Factors Influencing

Child Development
Neelkamal Soares, MD, FAAP
Developmental-Behavioral Pediatrics
Kentucky Childrens 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
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!

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 selfregulation 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
individuals temperament is compatible with
demands and expectations of social
environment
Parents can modulate childrens 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 Galtons English Men of Science found
more firstborn sons in prominent positions than
attributed to chance.
Adlers 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 Baumrinds 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 childrens 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 selfesteem, 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) dont 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 (BrooksGunn & 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 crosscultural 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 Familys
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 motherchild 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 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 childrens
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 < 3 rd %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 childs
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 MexicanAmerican 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 10g/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 handto-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 childs 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 g/dL
Fortunately, childrens current mean blood lead level
barely 2 g/dL, but still in problem in vulnerable
populations

Bellinger, DC 2004

Housing
A childs 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 childs 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
Familys 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

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,
Jehovahs witnesses

THANK YOU
February 8, 2008
University of Kentucky IHDI