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Child development

Since When is Same-Sex Marriage a Pediatric Health Issue?

By June 29, 2015 No Comments
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Shortly after the U.S. Supreme Court issued its landmark decision effectively legalizing same-sex marriage in all 50 states, the American Academy of Pediatrics (AAP) released a brief statement applauding the decision. It didn’t take long after that for my friends to start weighing in on the statement on Facebook.

Part of me was super psyched because I had so many friends talking about the AAP on social media (hooray for informed parents!) and the other part of me wanted to slam my head on the desk as I realized how misunderstood the statement had been. Even the friends who were happy about the SCOTUS decision seemed wary about what they viewed as a neutral health care organization venturing into a divisive political issue.

I can totally understand my friends’ confusion. We’re used to the AAP talking to us about ear infections and car seats, not so much about two adults of the same sex being able to marry or not. The AAP’s release didn’t exactly clarify matters as it was extremely short and without any background to explain why the organization viewed this decision as having an impact on child health.

For starters, the AAP is an organization that focuses on all factors that impact a child’s physical and mental health. This includes things such as family structure and a child’s home environment, which are part of what public health nerds call the psychosocial determinants of health. In short, psychosocial factors are generally created by other people in a child’s life and are things in which the child has little control. Things like home environment, family structure and stability all have massive impacts on a child’s physical and mental health, which is why organizations like the AAP, the American Academy of Family Physicians and the CDC study them.

For decades social scientists have studied children of same-sex couples and for just as long those on both sides of the same-sex marriage debate have used those studies to support their side. In 2013 the AAP reviewed the existing meta analyses of these studies and came to the same conclusion that the SCOTUS did after reviewing the same studies: A child’s well being depends much more on their relationship with their parents than it does on their parents’ gender or sexual orientation.

After reviewing the studies in 2006 and 2013 the AAP found that children of same-sex parents do not disproportionately suffer negative outcomes as a result of their parents sexuality. What the AAP did find was that the lack of uniform same-sex marriage rights across all 50 states does put children of same-sex couples at a disadvantage. This may seem bizarre as there are many children being raised by unmarried opposite-sex parents, or by single parents or by divorced parents. But the difference here is that the children of those relationships are legally recognized as being the children of those parents, which matters significantly in terms of custody and visitation rights, as well as access to medical benefits through the parents’ employers. It’s those disparities that negatively effect the physical and mental health of the children of same-sex couples, and why the AAP supports the same-sex marriage movement.

 


Resources:
The American Academy of Pediatrics Applauds Supreme Court Decision to Recognize Same-Gender Marriage in All 50 States. American Academy of Pediatrics. Published online 06/26/15. Accessed 06/28/15
The Social Determinants of Health FAQ. The Centers for Disease Control. Accessed 06/28/15

Collection: The Committee on Psychosocial Aspects of Child and Family Health.  Pediatrics -Official Journal of the American Academy of Pediatrics. Accessed 06/28/15

Definition: Social Determinants of Health Policy.  American Academy of Family Physicians. Accessed 06/28/15

Perrin, E.C., Siegel, B.S., et al. Technical Report: Promoting the Well-Being of Children Whose Parents are Gay or Lesbian. Pediatrics – Official Journal of the American Academy of Pediatrics. March 30, 2013. doi: 10.1542/peds.2013-0377. Accessed 06/28/15.

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Categories: Mental, Emotional, + Behavioral Health, Policy, Politics, + Pop Health

AAP Recommended Technology Limits in a Media-filled World Promote Healthy Language Development

By April 30, 2015 2 Comments
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Let’s face it – technology is an integral part of our daily lives. Some of us spend entire days working in front of computers, we use our phones to read the newspaper during the morning commute, play games, stream Netflix, and browse the internet. It is a constant around us, so why not incorporate it into our kid’s lives beginning when they are infants? In fact, many of us do so without a conscious choice. It just happens, after all, “there is an app for that.”

While I’m guilty of handing over my phone when my niece and nephew begin to get antsy at restaurants, or while they’re waiting for the adults to finish their conversations to avoid meltdowns, as a speech-language pathologist, I am a believer that a parent should not rely on television/media. Particularly, a parent shouldn’t rely on apps, TV, or other entertainment media to help their children with developmental growth – especially for language skills.

The American Academy of Pediatrics recently came out with “screen time” guidelines and recommend children under 2 avoid all types of media as the brain develops. It is not the usage of media that is negative per se, although there have been studies linking the use of excessive screen time to behavioral issues, difficulty with attention and focus, and difficulty developing social skills and language patterns, according to the joint position statement issued by the National Association for the Education of Young Children and the Fred Rogers Center for Early Education and Children’s Media at St. Vincent College. So why are these studies focusing so much on the effects of media on children under the age of 2? Simple answer: the brain is developing rapidly during this time period.

At birth, an infant has 2500 synapses per neuron, which increases to 15000 per neuron by the age of 3. [click to enlarge]

At birth, an infant has 2500 synapses per neuron, which increases to 15000 per neuron by the age of 3. [click to enlarge]

At birth, an infant has 2500 synapses per neuron, which increases to 15000 per neuron by the age of 3. Children learn language from things such as simple conversations with their parents and siblings, songs, rhymes, and books – these interactions are how the neural connections for their language development are stimulated to grow. It is this earliest stimulation that sets the tone for their continual development, so if parents provide little direct stimulation, the connections will not be made, and their language development could be at risk for being delayed.

Not all studies unilaterally agree with the AAP’s total avoidance policy for children under the age of 2, because if utilized properly, it can actually be very beneficial. A 2013 study from Stirling University’s School of Education found that a family’s attitude of technology influenced the children’s reaction. If the parents engage in passive media time (meaning not interactive or requiring much thought), children will then make the connection that it is ok for them to utilize passive media as well, which as explained earlier does not stimulate the neuronal connections. However, active engagement poses a different story. I utilize apps during my therapy time, as it is an easier way to have all of the materials I need readily on hand, though I do not solely rely on it. Children may also need to use media in other ways, such as those who rely on the technology to help communicate as an assistive device due to communication disorders. In this case, their media usage is essential.

Parents.com has what I consider an excellent list of the top educational apps for kids. Here are my picks for the top 3:

  1. Elmo loves 123s. This app works on identify the numbers, tracing the numbers, simple addition and subtraction.
  2. Disney Story Central. This app houses a collection of e-books that consists of a read-along narrative. These are characters that your children can make connections with and lets face it. Who doesn’t love Disney?
  3. The Sight Word Adventure. This app works on visual attention, memory and listening comprehension while the child practices the sight words they need for the foundation of reading.

A good list of the worst educational apps can be found over at Education.com. You’ll find a list of apps that are considered inappropriate for those kids 17 and under. Their list includes: Snapchat, the app that allows you to send pictures that self-destroy after 90 seconds; Poof; the app that is able to make apps disappear with one touch, and Samari vs. Zombies Defense; this app is violent and characterized as gruesome, to name a few.

As a parent or loving family member we are the ones that influence the younger generations, from their values, outlooks on life, and the most basic functions of their language skills. It is our responsibility to guide them and help the develop the skills needed in life the best way we know how – so remember to interact and engage with them as much as possible in positive ways. Technology is not detrimental to the development of the child if utilized properly – but be sure to connect with professional resources if you have any questions or concerns.

 


 

Resources:

Media & Children Policy Statement. American Academy of Pediatrics. Accessed April 29,2015

Technology and Interactive Media as Tools in Early Childhood Programs Serving Children from Birth through Age 8. Joint Position Statement of the National Association for the Education of Young Children and the Fred Rogers Center for Early Education and Children’s Media at St. Vincent College. Accessed April 29, 2015.

Phillipa Roxby. Does Technology Hinder or Help Toddlers’ Learning? BBC Health News. Accessed April 29, 2015

Judith Graham. Children and Brain Development: What We Know About How Children Learn. University of Maine Cooperative Extension Publications. Bulletin #4356. Accessed April 29, 2015.

Augmentative and Alternative Communication. American Speech-Language-Hearing Association. Accessed April 29, 2015

Christen Brandt, Cheryl Lock, and Chrisanne Grise. The Best Educational Apps for Kids. Parents.com. Accessed April 29, 2015.

http://www.education.com/magazine/article/worst-apps-kids/

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Categories: Ages + Stages, Policy, Politics, + Pop Health, Toddlers + Preschoolers

Teaching Kids to Unplug – A Parenting Battle Worth Fighting

By April 27, 2015 2 Comments
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The nature of blogging here at The Scientific Parent is that we typically write and post about issues that we’re tackling in our daily lives – or hot button topics that get us really revved up about science and health policy. Here’s one that’s happening in our home and gets me rowdy!

I recently posted Missy Keenan’s 10 Tips: Help Kids Strike A Better Balance With Tech on The Scientific Parent’s Facebook page, since my household features my tech-loving fiance and his young teenage sons, and we’re always looking for ways to balance tech time with real, human connection. In non-flowery language this means: teenagers + freedom + video games + pew pew pew + phones = countless hours of staring at screens syncopated with cranky chaos and fights. Oh, those boys. They’re wonderful. And when they’re tired, and we’re tired, we all just need someone to turn off those screens for us, shelve the protests, and send us all to our bedrooms for an early bedtime.

This non-stop tech time that the kiddos crave is generally unworkable (read: exhausting) in our lives for so many reasons, and from what it sounds like, many of yours too. According to the American Academy of Pediatrics, kids spend an average 7 hours a day on entertainment media such as TV, computers, and phones, which is slightly horrifying when you really think about the weekly tally on that one – an average of around 50 hours a week! I’m guessing many of you might be doing a mental tally to figure out how far below that total your kids might be to feel better about it. We did too – and you know what? It’s right. Ack.

I’ve first-hand watched a request to turn off the TV or to put down a phone after hours of use dissolve into an hours-long protest and tears, conflict that is supported by studies that show statistically significant positive associations between behavioral problems and media time. I’ve also seen the heavy impacts that late-night TV and video games have on healthy sleep patterns (theirs, and in turn, ours). There are late nights that the boys are both exhausted and wide awake, and hoping for just a bit more time on the Playstation, which is not surprising given that late-night TV, screen, and phone time is associated with decreased physical activity, increased physiological and mental arousal, and possible inhibition of the appropriate brain patterns and chemicals for effective sleeping.

The bottom line is, this battle of technology is a losing proposition for everyone if parents/stepparents/guardians don’t hold the line. And it’s really not a technology demon to battle; this generation is being raised seamlessly with technology and media that most of us didn’t have growing up, and it shows no signs of stopping. This is actually a parenting issue. As Leslie and I discussed this topic, we quickly turned to parenting styles and frustrations on how to parent and set structures for children based on their particular personalities and needs. Should we be doing what our parents did, do something else, or do helicopter parenting, free-range parenting, tiger parenting, attachment parenting, to name a few? How do we allow them freedom and time to relax with passive activities (TV, video games), and take those activities away when needed without harming them mentally or ruining their lives? Really, how do we not break our kids?

The good news and bad news is… I don’t have any official answer for you, since my parenting handbook got lost in the mail like all of yours did, too. What I can tell you is that the science says that kids need time to connect with each other, their parents, and their world to develop key social skills and instill a sense of curiosity and interest in their lives. The Ten Tips provided some great starting points to alter the relationships that kids have with technology, and they come just one week before International Screen Free Week (May 4-10) this year, a celebration where families put away digital entertainment and spend time together.

logoforsite

A celebration of families disconnecting from electronics and reconnecting with each other

In our home, currently we’re moving away from technology-heavy activities and trending toward things that bring us face-to-face. We put in a table that is far enough away from the TV that the TV isn’t visible from it – an incompatible behavior trick we learned from What Shamu Taught Me About A Happy Marriage. We eat dinner there, we do homework there, we have fun, and eat our latest snack experiments there. We created phone-free zones, and created video game “relaxation” time limits that they’re able to use however they see fit, since micromanaging is the pits for everyone. And we make sure that physical activities like sports, karate classes, and 4-person living room dance parties take precedence over screen time.

It doesn’t stop all the fights, but I suppose if they’re not arguing with you and complaining at you sometimes, you’re probably not doing it right. After all, we generally want to raise independent, capable, thinking human beings who can go live their lives well. So I’d urge that the battle of the tech is a battle worth fighting – it’s our job to make sure their brains and bodies have the best chance possible during these key developmental stages. And that means unplugging while also learning how to connect.

 


Resources:

Amy Sutherland. What Shamu Taught Me About A Happy Marriage. New York Times. Accessed April 25, 2015.

Missy Keenan. 10 Tips: Help Kids Strike A Better Balance With Tech. Des Moines Register. Accessed April 25, 2015.

Media and Children. American Academy of Pediatrics. Accessed April 25, 2015.

Media Kit: Children and Media. American Academy of Pediatrics. Accessed April 25, 2015.

Nuutinen, T., Ray, C., Roos, E. Do computer use, TV viewing, and the presence of the media in the bedroom predict school-aged children’s sleep habits in a longitudinal study? BMC Public Health 2013, 13:684. Accessed April 25, 2015.

Zimmerman FJ, Christakis DA. Children’s Television Viewing and Cognitive Outcomes: A Longitudinal Analysis of National Data.  Archives of Pediatrics and Adolescent Medicine. 2005;159(7):619-625. doi:10.1001/archpedi.159.7.619. Accessed April 25, 2015.

Ginsburg, K., et al. The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bonds. American Academy of Pediatrics. Vol. 119 No. 1 January 1, 2007. pp. 182 -191 (doi: 10.1542/peds.2006-2697). Accessed April 25, 2015.

Lillard, A., Peterson, J. The Immediate Impact of Different Types of Television on Young Children’s Executive Function. PEDIATRICS. Vol. 128 No. 4 October 1, 2011 pp. 644 -649
(doi: 10.1542/peds.2010-1919) Accessed April 25, 2015.

Özmert E, Toyran M, Yurdakök K. Behavioral Correlates of Television Viewing in Primary School Children Evaluated by the Child Behavior Checklist. Archives of Pediatrics and Adolescent Medicine. 2002;156(9):910-914. doi:10.1001/archpedi.156.9.910.

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Categories: Ages + Stages, Mental, Emotional, + Behavioral Health, School-Aged Children, Toddlers + Preschoolers

Hitting Language Development Milestones: Stop Stressing and Start Talking!

By April 6, 2015 1 Comment
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“Why is Christopher not saying anything yet when Abigail couldn’t stop talking at that age?”

I hear this type of question often when working with parents on their children’s language development plans. Their thinking is not unusual – society has placed expectations on when it’s developmentally appropriate for children to communicate. Parents often worry and want to know why their child is not pacing others their age based on these norms, but as a Speech-Language Pathologist, I can tell you that milestones that use exact ages should be taken with a grain of salt. I personally was one of those people asking why my nephew wasn’t speaking at 12 months, even though I professionally knew better than to expect him to conform to those standards.

So what are the general expectations?

A true vocabulary word means that they look at the person and say the word with intent (i.e. look at Mom and say “mama”). It’s believed that by 12 months of age, children should have one or two words that they say meaningfully (i.e.: “hi!” “mama” and “dada”) and a vocabulary of about 50 words at the age of 24 months. But these aren’t set in stone, nor are they appropriate for every child. The American Speech-Language-Hearing Association (ASHA) website has an extensive listing of those milestones to review, and is a great place to look for further information about the development of language.

What concerns me is the way some statistics and guidelines are taken very literally, and how language development studies can be misinterpreted in a way that causes parents undue worry. For example, a UC Berkeley study recently published in the Hispanic Journal of Behavioral Sciences indicated that language skills of Mexican-American babies lag behind their white peers by the age of two. This research found that lag occurred for babies whose parents lived below the poverty line and had not attained high school diplomas, whose mothers were generally born outside of the U.S. Unfortunately, for non-clinicians, it is easy to misinterpret this study as something resulting from strictly cultural or bilingual origins, as opposed to the myriad of factors that affect a child’s language.

Being bilingual is an asset – for example,  children with bilingualism have been found to obtain increased metacognitive skills (i.e. self-awareness) due to their understanding that an object may have more than one word to label it. Further, according to an article from the Journal of Cognition (summary here), monolingual infants expect that an unfamiliar person would only understand one language, whereas bilingual infants understand that all speech would not communicate to all people.  So to answer a question brought forth by a concerned parent to The Scientific Parent’s Facebook page asking if speaking more than one language affects a child’s ability to learn to speak, the simple and short answer is no.

Let’s break it down. There are two types of language skill sets that every person utilizes. Receptive language (where one takes in what others are saying and is able to understand what is being said) and expressive language (how we are able to get our thoughts, feeling and ideas across, either through nonverbal/verbal language or written expression). Babies begin developing receptive language at birth when infants learn that crying will bring them food and comfort and by hearing the environmental noises around them. They begin to comprehend the various speech sounds of which their native language is comprised. It is vital to assess infants’ hearing to ensure that they are able to hear speech sounds and environmental noises. This normally occurs early on however should be reassessed if the child suffers from chronic ear infections. By the age of 2, a child should be able to increase their vocabulary every month, point to a couple body parts, point to pictures in a book when named, and ask a two-worded question, for example, what’s that? But also remember, when it comes to speech and language development there are many things that you can do at home:

Structured Parenting Activities:
Regularly read to your child.Children pick up that words have different uses and the visual of the picture book help children comprehend what the word means. Limit media time.According to the American Academy of Pediatrics television and other media should be avoided by children under 2. See the journal link for more details.
Limit the amount of toys that make noise.These often overstimulate children. Your words as a parent are more powerful than sound from a toy. Provide positive reinforcement when your child attempts to communicate. There is nothing like seeing a child smile and excited because you responded to them!

 

Regular Verbal Exercises:
Have your child imitate your sounds. (i.e. mamamama, papapa). This helps children produce the sound as they are being given a visual. Also, practice making these sounds on their cheeks to give them the sensation. Teach your child to imitate your actions.Use gestures to help convey meaning (i.e. waving bye, blowing kisses). Many children will use gestures to help them communicate (i.e. point to the juice and say please since they can’t produce the word juice.)
Talk as you complete everyday routines.Expose the child to everyday vocabulary (doing the dishes, taking a bath, folding laundry). Identify what you see around you (see the white cat?), count items (I see 1, 2,3 fish!). Sing songs. (i.e. Old MacDonald, The Wheels on the Bus, Hokey Pokey). Repetitive words and sounds help children remember vocabulary and correlate the sounds/actions with words (i.e. sheep says baa, dog say woof).
Expanding any language opportunities.If the child says “doggie,” the parent responds, “yes I see the little black doggie.” This will convey the message to the child that there is more that can be said to get their point across. Use hand over hand cuing to point to items in a book.I.e. place your hand on your child’s when pointing to an apple and say “apple” while touching the item. 

If you are concerned that your child has not reached developmental milestones you should contact your pediatrician and explain your concerns and observations. They can refer you to a professional for an evaluation to determine if a child has a developmental delay, and if they do, a program called Early Intervention (EI) provides services in support of children from birth to age three before they enter the school systems. I have seen children benefit greatly from the services through EI, not just because I work in EI but through the growth of my nephew’s expressive language when he was little. EI is parent-centered, and is able to work with children who experience delays in physical (reaching, rolling, crawling, and walking); cognitive (thinking, learning, solving problems); communication (talking, listening, understanding); social/emotional (playing, feeling secure and happy); and self-help (eating, dressing). Therapists that work in EI such as myself want you to participate in therapy and also strive to leave you with customized strategies to help enhance your child’s abilities.


 

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Categories: Ages + Stages, Toddlers + Preschoolers

The Walking Dead: Sorry Rick, The Kids Aren’t Alright

By February 22, 2015 1 Comment
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Judith has it hardest during the zombie apocalypse.

On an episode of The Walking Dead the group’s leader, Rick, postulated that the zombie-filled post-apocalyptic world is easier for children to cope with because they don’t remember the world the way it used to be. That’s an interesting theory as it cuts to the heart of how child and adult brains cope with trauma and heal afterwards.

Let’s put Rick’s theory to the test: Do kids in the zombie apocalypse really have it easier than the adults?Requisite spoiler alert.  If you have not watched The Walking Dead season five, episode 10 and do not want to be spoiled stop. Turn back.  Here there be spoilers.  You have been warned …

The Adults:

If we’ve spent our childhood in a loving and stable environment, chances are our adult brains have developed relatively normally. Most importantly, our brains have learned normal and established patterns of functioning. When extreme stress disrupts the normal adult brain (say, with the loss of a loved one, the sleep deprived first few months of parenthood, job loss), the brain wants to reestablish those normal patterns.

Serious problems occur when the adult brain is repeatedly exposed to trauma (say, watching zombies kill your loved ones over and over, and then watching your loved ones rise again as zombies themselves) and it isn’t able to reestablish those normal patterns once the threat has passed. This is most commonly known as Post Traumatic Stress Disorder (PTSD). PTSD means the brain is unable to recognize it is no longer in a high-stress environment and doesn’t need to maintain a state of hyper arousal, emotional numbness and replaying the traumatic event. Right now those states and behaviors are actually helping the adults survive in the apocalypse, but not without doing major emotional damage.

Carl:

The developing brain is much more plastic (meaning easily changed by repeated stimuli) than the adult brain.  This means the trauma from the zombie apocalypse has likely interrupted Carl’s normal brain development at key phases.

Multiple studies have shown repeated exposure to traumatic events in childhood results in more complex symptoms in adulthood, compared to traumatic events endured as adults. What this means is that an adult who has experienced a traumatic event is likely to present with symptoms that are more easily recognized as PTSD. But if the event was experienced as a child, the patient is likely to present with additional symptoms along with PTSD that can mask or delay an accurate diagnosis once he or she is grown. These symptoms can include eating disorders, self-harm and generalized anxiety.

This means that if Carl survives to see a zombie-free adulthood, he’s likely to experience much more severe and complex psychological impacts of his time in the zombie apocalypse than say, Rick, Dale or Carol.

Judith:

Even before she was born, Judith had it rough. Her mother Lori experienced severe stress and poor maternal care during pregnancy which can significantly impair brain development in the growing fetus.

I can’t be the only parent that marvels at how quiet and still Judith is and how she never seems to grow up. Until I started researching this article, I’d chalked this up to a writers’ oversight. But it seems Judith may be a victim of her environment. Infants that endure high levels of stress can experience delays in developmental milestones like vocalizing, walking and tracking objects. Their growth can also be

Being a baby in the zombie apocalypse isn't all it's cracked up to be. (photo via AMC TV.)

Being a baby in the zombie apocalypse isn’t all it’s cracked up to be. (photo via AMC TV.)

inhibited.

Judith is obviously too young to understand what is happening around her, but the constant loud noises, violent movements, frightening images and unpredictable adult behavior are sensory stresses for infants. On top of that, she hasn’t been able to form attachment bonds with the adults in her life: her mother died in childbirth, she was separated from her first primary caregiver Beth when the prison was attacked, and then lost her second primary caregiver when Tyreese was killed.

Most importantly, Judith’s brain is keenly plastic and seeks to establish those normal patterns. But her infant brain is being bombarded with environmental stresses it doesn’t have the capacity to process. While on the surface Judith seems to have it easy being carried around in a sling, she actually likely has the most difficult existence out of the entire group, and will suffer the longest-lasting effects.

While Rick’s intuition is usually spot-on, he’s way off on this one. The kids don’t have it easier in the post-apocalyptic zombie-filled world than the adults do, and they likely will have a harder recovery.


Resources:
National Institute of Mental Health. What is Post-Traumatic Stress Disorder or PTSD.  National Institutes of Health. Retrieved February 22, 2015.

Bremner, M. Traumatic Stress: Effects on the Brain. Dialogues in Clinical Neuroscience. 8(4) 445-461. December 2006. Retrieved February 22, 2015.

Cloitre, M., Stolbach, B., Herman, J. et al. A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress. 22(5). 2009. Retrieved February 22, 2015.

National Scientific Council on the Developing Child. (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper 3. Updated  Edition. Retrieved February 22, 2015.

Slykerman, R., Thompson, J., Clark, P., et al. Determinants of Developmental Delay in Infants 12 months. Journal of Pediatric and Perinatal Epidemiology. 21(2) 121-128. March 2007. Retrieved February 22, 2015.

US Department of Health and Human Services. Administration for Youth and Families. Understanding the Impact of Maltreatment on the Brain. ChildWelfare.gov. 2009. Retrieved February 22, 2015.

National Child Traumatic Stress Network. Effects of Complex Trauma. Retrieved February 22, 2015.

Kolb, B., and Gibb, R. Brain Plasticity and Behavior in the Developing Brain. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 20(4). November 2011. Retrieved February 22, 2015.

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Categories: Mental, Emotional, + Behavioral Health