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.

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.

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.

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?

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!

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.

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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. 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.

Shelter-in-place orders are meant to help protect our communities from the current coronavirus pandemic. But for some people, home isn’t always a safe place. For those who are experiencing domestic violence, or believe they know someone one who is, what options are available to stay both physically healthy and safe from violence?

In this fourth episode of our COVID-19 series of The Brain Architects, host Sally Pfitzer speaks with Dr. Tien Ung, Program Director for Impact and Learning at FUTURES without Violence. Prior to her work at FUTURES, Tien spent five years as the Director of Leadership and Programs at the Center on the Developing Child.

Tien discusses important, practical steps those at home can take to keep themselves and their children safe, as well as strategies others can use if they think someone they know may be experiencing domestic violence. She also addresses the resilience of survivors, and what our communities can do both during and after COVID to listen to and engage in real responsive relationships with adults and children alike.

The next episode of this special podcast series will focus on the mental health implications of a global pandemic. Subscribe below via your podcast platform of choice to receive it as soon as it’s released.

A note on this episode: If you or someone you know is experiencing domestic violence, you can contact the National Domestic Violence Hotline: 1-800-799-SAFE (7233) or the National Sexual Assault Hotline: 1-800-656-HOPE (4673).

For a list of state/territory/tribal domestic violence coalitions, please visit:

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. A quick word about today’s episode: as you’ve probably guessed from the title, we’ll be discussing the subject of domestic violence, including mentions of sexual violence and abuse. We just want to give a heads up to those who may be sensitive to this subject matter so you can make an informed decision about whether this topic is right for you at this time. If you or someone you know may be experiencing domestic violence, you can contact the National Domestic Violence Hotline at 1-800-799-SAFE, that’s 1-800-799-7233, or the National Sexual Assault Hotline at 1-800-656-HOPE, that’s 1-800-656-4673. This podcast is the fourth in our series, and our guest today is Dr. Tien Ung, Program Director of Impact and Learning at FUTURES Without Violence. Prior to her work at FUTURES, Tien spent 5 years as the Director of Leadership and Programs here at the Center on the Developing Child. Thank you so much for being here with us today Tien, we’re really glad to have you.

Dr. Ung: Thank you, Sally. I’m glad to be back here to talk with you all about this.

Sally: Just so our listeners know, we’re recording this podcast today on a video call, so the sound quality may be different from what you’re used to hearing when we typically record this podcast in the studio. I’m going to start us with this first question. Tien, what are you seeing and hearing from your local partners, law enforcement, and families about indicators of domestic violence since stay at home orders started?

Dr. Ung: Sheltering in place does present very unique circumstances and challenges for people who are not safe at home. We know for example, that 1 in 4 women experience violence by an intimate partner in their lifetime. We know that 2 out of 3 children are exposed to trauma and violence. We know recently from the Rape, Assault & Incest National Network that for the first time in 25 years, their national hotline is receiving calls from minors, such that more than half of their calls coming in over the last couple of months have been from minors. We also know that at this time, reports of abuse and neglects against children are dropping. We know at least in Massachusetts, and I suspect in other states across the U.S. as well, that 80% of reports that come in from mandated reporters about child abuse and neglect are coming in from health professionals, educators, first responders, people who do not have eyes and ears on what’s happening behind closed doors at home right now. We also know very recently that phone calls to police stations across the nation are rising in response to domestic disputes. I think in fact, just today, we learned that a mass shooting in Canada had roots in domestic violence, which highlights, actually, what we’ve known for quite some time, that there is a strong correlation between domestic violence and mass shootings. Current stay in place orders present very specific challenges to people who are not safe at home. There’s also good news. While it is true that communities of care serve as an organic system of surveillance and monitoring bringing attention to harm that’s being done behind closed doors, we also know that those same communities serve as protective factors for children and victims of family violence and domestic violence. Faith communities, social communities, health and medical communities, as well as human service and educational communities, and legal and judicial communities—they all come together under normal circumstances to create a system and an ecology of care and protection. Those are things that I think will be important for us to unpack a little bit on the call today.

Sally: This is obviously a really challenging time, and if someone is experiencing domestic violence and they are a parent, what might they be able to do to escape that given we are in the shelter in place?

Dr. Ung: Because parents don’t have access to their normal pathways for connections, it really is very hard for them to reach out and get the help and support they need. It goes back to basic safety planning; things like making sure survivors know to put their hair in a bun rather than in a ponytail, because when your hair is in a ponytail there is more to grab onto which can cause injury. Making sure they are scanning their environments and looking for places to shelter in place in their homes where there’s not easy access to knives, for example, so don’t run into the kitchen. Doing a quick scan to see what they can use as shields or whatnot to protect themselves and reduce the likelihood of serious injury if a fight does breakout. We’re really back to basics, Sally, which is hard to believe. Some of the things we marvel about are the ways in which, and this is something that I think the Center knows well and talked about a lot when I was there, that survivors in children are incredibly resilient, and they know how to keep themselves safe, and they know what to do to manage the episodes of violence and aggression in their homes. It’s just really about giving them the support and letting them know that if things are really, really bad and they need to get out and get out quick, finding ways for them to have that. Every state, for example Sally, has a state collation for domestic violence. They are the people who know what services are in place for each state, what shelters are up and running, and what, importantly, batterer intervention programs are also up and running. They also have wonderful relationships with local law enforcement and the courts and are really good partners.

Sally: Those resources that you were saying that each state provides, how would someone get connected to that if they weren’t aware? Is that a website, or how would someone find that information?

Dr. Ung: That’s a great question. It is a website. I can make sure you all have information to that as part of this podcast so that you can put it on your website for people. It is split out by national level resources, as well as youth specific level resources, as well as resources specifically for the LGBTQ community. (Editor’s Note: That website is available here: https://ncadv.org/state-coalitions)

Sally: That’s really helpful, thanks. I’d like us to think a little bit more about what listeners or friends and family and neighbors could do to help prevent increases in domestic violence from affecting more kids.

Dr. Ung: I think that’s a good place to move into. We developed, actually on our website you can find a tip sheet of 10 simple steps that friends and family can take during this time if you’re worried about a loved one sheltering at home, or specifically about the safety; the physical, psychological, sexual, and emotional safety of someone sheltering in place. Some of them involve continuing to reach out and check in. We are sort of punctuating the notion that social distancing really isn’t the goal, physical distancing is the goal, but social connection should not go away in the face of requirements around physical distancing. We’ve been trying to practice ourselves by using the concept of physical distancing to promote the idea that finding ways to connect socially and support socially is really important. Checking in and reaching out to your family member and your friends are really important. Asking them what they need on a day to day basis, asking them if they’re okay, asking them directly if they are feeling safe. We like to encourage family members, and also community based social groups, like faith-based groups, to come together and think about how you might support families that you know are more vulnerable by preparing meals, by pulling dollars and helping families with real concrete, basic material needs. We’ve been encouraging family members and friends to reach out and offer parents relief from 24/7 parenting by offering to read a young child a book on the phone, or get on Zoom and do some crafts with someone, or even just getting on Zoom and watching a movie, or finding ways to engage in just fun. You can take your iPhone, for example, we’ve talked to people about playing hide and seek with young people with the iPhone around the house. Finding ways to offer some respite, relief, and support and connection. We’ve invited family and friends who know there might be family violence at home to find safe ways to have private conversations and establish a code word. Some of the words that some of our shelters are using have to do with “masks needed please,” so the survivor at home who’s not safe might text a service provider a code word: “masks needed please,” and that would indicate that that provider needs to initiate a police response to the house. Finding code words like that, so people can have strategies where they can get help and support in the height of the state of emergency is something we’ve talked about as well.

Sally: I love the concrete examples that you gave how you can interact with people who aren’t actually in that space. Although, I do imagine some families don’t even have access to technology, which might compound that even more.

Dr. Ung: Yes, I think that’s absolutely true. I think in those cases, families have their networks. The friends and neighbors of families who don’t have access to technology—they find ways to communicate and stay in touch, so what we’ve been inviting people to do is to find ways to maintain those connections to check in on people, and first and foremost to offer support. Anything that we can do to reduce stress and reduce burden is really important right now.

Sally: So, back to the resilience piece, obviously you spent a lot of time when you were at the Center helping us craft this curriculum around the 3 Science Principles. We were curious if you could talk a little bit more about what the science of child development tells us about what we need to do to prevent or alleviate the problems you were just describing.

Dr. Ung: You know, we know that the experience of trauma like exposure to domestic violence for children has three broad-level impact levels on children. They have biological impacts, which I think at the Center we talk about as the ways in which adversity gets under the skin and impacts children’s health system—raising risk across the life course for negative impacts in learning health, and behavior. We also know that it has psychological impacts, relative to influencing how young people think, feel, act, and interact with others. Lastly, we know that the exposure to prolonged trauma like witnessing domestic violence or experiencing family violence in the home can lead to negative social impacts, interfering with how children and young people relate and make decisions in the context of interpersonal health and engagement. In that context, we’ve been trying to draw a lot on the science that the Center organizes and produces to help people design strategies and programs and policies that buffer impacts in those three areas. When this is all said and done, which seems to be a very relative framing, there will be – we all anticipate—a long period of recovery. A lot of the conversation right now, Sally, is focused around the stress and the trauma of sheltering in place when home is not a safe place, but we’ve been paying a lot of close attention to near-term and long-term stressors that families that were already vulnerable before COVID are going to be facing sort of burdens and levels of stress. There have been 58,000+ deaths in the U.S. right now, and that number is going to continue to sore while we live through all of this. It’s not just family members of young people and children and youth who are dying, but teachers and coaches and people who represent really important relationships in the lives of young people. That’s a wave that we’re really trying to get ahead of and prepare for now. We think the best systems of care pre-COVID, during-COVID, and post-COVID ought to be organized around creating experiences and conditions that help young people and their families thrive, survive, reduce burden and stress in their lives, and create and sustain meaningful, interactive, positive relationships. A lot of that is promoting people’s capacities and skill in terms of being able to have very authentic and genuine conversations with their service providers, with their neighbors, with their faith communities, with their family, about what it means to be in a safe and healthy relationship, and to really promote that as doorways to service deliveries and service provision, rather than business as usual, which is the only access to serve this provision a vulnerable children in a family can have is through a surveillance and a monitoring system, which only produces stigma and also decreases, I think, the likeliness that if you need help and want help you can actually get it. Nobody wants to get help when help comes with the conditions of needing to be labeled a victim or a batterer, frankly.

Sally: It’s so challenging to take such a huge topic and cut it down into 15 minutes, so thank you for allowing us.

Dr. Ung: Thank you for inviting me.

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.

While the current coronavirus pandemic is affecting all of us, it isn’t affecting all of us equally. Some communities—especially communities of color—are feeling the brunt of the virus more than others, in terms of higher rates of infection as well as economic fallout, among many other ways.

In this third special COVID-19 episode of The Brain Architects podcast, host Sally Pfitzer is joined by Dr. David Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health, Harvard T.H. Chan School of Public Health, and Professor of African and African American Studies, Harvard Faculty of Arts and Sciences. Dr. Williams discusses ways in which the coronavirus pandemic is particularly affecting people of color in the U.S., and what that can mean for early childhood development. He also pinpoints the importance of creating “communities of opportunity” that will allow all families to thrive—both during and after this pandemic.

Upcoming episodes of this special podcast series will focus on domestic violence, and the mental health implications of a global pandemic. 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. 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 third in our series, and our guest today is Dr. David Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health – Harvard T.H. Chan School of Public Health, and Professor of African and African American Studies -Harvard Faculty Arts & Sciences. Thanks for being with us today, Dr. Williams.

Dr. Williams: Thank you, it’s good for me to be here with you.

Sally: Just so our listeners know, we’re recording this podcast today on a video call, so the sound quality may be different from what you’re used to hearing when we typically record this podcast in the studio. So, the data that’s coming out now that we’ve been seeing continue to reinforce the research that you have been doing for many years around racial disparities, and we’re seeing that this virus is disproportionately effecting people of color. What are you seeing now in terms of the data?

Dr. Williams: We are seeing in multiple states more than half of all deaths from the Coronavirus are African American, and in virtually every state the percent of deaths of African Americans who die from the Coronavirus exceeds—it’s larger than the percent of African Americans in the population in that state. So, there is a disproportionate negative impact on African Americans in New York City, and we see a similar pattern for Hispanics. I think the important point I would like to make at the onset is that first, this is not a surprise. Two, this reflects a longstanding pattern, not just for Coronavirus but for virtually all of the leading causes of death. And that this pattern does not reflect failures on the part of the individuals, the families, and the communities that experience such disproportionate losses.

Sally: I think a lot of times when we’re hearing about this data coming out, there is a missing component where people are hearing this is disproportionately affecting communities of color, but there is not a lot of talking happening right now around the ‘Why?’. Could you share a little bit more about what the underlying causes of this disproportionate impact actually are?

Dr. Williams: Sure. Before we talk about underlying causes, I think it’s also important to emphasize that when we see one group in our society disproportionately affected, it affects all of us. It is about all of us. We are all connected. Higher rates of death for one population effects the entire profile and the entire risk for all of the population. In terms of what are the causes of these patterns? We’ve known for a long time many of the culprits. Number one I would mention is lower income, lower education, lower occupational status. In virtually every country of the world, persons of lower levels of education and income have higher rates of disease and death than those who are better off than they are. And when we say race and ethnicity in the United States, we are talking about groups that really vary dramatically in economic resources. I’ll give you two numbers that makes this very concrete. If you look at the latest income data for the United States, published in 2019 by the U.S Census Bureau1, we find that for every dollar of household income White households receive, African American households receive .59 cents. That .59 cents to the dollar figure is identical to the racial gap in income in 1978. Most of my students think we have made a lot more progress than that. As bad as the income gap is, it dramatically understates racial differences in access to economic resources. Because income captures a flow of resources into the household, it tells us nothing about the economic reserves that households have to cushion short falls of income. We get that from data on wealth. The latest report from the Federal Reserve Board indicates that for every dollar of wealth White households have, African American households have .10 cents, and Latino households have .12 cents.2

So, we are looking at groups that are disproportionately, economically disadvantaged; number one. And in multiple ways that raises the health problems and challenges that they will face. COVID-19 really illustrates this phenomenon very powerfully. What we know is that minorities have early onset of disease, early onset of chronic conditions, hypertension, diabetes, heart disease, all occur at younger ages. Part of this is driven by the lower economic status and higher levels of stress. Also, persons of color disproportionately in jobs where they have to go to work in order to get paid. We are working in jobs that don’t provide benefits, often don’t provide healthcare benefits, which lowers access to medical care. In New York City, for example, the hardest hit area of the pandemic, 60% of the essential workers in New York City are persons of color.3 Research also documents that in disadvantage communities, even if you get access to primary medical care, many of those primary care providers do not have admitting privileges at the best academically based or private health care systems where the best specialists are, so that those populations are also limited in the access to quality care. More generally, there is at least one study since the COVID-19 epidemic has begun that looked at a data from multiple states and that reported for testing for COVID-19 that African Americans, with the same symptoms as whites, showing up requesting a test were less likely to get the test.4 We also have evidence of the persistence of discrimination in terms of access to tests in addition to the fact that most of the testing sites are in suburban communities and there are fewer testing sites in central city communities that have a larger unrepresentative minority population.

COVID-19 is a perfect storm in terms of having a disproportionate negative impact on disadvantaged populations in the United States.

Sally: A lot of what you’re describing reminds me of that saying, “a person’s zip code has more to do with their health outcomes than their genetic code does.” What does that mean and how does that relate to this current situation?

Dr. Williams: I think it’s important to recognize that challenges these communities face are long standing and it didn’t happen by chance – they are not random events. They actually reflect the successful implementations of social policies. We had social policies implemented in the United States, but residential racial segregation being one of the most profound of them in terms of its far reached negative effects that still persist today that restricted a way a person lives based on race or ethnicity. That has had a dramatic effect in reducing access to opportunities – opportunities in early childcare and good early childcare environments. Access to good early education, access to employment opportunities. Opportunity in terms of the quality of neighborhood and housing environments and whether it’s easy or difficult to get exercise safely in your neighborhood. Whether it’s easy or difficult to have access to good primary care in your neighborhood. Across a broad range of factors that drive opportunity and success and society, we have large segments of our population restricted by these historic inequities.

Just to illustrate how powerful some of these effects are; a national study led by Harvard economists showed that if we could eliminate residential segregation in the United States overnight, we would completely eliminate or erase black and white differences in income, in education, and in unemployment, and reduce the black white differences in single motherhood by two-thirds.5 All of those differences driven by opportunities linked in place. What we need to think is how can we create communities of opportunity? Communities with high-quality early childhood programs, where every child is given a fighting chance to be successful—not only prepared for school, but also prepared for good health – a good foundation for health for the rest of their life. What can we do to reduce childhood poverty? What can we do to enhance employment opportunities for parents? One of the ways we can improve outcomes for children is by enhancing opportunities for their parents. How can we improve housing and neighborhood conditions?

The good news is there are examples of programs in the United States that are doing these things right now, and many of the studies show that these programs not only work but they will save society money. There is a range of opportunities of things we could do now to make a difference. When we take care of all of us and all of us have the opportunity, we not only build a more educated, a more productive workforce, we not only enhance the economic productivity of our society and the global economic competitiveness of our nation, but we also do something more that is profound, and that is we take care of all of us. We are all in this together, and what hurts one of us hurts all of us. It is in our best interest to work together to create a society that provides opportunity for everyone.

Sally: You mentioned stress as a factor contributing to the racial disparities and outcomes. Would you mind talking a bit more about how stress can affect communities and long-term health?

Dr. Williams: Sure. I want to talk a little bit more about the fact that minorities; African Americans, Latinos, Native Americans, have higher rates of underlying chronic conditions. The question is why? Is it their fault? Is it all linked to the bad choices that they are making? What the research points to is that you are looking at populations that are experiencing higher levels of stress. In some of my own work, I have found that the most of common stressors—stressors like loss of a loved one, unemployment, financial difficulties, violence in a neighborhood—all of these occur at higher levels among African Americans and among U.S. born Latinos.6 Not only do they have higher levels of the individual stressors, but they have greater clustering of stressors, so if you have one you are more likely to have multiple. What research is pointing out is that living out of the conditions of high levels of chronic stress leads to a physiological dysregulation across multiple biological systems. There is a body of research suggesting that at the same chronological age, racial ethnic minorities may be biologically older than Whites in the United States.7 It reflects the high levels of exposure to psychosocial as well as physical chemical stressors.

Let me give a practical example of the physical chemical stressors. There is one recent study done by researchers at Harvard University documenting that persons who live in areas with higher levels of air pollution, which are disproportionate minority, those persons if they get COVID-19, it is more severe and they’re more likely to die.8 The air pollution, this chemical stressor, has a negative effect in terms of adversely impacting health. In addition to higher levels of the chronic stressors, one of my areas of research has also been looking at stress of racial discrimination. I have developed measures to capture discrimination. One of them that is very widely used around the world is called The Everyday Discrimination Scale.9 It captures minor indignities – being treated with less curtesy and respect than others, receiving poorer service than others at restaurants or stores. The research documents that these little indignities accumulate and adversely impact physical health, mental health, the quality of sleep. It predicts early onset of multiple chronic diseases and even adversely impacts how individuals access and utilize medical care. If you’ve been treated badly in multiple domains of society, then you become less trusted in even the healthcare context. What emerges is a picture of the cumulation of negative experiences of chronic stress that have long term negative impacts on health.

The challenge, though, is that most Americans are unaware that racial ethnic disparities even exist. Raising awareness levels is really important, because if we don’t even know a problem exists, we are not mobilized to address it. Maybe COVID-19 provides us an opportunity to become more informed and hopefully to become more committed to working together to create a better future for all.

Sally: So, we’ve talked a lot about racial disparities in physical health related to COVID-19, but could you talk a little bit more about other ways in which people of color may be disproportionately impacted by this pandemic?

Dr. Williams: COVID-19 is an unprecedented challenge that we are all facing together as a society. This unprecedented challenge is a physical health problem, but it is going to produce a large scale of economic devastation, which we have touched on to some degree. It also will have large scale, negative emotional consequences. One of the things that we really need to think of is how do we provide support for all communities, but especially those who are already suffering disproportionately from the economic effects—those who are suffering disproportionately from the loss of loved ones. When we say that African Americans and Latinos are experiencing higher rates of death, that’s people losing mothers and fathers, grandparents, brothers and sisters. This is a community that will also be experiencing higher levels of grief and loss in addition to all of the negative effects of the pandemic. So, we really need to think of how can we enhance the access to emotional resources that helps people cope, and how all of us as individuals, even as we socially distance, we do not emotionally distance. That we do reach out to others and be supportive and be helpful, so that people can still have that sense of caring from others and that sense of emotional support from others.

Sally: I’m imagining that many listeners might be wondering what they can do, and how we might be able to help change this for the future?

Dr. Williams: Sure. I think when it comes to stress and environment, there are things that individuals who are suffering now can do that can protect them from some of the negative effects of stress. So for example, even the research on stress in general, but also research on discrimination in particular, points out that individuals who are embedded in close-knit, emotionally supportive relationships, the quality of social ties can reduce at least some of the negative effects of stress on health. There are some research suggesting that higher levels of religious involvement can also protect individuals from some of the negative effects of stress on health. There are things that can be done at the individual level. At the same time, what can we do to create environment where stress levels are lower? How can we create high quality neighborhoods so we will reduce the levels of neighborhood stress? How can we promote greater civility and respect of others as a value, so that we reduce the occurrence of discrimination in the first place? How do we make workplaces more friendly and more stress free than they currently are today? So, I think we do need to think of the high-level policy solutions that create environments that are low in stress, even as we empower individuals to more effectively cope with and deal with the stresses they face.

Sally: I really appreciate you taking the time, I know it’s incredibly busy and I know there are a lot of people asking for your time, so thank you so much for the opportunity to interview you.

Dr. Williams: You’re very welcome.

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.

1U.S. Census Bureau 2019 Income Data

2https://www.federalreserve.gov/econres/scfindex.htm?mod=article_inline

3https://comptroller.nyc.gov/reports/new-york-citys-frontline-workers/

4https://rubixls.com/2020/04/01/health-data-in-the-covid-19-crisis-how-racial-equity-is-widening-for-patients-to-gain-access-to-treatment/

5Cutler, David M., and Edward L. Glaeser. 1997. “Are Ghettos Good or Bad?” The Quarterly Journal of Economics 112(3): 827–72.

6https://scholar.harvard.edu/files/davidrwilliams/files/williams_dr_pearlin_paper_stress_mental_hlth_jhsb_2018.pdf

7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197001/

8https://projects.iq.harvard.edu/covid-pm

9Everyday Discrimination Scale

In the midst of a global pandemic, pediatricians are serving a unique role. While the coronavirus is generally showing milder effects on babies and children than on adults, there are still health concerns and considerations for infants in need of scheduled vaccinations, and kids who are home all day with parents who may be facing stressful situations.

In the second episode of our special COVID-19 series of The Brain Architects, host Sally Pfitzer speaks with Dr. Rahil Briggs, National Director of ZERO TO THREE’s HealthySteps program, to discuss how pediatricians are serving their patients during the pandemic, including using telehealth; why caregiver health is child health; and what she hopes the healthcare system can learn as a result of the pandemic.

Upcoming episodes will focus on racial disparities in the effects of the virus, and domestic violence. 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. 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 second in our series, and our guest today is Dr. Rahil Briggs, the National Director of ZERO TO THREE’s HealthySteps Program. Good morning, Rahil.

Dr. Briggs: Good morning, Sally.

Sally: And just so our listeners know, we’re recording this podcast today on a video call, so the sound quality may be different from what you’re used to hearing when we typically record this podcast in the studio. Rahil, what are you starting to see out in the field with pediatric practices effected by this virus, particularly in the HealthySteps locations, and how are the pediatricians starting to respond to the Coronavirus situation?

Dr. Briggs: Sure, thanks Sally. It’s an excellent question and honestly, depending on when listeners are catching this it may have already changed by now. The American Academy of Pediatrics is really our guide star for figuring out what’s going on and what they’re recommending, but a couple of facts on the ground really remain the same. That pediatric primary care is the main system we have for reaching young children. In a normal time, whatever that was and may be in the future, pediatric primary care reaches nearly all young children in our country. Right now, the American Academy of Pediatrics in recognition of the importance of vaccinations, and in recognition of the importance of really high quality newborn pediatric care continues to recommend actually, that families bring newborns, and bring infants and toddlers who need vaccinations into the primary care practice. So, that is pretty extraordinary and speaks to the importance of those services even with the Coronavirus swirling around. As you know, there are about 12-13 well child visits in those first three years. 7 of them occur in the first year of life, and a big chunk occur in that newborn period where they are checking everything from the bilirubin levels to maybe redoing the newborn blood stick to the weight gain and all these really critical pieces. So to your question – what are we hearing now and what are we hearing from our HealthySteps specialists who work side by side alongside the pediatricians in these practices? We’re hearing that babies still need vaccinations, and parents are more stressed than ever. That really needs attention. All of this discussion about how children are saved by the worst impacts of the medical parts of the Coronavirus, they are at home often with parents who are incredibly stressed and really looking for new approaches and ways to just frankly get through the day. So that is where our HealthySteps specialists are really coming in handy. I’ll leave you with one particular point that has really stuck with me. We had one of our HealthySteps practices in Colorado say that they were going to move to drive through vaccination services, which sort of boggles the mind, but I suppose that’s the world we are living in right now. And as they grappled with that and went back and forth with whether or not that was the right thing to do, they decided they weren’t going to do drive through vaccination services. One of their driving pieces was knowing how important it would be for the family to still touch base with the HealthySteps specialist. They’re hearing that families are running out of diapers, families are struggling to get formula, families are struggling to get needed medications for children with special healthcare needs. The HealthySteps specialists are doing so much of that care coordination and that systems navigation because as we know this is disproportionately affecting those who are impacted by poverty.

Sally: Would you mind giving us a really quick summary of what HealthySteps is for the listeners who may not know about the program?

Dr. Briggs: Sure. HealthySteps is a team-based, evidence-based primary care program where we add a new team member to the primary care network, which is a HealthySteps specialist who is an expert in child development, focusing a lot on parent-child relationships, focused on infants and toddlers; babies, toddlers, birth to three. We are an evidence-based program and have a three-tiered system of intervention with a universal level of services that include needed screenings for family concerns and child concerns and follow up on those screenings. And then a tiered level of intervention based on need for families with young children.

Sally: That’s really interesting, and you’re actually teeing us up for our next question. How are pediatricians helping families manage stress with all that’s happening right now, and what advice would you be thinking about giving to those families that are dealing with the highest adversity and stress?

Dr. Briggs: It’s a great question, Sally. I think a couple of things remain true, even though we are living through pretty extraordinary times. We know that there are two main ingredients for happy families with healthy children, and those continue to be safe, stable and nurturing relationships and a sense of routine and predictability to some extent. So obviously right now people are very stressed, and families are worried about lost income or even about not having enough groceries on the table. We also know from some of the great work that’s been done that babies pick up on that stress. They’re like recording devices that are always on. We don’t get to choose whether they record just the good or some of the bad, it is always on. So, what do you do and what can pediatricians do to help families during this time? I’d say three important things. One, and again this remains true no matter what time we are in – take care of yourself so that you can take care of your children. It’s about going easy on ourselves. Recognizing that nobody can overnight, turn into a perfect stay at home employee, pre-school teacher, care coordinator, systems navigator and parent when you’re not sleeping because you’re worried about trying to get food on the table. It’s about asking for help and organizations are scrambling to try to figure out the best ways to help families – moving to telehealth and moving to much more nimble service delivery options. Two, some semblance of a daily schedule. I think again this is a moment to go easy on yourself. It doesn’t have to be color coded and beautiful and every 5 minutes mapped out, but some daily schedule where there is some play time, time without screens and hopefully safe outdoor time. We’re advising families to expect that behavior will change and you may see in young children sleep disruptions or feeding difficulties. One thing we know for sure is that they’re going to be sensing the worry in the house and the stress in the house and needing a few extra hugs. And three, connecting with children when parents are in a good place. When they feel that they can be that safe, stable and nurturing environment for the children, and if not then to take a break and to ask for help. Maybe one of the best parts of being a toddler is that favorite books are just that and can be read every single day and multiple times a day. There’s not that exhaustion. Being able to just spend that 5 minutes. Depending on the age of the kid and how good their receptive language and understanding is, we can also explain to them a little bit about what is happening here in a developmentally appropriate way, but they rely on parents to interpret the world around them. If parents are sort of saying ‘no, no it’s fine, it’s all good you have nothing to worry about’, that’s going to feel discordant to a young child. So I would say really helping parents develop the language to explain that there is a virus and it’s making some people sick, children are not getting very sick from it, we’re staying home to help keep other people from getting sick and what can we do to really make sure we stay well? We have to wash our hands and not give hugs to prevent the spread of the virus. And we have to focus on our youngest patients to ensure that there are healthy and resilient families in the future.

Sally: Yeah, I hear a lot of what you are talking about also kind of swirling around mental health needs. I was wondering if you could speak a little more to what families and friends and neighbors and communities could do to help support the entire family’s mental health needs in the current situation.

Dr. Briggs: I was reflecting back I think earlier this week when a friend of mine who is a social worker himself, and someone that I’ve always thought of as very mentally healthy. He hasn’t seen struggle with depression or anxiety, and he is one of those folks who can be the calm within the storm. We were chatting and he told me he had a panic attack. He’s 45 years old, never had a panic attack before in his life. These are pretty extraordinary times and so they are taking a toll on folks. I think with all of this worry that we are hearing it’s incredibly important for parents to be that home base, for parents to be able to provide some of that calmness routine. They don’t need the latest game, they don’t need the latest app, it’s not about the latest and greatest sort of interventions. It’s about just some level of safety and stability in this highly stressful situation. Self-care is not selfish. It’s the best way that we can take care of ourselves and our children. There are plenty of resources out there that used to be fee-based and now are free, like Headspace and Calm. Physical activity to the extent we can get it; walking, jogging, jogging in place if need be, dancing, whatever it is that feels good and can be done safely. Cooking, journaling, taking a bath, having a cup of tea, chatting with friends, getting on a video chat. If you’re not a member of a HealthySteps practice and don’t have access to that mental health support right there in pediatrics, there are also other support organizations that have moved completely to an online service delivery model and are free. The Erikson Institute’s Fussy Baby Network is one of them. They’re starting to, I think starting last week, providing online support, video home visits, parent web support groups, they’re launching Facebook live sessions for infant massage and baby yoga and play and connection ideas. So, all sorts of options. And again, just asking for help. One thing that I’ve learned through this last month already is that we’re all just doing the best we can and we’re all struggling in one way or another. We have a section on our website on healthysteps.org on caring for yourself during Coronavirus, and there is also a zerotothree.org for tips for families Coronavirus if that could be helpful.

Sally: What are the pros and cons of health services that are delivered by technology instead of in person?

Dr. Briggs: Telehealth is emerging as this wonderful solution to so many of our problems, and it is absolutely a vehicle that can really help us reach families right now. There are some challenges to telehealth, not the least of which is that the guidelines around telehealth vary state by state. So you have 50 sets of guidelines about how to use telehealth, who can be reimbursed, what qualifies as a telehealth visit and then when we think about infants and toddlers, if you’ve ever tried to get an 18 month old to just stand in front of the camera for a 20 minute telehealth visit – good luck, right? I think as much as it’s an extraordinary platform and we can really extend the reach of services through telehealth, we’re going to see limitations both because we don’t have a national infrastructure around this and because infants and toddlers are not great at sitting still for the camera. We’re losing some of that key interaction piece of the parent and the child together perhaps and creating even more stress for a family because Dad is worried making sure that the baby stays in front of the camera for this visit. So, we are thinking a lot about yes, the promise of telehealth and the unique challenges particularly related to infants and toddlers.

Sally: You’re definitely speaking to the fact that our healthcare providers are being seen as real heroes right now, and we are wondering what should our healthcare system learn from this experience in order to adapt and improve the system for the future?

Dr. Briggs: Maybe, we finally recognize that we absolutely need a healthcare infrastructure for everybody in our country, and maybe we finally recognize that that healthcare infrastructure includes mental health. That there is no health without mental health. That there is no child health without caregiver health, and that goes for mental health as well, and that developmental wellbeing is a key construct in there. I am thinking so much about our increased understanding of all of these drivers of health. We’ve known for a long time that you can’t solve all problems within those four walls of the medical practice. That if someone goes back to unstable housing, if someone goes back to community violence, that those things are going to undo the important health interventions efforts we’ve made. My first decade of work was at Montefiore Health System in the Bronx, a borough where people are dying from COVID at twice the rate of their neighbors and the rest of New York, due largely to pre-existing health conditions and other risk factors associated with poverty. There is a higher incidence of asthma in the Bronx, largely based on a higher incidence of air pollution in the Bronx. And so, my greatest hope for all of us is that we recognize what heroes healthcare workers are and we recognize that we need a massive rethinking of the healthcare system to focus on those drivers of health that have to do with safe housing and environmental justice and safe and stable and nurturing relationships that are going to really create the foundation for health for folks, whether they’re facing this virus or another one down the road. We’ve got an extraordinary moment to get this right coming out of it, and it’s about whether or not we’ll have the courage to do so, the will to do so, and the resources to do so.

Sally: Thank you so much, Rahil for taking the time to be with us today. You’ve articulated so clearly the importance in making sure healthcare, including mental healthcare, is available for all. And that as you said, caregiver health is child health. We’re really grateful that you took the time to speak with us today.

Dr. Briggs: 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.

While the coronavirus pandemic has changed many things around the world, it has not stopped child development. In this series of special episodes of The Brain Architects podcast, we aim to share helpful resources and ideas in support of all those who are caring for children while dealing with the impacts of COVID-19.

The first guest of this special series is Center Director Dr. Jack Shonkoff. He and host Sally Pfitzer discuss how to support healthy child development during a pandemic, including the importance of caring for caregivers. They also talk about what we’ve already learned as a result of the coronavirus, and what we hope to continue learning.

Upcoming episodes of this special series will focus on how pediatricians are responding, racial disparities in the impact of the virus, and more. 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. Since our last podcast episode was released, things have changed quite drastically as a result of the Coronavirus pandemic. We hope you and your loved ones are safe and well. During this unprecedented time, we would like to share resources and provide guidance that you may find helpful, so we’re creating a series of podcasts episodes that address COVID-19 and how it relates to child development. Our guest today is Center Director, Dr. Jack Shonkoff. Jack, thanks so much for joining us.

Dr. Shonkoff: Thank you, Sally. It’s always a pleasure.

Sally: So just so our listeners know, we’re recording this on a video call, so the sound quality will be a little different from when we are in the studio. We hope these conversations will be useful anyway. Especially to those parents, childcare providers, social workers, teachers, healthcare providers and any others who are with children every day during this crisis. So, I’ll start with the first one. Jack, how do you think the pandemic may be affecting very young children, so the infants and toddlers? There has been a lot of attention to the need for distance learning for older kids. But, what do you think about what these younger children might need?

Dr. Shonkoff: That’s a really important question, Sally, because this pandemic is different from anything that any of us have experienced around the world. Basic principles of child development, basic concepts of the science that we know don’t change, then I would say from my perspective try it on both the best science we have and the best common sense that once again this is all about relationships. This is all about the environment of relationships in which young children are developing and which they are growing up. So, the risk of the conversation is how do we feel that in this context, but it’s not a difference science, it’s not a different understanding of what children need, it’s just a different world right now.

Sally: Yeah. So, I am sure many of our listeners have heard this term “social distancing,” but I know that it is also lately being referred to as the need for physical distancing. Can you talk a little bit more about the science behind that, and what it means for children?

Dr. Shonkoff: Yeah, this is the question that I’m most concerned about. There are two different bodies of science that we are talking about right now. Normally, we talk about the science of early childhood development—science of brain development—and now we are also dealing with the science of infectious disease. It’s really physical distancing that we are talking about. Actually, social distancing is exactly what we don’t want if social distancing means that we get further apart in terms of our interactions socially as opposed to physically. Let me just talk a little bit about each. So, why is physical distancing so important? Because this is the way we stop the spread of this virus. This virus is incredibly contagious. It can jump from one person to another over a six-foot span. Everybody has heard about keeping 6-feet away. And, because it is so contagious and spreading all over the world, and without a treatment and without a vaccine, the only real strategy we have to stop the spread of this virus is to not have people be close enough to each other so they can pass the virus from one person to another—it’s a population issue, it’s a community issue. So yeah, we have to do that. We have to minimize the physical contact to stop the spread of the virus. They’re saying time—social connection, hugging, being together— is one of the most critical dimensions of healthy development. It is the heart of serve and return interaction between young children and the adults that care for them. So, that’s a core concept for healthy development. Physical distancing is a core concept for stopping the spread of a virus. The challenge is: how do we reconcile those two? If we just come together physically, the virus doesn’t stop. If we separate physically and don’t find a way to stay connected, then we are creating an environment that is undermining the healthy development in young children. I have to say, I want to express tremendous solidarity with the parents, the caregivers, service providers, who are struggling with this tension between the need to get connected and the mandate to stay physically apart.

Sally: Would you have any recommendations for any family members of caregivers who are experiencing that tension that you were just describing?

Dr. Shonkoff: Absolutely. So, I think the first thing—and this is again, a good example of where basic principle in development under normal circumstances doesn’t change—in a crisis, development goes on, even though the crisis is here. So, one really important thing to remember is that interaction between young children and the adults who care for them and serve and return responsiveness is not something that has to happen every minute of every waking hour. The issue is not all or nothing. And the extent to which it may be more difficult—not because people don’t have opportunities—because adults are really struggling with the pressures and the tensions that they’re feeling. I think many parents out there, many of the caregivers, all of us know that when we’re feeling significant stress, anxiety, unease and maybe even depression about what’s going on, that you don’t have as much energy to be on your best game all of the time. In this particular crisis, it is very important for people to understand that it is okay, and it is important for adults to have a little bit of downtime and pay attention to their own needs. It’s all a matter of balance, right? So, the first thing to think about is what your child needs is a reasonable amount of attentive interaction with you during the day, but that you also need time for yourself. You need time to have your needs met, and that’s also very true in non-crisis situations. In fact, one of the cardinal principles of the science of early childhood development is that if we want to create the best kind of environment for learning and healthy development for young children, we have to make sure that the adults who care for them are having their needs met as well. You know, people often use the example of the airplane: ‘parents put your own mask on before you put your child’s mask on.’ That’s not: ‘you’re more important than your child.’ It’s a way of saying, ‘you can’t take care of your child if your basic needs aren’t met.’ So this is where social relationships—networks—this is where parents supporting each other by smartphone, by FaceTime, or whatever. Interactions that parents have with other members of extended family, their community, their faith-based organizations, service providers you have a relationship with. All of these are necessary, not just to help you meet your child’s need, but to help you meet your own needs. In this particular crisis we are in right now, meeting the needs for the adults who care for children is the only way to meet the needs of children. You can not bypass the needs of the adults.

Sally: So, I think one of the things that’s really obvious about this pandemic is that it is affecting everyone, and every person has some connection or story or something that they are grappling with. I have been thinking about a lot of families that are dealing with economic distress, and wondering if the children who are living in those families are more at risk for toxic stress, and if we can think more about how we might instead try to build resilience.

Dr. Shonkoff: Let’s talk a little bit about toxic stress first, before talking about if you’re more or less at risk for it. It’s very important to start with that toxic stress does not refer to the cause of the stress. It refers to the body’s physiological response to the stress: your heart rate goes up, your blood pressure goes up, your stress hormones are activated. The difference between toxic stress and what we call tolerable stress is the extent to which people can manage the stress and feel some sense of safety and control, which brings your stress system back down to baseline. So, for young children—babies, toddlers, preschoolers—obviously their capacity to manage their own stress is not entirely up to them, it’s up to the adults who care for them, who do two very important things that make toxic stress tolerable. One is to provide a sense of safety in the children—a sense that you are being taken care of in spite of what is going on around you by the adults who are caring for you. So, once again, we come back to the fact that the adults who provide that sense of safety have to feel that sense of safety themselves. And, none of us—none of us—are capable of feeling safe and secure all by ourselves, all of the time. It doesn’t matter how much money you have, how much education you have—we all need relationships to help us deal with stress. Now, the other part that turns toxic stress into tolerable stress is helping a child develop a sense of being able to cope. So, it’s not just protecting the child from the stress, but helping to build the skills that really make for resilience. It’s basically having some sense of regulating your activity and being engaged in things, but maybe you feel some sense of mastery. That’s why play is so important. Play is probably the most important thing. For those parents out there—anybody who is involved in childhood programs already knows this—let me tell you from a science point of view that if you’re concerned about how a young child can manage and learn to cope with the stresses going on around a family, create opportunities to play with your child, create opportunities for your child to play alone and not necessarily having always to play with an adult. Focus on: ‘how do I provide an environment in which my child can play?’ Because that kind of play is the way the brain builds strong circuits for resilience—for mastery. Give your child and yourself a break. Be comfortable with playing with your child and following your child’s lead and engaging with serve and return interactions will be tremendously protective for your child’s brain and the rest of the body. Your question, Sally, was is this even tougher for families who are more economically insecure, and certainly for families whose economic insecurity under normal times is not very stable, in these times right now, the pressures are immensely greater, So, what we have to do as a society—as human beings— is to recognize that some people are going to need more help from others to create that sense of safety and security in their homes while everyone is being isolated, and to be sure that we are protecting the developing brain, the physical and mental health for young children. Why is that important? It’s important because it’s the right thing to do. What kind of human beings would we be if we didn’t do that? It’s important also, because that’s how we are protecting society by making sure we are promoting healthy development in everyone so that we all benefit later because we have a healthier population and a more productive population. So, yes, some people need more support than others, particularly families who are dealing with housing instability, families who are dealing with food insecurity—those very basic bare essentials. There are a lot of families dealing with those kind economic insecurities now who have not dealt with this before. We absolutely have to pay attention to the needs of families who need extra support, who don’t have the reserves or the resources themselves—it’s an absolute imperative certainly for the well-being of the children. Give families security and stability, and they will provide a protective and safe environment for their children.

Sally: I’ve certainly heard you say—and I know others have often said— that small things can make a big difference for kids and families. As I’m listening to you talk, I keep thinking it would be helpful to get again some concrete examples of what families, friends, neighbors, communities could do at this time to support each other, just to get us through with the least, long-term harm to children’s development.

Dr. Shonkoff: I’m going to start mostly with what adults can do for each other. I really think that the answers for what—in this crisis—what adults can do for children is very basic and simple: provide a sense of safety and security, provide opportunities to play, engage in an interactive way—serve and return interaction—and your child will get through this just fine. So, the concrete things that can be done to protect the development of children come down to a pretty standard list of things that basically adults need to feel safe and secure. I can mention a few of them, but I think the most important thing for starters is to say just like when we think about experiences and finding experiences for young children, there is no one size fits all, right? So, what do adults need to feel a sense of safety and security in the face of this tremendous anxiety? Before we go to services, let’s start with what people informally provide for themselves. You have friends. You have neighbors. You have extended family. They may be close by, they may be far away—ironically, in the world we are living in right now, it doesn’t matter how far they are away. You can’t be that close to them physically, so you have a telephone and a smartphone, you can look at people with whatever that media would be. People need to be able to share with each other what they need—generally emotionally, and socially—and be ready to give to each other what we’re each asking of each other. And that includes informal arrangements with communities that could include the house of worship and the community around that you may be affiliated with. It could be a mother’s group or play group, it could be whatever. So, that’s for starters. Some people really have a rich network of relationships to draw on—independent of income or education. But then there are people who either don’t have a rich network to start with, or have it and it’s not meeting the needs, and that’s where we could provide more assistance through services. This is a great investment, especially now, by us as a society to provide a safety and support and reassurance for families who don’t have the informal supports that are needed. There is no shame in asking for that and there should be no hesitance in providing that. Stress reduction, right? You need ways to reduce your stress, but different things work for different people. The list of the usual things that work for most people in some way in combination, start as simple as taking deep breaths. Especially if you’re feeling like you’re getting very stressed out. It’s not just a mindset thing, it’s actually physiologically—it’s helping to bring your blood pressure down, it’s helping to bring your heart rate down, so a deep breath and a slow exhale. Some people have learned how to do meditation. That’s important, that’s good. If you need a few minutes to do that, do it, and don’t worry about the fact ‘oh my goodness I am not interacting with my child’. Let your child play while you just go off on the side and relax. Music—dancing—could be a great way to reduce stress. And for some people, stress reduction is just getting on the phone with a good friend and pouring your heart out, and in the end saying, ‘thank you for this conversation, I feel so much better.’ So, stress reduction, finding what works for you—there’s no one size fits all. You’re giving yourself a little bit of space from your child during the day. Because at the end of the day, it’s all about us helping each other. So, the concrete things are not hard to remember and they’re not complicated. There is a lot of heavy-duty science behind it, but it can just point out to a few things: take care of yourself, figure out how to reduce the stress you’re feeling—the stress you’re feeling is normal, if it’s feeling out of control, then get some help. Don’t be afraid to ask for help, we all need help. The bottom line being is that it varies from person to person. This is the time to really be in touch with what works for you.

Sally: So Jack, even though we are still in the really early days of this crisis, and I think it’s really important to emphasize that right now we’re completely, as you said, just try to get through day to day and understand the science behind this. It can also be tempting to start thinking about if there might be any long-term lessons that we could have in mind as a society that might eventually emerge. Again, recognizing fully that we are just at the beginning.

Dr. Shonkoff: I think that is a really important question, and for me, the first answer to that lessons learned is not so much a new lesson to be learned, but an old lesson that maybe we will learn this time in a way we haven’t before. We are all in this together. Everybody is affected by what is going on right now. The extent to which we share responsibility and help each other get through is really important for all of us, right? I mean, in some ways COVID-19 is an amazing example of how we each need everybody to behave responsibly and protect everybody else. This is not just about what is good for you. Let’s just take the physical distancing, right? If people don’t do it, other people are hurt by that. And if other people don’t do it, you are hurt by that. So, if we all share the responsibility, we all benefit. And if some part of the population is indifferent, doesn’t care, doesn’t pay attention,  is just focused on its own needs, then we all pay a price for that. I mean, what great messages and lessons to take out of this crisis for how we should be under “normal circumstances.” Fast forward, at some point we’ll go back, and we will know that everybody with young kids is doing the best they can to raise healthy kids, and we all depend on that as a society. And some people are struggling more because they have less money, they have less education, they have less economic opportunity. We all benefit if we all take care of each other and do our job, and we all suffer, and we all pay a price if we don’t take care of each other and share the responsibility. I’d love that lesson to come out of this pandemic.

Sally: Thank you so much, Jack for taking the time to be with us today. I really appreciated your concrete advice, and I also especially appreciated the remarks you made about how this might be affecting different families in a variety of ways. I know at the Center, we’re trying to think of ways in which we can support our community, and some of that, of course means that we’re asking. But it also means that we’re trying to be responsive and put out resources that we hope will be beneficial. In that way, we hope whatever was said here will be helpful. We recognize that it might not be beneficial for every person listening, but we hope that today we could have hit on something that might help someone through this time. We’re really looking forward to continuing to hear from some of your friends and colleagues, Jack, in upcoming episodes of this short podcast series we’re doing on COVID-19. And we’re really grateful for your time, so thanks again.

Dr. Shonkoff: Thank you, Sally. I’s always a pleasure to have these conversations with you. Thank you very much.

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.