The first thousand days of life are a critical and important period of development. Primary care pediatricians and public health professionals play an important role in fostering healthy child development and opportunities to thrive by providing preventive care that promotes safe, stable, and nurturing caregiver relationships.
Brain development is cumulative in that early, simple connections and circuits form the foundation for more complex pathways and behaviors. Much like muscles, connections and circuits that are used frequently become stronger and more efficient over time (“neurons that fire together, wire together”). However, those connections and circuits that are not utilized are pruned and eliminated (“if you don’t use it, you lose it”).
Brain plasticity declines with age. Plasticity, or the ability of the brain to rewire itself in response to changes in the environment, is waning by the time children begin kindergarten.
Translating the Science into Practice
The basic developmental science is clear, but how do we take that science and apply it in the clinical setting?
Brain development is dynamic, with different structures/functions developing at different rates and times. Specifically, structures that underlie the physiologic stress response (e.g., amygdala) appear to mature sooner than those structures that assist in modulating or turning off the stress response (e.g., prefrontal cortex).
Brain development is disrupted by chronic exposure to the mediators of the physiologic stress response (CRH, cortisol, adrenaline, etc.). Significant adversity in childhood can lead to a vicious cycle of stress that is toxic to important structures like the hippocampus and prefrontal cortex. This “toxic stress” is a “common denominator,” a biological mechanism underlying well established associations between various forms of childhood adversity (abuse, neglect, domestic violence, parental mental illness or substance abuse) and less than optimal life course trajectories (see the ACE Study).
View training modules on the following topics:
Supporting Brain Development Through Well-Child Visits
Pediatricians can educate families that young children need safe, stable, and nurturing relationships to assist them in regulating their stress.
Connected Kids: Safe, Strong, Secure offers child healthcare providers a comprehensive, logical approach to integrating violence prevention efforts in practice and the community. The program takes an asset-based approach to anticipatory guidance, focusing on helping parents and families raise resilient children. Connected Kids Includes a Clinical Guide and 21 handouts for parent and teen topics such as bullying, discipline, interpersonal skills, parents, suicide and television violence.
The AAP’s periodicity schedule for recommended preventive health care services provides several opportunities for primary care pediatricians to promote early brain development as well as assess for development, behavioral, and social-emotional concerns.
The well child health visit is an opportunity to
- Review a child’s history,
- Conduct developmental screening and surveillance,
- Conduct psychosocial/behavioral assessment,
- Screen for lead, and
- Use anticipatory guidance to discuss child and family strengths and challenges.
Building Partnerships to Support Early Brain Development
Supporting early brain development involves more than anticipatory guidance at well child visits. There are common messages and overlapping services that aim to build children’s brain with early learning environments and/or positive parenting approaches.
See this Early Learning Systems PBS video.
Develop collaborative relationships with the resources in your community that might assist parents and caregivers and prevent and/or mitigate the precipitants of childhood toxic stress.
- Home visitation programs (eg, Nurse Family Partnership)
- Early Intervention services
- Head Start
- Infant and early childhood mental health providers
- Parent/Family support systems (eg, Circle of Security, Triple-P, Nurturing Parenting, addressing illiteracy, unemployment, unsafe housing, food scarcity, Parent-Child Interaction Therapy).
- Legal Aid and medicolegal partnerships, child care networks/resource and referral agencies.
- Community libraries, assistance for victims of domestic violence, care for parents with substance abuse or mental health issues.
- Advocate for the development of resources to fill the gaps that exist in your particular community.
- Encourage consistent, community-wide messaging (prenatal, home visits, WIC, early intervention, preschools, early childhood PTAs, etc.) on issues related to early brain and child development (e.g., promoting Reach Out and Read, limiting screen time, alternatives to corporal punishment).
- Identify (and collaborate with) high quality early education and child care settings.
Communicating with Families
- Discuss with parents and caregivers the pivotal and foundation role of the first 1000 days.
- Emphasize that early relationships need to be “safe, stable, and nurturing.” Parents and caregivers should therefore “Protect, Relate, and Nurture” – PRN all the time!
- Communicate and interact with parents and caregivers to provide anticipatory guidance that assists parents and caregivers in proactively building the critical social-emotional-language skills that buffer toxic stress. Examples include: Bright Futures, Connected Kids, the 6 Ps of Purposeful Parenting (Purposeful, Protective, Personal, Progressive, Positive and Playful), and the 5 Rs of Early Literacy: Reading, Rhyming, Routines, Rewards, and Relationships.
- Assess the social-emotional status of the family at every visit (“the Relationship as a Vital Sign” surveillance).
American Academy of Pediatrics