Improving the early years for lifelong health
What a difference a decade can make. At the turn of the millennium, every child in kindergarten in the small mountain city of Revelstoke, B.C., became part of a national pilot program to assess school readiness, and the results were worrying.
Based on standardized surveys conducted by teachers, only 78 per cent of Revelstoke’s kindergartners were considered developmentally ready to learn in school. More than 22 per cent weren’t. Those children showed vulnerabilities in the physical, emotional, social, cognitive or communication realms. Some kids in the middle-class community of 8,000 were coming to school hungry, listless or aggressive, while others, even more than halfway through the school year, still couldn’t follow rules, hold a pencil or play with other children.
Although Revelstoke’s results were not as bad as the national average, which showed a disturbing 30-per cent vulnerability rate, the findings galvanized the community to do better. An inter-sectoral partnership emerged. Schools, daycares, community groups, public-health agencies and the local chamber of commerce, as well as politicians and the media – all were united in a unique commitment. The goal was to connect every child with the appropriate services – such as preschool, speech therapy and parenting programs, Aboriginal services or free pool passes to the new aquatic centre – and with a minimum of red tape.
The change was dramatic. By 2009 the vulnerability rate of Revelstoke’s kindergartners had plummeted to 6.7 per cent, the lowest in the province and one of the lowest in the country. The community changes began impacting older kids, too. The latest figures show that 99 per cent of Revelstoke kids graduate from high school, up sharply from 82 per cent in 2005/06. Earlier this year, the community became one of the first in the province to establish a neighbourhood learning centre with all educational and community services under one roof and available to all. The longer-term benefits remain to be seen, but a growing body of research suggests that social inequalities in children’s development have huge effects on their health, well-being and life chances later on. And it all starts with their earliest environments and experiences.
Published in 1994, this award-winning book on the health of populations continues to have a profound effect on today’s policy decisions. (Courtesy of Transation Publishers)
“The early years are way more important than we ever thought,” says Clyde Hertzman, director of the Human Early Learning Partnership (HELP), a collaborative, interdisciplinary research network at the University of British Columbia in Vancouver, as well as a Fellow in two CIFAR programs – Successful Societies and Experience based Brain & Biological Development.
Revelstoke’s turnaround might not have happened without the emergence of a big idea more than a generation ago. Since the wealthiest countries also seemed to be the healthiest countries, the assumption had long been that rising longevity rates in the Western world were directly linked to the ability to afford organized medicine and pharmaceuticals. But that didn’t tell the whole story. In fact, research from the 1970s had found that rates of death from tuberculosis, smallpox, diphtheria and mumps had begun to decline long before any medical treatment became available.
“The research identified right off the bat that effective clinical prevention was not the primary cause of rising life expectancy,” Hertzman says. “Much more important were nutrition, literacy and other factors associated with socioeconomic change. And that idea was a huge game changer.”
Hertzman was recruited by CIFAR founder Dr. Fraser Mustard in 1987 to help create a program to investigate why some populations were healthier than others. It was becoming increasingly clear that medical care and healthcare spending weren’t necessarily the primary determinants of health. For example, compared to Canada, the United States, which has a higher gross domestic product and spends far more per capita on health care, has a lower health status. Researchers began observing health differences among individuals living in the same neighbourhoods. Some people had heart attacks; others didn’t. Some had depression; others didn’t. The new question became: What drives those differences in health status in the same society?
Interested scientists got together to study that question, and they represented a diverse range of fields. The group, which grew from three members to fifteen in its first year, included experts from diverse disciplines: health economists Bob Evans, Morris Barer and Greg Stoddart, health policy advisor Ted Marmor, epidemiologists John Frank and Michael Marmot, sociologist Marc Renaud, medical geneticist Patricia Baird, community health scientists Leslie and Noralou Roos, and others from the fields of healthcare policy and statistics.
Their ensuing research found that in a wealthy society, instead of a stark contrast between the haves and the have-nots, there were gradients, or slopes, linking socioeconomic status – which includes income, education and occupation – with health status. Gradients were often gradual: for example, people who finish high school live longer and healthier lives than people who don’t; those who have some postsecondary education do even better; and those who finish college do better still. Moreover, these gradients corresponded to almost all diseases and conditions, including heart disease, mental illness, arthritis and accidents. In 1994 the group authored the groundbreaking book Why Are Some People Healthy and Others Not? The Determinants of Health of Populations.
Linking health status to socioeconomic status was initially a controversial idea. “It was undoubtedly received skeptically,” says Dr. Alan Bernstein, CIFAR’s new president. “It was a very tough thing for that group to convince their colleagues in the field, but the weight of solid evidence won out, and it could no longer be ignored. That idea is now in the mainstream.” The World Health Organization (WHO) has made the idea not only official health policy, but also a global priority. WHO has confirmed that the social determinants of health are the biggest factors in creating health inequities, and in 2005 it established a commission to address this issue.
While the connection between socioeconomic status and health status was in itself a huge idea, it gave birth to a second, equally grand idea – that the roots of these gradients are planted long before the health conditions manifest themselves. “It was thought that these gradients emerged in adulthood, but it’s not true,” recalls Hertzman. “We were asking, ‘What happens between birth and the expression of disease 40 years later?’” recalls Hertzman. “We started to look at the early years as a source.”
A new CIFAR program focused on human development was formed to look at how people’s early experiences – including stimulation, support, nurturance and opportunities for engagement – contribute to social inequalities and to differences in health status later on. Had the person been read to as a child? Was there a rich language environment? Nutritious food? A safe neighbourhood? High-quality childcare versus TV as a babysitter?
Children at Revelstoke Child Care Society’s Leap and Learn Preschool in Revelstoke, B.C. (Courtesy of Lead and Learn Preschool)
Among the 27 members of this new multidisciplinary research group were child health epidemiologist Chris Power, child psychiatrist Stephen Suomi and psychologists Daniel Keating and Dan Offord. In 1999 the group published the book Developmental Health and the Wealth of Nations: Social, Biological and Educational Dynamics, providing evidence-based research that showed a striking connection between early experiences in childhood and physical and mental health decades later.
It was this recognition of the importance of early experience that led members of the CIFAR Human Development program to create the Early Development Instrument (EDI), the Canadian-pioneered tool that acted as a catalyst to the city of Revelstoke. Funded by provincial and territorial governments, the EDI is a 104-question checklist that kindergarten teachers complete in mid-year for every one of their pupils to provide a snapshot of vulnerabilities and identify individual, family and community supports that may be needed. Quick, easy and relatively inexpensive, the EDI now covers 80 per cent of kindergarten children across Canada, in all 10 provinces, as well as Yukon and Northwest Territories. The EDI is now used in 14 other countries – including Scotland, Italy, Kosovo, China, Australia, Mexico, Chile and Peru – and garnering interest from many others. That early research also influenced certain programs in Canada, such as the rollout of full day kindergarten, which is being increasingly implemented throughout the country, and the expansion of paid parental leave to one year.
The EDI is the longest-running program of the HELP research network at UBC. With its mandate to foster environments where children and families can thrive, HELP connects researchers and practitioners from local communities as well as national and international institutions. Increasingly, communities are using the EDI data to create or improve programs that support children and families.
“The reach of the research has been very wide,” says Joanne Schroeder, HELP’s deputy director. In British Columbia, for instance, HELP currently tracks more than 700 local childcentred community initiatives that are linked to its database. Schroeder says, “When you look at what Revelstoke and other communities have done, you see common characteristics: a strong community-wide commitment to the early years, collaboration across sectors, people in senior leadership positions reallocating resources, and lots of family-friendly businesses.” But there’s more to be done, Schroeder adds, including policy changes such as quality childcare for all, longer parental leaves, and a redress of employment standards to help parents achieve a healthy work-life balance.
Meanwhile, the EDI enables communities to explore their own vulnerabilities, interpret the data with a local perspective and explore solutions that suit their needs. For example, according to Tracy Smyth – a community facilitator with the Alberni Children First Network in Port Alberni, B.C. – the lack of transportation is a major barrier to access in her rural community. “If you have no car and you’ve got a stroller and two little kids and you’re trying to get to a speech therapist’s appointment, you need a bus route to get there,” she says. To solve this, she’s been working with BC Transit and the City of Port Alberni toward redirecting a bus route. She also works with many social agencies to help them incorporate prevention into their initiatives.
“If an organization is building a homeless shelter, for example, I’ll suggest they think about programs for parents with children to prevent the cycle continuing,” she says. Smyth is a co-author of the book Raising the Village: How Individuals and Communities Can Work Together to Give Our Children a Stronger Start in Life – a resource for community leaders, teachers and child advocates.
The early-years research has produced a variety of programs and projects here and around the world, but it also produced something else: a new question. How does early experience get under the skin in ways that can actually influence brain and biological development? This question has led to the third big idea, for which Hertzman has coined the term “biological embedding.” A subject of research only in the past few years, biological embedding suggests that children’s development isn’t based on either nature or nurture, but on the interplay of the two. “We are at the point now of showing that the sorts of differences in early experiences that predict gradients across the lifespan are capable of influencing gene expression,” Hertzman says.
Genes, which sit on a strand of DNA like beads on a string, appear to “listen” and respond to environmental influences, which then affect when, where and how much of a gene’s proteins will be expressed. These actions in turn affect endocrine, immune and neural systems at the molecular level. Epigenetics, the study of this gene-environment interplay, is rapidly becoming a major area of research around the world.
“Epigenetics is a humongous thing now,” says Marla B. Sokolowski, co-director of CIFAR’s Experience based Brain & Biological Development program. Launched in 2003, this program, which includes 18 researchers from a diverse range of fields – neuroscience, genetics, psychology and nutrition, among others – explores new techniques for measuring these physiological changes that may influence everything from the strength of the immune system to social behaviour.
Sokolowski, Canada Research Chair in genetics and behavioural neurology at the University of Toronto, studies the foraging gene. Almost all organisms, including humans, have this gene, which affects how we search for food, as well as our food intake, energy balance, food-related movement, fat storage, learning and memory.
In studying fruit flies, Sokolowski identified two variations with respect to the foraging gene: the more resilient rovers, who move a lot when they eat, and the more vulnerable sitters, who don’t. Rovers have more of a brain protein enzyme called PKG. But Sokolowski found that when chronically food-deprived, rovers change into sitters, moving less and conserving energy. “We’ve shown that nutrition, good or poor, when [we’re] growing up, influences the amount of exploratory behaviour you’re willing to do.” Having identified the foraging gene in humans, she has gone on to screen samples of DNA from people with food-related disorders, such as overeating, to learn more about how genes affect food intake and energy output. Her findings may one day lead to a better understanding of the early roots of obesity and other eating disorders.
Meanwhile, another CIFAR Fellow, Michael Meaney, has been studying the epigenetic effect of maternal stress on baby rats. If the pups are raised by a relaxed and nurturing mother, many of the “methyl marks” – specific chemical modifications of genes that increase the animals’ sensitivity to stress – will melt away, leaving them calmer and, later on, becoming more relaxed parents themselves. But if they’re raised by a neglectful or fearful mother, their methyl marks will increase. Not only will these pups grow up to be nervous, inattentive parents themselves, but they’ll also become predisposed to obesity, anxiety and chronic illness.
Remarkably, the epigenetic effect has been shown to be reversible, says Meaney, a professor in the department of psychology at McGill University in Montreal. Cross-fostering the rat pups – moving the neglected ones to a nurturing mother – changes the methyl marks and the pups’ subsequent stress reactivity and later parenting behaviour for the better. “We had come to think of everything beginning from DNA, but epigenetics repositions DNA more so in the middle, as an active participant in biology and health,” says Meaney, who is also an associate director of the Douglas Mental Health University Institute in Montreal. “That’s what makes epigenetics so exciting. It changes the way people think.”
A little boy plays in the snow on Mount Mackenzie, southeast of Revelstoke, B.C. (Photo by Caroline Grenier)
And where do human children fit into all this? In what is believed to be the first paper of its kind in the world, Hertzman and Tom Boyce, a Co-Director of the CIFAR program – along with their colleagues at UBC and the University of Wisconsin – published a study in September 2011 showing a link between adversity in early childhood and DNA methylation in adolescence. According to their research findings, 15-year-olds whose parents – especially mothers – reported high stress during their children’s early lives showed vestiges of that adversity in the number of their methyl marks 15 years later. The parental stress included such problems as financial worries, marital conflict, health concerns and employment issues. “We think we are now showing that these kinds of early adverse conditions and disadvantages that kids experience, especially in the first few years, really have profound biological effects that affect health and development over years, and perhaps over decades,” says Boyce, a professor of pediatrics and child development at UBC.
The research remains cuttingedge, but as more evidence builds, epigenetics could prove to be extremely powerful in shaping our thinking about the importance of early childhood experiences in affecting health throughout the lifespan. “If they affect biology as fundamentally as affecting gene expression,” says Boyce, “we as a society need to be very attentive to what kids experience and what supports we give to families.”
It’s becoming clearer that funding early education and community supports is a far more economical and efficient way of improving health outcomes than simply increasing funding of health-care delivery, says Hertzman. For example, it’s estimated that every dollar spent to support a healthy start in the early years can save between $8 and $20 per child in future long-term costs associated with healthcare, addictions, crime, unemployment and welfare.
“What has happened over time is that a new consciousness has emerged,” Hertzman says. “More and more people are thinking of the local community as an ecosystem and they are the managers of the ecosystem.” And a healthy ecosystem can help ensure that its youngest residents develop to their strongest, healthiest potential. As Hertzman says, “We’re creating a whole new set of possibilities.”
Marcia Kaye of Aurora, Ontario, is an award-winning magazine journalist specializing in health issues.
CIFAR is a registered charitable organization supported by the governments of Canada, Alberta and Quebec, as well as foundations, individuals, corporations and Canadian and international partner organizations.