Factors

Factors Influencing
Influencing
Child
Child Development
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

• Gross motor
• Fine motor
• Language
• Adaptive
• Cognitive
• Social-emotional
 Factors Influencing
Development
 Innate  Environment
 Genetic endowment  Nutrition
 Prenatal  Housing
environment  Medical care
 Temperament  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 novelty-
seeking, 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  Toxic Influences
 Maternal Hormones:  Medications:
thyroid teratogens
 Maternal Health  Illicit Drugs: opiates,
conditions (diabetes) cocaine, smoking
 Maternal nutrition:  ALCOHOL
folic acid  Environmental toxins:
 Maternal infections: e.g.. Mercury from
STDs (syphilis etc) 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!
• 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 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
 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 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
 Parenting styles
Emotionality

Warm, responsive Rejecting,

unresponsive

Authoritative Authoritarian
Control

Restrictive,
demanding

Permissive Uninvolved
Permissive,
not demanding

Maccoby & Martin, 1983

 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

 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

• 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, 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
 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 $ 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
 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 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
 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 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
 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’ well-

being 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

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