Prof. Pratibha Singhi Professor, Chief Pediatric Neurology and

Neurodevelopment, Department of Pediatrics,

Postgraduate Institute of Medical Education and Research, Chandigarh- INDIA

“AT RISK” CHILDREN

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” 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

“AT RISK” Definition• How do you define ? No consistent definition

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

Why is Under 3 so important

There is a high correlation between the density of the

neural connections and one’s specific knowledge,

abilities or skills

Critical periods

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

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

0 1 4 8 12 16

AGE

Human Brain Development – Synapse Formation

Sensory Pathways(vision, hearing)

LanguageHigherCognitive Function

3 6 9-3-6

Months Years

C. Nelson, in From Neurons to Neighborhoods, 2000

Con

cep

tion

Cortical organization, especially for the sensory systems, is often described in

terms of maps.

Cortical Maps

Brain Development in Early Life Sets Trajectories for Development Throughout

Life

Foundations of brain architecture

Genetic factors

Biological factors

Psychosocial factors

Brain architecture

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 socio-

emotional competence and a secure base

Kangaroo mother care

Risk factors

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

Parental / Family

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

Poverty

Chaotic or unsafe home environment

Isolation

Household composition

Community rates of poverty, crime, unemployment,

Environmental risk factors

At risk children

Low birth

weight

Malnutrition Anemia

Vit A deficiency

Orphans,street children

Sexual exploitation

Disabilities,Other chronic

medical conditions-

epilepsy

Disasters - floods,Famines,

Earthquakes, Nuclear explosion

Drug trafficking

Unwanted, girl child

Iodine , Micronutrient,

deficiency

Commercial exploitation

Poverty

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: 314–26Infant 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 20118, 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 MR-

single 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

• 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??

Prevalence of vitamin A deficiency. Source: WHO

Vitamin deficiency

Vitamin C – Scurvy Vitamin D – Rickets

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

• 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

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%

Consequences -Child – Poverty, malnutrition,

diseases, separation from parents, loss of school etc etc

How to Reach In homes

Anganwadis

Construction sites

At Risk Children

Slums

Day-care-centres

Creches

Follow up clinics

the reality…

…and the inequity…

Can be enrolled for Child to Child Education

programme !

Little Mothers !

What needs to be donePolicy 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 !

Physical

Motor

Social

Cognitive

Emotional

Sensory

Child Development

ECD Multidimensional and

Multifactorial

EIP

Teach mothers to interact and communicate better with

their children

Provide information to parents on child management and development

Provide appropriateexpectations for children

and general social support

Enhance the child ‘s intellectual language and social competence

Remove externalrisk factors

Place children in developmentally enriching

settings

Train parents in responsiveness and effectiveness

Provide continuouspositive redirection

and focused building skills

The value and availability of early intervention programs

The benefits of EIP clearly depend on early detection and early referral

PED 96, 95, 97, 2001. PED REV 2000 & 2001

Optimize theabilities of the

families to meetthe special needsof their children

Educational

Neuro-protection

Early interventio

n

Early education (advantage of cerebral

plasticity)

(All interventions to promote normal development and

prevent disability) organizational, therapeutic,

environment – modifying measures

Programs involving parents

most successful !!

Health and

nutrition

Conducive Environme

nt

• 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

Importance of A Stimulating Environment

Health PromotionHealth 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

• Government Department

• Health authorities & Trust

• Primary Health care team

• Hospitals

• Professions allied to medicine

and early childhood education

• Local authorities

• Community groups & Voluntary

organizations

• Schools

• Mass Media

Building and connecting bridges

It is partnership at different levels and

among different stakeholders including government, medical

associations, academics and civil society that is

difficult to realize.

Key stakeholders

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