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

2. 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

3. From Neurons to Neighborhoods, 2000
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

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

5. Developmental Streams
Gross motor
Fine motor
Language
Adaptive
Cognitive
Social-emotional

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

7. 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!)

8. Genetic Endowment
Evidence of genetic influence for personality traits, intelligence, and disorders
DRD4 dopamine receptor gene linked to novelty-seeking, such as drug abuse and AD/HD
5-HTTLPR serotonin transporter gene linked to neuroticism and harm avoidance.
APA Online genetics in psychology with links, resources & research opportunities

9. From Neurons to Neighborhoods, 2000
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

10. 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,

11. 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

12. 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.

13. 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

14. 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

15. 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

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

17. Sequelae of Prenatal Influences

18. 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.

19. 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

20. Environment Influences

21. The Microenvironment- La 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

22. 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.

23. 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

24. 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

25. Parenting Styles Parenting style captures 2 elements
Parental responsiveness /supportiveness
"the extent to which parents intentionally
foster individuality, self-regulation, and self-
assertion 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

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

27. Parenting Styles- Consequences 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

28. 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

29. Attachment Categories
Ainsworth, M

30. 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

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

32. 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.

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

34. 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, high-quality 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

35. 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

36. 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

37. Poverty & Child Development
Consistent associations between economic hardship and compromised child development.
Poverty measurement: family income between $ 16K-20K 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

38. 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).

39. From Neurons to Neighborhoods, 2000
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

40. 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

41. From Neurons to Neighborhoods, 2000
Family Structure
On average, children raised by single parents have lower levels of social and academic well-being 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

42. 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

43. 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

44. 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

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

46. 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

47. US Census Bureau, 2005 pub

48. Child Care situations
Capizzano et al, 2000

49. 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 family-based 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

50. 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

51. NICHD Study of Early Child Care & Youth Development 2003
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

52. 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

53. Social Support of Family
Has direct effect on parents’ well-being across a number of important domains that facilitate children’s development
Buffers parents during periods of stress

54. 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.

55. 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

56. 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

57. 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

58. 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

59. “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

60. 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

61. 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

62. Iron Deficiency
Iron deficiency is commonest single nutrient disorder, ~ % 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).

63. 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

64. 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

65. 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

66. 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

67. 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.

68. 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

69. 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

70. 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

71. 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!

72. 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

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

74. 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

75. Perrin, E Handbook DB Peds 1995
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

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

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

78. 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

79. 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

81. The Good & The Bad of greater survival

82. 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.

83. 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

84. Neurodevelopmental outcomes of extreme LBW
Cognition
Studies reveal a SD  = 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

85. 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

86. Trauma & Development Physical trauma: Accidental: injury
Non-accidental: child abuse
Emotional trauma: Neglect
Inflicted by : Surgery, procedures

87. 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

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