BULLETIN

bulletin on early childhood development

Centre of Excellence for Early Childhood Development

VOLUME 11, NO 1-DECEMBER 2013

TOP 10 topICS:
AUTISM n ADHD
n n

STRESS n LANGUAGE

MATERNAL DEPRESSION n ANd MUcH MOrE

n

Centre dexcellence pour le dveloppement des jeunes enfan Centre of Excellence for Early Childhood Development

2011-2012: THE BESt ECD RESEArcH IN CANAdA A TrIbUtE tO CLYdE HErtZMAN

U. McGill U. Toronto U. McMaster U. Montral U.B.C. BY MICHEL BOIVIN AND RICHArD E. TrEmbLAY U. Laval U. Dalhousie Celebrating the best ECD scientic publications by Canadian investigators is always U. Alberta a gratifying experience. This year, however, the pleasure is clouded by the untimely death of Clyde UQAM Hertzman, a long-time compagnon de route of the CEECD and the SKC-ECD. Clyde U. Western Ontario was a leading scholar, and an amazing mover and shaker of the ECD community in Canada and abroad. We dedicate this Top 10 issue to his memory. U. Queen's

tissue of men who committed suicide and 1 expert panel chairing 0 an RSC/CAHS abused childhood had 5 10 15 were severely 20 25 in early30 35* report on the role of early adversity in several genes, such as those involved in neu* Nombre de publications comprenant au moins un auteur par institution canadienne. childrens development adans topic addressed in obtenu roplasticity, that were differentially activated. Ne sont affiches ce graphique que celles ayant au moins trois publications dans leyears palmars des 110 meilleures publications (2001-2012).Early assessment of risk is also addressed at least three of this nominated articles, as if in nal tribute. Two papers (pages 3 and in papers on various disorders, including 4) review evidence on the effects of early-life ADHD and Autism Spectrum Disorders (ASD), adversity and exposure to poverty on long- two prevalent themes in our Top 10 bulletin. term physical health, pointing to possible Disentangling the inattention dimension from mechanisms such as epigenetics, learned be- the hyperactive component, a rst longitudinal haviours and neurobiological changes that set study (page 9) nds that childhood inattention, the stage for chronic inammatory processes. but not hyperactivity, predicts non-graduaAnother paper (page 5) reveals that the brain tion. Another paper (page 8) reveals that from

U. Manitoba ne of Clydes recent contributions was

TOP 110 PAPErS (2001-2012)

McGill U. U. Toronto McMaster U. U. Montral U.B.C. U. Laval Dalhousie U. U. Alberta UQAM U. Western Ontario Queen's U. Manitoba U. 0 5 10 15 20 25 30 35*

* Number of papers with at least one author from a Canadian institution. Only shown in this graph, those with at least three publications in the top 110 (2001-2012).
VOLUME 11, NO 1 DECEMBER 2013

18months, a small group of children show early signs of hyperactivity-impulsivity and inattention, and this group is characterized by a host of early child, family and social risk factors. Using magnetic resonance imaging (MRI) at 6, 12 and 24 months, a third paper (page 10) found that the brains of children meeting early criteria for ASD developed white matter differently than the brains of unaffected children. These ndings clearly underline the possibility of early identication of children at risk. However, that endeavour is not without challenges. For example, one paper (page 7) reveals that early signs of adult bipolar disorder are non-specic and include general symptoms such as anxiety and depression (not ADHD). Another paper (page 10) reports broad variations in diagnosing ASD, a nding that backs the DSM-5 change from a categorical approach to a dimensional approach to qualify the severity of ASD symptoms. An additional paper (page 11) reports on failure to improve language development in 18-montholds, suggesting that being slow to speak at that early age may not be a good marker for subsequent language delay. All this indicates that early identication is no simple task, and we should be aiming to assess early development trajectories, rather than developmental states at a single point in time to more precisely qualify childrens early development. Finally, two important papers are service/ policy-oriented. The rst (page 6) found that taking antidepressants during pregnancy reduced the risk of postpartum depression and did not have iatrogenic effects on children. The second (page 12) looked at administrative records in different countries for indices of child maltreatment, nding no clear decrease or increase in child maltreatment, but large differences across countries, attributed to broad, favourable policies toward children and families rather than specic programs and services. Again this year, this solid group of papers shares excellence in theory, methods and relevance. We are pleased to celebrate the authors scientic contributions.
1. Royal Society of Canada/Canadian Academy of Health Sciences
BULLETIN ON EARLY CHILDHOOD DEVELOPMENT PAGE 1

Profile 2011-2012

CLYdE HErtZMAN:
For optimal development, young children need high-quality nurturing environments. That means parents with primary caregiving responsibilities need a good social support system, as well as exible work schedules that allow them to earn a living and take care of their families. When parents are working or studying, young children need quality, affordable daycare programs and a connected, compassionate community to contribute to their support and well-being. Without that type of care, children may fail to reach their potential, and in the worst cases, spend the rest of their lives dogged by problems ranging from chronic failure to mental illness.

PUttINg EArLY CHILdHOOd ON tHE MAP

f all of this sounds self-evident, its likely due in part to the life work of Clyde Hertzman. The idea may not be new, but Dr. Hertzman and his team produced, synthesized and disseminated the data to back it up. He was the pioneer in this idea of linking population health to early child development and establishing early child development as a social determinant of health, says long-time colleague Joanne Schroeder, Deputy Director of the University of British Columbias Human Early Learning Partnership (HELP), of which Dr.Hertzman was founding director.

and very humble, says Schroeder. His charisma and tireless lobbying helped spread his message, as did his publications and his work with the World Health Organization. HELPING CHILDrEN tO THrIVE According to Schroeder, Dr. Hertzmans biggest impact was putting the importance of early child development on the map, especially in international settings where traditionally there has been more focus on just keeping babies alive. Clyde made the point very strongly that babies have the right not just to live, but to thrive and have optimal development. He helped construct the metrics that developing countries use to monitor and report on how well they respect the rights of their children. Dr. Hertzman was also a passionate and elo quent contributor to the relatively new eld of social epigenetics, the study of how early environmental experiences can shape genetic expression in a way that is passed on to future generations. So, taking care of our children today means we are also taking care of future generations. He coined the term

IDENtIFYING CHILDrEN At RIsk Dr.Hertzmans inuence started in B.C., where for his 2000 landmark study, kindergarten teachers from 23 Vancouver neighbourhoods rated their students on physical well-being, social competence, emotional maturity, language and communication. While children from the lowest-income neighbourhoods fared the worst, the biggest surprise was how many children from more afuent neighbourhoods were also at risk. Schroeder estimates that more than 700initiatives in B.C. alone have sprung up as a result of that seminal work, and there are hundreds, even thousands, of others across Canada and the rest of the world. Daycare centres as far away as Malawi use his principles. Not only was he a very brilliant scientist, he was a very charismatic, engaging individual
PAGE 2 bulletin on early childhood development

He was the pioneer in this idea of linking population health to early child development and establishing early child development as a social determinant of health.
biological embedding, which refers to how our early life experiences literally get under our skin and shape future well-being. Dr. Hertzman was made an ofcer of the Order of Canada early in 2013, an accolade of which he was particularly proud, says Schroeder. He died suddenly in February 2013 at the age of 59. With funds collected in his name, his colleagues and family have set up the Clyde Hertzman Legacy Fund, which supports academic and community initiatives aimed at strengthening the social and emotional development of young children.
BY ALIsON PALkHIVALA
VOLUME 11, NO 1 DECEMBER 2013

Photo credit: Human Early Learning Partnership

SPECIAL FEATURE ON RESEARCH

NUrtUrINg
If youre struggling to put food on the table and worrying about how that stress is affecting your children, your best approach may be simply to show them love, warmth and support. New research suggests that maternal warmth can go a long way towards mitigating a disadvantaged early life.

OUr YOUNg PAYS OFF

he link between poor socioeconomic status early in life and poor physical and mental health later on has long been known. This is the case even among those who manage to climb the socioeconomic ladder as they grow older. Michael Kobor, from the Human Early Learning Partnership (HELP) and the Centre for Molecular Medicine and Therapeutics (CMMT) at the University of British Columbia, and colleagues helped uncover the biological mechanisms behind this association by demonstrating that individuals who spent the rst few years of their lives in poverty developed a gene expression pattern that promoted the production of inammatory compounds in the body. They also had higher levels of the stress hormone cortisol and hyper-reactive white blood cells. This kind of ongoing inammation and bodily stress can contribute to multiple chronic disease states, including cardiovascular disease, cancer and depression. A MEssAGE OF HOPE The obvious question that emerged from this research was: are those who are born into poverty doomed to an unhealthy future? Dr. Kobors latest research demonstrates that the answer is a denitive no. The key message here is a message of hope, he says. The immune cells of people with a low early-life socioeconomic status who experienced high maternal warmth reacted less vigorously to stimulation and their gene expression prole was less skewed toward pro-inammatory gene expression patterns. In other words, a mother who speaks softly and warmly to her children, offers help and support when needed, shows interest and

Parents who provide warm, supportive family environments are able to counteract some of the negative neurobiological pathways that seem to be initiated when growing up in a low-resource environment.
warmth, and encourages her childrens development can protect them from the negative results of being born into poverty. Katie McLaughlin, an expert in childhood trauma from the University of Washington, agrees. This paper is particularly promising because it examined normal variations in parent-child relationships. This wasnt an expensive long-term intervention that was tested. Instead, it showed that in the context of normal caregiving, parents who provide warm, supportive family environments are able to counteract some of the negative neurobiological pathways that seem to be initiated when growing up in a low-resource environment. This suggests that there are a whole variety of things we could be doing to prevent some of the cascading neurobiological consequences of growing up in poverty. What we should be thinking about at the clinical and policy level is what we can do to improve warm, supportive, responsive parenting and to provide parents with the skills to support their children. Dr. Kobor emphasizes that his work should not be interpreted to mean that women should stay at home during their childs early years rather than returning to work. The study was conducted in a fairly small sample of individuals only 53. Therefore, any interpretations of the results can only be considered to be preliminary until a larger study conrms the ndings. Dr. Kobors team is working on just such a study.
BY ALIsON PALkHIVALA

Ref.: Chen E, Miller GE, Kobor MS, Cole SW. Maternal warmth buffers the effects of low early-life socioeconomic status on pro-inammatory signaling in adulthood. Molecular Psychiatry 2011;16(7):729-737.
VOLUME 11, NO 1 DECEMBER 2013 BULLETIN ON EARLY CHILDHOOD DEVELOPMENT PAGE 3

SPECIAL FEATURE ON RESEARCH

HAPPY CHILdHOOd,
HEALtHY LIFE
A new review paper reveals the current state of knowledge on the effects of early-life adversity on long-term health and the potential psychosocial and neurobiological mechanisms that explain the link. The implications of putting all these pieces together are considerable, because the research lays the foundation for developing long-term preventive strategies for the chronic diseases that plague industrialized nations, including cardiovascular disease, diabetes, cancer, arthritis and depression.

n looking over human studies, says lead author Gregory Miller, currently of Northwestern University (at the time of the research he was at the University of British Columbia), we nd very consistent evidence that kids who grow up with ongoing forms of adversity, whether they be socioeconomic or more psychosocial, are more prone later in life to have premature heart disease, premature and more disabling autoimmune conditions, certain kinds of strokes, and to be more vulnerable to certain kinds of cancers. So how does poverty or abuse in the rst decade of life contribute to the risk of a heart attack or stroke more than 40 years later? Possibilities include epigenetics, or heritable changes in genes that occur in response to the environment; learned behaviours, lifestyle

choices or cognitive tendencies; and neuro biological changes at the molecular level that set the stage for chronic inammatory processes. And these changes persist, even among those who have pulled themselves out of adverse circumstances. For instance, one key study demonstrates that graduates of Johns Hopkins University Medical School one of

the worlds most prestigious university programs were still more likely to develop heart disease if they had spent their early years in conditions of economic adversity. ImPLICAtIONs FOr REsEArCH AND PubLIC POLICY According to Miller, there is evidence that early childhood conditions have implications for long-term health. We should as a society be investing a lot more in early childhood through things like increasing family leave and making it paid. We should have low-cost, high-quality child care and preschool for all kids, especially the most disadvantaged, and do whatever we need to do to make it easier for parents to parent the way that they would ideally. Right now, we put a lot of obstacles in the way of effective parenting. Thats not good long-term thinking. If we dont put the resources in now for kids and families, its going to come back to bite us 30, 40, 50 years from now. Katie McLaughlin, an expert in childhood trauma from the University of Washington, says the paper also provides direction for future research that can help provide targets for preventive interventions. If you design an intervention that you think might disrupt some of the pathways [that link early adversity with poor health] and ultimately prevent the onset of disease [among disadvantaged youth], she says, youd have to follow children for an extremely long period of time decades before youd know if the intervention impacted long-term disease outcomes. This paper provides very clear targets [such as markers of chronic inammation] that can be used as intermediate outcomes to determine whether an intervention is having an effect.
BY ALIsON PALkHIVALA

There is evidence that early childhood conditions have implications for long-term health.

Ref.: Miller GE, Chen E, Parker KJ. Psychological stress in childhood and susceptibility to the chronic diseases of aging: Moving toward a model of behavioral and biological mechanisms. Psychological Bulletin 2011;137(6):959-997.
PAGE 4 bulletin on early childhood development VOLUME 11, NO 1 DECEMBER 2013

SPECIAL FEATURE ON RESEARCH

THE BIOcHEMIStrY OF

RESILIENcE

Abuse early in life produces epigenetic changes that result in a brain that is less able to adapt to change or handle stress. This may help explain why abuse victims can become stuck in patterns that promote and perpetuate negative emotional states and mental illness. These are the main ndings of research by Dr. Gustavo Turecki and his team at the Douglas Mental Health Institute in Montreal.

r. Tureckis team has been studying brain tissue taken from abuse and suicide victims for years, comparing its biological features with those of brain tissue taken from men without such tragic histories. Their work falls into the eld of epigenetics, the study of heritable changes in gene functioning that occur as a result of environmental factors such as abuse. For this study, Dr. Turecki and colleagues again compared brain tissue samples from men with and without a history of severe abuse in early childhood. Previously, they had looked for specic genetic differences identied by other studies as being associated with stress or neglect. This time, they compared the mens entire genomes and found several genes that, through a process known as methylation, were differentially activated in the two groups. One in particular, known as Alsin (ALS2), is noteworthy because of its relationship to neuroplasticity, the brains ability to adapt to change. Regaining the ability to talk after a stroke has damaged parts of the brain associated with language is an example of neuroplasticity. This is an important feature of the ability to bounce back after suffering a trauma, either physical or mental.

NEurOPLAstICItY AND RECOVErY FrOm AbusE Many patients who go through early life trauma have a hard time moving on, says Dr.Turecki. For many of them, that trauma is at the core of many of the mental health prob-

lems that they eventually develop. We need to understand how this psychological trauma impacts brain function and physiology and leads to pathology. These types of studies set up the foundation for that knowledge. Once you understand what happens to the brain in these people, we may be better able to help, by either producing medications or by leading to other therapies for people to move on and for these events to not cause the harm and the pain they usually do. Mimi Isral, Chair of the Department of Psychiatry at McGill University, agrees that neuroplasticity (or the lack thereof ) could be at the heart of ongoing mental health issues following early life trauma. People who commit suicide and people who have been abused are extremely sensitive, and they tolerate stress very poorly. They dont adapt well to their environment. They turn against themselves, put themselves down easily, and have very low self-esteem. These become risk factors for suicide. And now were seeing that their brains are potentially less capable of

Abuse early in life produces epigenetic changes that result in a brain that is less able to adapt to change or handle stress.
adapting to their environment than those who have not been abused. Dr. Tureckis ndings suggest that interventions, be they pharmaceutical or behavioural, that focus on improving neuroplasticity could be hugely benecial for abuse survivors. Dr. Isral points out that epigenetic research in cancer has already led to therapies that help undo pathological genetic changes. There is every reason to hope that it could do the same for psychiatry.
BY ALIsON PALkHIVALA

Ref.: Labont B, Suderman M, Maussion G, Navaro L, Yerko V, Mahar I, Bureau A, Mechawar N, Szyf M, Meaney MJ, Turecki G. Genome-wide epigenetic regulation by early-life trauma. Archives of General Psychiatry 2012;69(7):722-731.
VOLUME 11, NO 1 DECEMBER 2013 BULLETIN ON EARLY CHILDHOOD DEVELOPMENT PAGE 5

SPECIAL FEATURE ON RESEARCH

MAtErNAL DEPrESSION
Pregnant women are typically advised to avoid medication when possible, since it is not always clear whether drugs may negatively affect the development of their unborn child. But when pregnant women are depressed, staying away from antidepressants may not be the best option. hats because having a mother who is depressed during pregnancy or the early stages of a babys life has itself been linked with various negative health outcomes for the child, including prematurity, impaired growth, alcohol and substance use and mental health problems. This is why intensive research into the safety of taking antidepressants during pregnancy has been conducted over the past several years. Among the most recent of these studies is research led by Irena Nulman, from the Motherisk Program at the Hospital for Sick Children in Toronto. The investigators compared outcomes among infants born to pregnant women who were depressed and took a commonly prescribed antidepressant; pregnant women who were depressed but took no medication; and non-depressed, healthy pregnant women who took no medication. The antidepressants taken by the women in the study were the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine or a selective serotonin reuptake inhibitor (SSRI), a class of drugs that includes such commonly prescribed antidepressants as uoxetine, paroxetine and sertraline. For this study, the investigators specically looked at differences in the infants neurocognitive development, including intelligence (IQ) and behaviour outcomes, as measured by standardized psychological assessments. ANtIDEPrEssANts SAFE, but NOt tHE WHOLE ANswEr The good news is there was no sign that taking antidepressants during pregnancy had any deleterious effects on infants IQ or behaviours, the results showing no difference between exposed and non-exposed children to the medication. It also reduced the risk of the women having a relapse of their depres-

REQUIrES MULtIMOdAL APPrOAcH

sion in the postpartum period. The less heartening news is that antidepressant therapy failed to prevent any of the neurocognitive and behavioural issues that have been seen in the offspring of women who were depressed during and immediately after pregnancy. The severity of maternal depression (and not the dosage or length of the pharmaceutical treatment) came out as an important risk factor for later behavioural problems in children. Dr. Martin St-Andr, an expert in perinatal and infant psychiatry from CHU Sainte-Justine and the Universit de Montral, says this study helps emphasize the importance of treating depression during pregnancy. Thats the current paradigm: that it needs to be treated and that antidepressants all by themselves are not associated with an increased risk of IQ problems when compared with an untreated depressed group. That can be reassuring for parents who are debating whether or not to take antidepressants. But it also highlights the need to take a broader approach to depression in pregnant women, says Dr. St-Andr. Treating [maternal] depression all by itself is not a panacea against early childhood developmental and behavioural issues. Treating women just from their perspective and just targeting their very

If you really want to have a preventive approach for infants, you need to have a more multimodal approach to families.
personal symptoms does not mean it will translate into helping the parenting process unfold in a positive way If you really want to have a preventive approach for infants, you need to have a more multimodal approach to families. You need to look at fathers, relationship issues, infant developmental risks, etc. You need to take a broader view. Anti depressants are just one among many treatments available to treat perinatal depression. He adds that treatment needs to take place along a conti nuum that includes the antenatal, postnatal and early childhood periods, because these are critical times for parental bonding and infant development. Frequently, the seeds of future psychopathology are sown during this vulnerable period, so it is important to address any problems that may arise promptly.
BY ALIsON PALkHIVALA

Ref.: Nulman I, Koren G, Rovet J, Barrera M, Pulver A, Streiner D, Feldman B. Neurodevelopment of children following prenatal exposure to venlafaxine, selective serotonin reuptake inhibitors, or untreated maternal depression. American Journal of Psychiatry 2012;169(11):1165-1174.
PAGE 6 bulletin on early childhood development VOLUME 11, NO 1 DECEMBER 2013

SPECIAL FEATURE ON RESEARCH

DIAgNOSINg CHILdHOOd

IMPrOVINg tHE OddS

MENtAL ILLNESS:

Imagine that you have a troubled child whos throwing tantrums at school and is morose at home. Now imagine taking that child to a psychiatrist who makes a diagnosis by rolling a set of dice. While no one literally does this, clinicians faced with identifying serious mental illness in children can sometimes feel as if they are playing a high-stakes game of chance. Thats where the work of Dr. Anne Duffy comes in.

r. Duffy, of the Mathison Centre for Mental Health Research and Education in Calgary, has focused her research on bipolar disorder, particularly the classic form, characterized by periods of mania and depression followed by complete remissions of illness. To gain a better understanding of the natural course of the disease, Dr. Duffy and her colleagues have spent nearly two decades following more than 250 children who have a parent affected by bipolar disorder and comparing them with a group of children who do not have such a history, with regard to an array of genetic, epigenetic, academic, environmental, psychosocial and biological factors. Is It MANIA Or ADHD? Theres a lot of confusion regarding whether a hyperactive, emotional, aggressive child has ADHD [attention decit hyperactivity disorder] or mania, says Dr. Gabrielle A. Carlson, Director of Child and Adolescent Psychiatry at Stony Brook University School of Medicine in New York. And some research has suggested that ADHD-like symptoms may be a risk factor for developing bipolar disorder later in life. But Dr. Duffys research has demonstrated that there is no link between ADHD in childhood and bipolar disorder in adulthood, a nding that has been conrmed by a series of other longitudinal studies. Rather, the early signs of bipolar disorder are non-specic and include such common, general symptoms as anxiety and depression. Clinicians working with disturbed young children, says Dr. Duffy, must understand that what youre seeing may be a trajectory and not end-stage illness. In psychiatry, the current diagnostic system only looks at whats in front of you, not where this could be going, not early clinical stages, like we do in other medical illnesses.

FAmILY HIstOrY Is CruCIAL A crucial component of making a correct diagnosis in these children is family history, says Dr. Duffy. You might see anxiety or moodiness or you might see cognitive difculties acutely, but you really have to use the family history to guide you as to where this might be coming from and where it might be going. Identifying bipolar illness early on has important clinical implications, says Dr. Carlson. The reason we have feared bipolar illness for so long is because of mania. Mania is very

destructive. It cuts a wide swath. Thats what people dont want. They dont want to be stark raving mad Avoiding those devastating symptoms means providing the right treatment as early as possible and avoiding the wrong one. Giving a bipolar child antidepressants as a result of misdiagnosis, for instance, can trigger a manic or psychotic episode. Dr. Duffys work has stacked the odds in favour of sound clinical decision-making.
BY ALIsON PALkHIVALA

There is no link between ADHD in childhood and bipolar disorder in adulthood.

Ref.: Duffy A. The nature of the association between childhood ADHD and the development of bipolar disorder: A review of prospective high-risk studies. American Journal of Psychiatry 2012;169(12):1247-1255.
VOLUME 11, NO 1 DECEMBER 2013 BULLETIN ON EARLY CHILDHOOD DEVELOPMENT PAGE 7

SPECIAL FEATURE ON RESEARCH

ADHD:
R
esearchers looked at a sample of 2,057 children in Quebec, followed from age ve months to eight years as part of the Quebec Longitudinal Study on Child Development. They found that about 16% of the children had high levels of hyperactivity-impulsivity, which declined slightly with age. About 13% of the children had high levels of inattention, which tended to increase slightly, up to age six. This means that if a child already has a high level of symptoms at 18 months old, these symptoms will likely remain high, explains Dr. Sylvana Ct, Associate Professor, Social and Preventive Medicine, at the Universit de Montral, and one of the studys authors.

ENVIRONMENTAL RISK FACTORS ANd trAJEctOrIES

daycare educators could tell you who is more inattentive or impulsive, and if its a problem for group activities. This study measures that in a formal way. ENVIrONmENtAL rIsk FACtOrs The study also sought to identify environmental risk factors. It found that premature birth, low birth weight, maternal smoking during pregnancy, non-intact family (e.g., single-parent family or blended-family), young maternal age, maternal depression and paternal history of antisocial behaviours were all risk factors for high trajectories of both hyperactivity-impulsivity and inattention. Dr. Russell Schachar, child psychiatrist at the Hospital for Sick Children in Toronto, says these ndings are important, given the ongoing debate about the relative roles of genetic and environmental risk factors, and how they inuence each other a phenomenon known as geneenvironment interactions or epigenetic effects. Environmental risk factors very likely affect the way our genetic potential is translated into action, he explains. To better understand this, work will need to advance on both the genetic and environmental fronts simultaneously. This work shows which environmental risks we need to focus on when looking at the neurobiology of ADHD. From a public-health standpoint, says Dr. Schachar, the strong evidence provided in this study tells us that these environmental risk factors are highly important, and may have more public-health implications than the genetic results that we have so far. Dr. Ct says her groups ndings reinforce the critical importance of promoting healthy behaviours during pregnancy, helping mothers with depression, and supporting young families. The risk factors [for many childhood problems] are often the same, she notes. The accumulation of research results, combined with the evidence for supporting young, isolated, low-educated or poor mothers, suggests we cannot really go wrong by giving lots of support to these mothers. Clearly, were not doing enough.
BY EVE KRAKOW

Children at risk for developing hyperactivity-impulsivity and inattention problems may be identied as young as 18 months old, say researchers. As well, new information on early risk factors reinforces the need to support pregnant women and young families. It doesnt mean the child will necessarily have problems of clinical severity. But if we could identify these children early on, we could do something to support them. Trajectories of hyperactivity-impulsivity and inattention were also signicantly associated with each other meaning that when a child displays symptoms of one problem, there is a high chance that he or she will have symptoms of the other too. Dr. Ct notes while there have been many studies on ADHD (attention decit hyperactivity disorder) in school-aged children, this is the rst to look at symptoms of hyperactivity and inattention in very young children, using a representative population sample. Im sure most

This work shows which environmental risks we need to focus on when looking at the neurobiology of ADHD.

Ref.: Galera C, Ct SM, Bouvard MP, Pingault JB, Melchior M, Michel G, Boivin M, Tremblay RE. Early risk factors for hyperactivity-impulsivity and inattention trajectories from age 17 months to 8 years. Archives of General Psychiatry 2011;68(12):1267-1275.
PAGE 8 bulletin on early childhood development VOLUME 11, NO 1 DECEMBER 2013

SPECIAL FEATURE ON RESEARCH

POOr

ScHOOL PErFOrMANcE:
INAttENtION Or HYPErActIVItY?

When it comes to academic achievement, children who are inattentive may be at greater risk than those who are merely hyperactive. This was the key nding in a study that looked at hyperactivity and inattention symptoms to determine their association with educational achievement.

r. Jean-Baptiste Pingault, a researcher at the CHU Sainte-Justine and the studys lead author, explains that while many studies have linked ADHD (attention decit hyperactivity disorder) with difculties at school, this was the rst to look at hyperactivity and inattention symptoms separately in the general population over a long period of time. You can easily imagine that its hard for children who are hyperactive to concentrate, because theyre moving around all the time, says Dr. Pingault. But you can also have children who are sitting quietly but not really paying attention. Our study shows that these children are at the same risk as those who show both inattention and hyperactivity. In fact, he adds, they are probably more at risk than the few children who are hyperactive but are still able to concentrate on their work. The study included 2,000 children in Quebec who were assessed every year between the end of kindergarten (age 6) and the end of elementary school (age 12). The study then looked at their ofcial high school graduation records at age 22-23. Inattention was measured using indicators such as not being able to maintain attention for a long time, being easily distracted, being absent-minded (looking around, not staying focused), and giving up easily (starting a task but not necessarily completing it). The results showed that a high inattention trajectory in children between the ages of 6 and 12 strongly predicted not earning a high school diploma by 22-23 years of age. A declin-

This study underlines the importance of identifying children with symptoms of inattention as early as possible.
ing or rising trajectory of inattention also contributed to this result. Hyperactivity, however, was not a signicant predictor once inattention was taken into account. SIGNs OF INAttENtION IN YOuNG CHILDrEN This study underlines the importance of identifying children with symptoms of inattention as early as possible, says Dr. Sylvain Palardy, a child psychiatrist who has worked extensively with children from birth to age ve at Hpital Rivire-des-Prairies, and works with children and adolescents at the Clinique TDAH de Montral (attention decit disorder clinic). Children who are hyperactive often stand out, because their behaviour is disruptive. But other children who are very quiet may get labelled lazy or unmotivated, when really its because their brain is saying, this is too much. In young children, signs of inattentiveness may include being easily distracted by external stimuli, taking longer to complete tasks, having difculty organizing themselves, or forgetting things. Because it takes more effort for these children to concentrate, they may get tired more quickly or give up more easily. Dr. Palardy says that schools need to put measures in place to support children with attention difculties. Sometimes even simple measures can help: a hypo-sensitive child needing more stimulation to stay attentive might use a special kind of seat; a hyper-sensitive child who gets distracted by others being too close might be given a locker slightly apart from the group. Other measures might include giving a child more time to complete a task or breaking it down into parts. Young children who are easily distracted need support to maintain their concentration during activities, he notes, adding that in more severe cases, medication may need to be prescribed.
BY EVE KRAKOW

Ref.: Pingault JB, Tremblay RE, Vitaro F, Carbonneau R, Genolini C, Falissard B, Ct SM. Childhood trajectories of inattention and hyperactivity and prediction of educational attainment in early adulthood: A 16-year longitudinal population-based study. American Journal of Psychiatry 2011;168(11):1164-1170.
VOLUME 11, NO 1 DECEMBER 2013 BULLETIN ON EARLY CHILDHOOD DEVELOPMENT PAGE 9

SPECIAL FEATURE ON RESEARCH

EArLY

BrAIN CHANgES
IN INFANtS WItH AUtISM
The scans for these children showed more rapid development of white matter ber tracts by age six months than the scans of those who did not develop ASD. After this initial accelerated development, by age two these children had less new white matter development than the unaffected children. This suggests that the origins of autism in terms of brain differences are really quite early, tracking back to the rst year of life, says Dr. Lonnie Zwaigenbaum, Co-Director of the Autism Research Centre at Glenrose Rehabilitation Hospital in Edmonton and one of the studys authors. White matter refers to the myelin that covers the connections between brain cells, helping the impulses move more quickly. Its kind of the communication system of the brain, says Dr. Zwaigenbaum, explaining that increasingly, autism is being thought of as a disorder of brain connectivity. Theres evidence from older children with

Differences in brain development in people with autism may start as early as six months old. hat was the key nding in a study of 92 at-risk infants (at risk because an older sibling had autism). Researchers conducted magnetic resonance imaging (MRI) brain scans at 6, 12 and 24 months. At 24 months, behavioural assessments showed that 28 of the infants met the criteria for autism spectrum disorders (ASD).

autism that the short-term connections are over-developed and the longer-term connections are under-developed. This could explain why people with autism may be very good at detail-oriented processing (noticing patterns), yet miss out on the big picture (difculty generalizing). Dr. Mayada Elsabbagh, Assistant Professor in Psychiatry at McGill University, says these ndings show the dynamic nature of brain development in infants at risk, reinforcing the need to think about autism from a developmental perspective. This means that it is very important for clinicians to work with families when there are concerns about the child and monitor these over time. Dr. Zwaigenbaum says that signs to watch out for between the ages of 6 and 12 months include decreased eye contact, lack of sharing of positive or joyful emotion, not responding to name, becoming preoccupied with repetitive kinds of interests, such as xating on minor visual details, and becoming more oriented to objects and less to people. Differences in early motor development may include lower tone, not manipulating objects as efciently, or poorer postural control. For families who have a child with autism, the risks of a younger sibling developing the disorder are about one in ve.
BY EVE KRAKOW

Ref.: Wolff JJ, Gu HB, Gerig G, and al. Differences in white matter ber tract development present from 6 to 24 months in infants with autism. American Journal of Psychiatry 2012;169(6):589-600.2012;169(6):589-600.

ASd: FOCUSING ON THE

INDIVIDUALS NEEDS
Children may be diagnosed with different types of autism spectrum disorders (ASD) depending on where they are diagnosed. These ndings support a recent move to do away with ASD subtypes in North America and to focus on the individuals needs instead.

r. Mandy Steiman, a psychologist with the ASD Program at the Montreal Childrens Hospital, was one of the researchers who carried out the study. Until recently, she explains, clinicians were using the DSM-IV1, which included three major ASD subtypes: autistic disorder (autism), Aspergers disorder, and pervasive developmental disorder not otherwise specied (PDD-NOS). However, theres been

some controversy as to whether clinicians can reliably discriminate between these different disorders, whether theyre meaningful categories, she says. In this study, experienced clinicians at 12sites in the U.S. and Canada were given standardized information on 2,100 children between the ages of four and 18 who met autism spectrum criteria, and asked to give their diagnosis. Within each site, clinicians were quite consistent in how they diagnosed the subtypes, says Dr. Steiman. Between sites, however, there were large variations. This was especially true for children with milder symptoms. She notes that these results support the direction taken in the DSM-5: released in

May 2013, it no longer includes the subtypes. Clinicians now qualify ASD by the level of severity of two key dimensions social communication and interaction, and restricted/repetitive behaviours and interests and by the level of support the person needs. Dr. Nathalie Garcin, a clinical psychologist and Executive Director of the Gold Centre, which provides diagnostic and early intervention services to children with ASD, says this study conrms that the subtypes being used were not backed by the evidence. She also believes the new approach is much less confusing for parents. In the past, we were using different terms to mean the same thing because really, its a continuum, with different levels of severity. Now, instead of focusing on the diagnosis, we can focus on the childs needs, and on the supports that should be put in place to enhance the childs development.
BY EVE KRAKOW
1. Diagnostic and Statistical Manual of Mental Disorders.

Ref.: Lord C, Petkova E, Hus V, and al. A multisite study of the clinical diagnosis of different autism spectrum disorders. Archives of General Psychiatry 2012;69(3):306-313.
PAGE 10 bulletin on early childhood development VOLUME 11, NO 1 DECEMBER 2013

SPECIAL FEATURE ON RESEARCH

LANGUAGE DELAYS:

About 5 to 8% of preschool children have a delay in language development that puts them at major risk of poorer school and academic performance, more limited employment opportunities, and difculties with social interactions and relationships.

TRYING TO IDENTIFY CHILDREN AT RISK

t is absolutely crucial for children to acquire good language skills, says Dr. Melissa Wake, a pediatrician at the Royal Childrens Hospital and researcher at the Murdoch Childrens Research Institute, both in Melbourne, Australia. The dilemma, she explains, is how to determine whether early screening and prevention initiatives are effective.Should you go in early, when the language system is malleable and you are more able to inuence the trajectory, or should you go in late, when you can be much surer of who really has a language delay and who doesnt? Dr. Wake led an Australian trial examining the effects of a language promotion program. Dr. Luigi Girolametto, a professor in the Department of Speech-Language Pathology at the University of Toronto, was one of the studys chief investigators and provided extensive expertise on language development. Instead of targeting older children identied as having language delays, the study focused on very young children deemed at risk of developing a delay because they were saying no or very few words at 18 months old. Parents attended sessions at which they learned and practiced strategies to support their childs language development. Researchers then looked at the childrens outcomes at ages two and three. They found that although the parents loved the program, it did not appear to have any substantial effect on improving the childrens outcomes compared to the control group. The main reason may be that children in both groups improved so rapidly. In other words, being slow to talk is not a good marker of subsequent language delay. Although these children were much slower to start

talking than their peers, by age two, just six months later, their average language scores were into the normal range and by age three were close to the population average, says Dr. Wake. This high rate of natural resolution had not been expected, as it had not been well documented before. She notes that the studys ndings suggest that a one-time screening for expressive language skills alone in toddlers is unlikely to be a helpful strategy at a population level. Wed like to try a more sophisticated model of identication that draws on the childrens skills and risk factors over a number of time points, to really identify the children who are likely to have lasting, damaging language delay. Dr. Sarah Shea, a developmental pediatrician at the IWK Health Centre in Halifax, supports the idea of having some kind of tool to help identify at-risk children when they come for their regular check-ups. Eighteen months is a predictable immunization contact point and a good age to pick up major motor, social and language delays, she points out. Receptive language is especially key, along with social development. In terms of prevention, she underlines the importance of looking at the big picture. As a nation, we seem to be catching on to the power of the social determinants of health and understanding how they inuence developmental outcome, she says.Were also starting to hear the message that developmental outcome equals health outcome in many respects. Efforts to eliminate child poverty and to improve child care will likely have the biggest impact in this area.
BY EVE KRAKOW

Being slow to talk is not a good marker of subsequent language delay.

Ref.: Wake M, Tobin S, Girolametto L, Ukoumunne OC, Gold L, Levickis P, Sheehan J, Goldfeld S, Reilly S. Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: Lets Learn Language cluster randomised controlled trial. British Medical Journal 2011;343:d4741.
VOLUME 11, NO 1 DECEMBER 2013 BULLETIN ON EARLY CHILDHOOD DEVELOPMENT PAGE 11

SPECIAL FEATURE ON RESEARCH

ARE POLICIES HELPING TO REDUCE CHILD

ABUSE AND NEGLECT?

Over the past 30 years, many countries have implemented policies and programs designed to reduce child abuse and neglect. The question is, are they working? o nd out, researchers studied six countries and states: Sweden, the United States, England, New Zealand, Western Australia and the Canadian province of Manitoba (chosen for the availability of quality data). They looked at rates of hospital admissions for maltreatment-related injuries, violent deaths, and child protection agency contacts, including investigations, substantiations and out-of-home care. Overall, they found no clear decrease or increase in child maltreatment. This could mean that interventions are not working or it could

mean that increased awareness and action have resulted in more cases being reported, balancing out the numbers. By choosing countries with different levels of inequality and social supports and different child maltreatment policies, researchers also hoped to assess the effects of different types of policies. The biggest contrast was between Sweden and the U.S., says Dr. Marni Brownell from the Manitoba Centre for Health Policy, one of the studys authors. We associated this difference not so much with specic policies around child maltreatment, but with broader policies. For example, Sweden has much lower rates of child poverty and parental risk factors, such as addictions and intimate partner violence. At the policy level, Sweden offers much more support for parents, such as the length of paid

leave, and spends more on early childhood programs. Across all countries, the study found tenfold differences in rates of children being placed in out-of-home care, with Manitoba having the highest rates of all. Dr. Brownell says this is disturbing, especially considering that there are no controlled trials comparing the effectiveness of out-of-home care with intensive home support. She concludes by stressing the importance of preventive initiatives. Surveys show there are lots of kids who experience maltreatment who never come to the attention of authorities. A universal public-health approach would be more likely to reach them, and potentially reduce the numbers of kids needing protection services.
BY EVE KRAKOW

Ref.: Gilbert R, Fluke J, ODonnell M, Gonzalez-Izquierdo A, Brownell M, Gulliver P, Janson S, Sidebotham P. Child maltreatment: Variation in trends and policies in six developed countries. Lancet 2012;379(9817):758-772.

BULLETIN
This bulletin is a publication of the Centre of Excellence for Early Childhood Development (CEECD) and the Strategic Knowledge Cluster on Early Child Development (SKC-ECD). Several funding agencies nancially support the CEECD and the SKC-ECD, among which are the Universit Laval, the Canadian Social Sciences and Humanities Research Council (SSHRC) and private foundations. The views expressed herein do not necessarily represent the ofcial policies of these agencies. We are grateful to The Lawson Foundation and the Margaret & Wallace McCain Family Foundation for their nancial contribution to produce this bulletin.

Editors: Kristell Le Martret, Michel Boivin and Richard E. Tremblay Collaborators: Eve Krakow, Alison Palkhivala Scientic Proofreading:  Marni Brownell, Gabrielle A. Carlson, Sylvana Ct, Anne Duffy, Mayada Elsabbagh, Nathalie Garcin, Luigi Girolametto, Mimi Isral, Michael Kobor, Katie McLaughlin, Gregory Miller, Sylvain Palardy, Jean-Baptiste Pingault, Russell Schachar, Joanne Schroeder, Sarah Shea, Martin St-Andr, Mandy Steinman, Gustavo Turecki, Melissa Wake, Lonnie Zwaigenbaum Copy Editor: Lana Crossman Layout: Guylaine Couture Printing: SIUM Centre of Excellence for Early Childhood Development Strategic Knowledge Cluster on Early Child Development Universit de Montral 3050, douard-Montpetit Blvd., GRIP P.O. Box 6128, succursale Centre-ville Montreal, Quebec H3C 3J7 Telephone: 514 343-6111, extension 2541 Fax: 514 343-6962 E-mail: cedje-ceecd@umontreal.ca Websites: www.excellence-earlychildhood.ca www.skc-ecd.ca ISSN 1499-6219 ISSN 1499-6227
VOLUME 11, NO 1 DECEMBER 2013

To read about the most up-to-date scientic knowledge on early childhood development, visit www. child-encyclopedia.com

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