Practice & Policy Lecture: October 2010

Connie Schlittler: -- Chief Information Officer for the Oklahoma Department of Human Services. My office coordinates these events each month. If you've never been, you're certainly welcome any time you're in Oklahoma City to attend these. I know many of you picked up the programs. We have Dr. George Young -- will be speaking in November -- I believe it's November 19 -- on customer service. He's one of our commissioners for the Department of Human Services, but also a pastor here in northeast Oklahoma City, and he'll talk about his experiences of working with his folks that come to his church and their experiences of dealing with DHS. So, I think it's a good challenge for all of us DHS employees, as well as others who do customer service. Today our person to introduce the speaker is Lesli Blazer. I'm sure most people that are here know Lesli. She's been the director of Childcare Services at DHS since January 2010. Her division licenses 4,500 hundred homes and childcare centers, which employ 25,000 childcare workers in the state, and they serve probably more than this, 140,000 children each year in those facilities. Please join me in welcoming Lesli Blazer.
Lesli Blazer: Thank you, Connie. Well, when I heard about the topic of our lecture today, I had to pull this old magazine off my bookshelf, and from the nods out there, I see you all have this, too. At least since 1997, when the article "How a Child's Brain Develops and What It Means for Childcare and Welfare Reform" was published, we've tried to use what we know about brain development to inform our policies. For this reason, Oklahoma Childcare Services is thrilled to have such a passionate, prolific speaker with us today. Dr. Gerard Clancy will offer a discussion on new advances in understanding brain development and provide new insights that will guide early childhood programs of the future. He was named president of the University of Oklahoma Tulsa in 2006 and he's responsible for all OU Tulsa programs and the development and growth of the OU Schusterman Center. Dr. Clancy was named dean of the University of Oklahoma College of Medicine Tulsa in 2001. Please help me welcome Dr. Gerard Clancy.
Gerard Clancy: Thank you. Thank you. All right. Well, thank you for that very nice introduction. And thank you for having me. I'm actually doing business in Oklahoma City and Norman, so it was very convenient for me to come down today. I'll apologize, my allergies are sky high right now, so if I start coughing, it's nothing psychosomatic, it's just -- So, we're going to talk about the brain, from infancy to adolescence to adulthood, and I'll just give you an update on what we know, as well as some of the things that we're heading toward as far as new areas of investigation. I'm a psychiatrist by training and so 25 years ago when I was in medical school deciding what should I be, these types of studies and conclusions were on the horizon. And I though, I want to be part of that. And I -- the brain and psychiatry is really the last field in medicine to really have tools and technology to really do the research to break open the understanding that we need to have. And so finally psychiatry is back with the rest of medicine as far as understanding. You'll see that psychiatry and early childhood development and environment, all these things actually overlap with each other and it's a fascinating story. I'll talk a lot about neuroplasticity. And neuroplasticity is really changes in the brain structure connections and chemistry in response to the environmental input. And that's really a big part of talk today, how do all those changes occur. One of the things that you all know already is that we are most plastic early in life, and if you think about kids learning a foreign language. Piece of cake for them compared to a 49-year-old. It's virtually impossible for me to pick it up. I forget it within 15 minutes. I put up a picture of Albert Einstein because after -- when Albert Einstein died they did an autopsy of his brain, and one of the things they found is one part of his brain was abnormally large. And it was the parietal lobes of the brain. The parietal lobes of the brain, right along here, are responsible for calculation. So Albert Einstein, a mathematician, a physicist, an astronomer -- I mean, a brilliant man -- had a brain that was geared to do the things that he was best at. Now the question is, did his parietal lobe grow because he was practice so much calculation, or was it the other way around. Was he so good at calculation because he was already wired that way? We'll never know. We'll never know. It's probably a little bit of both. So, let's -- part one, let's talk about what we know about brain development. Well, first of all, we know that the brain starts with a simple layer of stem cells, and those stem cells begin to, what we call, differentiate and say, altogether they say, let's all become nerve cells. So you've got this flat layer of stem cells on their way to becoming nerve cells. As they grow and divide, the go from a layer to a tube, and that long tube, almost like a straw, starts folding on back and forth, back and forth on itself in-growing, and you develop a spinal cord and you develop the brain. And that occurs really very, very early from conception all the way obviously to the newborn as well. So here's just a depiction of how that tube of cells forms more and more into the brain and the spinal cord, which we call the central nervous system. Here's just another picture of it. Starting from that little bud and tube of cells, more and more growth, more and more growth, starts folding on itself, folding on itself, folding on itself, and you've got this very, very dense organ, as far as cells, in a very, very tight space. The skull is a great thing as far as protecting the brain and it's also a harmful thing, because when that thing gets hit really hard, it jostles around and we have what happens with our football players. We have all those concussions that we have. This is a graph. The top one shows brain weight over the years. And out here is 86 years old, and right in here really kind of condensed pretty tightly is zero to five years old. And what you see is almost all of the brain growth of us after birth is really in those first five years. And so, very, very important time. The curve on the bottom is -- has got the same axes, but it is the ratio of brainwave compared to the rest of the body. So when you're born, your brain is such a big, important and dominate part of the weight of your entire body and then as time goes on, that brain becomes less of a factor obviously, as we grow. The -- you also notice that with the infant. I mean, their brain is -- their head is so big that they kind of -- they're top heavy. They topple over, and that's really in part because it's not the skull that's so heavy, it is the brain itself that is so heavy compared to the rest of the body. So we see that all the time. Well, what's going on inside that skull at birth is all sorts of growth of those cells, but then connecting of those cells as well. And synapses are those neuro-connections where one brain cell connects to another brain cell. The brain cell is called gray matter. The connecting material is called white matter. And at birth we have 100 billion neurons and at its peak there's 1,000 trillion synapses or connections. Ninety percent of those connections are at age three, and 100% by age 12. In the later teen years, those connections are actually peeled back, or the word we use is "prune." There's some cutbacks in the number of connections because some of them are just not used. Your brain is really set up to do many, many things, and dependent on the environment you're on, those are the connections that are saved versus the other parts of the environment that maybe you're not tapping into, those things are actually peeled back. Now, I give you a picture, here, of what looks like a diagram, a wire diagram of a silicon chip. You'd think, oh, that's a silicon chip. This is actually a depiction of your visual system, as far as the nerve centers and the connections between the different nerve centers across the brain. And what you see from it is there is lots of redundancy. There's lots of areas where the brain can work around. That's a really good thing. But there's certain areas where a little bit of damage can cause a huge amount of connection difficulties. We see that with strokes. If somebody has a stroke in the lower part of the brain, the mid-brain or the pons where a lot of tissue then goes to the rest of the brain. It can be major, major problems. It can be a tiny, tiny stroke. It can cause major problems. The opposite is true in that you can have a very large stroke in these temporal and parietal parts of the brain, and actually people can continue function pretty well. When I was working at the VA, a patient came in who was very depressed, very depressed, but walking and talking and doing fine and eating, but he was very depressed. And we started him on treatment and he just wasn't getting better, and I said, you know, I wonder if there's something else wrong with this guy. So we did an MRI of his brain, and what I found out is that he had an absolutely huge stroke on the left side of his brain. I mean, it was about half the size of my fist as far as lost brain tissue. And you could not tell in any way as far how -- as he was physically behaving. It had just knocked out his emotional system, but the rest of him was actually function relatively well. So that, that -- the workaround piece I think is very promising as far as rehabilitation. For those that have been injured or those who have been in very, very harsh environments, this redundancy in the nervous system, to me, points to what rehabilitation can do in the long run, that we could actually do more and more if we light up some of these redundant pathways. Something that was not taught to me in medical school 20 years ago that is now really a growing area of research. It's this concept of neurogenesis. When I was in medical school we were pretty much told that the brain is a static organ as far as regeneration of anything. It doesn't really regenerate any tissue. If you injure the brain, it's not going to do much more. That's not true. We have this concept called neurogenesis where new brain cells are actually created fairly regularly and they're in two areas primarily. One is in the temporal area of the brain -- that's where your memory center is, the hippocampus -- and one in the frontal part of the brain. That's where you do a lot of planning, decision-making, as well as emotion. At first you think, well, that makes sense in memory area, because we're laying down new memories all the time. Well, the memory center is a very factual center. It just says, this happened on this day, this happened on that day; the name of that song is this. The front part of the brain is what ties all the emotion to those memories, and so, you're laying down memory as far as fact, and you're laying down emotional memory as far as the experience, as well, and they go back and forth, back and forth, and there's very strong connections between the hippocampus and the front part of the brain, as we go forward. The little slide on the left is -- this is a brain cell strand over five days in the optimal growing conditions, and what you see is that brain cell grows and sends out little buds and little shoots all the time. Those brain cells are changing all the time, and until we had the technology, we didn't know that was happening. This is just a depiction of the stages of brain development from zero to seven years old. And you see right at birth -- I mean you all know this -- vision is developing, speech is developing, emotion is developing, math and logic is developing, social attachment skills are developing right away. The only one that delays a little bit are those more formal peer social skills. But right from birth, major things are happening. And so, the environment that that infant is raised in is vital, is very, very important. This is a measure of the neuro-connections for different brain functions over the first 13 years of life or so. And right in here they actually kind of squeeze the -- or stretch out the graph, so this is birth to one year old, and then this is one year until 19 years old. But you see right away the connections for the sensory pathways are firing up right at birth, language is firing up right away, then the higher cognitive functions are actually in process right from birth, but peak out as far as connectivity, out at one year, but there's a lot of activity in that brain zero to one year old. I remember when I first started learning about early childhood development, I said, "Yeah, right. There's really something going on." There really is a ton going on, on that brain from zero to one year old. I mean, I have three kids, raised all of them, you know, I didn't think that much was going on. There's a ton going on. [Laughter.] They couldn't throw the ball, they couldn't do anything I wanted them to do. This is from five years old to 20 years old, and the -- this looks at the brain after that really rapid growth -- period of growth. In the more intense purple and blue are areas that you have actually lost connections and lost brain tissue. And so, you see over time, that's the representation of the pruning, that those different pieces come back and -- that aren't used very much -- are pulled away. Now, one of the most important pieces, here, is the adverse environment that a child is raised in, and we'll talk about the ACEs study in a little bit. The brain is changing itself for the environment it is in. So, if it's a very positive environment, it is putting itself in position to benefit from that very positive environment. If it's in a negative environment, the brain is preparing itself and positioning itself to be able to deal with a very negative environment: defensiveness, suspiciousness and protection, on that negative side, versus growth, love, learning, connecting with people. And the brain is really kind of going in two different pathways. And depending on that environment they're raised in, that's how the brain is set to go. This is spending, from zero to 20 years old -- public spending on an individual versus our brain growth in blue. And what you see is, we're still not spending a whole lot of money at early childhood level. We're spending a lot of money way out here, way out here. And we probably would do much better way out here if we put more spending there. I think -- anybody disagree? All right, good. I think I have a pretty friendly crowd today. All right. So let's watch the brain in action. Let's look at some things about seeing the brain rather than just pictures of the brain, actually the brain doing something -- and we're going to build toward that. Let me give you a little history. So this is -- this is a cadaver brain from someone who has had a stroke here on the right. On the left is what normal brain tissue -- the very pink, that is gray matter. Those are the brain cells, the nerve centers of activity. The lighter color we call white matter, those are the connection -- the connection areas. And so, you've got connectors and brain cells. So this -- what you see here in the dark color, that is someone who has had a stroke. And that's dead brain tissue. Very interestingly, if you take a traditional X-ray of a brain, you see nothing of this. You virtually see no brain tissue. So, here is a traditional skull X-ray and all I can tell is it's kind of gray in there. I see no architecture whatsoever as far as the brain. The traditional X-ray doesn't do anything, and this is a poor individual, so I don't know how he did it, but he -- but he had a nail gun accident. And why this picture is famous is, he's got no problems from it. Again, damage to this part of the brain as far as walking and talking -- he's entirely fine. Now, he's put this thing into a part of the brain that has got to do with control, inhibition versus disinhibition, and so he misbehaves and makes bad decisions, but as far as walking, talking, he's O.K. And you can have a nail there. All right. So, the point here is that -- and the next slide, as well -- our technology for so long lagged in understanding how the brain works. After the traditional X-ray was developed, we said, gah, you know, you just can't see the brain, so they started doing things called pneumoencephalograms, and that was actually injecting air into the cerebral spinal fluid around the brain to be able to show some contrast between air, which is very dark black on the X-ray, versus brain tissue, which shows up more white. And so you see a little bit of brain architecture here, but, boy, it's not very helpful. Then we went into the field of EEG and brain mapping. So, somebody had to wear that. [Laughter.] But, those are all electrode sensors across a skull looking for increased or decreased brain activity by the EEG, the same thing that measures seizure activity. And what you do is, you know, you may get an area of increased activity right here. Big deal. I mean, it doesn't tell us anything at all right now. And the problem with the EEG is it only goes about that deep, whereas the brain is that deep. It only gets about 20% depth as far as what's going on in the brain, so not a very helpful tool. Even though this continues to be advertised and marketed as a very efficient diagnostic tool for things beyond seizures, it's not very helpful. Then we started getting into more advanced imaging tools, and those were both the traditional MRI and the CAT scan. Traditionally, those pictures were taken as slices of the brain, and you can slice this way, you can slice this way or you can slice this way. And -- so here, this is a cross-section brain. Nose is here, tongue is here. Here's the skull in white and here's the brain tissue in here. So you're starting to see some real nice, beautiful architecture when you -- psychiatrists like me get real excited. This is really cool, you know. Hun, can we put this up in the living room. You know. She really like -- I just love looking at how the brain came together and all the things it does. So the MRI started giving us some real important data on what structure actually looks like in living individuals. And we put it into these different slices in these different planes and the computers now can recreate a 3D image of the brain, right here. And that's -- so that's actually not a brain. That is a recreation of the brain from all the different slices that the MRI can do. So here's something that I can use diagnostically. Here's a cross-section of the brain: ear, ear, top of head, nose would be coming out here. Person on the left, 43-year-old, has lived a healthy life and is doing fine. You see brain tissue filling the skull, both white and gray. Person on the left [sic] has been drinking heavy for 20 years and what you see is a lot more dark, black color. That's air and -- or fluid, and not brain tissue. So, alcohol being a direct toxin to the brain has whittled away and taken away brain tissue. So if I see an MRI like this on someone who's been drinking heavily, I know, boy, they have really been drinking heavily and it killed off a lot of brain tissue. Fairly helpful for me. But it gets better. So now we get into the virtual brain, and the first technique that we could use to go from looking at structure of the brain -- this is a traditional CAT scan where bone is in white, fluid is in black and then brain tissue is in gray -- was called the SPECT scan. And if you have to inhale radioactive oxygen. And most people kind of say, "What are you talking about?" It only lasts about two minutes. I mean, they have to do the scan very, very quickly. But this was the first time that we were able to show the brain in action. Radioactive oxygen goes to what parts of the brain. And so, here, the skull not using very much in blue and the fluid not using very much in blue, and then certain centers of the brain in white, a lot of brain activity. This is 25 years old, now. This is old technology. It is overused, it is over-diagnosed. You really can't tell much with this other than it was our gateway to being able to do a lot more as far as understanding the brain. Here's where we are now. We have functional brain imaging called the fMRI, "functional magnetic resonance imager." You don't have to breathe anything radioactive at all. The sensors can just pick up what you're trying to measure as far as brain activity. A lot of times it's blood flow and oxygen utilization, is what they're sensing, but you can do much more. So the back part of the brain, this part back here, lights -- that's your visual center, and when it lights up, it's when you're very actively doing something. So the picture here is of this individual actually reading a book, and the visual center lights up as it would. You can more than some of those basic functions. You can look at the hearing center and the visual center. So here is someone who is -- both the visual center and the hearing center are lit up. They're probably listening to a lecture. You're hearing me and you're reading at the same time. So this is somebody's brain out here, right now. [Laughter.] It's not everybody's, but somebody's. Then we can look at shifts. And this is a very interesting one, where -- this is measuring the changes, the shifts in brain activity when someone is learning a new language task. The top one is where they're -- it's unpracticed, and the parts of the brain that are lighting up are the concentration and planning area, and the hearing area of the brain. Once the person has learned whatever language they are learning here, really the only area that lights up is the speech and talking center, essentially the motor control of the mouth. So, I have a 16-year-old, and I think this part -- you know, she's really not thinking a whole lot about what she's saying. She's just going all the time. And you see that. You see that in teenagers. They're talking without thinking. I mean it's all just "brrrrrrrr" -- just go, "what do you say?" You know. And so you see that. You see that. But you also see it with -- you know, all my kids are now very fluent in Spanish, and I'm not, but I'm trying to hang in there, you know. And they're just rattling along, going very, very fast between each other, and I'm over here just going, "gah," back and forth, back and forth, and they're actually here with Spanish now. They don't have to think about it near as much as they did when they started. So it's very interesting. One of my favorite slides -- this is a functional MRI. Nose would be up here. Ear, ear, back of head here. This is the frontal part of the brain, and what we call the pre-frontal part of the brain. This is a characteristic pattern when someone is asked to do something intentionally wrong. And what they're asked to do, here, is not tell the truth. So there is a diagnostic brain pattern of activity when someone lies. And what that -- what you need to think about there is, what are the ethics of being able to have this knowledge. You know? So let's take this to divorce court. I say he was unfaithful. I say he wasn't unfaithful. Put him in the scanner. You know. Let's see what it says. You know. Scanner says -- unfaithful. [Laughter.] But there -- these tools -- this is one of these instances where technology is barreling ahead of our society's ability to say, you know, this is really where we don't want to go with this. It's getting ahead of us as far as society. There was a Tom Cruise movie several years ago called "The Minority Report" where the systems of crime analysis were so good that they could predict a crime ahead of time, and Tom Cruise was a detective and he was labeled as someone who was going to commit a terrible crime, and so they were after him before he committed the crime. It's not done yet, but there are at least some signs that you can put somebody in a scanner who has the proclivity to be aroused by child pornography, and that part of their brain will light up versus those that are not aroused by child pornography will not light up. And what do we do with that information? You know, the person has never committed an act, but they've got the potential to, because you can tell that they're aroused by it. This may be a favorite to a lot of people. There's parts of the brain that we can detect craving now. This is -- when -- this is where you dangle chocolate in front of someone and they can smell it and see it, and these are the parts of the brain that actually light up. It's very interesting. These are the craving centers. Well, we relate that now to those that have used drugs, and this shows the differences in -- the person up here has not used methamphetamine, the person down here has used methamphetamine. This is measuring dopamine. So we're going from measuring blood flow and oxygen utilization to something much more specific, one of the nerve chemicals that the nerves use to talk to each other, and dopamine is one of our main nerve chemicals to be able to talk back and forth, as far as across parts of the brain. Well, what methamphetamine does is releases dopamine across the entire brain and it feels really good. Gives you energy, gives you a great feeling. Well, the chronic methamphetamine user has actually released so much dopamine, which would be in the red color, here, that they're depleted. Their dopamine reserves are down very low. That says two things. First of all, you see why they want more methamphetamine, so they can kick out more methamphetamine to keep things just kind of going now, because you're so low. I need a boost, I need a boost, just to get back to where I was. The second thing is, this does not correct immediately. Actually, it takes months for this to correct. And so, I've got somebody in an acute psychiatric hospital for five days who has been a heavy meth user that I'm going to put back out on the street and put him into outpatient therapy and expect everything to be O.K. when their brain looks like this. It's just not going to work. It's just not going to work at all. Just not going to work. Well, we can look at ADHD, as well. The next slide will help you more, but this -- the slide on the left versus the slide on the right -- the person on the left is the same person as person on the right. On the left is just when they're coming into treatment. And what -- this is dopamine activity again. You're surprised. This is the hyperactive 18-year-old and there's more color after they've been treated versus when they've been treated. That doesn't make any sense. They're ADHD. They're hyperactive. You'd think that brain would be more on fire. That brain would be more active. It's counterintuitive. Well, when it -- actually what's happening with ADHD is, the part of the brain that is not active is the brakes. So your braking system has slowed down allowing the go system to say, "Hey, I'm having a great time now. Let's just run." And so, person on the left, no ADHD, person on the right ADHD. You actually see less brain activity in the ADHD kid than you do in the non-ADHD kid. You see less brain activity in the ADHD kid before they're treated. When they're treated, actually the brain is activated. That makes sense. Our ADHD medications that are most effective are the stimulants, Ritalin, Concerta -- they all activate the brain. And that made no sense to me until someone said, "We're activating the brakes, is what we're doing, to slow people down." These techniques, now, have become so technologically advanced that one part of the functional MRI can be following specific nerve tracks themselves. And that's what this is here. This shows the connectivity for ADHD, from one minute to the next, as far as flow of information across the brain. We haven't really gotten great conclusions from this yet, but clearly ADHD is a connectivity problem. One part of the brain is not connecting well to the other part of the brain. The brakes are not connecting to the go. This is also becoming true in autism, that the brain, structurally, for some autistic kids, is very abnormal, even with the first usual MRI. But for other kids the brain looks very, very normal, on structure. When we start looking at the how the brain connects to itself, what parts of the brain rely on other parts of the brain, to make sense of a situation, the kids with autism have a real connectivity problem. I think in the next ten years autism will be just cracked wide open as far as what is actually going on. And this is one area that we've been able to show. Normally, without autism, if you see someone, you immediately look at their face, and you're reacting back and forth, how are they reacting to me? The neurons that do that are called mirror neurons. How am I being perceived, how are they perceiving me, and you are reading that person back and forth. Autistic kids, when they look at a stranger, have virtually no brain activity, as far as reading the other person's face. And you see that all the time. We have autism in my -- I have a niece and a nephew with autism, a brother and a sister, both with an autistic kid. My sister's son with autism has it very severe, and I see him about three or four times a year. And when he sees me, he looks right through me. He doesn't connect with me. This is what's happening to him. If I've been with him for a week, it finally starts warming up and he starts remembering me and he pulls out, actually, the pictures of me when I was there last time, and he starts remembering. But his ability to connect with me is virtually zero at the start, versus someone that they love and know and see every day -- the autistic kid -- the mirror neurons light up right away. He has got -- my nephew has such a good relationship with his mom and his dad, that when he's in a complicated surrounding, he just wants to be with his mom and dad. And so you see that the autistic kids sometimes become very, very clinging. They just want to be with one person. It's because it's who they recognize. And that's one of the connectivity problems with the autistic kids. We're going to skip that one. So let's look at the effect of the environment on brain development and performance. So, now we've kind of -- how does this brain work and how does it connect and how does it all come together? Let's look at the environment. These are two different brain maps of nerve cell density, and where you see the blue peaks is where the nerve cells are the densest. And so, these are some of those nerve centers we talked about in the gray matter. As you grow up and hear the language of your country that you're being raised in, your brain modifies itself to hear and produce the sounds of that language. So on the left is someone who is raised with American English, and there's a part of the brain that develops an "r," "ruh," right here, and there's a part of the brain that develops an "l," "luh," to hear it and to make that sound. If you are raised hearing Japanese, you only develop an "r". "Ruh." And so those that are -- that have been raised in a Japanese environment really struggle with "l". "Luh." I remember my laboratory assistant, when I was a biochemistry major at Iowa, could not say laboratory. He said "raboratory." And I'd say, "luh." And he'd say, "ruh." [Laughter.] It was simply because he didn't have -- this part was not developed at all. Now it comes back over time. Our priest at our church is Vietnamese. And there are certain letters he just -- he knows it's not right and he slows down when he's reading the gospel, but he just can't get it out, and it's part because he's just not wired to be able to make that sound as he wants to make. Just says so much. Your environment develops your brain even at the level of R's and L's. What else, as far as ability to love, connect with each other, learn, your environment is so important. So important. So, you know after 9/11, a lot of people with post-traumatic stress disorder. This is the map of Manhattan Island. The World Trade Center was down here. Substance Abuse and Mental Health Services Administration did door-to-door surveys to see how many people had post-traumatic stress disorder. If you lived within about ten blocks of ground zero, one out of five individuals had very severe post-traumatic stress disorder, which is anxiety, vigilance, depression, nightmares, flashbacks of the event and survivor guilt. It really can occur within anyone. And so this is a situation where an overwhelming stress can take even the very, absolutely healthiest, most stable, in a great environment person and push them into a mental illness. The environment, the environmental stress can be that strong. It pushes you over. Up the island a little bit more about 7 1/2% of the population had post-traumatic stress, and the north of 110th St. very few people had post-traumatic stress, so the close you were to the event the more you really lived it. My sister lives right there. Right there at the Brooklyn Bridge. And to this day, just really, really struggles with 9/11. Really, really does. Well, this relates to brain, the healthy brain reacting to stress. And there are certain parts of the brain that under a stressful situation -- it's right in the inner core part, central part of the brain up front that starts to actually physically change under stress. It actually swells. It increases in volume. And if that -- if that increase in volume stays on over time because the stress stays on that kicks into depression. What is interesting here is that antidepressant medications can actually reduce the swelling, if someone has been depressed, and the antidepressant medications can prevent the swelling in the first place under a stressful situation, which begs another ethical question. If you know you're going into a stressful environment, should you take an antidepressant ahead of time. If you are going into Afghanistan as a marine corps fighter, should you take Prozac ahead of time, or is it -- are you having a natural reaction to that stress and we need to allow that to happen? I don't know the answer on that. I don't know. But it's again an ethical question. As advances in medicine put us in a position to have another view of what's happening, we have to think to ourselves what's the right thing to do. Yes?
Question: [Inaudible.]
Gerard Clancy: Exactly. That's where they're going, yeah. Because now that we know, the drugs are easy. Here's a drug. Let's see if the brain swells or not. You know, the pre-emptive therapy obviously takes more time. I would suspect that the pre-emptive therapy would be very helpful. Now, I'm going to say that in a roundabout way. There are characteristic brain function changes with obsessive compulsive disorder, that both medication improves and therapy improve, and it's the same improvement in brain function on the images, drugs or therapy. So the psychologist -- yeah! The psychiatrist -- yeah! All right. All right. Let's move on to the ACE study. The ACE study was a huge study, 18,000 people in San Diego County, four years old or so, and they looked for correlation of adverse child experiences, child abuse, child neglect, sexual abuse and chaotic home environment with how you ended up as an adult, as far as medical conditions. We always knew that psychiatric condition is stress related, but what about medical conditions. And the theory was, adverse childhood experiences during periods of key brain development prepare the individual for a harsh world, as we talked about those two different path ways. The brain goes into a survival pathway, rather than into that nurturing, learning, loving pathway, and things such as self-defense, aggression, anxiety relief, are really fostered as far as how the brain wants to organize itself and what it's going to seek out. It was a partnership of Emory University, University of Arizona and Kaiser Permanente in San Diego County, and it's continuing to go on, and so all you have to do is Google ACE study, and about every year they put out another report, because they're following these 18,000 individuals. And it's really, really an interesting study, and it's the first time it took what we thought was happening and we were able to put some real teeth to it. What they found is the more adverse experiences -- and you got a score from zero to six, or more -- the more likely you were to smoke. So, using tobacco as anxiety relief, as a calming self-medication. The more adverse child experiences, the more likely to use I.V. drugs, as well. The more adverse child events, the earlier one begins smoking, and the more likely to develop emphysema. So here you have that final link of difficult environment to neurologic development to behavioral activities that help you in the short run to feel better, but in the long run cause medical conditions. So, we're able to show it. And this is really the pathway, that the adverse child experiences lead to disruptive neuro-development, which socio-emotional and cognitive impairment, leading to at risk behaviors, that then lead to medical conditions. And so, our pediatricians over at OU are saying, you know, if we look at heart disease, if we look at respiratory disease, if we look at cancer risk, it actually starts with the home environment. Where's a good investment for us, as far as the health of our population? Oklahoma ranks 49th in the nation in health status. Where's a good place for us to invest as far as health? Medical health? Early childhood. So the more adverse childhood experiences, the more likely that the adult has risky behaviors that lead to those diseases related to risky behaviors. Now heart disease, cancer and stroke are starting to come through in the ACE study. We're starting to see, those adults are getting into that age category that all these risky behaviors over 20 years are leading to major medical conditions. And if you had no adverse childhood experiences, the risk of these behaviors and these diseases is actually very low. We really do have a separating out at childhood of, are you going to be on a pathway that is successful and healthy, or a pathway that is not going to be successful and not healthy. All right. Let's move on to early childhood programs. I'm just going to mention a little bit on EduCare. We have two EduCare facilities in Tulsa. Now we have one in Oklahoma City. I think they're working on the second in Oklahoma City, and I think we're working on a third in Tulsa. EduCare programs are really focused on very early childhood development and it's really the zero to four-year-old group. Low teacher to child ratios. And those teachers are well trained. Really, we're offering in partnership with TCC a bachelor's in early childhood education, and soon we'll have a Ph.D. program in early childhood education at OU. The philosophy of the center really integrates the social, physical and academic learning. Health care is provided on site, and in Tulsa we do it at Kendall-Whittier School and the second one is actually up at Hawthorne School up in north Tulsa. So we have one that's kind of north central and then one farther north, as well. EcuCare is really driven off the studies that were done with what's called the Abecedarian Program that showed that, if you had very early childhood programs that are really strong, out here at 20 years old, the differences between usual childhood care and EduCare type programs persisted. So these -- the cognitive test score, essentially your IQ testing, was higher if you were in an EduCare-like program than if you were in a non-EduCare-type program, and what was interesting is then these kids got put back into the real world, again, but the difference persisted. So you have wired the brain to be able to learn a little bit better. So that showed with IQ testing. It showed with just attendance at school. The treated group versus the untreated group. It showed with going to college. So, you know, a significant improvement in getting to college. You know, my wife is an accommodation counselor at a school, and so she sees the IQ tests of the kids. The difference between a kid with an IQ of 95 versus a kid of 105, just a ten-point difference, as far as being able to get to college, is phenomenal. Phenomenal. The 95 kids try and try, and work at it, but it's just not there to get them over the line. If they're at 105, they're probably going to make it. They're probably going to make it. It's really dramatic. It's really dramatic. Then follow on from that, ability to get a skill job or higher education, the treated group again did much better. So, just a little bit to close on where we're going. In Tulsa very quietly we've been able to develop a really wonderful partnership, with St. Francis health system and the Warren Foundation really putting things in place, and this is our Laureate Institute for Brain Research. This is Dr. Wayne Drevets. We recruited him from the National Institute of Health and he's a really good, nice guy, in the first place. And he's really, really smart. And he's the medical director, and his -- this center is really around linking state of the art brain imaging with state of the art genetic studies with state of the art neuro-psychological testing, around all sorts of conditions. And the first thing they're studying is mental illness. But now they're building the team -- they've got about 60 researchers on site there -- and this is their building that the Warren Foundation built -- the next area that they're moving into is learning and the effect of the environment on brain function. It's just fascinating. It's great stuff. And so this is one of those areas that we're thrilled with because we really think Oklahoma can be a leader. We're a leader in early childhood education already. I think we can be a leader in understanding brain function. The 60 researchers that he's been able to recruit -- Dr. Drevets -- Harvard, Yale, Stanford -- just from all over the country. And the reason they come to Oklahoma is it's a better place to live, it's a better place to raise your kids and the center that they developed is just fascinating. Just fascinating. So, it's very encouraging. Very exciting. So, you'll hear more about the Laureate Institute for Brain Research. They're just doing phenomenal work. All right. Now we can play stump the psychiatrist, if you'd like. It -- whenever I open it up to any questions, it usually is between one and three questions, before I say, "Ah, I don't know." So. Go ahead.
Question: I was wondering when you were talking about the [inaudible]?
Gerard Clancy: Yeah, exactly. I mean that -- the question is, if you essentially put a drug on board to deal with stress, does it impair what would be a normal response, such as fight or flight. And sometimes that fight or flight's the right thing to do. You know. It really is. You know. I'm getting away from this because if I fight, I'm going to get in trouble here. So I'm just going to walk away from this conflict. So I -- yeah, yeah. I -- but, you know, on the other hand, if we know we're sending, you know, essentially a hero into a very difficult situation, is it a disservice to us or to them to not help them and protect them ahead of time. The wave of post-traumatic stress coming back from the Middle East to this country is enormous. Enormous. And will be the health care system's responsibility for the next 50 years -- 60 years. I mean, it is enormous. And so, if we can do something ahead of time. We know how we send someone into battle and how they are received back from battle is a major determinant on how they deal with post-traumatic stress, and we've actually learned that from the Israelis. And -- but where really -- a country close to war for many, many years. And if you keep people in units, if you let them have camaraderie, if you put the psychiatrists up on the front line, it makes a big, big difference. Big difference. I was a flight surgeon in the Air Force. My job was to be on the front line. Me and the orthopedic surgeons. Hi, buddy. How are you doing? Did know I signed on for this.
Question: When you were discussing the fMRI, I was wondering [inaudible], can that be manipulated by someone who may by psychopathic? So, they just don't have that kind of [inaudible]?
Gerard Clancy: So can the psychopath beat the brain scan? I don't know. They certainly can beat the lie detector test. There are some people that can tell a lie, they're so used to and comfortable telling a lie, they don't have that guilt response. Most of the response from the lie detector test that you have is changes in skin electrical activity and conduction because you feel guilty. And if you're not really feeling guilty about lying -- and, so I don't know. I don't know. So far I've heard that this one is actually pretty hard to beat. Yes sir.
Question: Is any work being done in the area of bypassing the oral and visual senses in education and training people at communicating with the brain by doing it directly, more directly, and -- in other words, somebody could just put on a -- you know, some sensors and overnight would learn another language, or learn whatever is necessary?
Gerard Clancy: Yeah, you know, I've not seen that yet. I've not seen that yet. What I have seen is individuals that have had strokes, that have lost, you know, dramatic function in an arm or a leg or speech, with certain types of therapy that can go back and forth with the brain imager to see if we're activating a certain part of the brain. You can do the workarounds, but it really takes an active therapist doing essentially brain physical therapy. Not physical therapy, but just, you know, getting that brain to do something different. We also know that after someone has had a stroke, and they're in the intensive care unit recovering from that stroke, if we put a therapist right next to them on a fairly regular basis and they do imagery of them moving their arms and the legs, essentially coaching those pathways to activate again, it actual can be very helpful, as well. So imagine yourself speaking after your stroke. Imagine yourself moving your arms and your legs, rather than getting frustrated and just, you know, forgetting about it, think and do imagery. It works. Went to University of Cincinnati Children's Hospital, and -- you know, I think the best children's hospital in the country. They have a functional MRI in the children's neurosurgery suite. And so they're doing brain surgery on kids with seizures and other conditions. They do the surgery and they put the kid in the scanner and say, what have we done. And then come back and forth. I mean, it is active surgery while you're scanning the brain back and forth. Fascinating. And then they -- the brain imaging pictures for the surgeon are this big. You know, and so he's got the kid on the table here, who's just gone through the scanner. He's still under anesthesia, and he's looking at what he just did, as far as activating parts of the brain. Fascinating. It's great stuff. Great stuff.
Question: Is there an emotive link with the development [inaudible] developing therapies of this sort?
Gerard Clancy: Is there an emotive link?
Question: The emotive state of a child [inaudible] therapy [inaudible].
Gerard Clancy: Oh, I think so, very much so. Very much so. You know, if you're a cognitive behaviorist, you know that thought causes behavior which causes emotion. You know, you link them all together. You can never unlink those. And often times, you know, inappropriate emotions are linked to actually inappropriate thoughts and back and forth, and so the therapy is really focused on getting the thoughts right so the emotions are more accurate to the situation.
Question: [Inaudible] children or adults who have very negative experiences as children [inaudible] research [inaudible]?
Gerard Clancy: Great. Great question. So, is there good research so far on, you know, children in very negative environments, coming out if. A lot of that is I think just starting. If you go into the field of psychiatry, child psychiatry, you've got to have that attitude that no matter what somebody's been through, I'm going to be able to help them. And so, yeah, there's certainly success stories. But there's really not the tool kit for it, yet, of really what works best. There are also great studies on resilience and how does somebody do well in a very, very negative environment, and the best study was done in Kawai, one of the islands of Hawaii. And you might think, Kawai? Who's having trouble in Kawai? [Laughter.] Kawai -- the Hawaiian islands on the non-tourist side of it are very much in poverty. And it's not near as glorious a life as it may appear. The resiliency studies show that even one individual who is a mentor, guide, guide on for that person, can keep someone from really slipping into that adverse pathway and can hold them up. And so that's why Big Brothers and Big Sisters is such a strong program. Mentor programs, we see the ads on TV for mentorship. It's the real deal. I'm a huge -- yes, mentorship is real and the studies show it. But, you know, you've got to have somebody there in the community, in the family around that person to help them go.
Question: What about once that child is an adult? Is there any research on that?
Gerard Clancy: What about when they're adult?
Question: And all they need [inaudible] pathway.
Gerard Clancy: Yeah. I myself have seen many people who have, you know, somehow some way been able to say enough's enough. I'm doing it differently. Yeah, we see it all the time. I mean, we even see it in corrections. We see people who've been in jail for 20 years and say, you know, I'm going in a different direction. I'm going to do it. So, yeah. I mean, just the power of change is still enormous. And, you know, all of us as -- essentially as practitioners -- you can't forget that. I worked at a tertiary psychiatric hospital, meaning everybody that I saw had failed treatment in primary care and secondary care type of situations. So they were coming to me as the expert. And so they'd hand me the medical chart and, you know, we tried this, we tried this, we tried this, we tried this, you know, and they tried ten different things, all of them seemed reasonable. What do you want to do now, Dr. Clancy? And I went, ugh. You know. But, you know, and we still -- you have to have that "we can do it, we can take it on" attitude. My son did a -- was an intern for the George Kaiser Family Foundation this summer and his research project with the Kaiser Foundation was, what are the defining characteristics of successful public schools in very, very adverse environments, and the defining characteristic was the leadership of the principal, that if the principal created a culture that said, we're going to do this and we're going to take this serious, and we're going to make improvement, that went down to everybody else. It was the culture of, this is important and we're going to do something about it. Then, it's kind of like that mentorship at a bigger social scale.
Question: One last question.
Gerard Clancy: Sure.
Question: In terms of a mentor for the child, is there any information about how long that child [inaudible], three months, three years or how long?
Gerard Clancy: You know, I really don't know. I would just say, you know, obviously they need it early childhood, and then those teenage years. You know. The studies show that who the teenagers hang out with is actually more predictive than the parents' interventions. If your kids are hanging out with good kids, their chances of doing better are going to be great versus if your kids are hanging out with the tough crowd. And that's the curse of being a psychiatrist, that, actually, can kind of diagnose in the waiting room, and, so I know trouble when I see it. And so, I -- [laughter]. So, my son, you know, says, "Hey, look at my new friend." Unh uh. He's not your friend. [Laughter.] Nope, nope, nope. This guy's trouble. You know, and I'm always right. [Laughter.] O.K. anything else. Yes.
Question: Yes, have you ran into any [inaudible] alternative methodologies for [inaudible] things like autism? Like amino acid therapy and fatty acid.
Gerard Clancy: Yeah. I think the jury's out on all of that right now, and we need to be open minded, because autism is such a complex thing, that if we don't know really what's causing it, yet, then we really are in the trial and error mode of trying to treat it. And we shouldn't shut our doors to it, but on the same side, at the same time, you should not believe there's just a panacea out there. There is not a panacea. There is not a silver bullet now for autism, at all. I do know from firsthand experiences, our youngest child was adopted, from Korea. He came to us at five months old. He had a very, very adverse, negative first five months of his life in an orphanage. For the first two years, never said a word. First two years, did not want to be held. I mean, I as a psychiatrist -- this is autism. This is autism. And when we had the neuro-psych evaluation, they said, you know, he's kind of on the spectrum right now. We went full-bore physical therapy, occupational therapy, speech therapy, had him in play groups all the time and if he was developing autism, we steered him in a different direction and he is a -- he's now the spelling bee champion, so he's got language skills, which is good. And, you know, just a wonderful, great sixth grader, and he's doing great. So, I'm a believe that, if that was autism, if that was on the pathway to autism, intervention can help, but it takes that multidisciplinary approach. So, I think, you know, as you're dealing with family members, don't ever let them go down that pathway of one thing that's going to save them. You really have speech, physical therapy, social therapy. You know, if the kid is depressed, if the kid does have ADHD, you've got to have those interventions taken care of, as well. It's just such a complex.
Question: Sounds like that you were kind of like encouraging the ways that the neural pathways develop, [inaudible] another way where they weren't going.
Gerard Clancy: Yeah, and when Blue Cross, Blue Shield of Iowa didn't want to pay for anything, I sent them a stack of papers that much. I said, you're wrong. There is medical evidence of this, and you know what? They surrendered and said, yep, you're right. I was ready to take them to court on it, because they didn't want to pay for physical therapy, they didn't want to pay for speech therapy, they didn't want to pay for anything, because this is autism, because autism should be over on the education side of things, is always the, you know -- and it's a lot more -- yes. It is a learning condition, but is it a medical condition, as well. There's a lot of things going on with autism. Great. Great. Well, it was a pleasure being here.
[Applause.]