The Learning Connection Elizabeth Zmuda D.O.

Nationwide Children’s Hospital American Academy of Pediatrics

The Learning Connection

The Science of Early Brain and

Child Development

Epigenetics Physiology of Stress Neuroscience

Education Health Economics Health

New Science – Many Implications

Brain Structure Changes With Experiences,

Especially in The Developing Brain

Parenthood begins at Conception

Not Just Nutritional Stress

• Energy or protein • Micronutrients • Placental failure • Blood flow • Medications • Physical/ Mental Stress • Smoking, alcohol • Toxins • Oxygen • Blood sugar • Weight gain

Fetal Experiences “Program” Future Disease

• Growth • Obesity • Hypertension • Abnormal Lipids • Cardiovascular Disease • Diabetes • Metabolic Syndrome • Behavioral Health

P Gluckman, NEJM 2009

a

Genotype

Phenotype I Phenotype II Phenotype III Phenotype IV Phenotype V

Environment

What if genes were modifiedby experiences?

In Utero

Brain Development

Diet/Activity/Fitness

Environment

Social & Economic Cultural

Internal Stress

Support Behavior

Genes/Family

Cognition Learning Memory

External

We Can Do Something

Brain Stem & Cranial Nerves: Vital functions Swallowing

Cerebellum: Smooth movements Coordination

Occipital Lobe: Visual processing

Parietal Lobe: Integration of sensory data and movement

Temporal lobe (outside): Processing sound and language

Limbic System (inside): Emotions and impulsivity

Frontal lobes: Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences

Brain Structure (and Function)

+ The Gas Pedal + Amygdala

- The Brake – PFC (with some hippocampal help)

The Developing Brain

Brain doubles in size in first year Reaches 80% of adult volume by third year Massive synaptic connections by third year “Pruned” to half by adulthood Strengthened by electrical & chemical signals

Developmental Origins of Health and Disease

Hansen and Gluckman, 2011. Am J Clin Nutr doi 10.3945/ajcn.110001206

Healthcare Expenditures

The emotional stress centers of

the brain

• Positive Stress is

– Is brief, infrequent, mild or moderate

– Is normal in everyday life

– Motivates, builds exploration and curiosity, and teaches the child to adjust

The child’s social and emotional supports help manage stress

and allow a return to normal

Stress Shapes the Brain

• Poor nutrition • Illness • Injury or trauma • Neglect • Violence • Family problems • Environmental toxins • Inadequate health care

Prolonged Stress can Harm a Child

http://feedingamerica.org/SiteFiles/child-economy-study.pdf

• Toxic Stress

– Long lasting, frequent, or intense

– Adverse childhood events (ACEs)

– Perceived by the child as overwhelming – Results in

• Anxiety • Anger • Emotional outbursts • Fear

Harmful if the child does not have enough social and emotional buffers

Toxic Stress

Toxic Stress Damages Brain

How Children Succeed by Paul Tough

• Why do some children succeed and some fail?

• Adverse Childhood Experiences (ACEs) reflect toxic stress -- correlates with poor academic, behavioral, lifestyle and physical/mental health outcomes

• Social emotional skills can mitigate toxic stress

ACE Categories Women Men Total

• Abuse (n=9,367) (n=7,970) (17,337) – Emotional 13.1% 7.6% 10.6% – Physical 27.0% 29.9% 28.3% – Sexual 24.7% 16.0% 20.7%

• Household Dysfunction – Mother Treated Violently 13.7% 11.5% 12.7% – Household Substance Abuse 29.5% 23.8% 26.9% – Household Mental Illness 23.3% 14.8% 19.4% – Parental Separation or Divorce 24.5% 21.8% 23.3% – Incarcerated Household Member 5.2% 4.1% 4.7%

• Neglect*– Emotional 16.7% 12.4% 14.8% – Physical 9.2% 10.7% 9.9% * Wave 2 data only (n=8,667) Data from www.cdc.gov/nccdphp/ace/demographics

1:4!

1:4!

Skeletal Fractures

Relationship Problems

Smoking

General Health and Social Functioning

Prevalent Diseases

Sexual Health

Risk Factors forCommon Diseases

Hallucinations

Mental Health

ACEs Impact Multiple Outcomes

Difficulty in job performance

Married to an Alcoholic

High perceived stress

Alcoholism

Promiscuity

Illicit Drugs

Obesity

Multiple Somatic Symptoms

IV Drugs

High Perceived Risk of HIV

Poor Perceived

Health

Ischemic Heart DiseaseSexually

Transmitted Diseases

Cancer Liver Disease

Chronic Lung Disease

Early First IntercourseSexual Dissatisfaction

Unintended Pregnancy

Teen Pregnancy

Teen Paternity Fetal Death

Depression

Anxiety

Panic Reactions

Sleep Disturbances

Memory Disturbances

Poor Anger Control

Poor Self-Rated Health

We Can Build SOCIAL-EMOTIONAL BUFFERS

Self-Regulation

Coping, Persistence Organization, Planning

Relief of anxiety and stress Curiosity, Exploration

• Learned, practiced • Modeled by others • Turns off emotional over-reactions • Increases test scores in school

ACEs Impact Life Long Health

Adverse Childhood Experiences

Social, Emotional, andSocial, Emotional, andCognitive Impairment

Adoption ofHealth-Risk Behaviors

Disease &Disability

EarlyDeath

Death

Birth

Slide modified from V. J. Felitti

Lickers & Groomers

• Handling rat pups caused anxiety = stress

• Maternal behavior* – High L&G – Low L&G

• High = greater exploration, curiosity, socialization, healthier, less anxious, less aggressive

• Biochemical changes in brain

M Meany et al, McGill University

Overweight

Undernourished

Unfit

What you eat or don’t eat matters

to your brain

Hunger Impacts Mental Health & Development

• Worse developmental outcomes • Psychosocial, behavioral, and attention problems • Depressive and suicidal symptoms in adolescents • Lower academic performance

Weinreb; Pediatrics; 2002; 110; e41 Dunifon; Social Service Review; 2003; 77; 72–92

Kleinman; Pediatrics; 1998; 101; e3. Murphy; Journal of the American Academy of Child and Adolescent Psychiatry; 1998; 37 (2), 163–170

Whitaker; Pediatrics; 2006: 118(3); e859–e868 Slack; Social Service Review; 2005; 79(3); 511–536

Jyoti; Journal of Nutrition; 2005; 135; 2831–2839 Rose-Jacobs; Pediatrics; 2008; 121(1); 65–72

Skalicky; Maternal and Child Health Journal; 2006; 10(2); 177–185

Kids & Energy-Dense, Nutrient-Poor Foods

• Snacking = 30- 40% of daily energy• Daily calories increased • Carbohydrates increased • Fats increased

• Displace: Protein, fiber, vitamins, folate,calcium, magnesium, iron, zinc

0 10 20 30 40 50 60 70 80 90 100

Vitamin C

Phosphorus

Vitamin A

Magnesium

Calcium

Vitamin E

Vitamin D

Many American children fall short on nutrient intakes

Percent with nutrient intakes from food and dietary supplements below the EAR

Ogden, JAMA 2010 Fulgoni et. al., J of Nutrition, 2011

Only 2% of children have potassium intakes above the AI

The School Nutrition Success Story

• 55 million students • 32 million lunches/d • 35-40% kcals school vs

56% kcals at home • Improve nutrition • Lessen obesity • Improve behavior • Boost academic

achievement

Nutrients of Public Health Concern • Four nutrients of public health concern – calcium, vitamin D,

potassium and dietary fiber due to inadequate intake of key food groups

*NHANES 2003-2006; 2+ yrs Milk is the number 1 food source

2010 Dietary Guidelines for Americans -

Recommendations Age Servings of Dairy per Day

2-3 years old 2 Servings

4-8 years old 2.5 Servings *

9 and older 3 servings

What’s the Scoop On Flavored Milk?

• Dietary Guidelines uses fat- free chocolate milk as example of nutrient dense beverage

• Only 15 % of milk consumed is flavored contributing only 3 % of the added sugar and 2 % of the calories in children’s diets on average

• Children who drink flavored milk have better nutrient and total milk intake and similar added sugar intake and body weight as non drinkers

Dairy Research Institute NHANES 2001-2010 Johnson, JADA 2002, Murphy, JADA 2008

#tcotraining

School Lunch: Findings • 10 years: rapid improvements (SNDA I,II,III)

– Protein, vitamins A & B-12, riboflavin, calcium, phosphorus, potassium and zinc

– Choices for entrees, fruit, vegetables the norm – More than half of the milk was no- or low-fat

• New Standards meet Dietary Guidelines 2010: – Less saturated fat, sodium – More fresh fruit & vegetables, whole grains – Better balanced, fewer calories

Not a Cause of Obesity

Benefits of Breakfast at School

Fewer disciplinary referrals

Improved attendance

Energy and micronutrients not consumed in SBP are not made up over 24 hrs in non-participants

The Learning Connection: The brain develops through childhood & adolescence Experiences alter brain structure and function Health, physical activity, fitness, nutrition, emotional

support, peer interactions, and play* improve Cognitive Processing

Experiences alter brain structure

Health, physical activity, fitness, nutrition, emotional

Inhibition the ability to ignore

distraction & stay focused

Cognitive Flexibility the ability to switch

perspectives, focus of attention, or response

mappings

Working Memory the ability to hold

information in mind and manipulate it

Building Cognitive Control

Cognition is a Struggle

Cool Intelligence Hot Intelligence

Executive Function = Prefrontal Cortex

When Functional… • Make plans • Keep track of multiple

things • Discuss using past

knowledge • Evaluate ideas, reflect on

work • Make corrections • Engage in group dynamics • Control impulsivity

When Dysfunctional, struggles… • Planning projects • Time management • Verbal, written stories in a

sequential manner • Memorizing and retrieving

key information • Initiating tasks or generating

ideas independently • Retaining information while

using it (working memory)

FITNESS & PA

The Brain on Exercise

41

How Play* Shapes the Brain

• More connections between neurons • Faster communication between neurons • Greater blood flow: glucose, oxygen

The FITKids Randomized Trial

151 Children (Rx = 82, Con = 69)

participated in >70 minutes of

intermittent moderate to vigorous PA

daily

After-school physical activity on 150 of the 170 school days

0

2

4

6

8

FITKids Waitlist Control

Δ%

VO

2

*

Fitness & Hippocampal Volume

Chaddock et al. (in prep).7.15

7.25

7.35

7.45

7.55

Pre-Test Post-Test

FITKids Controls

Hip

poca

mpa

l Vol

ume

(cm

3 )*

Δ%

VO

2

*

0

4

8

12

16

20

24

FITKids Control

relational memory

Monti et al. Hippocampus; 22:1876–1882 (2012)

Chaddock et al. (2010). Brain Research, 1358, 172-183

50

55

60

65

70

75

80

Item Accuracy Relational Accuracy

Memory Performance

Low Fit

High Fit

Res

pons

e A

ccur

acy

(%)

*

Fitness, Hippocampus, & Memory

PA & Cognition in Children

Hillman CH et al. Nature Reviews Neuroscience 9, 58-65 (January 2008) |

Exercise, Executive Function and Math in Obese Children

CL Davis, et al. Health Psychol 2011, 30:91-98

Neuro-imaging

Neuro-cognitive

Increased physical activity leads to more focused classroom

behaviors and

improved mathematics, reading, and writing test scores

49

Neuro-imaging and Neuro-cognitive testing

prove that

A growing number of schools are cutting daily physical activity opportunities

to provide additional classroom time on formal academic topics.

Does Activity Time Hinder

Academic Achievement?

No. CDC reviewed 50 school studies: No decrease in academic achievement when time

is allotted for physical education/recess/sports, and in fact… Positive relationships between classroom physical

activity time and indicators of academic achievement, classroom behavior, and cognitive function

www.cdc.gov/HealthyYouth, April, 2010

Optimal cognitive processing in a child

necessitates a period of decompression

after a period of concentrated instruction

Regularly scheduled periods within the [elementary school] day for unstructured physical activity and play.

(CDC, 1997)

Recess is …

The fewest minutes of recess occur in those schools

with 75% or more of its kids

on free & reduced meals – those with the highest need

Recess Augments PE Recess is not a substitute for PE PE is education, teaching the acquisition of motor skills for life-long physical activities and free play

PLAY* DEVELOPS SOCIAL & EMOTIONAL SKILLS

Play* = A Life Skills Class

Adapt, adjust to complex school environment

Practice and role-play social skills Learn communication skills:

negotiation, cooperation, sharing and problem-solving

SocialEmotional Learning

manage stress, organize learn and practice coping skills, curiosity, perseverance and self-control

Institute of Medicine Report May 2013

60 minutes per day Whole-of-School Approach:

• Before school • PE Daily • Recess Daily • 10-minute Breaks

between classes • After-school

http://iom.edu/Reports.aspx

The Learning Connection: The brain develops through childhood & adolescence Experiences alter brain structure and function Health, physical activity, fitness, nutrition, emotional

support, peer interactions, and play* improve Cognitive Processing

Experiences alter brain structure

Health, physical activity, fitness, nutrition, emotional

We can’t raise a child’s IQ,

and we aren’t their teachers,

but if we are allowed

through improved nutrition and regular physical activity we can put a better student

in the chair -Robert Murray MD

School Wellness Committees

www.ActionForHealthyKids.org/

Fuel Up to Play 60 Child-Led Wellness Programs

http://www.fueluptoplay60.com/

•CDC “Report on PA, PE and Academic Performance” www.cdc.gov/HealthyYouth/health_and_academics •NASPE Initiative “Let’s Move in School” www.NaspeInfo.org •GenYouth, NFL “The Wellness Impact” www.GenYouthFoundation.org •Action for Healthy Kids “The Learning Connection” www.ActionForHealthyKids.org

The Science of The Learning Connection

, NFL “The Wellness Impact”Action for Healthy Kids “The Learning Connection”

Tell the Story

FIND THE FULL STORY! Bookmark these resources! * Learning Connection Summit-- http://www.ohioactionforhealthykids.org/resources/school-wellness/healthy-students-are-better-learners/ * Wellness Impact Report-- http://www.drink-milk.com/child-nutrition/learning-connection.aspx#.UjGwNMbkt6k * Learning Connection Report--http://www.actionforhealthykids.org/media-center/reports

It is easier to build strong children, than to repair broken men. -Frederick Douglass