“AT RISK” CHILDREN
Prof. Pratibha Singhi
Professor, Chief Pediatric Neurology and
Neurodevelopment,
Department of Pediatrics,
Postgraduate Institute of Medical Education and
Research, Chandigarh- INDIA
Plan of Talk
• What is “At Risk”.
• Why is it so important in first 3 yrs of life
• Why are under three’s more vulnerable
• What are the risk factors.
• What is the current status.
• How to reach the under 3s.
• What needs to be done.
“AT RISK” Definition
•
How do you define ? No consistent definition
“At risk” is a concept that reflects a
chance or a probability of adverse
outcome,
the outcome is determined by a
balance of adverse and protective
factors
WHO IS “AT RISK”?
•
All children are at risk in some way or another
•
Some children face much higher risks
•
WHAT ARE CHILDREN AT RISK OF?
•
Poor life outcomes - death, inadequate development, school failure,
economic dependency, etc
Critical periods
Why is Under 3 so important
Time window during which a specific function develops normally
provided conditions are favorable
Neuroplasticity - Synaptogenesis and Synaptic Pruning
Age of two, child’s brain contains twice as many synapses
and consumes twice as much energy as the adult brain.
Developmental and environmental changes increase or
decrease the strength or efficacy of synapses as well as lead
to the addition or pruning of synapses.
It is easier to expand a child’s future proficiencies by using
the existing fertile neural networks
There is a high correlation between the
density of the neural connections and one’s
specific knowledge, abilities or skills
Brain Development in Infants And Early
Childhood
Learning with all five senses
• During the first 3 years of life, children experience the world in
a more complete way than children of any other age.
• The brain takes in the external world through its system of
sight, hearing, smell, touch and taste.
•
Infant - social, emotional, cognitive, physical and language
development are stimulated during multisensory experiences.
• Infants and toddlers need the opportunity to participate in a
world filled with stimulating sights, sounds and people.
Early abuse and emotional deprivation are extremely damaging
Human Brain Development –
Synapse Formation
Sensory
Pathways
(vision, hearing)
-6
-3
0
Months
Language
3
6
9
AGE
Higher
Cognitive Function
1
4
8
12
16
Years
C. Nelson, in From Neurons to Neighborhoods, 2000
Brain Development in Early Life Sets
Trajectories for Development Throughout Life
Cortical Maps
Cortical organization, especially for the sensory
systems, is often described in terms of maps.
Foundations of brain architecture
Genetic
factors
Brain
architecture
Biological
factors
Psychosocial
factors
The foundations of brain architecture are laid down early in life through
dynamic interactions of genetic, biological, and psychosocial influences,
and child behaviour
Attachment
• Attachment - deep emotional bond with a specific person that
lasts over time and spaces
• Stays with us for our lifetime and guides our behavior
• Secure attachments – greater independence and socioemotional competence and a secure base
Kangaroo mother care
Risk factors
Parental / Family
Poverty
Mental illness
Young age
Stress
Poor pre-natal care and nutrition
Low self-esteem
Domestic violence
Poor parenting skills
Poor physical health
Unemployment
Low educational status
Homelessness
Childhood experience of abuse
Single parent
High family conflict
Poor family attachment/bonding
Child risk factors
Poverty
Adverse prenatal period
(infections, drugs, hypertension)
Poor nutrition
Stress and depression
Pre-mature/low-birth weight
Domestic violence
Unwanted pregnancy
Maternal smoking or substance
abuse
Girl child
Disability
Environmental risk factors
Poverty
Chaotic or unsafe home
environment
Isolation
Household composition
Community rates of poverty,
crime, unemployment,
Unwanted, girl
child
Malnutrition
Iodine ,
Micronutrient,
deficiency
Low
birth
weight
Poverty
Vit A
deficiency
At risk
children
Disabilities,
Other chronic
medical
conditionsepilepsy
Disasters - floods,
Famines,
Earthquakes,
Nuclear explosion
Orphans,
street children
Commercial
exploitation
Anemia
Sexual
exploitation
Drug
trafficking
Data from Guatemala show a linear decrease in adolescents’ school
achievement and cognition with an increase in risk factors encountered by age 3
years.
Child Dev 1996; 67: 314–26
Infant Behav Dev 1992; 15: 279–96
Current Status
•
Global
•
Millions of children, particularly in Africa and Asia, lack access to quality health-
care services, micronutrient supplementation, education, improved water sources
and sanitation facilities, and adequate shelter.
•
In excess of 140 million under fives are underweight for their age, 100 million
children of primary school age are not enrolled in primary school.
•
500 million to 1.5 billion children experience violence annually.
•
Around 150 million children aged 5–14 are engaged in child labour
•
India
•
Every fifth child in the world and every third malnourished child in the world lives
in India, Every second Indian child is underweight, three out of four children in
India are anaemic.
•
Every second new born has reduced learning capacity due to iodine deficiency
Causes of mortality under 5yrs of age
Globally > a third of deaths are due to underlying malnutrition
Childhood Malnutrition
•
Worst-affected region is not Africa but South Asia!!.
•
Underweight children - Africa 30%, South Asia - over 50%.
•
Bangladesh and India,- proportion of malnourished children significantly higher than in even
the poorest countries of the sub-Sahara.
•
Not just because of sheer size of its populations but even the proportion affected is far higher
•
Half of the world's malnourished children are to be found in just three countries - Bangladesh,
India, and Pakistan.!!!
Malnutrition Among Children
Under Five Years
%
•
Stunted
48
•
Wasted
20
•
Underweight
43
Childhood Malnutrition – long term effects
•
Beyond the age of 2-3 years, the effects of chronic malnutrition are
irreversible •
Cognitive impairments
•
Greater risk of infection
•
Less physical capacity for work
•
Less Educational attainment- stunted children in the first two years of life
have lower cognitive test scores, delayed enrolment, higher absenteeism
and more class repetition compared with non stunted children.
To break the intergenerational
transmission of poverty and malnutrition,
children at risk must be reached during
their first two years of life
(N Engl J Med 1991; 325: 231–7.)
(J Nutr. 125: 2221S-2232S, 1995)
Int. J. Environ. Res. Public Health 2011
8, 590-612; oi:10.3390/ijerph8020590
Malnutrition and infections – a Vicious circle !!
•
Poor immune response
•
Unusual organisms
•
Severe infections
•
Poor outcome
•
Recurrent infections—further malnutrition
Malnutrition - impact on behaviour
Children malnourished at age 3 were more
likely than other children to be aggressive or
hyperactive at age 8,
To exhibit externalizing behaviors at age 11,
Exhibit conduct disorder and
Hyperactivity at age 17.
Crime times Volume 11, Number 1, 2005
Child malnutrition is a gender issue in India and is
Intergenerational
Prevention of chronic fetal
malnutrition is a high priority
for developing countries !!
Anemia in Children and Anemia
in Pregnancy
•
70% of children age 6-59 months are anaemic.
•
Severe 3%, Moderate 40% , Mild 26%
•
Iron deficiency anemia in early life - altered behavioral and neural development.
•
Irreversible effect that may be related to changes in chemistry of neurotransmitters, organization and
morphology of neuronal networks, and neurobiology of myelination.
•
India –
•
58.7% of pregnant women, 63.2% lactating mothers are anaemic.
•
Iron deficiency in pregnancy affects cells which are involved in building the embryonic brain during first
trimester - most sensitive to low iron levels.
•
Critical period starts in the weeks prior to conception and extends through the first trimester till the
onset of the second trimester.
•
Iron deficiency which starts in the third trimester
does not seem to harm the developing brain.
Iodine deficiency
•
Iodine deficiency during pregnancy can cause abortion, CP and MRsingle largest preventable cause of mental retardation in the world
Fifty per cent of children born every year in India are unprotected against Iodine
Deficiency Disorders such as brain damage, deaf mutism, dwarfism and severely
depleted levels of productivity.
•
The degree of impairment in function is related to the severity of iodine deficiency.
Even marginal degrees of iodine deficiency have a measurable impact on human
development
•
Only 71% of households currently consume adequately iodized salt.
Vitamin A Deficiency
Prevalence of vitamin A deficiency.
Source: WHO
•
62% of pre-school children are deficient in vitamin A
-
Leading to an annual 330,000 child deaths.
•
Night blindness - first sign of vitamin A deficiency.
•
Xerophthalmia and complete blindness can also occur .
•
Approx 250,000 to 500,000 malnourished children in the developing world go
blind each year from a deficiency of vitamin A.
-
Approx half of them die within a year of becoming blind.
•
Vitamin A deficiency reduces immunity
•
The Unites Nations Special Session on Children in 2002 set the elimination of
vitamin A deficiency by 2010.
- but have we achieved it??
Vitamin deficiency
Vitamin D – Rickets
Vitamin C – Scurvy
NUTRITIONAL DEFICIENCIES AND
COGNITION
•
Nutritional deficiencies-
•
General - protein energy malnutrition (PEM)
•
Stunting – (chronic PEM)
Consistent predictor Vs wasting
•
Low birth weight
•
SGA babies (12 long studies)
•
Lack of breast feeding (14 studies)
•
Specific - deficiency of iodine, trace metals, essential fatty acids
•
Prolonged anemia
? Confounding environmental variables
Developmental delay and Childhood Disability
•
Factors adversely affecting development
•
Perinatal: traumatic labour, hypoxic ischemic encephalopathy, intraventricular
hemorrhage,
•
Postnatal: neonatal seizures, infections, symptomatic hypoglycemia, hyperbilirubinemia
•
Miscellaneous:
Socio-environmental influences- Low socioeconomic status - A key determinant of development during the first 5 years
- Child abuse & neglect
Disease states-e.g. severe epilepsy, certain neurological infections & disorders, chronic
debilitating illness
Childhood Disability – Associated problems
Speech and Language
Hearing and Vision
Epilepsy ,
Behavior Problems
Feeding and Nutrition
Co-morbidities
Non Accidental Injury
• Death due to abuses – most common in infancy
- of severe head injuries in infancy 95% are due to abuse
• Pattern of NAH injuries in infancy –
• Skull rib and long bone fractures,
bruising anywhere
retinal hemorrhages
subdural hematomas
• Poverty, Drugs and alcohol, unwanted child
Long-Term Consequences of Child
Abuse and Neglect
• Factors Affecting • The child's age and developmental status when the abuse or
neglect occurred
• The type of abuse (physical abuse, neglect, sexual abuse, etc.)
• Frequency, duration, and severity of abuse
• Relationship between the victim and his or her abuser
•
(Chalk, Gibbons, & Scarupa, 2002 )
• Physical, psychological, behavioral, and societal consequences
Non-organic failure to thrive
•
Typically develops in the early months of postnatal life; may develop later
•
Long term deficits in physical growth, cognitive functioning and emotional and
social development, inadequate nutrition
•
Development delays ,behavioural and emotional signs are frequent
•
Risk factors -
•
Poor Maternal attachment
- Unwanted pregnancy or the result of rape or abuse
- Maternal postnatal depression, drug or alcohol abuse,
- Domestic violence,
•
Less frequent verbal and physical contact less positive reinforcement and warmth
•
Lack of parenting skills, emotional hostility, parental indifference, withdrawal and
rejection common features of NOFIT emotional abuse and neglect - links with
physical and sexual abuse
Disasters
Asia Pacific region vulnerability
Over 50% of the total world disasters
Over 70% of lives lost to disasters occur in
this region
75% of global flood mortality risk is in
Bangladesh, China and India
GDP losses of between 2-20%
•
Sikkim earthquake
•
More than 200,000 hit by floods in India, Nepal
•
Kathmandu July 13, 2011
•
Millions of Pakistan children at risk of flood diseases
Consequences -Child –
Poverty, malnutrition, diseases,
separation from parents, loss of
school etc etc
How to Reach
In homes
Follow up clinics
Creches
Anganwadis
Construction sites
Day-care-centres
Slums
the reality…
…and the inequity…
Little Mothers !
Can be enrolled for Child to Child
Education programme !
What needs to be done
Policy and Action Implications
•
Ongoing care from the beginning of pregnancy
through the birth of a child and into adolescence
particularly the girl child
•
Antenatal care
•
Perinatal care
•
Early detection and early intervention
•
Provision of child care support to working mothers
•
Promote female literacy / family education /life
skills
•
LIFE CYCLE APPROACH !
ECD
Multidimensional and Multifactorial
Motor
Sensory
Physical
Child
Development
Emotional
Social
Cognitive
The value and availability of early intervention programs
Teach mothers to interact and
communicate better with
their children
Provide information to parents on child
management and development
Provide appropriate
expectations for children
and general social support
Remove external
risk factors
Train parents in
responsiveness and
effectiveness
Enhance the child ‘s intellectual
language and social competence
EIP
Optimize the
abilities of the
families to meet
the special needs
of their children
Place children in
developmentally enriching
settings
Provide continuous
positive redirection
and focused building skills
The benefits of EIP clearly depend on early detection and early
referral
PED 96, 95, 97, 2001. PED REV 2000 & 2001
Conducive
Environment
Early
intervention
Educational
Early education
(advantage of cerebral plasticity)
Health and
nutrition
Neuroprotection
(All interventions to promote
normal development and prevent
disability) organizational,
therapeutic, environment –
modifying measures
Programs involving
parents most
successful !!
Importance of A Stimulating
Environment
•
Deprived of a stimulating environment, a child’s brain suffers children who don’t play much or are rarely touched – adverse
effects on development
•
Rich experiences produce rich brains
•
Importance of hands-on parenting
•
An urgent need for well designed preschool programs
Health Promotion
Health Promotion: the science and art of helping people change
their lifestyle to move towards state of optimal health
Strengthen health systems by involving communities in
preventative public health interventions
Change attitudes towards the girl child
Partnerships
Key stakeholders
•
Government Department
•
Health authorities & Trust
•
Primary Health care team
•
Hospitals
•
Professions allied to medicine and
Building and
connecting bridges
early childhood education
•
Local authorities
•
Community groups & Voluntary
organizations
•
Schools
•
Mass Media
It is partnership at
different levels and among
different stakeholders
including government,
medical associations,
academics and civil society
that is difficult to realize.
Policy and Action Implications
•
Universal immunization
•
Addressing malnutrition
•
Most of these children can be successfully treated at home
with ready-to-use therapeutic foods (RUTF).
•
Vitamin A syrup to all children 9-59 months in priority states.
•
Zinc supplementation along with Oral Rehydration Salts (ORS)
for the treatment of childhood diarrhoea in priority states.
•
Iodized salt –compulsory, cheap.
•
Double fortified salt (DFS), iodine and iron, for the most vulnerable.
•
Expand iron and folic acid (IFA) programs
for preschool children, adolescent girls, pregnant and lactating women.
•
Wheat flour fortification,
•
Micronutrient supplementation programs .
Convention on the Rights of the Child
•
20th anniversary - 20 November 2009,
•
Signed by every country in the world, and currently ratified into law by all but two
•
Activities covered
•
Exclusive breastfeeding
•
Vaccines, Routine immunization
•
Malaria prevention
•
Micronutrient Supplementation
•
Improved drinking water
•
Primary school enrolment and completion
•
Gender parity in primary education
•
Reduction of HIV prevalence and HIV treatment
•
Child protection as a holistic concept, offering children the right to be safeguarded
against a broad spectrum of violence, exploitation, abuse, discrimination and
neglect
ICDS
•
Launched on 2nd October 1975,, ICDS Scheme
world’s largest programmes for early childhood development..
•
Objectives:
•
Improve the nutritional and health status of children in the age-group 0-6
years;
•
Lay the foundation for proper psychological, physical and social development of
the child;
•
Reduce the incidence of mortality, morbidity, malnutrition and school dropout;
•
Achieve effective co-ordination of policy and implementation amongst the
various departments to promote child development; and
•
Enhance the capability of the mother to look after the normal health and
nutritional needs of the child through proper nutrition and health education
ICDS
• Services:
• Supplementary nutrition,
• Immunization,
• Health check-up,
• Referral services,
• Pre-school non-formal education and
• Nutrition and health education
Helping children with special needs
Children With Special needs Learning
Conclusions
•
Under three children are in the critical phase of development and are
vulnerable in the context of being at risk.
•
Reaching this age group has many challenges.
•
Infants cannot be considered in isolation, involvement of parents
particularly mothers, and even grandparents is extremely important.
•
Early comprehensive intervention programmes are required.
•
Female literacy, health, family education, and parenting skills are
important issues.
•
Building partnership between stake holders is essential for any
meaningful action.
Thank you