Parents Predicts: The Big Issues for 2014

A look ahead at the children's health and development stories you'll be hearing about next year.

How "Obamacare" affects children and families

happy child

Alexandra Grablewski

The Affordable Care Act (ACA) -- a loaded topic if ever there was one. At press time, the much-maligned healthcare.gov website was working 90 percent of the time, compared to 43 percent in October. So it stands to reason that most of the people who are seeking new coverage during this open enrollment period (which ends March 31 for coverage starting in 2014) will be able to get the information they're looking for. But site functionality isn't the biggest issue when it comes to children; it's whether all children will be covered under ACA, and whether families will indeed be able to select a better and more affordable plan. To help cut through the inevitable confusion, the American Academy of Pediatrics (AAP) has created a helpful interactive map linking to state-specific fact sheets that will help parents learn more about the insurance options in their state. The map will also take them to each state's health insurance marketplace.

Come January 1, 2014, a key part of ACA will be implemented: Insurance companies will not be able to deny coverage to anyone because of gender or a pre-existing condition. This is fantastic news not just for parents of children with chronic or life-threatening health issues, but for women as well. When we interviewed Health & Human Services Secretary Kathleen Sebelius in 2012, this is what she had to say about this part of the law: "Right now [September 2012], a lot of women can be charged up to 50 percent more for exactly the same coverage that a man has -- even if that coverage doesn't include maternity care -- because the practice of 'gender rating' is legal until 2014. But after that, insurers will not be able to charge women more for their health coverage. Also, starting in 2014, no one can be denied coverage because they have a pre-existing condition. For women, a pre-existing condition could mean you're a breast cancer survivor, you're a victim of domestic violence, or you've had a Cesarean section in the past. Right now, insurance companies can refuse to insure you or refuse to pay for any kind of complication that may arise in the future from those circumstances. But those rules will change across the board. What I like to say is, 'Being a woman will no longer be a pre-existing condition.'"

Early detection of autism

We've seen great progress in detecting autism in the toddler years and we know that starting interventions leads to significant improvements in social and cognitive functioning. Pediatricians have been vigilant about screening for autism, typically at 18 months and 24 months, with the goal of beginning interventions as early as possible to maximize the positive effects on development. Parents have also become well informed on the early signs of autism, thanks in part to programs like the "Learn the Signs. Act Early" initiative led by the Centers for Disease Control and Prevention and the National Center on Birth Defects and Developmental Disabilities.

The next steps for research, however, hold even more promise. A paper published in 2013 provided evidence that early signs of autism can be detected in the first 6 months of life. The key indicator was observing how babies typically increase their visual attention on people's eyes in the first months of life, whereas babies later diagnosed with autism went on to focus less on people's eyes. This study took a bold step forward by studying these infants over time so that prediction of a formal diagnosis of autism could be confirmed, lending substantial weight to the findings. In addition, a number of the babies had older siblings with autism, and therefore were at an elevated risk -- and the method was able predict which high-risk babies were later diagnosed.

This study is provocative in a number of ways and will stimulate a number of research directions in the next year and beyond. There are three to consider.

  1. It may provide an important clue that will focus research on the early brain processes that lead to the development of autism. Having a way to demonstrate a measurable process -- decreasing attention to the eyes in infancy -- may provide a platform for directing new research on the underlying neurobiology of the disorder.
  2. Although this technique holds substantial potential for early detection, it does require specialized equipment and expertise. New studies will be needed to gauge its potential as a screen for early signs of autism. Researchers will also need to figure out whether it is best suited (in the nearer future) for screening infants at high risk (such as those who have an older sibling with autism), rather than all infants.
  3. The idea of identifying infants at risk for autism will lead to partnerships to design and initiate interventions within the first year of life. The potential here may be profound -- studies consistently show that the earlier an appropriate intervention is started, the more benefits that will accrue developmentally. The idea that we may be able to intervene in infancy raises exciting possibilities for early detection of autism.

Children in Poverty, Concussions, and Why Art and Music Matter

Children in poverty

The awful statistic that bears repeating: 1 in 5 children live in poverty. More specifically, roughly 16.1 million kids in the United States now come from families where the total household income is less than the federal poverty level of $23,550 per year for a family of four. Almost half of those children live in deepest poverty, on household earnings of less than $11,775 per year.

Poverty touches every single area of a child's life -- and if a child is born poor, the damage can be especially devastating. Research shows that low-income children as young as 9 months of age show weaker cognitive and social development than their advantaged peers. "These children are dealing with all the repercussions of poverty during the crucial years for early brain development," says Benard Dreyer, M.D., professor of pediatrics at New York University's School of Medicine and cochairman of the Academic Pediatric Association's Task Force on Childhood Poverty. "After these effects take hold in the first three or four years, it's hard to catch up."

We interviewed Dr. Dreyer, among others, for a feature about poverty in our December issue. We reported that more than 30 percent of children in poverty show signs of emotional or behavioral problems. Their physical health suffers, too. Children born into poverty experience dramatically higher rates of infant mortality and low birthweight. As they grow, they are more likely to struggle with hunger and weight problems, as well as chronic medical issues such as asthma and diabetes.

Researchers and pediatricians have become increasingly aware of poverty's role in creating what is known as toxic stress. When children go through intensely difficult experiences for extended periods of time, their stress response is altered, this it actually changes how the brain develops. This is, in part, what prompted the AAP to create a Poverty and Child Health Work Group. This group will examine ways to expand access to affordable health care; broaden access to food, housing, and transportation; promote positive early brain and child development and school readiness and success; and support parents. In the meantime, we can consider helping children and families in poverty, or supporting organizations that do this work, knowing that their future directly affects all of us.

Concussions and other brain injuries

2014 is certain to bring continued discussion on the topic of concussions, because researchers are discovering more about the health risks associated with them, and because parents and coaches are taking them more seriously than ever before. In fact, startling new numbers have just been released showing that between 2010 and 2012, participation in Pop Warner (youth) football dropped by more than 23,000 players. The medical director of Pop Warner, neurosurgeon Julian Bailes, M.D., was quoted on ESPN.com as saying that the number-one cause of the decline was parents' fears of head injuries. Of course, football is just one of many sports that can lead to head injury; soccer, ice hockey, lacrosse, and cheerleading are other activities most likely to involve concussions.

At its annual conference in October, the AAP highlighted how crucial it can be for kids who have had concussions to make a gradual return to school. Put simply, a child who has had a head injury needs to give his brain a true rest, and it can be too taxing for a student to try to learn, memorize, and study under those circumstances. The AAP also released research on a topic that hadn't been examined too closely yet: the likelihood that children with concussion or brain injury will develop depression later on in life. There's plenty of data to prove that adults with head injuries are at risk for depression, and now it's clear that children are prone to be diagnosed, too: A study out of Brown University revealed that they're twice as likely to develop depression than kids who have not suffered from brain injury. You can expect more coverage in the coming months on how to spot a concussion -- did you know that less than 10 percent of concussions involve a loss of consciousness? -- and the safest way to recover from one.

Why art and music matter so much

We live in an economic climate that frequently leads schools to reduce their arts programs. But lately there have been new findings and fresh thinking that suggest we'll be seeing much more evidence in the coming year supporting the role of the arts.

We continue to see many eloquent testimonies to the role that the arts have played in the lives of successful people. Such retrospective accounts, including recollections by adults about how learning music in childhood carried over to their work in other professions, impart a powerful message on the multiple skills promoted by the arts. In the case of music, these include creative thinking, collaboration, listening skills, and focusing on the present and future at the same time.

These types of recollections may inform the next wave of research that will go beyond the prior work (which was often limited) that examined links between the arts and academic achievement. A recent paper presented novel evidence that experience with arts in childhood -- visual arts as well as music -- predicted entrepreneurial success in adulthood, including generating patents, creating businesses, and producing professional publications.

Three areas are likely to generate increasing attention next year. First is the link between math and music. Second is the role of the visual arts in promoting cognitive skills, including processing visual information in childhood and beyond. Third is the importance of early fine motor skills, such as those promoted by doing arts and crafts, as a precursor to academic readiness. This is receiving fresh attention, particularly as the connections between motor development and cognition are recognized as a fundamental feature of brain development. The key advance in all cases is the recognition that there are cognitive and brain processes that intersect the arts and traditional academic areas such as math and reading -- so, rather than being treated as separate domains of development, they should be seen as complementary. We're expecting more thinking and research to follow this perspective in the near future.

Resilience, Epigenetics, and Gun Violence

Resilience

We like to think of childhood as a carefree time, but the reality is that many children will, at some time, face substantial hardships, challenges, and stressors that can compromise development. In recent years we've seen a variety of them:

  • Natural disasters. We've witnessed the horrific effects of hurricanes and tornados, which can leave many children (and families) without shelter and emotionally challenged
  • Military deployment. Many children have had to deal with the stress of having a parent deployed. There are emotional and cognitive challenges that come from dealing with the absence of a parent, as well the dangers involved. Unfortunately, in some cases, kids must also face the additional challenge of coping with the injury or death of a parent.
  • Economic stress. Economic stress can have a cascade of effects on children's development. It can change how parents parent, tapping their emotional resources and compromising their ability to handle stressors that accumulate daily.
  • Bullying. Children who are victims of bullying face a variety of social, emotional, and cognitive challenges that could promote risk for many adverse outcomes, including severe depression and anxiety.
  • Maltreatment. Not every child grows up in a loving home. Many children experience some form of maltreatment, which can have devastating effects on their development.

Given this sobering perspective, research on resilience -- the ability to withstand adversity and reduce the likelihood of maladaptive development -- is happening at a fast pace. Three issues stand out as important subjects for examination in 2014.

A prominent focus will be on genetics, as not every child responds the same to stress and adversity. Some seem especially vulnerable, whereas others seem to have natural buffers in place. Different gene variations that provide some degree of resilience versus risk in the face of substantial adversity have been reported. Expect to see more of these studies that may offer clues on how to promote resilience in children who may be most vulnerable genetically.

A related concept that is receiving intensive attention is epigenetics, which is the way environmental experiences influence which genes get expressed and when. (See the next section for more about epigenetics.) The important point here is that children's DNA can be influenced strongly by early adverse experiences and exposure to risk factors and can compromise their social, emotional, and physical development. For example, prenatal exposure to tobacco can affect how specific genes function, which can have long-term effects on health. Anticipate studies that begin to consider how to buffer children against these experiences and potentially encourage resiliency early in life.

There is also much interest in developing family-based programs that can help parents and children deal with acute stress. For example, prevention programs offer support and techniques to deal with the inevitable stresses faced by military families and nurture family resilience. We're sure to see more of these studies on parents and children, applied to different sources of stress.

Going beyond genetics to "epigenetics"

The nature-nurture debate has led to many attempts to understand how genes and environment combine to shape a person's experiences, including her health and behavior. Over the past decade there has been an explosion of research and thinking focused on the multiple ways in which nature and nurture intersect.

This work is not controversial, but in 2014 you will hear about a much more controversial idea: a concept known as epigenetic inheritance. The "epigenetic" part isn't what leads to heated debate; you can think of epigenetics as a way of understanding how genes affect development. Both normal development and disruptions in development depend on genes turning on and off. Put another way, genes aren't always "active," and there are many factors that influence when they get expressed. The important point about epigenetics is recognizing that many environmental factors can serve as triggers for genes and can directly influence which genes get turned on and when they become activated. This means that our genes respond to all kinds of environmental exposures, including diet, chemicals, and stress.

But what about the "inheritance" part of this phrase? The idea is that a parent's experiences -- the kind that influence the expression of their genes -- might be passed on (along with the genes) to their children. Imagine a reaction to a certain food that is, in part, caused by a genetic susceptibility. An epigenetic theory would say that exposure to that food, even in utero, could activate those susceptibility genes. In contrast, the epigenetic inheritance model would suggest that a child might inherit not just the susceptibility genes but also the experience of exposure to the food -- even without direct exposure to the food.

Are there good examples of this right now? Well, no, at least not in respect to humans. But you will be seeing more and more speculation about epigenetic inheritance in 2014, with more discussion focused on the implications for child development and parenting.

Gun violence

At this writing, we are nearing the first anniversary of the shooting at Sandy Hook Elementary School in Newtown, Connecticut, which resulted in the death of 20 children and six educators, as well as the deaths of the shooter and his mother. Even if that tragedy hadn't occurred, there would still be plenty to say about gun violence. Firearm injuries are one of the top three causes of death among children in this country and, as the AAP reports, studies show that strong gun laws play an important role in reducing the number of injuries and deaths caused by firearms.

Nearly 1.7 million children under age 18 live with a loaded and unsecured gun in their home, according to a study in Pediatrics. What are the odds that your child is friends with one of them -- or is one of them? Because the risk of children being accidentally shot is so high, the conversations surrounding gun violence will continue long past the Sandy Hook anniversary. More moms and dads will be pushing past their initial discomfort and asking other parents if they have a gun in their home before leaving their child in the home for a playdate. When we covered this topic in Parents, we stayed away from the debate over gun control and focused solely on gun safety. The message that we, and child safety advocates, will continue to convey is: Guns should be unloaded and stored in a locked cabinet that children can't access. The ammunition should be stored in a separate locked location, too. And all firearms should have child-resistant gunlocks.

Another aspect of this topic that will continue to get attention is how guns and gun violence are portrayed in the media. Brand-new research from Ohio State University reveals that gun violence in PG-13 movies has more than tripled since 1985. In fact, there's now as much -- or more -- of this kind of violence in PG-13 movies as there is in R-rated movies. Knowing how much our kids are exposed to in the media and how suggestive young children, in particular, can be, we'll be hearing more in 2014 about how all of this affects children's development.

Guns in the Home: Playdates and Safety
Guns in the Home: Playdates and Safety

Richard Rende, Ph.D., is a developmental psychologist and author of the Red-Hot Parenting blog at Parents.com. Kara Corridan is Parents' health director.

Copyright ? 2013 Meredith Corporation.

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