Transcript Factors Influencing Child Development

Factors Influencing
Child Development
Neelkamal Soares, MD, FAAP
Developmental-Behavioral Pediatrics
Kentucky Children’s Hospital
Nature vs. Nurture
Centuries old debate (350 BC- 21st 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) 17th- 18th C
Twin studies in the 1950s-60s 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 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
Developmental Streams
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Gross motor
Fine motor
Language
Adaptive
Cognitive
Social-emotional
Factors Influencing
Development
Innate
 Genetic endowment
 Prenatal
environment
 Temperament
Environment
 Nutrition
 Housing
 Medical care
 Basic safety
 Education
 Family support
Genetic Endowment
Much improvement in field thanks to molecular
genetics, decoding the genome and mapping
certain behaviors and developmental traits to
certain genes
Helps to validate theoretical constructs for
developmental psychologists
Attempts to match genetics to neurobiology
(all development & behavior originates in the
brain!)
Genetic Endowment
Evidence of genetic influence for personality
traits, intelligence, and disorders
 DRD4 dopamine receptor gene linked to noveltyseeking, such as drug abuse and AD/HD
 5-HTTLPR serotonin transporter gene linked to
neuroticism and harm avoidance.
http://www.apa.org/science/genetics/
APA Online genetics in psychology with
links, resources & research opportunities
Genetic Influence
 Hereditary influences are polygenic and
multifactorial, with multiple genes coacting with
environment
 Genetic bases for developmental disorders
reflect, in most cases, extreme variations on a
continuum that includes normal variants
 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
 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
 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 25-28th
week of gestation
• Neurons begin death
soon after birth
• Synaptic connections
begin 3rd trimester,
increase first 2 years
• Pruning and refining of
synapses after
puberty till adulthood
Brain Development
 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.
 Timing important when considering potential
effects of exposure to environmental agent that
disrupts specific developmental processes.
 Neurotransmitters, hormones, neurotrophins, and
growth factors orchestrate the intricate process
of brain development.
 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
 Maternal Environment
 Maternal Hormones:
thyroid
 Maternal Health
conditions (diabetes)
 Maternal nutrition:
folic acid
 Maternal infections:
STDs (syphilis etc)
 Toxic Influences
 Medications:
teratogens
 Illicit Drugs: opiates,
cocaine, smoking
 ALCOHOL
 Environmental toxins:
e.g.. Mercury from
fish; PCBs, Aspartame
 Radiation: Xrays
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!
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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
Sequelae of Prenatal
Influences
Temperament
 Individual differences in emotion, motor
reactivity and self-regulation that demonstrate
consistency across situations & time
 Biologically based: Heredity, neural, and hormonal
factors affect response to the environment.
 It can be modulated by environmental factors
such as parental response.
 Thomas and Chess’ Temperament Types
 Easy babies: 40% of infants; adjust easily to new
situations, quickly establish routines, generally cheerful
and easy to calm.
 Difficult babies: 10% of infants; slow to adjust to new
experiences, likely to react negatively and intensely to
stimuli and events.
 Slow-to-warm-up babies: 15% of infants; somewhat
difficult at first but become easier over time.
Temperament &Social
Adjustment
 “Goodness of fit”: the degree to which
individual’s temperament is compatible with
demands and expectations of social
environment
 Parents can modulate children’s temperament
by their influences on the environment.
 Dynamic is one of mutual influences and
bidirectional effects
 Probably account for different children in
same environment with different personalities
Environment Influences
The MicroenvironmentLa Familia
 Ecological model views family as a “system”
where there is a dynamic interplay between
members; and between family and social
environment.
 Family Factors influencing child development:
Child Rearing/Parenting Styles
Cultural factors
Socioeconomic factors
Transgenerational effects
Birth Order?
 Believed to influence child development
 Sir Francis Galton’s English Men of Science found
more firstborn sons in prominent positions than
attributed to chance.
 Adler’s Birth Order Theory
 First-born: authoritarian, competitive
 Middle-born: Is "sandwiched" in. May feel
squeezed out of a position of privilege and
significance
 Youngest: Tends to be the “baby” of the
family; spoiled; less of an achiever
 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
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
 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)
 Parenting is a complex activity that includes
many specific behaviors that work individually
and together to influence child outcomes.
 Specific parenting practices (discipline,
reading aloud etc) are less important in
predicting child well-being than is the broad
pattern of parenting.
Nancy Darling, PhD, MS
Parenting Styles
Parenting style captures 2 elements
 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"
 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 Authoritarian
Permissive
Maccoby & Martin, 1983
Uninvolved
Parenting StylesConsequences for Children
 Children of authoritative parents are more socially
and instrumentally competent
 Children and adolescents whose parents are
uninvolved perform most poorly in all domains.
 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.
 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
 Bonding involves a set of behaviors that will help
lead to emotional connection (attachment). Based
on work of Bowlby and Ainsworth
 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.
 Scientists believe the most important factor in
creating attachment is positive physical contact
creating predictable experiences for infant
 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 and Developmental
outcomes
 Attachment theory has been found to be
predictive of later social competence and
adjustment.
 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)
 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
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Marital status
Family size
Parents’ education
Financial situation
Strength of parents’ relationship
Parents’ mental health
Impact of Stress
 Numerous studies have shown
that marital conflict is more
likely than any other family
variable to have adverse
effects on children
 Such discord is likely to
precede separation and
divorce, stressful times for
all family members.
 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
Parental work/occupational status
Family income
Parental education
Family structure
Socioeconomic factors
 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).
 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
 Increases in paid maternal
employment over the past
quarter-century (see right)
 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
 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)
 Low-income children are not hurt and may benefit from
maternal employment, particularly with cognitive outcomes
(Hoffman, 1999)
 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)
 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
 Consistent associations between economic hardship and
compromised child development.
 Poverty measurement: family income between $ 16K20K for 3-4 member (2-child) household
 The official poverty rate in 2006 was 12.3% (36.5 mil
people); Children < 18 form 17.4% (12.8 mil)
 On average, family incomes increase as children age,
but a great deal of year-to-year volatility
 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
 Family income may exert
its most powerful
influence on children
during the earliest years
of life (Duncan, 1998)
 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
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
Bidirectional influence:
Children with developmental and
behavioral problems cause greater
emotional distress to families
Families with emotional problems tend
to have greater difficulties with
parenting and are associated with
greater behavioral issues in children
Family Structure
 On average, children raised by single parents
have lower levels of social and academic wellbeing than do children from intact marriages
(Cherlin, 1999)
 However, these outcomes derive largely from
the socioeconomic realities of single parenthood
 lower income
 less parental time
rather than from any direct effects of living only
with one parent
From Neurons to
Neighborhoods, 2000
Cultural factors
 Child development research had incorporated a
cross-cultural perspective by middle of 20th century
 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).
 In early childhood development:
 Symbolic= parents' expectations, goals, aspirations for
their children; values that govern approaches to discipline;
gender roles; religious or spiritual values
 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
 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)
 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).
 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
 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.
 Direct influence also occurs between the
developing child and the extended family, e.g.
grandparents assisting in childcare, joint families
 Related to discipline particularly,
transgenerational influence seen in parenting
behavior.
 Transgenerational passage of myths, beliefs also
mold child development
The Family’s
Mesoenvironment
Extended family support
Child care
Social support network
Growing up in Childcare
 Second only to the immediate family, child care is the
context in which early development unfolds.
 Parents/ relatives continue to provide most early child care
 Rapid growth in paid care by non-relatives in center-based
settings and expansion in public subsidies for child care.
 Beneficial outcomes with settings that provide nurturance
and support for early learning and language development.
 Child care provides a number of services
 nurturance and learning opportunities for children
 preparation for school
 support for working parents
 respite care in child welfare cases; and
 access to supplemental services (vision/hearing
screening, developmental testing, feeding programs)
From Neurons to
Neighborhoods, 2000
US Census Bureau, 2005 pub
Child Care situations
Capizzano et al, 2000
Childcare & Development
 Effects of child care on mother-infant relationship is
neutral, with exception of very early, extensive
exposure to care of dubious quality.
 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.
 When child care is found to be associated with the
mother-child relationship, the link is as likely to be
positive as negative.
 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
 Positive relation between child care quality and
child development is one of the most consistent
findings in developmental science.
 High-quality care is associated with positive
outcomes in compliance with adults, peer
relations, and early academic competence.
 Critical to sustaining high-quality child care
 Providers' education
 Providers’ specialized training,
 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
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
 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.
 Most studies of neighborhood influence are done in
“high risk” neighborhoods, with few in affluent areas.
 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).
 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 of important
domains that facilitate children’s
development
• Buffers parents during periods of
stress
Nutrition
Pre & postnatal nutritional adequacy important for optimal
brain development and function (Georgieff & Rao, 1999)
Timing of supplementation/deficiency is important.
 deprivation in 2nd trimester = fewer neurons,
 deprivation in 3rd trimester = fewer glial cells and
maturation of neurons
 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).
However young children can show remarkable recovery in
growth and behavior even after gross early
(postnatal) malnutrition when fed adequately.
Complexities
 Link between nutrition and behavior is much more
complex than either of these two hypotheses
suggests
 Plasticity of the brain allows for adaptation to
environmental influences
 Effect on development can be sustained by:
Absolute reduction in the number of neurons,
neuronal size
Physiologic changes that accompany
undernutrition negatively affect their
behavioral repertoires may contribute to
altered cognitive development and performance
Failure to Thrive
 FTT defined in terms of body weight < 3rd
%tile for age
 More common among low-income children
 More common in children at high biological
risk
Low birth weight
Small for gestational age
Substance-exposed
Developmental delays
Special health care needs
Nutrition & Development
In both developing countries and in the United
States, relationship between FTT and lowered IQ
and/or poor academic achievement.
These associations have been found in a variety of
countries, including the Philippines, Jamaica,
Guatemala, Nepal, India and Malaysia.
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
 Deficiencies of key micronutrients, both
independently and in combination, affect cognitive
development of children after infancy.
 Particular the frontal lobes, responsible for
executive functions continue to develop during
childhood,
 Nutrients such as iron and omega-3 may have
specific effects on frontal lobe functioning.
Bryan, J et al 2004
“Micronutrients” and
Cognitive Development
 While malnutrition implies protein or calorie or
both, more emphasis recently on “micronutrients”:
vitamins, minerals and supplements
 Iodine
 Iron
 Zinc
 Vitamin B12
 Micronutrient effect hypothesized as a direct
effect changes in neuroanatomy/neurotransmission
 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
 Iodine deficiency is most preventable cause of
mental retardation in the world, mainly affects
children in mountain regions & flood plains
 Public health methods (iodized salt, oral iodine)
have been effective in preventing congenital
hypothyroidism and associated MR
 When deficiency occurs in utero, causes fetal
hypothyroidism and irreversible neurological and
cognitive deficits.
 Supplementation before conception or early in
pregnancy have better developmental outcomes
than those whose mothers are not supplemented
Black, MM 2003
Iodine & Development
 When iodine deficiency occurs postnatally, the
child may experience hypothyroidism.
 Some observational studies have reported
cognitive deficits among these children and
others have not.
 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
 Confounding factor is poverty in regions where
higher prevalence of iodine deficiency occurs
Black, MM 2003
Iron Deficiency
 Iron deficiency is commonest single nutrient disorder,
~ 20-25 % of babies worldwide (WHO, 1994).
 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).
 Non-poor white toddlers lowest prevalence ~ 3% while
Mexican-American toddlers highest risk ~ 18%
(Ogden, 1998).
 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
Role suggested because it is an essential
component of more than 200 enzymes
Evidence linking zinc supplementation
to early cognitive/motor development
is inconclusive.
Suggestions that zinc supplementation may
promote activity and perhaps motor
development in the most vulnerable infants
Black, M 2003
Lead
 Most studies concur that an IQ decline of 1-5
points is associated with a 10µg/dL increase in
blood lead
 Many studies have identified distractibility, poor
organizational skills, and hyperactivity as possible
reasons for reduced global cognitive function of
more highly exposed children.
 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
 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
 Children with nutritional deficiencies of iron,
calcium are at greater risk
 In the child’s developing nervous system, cognitive
effects do not reverse with removal of lead
 In the 3rd NAHNES sample, current blood lead
was inversely associated with cognitive function,
even when blood lead levels < 5 µg/dL
• Fortunately, children’s current mean blood lead
level barely 2 µ g/dL, 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
surroundings
Factors influencing housing:
 Inadequate housing
 Absence (homelessness)
 Geographic moves
 Multiple homes
Inadequate Housing
 Inadequate housing often poses health risks
 Respiratory illnesses: asthma,
 lead poisoning,
 mold allergies, and
 injuries from unsafe conditions.
 These are particularly problematic in substandard
or overcrowded housing, which is often the only
option for families at the lowest income levels.
 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
An extreme manifestation of poverty
Homeless children
have twice as many health problems
are more likely to go hungry
have higher rates of developmental
delay, lower academic achievement
have higher rates of depression,
anxiety, and behavior problems
Geographic Moves
A move can increase the likelihood that
the child does not have a specific site for
health care
Frequent changes in neighborhood place
the child at risk for problems with
 Academics
 Behavior
 Emotions
 Health
Basic Safety
 Particularly important in young children who are
exploring environment and have limited concept of
safety and causality
 More significant for developmentally delayed
children and those with communication and
impulse control disorders
 Areas of safety:
 Home
 Surroundings: neighborhood, school
 Personal: vehicular, recreation
Home Safety
 Housing (as above)
 Installed devices enhance child’s ability to
explore the environment in a safe manner.
smoke and CO detectors
window, door and stair guards; door locks
safe storage of firearms and ammunition
water and pool safeguards
No Substitute for Adult supervision!
Personal Safety
 Vehicular
 Seat belts, booster seats
 Recreation
 Helmets, extremity guards
 ATV and bicycle safety
 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
Acute Medical Illnesses
Hospitalization and surgery
Chronic Medical conditions
Trauma: accidental & non-accidental
Medications
Acute Minor Illness
Every illness, no matter how “minor” is a
stressor for a child
However, minor illness and its management
account for only a small portion of chronic
behavioral variations and problems in children
Possible some developmental regression in
sleep, toileting, autonomy for short while
Unlikely to have motor or significant language
regression, as a result of illness
Chronic Illness
 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.
 About 5% (3.3 mil) children affected by a chronic
disease in the US
 Effects depend on
 Characteristics of children
 Characteristics of conditions
 Characteristics of families
Perrin, E Handbook DB Peds
1995
Characteristics of the Child
Age of onset
Personality/temperament
Intelligence
Self-concept
Developmental level
Characteristics of Condition
Stable or unpredictable
Prognosis
Interference with mobility
Interference with normal activities
Visibility
Academic effects
Characteristics of Families
Family structure and extended
support
Parent reaction to diagnosis and
adaptation to chronic implications
Family’s ability to deal with conflict
and stress
Sibling involvement
Prematurity: A risk
factor for development
 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
 Survival and morbidity are inversely proportional
to gestational age
 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
60
50
40
Mortality
30
Disability
20
10
0
LBW
VLBW
ELBW
Term
Prematurity risks for
development
 Premature birth predisposes the infant to
pathological events that directly injure brain.
 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
 National Cohort of Extremely Low Birth Weight
Infants (birth weight <1000 g) assessed with
neurocognitive tests (WPPSI-R and a Developmental
Neuropsychological Assessment [NEPSY]).
 Rates of disabilities included:
 cognitive impairment 9%.
 cerebral palsy 14%
 hearing loss 4%
 eye problems 30%
 Total of 20% exhibited major disabilities, and 19%
minor disabilities.
 Only 26% of the total ELBW infant cohort were
classified to have normal outcome.
Mikkola et al 2005
Neurodevelopmental
outcomes of extreme LBW
 Cognition
 Studies reveal a 0.3- 0.6 SD  = 3.8-9.8-point  IQ in
those born prematurely.
 Higher percentages of borderline IQ have been
reported in the ELBW population, from 13-15%,
 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.
 IQ differences between LBW and normal birth weight
children exist, regardless of urban or suburban
environment
Aylward, G 2005
Neurodevelopmental
outcomes of extreme LBW
 Academics
 > 50% of VLBW and 60-70% of ELBW children require
special assistance in school
 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.
 It is estimated that 32% of VLBW/ELBW children are in
mainstream without services; functioning more than a
grade below placement; many repeat grades.
 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
Physical trauma:
Accidental: injury
Non-accidental: child abuse
Emotional trauma: Neglect
Inflicted by
: Surgery, procedures
Medical Neglect
Nonadherence is the act of not following
medical advice
It may result from lack of motivation,
resources, or understanding
When lack of adherence results in actual
injury, it becomes medical neglect
Caution in context of cultural and religious
situations that preclude adherence: Amish,
Jehovah’s witnesses
THANK YOU
February 8, 2008
University of Kentucky IHDI