EDITORIALS
Getting to the Roots: Early Life Intervention
and Adult Health
Ann Bullock, M.D.
Many adverse life outcomes have been shown to have their
roots in the earliest years of life. Chronic diseases, including
cardiovascular disease, diabetes, depression, and substance
abuse, as well as life skills, such as educational and vocational attainment and the ability to form meaningful relationships, are all made more or less likely depending on the
quality of in utero and early childhood experiences (1).
Given the enormity of these issues in the lives of individuals
as well as the costs to society when they go awry, as they
frequently do, it is imperative that their common early life
roots be understood and that successful interventions be
developed, tested, and widely disseminated with adaptations for populations with different backgrounds and risk
factors.
The evidence is now clear that adverse early life exposures increase disease risk, not only through an increase in
unhealthy behaviors, but also through mechanisms intimately
tied to physiologic regulation and brain development (2).
Landmark research such as the Adverse Childhood Experiences Study and the Dunedin Multidisciplinary Health and
Development Study have shown that childhood abuse and
neglect are associated with increased risk in adulthood for
conditions as diverse as cardiovascular disease, obesity, depression, substance abuse, and smoking (3, 4). These and other
studies have shown that childhood poverty, maternal stress
during pregnancy, poor maternal-child attachment, and inadequate access to quality nutrition in the in utero and early
childhood periods all convey increased risk for later disease
(1, 5, 6). Scientific advances are elucidating the physiological,
developmental, and epigenetic programming of early life experiences and the mechanisms by which they contribute to
adult conditions decades later (6, 7).
Given the strong science linking early life exposures and
adverse adult outcomes, attention has been turning to developing and studying interventions that may prevent or at
least reduce early life adversities. Because of the long lag
time between early life exposures and adverse adult outcomes, it is necessary to look at interventions that were done
long enough ago to determine whether a reduction in disease
parameters is occurring as well as to look at studies with
shorter-term follow-up to see if there are reductions in
important risk markers for later disease development.
Two randomized controlled intervention studies with longterm participant follow-up are the Nurse-Family Partnership
and the Carolina Abecedarian Project, both of which have
now followed participants for several decades. The NurseFamily Partnership, a home-visiting intervention that matches
trained nurses with first-time mothers beginning in pregnancy and continuing until the child’s second birthday, has
demonstrated significant effects on a number of health,
psychosocial, and educational risk factors (8). The Carolina Abecedarian Project, which provided an intensive
early learning program and enhanced nutrition from birth
to age 5, has shown significant reductions in cardiovascular
disease and metabolic risk markers in participants into
their mid-30s (9). An intervention study with 8-year followup involved a 7-week psychosocial intervention pro- With evidence such as this,
vided to rural low-income the discussion about early
African American mothers life intervention is starting
and their 11-year-old chil- to evolve from “Does it
dren. Compared with con- work?” to “What works and
trol children, the children for whom?”
in the intervention group
had significantly lower results for all six inflammatory markers
tested when the children reached age 19 (10).
With evidence such as this, the discussion about early life
intervention is starting to evolve from “Does it work?” to “What
works and for whom?” To produce the most benefits for the
most people, it is crucial to determine what types of interventions work best in different high-risk populations, especially those with unique cultural, linguistic, and historical
experiences. It is in this context that the article by Barlow et al.
in this issue (11) makes a major contribution to the science of
early life intervention. The Family Spirit home-visiting intervention was developed in partnership with community
members from the four southwestern tribal reservation communities where the randomized controlled trial was conducted. As the communities placed a high value on home
visitors who spoke their tribal languages and understood the
life experiences of their more vulnerable members, the Family
Spirit intervention was delivered by paraprofessional home
This editorial is featured in this month’s AJP Audio
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EDITORIALS
visitors recruited from those communities. High-risk pregnant (N5322) American Indian teens were randomly assigned to the Family Spirit home-visiting intervention
plus optimized standard care (transportation to prenatal
and well-baby visits, pamphlets on child care and community
resources, and referrals when needed) or to optimized standard
care alone. The intervention consisted of home visits beginning
in pregnancy and continuing through 36 months postpartum with delivery of a standardized curriculum focusing on
parenting skills, maternal drug abuse prevention, maternal
life skills, and positive psychosocial development. Child
outcomes at age 3 years showed significant reductions in
internalizing, externalizing, and dysregulation problems.
As discussed in the article, these types of behaviors are
risk factors for later substance use and obesity—two of
the most pressing health issues in indigenous communities (12).
The evidence for early life intervention is so convincing that
government and private organizations are now committing
funds and promoting evidence-based programs. The Affordable Care Act authorized $1.5 billion over 5 years for the Maternal, Infant, and Early Childhood Home Visiting Program.
Funding for the program primarily went to states for provision
of evidence-based home-visiting programs with 3% set aside
for tribal organizations (13). The Indian Health Service is the
federal agency responsible for providing health services to
American Indian and Alaska Native people. It is increasing
its early life intervention programs, implementing Family
Spirit with American Indian and Alaska Native community
health workers as home visitors, getting all of its obstetric
hospitals certified through the Baby-Friendly Hospital Initiative, and promoting improved nutrition through the First
Lady’s Let’s Move! in Indian Country program. Nongovernmental organizations, including the Robert Wood Johnson
Foundation (14) and the American Academy of Pediatrics (15),
have announced major initiatives related to early life risk and
intervention.
While much is yet to be learned, there are some common
themes emerging in research on in utero and early childhood
interventions: access to sufficient quality and quantity of nutritious foods, amelioration of the effects of poverty and stress,
the importance for children of nurturing relationships with
parents and other caregivers, healthy development and learning, safe neighborhoods, and intensive early life programs tailored to and in partnership with the communities where they
are implemented (1, 5, 11, 16). Estimates of the economic impact
of early life interventions over the lifespan show excellent
returns on investment (17). However, as those cost savings are
spread across different parts of municipal budgets, it will require long-term vision to shift resources to programs for pregnant women and young children.
The further into the lifespan we wait to intervene, the
lower the magnitude of success that can be attained across
the multiple domains of health, cognition, and life skills—and
at much higher costs (18). It is time to simultaneously
ramp up both implementation and evaluation of early life
Am J Psychiatry 172:2, February 2015
interventions (19). Learning from important work such as
Family Spirit will enable society to get to the roots of many
problems across the lifespan, reduce disparities, and realize
the potential of future generations.
AUTHOR AND ARTICLE INFORMATION
From the Division of Diabetes Treatment and Prevention, Indian Health
Service, Rockville, Md.
Address correspondence to Dr. Bullock ([email protected]).
The opinions expressed in this editorial are those of the author and do
not necessarily represent the official position of the Indian Health
Service.
Dr. Bullock reports no financial relationships with commercial interests.
Accepted November 2014.
Am J Psychiatry 2015; 172:108–110; doi: 10.1176/appi.ajp.2014.14111394
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