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The Lifelong Effects of Early Childhood Adversity and Toxic Stress
Abstract
This Technical Report was retired November 2021
Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. This converging, multidisciplinary science of human development has profound implications for our ability to enhance the life prospects of children and to strengthen the social and economic fabric of society. Drawing on these multiple streams of investigation, this report presents an ecobiodevelopmental framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress, offering intriguing insights into causal mechanisms that link early adversity to later impairments in learning, behavior, and both physical and mental well-being. The implications of this framework for the practice of medicine, in general, and pediatrics, specifically, are potentially transformational. They suggest that many adult diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood. An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. It calls for pediatricians to serve as both front-line guardians of healthy child development and strategically positioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and lifelong health.
... Within this category, there was a slightly greater focus on social service policy (N = 24, 86%) than on practice (N = 19, 68%). Key examples of neuro-informed policies discussed within these publications included those focused on (1) optimizing caregiving environments and conditions [48,[63][64][65][66][67][68][69][70], (2) supporting parents and families via formal and informal social supports [68,71], (3) encouraging community-focused and early intervention strategies [71][72][73][74], (4) reducing maltreatment and informing child protection decisions [20,68,73,75,76], and (5) reducing poverty and economic inequality [68,72]. ...
... Within this category, there was a slightly greater focus on social service policy (N = 24, 86%) than on practice (N = 19, 68%). Key examples of neuro-informed policies discussed within these publications included those focused on (1) optimizing caregiving environments and conditions [48,[63][64][65][66][67][68][69][70], (2) supporting parents and families via formal and informal social supports [68,71], (3) encouraging community-focused and early intervention strategies [71][72][73][74], (4) reducing maltreatment and informing child protection decisions [20,68,73,75,76], and (5) reducing poverty and economic inequality [68,72]. ...
... Three publications [77][78][79] within the area of law focused on how neuroscience can be applied to practice, for example, in determining criminal culpability or consideration of whether someone is classified as an adult, dangerous, cognitively impaired, or drug addicted. Two publications [73,80] that focused on the built environment looked at the application of neuroscience within the context of urban planning. ...
Background/objectives: Among the developmental sciences, discovery in neuroscience has underpinned research innovations and made a significant contribution to knowledge translation. With the growth of neuroscience discovery, policymakers and practitioner workforces have adopted ‘neuro-informed’ in decisions targeting the delivery of human, social, and economic wellbeing. Methods: In this scoping review, we examined the use and conceptualization of neuro-informed policy and practice (NPP) over the last two decades. We aim to establish a working definition of NPP and identify the key knowledge bases underpinning the application of NPP, with a specific focus on children and young people. Results: A total of 116 publications related to NPP were identified across academic and policy sources. Publications derived from diverse fields (e.g., psychology, social policy, medicine, urban planning). Health and Education were the most common target areas for NPP; however, applications of NPP to social services, law, and physical environments were also identified. Despite the growth in NPP, concept definitions of NPP were limited and primarily tautological. A four-stage process of concept definition was used to develop a working definition of NPP applicable to different systems, workforces, and contexts. By applying content analysis, 12 distinct knowledge bases underpinning NPP were identified. Conclusion: Our scoping review highlights the importance of defining the concept of neuro-informed policy and practice, extending beyond the brain or individual in isolation to include consideration of the brain in context.
... Similarly, physical neglect and collective violence were also negatively associated with academic performance, highlighting the detrimental effects of such adverse experiences on a student's educational outcomes. These results are consistent with the "toxic stress" hypothesis, which proposes that childhood adversity can lead to longterm alterations in brain function and behavior (Shonkoff et al., 2012). ...
... The results of the t-test comparing students with low and high ACE-IQ levels further substantiate the negative impact of childhood adversities on academic self-assessment. Students with higher levels of ACEs reported significantly lower perceived academic performance, which is consistent with research suggesting that trauma can impair cognitive functions, concentration, and overall academic motivation (Shonkoff et al., 2012;Jaffee et al., 2005). These findings call for targeted interventions to address the psychological and academic needs of students who have experienced significant adversities in their childhood. ...
Background: Adverse Childhood Experiences (ACEs) refer to traumatic and stressful events that occur during childhood and are recalled by the individual in adulthood, potentially influencing their physical, emotional, and mental well-being (Majid 2023).
Aims: Present study examines the relationship between Adverse Childhood Experiences and perceived academic performance among university students.
Method: A sample of 210 male and female students were administered Adverse Childhood Experiences International Questionnaire (ACE-IQ) and a Perceived Academic Performance Questionnaire.
Results: The results revealed that certain ACEs, particularly mental health issues within the household, physical neglect, and exposure to collective violence, were significantly associated with lower perceived academic performance. Male students reported higher exposure to substance abuse, incarceration, mental health issues, and emotional neglect within their households compared to females.
Conclusion: These findings highlight the detrimental effects of childhood adversities on academic self-perception and underscore the need for targeted interventions in higher education.
Keywords: Childhood Experience, Perceived Academic Performance, University Students, Causal Relationship,
... O desenvolvimento neurológico infantil é particularmente sensível a fatores ambientais, uma vez que o cérebro em crescimento está em constante formação, com processos como a neurogênese, a mielinização e a sinaptogênese ocorrendo de maneira acelerada durante os primeiros anos de vida (Shonkoff & Garner, 2012). Nessa fase, a exposição a agentes tóxicos presentes no ar pode interromper esses processos críticos, levando a alterações estruturais e funcionais no sistema nervoso central. ...
... Os efeitos da exposição prolongada a poluentes climáticos no neurodesenvolvimento infantil não se restringem à infância, mas podem ter consequências ao longo de toda a vida. Alterações cognitivas e comportamentais associadas à exposição precoce a poluentes são frequentemente irreversíveis, comprometendo o desempenho acadêmico, a inserção social e a saúde mental na vida adulta (Shonkoff & Garner, 2012). Além disso, a carga econômica associada ao tratamento e suporte para transtornos do neurodesenvolvimento representa um desafio significativo para famílias e sistemas de saúde. ...
A exposição prolongada a poluentes climáticos, como material particulado fino (PM2.5), dióxido de nitrogênio (NO₂) e ozônio, está associada a impactos significativos no neurodesenvolvimento infantil, contribuindo para o aumento de condições como Transtorno do Espectro Autista (TEA), Transtorno de Déficit de Atenção e Hiperatividade (TDAH) e outros transtornos relacionados à cognição e ao comportamento. Estudos recentes, como os de Perera et al. (2019) e Block e Calderón-Garcidueñas (2009), demonstram que esses poluentes, ao atravessarem a barreira hematoencefálica, desencadeiam inflamação neurotóxica e estresse oxidativo, comprometendo funções críticas do cérebro em desenvolvimento, como a memória, o aprendizado e a regulação emocional. Crianças que vivem em áreas urbanas densamente poluídas ou próximas a zonas industriais estão particularmente vulneráveis, com maior risco de apresentar atrasos no desenvolvimento cognitivo, dificuldades sensoriais e aumento de comportamentos desafiadores. A associação entre poluição ambiental e transtornos do neurodesenvolvimento é amplificada por fatores socioeconômicos, como desigualdades no acesso a cuidados de saúde e educação, criando um ciclo de vulnerabilidade que afeta desproporcionalmente populações marginalizadas. Além disso, a exposição pré-natal a poluentes, como apontado por estudos epidemiológicos, aumenta o risco de alterações epigenéticas, que podem predispor o feto a condições como TEA e TDAH. As evidências indicam a necessidade urgente de políticas públicas que priorizem a redução de emissões de poluentes e melhorem a qualidade do ar em áreas de alta densidade populacional, além de garantir acesso a serviços de saúde mental e suporte educacional para crianças afetadas. Estratégias de mitigação, como o uso de energias renováveis, o controle rigoroso de emissões industriais e o monitoramento contínuo da qualidade do ar, são fundamentais para minimizar os impactos da poluição no neurodesenvolvimento. Este estudo contribui para o entendimento das complexas interações entre fatores ambientais e biológicos no desenvolvimento infantil, destacando a importância de uma abordagem integrada que combine saúde pública, políticas ambientais e intervenções clínicas para proteger as gerações futuras dos efeitos adversos da poluição climática.
... Trauma, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes exposure to actual or threatened death, serious injury, or sexual violence (APA, 2013). Research has consistently demonstrated that trauma can profoundly disrupt cognitive processes, emotional regulation, and interpersonal relationships, leading to significant impairments in academic performance (Shonkoff & Garner, 2012;De Bellis & Zisk, 2014). Childhood adversity, in particular, has been linked to an increased risk of developing post-traumatic stress disorder (PTSD) and depression, conditions that further exacerbate educational challenges (Cross et al., 2017). ...
This study explores how trauma impacts students' preferences for different learning environments (in-person, online, hybrid) and their subsequent educational outcomes. Using a mixed-methods design, 56 participants were assessed using the PTSD Checklist for DSM-5 (PCL-5) and the Social Avoidance and Distress Scale (SADS). Results indicate that higher trauma severity significantly predicts a preference for online and hybrid learning environments, while social anxiety shows weaker influence. Thematic analysis reveals a preference for flexible learning environments among trauma-affected students. These findings underscore the importance of trauma-informed educational practices that support the unique needs of these students.
... This age group is critical as brain and physical development undergo during these early years. Adversity experienced during this crucial phase can result in physical and chemical disruptions in the brain (Shonkoff et al. 2012), leading to long-term implications for physical and mental health outcomes (Nelson et al. 2020). Notes: Robust standard errors clustered at districts of birth are reported in parentheses. ...
... Physical and mental stress in early life can contribute to unfavorable health outcomes. Clear evidence of the etiology of physical and psychological stress that can influence a child's NCD is needed to support initiatives for change (Black et al., 2017;Shonkoff et al., 2009;Shonkoff & Garner, 2012). Alterations in child NCD can impact the child's influence on society and the current and future economy. ...
... La ausencia de amor y apoyo emocional durante la infancia puede tener consecuencias devastadoras para el desarrollo emocional. Estudios longitudinales han demostrado que los niños que crecen en entornos donde carecen de apoyo emocional son más propensos a desarrollar trastornos emocionales y conductuales (Shonkoff & Garner, 2012). La falta de una base emocional segura puede llevar a una autoestima baja, ansiedad crónica y dificultades en la regulación emocional. ...
Introducción: Este estudio presenta una propuesta pragmática del concepto del bien como recurso para el desarrollo personal, enfocándose en cómo los eventos y procesos que forman nuestra realidad y nos construyen como individuos se vuelven conscientes e intencionados. Metodología: La investigación es básica, descriptiva y exploratoria, revisando estudios académicos sobre el bien como herramienta para el crecimiento y evolución personal. Se analizan conceptos como el bien, el mal, el tiempo y el lenguaje, vistos como construcciones intelectuales que ayudan en la formación del ser. Resultados: El estudio confirma que el bien, al igual que otras abstracciones del mundo como las matemáticas o la voz interior, es un proceso involuntario e inadvertido en la vida de las personas. A través de la toma de decisiones, el bien se construye de forma abstracta, influenciando nuestra ética personal. Discusión: El bien se muestra como una construcción intelectual accidental que orienta a las personas desde lo concreto hacia lo abstracto, en el proceso de formación de valores y ética personal. Conclusiones: El bien es una herramienta no intencionada que juega un papel crucial en la construcción de nuestra identidad y valores éticos a lo largo de la vida.
... Based on Table 1, it can be seen that the most frequently cited topics within the scope of developmental psychology are early childhood diversity (Shonkoff et al., 2012), origins of cultural cognition (Tomasello et al., 2005), measurement in the human sciences (Bond & Fox, 2007), empathy (Decety & Jackson, 2004), group trajectory modeling in research (Nagin & Odgers, 2010), developmental perspective on executive function (EF) (Best & Miller, 2010), adolescence (Sawyer et al., 2018), cognitive control development (Davidson et al., 2006), minds (Goldman, 2006), and cognitive development of adolescents (Casey et al., 2008). ...
... As such, children living and attending schools in urban communities have a higher risk of exposure to adversity (Woodbridge et al., 2016) and a greater likelihood of attending schools with disproportional school discipline rates (Brown et al., 2022;U.S. O ce of Civil Rights, 2019). Experiencing such adversities is associated with e ects on neurological, spiritual, social, and emotional development, as well as long-term consequences for physical and mental health (Hunt et al., 2017;Shonko et al., 2012;Weisburd et al., 2018). Children who experience ACEs often face a greater psychiatric toll, evident in high rates of stress, depression, substance abuse, post-traumatic stress disorder, and attention de cit hyperactivity disorder (Cisler et al., 2012;Costello et al., 2002;Horn et al., 2019;Jimenez et al., 2017). ...
This paper describes the relationship between student identity, adverse childhood experiences (ACEs), and risk for receiving calls home for problems in school. Data are drawn from the 2017 to 2018 National Survey of Children's Health (n = 4,579). Critical race theory and QuantCrit were used to frame the study and analysis. Findings re ect that ACEs were associated with a call home for all students, that students of color with ACEs were 1.24 times more likely to receive a call home for problems at school, and that speci c individual ACEs were associated with calls home for each student group.
... Some studies suggested that parental posttraumatic stress lingers over years. [15,34] Third, we determined neurodevelopmental outcomes in children at a young age. A longer-term study of the children's school outcomes in relation to parental stress would be important. ...
To determine: (i) frequency of probable post-traumatic stress disorder (PTSD) in mothers of infants after complex cardiac surgery (CCS), (ii) predictors of probable PTSD, and (iii) impact on child neurodevelopment. The Impact of Event Scale—Revised (IES-R) was administered to 60 mothers of infants ≥ 6 months after CCS at ≤ 6 weeks of age. The IES-R measures response to a specific traumatic event: Scores < 24, no concern; 24–32, clinical concern; and ≥ 33, probable diagnosis of PTSD. Post-survey childhood outcomes obtained at 21-months used Bayley Scales of Infant and Toddler Development—Third Edition. Multiple logistic and linear regressions were used to predict high IES-R scores from peri-operative and demographic variables and determine association between maternal IES-R scores and outcomes, reported as Odds Ratio (OR) and Effect Size (ES) with 95% Confidence Intervals (95% CI). IES-R scores ≥ 33 occurred in 14/60 (23%) of mothers. Significant risk factors for IES-R ≥ 33 were days of ventilation after first surgery, OR 1.149 (95% CI 1.037, 1.273), p = 0.008, and birth weight z-scores, OR 0.352 (0.140, 0.881), p = 0.026. Bayley cognitive, language, and motor scores were significantly lower for children whose mothers had IES-R ≥ 33. The IES-R was independently associated with cognitive, ES −0 .23 (95%CI −0 0.39, −0 0.08), p = 0.036 and language, ES −0 0.17 (95%CI −0 0.33, −0 0.06), p = 0.043 scores. Probable PTSD occurred in 23% of mothers ≥ 6 month after discharge of their infant following CCS. Toddlers of mothers with probable PTSD had lower cognitive and language scores suggesting a relation between PTSD and development requiring further study.
... This direct effect can be explained by the concept of embodiment, which suggests that early life experiences can become biologically embedded and influence health trajectories (Hertzman, 1999). For instance, exposure to limited peer interactions during childhood can activate chronic stress responses, leading to the dysregulation of the HPA axis and elevated cortisol levels (Shonkoff et al., 2012). This chronic physiological stress can contribute to systemic inflammation, accelerated cellular aging, and impaired immune function, increasing the risk for chronic conditions such as cardiovascular disease and arthritis (Danese & McEwen, 2012;Miller et al., 2011). ...
Despite the recognized importance of social connections in Chinese culture, research on how childhood peer relationship deficits impact health later in life has been limited. This study aimed to investigate the association between childhood peer relationship deficits and the odds of disability among older Chinese adults and to explore the potential mediating roles of social isolation, loneliness, and cognitive function. Using the longitudinal sample of respondents aged 60 years and older in the China Health and Retirement Longitudinal Study 2013–2018 (N = 7133), the link between peer relationship deficits in childhood and disability in late life was assessed using marginal structural models, and the potential mediating effects of social isolation, loneliness, and cognitive function were examined by the inverse odds ratio weighting technique. Participants who experienced greater childhood peer relationship deficits were more prone to disability (odds ratio: 1.19, 95% CI: 1.09, 1.29) than those with more positive childhood peer interactions. The inverse odds ratio weighting analysis indicated that social isolation, loneliness, and cognitive function individually played partial mediating roles in the association between childhood peer relationships and disability by 11.36% (95% CI: 4.04%–18.99%), 11.95 % (95% CI: 4.65%–19.23%), and 24.58% (95% CI: 17.01%–32.43%), respectively. The combined mediation effect of the three mediators was 30.57% (95% CI: 23.52%–39.91%). These findings suggest that interventions to enhance social connections and cognitive health in older adults may help mitigate the long-term impacts of childhood peer relationship deficits on disability among older Chinese adults.
... Research indicates that individuals, enjoying positive experiences with caregivers during childhood, show fewer depressive symptoms, experience fewer chronic illnesses, and have better health outcomes in adulthood (Chopik & Edelstein, 2019). Positive experiences also lay the foundation for healthy brain development and the acquisition of a broad range of learning and skills (Shonkoff & Garner, 2011). ...
This study examined the mediating role of the sense of coherence in the relationship between positive childhood experiences and alexithymia. The research was conducted with a total of 507 participants, including 259 women and 248 men aged over 18, selected through convenience sampling. Data were collected using a Personal Information Form, the Positive Childhood Experiences Scale, the Toronto Alexithymia Scale, and the Sense of Coherence Scale. Data analysis was performed using SPSS 25 and the PROCESS macro. The results indicated that positive childhood experiences significantly and positively predicted levels of sense of coherence, while they significantly and negatively predicted alexithymia. Furthermore, the sense of coherence was found to significantly and negatively predict alexithymia. It was also found that the sense of coherence mediated the relationship between positive childhood experiences and alexithymia.
Background
Childhood adversities, such as exposure to parental mental illness, domestic violence and abuse, substance use, and family poverty, have been linked to involvement in violence in early adulthood. However, evidence on the cumulative impact of multiple adversities throughout childhood on violence and crime in adolescence remains scarce. This study investigates the associations between trajectories of family adversity and poverty during childhood, and the risk of involvement in violence and contact with police in adolescence.
Methods
We used longitudinal data from the UK Millennium Cohort Study on 9316 children. Exposure trajectories of family adversities and poverty were characterised (from ages 0–14 years) using group-based multi-trajectory models. The outcomes were weapon involvement, for example, carrying a knife, and police contact measured at age 17 years. Odds ratios and 95% confidence intervals (OR, 95% CI) and population attributable fractions were estimated using logistic regression models, adjusting for confounding factors.
Results
The prevalence of weapon involvement and contact with police at age 17 years were 6.1% and 20.0%, respectively. Compared with children who experienced low poverty and family adversity throughout childhood, those exposed to persistent poverty and poor parental mental health were at notably increased risk of carrying weapons (adjusted OR (aOR) 2.2, 95% CI 1.3 to 3.6) and reporting contact with police (aOR 2.1, 95% CI 1.6 to 2.8). We estimate that about 32% of weapon involvement and 23% of contact with police at age 17 were attributable to persistent poverty and family adversity.
Conclusion
Exposure to poverty and poor parental mental health throughout childhood doubles the risk of weapon involvement and police contact in early adulthood. These findings emphasise the importance of lifecourse and anti-poverty approaches to reducing involvement in crime in the UK.
The Oxford SEEN (Secondary Education around Early Neurodevelopment) project developed Key Stage 3 (11–14 year olds) science lesson content about the importance of the early years for lifelong health and evaluated its impact on students' knowledge of the neuroscience and practical application to a real‐world scenario. A mixed methods approach was used collecting quantitative and qualitative data from students and staff using pre‐ and post‐lesson surveys and focus groups. Data were analysed from 2767 students from 20 schools in England. The new curriculum successfully increased both student's scientific understanding and practical application of knowledge about neurodevelopment and the role of the caregiver. students’ mean multiple choice question scores (assessing knowledge) were higher post‐lesson compared to pre‐lesson; this increase was consistent across gender and year group. The post‐lesson and 6–8‐week follow‐up scores were similar, indicating a retention in students' knowledge. Students were also asked how they would care for a 2‐year‐old child to promote brain development; before the lessons 89% of students provided no or a basic level answer, but after the lessons 50% of students provided detailed or advanced comments. The lessons were feasible and acceptable; both teachers and students stated the curriculum should be taught to other students. Qualitative analyses indicated that the lessons inspired the curiosity of both teachers and students and were perceived to impact on students' interaction with children in their current lives and their future career choices. The Oxford SEEN curriculum could serve as a foundation to build community‐wide knowledge about the importance of the early years, with the aim of enhancing mental and physical health outcomes for future generations.
Objective: This study investigates the resilience and happiness of Malaysian children during the COVID-19 pandemic, aiming to understand their coping mechanisms compared to peers in other Asian countries. Theoretical Framework: The research is grounded in Bronfenbrenner's ecological systems theory, which emphasizes the impact of various environmental systems on child development. This framework helps explore how families, societal and policy factors influence children's well-being. Method: A cross-national comparative study was conducted with seven Asian countries, led by the Child Research Network Asia, Japan. Participants included Malaysian children aged 5 and 7, with data collected through structured questionnaires on resilience and happiness. Results and Discussion: Findings revealed that Malaysian children aged 5 and 7 have the lowest resilience levels among the countries studied. Only 60% and 67% of these children reported feeling happy, compared to an average of 75% and 81% in other countries. The discussion highlights potential long-term impacts on development and future competencies, considering cultural differences and sample size as limitations. Research Implications: This research provides insights for Malaysian policymakers and educators on the need for improved support systems to enhance resilience and well-being, crucial for future competitiveness. These improvements align with the Sustainable Development Goals (SDGs), particularly those focused on ensuring healthy lives and promoting well-being for all at all ages. Originality/Value: The study offers a comparative analysis of children's resilience and happiness across Asian countries during a crisis, highlighting areas for policy intervention to improve child development outcomes.
O presente estudo teve objetivo refletir criticamente a respeito do tema da Parentalidade positiva no âmbito da primeira infância de acordo com os referenciais teóricos pertinentes. Trata-se de uma pesquisa de abordagem qualitativa do tipo reflexão teórica. Recentemente foi sancionada no Brasil a Lei nº 14.826, de 20 de março de 2024, a qual institui a parentalidade positiva e o direito ao brincar como estratégias intersetoriais de prevenção à violência contra crianças, se configurando em uma importante conquista para o avanço a favor da promoção da parentalidade respeitosa. A primeira infância é uma fase crucial no desenvolvimento e um momento em que são adquiridas e consolidadas competências fundamentais nas áreas cognitiva, emocional e social. Uma das maiores ameaças ao desenvolvimento infantil é a violência, a qual ocorre predominantemente no ambiente e contexto familiar. Considerando-se que a violência não se restringe à esfera física, a promoção da parentalidade positiva é uma importante estratégia para a prevenção das adversidades a que a criança pode estar sujeita durante a primeira infância. A importância da parentalidade positiva na primeira infância vai além do âmbito familiar, tendo implicações significativas para a saúde mental dos cuidadores e para a construção de comunidades mais resilientes. É premente a necessidade de construção de políticas públicas e iniciativas educacionais e de cuidado que promovam essa abordagem que permite que as crianças tenham maiores chances de acessarem ambientes que sejam físico, mental, emocional e cognitivamente mais seguros desde os primeiros anos de vida.
Background
The quality of parenting has a significant impact on healthy development across the life cycle. Recent research has highlighted the financial return of evidence‐based parenting programs that are well designed and implemented.
Objective
To analyze the impact of a psychoeducational guidance intervention program aimed at improving parenting skills.
Method
Thirty‐five families with children aged between 0 and 3.5 years referred from the educational, social, and health departments of the Vitoria‐Gasteiz City Council (Spain) participated in the study. Using a longitudinal approach, the intervention took place over the course of three home visits: initial pretest assessment visit, feedback and orientation visit, and a final posttest assessment visit.
Results
Statistically significant pretest–posttest differences were observed in parenting skills, including cognitive and socio‐emotional development scaffolding, parental self‐efficacy, parental adaptive stress, and diversity of experiences.
Conclusions
Several areas for improvement were detected in the context of an intervention based on customized guidance for individual families. The implementation process indicated issues to be improved in future program editions.
Implications
Our findings provide family and public health policy makers with empirical support for the implementation of parenting programs designed to help families to acquire and improve parenting competencies to foster their children's comprehensive development, focused on the period between 0 and 3.5 years of life. Results of the study favor the propagation among Spanish professionals who work with families of the use of quality standards of the evidence‐based approach related to quality of implementation and assessment of the impact of parenting programs.
Im Rahmen der Weitergabe verhängnisvoller transgenerationaler Beziehungsmuster in der frühen Kindheit spielt die wechselseitige Regulation von Stress und negativen Emotionen zwischen Eltern und Kind eine zentrale Rolle. Entscheidend ist, inwieweit die elterliche Co-Regulation dazu beiträgt, dass belastende Interaktionserfahrungen wiedergutgemacht werden können und ein interaktiver Repair gelingt oder nicht. Der Beitrag illustriert, wie traumatische transgenerationale Beziehungsmuster, sogenannte »Gespenster im Kinderzimmer«, erkannt werden können. Interventionen auf der Makroebene kindlicher Umgebungsfaktoren sowie auf der Mikroebene der Eltern-Kind-Interaktion werden vorgestellt. Konkrete Möglichkeiten, wie positive Interaktionen unterstützt und ein interaktiver Repair gelingen kann, werden aufgezeigt.
Objective
Evidence suggests that children with psychosocial problems face a higher risk of cardiometabolic diseases in adulthood. However, this may already be evident prior to adulthood. In this study, the associations between psychosocial problems at preschool age and cardiometabolic outcomes 6 years later were investigated.
Methods
Data from 936 participants from the Amsterdam Born Children and their Development (ABCD) study was used. Psychosocial problems were assessed using the Strengths & Difficulties Questionnaire (SDQ) when the children were 5–6 years old, reported by both mothers and teachers. Cardiometabolic parameters, including body mass index, waist circumference, total cholesterol, triglycerides, high- and low-density lipoprotein cholesterol, fasting glucose, systolic and diastolic blood pressure, and carotid intima-media thickness were subsequently measured at ages 11–12 years. The associations between psychosocial problems and cardiometabolic outcomes were assessed using multivariable linear and logistic regression models.
Results
In model 1, adjusted for age, sex, and puberty status, and in model 2, for sociodemographic and biological predisposition factors, the combined mother-teacher score yielded a positive association with clustered cardiometabolic score ( b = 0.05, 95% confidence interval = 0.03–0.10) 6 years later. Adjusting for lifestyle factors rendered this association nonsignificant. Significant associations between mother-reported SDQ scores and most cardiometabolic parameters, except for triglycerides, diminished after controlling for confounders. Children with higher total SDQ score (by mother) had 1.31 times higher odds of developing metabolic syndrome (95% confidence interval = 1.05–1.62).
Conclusion
This study established a small inverse association between mother-reported psychosocial problems at ages 5–6 years and cardiometabolic health profile at ages 11–12 years.
Ongoing discussions on what is “wrong” with global health or how to decolonialize global health tend to focus exclusively on structural shortcomings, such as effectiveness of global platforms and institutions or lack of truly participatory consultation strategies (downstream perspective). Thereby they fail to capture alternative approaches to global health leadership (upstream perspective) and to recognize the sovereignty of non-Western knowledge and the intrinsic value of community regeneration in all its forms as a key ingredient for effective global health practice. Women’s perspectives have been largely relegated to the gender agenda (balance, parity, equity) or proposed as models on “how to lead better” based on preconceived, male-based notions of what constitutes “effective” leadership, including setting and prioritizing goals. Instead of creating hierarchies of priorities, we must understand the complexity of human experience and the power and inequality patterns it is embedded in, and remain open to or embrace apparent contradictions when designing support mechanisms. This chapter centers on the disproportionate impact of COVID-19 in the lives of Latin American immigrants in Chelsea, Massachusetts, United States, during the 2020 pandemic. The chapter explores how public health prioritization of basic needs neither captured the relationship between impact and social response nor acknowledged the interplay between the different needs of people. Employing an insider’s look, we describe how the women leaders of the local organization La Colaborativa called upon culturally accepted codes to reverse power roles, questioned scientific definitions of needs and led their community out of potentially irreversible consequences of the crisis in a holistic and sustainable way. Their leadership serves as an example of how self-governed, women-led organizations that are rooted in the community may address the real needs of its members during a global catastrophic event.
Introduction
Children represent a large and vulnerable patient group. However, the evidence base for most paediatric diagnostic and therapeutic procedures remains limited or is often inferred from adults. There is an urgency to improve paediatric healthcare provision based on real-world evidence generation. Digital transformation is a unique opportunity to shape a data-driven, agile, learning healthcare system and deliver more efficient and personalised care to children and their families. The goal of Paediatric Personalized Research Network Switzerland (SwissPedHealth) is to build a sustainable and scalable infrastructure to make routine clinical data from paediatric hospitals in Switzerland interoperable, standardised, quality-controlled, and ready for observational research, quality assurance, trials and health-policy creation. This study describes the design, aims and current achievements of SwissPedHealth.
Methods and analysis
SwissPedHealth was started in September 2022 as one of four national data streams co-funded by the Swiss Personalized Health Network (SPHN) and the Personalized Health and Related Technologies (PHRT). SwissPedHealth develops modular governance and regulatory strategies and harnesses SPHN automatisation procedures in collaboration with clinical data warehouses, the Data Coordination Center, Biomedical Information Technology Network, and other SPHN institutions and funded projects. The SwissPedHealth consortium is led by a multisite, multidisciplinary Steering Committee, incorporating patient and family representatives. The data stream contains work packages focusing on (1) governance and implementation of standardised data collection, (2) nested projects to test the feasibility of the data stream, (3) a lighthouse project that enriches the data stream by integrating multi-omics data, aiming to improve diagnoses of rare diseases and 4) engagement with families through patient and public involvement activities and bioethics interviews.
Ethics and dissemination
The health database regulation of SwissPedHealth was approved by the ethics committee (AO_2022-00018). Research findings will be disseminated through national and international conferences and publications in peer-reviewed journals, and in lay language via online media and podcasts.
Context: Treatments for posttraumatic stress disorder (PTSD) in young children (ages 0–6) should be adapted to their developmental characteristics: to their cognitive, social, and emotional abilities, to their specific trauma reactions and adjustments, and finally, to their degree of dependency on adults. Due to the lack of official recommendations for the treatment of PTSD in young children and considering the high prevalence of PTSD among this population, there is a growing need for targeted psychological interventions and psychotherapies for the youngest children with PTSD or posttraumatic symptoms.
Objective: To provide an update on effective psychological interventions available for the treatment of PTSD and posttraumatic symptoms in young children (under the age of 6).
Design: Systematic review of automated searches conducted using the search engines Google Scholar, Science Direct, PsycInfo, and PubMed.
Results: This review identified 17 articles reporting on the efficacy of an individual therapy for treating PTSD or posttraumatic stress symptoms in young children. The therapies identified are TF-CBT, CPP, PCIT, DET, early pathway, EMI and EMDR.
Conclusion: No treatment can currently be identified as a level-one evidence-based treatment (Well-Established Treatment) in children younger than 6 years old with PTSD or posttraumatic symptoms. Further research is essential to validate existing findings on the effectiveness of trauma-focused therapies in young children in order to establish internationally recognized recommendations.
Background: Researchers and clinicians often use the six-item abbreviated Posttraumatic Stress Disorder Checklist–Civilian (PCL-6) for screening; however, the PCL-6 has not been validated for parents of children with cancer. A valid and reliable short screener like the PCL-6 would allow bedside and/or advanced practice nurses to quickly screen parents for traumatic stress and expedite referrals for support services. Method: This study used data collected during a multisite trial examining an intervention for children with cancer and their parents. This dataset included parental self-report measures of traumatic stress (PCL-6; Impact of Events Scale-Revised [IES-R]), mood disturbance (Profile of Mood States-Short Form [POMS-SF]), and wellbeing (Index of Wellbeing [IWB]). The sample included 136 parents of children (3-8 years old) undergoing cancer treatment at four hospitals. Analysis: For construct validity, we calculated Spearman’s correlation coefficient using baseline scores of the PCL-6 with baseline scores for the IES-R, POMS-SF, and IWB. For internal consistency, we calculated Cronbach’s alpha using the scores of each of the six items of the PCL-6 for all parent/caregiver participants at baseline. Results: Results indicate good convergent construct validity, reasonable divergent construct validity, and good internal consistency.
Previous reviews and meta-analysis have not adequately explored the impact of specific parental adverse childhood experiences (ACEs) subtypes on offspring’s health. This updated systematic review and meta-analysis aimed to investigate the association between parental ACE subtypes and various offspring health outcomes. A comprehensive search was conducted in electronic databases including PubMed, Web of Science, the Cochrane Library, WANFANG, and China National Knowledge Infrastructure for studies published in English and Chinese from January 1, 1998, until July 18, 2023. Two independent reviewers screened studies, extracted data, and assessed study quality using the Newcastle-Ottawa Scale. A random-effects model was applied to generate pooled odds ratios (ORs) and 95% confidence interval (95% CI). A total of 47 eligible studies were included in the final analysis. Overall, parental ACEs were significantly associated with several offspring’s health outcomes, including preterm birth (PTB), low birth weight (LBW), total developmental delay, social-emotional problems, and behavioral problems (total, externalizing and internalizing behaviors), with ORs ranging from 1.06 to 3.02. Specific subtypes of parental ACEs, such as household dysfunction, sexual abuse, and physical abuse (but not emotional abuse) were significantly associated with PTB. Household dysfunction was notably linked to delayed cognition ability in offspring. Parental sexual abuse, physical abuse, emotional abuse, and emotional neglect were significantly correlated with social-emotion problems, with the expception of household dysfunction. Regarding total behavioral problems, parental household dysfunction, physical abuse, emotional abuse, physical neglect, and peer bullying were all significantly associated with children’s behavioral issues, except for emotional neglect. There is a positive correlation between parental household dysfunction, sexual abuse, physical abuse, emotional abuse, emotional neglect, physical neglect, peer bullying, and neighborhood-related adversity and their children’s externalizing behavior problems. These findings underscore the significant impacts of parental ACEs on multiple adverse health outcomes in children, with specific parental ACEs subtypes exerting unique effects. This highlight the significance of comprehending the intergenerational effects of different ACE subtypes, and emphasizes the urgency of interventions to address these issues.
Os desastres ambientais, intensificados pelas mudanças climáticas, têm impactos profundos na saúde mental de populações vulneráveis, especialmente em crianças com Transtorno do Espectro Autista (TEA). Essas crianças, devido a suas características únicas, como sensibilidade sensorial aumentada, dificuldade de adaptação a mudanças e dependência de rotinas estruturadas, são particularmente suscetíveis ao estresse psicológico gerado por eventos climáticos extremos, como inundações, ondas de calor e secas. Estudos, como os de Howlin et al. (2004) e Clayton et al. (2017), indicam que o estresse pós-traumático, ansiedade e regressões comportamentais são mais prevalentes em crianças expostas a desastres naturais. Além disso, o deslocamento forçado e a interrupção de serviços essenciais, como terapias ocupacionais e educativas, agravam os sintomas do TEA, levando a crises frequentes, comportamentos desafiadores e impacto emocional significativo nas famílias. A exposição prolongada a poluentes ambientais, frequentemente associada a eventos climáticos extremos, também aumenta o risco de exacerbação dos sintomas, conforme estudos de Perera et al. (2019). Essas interações complexas entre fatores ambientais e condições clínicas evidenciam a necessidade de políticas públicas que priorizem a continuidade de serviços terapêuticos durante desastres, o fortalecimento de redes comunitárias e estratégias de suporte psicológico direcionadas a crianças neurodiversas. Intervenções baseadas na resiliência, como sugerido por Masten (2014), podem mitigar os impactos dos desastres climáticos, promovendo adaptação e bem-estar em crianças com TEA. Este estudo reforça a urgência de ações integradas entre saúde, educação e políticas climáticas para proteger a saúde mental dessas populações vulneráveis.
Childhood emotional maltreatment is a crucial risk factor for gratitude in adolescents. However, previous research has not investigated the effects of two types of emotional maltreatment (i.e., emotional abuse and emotional neglect) on gratitude, and explored the underlying mechanisms. To address existing research gaps, this study investigated how childhood emotional maltreatment affected adolescent gratitude, as well as the potential role of parent-child attachment in the Chinese context. A total of 491 Chinese adolescents from a public high school (Mage = 16.19 years, SD = 0.50; 60.5% female) participated in this 10-month, three-wave longitudinal study. The path analysis revealed that cumulative childhood emotional maltreatment and childhood emotional neglect at T1 predicted lower levels of gratitude at T3, while childhood emotional abuse did not. Additionally, parent-child attachment at T2 mediated the relationship between cumulative childhood emotional maltreatment at T1 and gratitude at T3. These findings underscore the enduring negative impact of childhood emotional maltreatment on adolescent gratitude and highlight the crucial role of parent-child attachment in this relationship.
Research suggests that adverse childhood experiences (ACEs) can have life-long consequences on emotional functioning. However, it is unclear how ACEs shape the dynamic features of everyday emotions. In the current preregistered study with two adult ecological momentary assessment samples (Ns = 122 and 121), we examined the linear and curvilinear associations of ACEs with daily emotion dynamic features. We expected ACEs to show linear associations with a higher baseline level, variability, and inertia of negative emotions, as well as a lower baseline level of positive emotions. Moreover, we expected ACEs to show U-shaped curvilinear associations with the variability of negative and positive emotions. The results did not support our hypotheses. Instead, ACEs showed an inverted U-shaped association with the baseline level and variability of negative emotions. Furthermore, ACEs also showed a U-shaped association with the baseline level of positive emotions and a linear association with higher variability of positive emotions. However, all associations were present in only one of the two samples. Our study underscores the critical need to incorporate a broad spectrum of ACEs in research samples to adequately capture their developmental consequences and the role of ACEs in contributing to the baseline level and variability of daily emotions.
Bullying victimization in childhood and adolescence is a global health priority, but little is known about the long-term economic impacts of bullying on the victim. The aim of this study was to analyze the relationship between bullying victimization in pre- or early adolescence and young adult income in a representative cohort of US youths. Data from a nationally representative longitudinal survey were analyzed. A total of 525 US youth-completed surveys that included questions on bullying victimization in 2002/2003 (at ages 9–14 years) and 2007/2008 (at ages 14–18 years) as well as provided their income at age 25 (±1 year) (mean follow-up time: 13.2 years). Associations between different types of bullying victimization (e.g., verbal and physical) and income at age 25 (±1 year) were assessed using multivariable linear regression, stratified by gender. Approximately half of participants reported being picked on at least once in the past month, and about one-fourth reported being left out of activities at least once in the past month. Bullying victimization at ages 9–14 years was negatively associated with income levels later in life, but victimization at older ages was not. Only two exposures were associated with adult income when adjusting for sociodemographic covariates: being left out of things and having your things taken by others. Among females, reporting being left out of things at least 2–3 days per week was associated with decreased adulthood income. Among males, having your things taken about once per week or more was significantly associated with income, but the pattern was inconsistent. This study provides evidence of differences in the relationship between bullying victimization and income between males and females, with females’ income differences associated with less aggressive forms of bullying than males.
Adverse Childhood Experiences (ACEs) are very common and presently implicated in 9 out of 10 leading causes of death in the United States. Despite this fact, our mechanistic understanding of how ACEs impact health is limited. Moreover, interventions for reducing stress presently use a one-size-fits-all approach that involves no treatment tailoring or precision. To address these issues, we developed a combined cross-sectional study and randomized controlled trial, called the California Stress, Trauma, and Resilience Study (CalSTARS), to (a) characterize how ACEs influence multisystem biological functioning in adults with all levels of ACE burden and current perceived stress, using multiomics and other complementary approaches, and (b) test the efficacy of our new California Precision Intervention for Stress and Resilience (PRECISE) in adults with elevated perceived stress levels who have experienced the full range of ACEs. The primary trial outcome is perceived stress, and the secondary outcomes span a variety of psychological, emotional, biological, and behavioral variables, as assessed using self-report measures, wearable technologies, and extensive biospecimens (i.e. DNA, saliva, blood, urine, & stool) that will be subjected to genomic, transcriptomic, proteomic, metabolomic, lipidomic, immunomic, and metagenomic/microbiome analysis. In this protocol paper, we describe the scientific gaps motivating this study as well as the sample, study design, procedures, measures, and planned analyses. Ultimately, our goal is to leverage the power of cutting-edge tools from psychology, multiomics, precision medicine, and translational bioinformatics to identify social, molecular, and immunological processes that can be targeted to reduce stress-related disease risk and enhance biopsychosocial resilience in individuals and communities worldwide.
Social determinants of health have been examined for several years in many fields of medicine. The importance of considering these factors when discussing mental health is indisputable, as the role of environmental interference cannot and must not be minimised. This chapter aims to provide an overview of the social determinants of mental health, making a distinction between individual-level and area-level determinants. From a public health standpoint, it seems increasingly important to distinguish between factors acting on a personal level and those acting on areas. Indeed, this makes it possible to better understand how the pressures exerted by certain factors are distributed, in a more or less targeted manner, throughout society, influencing different clinical domains. In order to provide a comprehensive approach, we will address transversal dimensions of psychiatric disorders, such as aggressivity, suicide, psychosocial functioning and loneliness. These dimensions are represented to varying degrees in the large spectrum of mental disorders, reflecting the multifaceted nature of this field and aiming to provide an alternative point of view to standard nosology.
Past experiences of mental healthcare which have been perceived as harmful can present significant barriers to accessing treatment again. This article draws upon research and lived experience to consider the ways in which conceptualisations of ‘trauma-informed care’ may better incorporate the role of iatrogenic harm, thus providing more acceptable and equitable treatment for those who have previously found treatment to be harmful. A more restorative approach is offered, founded in shared responsibility and compassionate relationships, to help minimise harms and create a more healing system for patients and clinicians alike.
Dysregulation of the hypothalamic‐pituitary‐adrenal (HPA) axis is one mechanism through which chronic stress during pregnancy and parenthood may affect parental, child, and family health. Hair cortisol concentration (HCC) may be well‐suited to elucidate associations between chronic stress and HPA axis regulation because HCC reflects cortisol output over several months. However, most previous studies that examine chronic stress in conjunction with cortisol in pregnant individuals or mothers use measures that reflect HPA axis output over a relatively limited time. We report findings from two longitudinal studies that tested associations between chronic stress and HCC in women during the perinatal period (Study 1; n = 144) and mothers of young children (Study 2; n = 102). Both studies measured chronic stress with a measure developed to comprehensively assess chronic stressors in community samples. Hair samples were collected three times in Study 1 (mid‐pregnancy, one month postpartum, and 12 months postpartum) and twice in Study 2, approximately one year apart. Chronic stress was associated with higher HCC in both studies. Exploratory analyses indicated that the strength of associations between chronic stress and HCC differed as a function of the life domain of chronic stress. Chronic work and family demands were associated with higher postpartum HCC in Study 1 whereas neighbourhood/housing and discrimination chronic stress were associated with higher HCC in Study 2. These findings provide evidence of a biological pathway through which chronic stress may influence health in mothers and support the utility of hair cortisol as a neuroendocrine measure of chronic stress during pregnancy and parenthood.
In March 2023, approximately 30,000 children in England entered the care system and were therefore deemed a Child Looked After (Gov UK, 2023). Over a third of whom (n=10,290) were aged under five years old.
The Children’s Act (1989) describes permanence as ‘a sense of security, continuity, commitment, identity and belonging’ (p.19) and is significantly dependent upon the quality and consistency of caregiving experiences (The Care Inquiry, 2013). However, this is often disrupted for infants in care, impacting upon their sense of a ‘secure base’.
A child’s environment and experiences in the earliest years of life are associated with a host of lifelong developmental outcomes (Easterbrooks et al., 2012; Friedman et al., 2015; Shonkoff & Garner, 2012).
As the youngest and arguably most vulnerable members of society, there is a risk that the ‘voice’ and experiences of pre-verbal infants are not always held in mind (NSPCC, 2024). It is therefore best practice that professionals aim to better understand the lived experience of infants living within the care system.
The aim of this article is to highlight how the Leeds Infant Mental Health Service’s (IMHS) professional consultation pathway enhances the voices of infants in care and promotes systemic change to strengthen a sense of security for infants, enabling them to lay down strong ‘roots’ to thrive later in life. The article further details the IMHS consultation process and offers practical guidance around supporting the infant’s voice and incorporating inclusive documentation and language.
About 50 percent of the variance in inequality in lifetime earnings is determined by age 18.1be family plays a powerful role in shaping adult outcomes that is not fully appreciated in current policies around the world. Current social policy directed toward children focuses on improving cognition. Yet more than intelligence is required for success in life. Gaps in both cognitive and noncognitive skills between the advantaged and the disadvantaged emerge early and can be traced in part to adverse early environments. A greater percentage of children in the U.S. and many other countries is being born into adverse environments. The problems of rising inequality and diminished productivity growth are not due mainly to defects in public schools or to high college tuition rates. Late remediation strategies designed to compensate for early disadvantage such as job training programs, high school classroom size reductions, convict rehabilitation programs, adult literacy programs and other active labor market programs are not effective, at least as currently constituted. Remediation in the adolescent years can repair the damage of adverse early environments, but it is costly. There is no equity-efficiency trade-off for programs targeted toward the early years of the lives of disadvantaged children. There is a substantial equity-efficiency trade-off for programs targeted toward the adolescent years of disadvantaged youth. Social policy should be directed toward the malleable early years. Any proposed program should respect the primacy of the family. Policy proposals should be culturally sensitive and recognize the diversity of values in society. Effective strategies would engage the private sector to mobilize resources and produce a menu of programs from which parents can choose.
Although asthma has emerged as a major contributor to disease and disability among US children, the burden of this disease is unevenly distributed within the population. This article provides a brief overview of social-status variables that predict variations in asthma risks and social exposures, such as stress and violence, that are emerging as important risk factors. The central focus of the article is on the distal social variables that have given rise to unhealthy residential environments in which the risk factors for asthma and other diseases are clustered. Effective initiatives for the prevention and treatment of childhood asthma need to address these nonmedical determinants of the prevalence of asthma.
Over the last decade, health care has experienced continuous, capricious, and ever-accelerating change. In response, the American Academy of Pediatrics convened the Vision of Pediatrics (VOP) 2020 Task Force in 2008. This task force was charged with identifying forces that affect child and adolescent health and the implications for the field of pediatrics. It determined that shifts in demographics, socioeconomics, health status, health care delivery, and scientific advances mandate creative responses to these current trends. Eight megatrends were identified as foci for the profession to address over the coming decade. Given the unpredictable speed and direction of change, the VOP 2020 Task Force concluded that our profession needs to adopt an ongoing process to prepare for and lead change. The task force proposed that pediatric clinicians, practices, organizations, and interest groups embark on a continual process of preparing, envisioning, engaging, and reshaping (PEER) change. This PEER cycle involves (1) preparing our capacity to actively participate in change efforts, (2) envisioning possible futures and potential strategies through ongoing conversations, (3) engaging change strategies to lead any prioritized changes, and (4) reshaping our futures on the basis of results of any change strategies and novel trends in the field. By illustrating this process as a cycle of inquiry and action, we deliberately capture the continuous aspects of successful change processes that attempt to peer into a multiplicity of futures to anticipate and lead change.
The brain is the key organ of stress processes. It determines what individuals will experience as stressful, it orchestrates how individuals will cope with stressful experiences, and it changes both functionally and structurally as a result of stressful experiences. Within the brain, a distributed, dynamic, and plastic neural circuitry coordinates, monitors, and calibrates behavioral and physiological stress response systems to meet the demands imposed by particular stressors. These allodynamic processes can be adaptive in the short term (allostasis) and maladaptive in the long term (allostatic load). Critically, these processes involve bidirectional signaling between the brain and body. Consequently, allostasis and allostatic load can jointly affect vulnerability to brain-dependent and stress-related mental and physical health conditions. This review focuses on the role of brain plasticity in adaptation to, and pathophysiology resulting from, stressful experiences. It also considers interventions to prevent and treat chronic and prevalent health conditions via allodynamic brain mechanisms.
This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children's health and health care.
A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included "child," "disparities," and the Index Medicus terms for each racial/ethnic minority group.
Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders.
Racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions.
Adverse early life events can induce long-lasting changes in physiology and behavior. We found that early-life stress (ELS) in mice caused enduring hypersecretion of corticosterone and alterations in passive stress coping and memory. This phenotype was accompanied by a persistent increase in arginine vasopressin (AVP) expression in neurons of the hypothalamic paraventricular nucleus and was reversed by an AVP receptor antagonist. Altered Avp expression was associated with sustained DNA hypomethylation of an important regulatory region that resisted age-related drifts in methylation and centered on those CpG residues that serve as DNA-binding sites for the methyl CpG-binding protein 2 (MeCP2). We found that neuronal activity controlled the ability of MeCP2 to regulate activity-dependent transcription of the Avp gene and induced epigenetic marking. Thus, ELS can dynamically control DNA methylation in postmitotic neurons to generate stable changes in Avp expression that trigger neuroendocrine and behavioral alterations that are frequent features in depression.
Biological, psychological, and social processes interact over a lifetime to influence health and vulnerability to disease. Those interested in studying and understanding how and why racial/ethnic and social disparities emerge need to focus on the intersection of these processes. Recent work exploring molecular epigenetic mechanisms of gene expression (in humans as well and other mammalian systems) has provided evidence demonstrating that the genome is subject to regulation by surrounding contexts (eg, cytoplasmic, cellular, organismic, social). The developing stress axis is exquisitely sensitive to regulation by social forces represented at the level of the epigenome. Old assumptions about an inert genome are simply incorrect. Epigenetic processes may provide the missing link that will allow us to understand how social and political conditions, along with individual subjective experiences, can directly alter gene expression and thereby contribute to observed social inequalities in health. Developmental neurogenomics may provide the direct link between the biological and social/psychological worlds. These biological mechanisms of plasticity (at the level of gene expression and regulation) may play a profound role in how we conceptualize health inequalities by informing our concepts regarding the somatization or embodiment of social inequalities.
Previously published analyses showed that inequalities in mortality rates between residents of poor and wealthy neighborhoods in New York City (NYC) narrowed between 1990 and 2000, but these trends may have been influenced by population in-migration and gentrification. The NYC public housing population has been less subject to these population shifts than those in other NYC neighborhoods. We compared changes in mortality rates (MRs) from 1989-1991 to 1999-2001 among residents of NYC census blocks consisting entirely of public housing residences with residents of nonpublic housing low-income and higher-income blocks. Public housing and nonpublic housing low-income blocks were those in census block groups with > or =50% of residents living at <1.5 times the federal poverty level (FPL); nonpublic housing higher-income blocks were those in census block groups with <50% of residents living at <1.5 times the FPL. Information on deaths was obtained from NYC's vital registry, and US Census data were used for denominators. Age-standardized all-cause MRs in public housing, low-income, and higher-income residents decreased between the decades by 16%, 28%, and 22%, respectively. While mortality rate ratios between low-income and higher-income residents narrowed by 8%, the relative disparity between public housing and low-income residents widened by 21%. Diseases amenable to prevention including malignancies, diabetes, and chronic lung disease contributed to the increased overall mortality disparity between public housing and lower-income residents. These findings temper previous findings that inequalities in the health of poor and wealthier NYC neighborhood residents have narrowed. NYC public housing residents should be a high-priority population for efforts to reduce health disparities.
Policy makers have widely endorsed the idea that educational and economic achievement are a function of early childhood experience and development and can be improved through interventions such as preschool.¹,2 However, they have yet to fully embrace that adolescent and adult health is also profoundly affected by early childhood experiences and can similarly be improved through wise public investments. Neurobiological, behavioral, and social science research conclusively shows that early adverse experiences can affect brain development and increase vulnerability to a broad range of mental and physical health problems.³- 5 In addition, health depends on developing psychological, behavioral, and social competencies built on a foundation of safety, stability, and nurturance that is laid down early in life and that buffers against early adversity.³,5
A scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life. These early experiences can affect adult health in 2 ways--either by cumulative damage over time or by the biological embedding of adversities during sensitive developmental periods. In both cases, there can be a lag of many years, even decades, before early adverse experiences are expressed in the form of disease. From both basic research and policy perspectives, confronting the origins of disparities in physical and mental health early in life may produce greater effects than attempting to modify health-related behaviors or improve access to health care in adulthood.
The relationship between adverse childhood exposures and poor health, illness, and somatic complaints at age 12 was examined.
LONGSCAN (Consortium for Longitudinal Studies of Child Abuse and Neglect) tracks a group of children with variable risk for maltreatment. Of the participating child-caregiver dyads, 805 completed an interview when the child was age 4 or age 6, as well as interviews at age 8 and 12. The relationships between 8 categories of childhood adversity (psychological maltreatment, physical abuse, sexual abuse, child neglect, caregiver's substance/alcohol use, caregiver's depressive symptoms, caregiver's being treated violently, and criminal behavior in the household) and child health at age 12 were analyzed. The impact of adversity in the first 6 years of life and adversity in the second 6 years of life on child health were compared.
Only 10% of the children had experienced no adversity, while more than 20% had experienced 5 or more types of childhood adversity. At age 12, 37% of the children sampled had some health complaint. Exposure to 5 or more adversities, particularly exposure in the second 6 years of life, was significantly associated with increased risks of any health complaint (odds ratio [OR] 2.24, 95% confidence interval [95% CI] 1.02-4.96), an illness requiring a doctor (OR 3.69, 95% CI 1.02-15.1), and caregivers' reports of child's somatic complaints (OR 3.37, 95% CI 1.14-1.0). There was no association between adverse exposures and self-rated poor health or self-rated somatic complaints.
A comprehensive assessment of children's health should include a careful history of their past exposure to adverse conditions and maltreatment. Interventions aimed at reducing these exposures may result in better child health.
Toll-like receptors (TLRs) form a large family of pattern recognition receptors with at least 11 members in human and 13 in mouse. TLRs recognize a wide variety of microbial components and potential host-derived agonists that have emerged as key mediators of innate immunity. TLR signaling also plays an important role in the activation of the adaptive immune system by inducing proinflammatory cytokines and upregulating costimulatory molecules of antigen presenting cells. The dysregulation of TLR signaling may cause autoimmunity. This review discusses the contribution of TLR signaling to the initiation and progression of autoimmune diseases, such as rheumatoid arthritis, experimental autoimmune encephalitis, myocarditis, hepatitis, kidney disease, systemic lupus erythematosus, diabetes, obesity, and experimental autoimmune uveitis as well as aging. The involvement of TLR signaling in the pathogenesis of autoimmune diseases may provide novel targets for the development of therapeutics.
We examined the socioeconomic distribution of adolescent exposure to bullying internationally and documented the contribution of the macroeconomic environment.
We used an international survey of 162,305 students aged 11, 13, and 15 years from nationally representative samples of 5998 schools in 35 countries in Europe and North America for the 2001-2002 school year. The survey used standardized measures of exposure to bullying and socioeconomic affluence.
Adolescents from families of low affluence reported higher prevalence of being victims of bullying (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.10, 1.16). International differences in prevalence of exposure to bullying were not associated with the economic level of the country (as measured by gross national income) or the school, but wide disparities in affluence at a school and large economic inequality (as measured by the Gini coefficient) at the national level were associated with an increased prevalence of exposure to bullying.
There is socioeconomic inequality in exposure to bullying among adolescents, leaving children of greater socioeconomic disadvantage at higher risk of victimization. Adolescents who attend schools and live in countries where socioeconomic differences are larger are at higher risk of being bullied.
Our goal was to determine whether adverse childhood experiences predicted the age at which drinking was initiated and drinking motives in a representative sample of current or former drinkers in the United States.
In 2006, a probability sample of 3592 US current or former drinkers aged 18 to 39 were surveyed. Multinomial logistic regression examined whether each of 10 adverse childhood experiences was associated with earlier ages of drinking onset, controlling for demographics, parental alcohol use, parental attitudes toward drinking, and peers' drinking in adolescence. We also examined whether there was a graded relationship between the number of adverse childhood experiences and age of drinking onset and whether adverse childhood experiences were related to self-reported motives for drinking during the first year that respondents drank.
Sixty-six percent of respondents reported >or=1 adverse childhood experiences, and 19% reported experiencing >or=4. The most commonly reported adverse childhood experiences were parental separation/divorce (41.3%), living with a household member who was a problem drinker (28.7%), mental illness of a household member (24.8%), and sexual abuse (19.1%). Of the 10 specific adverse childhood experiences assessed, 5 were significantly associated with initiating drinking at <or=14 years of age (compared with at >or=21 years of age) after adjustment for confounders, including physical abuse, sexual abuse, having a mentally ill household member, substance abuse in the home, and parental discord or divorce. Compared with those without adverse childhood experiences, respondents with adverse childhood experiences were substantially more likely to report that they drank to cope during the first year that they used alcohol.
Results suggest that children with particular adverse childhood experiences may initiate drinking earlier than their peers and that they may be more likely to drink to cope with problems (rather than for pleasure or to be social).
Over 60 years ago, Selye1 recognized the paradox that the physiologic systems activated by stress can not only protect and restore but also damage the body. What links these seemingly contradictory roles? How does stress influence the pathogenesis of disease, and what accounts for the variation in vulnerability to stress-related diseases among people with similar life experiences? How can stress-induced damage be quantified? These and many other questions still challenge investigators. This article reviews the long-term effect of the physiologic response to stress, which I refer to as allostatic load.2 Allostasis — the ability to achieve stability through change3 — . . .
Until recently, when anthrax triggered a concern about preparedness in the public health infrastructure, U.S. health policy and health spending had been dominated by a focus on payment for medical treatment. The fact that many of the conditions driving the need for treatment are preventable ought to draw attention to policy opportunities for promoting health. Following a brief review of the determinants of population health-genetic predispositions, social circumstances, environmental conditions, behavioral patterns, and medical care-this paper explores some of the factors inhibiting policy attention and resource commitment to the nonmedical determinants of population health and suggests approaches for sharpening the public policy focus to encourage disease prevention and health promotion.
Research into social inequalities in health has tended to focus on low socioeconomic status in adulthood. We aimed to test the hypothesis that children's experience of socioeconomic disadvantage is associated with a wide range of health risk factors and outcomes in adult life.
We studied an unselected cohort of 1000 children (born in New Zealand during 1972-73) who had been assessed at birth and ages 3, 5, 7, 9, 11, 13, and 15 years. At age 26 years, we assessed these individuals for health outcomes including body-mass index, waist:hip ratio, blood pressure, cardiorespiratory fitness, dental caries, plaque scores, gingival bleeding, periodontal disease, major depression, and tobacco and alcohol dependence, and tested for associations between these variables and childhood and adult socioeconomic status.
Compared with those from high socioeconomic status backgrounds, children who grew up in low socioeconomic status families had poorer cardiovascular health. Significant differences were also found on all dental health measures, with a threefold increase in adult periodontal disease (31.1% vs 11.9%) and caries level (32.2% vs 9.9%) in low versus high childhood socioeconomic status groups. Substance abuse resulting in clinical dependence was related in a similar way to childhood socioeconomic status (eg, 21.5% vs 12.1% for adult alcohol dependence). The longitudinal associations could not be attributed to life-course continuity of low socioeconomic status, and upward mobility did not mitigate or reverse the adverse effects of low childhood socioeconomic status on adult health.
Protecting children against the effects of socioeconomic adversity could reduce the burden of disease experienced by adults. These findings provide strong impetus for policy makers, practitioners, and researchers to direct energy and resources towards childhood as a way of improving population health.
Little is known about the mechanisms converting psychosocial stress into cellular dysfunction. Various genes, up-regulated in atherosclerosis but also by psychosocial stress, are controlled by the transcription factor nuclear factor kappaB (NF-kappaB). Therefore, NF-kappaB is a good candidate to convert psychosocial stress into cellular activation. Volunteers were subjected to a brief laboratory stress test and NF-kappaB activity was determined in peripheral blood mononuclear cells (PBMC), as a window into the body and because PBMC play a role in diseases such as atherosclerosis. In 17 of 19 volunteers, NF-kappaB was rapidly induced during stress exposure, in parallel with elevated levels of catecholamines and cortisol, and returned to basal levels within 60 min. To model this response, mice transgenic for a strictly NF-kappaB-controlled beta-globin transgene were stressed by immobilization. Immobilization resulted in increased beta-globin expression, which could be reduced in the presence of the alpha1-adrenergic inhibitor prazosin. To define the role of adrenergic stimulation in the up-regulation of NF-kappaB, THP-1 cells were induced with physiological amounts of catecholamines for 10 min. Only noradrenaline resulted in a dose- and time-dependent induction of NF-kappaB and NF-kappaB-dependent gene expression, which depended on pertussis-toxin-sensitive G protein-mediated phosphophatidylinositol 3-kinase, Ras/Raf, and mitogen-activated protein kinase activation. Induction was reduced by alpha(1)- and beta-adrenergic inhibitors. Thus, noradrenaline-dependent adrenergic stimulation results in activation of NF-kappaB in vitro and in vivo. Activation of NF-kappaB represents a downstream effector for the neuroendocrine response to stressful psychosocial events and links changes in the activity of the neuroendocrine axis to the cellular response.
This article establishes that a low-dimensional vector of cognitive and noncognitive skills explains a variety of labor market and behavioral outcomes. Our analysis addresses the problems of measurement error, imperfect proxies, and reverse causality that plague conventional studies. Noncognitive skills strongly influence schooling decisions and also affect wages, given schooling decisions. Schooling, employment, work experience, and choice of occupation are affected by latent noncognitive and cognitive skills. We show that the same low-dimensional vector of abilities that explains schooling choices, wages, employment, work experience, and choice of occupation explains a wide variety of risky behaviors.
Context In recent years, smoking among adolescents has increased and the decline
of adult smoking has slowed to nearly a halt; new insights into tobacco dependency
are needed to correct this situation. Long-term use of nicotine has been linked
with self-medicating efforts to cope with negative emotional, neurobiological,
and social effects of adverse childhood experiences.
Objective To assess the relationship between adverse childhood experiences and
5 smoking behaviors.
Design The ACE Study, a retrospective cohort survey including smoking and exposure
to 8 categories of adverse childhood experiences (emotional, physical, and
sexual abuse; a battered mother; parental separation or divorce; and growing
up with a substance-abusing, mentally ill, or incarcerated household member),
conducted from August to November 1995 and January to March 1996.
Setting A primary care clinic for adult members of a large health maintenance
organization in San Diego, Calif.
Participants A total of 9215 adults (4958 women and 4257 men with mean [SD] ages
of 55.3 [15.7] and 58.1 [14.5] years, respectively) who responded to a survey
questionnaire, which was mailed to all patients 1 week after a clinic visit.
Main Outcome Measures Smoking initiation by age 14 years or after age 18 years, and status
as ever, current, or heavy smoker.
Results At least 1 of 8 categories of adverse childhood experiences was reported
by 63% of respondents. After adjusting for age, sex, race, and education,
each category showed an increased risk for each smoking behavior, and these
risks were comparable for each category of adverse childhood experiences.
Compared with those reporting no adverse childhood experiences, persons reporting
5 or more categories had substantially higher risks of early smoking initiation
(odds ratio [OR], 5.4; 95% confidence interval [CI], 4.1-7.1), ever smoking
(OR, 3.1; 95% CI, 2.6-3.8), current smoking (OR, 2.1; 95% CI, 1.6-2.7), and
heavy smoking (OR, 2.8; 95% CI, 1.9-4.2). Each relationship between smoking
behavior and the number of adverse childhood experiences was strong and graded
(P<.001). For any given number of adverse childhood
experiences, recent problems with depressed affect were more common among
smokers than among nonsmokers.
Conclusions Smoking was strongly associated with adverse childhood experiences.
Primary prevention of adverse childhood experiences and improved treatment
of exposed children could reduce smoking among both adolescents and adults.
Curricular enhancements in early childhood education that are guided by the science of learning must be augmented by protective interventions informed by the biology of adversity. The same neuroplasticity that leaves emotional regulation, behavioral adaptation, and executive functioning skills vulnerable to early disruption by stressful environments also enables their successful development through focused interventions during sensitive periods in their maturation. The early childhood field should therefore combine cognitive-linguistic enrichment with greater attention to preventing, reducing, or mitigating the consequences of significant adversity on the developing brain. Guided by this enhanced theory of change, scientists, practitioners, and policy-makers must work together to design, implement, and evaluate innovative strategies to produce substantially greater impacts than those achieved by existing programs.
Every year, more than 400,000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pediatric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.
Although the future of pediatrics is uncertain, the organizations that lead pediatrics, and the professionals who practice within it, have embraced the notion that the pediatric community must anticipate and lead change to ultimately improve the health of children and adolescents. In an attempt to proactively prepare for a variety of conceivable futures, the board of directors of the American Academy of Pediatrics established the Vision of Pediatrics 2020 Task Force in 2008. This group was charged to think broadly about the future of pediatrics, to gather input on key trends that are influencing the future, to create likely scenarios of the future, and to recommend strategies to best prepare pediatric clinicians and pediatric organizations for a range of potential futures. The work of this task force led to the development of 8 "megatrends" that were identified as highly likely to have a profound influence on the future of pediatrics. A separate list of "wild-card" scenarios was created of trends with the potential to have a substantial influence but are less likely to occur. The process of scenario-planning was used to consider the effects of the 8 megatrends on pediatrics in the year 2020 and beyond. Consideration of these possible scenarios affords the opportunity to determine potential future pediatric needs, to identify potential solutions to address those needs, and, ultimately, to proactively prepare the profession to thrive if these or other future scenarios become realities.
Child and adolescent psychiatry is rife with examples of the sustained effects of early experience on brain function. The study of behavioral genetics provides evidence for a relation between genomic variation and personality and with the risk for psychopathology. A pressing challenge is that of conceptually integrating findings from genetics into the study of personality without regressing to arguments concerning the relative importance of genomic variation versus nongenomic or environmental influences.
Epigenetics refers to functionally relevant modifications to the genome that do not involve a change in nucleotide sequence. This review examines epigenetics as a candidate biological mechanism for gene x environment interactions, with a focus on environmental influences that occur during early life and that yield sustained effects on neural development and function.
The studies reviewed suggest that epigenetic remodeling occurs in response to the environmental activation of cellular signalling pathways associated with synaptic plasticity, epigenetic marks are actively remodeled during early development in response to environmental events that regulate neural development and function, and epigenetic marks are subject to remodeling by environmental influences even at later stages in development.
Epigenetic remodeling might serve as an ideal mechanism for phenotypic plasticity--the process whereby the environment interacts with the genome to produce individual differences in the expression of specific traits.
A growing body of evidence indicates that children reared in harsh families are prone to chronic diseases and premature death later in life. To shed light on the mechanisms potentially underlying this phenomenon, we evaluated the hypothesis that harsh families engender a proinflammatory phenotype in children that is marked by exaggerated cytokine responses to bacterial stimuli and resistance to the anti-inflammatory properties of cortisol. We repeatedly measured psychological stress and inflammatory activity in 135 female adolescents on four occasions over 1.5 years. To the extent that they were reared in harsh families, participants displayed an increasingly proinflammatory phenotype during the follow-up analyses. This phenotype was marked by increasingly pronounced cytokine responses to in vitro bacterial challenge and a progressive desensitization of the glucocorticoid receptor, which hampered cortisol's ability to properly regulate inflammatory responses. If sustained, these tendencies may place children from harsh families on a developmental trajectory toward the chronic diseases of aging.
Four decades of early childhood policy and program development indicate that evidence-based interventions can improve life outcomes, and dramatic advances in the biological and behavioral sciences now provide an opportunity to augment those impacts. The challenge of reducing the gap between what we know and what we do to promote the healthy development of young children is to view current best practices as a starting point and to leverage scientific concepts to inspire fresh thinking. This article offers an integrated, biodevelopmental framework to promote greater understanding of the antecedents and causal pathways that lead to disparities in health, learning, and behavior in order to inform the development of enhanced theories of change to drive innovation in policies and programs.
Variations in phenotype reflect the influence of environmental conditions during development on cellular functions, including that of the genome. The recent integration of epigenetics into developmental psychobiology illustrates the processes by which environmental conditions in early life structurally alter DNA, providing a physical basis for the influence of the perinatal environmental signals on phenotype over the life of the individual. This review focuses on the enduring effects of naturally occurring variations in maternal care on gene expression and phenotype to provide an example of environmentally driven plasticity at the level of the DNA, revealing the interdependence of gene and environmental in the regulation of phenotype.
The understanding of nature and nurture within developmental science has evolved with alternating ascendance of one or the other as primary explanations for individual differences in life course trajectories of success or failure. A dialectical perspective emphasizing the interconnectedness of individual and context is suggested to interpret the evolution of developmental science in similar terms to those necessary to explain the development of individual children. A unified theory of development is proposed to integrate personal change, context, regulation, and representational models of development.
The brain is the key organ of stress reactivity, coping, and recovery processes. Within the brain, a distributed neural circuitry determines what is threatening and thus stressful to the individual. Instrumental brain systems of this circuitry include the hippocampus, amygdala, and areas of the prefrontal cortex. Together, these systems regulate physiological and behavioral stress processes, which can be adaptive in the short-term and maladaptive in the long-term. Importantly, such stress processes arise from bidirectional patterns of communication between the brain and the autonomic, cardiovascular, and immune systems via neural and endocrine mechanisms underpinning cognition, experience, and behavior. In one respect, these bidirectional stress mechanisms are protective in that they promote short-term adaptation (allostasis). In another respect, however, these stress mechanisms can lead to a long-term dysregulation of allostasis in that they promote maladaptive wear-and-tear on the body and brain under chronically stressful conditions (allostatic load), compromising stress resiliency and health. This review focuses specifically on the links between stress-related processes embedded within the social environment and embodied within the brain, which is viewed as the central mediator and target of allostasis and allostatic load.
Early adversity, for example poor caregiving, can have profound effects on emotional development. Orphanage rearing, even in the best circumstances, lies outside of the bounds of a species-typical caregiving environment. The long-term effects of this early adversity on the neurobiological development associated with socio-emotional behaviors are not well understood. Seventy-eight children, who include those who have experienced orphanage care and a comparison group, were assessed. Magnetic resonance imaging (MRI) was used to measure volumes of whole brain and limbic structures (e.g. amygdala, hippocampus). Emotion regulation was assessed with an emotional go-nogo paradigm, and anxiety and internalizing behaviors were assessed using the Screen for Child Anxiety Related Emotional Disorders, the Child Behavior Checklist, and a structured clinical interview. Late adoption was associated with larger corrected amygdala volumes, poorer emotion regulation, and increased anxiety. Although more than 50% of the children who experienced orphanage rearing met criteria for a psychiatric disorder, with a third having an anxiety disorder, the group differences observed in amygdala volume were not driven by the presence of an anxiety disorder. The findings are consistent with previous reports describing negative effects of prolonged orphanage care on emotional behavior and with animal models that show long-term changes in the amygdala and emotional behavior following early postnatal stress. These changes in limbic circuitry may underlie residual emotional and social problems experienced by children who have been internationally adopted.
In this article we argue for the utility of the life-course perspective as a tool for understanding and addressing health disparities across socioeconomic and racial or ethnic groups, particularly disparities that originate in childhood. Key concepts and terms used in life-course research are briefly defined; as resources, examples of existing literature and the outcomes covered are provided along with examples of longitudinal databases that have often been used for life-course research. The life-course perspective focuses on understanding how early-life experiences can shape health across an entire lifetime and potentially across generations; it systematically directs attention to the role of context, including social and physical context along with biological factors, over time. This approach is particularly relevant to understanding and addressing health disparities, because social and physical contextual factors underlie socioeconomic and racial/ethnic disparities in health. A major focus of life-course epidemiology has been to understand how early-life experiences (particularly experiences related to economic adversity and the social disadvantages that often accompany it) shape adult health, particularly adult chronic disease and its risk factors and consequences. The strong life-course influences on adult health could provide a powerful rationale for policies at all levels--federal, state, and local--to give more priority to investment in improving the living conditions of children as a strategy for improving health and reducing health disparities across the entire life course.
To assess perspectives about the practice of well-child care among pediatric clinicians, especially in the areas of child development and behavior.
Thirty-one focus groups (282 pediatricians and 41 pediatric nurse practitioners) in 13 cities addressed current practices, priorities used to determine content of well-child care visits, and changes to improve visit quality and outcomes.
Although most clinicians were positive about their practice of well-child care, they reported areas of concern and suggested ideas for improvements. Establishing a therapeutic relationship and individualizing care were viewed as significant contributions to quality of care. Participants agreed about the importance of eliciting parent concerns as the first priority for all well-child care visits. Community resources outside the office setting were seen as both a major influence on and, in some communities, a limitation to pediatric care. The challenges of early recognition of developmental and behavior problems through standardized questionnaires and effective interviewing were viewed as a priority to improve pediatric effectiveness in monitoring and treatment. To enhance primary care practices in developmental and behavioral pediatrics, participants suggested innovations in practice organization, community linkages, information technology, and integration of existing innovative programs. Education for pediatricians and enhanced resident training in developmental and behavioral pediatrics were endorsed.
Pediatric clinicians' support a vision of preventive care that is comprehensive, family centered, and developmentally relevant, both for children with greater risk to long-term healthy development and for families with more normative child-rearing concerns.
The content and systems surrounding well-child care have received increasing attention, and some propose that it is time to rethink both the delivery structure and central themes of well-child visits. A key, but largely missing perspective in these discussions has been that of parents, whose experiences and expectations are central to developing approaches responsive to family needs. In this study, we asked parents to address several core issues: why they attend well-child visits; aspects of well-child care that they find most valuable; and changes that could enhance the well-child care experience.
Twenty focus groups with parents (n = 131 [91% mothers]) were conducted by using a semistructured interview guide. Verbatim transcripts were coded for key words, concepts, and recurrent themes.
Primary reasons for visit attendance included reassurance (child and parent) and an opportunity to discuss parent priorities. Families valued an ongoing relationship with 1 clinician who was child-focused and respected parental expertise, but continuity of provider was not an option for all participants. Suggestions for enhancement included improved promotion of well-child care, greater emphasis on development and behavior, and expanded options for information exchange.
As the consumers of care, it is critical to understand parents' needs and desires as changes to the content and process of well-child care are considered. Taking into account the multifaceted perspectives of families suggests both challenges and opportunities for the rethinking discussion.
The aim of this study was to examine sociodemographic disparities in having a quality medical home among a nationally representative sample of children with asthma.
The study examined data from the 2003 National Survey of Children's Health to identify 8360 children aged 2-17 years with asthma. Risk factors including nonwhite race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education less than high school, and non-English language, were examined individually and as a profile of risk in relation to a quality medical home. Fourteen questions were used to measure 5 medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. A poorer quality medical home was defined as < or =66 on a 100-point scale-corresponding to the feature being present less than "usually"-for each feature and for an overall score.
Before and after adjustment for demographics and asthma difficulties, most risks except less than high school parent education were related to a poorer quality medical home. Uninsured children had the highest odds of a poorer quality medical home overall (adjusted odds ratio [OR] 5.19, 95% confidence interval [CI] 3.52-7.65) and across most features, except for coordination. Children experiencing 3+ risks had 8.56 times the odds of a poorer quality medical home overall (95% CI 4.95-14.78) versus zero risks.
This study demonstrates large national disparities in a quality medical home for children with asthma. That disparities were most prevalent for the uninsured (insurance being a modifiable risk factor) suggests increasing coverage is essential to assuring that children obtain a quality medical home.
A 2003 publication by the Institute of Medicine raised awareness regarding persistent disparities in health care in the United States.1 However, of the 103 studies reviewed in the report, only 5 focused on disparities for children. Based on the expectation of a significantly more diverse child population by 2020,2 and the large number of children living in poverty, greater attention is needed on vulnerable children and their potential for a healthy and productive adulthood. Much research has documented persistent or increasing child health disparities by population, disease, risk factors, and geography, but there is a paucity of research on successful interventions. Life-course research demonstrates the power of early childhood health and experiences influencing adult health such as cardiovascular disease, type 2 diabetes, hypertension, and mental health.3 To eliminate health disparities, greater attention is needed for research and intervention within a life-course perspective,3- 4 with collaboration horizontally across the age span for obstetrics, pediatrics, and adult medicine, and vertically across multiple disciplines and perspectives.
Several lines of evidence point to the early origin of adult onset disease. A key question is: what are the mechanisms that mediate the effects of the early environment on our health? Another important question is: what is the impact of the environment during adulthood and how reversible are the effects of early life later in life? The genome is programmed by the epigenome, which is comprised of chromatin, a covalent modification of DNA by methylation and noncoding RNAs. The epigenome is sculpted during gestation, resulting in the diversity of gene expression programs in the distinct cell types of the organism. Recent data suggest that epigenetic programming of gene expression profiles is sensitive to the early-life environment and that both the chemical and social environment early in life could affect the manner by which the genome is programmed by the epigenome. We propose that epigenetic alterations early in life can have a life-long lasting impact on gene expression and thus on the phenotype, including susceptibility to disease. We will discuss data from animal models as well as recent data from human studies supporting the hypothesis that early life social-adversity leaves its marks on our epigenome and affects stress responsivity, health, and mental health later in life.
Several studies have suggested that high-sensitivity C-reactive protein (hsCRP) is a strong independent predictor of acute myocardial infarction and cardiovascular death. In the specific heart failure (HF) context, a low-grade inflammatory state can contribute to HF progression.
To perform a systematic review on the current knowledge about low-grade inflammation, as assessed by hsCRP, in the prediction of HF in general and in high-risk populations as well as its prognostic value in established HF.
We used a computerized literature search in the Medline database using the following key words: C-Reactive Protein, Heart Failure, Cardiomyopathy, Cardiac Failure, Prognosis, and Death. Articles were selected if they had measurements of hsCRP in different patient samples and reference to outcomes in terms of morbidity and mortality.
hsCRP is associated with incident HF in general and high-risk populations and provides prognostic information in HF patients. In almost all studies, the association of hsCRP with clinical events was independent of other baseline variables known to influence morbidity and mortality. Very different cutoffs have been proposed in each context across studies.
The prognostic power of hsCRP, whether we consider incident HF or adverse outcomes in established HF, is consistent in different patient populations.
Cardiovascular disease, in which atherosclerosis is the major underlying cause, is currently the largest cause of death in the world. Atherosclerosis is an inflammatory disease characterized by the formation of arterial lesions over a period of several decades at sites of endothelial cell dysfunction. These lesions are composed of endothelial cells, vascular smooth muscle cells, monocytes/macrophages and T lymphocytes (CD4(+)). As the lesions progress some can become unstable and prone to disruption, resulting in thrombus formation and possibly a myocardial infarction or stroke depending upon the location. Although the exact triggers for plaque disruption remain unknown, much recent evidence has shown a link between the incidence of myocardial infarction and stroke and a recent respiratory tract infection. Interestingly, many reports have also shown a link between a family of pattern recognition receptors, the Toll-like receptors, and the progression of atherosclerosis, suggesting that infections may play a role in both the progression of atherosclerosis and in inducing the more severe complications associated with the disease.
Using prospective data from 485 adolescents over a 10-year period, the present study identifies distinct segments of depressive symptom trajectories--a nonsignificant slope during adolescence and a significant negative slope during the transition to adulthood. The study hypothesized that different age-graded life experiences would differentially influence these depressive symptom growth parameters. The findings show that early stressful experiences associated with family-of-origin SES affect the initial level of depressive symptoms. Experiences with early transitional events during adolescence explain variation in the slope of depressive symptoms during the transition to adulthood. The growth parameters of depressive symptoms and an early transition from adolescence to adulthood constrain young adult social status attainment. Consistent with the life-course perspective, family-of-origin adversity is amplified across the life-course by successively contingent adverse circumstances involving life-transition difficulties and poor mental health. The findings also provide evidence for intergenerational transmission of social adversity through health trajectories and social pathways.
Chronic infection with the hepatitis C virus, a noncytopathic hepatotropic RNA virus, affects over 170 million people worldwide. In the majority of cases, neither the early innate immune response nor the later adaptive immune response succeeds in clearing the virus, and the infection becomes chronic. Furthermore, in many patients, the ineffective inflammatory response drives fibrogenesis and the development of cirrhosis. It is critical to understand this immune pathology if preventative and curative therapies are to be developed. Chemokines are a superfamily of small proteins that promote leukocyte migration and orchestrate the immune response to viruses, including hepatitis C virus. Chemokines are crucial for viral elimination, but inappropriate persistence of expression in chronic hepatitis C infection can drive tissue damage and inflammation. Here we review the role of chemokines and their receptors in hepatitis C virus infection.
Childhood maltreatment and early trauma leave lasting imprints on neural mechanisms of cognition and emotion. With a rat model of infant maltreatment by a caregiver, we investigated whether early-life adversity leaves lasting epigenetic marks at the brain-derived neurotrophic factor (BDNF) gene in the central nervous system.
During the first postnatal week, we exposed infant rats to stressed caretakers that predominately displayed abusive behaviors. We then assessed DNA methylation patterns and gene expression throughout the life span as well as DNA methylation patterns in the next generation of infants.
Early maltreatment produced persisting changes in methylation of BDNF DNA that caused altered BDNF gene expression in the adult prefrontal cortex. Furthermore, we observed altered BDNF DNA methylation in offspring of females that had previously experienced the maltreatment regimen.
These results highlight an epigenetic molecular mechanism potentially underlying lifelong and transgenerational perpetuation of changes in gene expression and behavior incited by early abuse and neglect.
To determine the relationship between housing instability, economic standing, and access to health care and use of acute care services.
We performed a meta-regression using four nationally representative surveys. The independent variable was an ordered measure of economic and housing instability: 1) the general population, 2) low-income population, 3) never homeless users-of-subsistence-services, 4) unstably housed, 5) formerly homeless, and 6) the actively homeless. Dependent variables were four measures of health care access and three measures of acute health care utilization.
Worsening housing instability and economic standing was associated with poorer access: being uninsured (5.4% per unit increase, 95% CI 1.7-9.2%, p=.011), postponing needed care (3.3%, 95% CI 1.9-4.7%, p=.001), postponing medications (6.1%, 95% CI 1.5-10.6%, p=.035), and with one measure of acute health care utilization: higher hospitalization rates (2.9%, 95% CI 1.2-4.6%, p=.008).
Economic and housing instability should be considered a graded risk factor for poor access to health care.
Millions of US children and adolescents lack health insurance coverage. Efforts to expand their insurance often focus on extending public coverage to uninsured parents. Less is known about the uninsured whose parents already have coverage.
To identify predictors of uninsurance among US children and adolescents with insured parents.
Cross-sectional and full-year analyses of pooled 2002-2005 data from the nationally representative Medical Expenditure Panel Survey (MEPS).
Children and adolescents younger than 19 years in 4 yearly MEPS files with positive full-year weights who had at least 1 parent residing in the same household. There were 39,588 in the unweighted cross-sectional analysis and 39,710 in the unweighted full-year analysis.
Prevalence of uninsurance among children and adolescents with at least 1 insured parent; predictors of uninsurance among children with at least 1 insured parent.
In the cross-sectional study population, 1380 of 39,588 children and adolescents were uninsured with at least 1 insured parent (weighted prevalence, 3.3%; 95% confidence interval [CI], 3.0%-3.6%). In multivariate analyses of children and adolescents with at least 1 insured parent, those uninsured were more likely Hispanic (odds ratio [OR], 1.58; 95% CI, 1.23-2.03) than white, non-Hispanic; low income (OR, 2.02; 95% CI, 1.42-2.88) and middle income (OR, 1.48; 95% CI, 1.09-2.03) than high income; from single-parent homes (OR, 1.99; 95% CI, 1.59-2.49) than from homes with 2 married parents; and living with parents who had less than a high school education (OR, 1.44; 95% CI, 1.10-1.89) than those with at least 1 parent who had completed high school. Those whose parents had public coverage were less likely to be uninsured (OR, 0.64; 95% CI, 0.43-0.96) than were those whose parents reported private health insurance. These predictors remained significant in full-year analyses. Similar patterns of vulnerability were also found among a subset of uninsured children with privately covered parents.
Among all US children, more than 3% were uninsured with at least 1 insured parent. Predictors of such uninsurance included having low and middle income. Having a parent covered by only public insurance was associated with better children's coverage rates.
ALTHOUGH I have considered presenting some of the work of our group on this occasion, I have elected, rather, to discuss an issue which I feel to be of importance not alone to those of us interested in child development, but to all pediatricians (and indeed to all interested in child welfare). I refer to the role of child development in pediatrics—most particularly academic pediatrics.
To the members of this section it is no surprise to observe that teaching and research in child development have not been integrated into the mainstream of academic pediatrics. It continues, with rare exceptions, to be treated as a minority group in the academic community, even though a knowledge of child development is a major concern of the practicing pediatrician. This relative neglect causes me to inquire as to whether we are to have two cultures or one in pediatrics. At the outset I wish to indicate that my bias is clearly in favor of a unitarian view. For, I believe we continue this dichotomy at our peril in pediatric teaching and research.
Perhaps we can deal with this problem better if we understand how we came to be this way. I will, therefore, attempt to develop my thesis from an historical perspective. These periods are arbitrarily defined; although starting dates are given, there are no end points, since each new period is telescoped into the rich history of its antecedents (Fig. 1).
The prescientific era in pediatrics (prior to 1900) was rich in contributions to our understanding of child development.
The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.
A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life.
More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.
We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
Stress is a condition of human existence and a factor in the expression of disease. A broader view of stress is that it is not just the dramatic stressful events that exact their toll but rather the many events of daily life that elevate activities of physiological systems to cause some measure of wear and tear. We call this wear and tear "allostatic load," and it reflects not only the impact of life experiences but also of genetic load; individual habits reflecting items such as diet, exercise, and substance abuse; and developmental experiences that set life-long patterns of behavior and physiological reactivity (see McEwen). Hormones associated with stress and allostatic load protect the body in the short run and promote adaptation, but in the long run allostatic load causes changes in the body that lead to disease. This will be illustrated for the immune system and brain. Among the most potent of stressors are those arising from competitive interactions between animals of the same species, leading to the formation of dominance hierarchies. Psychosocial stress of this type not only impairs cognitive function of lower ranking animals, but it can also promote disease (e.g. atherosclerosis) among those vying for the dominant position. Social ordering in human society is also associated with gradients of disease, with an increasing frequency of mortality and morbidity as one descends the scale of socioeconomic status that reflects both income and education. Although the causes of these gradients of health are very complex, they are likely to reflect, with increasing frequency at the lower end of the scale, the cumulative burden of coping with limited resources and negative life events and the allostatic load that this burden places on the physiological systems involved in coping and adaptation.
Atherosclerosis is an inflammatory disease. Its lesions are filled with immune cells that can orchestrate and effect inflammatory responses. In fact, the first lesions of atherosclerosis consist of macrophages and T cells. Unstable plaques are particularly rich in activated immune cells, suggesting that they may initiate plaque activation. We have seen a rapid increase in the understanding of the mechanisms that govern the recruitment, differentiation, and activation of immune cells in atherosclerosis. Experimental research has identified several candidate antigens, and there are encouraging data suggesting that immune modulation as well as immunization can reduce the progression of the disease. This review provides an overview of our current understanding of the role of immune mechanisms in atherosclerosis.