Prof. Pratibha Singhi

1. “AT RISK” CHILDREN • Prof. PratibhaSinghi • Professor, Chief Pediatric Neurology and Neurodevelopment, • Department of Pediatrics, • Postgraduate Institute of Medical Education and Research, Chandigarh- INDIA

2. 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.

3. “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 “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

4. Why is Under 3 so important Critical periods Time window during which a specific function develops normally provided conditions are favorable Neuroplasticity - Synaptogenesis and Synaptic Pruning There is a high correlation between the density of the neural connections and one’s specific knowledge, abilities or skills 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

5. Brain Development in Infants And Early ChildhoodLearning 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

6. Human Brain Development – Synapse Formation Language Sensory Higher Pathways Cognitive Function (vision, hearing) Conception 9 -3 3 1 0 6 4 8 12 16 -6 Years Months AGE C. Nelson, in From Neurons to Neighborhoods, 2000

7. Cortical Maps Brain Development in Early Life Sets Trajectories for Development Throughout Life Cortical organization, especially for the sensory systems, is often described in terms of maps.

8. Foundations of 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

9. 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

10. Kangaroo mother care

11. Risk factors Parental / Family

12. Child risk factors Environmental risk factors

13. Malnutrition Iodine , Micronutrient, deficiency Anemia Unwanted, girl child Vit A deficiency Low birth weight At risk children Poverty Disabilities, Other chronic medical conditions-epilepsy Orphans, street children Disasters - floods, Famines, Earthquakes, Nuclear explosion Commercial exploitation Sexual exploitation Drug trafficking

14. 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 BehavDev1992; 15: 279–96

15. 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

16. Causes of mortality under 5yrs of age Globally > a third of deaths are due to underlying malnutrition

17. 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

18. 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

19. 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

20. Child malnutrition is a gender issue in India and is Intergenerational Prevention of chronic fetal malnutrition is a high priority for developing countries !!

21. 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.

22. 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.

23. 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

24. Vitamin deficiency Vitamin D – Rickets Vitamin C – Scurvy

25. 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

26. 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

27. Childhood Disability – Associated problems • Speech and Language • Hearing and Vision • Epilepsy , • Behavior Problems • Feeding and Nutrition • Co-morbidities

28. 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

29. 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

30. 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

31. 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

32. How to Reach In homes Follow up clinics Creches Anganwadis At Risk Children Construction sites Day-care-centres Slums

33. the reality… …and the inequity…

34. Little Mothers ! Can be enrolled for Child to Child Education programme !

35. 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 !

36. ECD Multidimensional and Multifactorial Motor Sensory Physical Child Development Emotional Social Cognitive

37. 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 Enhance the child ‘s intellectual language and social competence EIP Place children in developmentally enriching settings Remove external risk factors Optimize the abilities of the families to meet the special needs of their children Provide continuous positive redirection and focused building skills Train parents in responsiveness and effectiveness The benefits of EIP clearly depend on early detection and early referral PED 96, 95, 97, 2001. PED REV 2000 & 2001

38. Conducive Environment Health and nutrition Early intervention Educational Neuro-protection (All interventions to promote normal development and prevent disability) organizational, therapeutic, environment – modifying measures Early education (advantage of cerebral plasticity) Programs involving parents most successful !!

39. 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

40. 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

41. Partnerships Key stakeholders • 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.

42. 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 .

43. 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

44. 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

45. ICDS • Services: • Supplementary nutrition, • Immunization, • Health check-up, • Referral services, • Pre-school non-formal education and • Nutrition and health education

46. Helping children with special needs

48. Children With Special needs Learning

49. 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.

50. Thank you