Neurocognitive impacts for children of poverty and neglect

Most human brain growth occurs during our first 6 years of life. Extending through early childhood, there are many factors which continue to be relevant to brain development. High levels of nutrition, appropriate stimulation, and attention and emotional support all help contribute to healthy brain growth, maximize its productivity and essentially prepares the mind for future learning capability. However, many aspects of a child’s environment can adversely affect maximum brain functioning. Two significant and negative environmental factors are poverty and neglect. Research substantiates the negative effects poverty can have on a child’s brain including development, learning and academic performance. Numerous studies have documented that low-income children, as young as age two, perform worse across cognitive measures (Duncan & Brooks-Gunn 1997; Feinstein 2003). Smith and colleagues (1997), using data from two national datasets, demonstrated that family poverty was significantly correlated with lower scores across cognitive and academic readiness in preschool-aged children (ages three to four). This held true even after controlling for the effect of mother's education, family structure, ethnicity, birth weight and gender. As children enter and progress through school, the kids living in poor families continue to perform worse on indices of school achievement. Specifically, poor children were twice as likely to have repeated a grade, to have been expelled or suspended from school, or to have dropped out of high school. Poor children were also 1.4 times as likely to be identified as having a learning disability in elementary or high school than their non-poor counterparts.

As if being raised in a low-income family did not present enough challenges, what is the impact on a child’s development when you compound these findings with child neglect? Sedlak and Broadhurst (1996) reported a strong inverse relationship between household income and likelihood of child neglect. Imaging studies focusing on neglected children have found significant cerebral abnormalities in the corpus callosum, left neocortex, hippocampus, amygdala, limbic areas, frontal lobe and cerebellar vermis (De Bellis, Keshavan, Clark, Casey, Giedd et al., 1999; Grassi-Oliveira, Ashy, & Stein, 2008). Investigations into the neurocognitive functioning of neglected children suggest possible sequelae, including compromised psychosocial functioning and psychopathology, brain dysfunction and cognitive deficits including impaired executive functioning, attention, processing speed, language, memory and social skills (Chugani, Behan, Muzik, Juhasz, Nagi, & Chugani, 2002; De Bellis,2005; DePrince, Weinzierl, & Combs, 2009; Gaudin, 1999; Gunnar & Vasquez, 2006; Johnson, Cohen, Brown, Smailes, &Berstein, 1999; Schwarz & Perry, 1994; Shonkoff, Boyce, & McEwen, 2009; Weber & Reynolds, 2004; Widom, 1999). When analyzing academic performance, Eckenrode, Laird, and Doris (1993) found that maltreated children were twice as likely to repeat a grade and score significantly lower on reading and mathematics testing than their IQ matched nonmaltreated peers.

Based on the aforementioned research, our neurorehabilitation facility set out to study children who were presented with both of these obstacles: poverty and neglect. Data were collected on 65 children (Girls = 23, Boys = 42; mean age 11 yrs old). All children were educated in the public school system and from low socioeconomic households. Specifically, all children were on Medicaid. According to Maine state law, children from ages 1 to 18 with family income up to 150 percent of the Federal Poverty Level (yearly income of $22,050 for a family of four) qualify for Medicaid. All children also had a reported history of neglect, which was defined as a report of physical, sexual and/or emotional abuse during childhood. Described in medical history reports, all children had Department of Health and Human Services or Child Protective Services involvement, and most were removed from their home environment where the neglect was occurring. All children completed an evaluation consisting of a clinical interview (with parent and child), records review, and neuropsychological tests, including the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV; Wechsler, 2003), Wechsler Individual Achievement Test – Second Edition (WIAT-2; Wechsler, 2002), Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay, & Curtiss, 1993), and Children’s Memory Test (CMS; Cohen, 1997). As part of the assessment, data were collected regarding developmental delays, a diagnosis of attention deficit hyperactivity disorder, learning disorders (reading,mathematics, or written expression), or an emotional/behavioral disorder. Diagnoses were made based strictly on DSM-IV (American Psychiatric Association, 2000) diagnostic criteria.

There was a wide range of scores presented in this sample. Investigation revealed that 56 percent of the children had below average IQ scores. Thirty-three to 52 percent of the sample demonstrated below average academic ability, 36 to 55 percent had below average memory testing, and 36 to 47 percent demonstrated below average executive functioning. Although group mean scores were relatively average, this analysis suggests close to half of the sample performed below expectations compared to their same-aged peers (base rates for disorders). Significant group differences were also found across all subsequent diagnoses investigated. The children with a history of poverty and neglect were more likely to be diagnosed with developmental delay (60 percent compared to 10 to 20 percent), ADHD (80 percent compared to 3 to 7 percent), and LD (28 percent compared to 5 percent). Additionally, 100 percent of our sample had emotional/behavioral disorders, compared to 46 percent of the general population.

Considered together, these results revealed that close to half of our population — children facing the challenges of poverty and neglect — demonstrated below average scores across measures of intellect, academic ability, memory and executive functioning and had a higher incidence of all diagnoses investigated, with 100 percent of this sample being subsequently diagnosed with an emotional or behavioral disorder. Our results are consistent with what would be expected if the brain functioning of these children was disrupted during early childhood, which is a time of significant brain growth and development of foundational academic skills. Moreover, these findings suggest the likelihood of long-term implications both educationally and occupationally for children who are of low-income families and victims of childhood neglect. This is a population who is in need of early identification and support services. Consistent with previous research, our data suggest that children who grow up in low income households and who have experienced neglect are at risk for difficulties with cognitive and academic achievement. The importance of these findings cannot be overstated given that appropriate early assessments and interventions may help change developmental trajectories and long-term outcomes. Future research should explore early screenings and potential interventions to help maximize children’s brain development and cognitive potential.

Ashlee R. Loughan, MEd, PhD, recently completed her doctorate in clinical psychology at Walden University. Previously a Neuropsychology Intern at Goodwill Neurorehabilitation in Maine, a neuropsychology extern at Children's National Medical Center in Washington D.C., and a research assistant at KIDLAB in Northern Virginia, Dr. Loughan will begin her residency this fall at Walton Rehabilitation in Augusta, Ga. Clinical and research interests center on pediatric neuropsychology specializing in medical populations and brain injury.

Robert Perna, BSN/RN,PhD, ABN, ABPdN is a board certified pediatric and adult neuropsychologist and nurse and recently started practicing at Walton Rehabilitation Hospital in Georgia. He worked for the past 15 years as clinical director of brain injury rehabilitation programs in Maine and New York. He does research and publishes articles on brain development and function and brain injury rehabilitation.

References

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Text revision.  (Rev. 4th ed.). Washington, D.C.: Author.

• Chugani, H.T. Behan, M.E., Muzik, O., Juhasz, C., Nagy, F., & Chugani, D.C. (2002). Local brain functional activity following early deprivation: A study of postinstitutionalized Romanian orphans. Neuroimage, 14, 1290-130.

• Cohen, B. (1997). Children’s memory scale. San Antonio, TX: The Psychological Corporation.

• De Bellis, M. D., (2005). The psychobiology of neglect. Child Maltreatment 10(2), 150-172. doi: 10.1177/1077559505275116

• De Bellis, M.D., Keshavan, M. S., Clark, D. B., Casey, B. J., Giedd, J. N., Boring, A. M., Frustaci, K., & Ryan, N. D. (1999). Developmental traumatology part II: Brain development. Biological Psychiatry, 45(10), 1271-1284.

• DePrince, A. P., Weinzierl, K. M., & Combs, M. D. (2009). Executive function performance and trauma exposure in a community sample of children. Child Abuse & Neglect, 33, 353-361. doi: 10.1016/j.chiabu.2008.08.002

• Duncan, G.J. and J. Brooks-Gunn (eds) (1997). Consequences of growing up poor. New York, N.Y.: Russell Sage Foundation.

• Eckenrode, J., Laird, M., & Doris, J. (1993). School performance and disciplinary problems among abused and neglected children. Developmental Psychology, 29, 53-62. doi: 10.1037/0012-1649.29.1.53

• Feinstein, L. (2003). Inequality in the early cognitive development of British children in the 1970 cohort. Economica, 70(277),73-98. doi: 10.1111/1468-0335.t01-1-00272

• Gaudin, J. M. (1999). Child neglect: Short-term and long-term outcomes. In H. Dubowitz
  (Ed.), Neglected children: Research, practice and policy (pp. 89-108). Thousand Oaks, CA: Sage.

• Grassi-Oliveira, R., Ashy, M., Stein, L. M. (2008). Psychobiology of childhood maltreatment: Effects of allostatic load? Revista Brasiliera de Psiquiatria, 30(1), 60-68. doi: 10.1590/S1516-44462008000100012

• Gunnar, M. & Vasquez, D.M. (2006). Stress neurobiology and developmental psychopathology. In D. Cicchetti & D. Cohen(Eds.)  Developmental Psychopathology, (2nd ed.). New York, N.Y.: Wiley.

• Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G., & Curtiss, G. (1993). Wisconsin card sorting test manual: Revised and expanded. Odessa, Fla.: Psychological Assessment.

• Johnson, J. G., Cohen, P., Brown, J., Smailes, E. M., & Bernstein, D. P. (1999). Childhood maltreatment increases risk for personality disorders during early adulthood. Archives of General Psychiatry, 56, 600-606. doi: 10.1001/archpsyc.56.7.600

• Schwarz, E. D., & Perry, B. D. (1994). The post-traumatic response in children and adolescents. Psychiatry Clinics of North America, 2, 311-326.

• Sedlak, A., & Broadhurst, D. (1996). The third national incidence study on child abuse and neglect (NIS-3). Washington, D.C: U.S. Department of Health and Human Services.

• Shonkoff, J., Boyce, W.T. & McEwen, B.S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities. Journal of the American Medical Association, 301, 2252-2259. doi: 10.1001/jama.2009.754

• Smith, J. R., Brooks-Gun, J., & Klebanov, P. (1997). The consequences of living in poverty for young children's cognitive and verbal ability and early school achievement. In G. J. Duncan & J. Brooks-Gunn (Eds.), Consequences of growing up poor (pp. 132-189). New York, N.Y.: Russell Sage.

• Weber, D.A, & Reynolds, C.R. (2004). Clinical perspectives on neurobiological effects of psychological trauma. Neuropsychology Review, 14, 115-129. doi: 10.1023/B:NERV.0000028082.13778.14

• Wechsler, D. (2002). Wechsler individual achievement test — Second Edition. San Antonio, Texas: The Psychological Corporation.

• Wechsler, D. (2003). Wechsler intelligence scale for children — Fourth Edition. San Antonio, Texas: The Psychological Corporation.

• Widom, C. S. (1999). Posttraumatic stress disorder in abused and neglected children grown up. The American Journal of Psychiatry, 156, 1223-1229.