Inequalities in Health and Educational Attainments of
Children
–
Could brain research help Public Health Interventions?
PD Dr. Freia De Bock Mannheim Ins+tute of Public Health, Social and Preven+ve Medicine Heidelberg University & Center on Child Neurology and Development, Frankfurt What‘s in a name?
•  „Chav“ Names
•  In Germany: „Kevinismus“ – „Kevinism“
„Kevin is not a name, Kevin is a disease“
De Bock I MIPH I Slide 2 of 12 I June 2010
Teacher expect
Issues with..
Behaviour
„Chav“ Names
Character/Motivation
„Kevin“ Names
Cognitive
Performance
?
Social Class
Socio-economic status
Poverty
De Bock I MIPH I Slide 3 of 12 I June 2010
How many children are relatively poor?
Mean
European
Union:
16.3%
De Bock I MIPH I Slide 4 of 12 I June 2010
Index of deprivation
No 3 meals/day
No quiet place for
homework
Less than two pairs
of shoes
No financial possibility
to celebrate birthdays
De Bock I MIPH I Slide 5 of 12 I June 2010
Unicef 2009
Children in a difficult social situation have...
More.....
Lack of exercise
Overweight
Entwicklungsstörungen
frühkindliche Regulationsstörungen
Depressionen
ADHS
Psychosomatische Beschwerden
Suchtprobleme (z.B. Rauchen)
Unfälle
Karies
Schlechtere.....
gesundheitsbezogene Lebensqualität
De Bock I MIPH I Slide 6 of 12 I June 2010
Children in a difficult social situation have...
More.....
Lack of exercise
Overweight
Developmental problems
Early childhood dysregulation
Depressionen
ADHS
Psychosomatische Beschwerden
Suchtprobleme (z.B. Rauchen)
Unfälle
Karies
Schlechtere.....
gesundheitsbezogene Lebensqualität
De Bock I MIPH I Slide 7 of 12 I June 2010
Children in a difficult social situation have...
More.....
Lack of exercise
Overweight
Developmental disorders
Early childhood dysregulation
Depression
ADHD
Psychosomatic disorders
Addictions (i.e. smoking)
Unfälle
Karies
Schlechtere.....
gesundheitsbezogene Lebensqualität
De Bock I MIPH I Slide 8 of 12 I June 2010
Children in a difficult social situation have...
More.....
Lack of exercise
Overweight
Developmental disorders
Early childhood dysregulation
Depression
ADHD
Psychosomatic disorders
Addictions (i.e. smoking)
Accidents
Caries
Worse.....
Health-related quality of life
De Bock I MIPH I Slide 9 of 12 I June 2010
Life satisfaction at 17 years
Zusammenhang von Armutserfahrung in der Kindheit und Lebenszufriedenheit im Alter von 17 Jahren
Life satisfaction
less than average
Average or Higher
Life Satisfaction
%
Years in relative poverty
De Bock I MIPH I Slide 10 of 12 I June 2010
Unicef 2013
„Poverty is the greatest health risk for children in Germany“
Bärbel-Maria Kurth,
Head of the division for epidemiology and health-reporting of the RKI
De Bock I MIPH I Slide 11 of 12 I June 2010
There is a strong association between a child’s social background an
readiness for school as measured by their scores on the schoo
assessments (p<0.001; confidence interval 0.71, 0.81). Table 5 sho
increasing score on the assessment with increasing social advantag
Educational
confirms our Risk
underpinning hypothesis that the child’s social backgr
associated with achievement in school.
Table 5. Distribution of social risk and entry assessment
Social risk score
0
1
2
3
4
5
6
Total
Number
(percent)
115 (1%)
467 (3.9%)
1022 (8.6%)
1475 (12.4%)
2886 (24.3%)
3322 (28%)
2566 (21.6%)
11853
School
score
11.04
10.63
11.24
12.17
12.68
13.37
14.69
28
De Bock I MIPH I Slide 12 of 12 I June 2010
entry
Alspac Study
What are the reasons for inequality?
De Bock I MIPH I Slide 13 of 12 I June 2010
Responsibility of individual behaviour –
It‘s your own fault!
De Bock I MIPH I Slide 14 of 12 I June 2010
In-utero Environment
Smoking during
pregnancy
1.5 times
higher risk
Overweight later in
life
Obesity during
pregnancy
3.8 times
higher risk
De Bock I MIPH I Slide 15 of 12 I June 2010
Oken, 2008
Monasta, 2010
Inherited intelligence deficit?
Born
Adopted
Low social status
Low social status
Youth
IQ=92
Δ Environ.= 12
High social
status
IQ=104
Δ Gen.= 16
High social
status
High social
status
Low social status
IQ=120
Δ Environ.= 13
IQ=107
Capron, 1989,
Nature
•  50% genetic, 50% Environment
•  Children with low social status:
Environment much more important (Turkheimer, 2003)
De Bock I MIPH I Slide 16 of 12 I June 2010
er 11- bis 17-Jährigen, die mindestens einmal
erlich
aktivenvironment
sind – Abweichung
vom Durchschnitt
Living
and exercise...
ährigen sind mindestens einmal pro Woche körperlich aktiv.
7,75
5,11
3,38
3,39
82.9%
–2,42
88
–7,68
–9,05
–10,23
Individual social
status of
Differenzierung
adolescents
Quartierstypen
High social
status
Middle
social status
Low social
status
Differenzierung Sozialstatus
De Bock I MIPH I Slide 17 of 12 I June 2010
plus Quartierstypen
From: „Gesundheit lernen“, Bertelsmann Stiftung
Social inequality=
Lifestyle, environment, intelligence?
De Bock I MIPH I Slide 18 of 12 I June 2010
The reverse effectiveness pyramid
Burden of risk
Effectiveness
Prevention
Social class lacking
ressources
Social class with many
resources
Prevention
De Bock I MIPH I Slide 19 of 12 I June 2010
Reduction in body fat after nutritional intervention
Reduction in body fat %
0
-0,1
High
Educational
status
Middle
Educational
status
Low
Educational
status
Total
-0,2
-0,3
Nicht signifikant
-0,4
-0,5
-0,6
P=0.002
-0,7
P<0.01
-0,8
-0,9
-1
P=0.018
De Bock I MIPH I Slide 20 of 12 I June 2010
De Bock et al., 2012
Reduction in body fat after nutritional intervention
Reduction in body fat %
0
-0,1
High
Educational
status
Middle
Educational
status
Low
Educational
status
Total
-0,2
-0,3
Nicht signifikant
-0,4
-0,5
-0,6
P=0.002
-0,7
P<0.01
-0,8
-0,9
-1
P=0.018
De Bock I MIPH I Slide 21 of 12 I June 2010
De Bock et al., 2012
Why do disadvantaged groups
benefit less from information
in terms of behaviour change?
De Bock I MIPH I Slide 22 of 12 I June 2010
How ‚poverty‘ gets under the skin and inside the
brain
Adverse
childhood
experiences
‚Poverty‘
•  Education
•  Material things
•  Relationships
Early childhood
Selbstregulation
Middle childhood
De Bock I MIPH I Slide 23 of 12 I June 2010
Adolescence
Adults
Adverse Childhood Experiences (ACE) - Study
Neglect and abuse in childhood
Examples
•  Repeated physical abuse/neglect
1
•  Repeated emotional neglect
0
•  Sexual abuse
0
Dysfunctionality of the household
•  Household member in jail
0
•  Violence against household member
1
•  Drugs and/or alcohol addiction in the household
0
•  Mental Health Problems, Depression or Suicidal tendencies among
0
parents
1
•  Loss of one parent during childhood(divorce, death)
ACE Score = 3
De Bock I MIPH I Slide 24 of 12 I June 2010
Fellitti et al. 1998
Prevalence of ACEs
Middle-class
Americans
> 1 ACE
50%
= 2 ACE
25%
> 6 ACE
Witness of a murder
Sexual Abuse (Girls)
22% (!)
De Bock I MIPH I Slide 25 of 12 I June 2010
Fellitti et al. 1998
Prevalence of ACEs
Middle-class
Americans
> 1 ACE
50%
= 2 ACE
25%
Youth in Prison
84%
> 6 ACE
50%
Witness of a murder
75%
Sexual Abuse (Girls)
22% (!)
De Bock I MIPH I Slide 26 of 12 I June 2010
40%
% Presently Smoki
ore, the greater the likelihood of current smoking. In other
16 words, current smoking is
related in a progressive dose-response manner to what happened
decades ago in
14
od. Finding ‘addiction’ attributable to characteristics that12are intrinsic in early life
ces challenges the conventional concept of addiction. The
10 psychoactive benefits of
are well established in the medical literature although they
8 are little remembered.
king and its related diseases the result of self-treatment of
6 concealed problems that
d in childhood?
4
ACE and health outcomes 25 years later
Smoking
2
ACE Score vs. Smoking
0
% Presently Smoking
20
0
18
1
2
3
4-5
ACE Score
16
14
Chronic obstructive pulmonary disease (COPD) also has a strong relationship
Score, as does the early onset of regular smoking. A person with an ACE Sco
more likely to have COPD than is a person with an ACE Score of 0. This rela
same graded, dose-response effect that is present for all the associations we fo
all the relationships presented here have a p value of .001 or stronger.
12
10
8
6
4
2
Chronic Obstructive
Pulmonary
ACE Score
vs. COPDDisease
0
0
1
2
3
4-5
6 or more
20
ACE Score
A C E S co re:
Percent With Problem
18
obstructive pulmonary disease (COPD) also has a strong relationship
to the ACE
0
2
3
1
6
s does the early onset of regular smoking. A person with an ACE Score of 14 is 260%
4
ely to have COPD than is a person with an ACE Score of 0. 1This
relationship has the
aded, dose-response effect that is present for all the associations
1 2 we found. Moreover,
elationships presented here have a p value of .001 or stronger.1 0
ACE Score vs. COPD
20
18
16
With Problem
6 or more
A C E S co re:
0
1
2
3
14
Felitti et al., 1998
12
10
4 o r m o re
4 o r m o re
8
6
4
2
0
In it ia t e d s m o k in g
b y a 2010
ge 14
De Bock I MIPH I Slide 27 of 12 I June
CO PD
How ‚poverty‘ gets under the skin and inside the
brain
Chronic stress
Adverse
childhood
experiences
‚Poverty‘
•  Education
•  Material things
•  Relationships
Early childhood
Selbstregulation
Middle childhood
De Bock I MIPH I Slide 28 of 12 I June 2010
Adolescence
Adults
How ‚poverty‘ gets under the skin and inside the
brain
‚Toxic‘ stress
Adverse
childhood
experiences
Development of the
brain
‚Poverty‘
•  Education
•  Material things
•  Relationships
Early childhood
Selbstregulation
Middle childhood
De Bock I MIPH I Slide 29 of 12 I June 2010
Adolescence
Adults
Effects of Poverty on Brain Development:
Systematic Review in Preparation
Recent Activity:
Extraction of data
De Bock I MIPH I Slide 30 of 12 I June 2010
De Bock et al., in prep.
Poverty and Brain Development: Preliminary Results:
Measurement
Findings
Effects on
Functional
correlates
MRI
Volume
Reduction
Prefrontal
Cortex
Executive
Function
EEG
EEG Changes
Thalamus
Working
memory
Evoked
Potentials
EP Changes
Basal Ganglia
Anatomy
Reduction of
Myelinization
and Synaptic
Connectivity
Left hemisphere Language
Inefficient
Pruning
De Bock I MIPH I Slide 31 of 12 I June 2010
De Bock et al., in prep.
Brain Changes through Child Development
3-28 y: prefrontal cortex, e.g. executive function
-7 y: language
Numbers of
synapses
3-6 y: logic planning
Birth
Time
8th week:
Birth:
Development 100 Milliards
brain and spinal neurons
cord finalized
1st year:
Myelinization
Synaptic
connectivity
End of 2nd year:
Myelinization
Synaptic
connectivity
End of 3rd year:
Synaptic
connectivity
increase
10th year:
Synaptic
connectivity
highest in life
Huge capacity for
De Bock I MIPH I Slide 32 of 12 I June 2010
learning
Youth:
Synaptic
connectivity
decrease
Adulthood:
Synaptic
connectivity
stable
Efficiency
How ‚poverty‘ gets under the skin and inside the
brain
‚Toxic‘ stress
Negative
childhood
experiences
Development of the
prefrontal cortex
‚Poverty‘
•  Education
•  Material things
•  Relationships
Early childhood
Self-regulation
Middle childhood
De Bock I MIPH I Slide 33 of 12 I June 2010
Adolescence
Adults
Self-regulation and later Health/ „sucess in life“
Indicators of physical and
mental health
Self-regulation in child age
Indicators of financial
prosperity
Self-regulation in child age
Moffitt, 2011, New Zealand (Scientific
Academy Leopoldina 2014)
De Bock I MIPH I Slide 34 of 12 I June 2010
Measuring cognitive self-regulation
Emotional
Selfregulation
Cognitive
De Bock I MIPH I Slide 35 of 12 I June 2010
Measuring cognitive self-regulation
Emotional
Selfregulation
Working memory
Executive
functions
Task-flexibility
„Shifting“
Cognitive
Behaviour inhibition
De Bock I MIPH I Slide 36 of 12 I June 2010
Green
De Bock I MIPH I Slide 37 of 12 I June 2010
Walter Mischel‘s experiment (1966)
The Marshmallow Test
De Bock I MIPH I Slide 38 of 12 I June 2010
Role of self-regulation in Behaviour change:
Information, Motivation, Behaviour Skills Model
Information
Behavioural Skills
Motivation
Health Behaviour
Self-regulatory competencies
Fisher & Fisher, 1992, Psych Bull
De Bock I MIPH I Slide 39 of 12 I June 2010
Self-regulation as a basis
Usage of information
Emotional
Health
Health-promoting
behaviour
Usage of a healthpromoting Setting
Selfregulation
Problemsolving
Cognitive
Creativity
Cognitive
Functions
e.g. language,
intelligence
De Bock I MIPH I Slide 40 of 12 I June 2010
Educational
success
Life-success
How can you use this knowledge for
health promotion?
De Bock I MIPH I Slide 41 of 12 I June 2010
‚Toxic‘ stress
Negative
childhood
experiences
Development of the
prefrontal cortex
‚Poverty‘
•  Education
•  Material things
•  Relationships
Early childhood
Self-regulation
Middle childhood
De Bock I MIPH I Slide 42 of 12 I June 2010
Adolescence
Adults
Methods against poverty: „New Public Health“ in
Sweden
Financial transfers....
De Bock I MIPH I Slide 43 of 12 I June 2010
‚Toxic‘ stress
Negative
childhood
experiences
Development of the
prefrontal cortex
‚Poverty‘
•  Education
•  Material things
•  Relationships
Early childhood
Self-regulation
Middle childhood
De Bock I MIPH I Slide 44 of 12 I June 2010
Adolescence
Adults
Development of the
prefrontal cortex/selfregulation
‚Toxic‘ stress
Information
Health Education
Fertilisation
Birth
1. Year of life
2. Year of life
Just a
small
effect!!!
Kindergarten School Adolescence
Changing the physical
environment
De Bock I MIPH I Slide 45 of 12 I June 2010
Development of the
prefrontal cortex/selfregulation
‚Toxic‘ stress
Successful
Relationship
parents
Fertilisation
Birth
1. Year of life
2. Year of life
De Bock I MIPH I Slide 46 of 12 I June 2010
Kindergarten School Adolescence
Nurse Family Partnership
3 Study from the USA
Veränderung
Cases of neglect
- 50 %
Admission to a hospital
- 80 %
Social welfare for mothers
- 20%
Other children under the age of 25
- 20 %
De Bock I MIPH I Slide 47 of 12 I June 2010
Parents-child-relationship
11/13 Visitation programmes: Significantly better Relationship
Parents
Children
Reading
é
Verhaltensprobleme
ê
Joint activities with child
é
emotionale Regulation
é
Interest in Kindergarten routine
é
Sichere Bindung
é
Sensibility during parents-child
interactions
é
niedriges Geburtsgewicht
ê
Educational stress
ê
Violence during education
ê
De Bock I MIPH I Slide 48 of 12 I June 2010
Brooks-Gunn, 2000
Parents-child-relationship
11/13 Visitation programmes: Significantly better Relationship
Children
Parents
Reading
é
Behavioural problems
ê
Joint activities with child
é
Emotional regulation
é
Interest in Kindergarten routine
é
Secure bond
é
Sensibility during parents-child
interactions
é
Low birth weight
ê
Educational stress
ê
Violence during education
ê
De Bock I MIPH I Slide 49 of 12 I June 2010
Brooks-Gunn, 2000
Development of
prefrontal cortex/selfregulation
‚Toxic‘ stress
Successful
Relationship
parents
Fertilisation
Birth
Relationships in
the
neighbourhood
1. Year of life
2. Year of life
De Bock I MIPH I Slide 50 of 12 I June 2010
Kindergarten School Adolescence
Participative strenghtening of social community
Implemented projects
How often conducted?
Vehicle park/Active with wheels
Once und 2x/month
Barefoot park
Bathing day
2x/month
Factory tour
Moving reading night
regularly
Grandparents playing afternoon
once
Adventure hiking/
Costume hiking
1
Monthly thematic excursion
More than twice
Seasons project
Children dance
One/week during Kiga-times
Outdoor day (kiteflying, exercise playground)
1x/Month
Bicycle parcours
For 1 week, summer programme
Building a cabin
Several dates
Exercise site
Garden arrangement (beds, climbing slope)
Several dates
Bonfire/ nature experience
2x/year to monthly
Children disco
Once every 2 months
Play afternoon
De Bock I MIPH I Slide 51
of 12 I June
2010
Several
times
Development of
prefrontal cortex/selfregulation
‚Toxic‘ stress
Relationships
in daycare
Successful
Relationship
parents
Fertilisation
Birth
Relationships in
the
neighbourhood
1. Year of life
2. Year of life
De Bock I MIPH I Slide 52 of 12 I June 2010
Kindergarten School
Adolescence
Figure 2. Total cost including parents’ fees (fixed rates) per fulltime child in day care/pre-school plus staffing levels within preschool and after-school care respectively per 100 children (index:
1991=100)
Quality of relationships in daycare
Better staffing rate
Sweden
140
120
100
80
60
40
1991
1992
1993
1994
1995
Pre-school: total cost per child
1996
1997
1998
1999
Pre-school: staff per 100 children
After-school care: staff per 100 children
Source: Bergqvist & Nyberg 2001.
Important: Objective needsTheassessment
dilution of resources, i.e. the lower staffing levels and larger
groups of children, can in themselves be seen as indirect indicators
of reduced quality within childcare. Another often used quality
indicator is the training level of personnel which has increased
Desubstantially
Bock I MIPH I Slide
12 I June 2010and after-school care as well as
in53 of
pre-school
registered childminding homes. The proportion of staff with
Strategic Promotion of Preschool Relationships
•  Adapting staffing to needs: Regional needs assessment
•  Cooperation with Early Human Learning Partnership
•  „Early Development Index“ – German Early Development Index (GEDI)
% Vulnerable Children/quarter (multiple risks)
De Bock I MIPH I Slide 54 of 12 I June 2010
De Bock et al., in prep.
Characteristics of preschool group affect relationship
quality - what to do?
Supervision and coaching of tutors
1 psychological expert/nursery in disadvantaged city areas (10h/week)
•  Observation of the interaction between child and tutor
•  Feedback and training/implementation
•  Workshops about stress-management for tutors
Better group-management skills
Less emotional and behavioural problems
Better Executive Functioning
De Bock I MIPH I Slide 55 of 12 I June 2010
Better
preschool
skills
Development of
prefrontal cortex/selfregulation
‚Toxic‘ stress
Relationships
in care
Successful
Relationship
parents
Fertilisation
Birth
Relationships in
the
neighbourhood
1. Year of life
2. Year of life
De Bock I MIPH I Slide 56 of 12 I June 2010
Self-regulation
of the child
Kindergarten School Adolescence
How to promote self-regulation in
preschool groups of socially
disadvantaged children?
De Bock I MIPH I Slide 57 of 12 I June 2010
The virtue of roleplays and drama: Tools of the Mind
In the morning every child
develops his/her own ‚play plan‘
Photos taken out!
„Mature“ drama play
Reading
and listening
De Bock I MIPH I Slide 58 of 12 I June 2010
Roleplays and self-regulation
Page 6
Roleplays (Tools
of the mind)
preschool reform
programme
EF Task 1
EF Task 1
EF Task 2
EF Task 2
Academic
results
as (red)
welldid
en (blue) performed
better on measures
of EFare
than better
dBL children
ent measure is percentage of correct responses.
Dots-Incongruent, Flanker, and
De Bock I MIPH I Slide 59 of 12 I June 2010
r tasks are described in the text. (B) The dependent measure is percentage of
Diamond, 2007
„By wide-spread implementation of „Tools of the Mind“, costs
for special education, antisocial behavior and ADHD could be
largely reduced “
Adele Diamond,
Developmental Cognitive Neuroscience Laboratory, University of British Columbia
De Bock I MIPH I Slide 60 of 12 I June 2010
In order to develop their natural
potential, children from social
disadvantage must be provided with
reliable and stable relationships in
their everyday environments.
De Bock I MIPH I Slide 61 of 12 I June 2010
Instead of focusing on language and
cognition in preschools, we should
strengthen self-regulation and the
character of the children.
De Bock I MIPH I Slide 62 of 12 I June 2010
Enabling this for such children is not
only good for our society, economy and
‚justice‘.
De Bock I MIPH I Slide 63 of 12 I June 2010
It would be a cultural accomplishment
of our civilisation.
De Bock I MIPH I Slide 64 of 12 I June 2010
Thank you for your attention.
•  Questions?
Contact:
PD Dr. Freia De Bock
Mannheim Institut of Public Health
Freia.debock@medma.uni-heidelberg.de
De Bock I MIPH I Slide 65 of 12 I June 2010