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Factors Influencing Child Development Neelkamal Soares, MD, FAAP Developmental-Behavioral Pediatrics Kentucky Children’s Hospital Factors Influencing Child Development Neelkamal Soares, MD, FAAP Developmental-Behavioral Pediatrics Kentucky Children’s Hospital

Nature vs. Nurture Centuries old debate (350 BC- 21 st century) Plato believed that Nature vs. Nurture Centuries old debate (350 BC- 21 st century) Plato believed that humans born with knowledge environment merely reminded of information known Aristotle argued that humans were not born with knowledge, but they acquire it through experience “Tabula rasa” further propounded by Empiricists (Locke, Bacon) vs. Internalists (Leibniz) 17 th- 18 th C Twin studies in the 1950 s-60 s began to show importance of both aspects Further advances in genetics, neurobiology and child development fields confirms that polarization artificial

Nature Nurture “Interactionist” theory combines both points of view, with hypothesis of interaction (Elman Nature Nurture “Interactionist” theory combines both points of view, with hypothesis of interaction (Elman 1996) However, debate regarding which component has preeminent influence on development continues “It is time to reconceptualize nature and nurture in a way that emphasizes their inseparability and complementarity, not their distinctiveness: it is not Nature versus Nurture, it is rather NATURE via NURTURE From Neurons to Neighborhoods, 2000

Heredity & Environment Interaction in Real Ways Ge et al, 1996 Heredity & Environment Interaction in Real Ways Ge et al, 1996

Developmental Streams • • • Gross motor Fine motor Language Adaptive Cognitive Social-emotional Developmental Streams • • • Gross motor Fine motor Language Adaptive Cognitive Social-emotional

Factors Influencing Development v Innate Ø Genetic endowment Ø Prenatal environment Ø Temperament v Factors Influencing Development v Innate Ø Genetic endowment Ø Prenatal environment Ø Temperament v Environment Ø Nutrition Ø Housing Ø Medical care Ø Basic safety Ø Education Ø Family support

Genetic Endowment v. Much improvement in field thanks to molecular genetics, decoding the genome Genetic Endowment v. Much improvement in field thanks to molecular genetics, decoding the genome and mapping certain behaviors and developmental traits to certain genes v. Helps to validate theoretical constructs for developmental psychologists v. Attempts to match genetics to neurobiology (all development & behavior originates in the brain!)

Genetic Endowment v Evidence of genetic influence for personality traits, intelligence, and disorders Ø Genetic Endowment v Evidence of genetic influence for personality traits, intelligence, and disorders Ø DRD 4 dopamine receptor gene linked to noveltyseeking, such as drug abuse and AD/HD Ø 5 -HTTLPR serotonin transporter gene linked to neuroticism and harm avoidance. v http: //www. apa. org/science/genetics/ APA Online genetics in psychology with links, resources & research opportunities

Genetic Influence v Hereditary influences are polygenic and multifactorial, with multiple genes coacting with Genetic Influence v Hereditary influences are polygenic and multifactorial, with multiple genes coacting with environment v Genetic bases for developmental disorders reflect, in most cases, extreme variations on a continuum that includes normal variants v Genetic effects increase likelihood that certain characteristics will occur, but do not directly cause them {probabilistic , not predetermined} (Plomin & Rutter, 1998). From Neurons to Neighborhoods, 2000

Prenatal Environments v Brain development begins within a week of conception. By the time Prenatal Environments v Brain development begins within a week of conception. By the time a baby is born, about 100 billion neurons or brain cells have been produced, migrated to their final destinations and begin synaptic connections v While structurally formed during the prenatal period, the brain is not completely developed at birth. Much of the connecting strengthening of those connections takes place after birth; influenced by the newborn's experiences with child-care providers and with the environment. Brain Wonders, www. zerotothree. org

Brain Development • Maximal neuronal density in 25 -28 th week of gestation • Brain Development • Maximal neuronal density in 25 -28 th week of gestation • Neurons begin death soon after birth • Synaptic connections begin 3 rd trimester, increase first 2 years • Pruning and refining of synapses after puberty till adulthood

Brain Development v Development does not progress uniformly in every area of the brain. Brain Development v Development does not progress uniformly in every area of the brain. At any time, some areas are undergoing cellular proliferation while others are undergoing primarily differentiation. v Timing important when considering potential effects of exposure to environmental agent that disrupts specific developmental processes. v Neurotransmitters, hormones, neurotrophins, and growth factors orchestrate the intricate process of brain development. v Cognitive functions (attention, memory, language skills) and behavior arise from multiple sources and depend on more than one neurotransmitter and more than one portion of the brain. www. preventingharm. org

Prenatal Influences v Maternal Environment Ø Maternal Hormones: thyroid Ø Maternal Health conditions (diabetes) Prenatal Influences v Maternal Environment Ø Maternal Hormones: thyroid Ø Maternal Health conditions (diabetes) Ø Maternal nutrition: folic acid Ø Maternal infections: STDs (syphilis etc) v Toxic Influences Ø Medications: teratogens Ø Illicit Drugs: opiates, cocaine, smoking Ø ALCOHOL Ø Environmental toxins: e. g. . Mercury from fish; PCBs, Aspartame Ø Radiation: Xrays

Toxins & Teratogens Environment through Nature! • Teratogenesis interferes with embryonic development by biological, Toxins & Teratogens Environment through Nature! • Teratogenesis interferes with embryonic development by biological, chemical, or physical agent. • Teratogens produce malformations of the unborn child without damage to the mother or killing the unborn child. • These malformations are not hereditary. • Timing and dose is critical in teratogenesis: “vulnerable period” and “threshold dose” of different organ systems cause different patterns of malformations

Toxins & Teratogens Environment through Nature! • • ACE inhibitors Zestril Acne med Accutane Toxins & Teratogens Environment through Nature! • • ACE inhibitors Zestril Acne med Accutane Antibiotics doxycycline Blood-thinner Coumadin. Seizure meds Dilatin, Anticancer drugs DES hormone. Antiemetic Thalidomide

Examples of Toxic Influences From Neurons to Neighborhoods, 2000 Examples of Toxic Influences From Neurons to Neighborhoods, 2000

Sequelae of Prenatal Influences Sequelae of Prenatal Influences

Temperament v Individual differences in emotion, motor reactivity and self-regulation that demonstrate consistency across Temperament v Individual differences in emotion, motor reactivity and self-regulation that demonstrate consistency across situations & time v Biologically based: Heredity, neural, and hormonal factors affect response to the environment. v It can be modulated by environmental factors such as parental response. v Thomas and Chess’ Temperament Types Ø Easy babies: 40% of infants; adjust easily to new situations, quickly establish routines, generally cheerful and easy to calm. Ø Difficult babies: 10% of infants; slow to adjust to new experiences, likely to react negatively and intensely to stimuli and events. Ø Slow-to-warm-up babies: 15% of infants; somewhat difficult at first but become easier over time.

Temperament &Social Adjustment v “Goodness of fit”: the degree to which individual’s temperament is Temperament &Social Adjustment v “Goodness of fit”: the degree to which individual’s temperament is compatible with demands and expectations of social environment v Parents can modulate children’s temperament by their influences on the environment. v Dynamic is one of mutual influences and bidirectional effects v Probably account for different children in same environment with different personalities

Environment Influences Environment Influences

The Microenvironment. La Familia v Ecological model views family as a “system” where there The Microenvironment. La Familia v Ecological model views family as a “system” where there is a dynamic interplay between members; and between family and social environment. v Family Factors influencing child development: Ø Child Rearing/Parenting Styles Ø Cultural factors Ø Socioeconomic factors Ø Transgenerational effects

Birth Order? v Believed to influence child development v Sir Francis Galton’s English Men Birth Order? v Believed to influence child development v Sir Francis Galton’s English Men of Science found more firstborn sons in prominent positions than attributed to chance. v Adler’s Birth Order Theory Ø First-born: authoritarian, competitive Ø Middle-born: Is "sandwiched" in. May feel squeezed out of a position of privilege and significance Ø Youngest: Tends to be the “baby” of the family; spoiled; less of an achiever Ø Only child: Has never been “dethroned” so tends to have high ego; tends to be neither spoiled nor especially high-achiever.

New Research in Birth Order • No empirical evidence for this, but it may New Research in Birth Order • No empirical evidence for this, but it may be factor for sibling relationships. • Not correlated with cognitive development, personality traits or adult outcomes • Recent study indicates that social order in family, not birth order per se is correlated with IQ scores Science June 2007 Vol 316

Parenting Styles v Diana Baumrind’s concept of parenting style has influenced greatly this line Parenting Styles v Diana Baumrind’s concept of parenting style has influenced greatly this line of thinking. It is meant to describe normal variants not deviant styles (abusive or neglectful styles) v Parenting is a complex activity that includes many specific behaviors that work individually and together to influence child outcomes. v Specific parenting practices (discipline, reading aloud etc) are less important in predicting child well-being than is the broad pattern of parenting. Nancy Darling, Ph. D, MS

Parenting Styles Parenting style captures 2 elements Ø Parental responsiveness /supportiveness Parenting Styles Parenting style captures 2 elements Ø Parental responsiveness /supportiveness "the extent to which parents intentionally foster individuality, self-regulation, and selfassertion by being attuned, supportive, and acquiescent to children’s special needs/ demands" Ø Parental demandingness (behavioral control) "the claims parents make on children to become integrated into the family whole, by their maturity demands, supervision, disciplinary efforts and willingness to confront the child who disobeys" Baumrind, D 1991

Parenting styles Emotionality Control Warm, responsive Restrictive, demanding Permissive, not demanding Rejecting, unresponsive Authoritative Parenting styles Emotionality Control Warm, responsive Restrictive, demanding Permissive, not demanding Rejecting, unresponsive Authoritative Authoritarian Permissive Maccoby & Martin, 1983 Uninvolved

Parenting Styles. Consequences for Children v Children of authoritative parents are more socially and Parenting Styles. Consequences for Children v Children of authoritative parents are more socially and instrumentally competent v Children and adolescents whose parents are uninvolved perform most poorly in all domains. v Children from authoritarian families tend to perform moderately well in school, uninvolved in problem behavior, but have poorer social skills, lower self-esteem, and higher levels of depression. v Children from indulgent homes are more likely to be involved in problem behavior and perform less well in school, but they have higher self-esteem, better social skills, and lower levels of depression. Weiss & Schwarz, 1996

Bonding & Attachment v Bonding involves a set of behaviors that will help lead Bonding & Attachment v Bonding involves a set of behaviors that will help lead to emotional connection (attachment). Based on work of Bowlby and Ainsworth v Capacity to form attachments is genetically determined. It is in context of primary dependence of infant, and maternal response to this dependence, that attachment develops which is crucial for survival. v Scientists believe the most important factor in creating attachment is positive physical contact creating predictable experiences for infant v Window of opportunity is far wider than previously thought, so early missed experiences (e. g. neglect) don’t necessarily have poor outcomes and attachment can be restored

Attachment Categories Ainsworth, M Attachment Categories Ainsworth, M

Attachment and Developmental outcomes v Attachment theory has been found to be predictive of Attachment and Developmental outcomes v Attachment theory has been found to be predictive of later social competence and adjustment. v Secure children are more autonomous, less dependent, more able to regulate their own negative emotions, less likely to have behavior problems, and more able to form close, warm relationships with peers (Lamb, 1987; Lieberman, 1977; Rothbaum 2000) v In contrast, a greater proportion of insecure children have behavioral problems, difficulties interacting with peers and poor problem-solving capacity and low self-esteem (Field, 1987) WHO Dept. Child Adol Health & Dev 2004

Family Characteristics • • • Marital status Family size Parents’ education Financial situation Strength Family Characteristics • • • Marital status Family size Parents’ education Financial situation Strength of parents’ relationship Parents’ mental health

Impact of Stress v Numerous studies have shown that marital conflict is more likely Impact of Stress v Numerous studies have shown that marital conflict is more likely than any other family variable to have adverse effects on children v Such discord is likely to precede separation and divorce, stressful times for all family members. v Furthermore, the stress of parental separation and divorce often leaves children in the greatest need of emotional support when their parents are least capable of providing it.

Indicators of Family Socioeconomic factors v. Parental work/occupational status v. Family income v. Parental Indicators of Family Socioeconomic factors v. Parental work/occupational status v. Family income v. Parental education v. Family structure

Socioeconomic factors v Families who occupy different socioeconomic niches because of parental education, income, Socioeconomic factors v Families who occupy different socioeconomic niches because of parental education, income, and occupation have strikingly different capacities to purchase safe housing, nutritious meals, highquality child care, and other opportunities that can foster health, learning, and adaptation (Becker, 1981; Brooks-Gunn et al. , 1995). v The psychological well-being of mothers and associated patterns of parenting are also much more likely to suffer in families with limited resources (Brooks-Gunn & Duncan, 1997). From Neurons to Neighborhoods, 2000

Caregiver employment and its impact v Increases in paid maternal employment over the past Caregiver employment and its impact v Increases in paid maternal employment over the past quarter-century (see right) v Parental employment often, but not always, entails supplementing parental care with substantial amounts of care by others. Thus, with increase in cash income of families, work-related expenses may increase not necessarily greater resources overall. From Neurons to Neighborhoods, 2000

Caregiver employment and its impact v Most children are positively affected or unaffected by Caregiver employment and its impact v Most children are positively affected or unaffected by maternal employment, except if it occurs in the child's first year, and mothers work long hours (Waldfogel et al, 2000) v Low-income children are not hurt and may benefit from maternal employment, particularly with cognitive outcomes (Hoffman, 1999) v Limited evidence suggests that infants and toddlers fare better in working-poor families than in poor families in which the parents do not work or work minimally (NICHD, 1999) v In sum, trends in parental employment can bode well or ill for young children depending on features of the work, the income it generates, the nature and structure of the job, its timing and total hours; and on the environments and relationships that children experience when they are not in the care of their parents. From Neurons to Neighborhoods, 2000

Poverty & Child Development v Consistent associations between economic hardship and compromised child development. Poverty & Child Development v Consistent associations between economic hardship and compromised child development. v Poverty measurement: family income between $ 16 K 20 K for 3 -4 member (2 -child) household v The official poverty rate in 2006 was 12. 3% (36. 5 mil people); Children < 18 form 17. 4% (12. 8 mil) v On average, family incomes increase as children age, but a great deal of year-to-year volatility v Welfare reform studies suggest that, in the absence of positive effects on young children 's home environments, parental mental health, and parenting, increases in family income and reductions in poverty are not in and of themselves sufficient to benefit young children. US Census Bureau

Poverty & Child Development v Family income may exert its most powerful influence on Poverty & Child Development v Family income may exert its most powerful influence on children during the earliest years of life (Duncan, 1998) v Household's long-term economic status has a much greater association with achievement and behavior problems than do single-year income measures (Blau, 1999).

Parental Education • Large, positive associations between parental schooling levels and children's achievement and Parental Education • Large, positive associations between parental schooling levels and children's achievement and behavior are among the most substantial and replicated results from developmental studies • Parental education levels are strongly associated with the home literacy environment, parental teaching styles, and investments in a variety of resources that promote learning (e. g. , high-quality child care, educational materials, visits to libraries and museums) (Bradley et al. , 1989) • However, no clear evidence from studies regarding the role of increasing parental education in promoting the well-being of children. From Neurons to Neighborhoods, 2000

Parental Mental Health & Child Development v. Bidirectional influence: ØChildren with developmental and behavioral Parental Mental Health & Child Development v. Bidirectional influence: ØChildren with developmental and behavioral problems cause greater emotional distress to families ØFamilies with emotional problems tend to have greater difficulties with parenting and are associated with greater behavioral issues in children

Family Structure v On average, children raised by single parents have lower levels of Family Structure v On average, children raised by single parents have lower levels of social and academic wellbeing than do children from intact marriages (Cherlin, 1999) v However, these outcomes derive largely from the socioeconomic realities of single parenthood Ø lower income Ø less parental time rather than from any direct effects of living only with one parent From Neurons to Neighborhoods, 2000

Cultural factors v Child development research had incorporated a cross -cultural perspective by middle Cultural factors v Child development research had incorporated a cross -cultural perspective by middle of 20 th century v Yet, much research and most definitions have focused on the intergenerational transmission of symbolic (ideas, beliefs, and values) and behavioral (rituals and practices) inheritances (Shweder, 1998). v In early childhood development: Ø Symbolic= parents' expectations, goals, aspirations for their children; values that govern approaches to discipline; gender roles; religious or spiritual values Ø Behavioral= embodied in the “scripts” that characterize everyday routines such as sleeping, feeding, and playing, and influence the acquisition of specific skills or behaviors. From Neurons to Neighborhoods, 2000

Cultural factors with respect to sleeping routines v In the United States, where autonomy Cultural factors with respect to sleeping routines v In the United States, where autonomy and independence are highly valued traits, most children sleep alone in a separate room away from their parents (Abbott, 1992; Lozoff, 1984) v In most of Asia, Africa, and Latin America, where interdependence and solidarity are preferred, children routinely sleep with one or more of their parents or siblings, even when separate rooms are available (Caudill & Plath, 1966; Shweder, 1995). v This pattern was also in highly industrialized societies such as Japan, where children typically sleep with their parents until age 5 or 6 years (Caudill & Plath, 1966). From Neurons to Neighborhoods, 2000

Transgenerational Factors v Relationship influences within the family may be directly handed down as Transgenerational Factors v Relationship influences within the family may be directly handed down as original to the family of origin or they may be indirectly received through those nuclear family members. v Direct influence also occurs between the developing child and the extended family, e. g. grandparents assisting in childcare, joint families v Related to discipline particularly, transgenerational influence seen in parenting behavior. v Transgenerational passage of myths, beliefs also mold child development

The Family’s Mesoenvironment v. Extended family support v. Child care v. Social support network The Family’s Mesoenvironment v. Extended family support v. Child care v. Social support network

Growing up in Childcare v Second only to the immediate family, child care is Growing up in Childcare v Second only to the immediate family, child care is the context in which early development unfolds. v Parents/ relatives continue to provide most early child care v Rapid growth in paid care by non-relatives in center-based settings and expansion in public subsidies for child care. v Beneficial outcomes with settings that provide nurturance and support for early learning and language development. v Child care provides a number of services Ø nurturance and learning opportunities for children Ø preparation for school Ø support for working parents Ø respite care in child welfare cases; and Ø access to supplemental services (vision/hearing screening, developmental testing, feeding programs) From Neurons to Neighborhoods, 2000

US Census Bureau, 2005 pub US Census Bureau, 2005 pub

Child Care situations Capizzano et al, 2000 Child Care situations Capizzano et al, 2000

Childcare & Development v Effects of child care on mother-infant relationship is neutral, with Childcare & Development v Effects of child care on mother-infant relationship is neutral, with exception of very early, extensive exposure to care of dubious quality. v When child care effects are examined net of parental effects on child outcomes, parent's behaviors and beliefs show substantially larger associations with their children's development than do any child care arrangement. v When child care is found to be associated with the mother-child relationship, the link is as likely to be positive as negative. v Clarify when child care protects children from familybased risk (such as poverty, maternal depression, high levels of conflict), when it compounds risk, and when it poses risks to children who otherwise are growing up in supportive home environments. From Neurons to Neighborhoods, 2000

Childcare & Development v Positive relation between child care quality and child development is Childcare & Development v Positive relation between child care quality and child development is one of the most consistent findings in developmental science. v High-quality care is associated with positive outcomes in compliance with adults, peer relations, and early academic competence. v Critical to sustaining high-quality child care Ø Providers' education Ø Providers’ specialized training, Ø Features of child care that enable them to excel in their work and remain in their jobs, notably small ratios, small groups, and adequate compensation. From Neurons to Neighborhoods, 2000

Childcare & Behavior • The more time spent in child care from birth-4 ½ Childcare & Behavior • The more time spent in child care from birth-4 ½ years, children rated as more assertive, disobedient, and aggressive • However, levels of the behaviors reported were within the normal range. • This link was greater for children in center-based care than other types and occur across all family backgrounds and all types and quality of care. • The researchers also found evidence that children who experienced better quality child care had fewer behavioral problems than those in lesser quality care NICHD Study of Early Child Care & Youth Development 2003

Neighborhood & Community v One striking result in broad-based studies of neighborhood effects on Neighborhood & Community v One striking result in broad-based studies of neighborhood effects on young children is that there are many more differences in families and children within neighborhoods than between them. v Most studies of neighborhood influence are done in “high risk” neighborhoods, with few in affluent areas. v Neighborhood violence may also have indirect effects on development, if mothers in physically dangerous neighborhoods restrict their children's interactions with peers and adults (Lipsey and Wilson, 1993). v Among physiological hazards, lead poisoning continues to pose a threat to the healthy development, disproportionately to low-income children in inner cities. From Neurons to Neighborhoods, 2000

Social Support of Family • Has direct effect on parents’ wellbeing across a number Social Support of Family • Has direct effect on parents’ wellbeing across a number of important domains that facilitate children’s development • Buffers parents during periods of stress

Nutrition v. Pre & postnatal nutritional adequacy important for optimal brain development and function Nutrition v. Pre & postnatal nutritional adequacy important for optimal brain development and function (Georgieff & Rao, 1999) v. Timing of supplementation/deficiency is important. Ø deprivation in 2 nd trimester = fewer neurons, Ø deprivation in 3 rd trimester = fewer glial cells and maturation of neurons v Postnatally, first 3 years of life is especially vulnerable time for brain growth. The earlier it occurs and the longer malnutrition continues, the greater the effect on the brain (Morgan & Winick, 1985). v. However young children can show remarkable recovery in growth and behavior even after gross early (postnatal) malnutrition when fed adequately.

Complexities v Link between nutrition and behavior is much more complex than either of Complexities v Link between nutrition and behavior is much more complex than either of these two hypotheses suggests v Plasticity of the brain allows for adaptation to environmental influences v Effect on development can be sustained by: v. Absolute reduction in the number of neurons, neuronal size v. Physiologic changes that accompany undernutrition negatively affect their behavioral repertoires may contribute to altered cognitive development and performance

Failure to Thrive v FTT defined in terms of body weight < 3 rd Failure to Thrive v FTT defined in terms of body weight < 3 rd %tile for age v More common among low-income children v More common in children at high biological risk Ø Low birth weight Ø Small for gestational age Ø Substance-exposed Ø Developmental delays Ø Special health care needs

Nutrition & Development v. In both developing countries and in the United States, relationship Nutrition & Development v. In both developing countries and in the United States, relationship between FTT and lowered IQ and/or poor academic achievement. v. These associations have been found in a variety of countries, including the Philippines, Jamaica, Guatemala, Nepal, India and Malaysia. v. Studies show that stunting in early life has lasting effects until at least age 8 or 9 and up to 15 years on IQ scores and school performance Bryan, J et al 2004

Malnutrition: Beyond the “vulnerable” period v Deficiencies of key micronutrients, both independently and in Malnutrition: Beyond the “vulnerable” period v Deficiencies of key micronutrients, both independently and in combination, affect cognitive development of children after infancy. v Particular the frontal lobes, responsible for executive functions continue to develop during childhood, v Nutrients such as iron and omega-3 may have specific effects on frontal lobe functioning. Bryan, J et al 2004

“Micronutrients” and Cognitive Development v While malnutrition implies protein or calorie or both, more “Micronutrients” and Cognitive Development v While malnutrition implies protein or calorie or both, more emphasis recently on “micronutrients”: vitamins, minerals and supplements Ø Iodine Ø Iron Ø Zinc Ø Vitamin B 12 v Micronutrient effect hypothesized as a direct effect changes in neuroanatomy/neurotransmission v However, possible that behavior changes seen with micronutrient deficiencies alter caregiving the child receives, compromising child’s development even further. Black, MM 2003

Iodine & Development v Iodine deficiency is most preventable cause of mental retardation in Iodine & Development v Iodine deficiency is most preventable cause of mental retardation in the world, mainly affects children in mountain regions & flood plains v Public health methods (iodized salt, oral iodine) have been effective in preventing congenital hypothyroidism and associated MR v When deficiency occurs in utero, causes fetal hypothyroidism and irreversible neurological and cognitive deficits. v Supplementation before conception or early in pregnancy have better developmental outcomes than those whose mothers are not supplemented Black, MM 2003

Iodine & Development v When iodine deficiency occurs postnatally, the child may experience hypothyroidism. Iodine & Development v When iodine deficiency occurs postnatally, the child may experience hypothyroidism. v Some observational studies have reported cognitive deficits among these children and others have not. v In a well-controlled observational study in Bangladesh, investigators found that children with mild hypothyroidism had deficits in spelling and reading compared to healthy controls v Confounding factor is poverty in regions where higher prevalence of iodine deficiency occurs Black, MM 2003

Iron Deficiency v Iron deficiency is commonest single nutrient disorder, ~ 20 -25 % Iron Deficiency v Iron deficiency is commonest single nutrient disorder, ~ 20 -25 % of babies worldwide (WHO, 1994). v In US, prevalence has decreased dramatically (Looker, 1997), due to fortification of infant formula, cereal and increased breast-feeding. However, poor and minority children are still at risk for iron deficiency with or without anemia (Ogden, 1998). v Non-poor white toddlers lowest prevalence ~ 3% while Mexican-American toddlers highest risk ~ 18% (Ogden, 1998). v Iron-deficient anemic infants generally test lower in mental and motor development (Nokes, 1998). Other behavioral differences, such as increased fearfulness, fatigue, and wariness, have also been noted (Honig & Oski, 1984; Lozoff, 1998; Walter et al. , 1989).

Zinc v Role suggested because it is an essential component of more than 200 Zinc v Role suggested because it is an essential component of more than 200 enzymes v Evidence linking zinc supplementation to early cognitive/motor development is inconclusive. v Suggestions that zinc supplementation may promote activity and perhaps motor development in the most vulnerable infants Black, M 2003

Lead v Most studies concur that an IQ decline of 1 -5 points is Lead v Most studies concur that an IQ decline of 1 -5 points is associated with a 10µg/d. L increase in blood lead v Many studies have identified distractibility, poor organizational skills, and hyperactivity as possible reasons for reduced global cognitive function of more highly exposed children. v History of childhood lead poisoning was strongest predictor of adult criminality among males in the Philadelphia subsample of the Collaborative Perinatal Project. Bellinger, DC 2004

Lead v Young children normally explore environment via hand-to-mouth activity, that increase lead intake Lead v Young children normally explore environment via hand-to-mouth activity, that increase lead intake especially around leaded paint in poor repair or elevated lead in house dust v Children with nutritional deficiencies of iron, calcium are at greater risk v In the child’s developing nervous system, cognitive effects do not reverse with removal of lead v In the 3 rd NAHNES sample, current blood lead was inversely associated with cognitive function, even when blood lead levels < 5 µg/d. L • Fortunately, children’s current mean blood lead level barely 2 µ g/d. L, but still in problem in vulnerable populations Bellinger, DC 2004

Housing A child’s ability to thrive can be greatly enhanced by stable and familiar Housing A child’s ability to thrive can be greatly enhanced by stable and familiar surroundings Factors influencing housing: Ø Inadequate housing Ø Absence (homelessness) Ø Geographic moves Ø Multiple homes

Inadequate Housing v Inadequate housing often poses health risks Ø Respiratory illnesses: asthma, Ø Inadequate Housing v Inadequate housing often poses health risks Ø Respiratory illnesses: asthma, Ø lead poisoning, Ø mold allergies, and Ø injuries from unsafe conditions. v These are particularly problematic in substandard or overcrowded housing, which is often the only option for families at the lowest income levels. v When families live in neighborhoods of concentrated poverty, greater risk of involvement in criminal behavior, and drug use. This is due in part to lack of role models and stabilizing influences.

Homelessness v. An extreme manifestation of poverty v. Homeless children Øhave twice as many Homelessness v. An extreme manifestation of poverty v. Homeless children Øhave twice as many health problems Øare more likely to go hungry Øhave higher rates of developmental delay, lower academic achievement Øhave higher rates of depression, anxiety, and behavior problems

Geographic Moves v A move can increase the likelihood that the child does not Geographic Moves v A move can increase the likelihood that the child does not have a specific site for health care v Frequent changes in neighborhood place the child at risk for problems with Ø Academics Ø Behavior Ø Emotions Ø Health

Basic Safety v Particularly important in young children who are exploring environment and have Basic Safety v Particularly important in young children who are exploring environment and have limited concept of safety and causality v More significant for developmentally delayed children and those with communication and impulse control disorders v Areas of safety: Ø Home Ø Surroundings: neighborhood, school Ø Personal: vehicular, recreation

Home Safety v Housing (as above) v Installed devices enhance child’s ability to explore Home Safety v Housing (as above) v Installed devices enhance child’s ability to explore the environment in a safe manner. Ø smoke and CO detectors Ø window, door and stair guards; door locks Ø safe storage of firearms and ammunition Ø water and pool safeguards No Substitute for Adult supervision!

Personal Safety v Vehicular Ø Seat belts, booster seats v Recreation Ø Helmets, extremity Personal Safety v Vehicular Ø Seat belts, booster seats v Recreation Ø Helmets, extremity guards Ø ATV and bicycle safety Ø Sports safety Greatest risk to cognitive and motor development is injury particularly closed brain injury • KY has mandatory seat-belt, child car restraint, and helmet laws; but booster seat bill in Senate Call state senators, ask them to vote HB 53

Medical Problems & Development v. Acute Medical Illnesses v. Hospitalization and surgery v. Chronic Medical Problems & Development v. Acute Medical Illnesses v. Hospitalization and surgery v. Chronic Medical conditions v. Trauma: accidental & non-accidental v. Medications

Acute Minor Illness v. Every illness, no matter how “minor” is a stressor for Acute Minor Illness v. Every illness, no matter how “minor” is a stressor for a child v. However, minor illness and its management account for only a small portion of chronic behavioral variations and problems in children v. Possible some developmental regression in sleep, toileting, autonomy for short while v. Unlikely to have motor or significant language regression, as a result of illness

Chronic Illness v Usually defined as illness that lasts > 3 months and impacts Chronic Illness v Usually defined as illness that lasts > 3 months and impacts functioning with medical interventions excessive that what is usually appropriate for a child that age. v About 5% (3. 3 mil) children affected by a chronic disease in the US v Effects depend on Ø Characteristics of children Ø Characteristics of conditions Ø Characteristics of families Perrin, E Handbook DB Peds 1995

Characteristics of the Child v. Age of onset v. Personality/temperament v. Intelligence v. Self-concept Characteristics of the Child v. Age of onset v. Personality/temperament v. Intelligence v. Self-concept v. Developmental level

Characteristics of Condition v. Stable or unpredictable v. Prognosis v. Interference with mobility v. Characteristics of Condition v. Stable or unpredictable v. Prognosis v. Interference with mobility v. Interference with normal activities v. Visibility v. Academic effects

Characteristics of Families v. Family structure and extended support v. Parent reaction to diagnosis Characteristics of Families v. Family structure and extended support v. Parent reaction to diagnosis and adaptation to chronic implications v. Family’s ability to deal with conflict and stress v. Sibling involvement

Prematurity: A risk factor for development v Advances in technology & neonatology has increased Prematurity: A risk factor for development v Advances in technology & neonatology has increased survival of extremely low birth weight infants, but with increased survival comes greater “morbidity”: disability esp. later in childhood v Survival and morbidity are inversely proportional to gestational age v Recent research with toddlers suggests that even low-risk preterm infants cannot be assumed to have caught up with their full-term counterparts in all aspects of cognitive development (de Haan et al. , 2000). From Neurons to Neighborhoods, 2000

The Good & The Bad of greater survival The Good & The Bad of greater survival

Prematurity risks for development v Premature birth predisposes the infant to pathological events that Prematurity risks for development v Premature birth predisposes the infant to pathological events that directly injure brain. v Premature birth interrupts the normal process of intrauterine brain development by denying it expected intrauterine stimuli and factors important for growth Ultimately, the morbidity seen at any gestational age is the result of the combination of the number and severity of exposure to both types of influence.

Neurodevelopmental outcome of extreme LBW v National Cohort of Extremely Low Birth Weight Infants Neurodevelopmental outcome of extreme LBW v National Cohort of Extremely Low Birth Weight Infants (birth weight <1000 g) assessed with neurocognitive tests (WPPSI-R and a Developmental Neuropsychological Assessment [NEPSY]). v Rates of disabilities included: Ø cognitive impairment 9%. Ø cerebral palsy 14% Ø hearing loss 4% Ø eye problems 30% Ø Total of 20% exhibited major disabilities, and 19% minor disabilities. v Only 26% of the total ELBW infant cohort were classified to have normal outcome. Mikkola et al 2005

Neurodevelopmental outcomes of extreme LBW v Cognition Ø Studies reveal a 0. 3 - Neurodevelopmental outcomes of extreme LBW v Cognition Ø Studies reveal a 0. 3 - 0. 6 SD = 3. 8 -9. 8 -point IQ in those born prematurely. Ø Higher percentages of borderline IQ have been reported in the ELBW population, from 13 -15%, Ø VLBW children who demonstrated suspect IQ findings at age 3 years had later school age IQ scores 12 to 14 points lower than their VLBW peers who did not have suspect findings at age 3 or full-term controls. Ø IQ differences between LBW and normal birth weight children exist, regardless of urban or suburban environment Aylward, G 2005

Neurodevelopmental outcomes of extreme LBW v Academics Ø > 50% of VLBW and 60 Neurodevelopmental outcomes of extreme LBW v Academics Ø > 50% of VLBW and 60 -70% of ELBW children require special assistance in school Ø However, by middle school age, ELBW children are 3 -5 times more likely than peers to have a learning problem with mathematics and broad reading most disrupted. These rates are independent of IQ scores. Ø It is estimated that 32% of VLBW/ELBW children are in mainstream without services; functioning more than a grade below placement; many repeat grades. Ø While the spectrum of learning problems does not necessarily differ from the general school population, prevalence of these disorders is increased fourfold Aylward, G 2005

Trauma & Development v Physical trauma: ØAccidental: injury ØNon-accidental: child abuse v Emotional trauma: Trauma & Development v Physical trauma: ØAccidental: injury ØNon-accidental: child abuse v Emotional trauma: Neglect v Inflicted by : Surgery, procedures

Medical Neglect v Nonadherence is the act of not following medical advice v It Medical Neglect v Nonadherence is the act of not following medical advice v It may result from lack of motivation, resources, or understanding v When lack of adherence results in actual injury, it becomes medical neglect v Caution in context of cultural and religious situations that preclude adherence: Amish, Jehovah’s witnesses

THANK YOU February 8, 2008 University of Kentucky IHDI THANK YOU February 8, 2008 University of Kentucky IHDI