Category Archives: resources

Irregular Bedtimes Impair Children’s Cognitive Development

Irregular Bedtimes Impair Children’s Cognitive Development

Article can be found at:
Caroline Cassels
Jul 08, 2013

Irregular bedtimes throughout early childhood may impair children’s cognitive development and have deleterious long-term knock-on health effects throughout life, new research shows.

A large longitudinal study conducted by investigators at University College London in the United Kingdom showed that irregular bedtimes in toddlers were associated with lower cognitive test scores at age 7 years, with girls particularly affected.

“Our findings suggest that inconsistent bedtimes, especially at very young ages and/or throughout early childhood, are linked to children’s cognitive development,” the investigators, led by Yvonne Kelly, PhD, write.

“Relations between inconsistent bedtimes and aspects of early child development may have knock on effects for health and broader social outcomes throughout the lifecourse,” they add.

The study was published online July 8 in the Journal of Epidemiology and Community Health.

Cumulative Effect

Although it is known that sleep plays a key role in maintaining healthy function, most of this evidence is based on studies in adults and adolescents, with little known about its impact in young children and their cognitive development.

The researchers note that previous small-scale studies examining its impact in a young pediatric population yielded mixed results. For the current study, the investigators aimed to examine the link between the time young children go to bed and their cognitive development in 11,178 7-year-olds who are participants in the Millennium Cohort Study (MCS).

The MCS is a nationally representative longitudinal study of infants born in the UK. The sample for the current study was drawn from births in the UK between September 2000 and January 2002.

The researchers sought to determine whether the time a child went to bed and the consistency of bedtimes had an impact on intellectual performance. They also wanted to determine whether any potential negative effects were cumulative and/or whether any particular periods during early childhood were more critical than others.

For the study, the researchers analyzed data on bedtimes from age 9 months and ages 3, 5, and 7 years. During structured interviews at home visits, questions were asked about socioeconomic circumstances, demographic characteristics, family routines, including bedtimes, and psychosocial environment.

At age 7, cognitive assessments that measured reading, mathematics, and spatial abilities were carried out by trained interviewers.

The investigators found that irregular bedtimes were most common at age 3, when about 1 in 5 children went to bed at varying times. By age 7, more than half of the children went to bed between 7:30 and 8:30 pm.

The investigators found that irregular bedtimes at age 3 were independently associated in girls and boys with lower reading (β: -0.10, -0.20), mathematics (β: -0.16, -0.11), and spatial (β: -0.13, -0.16) scores.

Further, they found that at age 7, not having a regular bedtime was related to low cognitive test scores in girls — reading, β: -0.22; mathematics, β: -0.26; and spatial, β: -0.15 — but not for boys.

The researchers also found that there was a cumulative effect, such that girls who had never had regular bedtimes at ages 3, 5, and 7 had significantly lower reading (β: -0.36), mathematics (β: -0.51) and spatial (β: -0.40) scores.

For boys, having irregular bedtimes at any 2 ages was linked to lower reading (β: -0.28), mathematics (β: -0.22), and spatial (β: -0.26) scores.

Key Health Determinant

The finding that irregular bedtimes at age 3 were linked to lower scores on all 3 study outcomes in boys and girls suggests that age 3 may be a particularly sensitive period for cognitive development, the researchers note.

As for potential mechanisms, the investigators suggest that inconsistent bedtimes could affect cognition in at least 2 ways: first, by disrupting circadian rhythms, and/or second, through sleep deprivation and its subsequent effects on brain plasticity, “including processes to do with embedding new knowledge, memory and skill into developing neural assemblies.”

“Sleep is the price we pay for plasticity on the prior day and the investment needed to allow learning fresh the next day…. Early child development has profound influences on health and well-being across the life course. Therefore, reduced or disrupted sleep, especially if it occurs at key times in development could have important impacts on health throughout life,” the authors conclude.

The authors report no relevant financial relationships.

J Epidemiol Community Health. Published online July 8, 2013. Abstract

Compensatory Cognitive Training Helps Patients with Psychosis

Compensatory Cognitive Training Helps Patients With Psychosis

This article can be found at:

By Will Boggs, MD

NEW YORK (Reuters Health) Aug 14 – Compensatory cognitive training (CCT) improves cognitive performance and functional outcomes in patients with psychosis, according to a new trial.

“CCT and other psychosocial treatments are showing real promise for treating the cognitive deficits, negative symptoms, and functional impairments of schizophrenia,” Dr. Elizabeth W. Twamley from University of California, San Diego, told Reuters Health by email.

“My hope is that in the next 50 years, psychosocial treatments will become a mainstay of treatment for schizophrenia, along with the antipsychotic medications that have been the mainstay of treatment for the last 50 years,” she added.

Dr. Twamley and colleagues created and pilot-tested a cognitive training intervention based on compensatory strategies, such as calendar use, self-talk, note taking, and a 6-step problem-solving method. They randomly assigned 69 outpatients with primary psychotic disorders to either cognitive training and standard pharmacotherapy or drugs alone.

The findings were published online August 7 in the Journal of Clinical Psychiatry.

Compared with controls, participants in the CCT program demonstrated significant improvements in attention and verbal memory at the 3-month follow-up, as well as a trend toward improved prospective memory.

CCT also boosted functional capacity such as household and shopping skills measured in role-play scenarios at the 3-month follow-up.

What’s more, Dr. Twamley and her colleagues found significant improvements in negative symptoms at post-treatment and 3-month follow-up, as well as significantly improved subjective quality of life at the 3-month follow-up.

CCT participants reported fewer cognitive problems and used more cognitive strategies than did standard pharmacotherapy participants.

“We consistently and overtly linked the CCT strategies to each participant’s real-world goals,” Dr. Twamley said. “From the man who used his calendar to track his glucose levels, to the woman who used flashcards to learn the names of her new friends in AA, the ability of our participants to creatively apply the CCT strategies to their own circumstances was really impressive.”

“The CCT manual was designed to be easy to deliver without extensive training,” Dr. Twamley explained. “To make it even easier for clinicians, we’ve created a therapist version of the manual that has tips on the back sides of the pages. The front sides of the pages are identical to the client version of the manual, so therapists and clients are literally on the same page during sessions.”

She added, “In our current NIMH-funded studies, we’re conducting randomized controlled trials comparing CCT to robust control conditions that match CCT for therapist time, so we’ll be able to demonstrate that the effects of CCT aren’t due to non-specific therapeutic factors. We’re also studying CCT in the context of supported employment and in other populations, such as people with first-episode psychosis and veterans with traumatic brain injury.”


J Clin Psychiatry 2012.

Developmental Screening in Children

Developmental Screening in Children: Promoting Healthy Development and Catching Problems Early

Jacqueline Sedgwick, MD, MPH

Posted: 07/17/2012

Increased Risks for Developmental Delay During Early Childhood

The early years provide the foundation for a child’s future development in most aspects of life, including health, academics, and social and emotional well-being. Epidemiologic studies demonstrate that adverse early childhood experiences, premature birth, and inadequate physical and social support contribute to inequality between and within populations, and that interventions with the child and family can help mitigate the effects of adversity.[1-3] In the United States, poverty, nutritional problems, and chronic physical or mental health issues are prevalent; these modifiable factors contribute to inequality in health, development, and lifespan.[4,5]

A recent study by the Centers for Disease Control and Prevention[6] found that in 2008, 15% of children in the United States were diagnosed with a developmental disability, including attention deficit disorder, intellectual disability, cerebral palsy, or autism, and the proportion of affected children was higher in low-income families. According to US Census statistics from 2010, 17.9% of children live in families with incomes at or below the poverty level.[4] Poverty is often accompanied by limited food options, exposure to environmental hazards, chronic physical and mental health problems, and restricted learning opportunities. Only 47.6% of children 3 and 4 years of age attend preschool, and attendance is lower among children living in low-income families.[7]

Another factor affecting child development is caretaker mental health, and 9% of mothers in the United States experience major depression during the year after giving birth.[8]

The Role of Screening for Child Developmental Delay

Screening is a public health service intended to detect specific medical conditions, even in people who believe they are well or who do not perceive that they are at risk for or are affected by a condition. For screening to be effective, appropriate screening tests and preventive care or treatments must be available and acceptable to clinicians and families. Screening tools can be integrated into well-child checks to identify patients and families at risk for nutritional, physical, mental, developmental, and social support problems.

To efficiently screen patients in busy clinics, clinicians can select age-appropriate screening tests for issues that are prevalent in their patient populations and train staff to implement these tests routinely during periodic well-child visits (Appendix, Table 1). Staff should be trained to:

  • Provide age-appropriate screening questionnaires to parents;
  • Conduct age-appropriate, routine developmental screenings;
  • Offer standardized age-appropriate health education;
  • Assist clinicians and parents to help arrange referrals;
  • Coordinate care between the practice and outside services; and
  • Follow-up with community agencies.

The Maternal and Child Health Bureau and the American Academy of Pediatrics partnered to develop Bright Futures,[9] a health promotion and disease prevention initiative that addresses children’s health needs in the context of family and community. Bright Futures offers excellent screening and health education practice aides.[9]

Having staff complete routine screenings and health education during periodic well-child visits frees clinicians to confirm and review the results with parents, identify parental concerns, and focus on treatment plans while supporting a healthy child/parent relationship.[9] The clinician can begin this portion of the patient visit by asking the parents, “Do you have any concerns or questions that you would like to discuss today?”[9] Addressing parents’ concerns and supporting their decisions helps to develop a relationship that ultimately will benefit the child.

Next, confirm and review the screening test results with parents. The clinician can then provide treatment or refer patients to appropriate community resources for patients and families with similar problems. Training staff to use a practice-specific referral form that includes your practice information and the names and contact information of your referral partners will facilitate this process (Appendix, Table 2).

The staff member who completes your practice’s referral form should give a copy to the child’s parents, fax it with the required information to outside referral agencies, and inform the parents on how best to contact your practice and the referral agency in case they have questions or need to reschedule their appointment. Your practice may want to develop a tracking system to monitor high-risk families. Having staff coordinate referrals, obtain results and recommendations from the outside agencies, and ensure that the patient has a follow-up visit with the clinician will help the clinician to support and monitor the patient’s care and create a medical home.[9,10]

Screening Recommendations

Nutritional and Environmental Issues

Nutritional and environmental issues, such as iron deficiency anemia and lead poisoning, affect a child’s health and ability to learn.[5,9] Nutritional and environmental issues may begin in the prenatal setting; adequate prenatal nutrition and healthcare for women with high-risk conditions, such as gestational diabetes, provide infants with a healthy start in life. Breastfeeding should be promoted for all infants, unless a contraindication is present.[9]

Iron deficiency. Iron deficiency occurs in up to 15% of toddlers in the United States. Iron deficiency anemia and lead exposure during infancy and childhood have been found to have long-lasting detrimental effects on neurodevelopment.[11]

Children should be universally screened for iron deficiency anemia at approximately 1 year of age. If the child is found to have mild anemia, standard clinical practice is to provide iron supplementation and repeat hemoglobin testing in 1-3 months. For all infants with anemia, measuring serum ferritin and C-reactive protein or reticulocyte hemoglobin is recommended.[11]

Because of the cost and difficulties of acquiring venous blood from toddlers, standard clinical practice is to evaluate further children with severe anemia, those with a family history of hematologic illness, or infants who have a follow-up hemoglobin level less than 10.0 g/dL. Treatment will depend on the diagnosis. If iron deficiency anemia is diagnosed, management is iron supplementation and dietary education.[11]

Exposure to lead and other chemicals. Risk assessment or screening for lead exposure should be done at 1 year of age unless local prevalence indicates that earlier screening is advisable. Lead testing also should be considered whenever a young child has persistent anemia, lives in housing built before 1977 (when lead was banned from being used in housing paint), or has developmental delay.[9]

It is also prudent to ensure that patients are not exposed unnecessarily to other chemicals that can affect their health, such as pesticides on a field worker’s clothing. This can be mitigated by having the parent change clothes before returning home (see “Center for Environmental Research and Children’s Health” under “Web Resources” at the end of this article).

Nutrition. Every physical examination is an opportunity to monitor the child’s growth and offer nutritional advice. Families who are having difficulty providing food for their children should be referred to such agencies as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which is intended to safeguard the health of low-income pregnant, postpartum, and breastfeeding women; infants; and children up to age 5 years. WIC provides nutritious foods to supplement diets and information on healthy eating, including breastfeeding promotion and support. Assistance from the Supplemental Nutrition Assistance Program (formerly known as “food stamps”) also may be available for low-income families; currently, only 56.7% of eligible families are receiving such assistance.[4]

Physical and Mental Health Problems, Including Developmental Delay

According to the 2009-2010 National Survey of Children with Special Health Care Needs, approximately 11.2 million children (ie, children in 1 in 5 households in the United States) have special healthcare needs.[12] During periodic physical examinations, all children should be screened for vision, hearing, speech, and developmental delays; chronic health problems; and functional disabilities, including motor, communication, cognitive, and socioemotional problems.[9]

Children with chronic physical and mental health issues, a history of in utero substance abuse exposure, high lead levels, child abuse, neglect, domestic violence, and developmental delay are generally eligible for early intervention services, as part of the Individuals with Disabilities Education Act (IDEA) Part C (birth to age 3 years) or part B (3 to 5 years).[12,13] These programs are state-required multidisciplinary services for children with developmental delays or at risk for delays.[12,13] Early intervention services offer the child and family treatment and support, giving the child the best chance to reach his or her potential.

Developmental surveillance should be incorporated into every well-child care visit.[9,14] The American Academy of Pediatrics[14] identifies 5 components of developmental surveillance:

  1. Eliciting and attending to parental concerns;
  2. Documenting and maintaining a developmental history;
  3. Making accurate observations of the child;
  4. Identifying risk and protective factors; and
  5. Maintaining an accurate record documenting the child’s development.

If a parent or clinician determines that a child is at risk for a developmental problem, specific standardized screening should be implemented.[14] This may be conducted in the medical home; by referral to a behavioral pediatrician; or by referral to programs that offer early intervention services, such as Babies Can’t Wait, state-funded programs for persons with disabilities (for example, the Lanterman Developmental Disabilities Services Act is part of California law that funds Regional Centers), or Early Head Start. In children with a positive screening result for a developmental problem, further developmental and medical evaluations are warranted to identify the specific disorder and refer for early intervention and family support services.[14]

Currently, on the basis of the available scientific evidence, the American Academy of Pediatrics does not have enough evidence to support the implementation of communitywide routine screening for autism. At this time, the American Academy of Pediatrics recommends careful assessment and surveillance of all preschoolers who present with impairments in language or social or cognitive skills development for autism spectrum disorders. None of the currently available autism screening tests has been shown to have sufficient accuracy (ie, high sensitivity, high specificity, and high predictive value) in population-wide screening programs.[15] In addition, neither proven therapies nor preventive measures exist for the universal treatment of children with autism.[15] At this time, the World Health Organization recommends careful surveillance and assessment of all preschoolers for impairments in their development of language, social function, or cognitive skills, with further evaluation of these high-risk children using available standardized testing whenever a problem is suspected.[15]

Family Problems and Social Support Issues

In the United States, up to 12% of all pregnant and postpartum women experience depression in a given year.[16] The consequences of maternal depression include negative effects on the cognitive, social, emotional, and behavioral development of their child.[16]

All parents of infants should be screened for depression (Appendix, Table 1) and offered intervention or referral to promote parental well-being and a healthy parent/child relationship.[9] The US Preventive Services Task Force[17] has endorsed a 2-question screen for depression:

Over the past 2 weeks:

  1. Have you ever felt down, depressed, or hopeless? and
  2. Have you felt little interest or pleasure in doing things?”

One “yes” answer is a positive screening result. Responses to a positive screening result range from reassurance to support and referral, depending on available resources, severity of depression, and duration of the parent’s symptoms.[16]

Children need cognitive stimulation to learn. Creating a dialogue with the family about ways they can help their child to learn and helping families who have inadequate resources and social support to identify community resources should be incorporated into routine well-child visits.[9] Such programs as Early Head Start and Head Start are federally funded community-based programs for low-income families with infants, toddlers, and preschoolers. They are designed to enhance the development of young children, and to promote healthy family functioning and school readiness through the provision of educational, health, nutritional, social, and other services. Currently in the United States, only 47.6% of children 3-4 years of age attend preschool,[4] and local Head Start programs may have insufficient funding to provide services to all eligible children.

Apart from these programs, parenting classes may be offered through the local adult school or community college. Libraries often have programs for children and their families, as do such organizations as the YMCA or YWCA. Your practice also may want to participate in Reach Out and Read, an evidence-based literacy promotion program for primary care providers (see “Web Resources”).

Bright Futures recommends screening for domestic violence and violence exposure.[9] Whenever problems are identified, referral to appropriate agencies, including law enforcement and child protective services, is mandated.[9] Development of a support system for your practice — including agreements with local service providers, such as public health nurses, social workers, and mental health professionals — can facilitate assisting families with these issues. Early intervention services offer patient and family support, giving children the best chance to reach their potential.


The foundations of healthy early child development include good nutrition; stable, responsive relationships with caregivers; adequate cognitive stimulation; and a safe, supportive environment. Family medical services must support healthy development while offering family-centered, community-based, and culturally competent services. Incorporating screening and health promotion services into routine well-child visits affords early identification of problems, including nutritional, physical, mental, developmental, and social issues. Training staff and creating and using a practice-specific referral form will facilitate this process. By offering treatment, referral, and follow-up, you can help families have healthy lifestyles and optimize child development, mitigating the adverse effects of problems. By developing an ongoing supportive relationship with families and referral agencies, you will create a medical home for your patients.


Table 1. Recommended Screening Tools

Condition to Be Screened Source
Age-Appropriate Development Bright Futures: Tool and Resource Kit
Parental Depression AHRQ: US Preventive Services Task Force, Guide to Clinical Preventive Services, 2010-2011 — Screening for Depression in AdultsBright Futures: Patient Health Questionnaire-2Bright Futures: Edinburgh Postnatal Depression Scale
Autism Bright Futures: Modified Checklist for Autism in Toddlers (M-CHAT)
Environmental Health Physicians for Social Responsibility: Pediatric Environmental Health Toolkit

Table 2. Suggested Format for Referrals

Referral for Family Support Services
Patient Name:Date of Birth:Primary Care Provider (PCP):Practice Contact:

Practice Phone/E-mail:

We are referring our patient to your agency for:


WIC Program:

Early Head Start/Head Start:

Mental Health Services/Family Support Services:


Agency recommendations:

Follow-up Appointment With PCP:




Web Resources

American Academy of Pediatrics: Bright Futures
Bright Futures provides recommendations for preventive pediatric healthcare.

Center for Environmental Research and Children’s Health (CERCH): The CHAMACOS Study
Parent education on preventing environmental exposures to toxic substances is available in the “health professionals” section.

National Head Start Association
Head Start provides a range of comprehensive education, health, nutrition, parent involvement, and family support services to serve primarily at-risk children and their families.

National Early Childhood Technical Assistance Center (NECTAC) 
NECTAC provides contact information for state Part C coordinators and other early childhood resources.

National Dissemination Center for Children with Disabilities (NICHCY)
NICHCY provides information on disabilities, Individuals with Disabilities Education Act (IDEA), No Child Left Behind, and research-based information on effective educational practices.

Reach Out and Read
Reach Out and Read prepares America’s youngest children to succeed in school by partnering with medical providers to prescribe books and encourage families to read together.


  1. Walker SP, Wachs TD, Grantham-McGregor SM, et al. Inequality in early childhood: risk and protective factors for early child development. Lancet. 2011;378:1325-1338. Abstract
  2. Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129:e232-e246. Abstract
  3. Engle PL, Fernald LC, Alderman H, et al; Global Child Development Steering Group. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet. 2011;378:1339-1353. Abstract
  4. US Census Bureau. American Community Survey Statistics. 2010. Accessed May 14, 2012.
  5. Satcher D. Ethnic disparities in health: the public’s role in working for equality. PLoS Med. 2006;3:e405.
  6. Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011;127:1034-1042. Abstract
  7. National Head Start Association. Benefits of Head Start and Early Head Start programs.
     Accessed April 28, 2012.
  8. Center on the Developing Child, Harvard University. Maternal depression can undermine the development of young children. Working Paper No. 8. 2009. Accessed May 14, 2012.
  9. American Academy of Pediatrics/Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008.
     Accessed July 10, 2012.
  10. Allen SG, Berry AD, Brewster JA, Chalasani RK, Mack PK. Enhancing developmentally oriented primary care: an Illinois initiative to increase developmental screening in medical homes. Pediatrics. 2010;126 Suppl 3:S160-S164.Abstract
  11. Baker RD, Greer FR; Committee on Nutrition, American Academy of Pediatrics. Clinical report: diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126:1040-1050. Abstract
  12. US Department of Education. The Individuals with Disabilities Education Act. October 5, 2011. Accessed April 28, 2012.
  13. US Department of Education. Early intervention program for infants and toddlers with disabilities. Accessed April 28, 2012.
  14. Council on Children with Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405-420. Abstract
  15. Al-Qabandi M, Gorter JW, Rosenbaum P. Early autism detection: are we ready for routine screening? Pediatrics. 2011;128:e211-e217.
  16. Earls MF; Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Clinical report: incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126:1032-1039. Abstract
  17. US Preventive Services Task Force. Screening for depression in adults. 2009. Accessed April 28, 2012.