development and adverse experiences or exposures can disrupt development. That question about prenatal substance exposures, substance abuse is a critical question because it’s the poster child for how we need to pay attention to making sure that we promote a healthy environment in which pregnancy takes place.
All of the systems, the biological systems that we’ve been talking about, the brain, the immune system, the metabolic system develop over time. And when we’re very young, including before we’re born, these systems are relatively immature and they are developing their capacities and they’re developing their structures in part on a timetable that’s genetically determined. When things develop is pretty much genetically determined, but how they develop is literally shaped by the environment in which that development is taking place.
So, if we think about alcohol, whether this is threatening or not to health depends not simply on exposure, but on the timing. And so that’s why from a prevention point of view, the more we know about when are the sensitive periods and how can we prevent exposure to substances or infections that can influence later development, that’s how we promote and preserve good health and promote healthy development. It’s about timing and it’s about the differential sensitivity, the different levels of sensitivity of different parts of the developing brain and developing body as the normal processes of growth and development take place.
Sally: Thanks Jack. And thanks Sid for that great question. Remember if you have a question for Dr. Shonkoff, you can always send us a message on one of our social media channels. We’re on Twitter, Facebook, Instagram, and LinkedIn. Up next, our panel will dig even deeper into the science of early childhood development.
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Sally: Joining us on this podcast today is Dr. Damien Fair. Dr. Fair is the Redleaf Endowed Director of the Masonic Institute for the Developing Brain, Professor in the Institute of Child Development, College of Education and Human Development, Professor in the Department of Pediatrics at the University of Minnesota Medical School and a 2020 MacArthur Fellow. Thanks for being on the podcast today, Dr. Fair.
Dr. Fair: Thanks, Sally. Glad to be here.
Sally: Also joining us is Dr. Nicole Bush, Associate Professor in the University of California, San Francisco Department of Psychiatry and Pediatrics, the Director of the Division of Developmental Medicine and the Lisa and John Pritzker Distinguished Professor of Developmental and Behavioral Health. Welcome to the podcast, Dr. Bush.
Dr. Bush: Thank you. It’s a pleasure to be here.
Sally: We also have Dr. Fernando Martinez, University of Arizona Regents Professor of Pediatrics and the Director of the Asthma and Airway Disease Research Center. Nice to speak to you, Dr. Martinez.
Dr. Martinez: Nice to be here.
Sally: I’m going to start by asking this question to you Dr. Fair. Science is now telling us more about how the brain works with other systems in the body to respond to adversity, and could you say more about what’s actually happening in a child’s body developmentally among these systems?
Dr. Fair: That’s a great question. Now, some would argue that the two most complex systems of the body are the brain and the immune system. Of course, I’m a neuroscientist so I always put the brain at number one. But unlike other organs in the body, like the heart or the lungs or the gut, which are located in very specific parts of our body, the immune system is simply everywhere. Immune cells and the chemical messengers flow freely through our bloodstream. They wiggle their way into different parts of our body everywhere.
For many years, it was very difficult to identify or even think about how the brain might interact with the immune system in response to stress or adversity, anxiety, things like that. And it’s now quite clear that they interact in lots of ways and very specifically in development. For example, immune cells, and again, the chemical messengers that are generated in these immune organs like bone marrow, the spleen, lymphatic system, which kind of cleans out a lot of stuff related to the immune system, all have very intricate ties to the brain.
And we know that stress in particular has a very large effect on the immune system in development. The highest vulnerabilities are likely in younger ages. The immune system is critical for normative development. It may actually come to some surprise to most, but all the neurons that we’re ever going to have for our lives typically are at their final resting place right about the time that we’re born.
And then by the time we’re two, you have this proliferation of connections that go throughout the entire brain related to all those neurons. And then over time, over development, we slowly start to prune away these neurons and these different connections. That’s what it means to mature. Now it’s almost like a sculpture where you’re slowly chipping away to get the final product. Well, it turns out that the immune system is really important for that pruning and that cleaning things up. It probably doesn’t come to too much surprise that the changes in the activity of the immune system have very big impacts on brain development over our lifetime.
Dr. Martinez: I think it’s important to stress what Damien was saying. There’s no one system that reigns. We are one thing. And therefore, while we’re developing, if there are extreme sources of stress, it is the whole system that responds wrongly. That’s why none of these effects are on just one organ. Of course, they may be more important for one organ, for example exposures to pollution may affect more the lungs, but now we know that it affects all other organs, including the heart, the brain, of course, the immune system and so forth. That’s an important concept, that we respond like a whole body, not like a single organ.
Sally: That’s actually a really good segue into the next question which I have for you Dr. Martinez. Could you for our listeners go into more detail about inflammation’s role in the stress response system and how it can help or actually hurt us, especially young children whose systems are still developing.
Dr. Martinez: Well in the face of exposures, the body has a system of recognition of these exposures. This process of recognizing what is out there that is not dangerous and what is out there that is dangerous. The response is that of activating the cells that are there, that are part of the immune system that are kind of the first stage of response. That first stage of response is perhaps the most primitive that we have, but it’s very effective sometimes and it’s enough for this danger to go away.
When we are unable to completely clear that first stage, then the second stage occurs. And during that second stage, other cells come from other organs, and a full-blown response develops. Inflammation then is the result of these two phases of the response. Its main objective is to get rid of an acute insult, whatever that insult may be. But when these insults become chronic, in other words, when they develop for a long period of time, or when we have learned not to recognize what is acute and what is dangerous, we start developing what is called a chronic inflammatory response. It’s almost as if we are overdoing it as thinking that we have to be defending ourselves constantly. And that is what is called the chronic inflammatory response.
It’s important to understand that there are these two dimensions of inflammation. One is inflammation as a good thing. Inflammation is a way in which the body responds to an insult to get rid of the insult, to control the insult, to destroy bacteria, viruses, whatever it is that is attacking. But there is a second aspect to it which is this chronic aspect. When you have all these chemical signals and all these cells hanging around the organs that are affected by chronic inflammation, what starts happening is that the organ starts something that we call remodeling. In other words, it starts reorganizing itself. And this is very important during development when the organs are growing. Because now, together with the normal signals of growth and development, you’re seeing these other signals that are interfering with the normal signals that tell the organs how is it that they have to grow. And they start growing “the wrong way.” Asthma, for example, becomes a disease that has transformed the organ. And now we don’t only have to reverse the inflammation that caused this in the first place, but we have to reverse the remodeling of the organ, the remaking of the organ. That’s why it’s important to understand that avoiding the factors that determine chronic inflammation is very important because it has long-term consequences for the individual.
Sally: Dr. Bush, what does the science say about the effects of adversity and stress during the prenatal period and the first few years after a baby is born?
Dr. Bush: It’s a great question. Young children’s brains are remarkably malleable and they constantly are seeking and absorbing information from their environments that their brains need and use to adapt. And this helps ensure their survival and optimize capacity to learn and thrive. But childhood adversities have the potential to affect these systems in a way that leads to impacts on things such as cardio-metabolic health, depression, diabetes, and multiple other health domains across the life course.
People have been getting kind of earlier and earlier in the chain of development to understand where can we make the biggest impact? Where can we understand both the influence and opportunity for intervention? And so, some folks are leaning closer towards thinking their priorities should be focused on the first 1000 days of life. Adversity during this period has strong prediction of a variety of health outcomes. That’s why early safety–net programs, paid parental leave, and high-quality childcare and preschool are so critical to our nation’s health.
Something that hasn’t received as much public attention is that an increasing number of studies are demonstrating that children’s biological systems begin to be shaped in the womb during pregnancy, and at this developmental stage, they’re substantially influenced by their mother’s biology. Most people recognize that a mother’s pregnancy nutrition or her exposure to cigarette smoke is something we really need to be careful about because they’re so important for the baby’s development, but also things like her sleep health and experiences of stress actually affect her physiology in a way that programs the fetus’s development, and then influence that fetus’s risk for a range of developmental, emotional and physical health problems throughout their life course.
One of our team’s studies of low-income families just recently showed that mom’s reports of feeling overwhelmed by stressors during pregnancy predicted major increases in number of infants’ infections and non-infectious illnesses. So basically, babies of stressed pregnant mothers were sicker and they required more care from their pediatrician in the emergency room. And findings like this point to how critical it is for us to take care of pregnant women, not just for their own health and wellbeing, but for that of their children.
Recent evidence that it isn’t just maternal stress during pregnancies that’s transmitted, but a mother’s own adverse childhood events, her ACEs, or her traumatic experiences during her own childhood appear to affect her biology through her adulthood in a manner that affects her baby’s development in utero. So, to put that in another way, a mom’s own childhood stress can 20, 30 years later have a programming influence on her offspring’s early and later life mental and physical health. This shows a truly trans-generational inheritance of the experiences of major environmental stressors, and it also shows us that intervening to help children either by preventing trauma or supporting them in coping with it after the fact can impact future generations’ health too.
Sally: Our listeners may be hearing this and they may be thinking something along the lines of, if my children experienced a lot of adversity or stress early on that they might be in trouble in terms of their development. Or even if I experienced a lot of stress and adversity early on that I might be in trouble. What could you do to prevent chronic health conditions from developing or to help build resilience?
Dr. Bush: Well, since I just ended with some stressful news about pregnancy stress, I’m really happy to point out that we are finding out a lot about how pregnancy is also an incredible window of opportunity to improve maternal and child health. We have findings showing that a stress reduction intervention in pregnancy leads to improved stress physiology, function, and more adaptive, emotional, and behavioral responses in infants. And we’re also finding that high–quality parenting in the first year of life buffers infants from prenatal stress effects. And another study showing that parental understanding of infant development and having appropriate expectations for infant or toddler behavior completely buffer one-year-olds from the risk of prenatal stress associations. Although more importantly, data suggests that if we were to reduce or eliminate major stressors like racism, poverty, food insecurity, and abuse, we would prevent the need to focus on building up those protective factors, and it would certainly have major cost benefits for society.
Dr. Fair: I will add to that great discussion and just highlight that the early brain, the child brain, just as it’s vulnerable to certain types of changes with regard to stress and factors that we’ve been discussing here, the time is also when it’s most malleable, plastic, and resilient. Meaning the interventions are going to be more effective at this early age as well. And it provides an opportunity for us to really try to change thetrajectory by correcting things that may have gone wrong in the past.
Dr. Martinez: It’s also important to understand that for anything that we’re exposed to, there is a very high diversity of responses in the population. There are many sources for this diversity, which is also called heterogeneity of response. Among these sources, there are exposures and behavioral changes and so forth that Dr. Bush was saying counteract other exposures and other effects. It’s not written than the person who is exposed to a very significant amount of distress during the first years of life is condemned to have chronic inflammation and to have remodeling, reorganization of the organs, and there’s nothing to do about it. Quite surely, there are people who live in that situation but come along and don’t develop those responses. That may be in the future a way in which we counterbalance those negative effects by this resilience that is also so marked as a characteristic of human beings.
Dr. Bush: I love that Dr. Martinez highlighted the kind of individual differences in who has adverse outcomes after experiencing a lot of chronic adversity. At the same time, a lot of people are remarkably resilient for a variety of reasons, some internal, some external. And what we want to do is promote that resilience, but also not frighten everyone into thinking they’re doomed to cardiovascular disease because they had a difficult childhood. The flip side, also very glad that Dr. Fair highlighted how malleable we are for positive changes in early childhood. We have some really exciting evidence across a range of studies that show you can reverse the harmful effects of traumatic events on child biology, through evidence-based therapy interventions. In some cases, the children receiving therapy actually show biological repair and healthier outcomes than some control group kids. And so, there’s lots of reasons to be hopeful that our bodies have the capacity to not only survive and cope with adversity, but rise above sometimes doing better in the end.
Dr. Fair: And the good news is there are a whole host of things that our policy makers can assist to make sure the trends are good. Individual and family support structures, strong access to good education, economic security, all those social factors have a large, large impact on long-term outcomes in our kids, depending on some of the things that we’re talking about today.
Dr. Bush: In addition to caring for children and their parents, it’s also really important for listeners to recognize that adversity and trauma do harm children and families across the entire socioeconomic spectrum. We need to address those directly for all people, all communities by screening in early childhood, screening in pregnancy and screening in adulthood for histories of trauma, so that we can address these social needs of individuals. I’m really hoping that we can make efforts to help insurance providers see the benefit of evolving their understanding, how to care for children, and that that includes caring for their caregivers, both family caregivers, and preschool and early childcare, reimbursement for screening and follow-up for treatment. The data are really compelling that in addition to those solutions being both just and right, that investments in prevention and early treatment could save incredible amounts of money in our societies.
Sally: Thank you all for being here. We really appreciate hearing your individual expertise and also how your knowledge can really build off of each other to give us a full picture of what’s going on. When we come back, Dr. Shonkoff will be discussing a common misconception about early childhood development and lifelong health.
Musical interlude
Sally: I’m joined again by Dr. Jack Shonkoff, who’s going to help clear up some myths and misconceptions in early childhood development. So, Jack, we’ve talked a lot about how early experiences can affect health many years later, but many people wonder how it can be possible that experiences we have before we can even remember them could affect lifelong health.
Jack: It’s really one of the most important myths that we need to bust. And the simple answer to that is that we may not have conscious memories of things that happened very early in our lives, in our infancy, especially traumatic experiences or significant adversity, but what the science is telling us is, the body doesn’t forget what’s happening in these very early months and years. We’re not talking about inevitable poor outcomes,but significant stress activation well before a young child tends to have any sense of what’s going on, creates physical changes, physiological changes, inside the body that affect brain development, can affect the development of the immune system, the cardio-metabolic systems.
So, people who may be a little bit skeptical that something that happened when you were an infant can affect your mental health later, but at least you could begin to see the connection. There’s no logic for people to think that that would have something to do with whether you get heart disease 50 years later. But what the science is telling us is that those biological changes early on can increase your risk for these physical health problems later on. That’s one of the most important messages coming from this new science that is compelling us to connect the brain to the rest of the body. Because what happens early on is not only important for learning and social and emotional development and school achievement, but it’s an important influence on your physical and mental health for the rest of your life.
Sally: That’s such an important point Jack. And I think today’s myth was a particularly dangerous one. I’m really glad we had an opportunity to discuss it at greater length and that you were able to bust it.
Musical interlude
Sally: We discussed a lot of important issues today to explain why the early years are so important and especially why intervening early is so important. And I’m sure we gave our listeners a lot to consider or at least I hope we did. I’d like to end by asking you, Jack, to give our listeners one key takeaway that they should leave this podcast with today.
Jack: I think what’s really important about the big picture for what the science is telling us is a couple of things. Number one is, there are no perfect brains, there are no perfect immune systems. How we grow up, how we learn, what our health is like is related to the interaction between how we are individually wired to begin with and what our life experiences are about. And the important part of our life experiences, the most important, is the environment of relationships that we grow up in. And then also of importance is the physical environment in which we grow up. How safe is it? How protected or exposed are we to toxic substances in the environment, lead, mercury? How much space do we have to move around? So all of these things together, interacting with how everybody is unique from a genetic point of view results in a wide, wide range of normal development.
Our role as parents, as other caregivers, as a community and as a society is to do whatever we can to provide a health-promoting and growth-promoting environment for children, recognizing that everything we do that’s supportive will increase the likelihood of a very successful and fulfilling life.
The bottom line for all of this is it’s a matter of balance. The more the pile up of risk factors and threats, the greater the risks. The more we build up protection and support for the environment in which children grow up, the smaller the likelihood of problems. The important thing to remember is that the way biology works, it’s always trying to make things right. When things happen in the environment that threaten health, all of the systems in our body are reading the environment and they are responding to try to keep us healthy, they’re responding to get us back on track. These new scientific insights should really be a source of reassurance for us and at the same time, a wake-up call about the kinds of life experiences that are threatening so that we can protect children as early in their lives as possible.
Sally: Thanks so much for your time again today, Jack.
So how can we protect children and promote healthy development and lifelong health as early as possible? In our next episode, we’ll discuss what this science means for listeners, including caregivers, policymakers, practitioners, and system providers.
I’d like to once again thank our guests, Dr. Damien Fair, Dr. Nicole Bush, Dr. Fernando Martinez, and Dr. Jack Shonkoff. And thanks to Sid Gardner for your question. I’m your host, Sally Pfitzer, and we hope you’ll join us next time!
The Brain Architects is a product of The Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter, @HarvardCenter, Facebook, @centerdevelopingchild, Instagram, @developingchildharvard, and LinkedIn- Center on the Developing Child at Harvard University. Brandi Thomas and Charley Gibney are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org.
While some countries and U.S. states are beginning to reopen businesses and other gathering places, the pandemic is still very much with us. Physical distancing will likely be a way of life until a vaccine for COVID-19 is widely available. So much change, including the threat of illness, and grief of those who have lost loved ones, means that mental health is a great concern.
Fortunately, there are things we can do to support our mental health at this time, especially when caring for young children or other family members. In this episode of The Brain Architects, host Sally Pfitzer speaks with Dr. Karestan Koenen, Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health, and Dr. Archana Basu, Research Associate at the Harvard T.H. Chan School of Public Health, and a clinical psychologist at Massachusetts General Hospital. They discuss what supporting your own mental health can look like, as well as ways to support children you care for at this time. They also talk about what mental health professionals all over the world are doing to help take care of our societies in the midst of the pandemic, and how they’re preparing for the challenges that come next.
Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast series was released, things have changed drastically as a result of the Coronavirus pandemic. During this unprecedented time, we’d like to share resources and provide guidance that you may find helpful. So, we are creating a series of podcast episodes that address COVID-19 and child development. This episode is the fifth in our series, and todays guests are Dr. Karestan Koenen, Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health, and Dr. Archana Basu, Research Associate at the Harvard T.H. Chan School of Public Health and the Clinical Psychologist and Massachusetts General Hospital. Thank you both for being here I’m really looking forward to the conversation.
Dr. Koenen: Thank you Sally. It’s great to be here.
Dr. Basu: Thank you so much.
Sally: So Karestan, what makes this pandemic different from other traumatic events that many people have experienced in terms of mental health?
Dr. Koenen: There are a number of characteristics that make the COVID-19 pandemic different than other traumatic events, even than other disasters. I actually lived in New York City during the 9/11 terrorist attacks, and I’ve seen some similarities in terms of this in that things were shut down, there was a pervasive feeling of threat, there was loss of life, and it was very disruptive and it was something that people really – in New York, anyway – talked about for a long time. It persisted and affected everyone in the city. What’s different about this is the length of time people are being affected, how pervasive it is in terms of our community but the state, nationally, and globally it’s the first time that I’ve had experienced a traumatic event that my colleagues in Africa are experiencing some version of it, my colleagues in Mexico, and then I think because it affects so many different aspects of our lives. We talk about trauma, and we think of things that are unpredictable and uncontrollable and overwhelm our ability to cope. This has certainly been unpredictable; a lot of things feel out of our control and on top of that we have other things that can in themselves be traumatic like unexpected bereavement, job loss, a stigma people are experiencing. I think the sheer pervasiveness of it – how it’s affected every aspect of our life. Finally, I think one of the things we know about disasters is that social support is so important for resilience, for people’s recovery, and to buffer them from the effects of disaster. In the middle of this, we’re being told to physically distance to prevent the spread of COVID, and that really cuts into our ability to get social support or to socially support each other, so that is something certainly different than I’ve experienced before or anything I’ve studied actually.
Sally: So Archana, I know you work with children and families on all of these issues around grief, which I know we were just kind of referencing. I’m wondering if you can talk a little bit more about the different kinds of grief that families might be experiencing at this time.
Dr. Basu: I guess I’d like to start by acknowledging that loss is a very common part of human experience, even outside of the pandemic. As an example, in the U.S. each year more than 600,000 people die of heart disease alone. This is not to minimize the losses that we’re experiencing now, but only to say that we as humans are used to experiencing losses and adapt to it on a pretty ongoing basis, and there’s a large body of evidence to suggest that we are adaptive and resilient. This is especially true for children because child development inherently offers many opportunities for change and positive adaptation with appropriate support. That being said, as Karestan highlighted, there are many unique elements to the pandemic in terms of the pervasiveness and the unpredictability as well as the limited or lack of access to typical support systems or resources, for instance due to physical distancing requirements. That certainly makes it unique and challenging. As of today, more than 80,000 fatalities have been reported in the U.S. alone. Families are certainly worried about their own health, their loved one’s health and well-being, or are coping with a death of a loved one. Right now, with travel restrictions, not being able to come together as families or with friends, that’s definitely a pretty big challenge. Many families have been unable to engage in typical funeral rituals, and parents are wondering how to support kids, and some are even wondering whether to say something. Generally, the research supports the idea that open age-appropriate communication can be very valuable in helping children. There are some specific helpful resources; really practical tips in terms of what language or words parents can use to explore how their kids are understanding these experiences, what worries they might have, and we can certainly provide links to that in perhaps the website to our podcast. Briefly, I will just say that open communication really helps to understand what children are observing and experiencing and can help them not be alone in their worries. I would say that would be the number one goal is to help children recognize what they’re feeling, validate those emotions, and for them to feel that they are not alone in this experience. The other element is what you referred to in your question is outside of bereavement, all of us are experiencing losses in our everyday lives. I think one way in which we support each other through tough times is by reaching out and connecting with our friends and family, by holding hands, by giving each other a hug, and we can’t do that right now. Also, I’ve been hearing from younger adults graduating; seniors in college, that they’re experiencing a pretty tremendous sense of loss around routine rituals that form a sense of community like graduation ceremonies. They don’t have that sort of eager anticipation as they’re launching into adulthood. Overall, I guess I would say children can be resilient, but the way forward may not always look and feel that easy. They’ll be moments of frustration and confusion. We would expect that – there is nothing normal about what we are experiencing, so to acknowledge and validate even these everyday experiences of loss would be quite valuable in supporting kids and families.
Sally: I’ve been thinking so much about how so many different people that I know have been experiencing this grief in different ways. You think, “Those high school students – that’s so hard”, or you think, “Oh, those college students – that’s so hard.” There’s so many different traditions and cultural pieces that we are missing right now, and that just changes how we are in our society. Karestan, I’m wondering if you could provide some specific examples; our listeners have often found it helpful to have some concrete ideas about how mental health experts are supporting families now, and then also how they’re preparing for those long-term health impacts.
Dr. Koenen: So, what’s been remarkable to me in terms of the pandemic is how the mental health community, and I mean that in academics, but frontline practitioners and students and people just interested in mental health, or companies that are interested in mental health have really stepped forward to offer resources from something like Headspace is offering free services to health care workers, and we’ve been offering these mental health forums at Harvard Chan School of Public Health. ADAA and CDC are offering all kinds of mental health resources. People have really stepped up to put those resources online, and I think that’s been unparalleled. I’ve never seen, again I worked in New York after the 9/11 terrorist attacks, and there was a cooperation around the mental health community, but I didn’t even see it at this scale then. I guess the other piece is the global collaboration I’ve never seen before. I’ve been on email chains with colleagues from Italy, China, South Korea; some of whom I knew before, some of them I didn’t. Figuring out what they are seeing and what has helped in terms of mental health locally. One center that I am affiliated with at Harvard decided to have a panel of people from China and South Korea talk about going back to work. Using the fact that it is global, and that countries are in different stages to problem-solve some of the things that would come up. Not that necessarily whatever they do would work here, but it would at least perhaps give us some ideas. Another thing has been a sort of rapid move to telehealth, which is something that actually insurance providers have been quite challenging to get reimbursed prior to the pandemic. It seemed like within weeks people had moved their practices to some form of telehealth, which could mean video, or it could mean telephone. That is something that I think has made services to people, especially to people who already had them, more accessible. Those are some things the community has done, and I think is a really positive thing going forward.
Sally: Absolutely. I’m wondering if you could help us think about what parents and other caregivers could do, specifically what they could do right now to support children’s emotional and mental wellbeing.
Dr. Basu: Foremost, readjusting expectation. Whatever little the parents can do to support themselves really matters because they are right now in fact the primary support system for kids. Obviously, parents are the most influential in terms of child development, but right now when kids don’t have access to other support systems, I would say it is even more important. As parents, we are not that great with prioritizing our own needs. It’s sort of kids, and work, and what everybody else needs in the household. Maybe, their own parents, and then if you get 5 hours of sleep, you’re lucky. I get that this is not an easy thing to focus on, but it’s sometimes just helpful to remind ourselves that every little bit counts even if it’s just twenty extra minutes of sleep, if it’s seven minute cup of coffee in the morning, maybe that sets the tone for the start of the day – simple, deep breathing. Another element could be focusing on what kids and families can control. So, thinking about your own routine – what’s helpful for yourself. Doing what works but keeping it simple – basic stuff. Managing sleep routines, eating, exercise, maintaining virtual social connections through technology. All of those things help. So, readjusting expectations and taking the time to sort of figure out routines that can be helpful, help us think about what we can control, and talking about it and checking in to see what’s working. These are some of the basic things I would highlight, and of course one of the biggest advantages right now to telemedicine is that it is more accessible if you have a phone, a computer, or a tablet. Get in touch with a primary care provider to seek guidance and support if this remains challenging, which would be quite understandable.
Dr. Koenen: Outside of COVID, providers are being underutilized. My colleagues who study health care services report that I think that it is down to somewhere 30% of capacity for non-COVID related medical calls, so thus, people should not hesitate as providers are actually available. One of the things that Archana and I have talked about, because we both have sons but they are very different ages, is that kids tend to be most concerned about what directly affects them, while adults we can get concerned about all of these things that might be abstract. One of the examples we have given is that when my son’s school was cancelled, the first thing he worried about was whether the homework due on Monday was going to be due, and whether it is going to be graded, and if they’re going to have to go to school longer. These very specific things, not to say he doesn’t worry about other things, but they are specific things. The younger kids – the playground that they usually run up to there’s yellow tape around it, so there’s these very immediate things. I think as a parent myself, I sometimes can trivialize these things. I find myself being like, “You’re worried about that, we’re in a pandemic, why are you worried about that?” But kids do worry about what is most direct and sometimes most concrete, and so by acknowledging and responding to those concerns which may seem kind of silly in our adult heads, that can provide a lot of comfort to them too.
Sally: Absolutely. You’ve both touched quite a bit on this, but I think I’ll throw this question to both of you to answer. We’ve been talking a little bit about how you’re saying that kids are responding to things that are most direct in their environment, and we know that the toll in this pandemic hasn’t been evenly distributed and will likely continue to not be evenly distributed. Some people are at much greater risk for both medical and economical consequences, and are you seeing that to be true for emotional and mental health consequences as well? If so, what could be done about that?
Dr. Koenen: Great question. When some of the groups we are seeing as most at risk for mental health consequences are 1 in 5 people in the U.S. – adults in the U.S. – live with a mental health disorder, so people who already had a prior mental health disorder or mental health condition, the conditions of the physical distancing for people with a mental disorder removed social supports and things that also may be accessed to other care groups – day programs, etc. Those people have been particularly affected had they already been socially isolated. The Kaiser Family Foundation came out with some statistics, and some of it’s not surprising. It’s families, actually parents, parents are reporting more mental health issues and people who experience economic downturn or job loss. We know from the 2008 recession that job loss and foreclosure are associated with increased risk of mental health issues. Thirdly, low income in communities of color have been disproportionately affected. I saw some data from a colleague published in New York which showed that higher mortality from COVID was related to income. We know that there’s been disproportionate mortality for communities of color. Also, in such communities, there is a greater digital divide, so we talk about a lot of these resources have been put online and there’s a lot of virtual support. But, we also know that 15% of Massachusetts households kids don’t have computers or didn’t have computers before this. And those again tend to be disproportionately in low income and communities of color. Those are some of the people I think disproportionately affected with risk of mental health problems who are disproportionately experiencing the COVID as well as the financial consequences.
Dr. Basu: I think the family focused care piece is really critical, and this is again very consistent with the Center’s philosophy around multi-generational models to support kids and families. I can’t really say this enough – I think supporting kids also needs to involve a model that supports parents. I would say that type of family focused care as one possible model moving forward is very key. The second one that Karestan and I and others have talked about, and maybe Karestan can chime in on this, is the aspect that there are many other communities or system within which kids and families live, work, and develop. That includes schools and community-level organizations, and faith-based organizations. I think part of supporting mental health care would involve partnering with these community-based organizations. This might include formal leaders and key stakeholders, but also potentially developing collaborations with more informal key stakeholders. There’s a lot of evidence that we can provide effective mental health care by not just working with specialists like psychologists and psychiatrists which is absolutely necessary, but also with more community-based healthcare workers, for example, and Karestan can speak of what we can learn in terms of the global context.
Dr. Koenen: Sure. Something that I hope that can come out of this pandemic is the better recognition that mental health is critical as the foundation of all health and the foundation of a healthy society. Rather than treating mental health like a side issue that we deal with when it’s an apparent big problem, we think of it more proactively. The burden isn’t left on individuals or even on families to seek help when things get to the crisis point. I think one of the things we can learn from our global partners and countries, where there may be 60 psychiatrists in the entire country treating a population and very few other trained medical professionals, is people having to introduce other models where community health workers or just leaders in the community, people who the community would acknowledge they look up to, training them in mental health practices that can then be disseminated into the community.
Dr. Basu: I think what Karestan highlighted in her previous comments is that there is also a lot of research to suggest that longstanding systemic issues can manifest in mistrust of health systems and beliefs about mental health that can impact engagement with care. So, engaging in the ways that Karestan highlighted, where people trust. Those are really valuable ways to engage people in just thinking about social and emotional health – engaging and starting that conversation.
Sally: Interesting. A lot of times at the Center when we’re talking about stress effects or stress response, we also like to talk about resilience. I’m wondering what you would say in terms of resilience around this pandemic.
Dr. Koenen: One of the things that has come up for me in terms of resilience is flexibility. We’re being called on to be very flexible, and we don’t always think of that in terms of resilience, but I think in this it is particularly true. I give my own example, one of my main coping strategies that works tremendously well 95% of the time is that I am a planner and I can see my plan backwards. I really had to be like “I plan, God laughs right now”, because so many things change all the time and as a parent now, we don’t know what this all brings. Having to be flexible myself, and model flexibility for my son who’s doing online school, he doesn’t know what the week is going to hold. The schedule is different everyday for his school, etc. Learning to roll with it and change your expectations. The other thing is I’ve been trying to figure out is, “What are the things that are most important to me? What are the priorities for my family, for myself”, and keeping them simple and only having a few of them. The normal expectations of everything we’re going to get done is not going to happen, and I also think that as a parent you have to choose your battles. An example is, well if your kids doing all their work and been on their Zoom calls for school and did all of their homework without complaint, does it matter if they got dressed? Maybe it does, maybe it doesn’t, but do you want to fight over what they’re wearing? Maybe you do, maybe you don’t. There are probably other things about having to choose what you’re going to focus on, and are you going to let go of some of the things or some of the time to make it more manageable.
Dr. Basu: To follow up on one of the things that Karestan started with was this idea of flexibility and it’s really something in our work with kids and families we talk up front about. One of those ideas is developing a toolbox of things that work for you as a family, and really think about what works for your child. I will often ask parents and older kids, “what has worked for you in the past?” So, we may not have been in the pandemic before, but we certainly experienced transitions and stressors and challenges in other ways. Asking them what has worked for you in the past and then thinking about how we can adapt those for right now. Also, recognizing that especially with kids, what works this morning, may not work at night or the next day, so thinking of it as a toolbox of skills or ideas they can use to cope is very helpful and certainly along the lines of having a flexible approach and definitely underscoring readjusting the expectations. I would definitely agree with both of those. I think the other thing that I would say is that individual resilience partially depends on systemic resilience. Really thinking about what are ways in which we can support families and schools and some of the other community-based organizations because those are the contexts in which children and families and all of us live our lives. There’s a recent study that found that among adolescence who received any mental health services between 2012-2015, that for 35% of the kids the only point of contact for getting mental health services was from their schools. So, forming partnerships with schools is actually really important because kids may not even access care through hospitals or specialists, but for a large portion of kid’s, schools might be the only point of service for them.
Sally: Excellent. I think that there are so many listeners who are especially going to relate to that readjusting expectations piece. That one really resonated with me as well. Well, thank you both so, so much.
Dr. Basu: Thank you so much.
Dr. Koenen: Thanks, Sally.
Musical interlude
Sally: I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.
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