The Future of Preschool Prevention, Assessment, and Intervention
The Future of Preschool Prevention, Assessment, and Intervention
The Future of Preschool Prevention, Assessment, and Intervention
P re v e n t i o n , A s s e s s m e n t ,
and Intervention
Jim Hudziak, MD*, Christopher Archangeli, MD
KEYWORDS
Preschool Children Brain health Wellness Mindfulness Exercise Music
Nutrition
KEY POINTS
Promoting brain health improves the emotional-behavioral health of all children, can pre-
vent problems in children at risk, and can alter the trajectory of children already suffering.
The environment shapes the structure and function of the developing brain, so promoting
brain health requires cultivation of healthy environments at home, school, and in the
community.
Promoting brain health requires assessing and treating the entire family and equipping
parents with the principles of parent management training.
Clinicians should incorporate wellness prescriptions for nutrition, physical activity, mind-
fulness, and music into work with families.
INTRODUCTION
This article presents neuroscience that establishes that it is possible to promote brain
health as a pathway to
Improving emotional-behavioral and general medical health in all children.
Preventing the development of emotional-behavioral problems in those at very
high risk.
Staying and reversing the toll of pre-existing emotional-behavioral problems in
children who are already suffering.
Added to the extant neuroscience data, it presents health promotion prescrip-
tions that the authors believe are the future of brain and body health. The goal is
to promote the argument that building healthy brains in young children promotes
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612 Hudziak & Archangeli
healthy bodies, families, and communities. The article provides examples of how
these interventions are interrelated and must be integrated into a family-based
model.
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Preschool Prevention, Assessment, and Intervention 613
Wellness Prescriptions
In the authors’ center and in our applied work in pediatric settings, preschool, and
school settings all the way through the college period,4 as well as in obstetrics or gy-
necology settings, we prescribe to our patients and families these wellness interven-
tions. We have included these recommendations at the end of each section.
The preschool period, which the authors define as conception to age 5, is the most
pivotal period of brain development. Neurogenesis, synaptogenesis, and apoptosis
occur more rapidly during this period than in any other. Large-scale projects, such
as the Human Connectome Project, have led to substantial advances in the under-
standing of the structure and function of the brain. Glasser and colleagues5 recently
identified 180 distinct brain regions, including 97 which were completely novel.
Although large studies of the adult brain remain essential to progress in neuroscience,
work to understand the developing brain is equally essential, such as that of Kim and
colleagues,6 who published new measures of cortical development in a sample of chil-
dren 6 to 24 months of age.
In step with colleagues studying normal brain development, others are making great
progress in describing the exquisite sensitivity of the brain to environmental influ-
ences. Research on the prenatal environment shows profound effects of maternal
psychopathologic states on the structure of a child’s brain. Prenatal anxiety affects
hippocampal development.7 Maternal depression leads to alterations in right amyg-
dala microstructure in newborns8 and cortical thickness in late childhood.9 Specific
molecular exposures are even being related to functional outcomes. Howland and col-
leagues10 found exposure to placental corticotropin-releasing hormone is associated
with elevated internalizing symptoms at age 5 years, and low internalizing and exter-
nalizing problems at age 5 years predicts mental toughness at age 14.11
In infancy and early childhood, the home environment continues to affect the devel-
oping brain. Luby and colleagues12 have linked maternal support with the trajectory
of hippocampal development throughout the preschool period. Larger hippocampal
volume is associated with a combination of high maternal support and less preschool
depression, whereas a smaller hippocampus is associated with combination of low
maternal support and severe preschool depression.13 Researchers have also demon-
strated the effects of poverty on brain development, leading to smaller white and
cortical gray matter volumes, as well as smaller hippocampal and amygdala
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614 Hudziak & Archangeli
NUTRITION
Parental Influences
Nutrition interventions should be used throughout the preschool period, should
target all family members, and may enhance other wellness interventions. Starting
prenatally, maternal obesity is linked to autism spectrum disorders, ADHD, anxiety,
depression, schizophrenia, and eating disorders in offspring.21 At the same time,
maternal stress hormones (potentially reflective of untreated psychopathologic condi-
tions) seem to increase risk for obesity in offspring.22 Abnormal eating behaviors are
regularly established by preschool age, lead to high rates of children both underweight
and overweight, and are influenced by parents.23 Increased structure of meal time and
responsive feeding (not restricting or pressuring a child to eat) are associated with
more desirable eating behaviors.24 Families will make healthier eating choices, such
as increasing vegetable consumption and decreasing soda consumption, when
incentivized.25
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Preschool Prevention, Assessment, and Intervention 615
Taken collectively, these studies show benefits of good nutrition from the prenatal
period onward, and it provides evidence for interconnectedness of parental nutrition
and eating behavior with child nutrition and eating behavior. Finally, there is also evi-
dence that psychopathologic conditions can contribute to eating abnormalities.
Pieper and Laugero32 demonstrated that preschool children with lower executive
function are more vulnerable to eating in the absence of hunger. Practically, this evi-
dence informs the authors’ strong recommendations that patients and their families
work toward a healthier diet.
Wellness Prescription
Eat structured meals together as a family. Meditate for 2 minutes before and after. Pro-
vide your child with 5 meals a day: large breakfast, 10 AM snack, lunch, 3 PM snack, and
family dinner. Meals and snacks should be based on fruits and vegetables; include
sources of omega-3 fatty acids, such as fish; and probiotic Greek yogurt should be
considered (given the growing evidence of the role of the gut-microbiota-brain axis
on neuropsychiatric disorders33).
PHYSICAL ACTIVITY
Correlates of Physical Activity in Children
Low levels of leisure time physical activities in adolescent girls predict poor mental
health in adulthood.34 Sport participation was positively associated with emotional
wellbeing independently of sex, social class, and health status in a cohort study of
16-year-olds.35 Physical activity incorporated into a school curriculum led to lower
levels of conduct and hyperactivity problems in girls when compared with control
schools.36 A cross-sectional study of Chinese adolescents demonstrated physical ac-
tivity improved mental wellness and the effect seemed to be mediated by developing
resilience.37
Physical Activity Effects on Psychopathologic Conditions
Cerrillo-Urbina and colleagues38 conducted a systematic review of exercise in chil-
dren with ADHD and found 8 RCTs that met their inclusion criteria. One of these
was a yoga program that showed improvement in core ADHD symptoms. They per-
formed a meta-analysis of the remaining 7 studies, which were aerobic exercise pro-
grams. These programs demonstrated moderate to large effect sizes on core
symptoms, including attention (standardized mean difference [SMD] 0.84), hyperactiv-
ity (SMD 0.56), and impulsivity (SMD 0.56); and related symptoms, including anxiety
(SMD 0.66), executive function (SMD 0.58), and social disorders (SMD 0.59).
Carter and colleagues39 recently published a systematic review of 11 trials on exer-
cise (all included either aerobic, resistance, or strength exercises) in children with
depression. Eight of the studies were used in a meta-analysis that showed moderate
overall effect in reducing depressive symptoms and, in trials with exclusively clinical
samples, moderate effect (SMD 0.43) on depressive symptoms with lower levels of
heterogeneity. Aerobic exercise as short as 10 minutes has demonstrated improved
impulsivity and affect among children with behavioral problems (with 72% of the sam-
ple already taking medications).40 Our own group demonstrated that 4 or more days of
exercise per week led to a 23% reduction in suicidal ideation and attempts among
bullied students.41
Factors Affecting Physical Activity in Children
A Brazilian sample of 328 children whose physical activity was measured with actig-
raphy found that maternal employment, travel mode to school, and having a television
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616 Hudziak & Archangeli
in the bedroom were correlated with physical activity levels.42 An Irish sample demon-
strated social factors (activities with friends, popularity) were associated with physical
activity, whereas individual factors (body mass index, access to play space) were
associated with screen time.43 A Canadian sample of children 7 to 14 years of age
examined the role of outdoor time and found that each additional hour spent outdoors
was associated with 7.0 more minutes of moderate-to-vigorous physical activity, 13
fewer minutes of sedentary time, 762 more steps, and lower odds of negative psycho-
social outcomes.44 Physical activity is associated with better mental health in children
and adolescents, and is effective in treating symptoms of ADHD and depression. Mov-
ing forward, clinicians will need to incorporate this in practice via individual recom-
mendations, such as removing a television from the bedroom, and through
advocacy for access to play space and the outdoors, as well as physical activity in
schools. Although these studies were in children older than preschoolers, they may
inform the need to incorporate at earlier ages.
Wellness Prescription
Thirty-five minutes of moderate physical activity every day for the whole family are
advised. Where possible, families should find activities they enjoy doing together to
provide natural positive reinforcement. Additionally, television should be removed
from the bedroom and screen time limits enforced (see later discussion).
MINDFULNESS
Mindfulness is an intervention that has been the subject of great public interest and
increasing scientific inquiry over recent years. Some work is being done to understand
the relationship between brain structure and mindfulness. Adolescents with naturally
higher levels of mindfulness demonstrated less thinning of the left anterior insula over
a 3-year period.45 However, the greater question remains how to use mindfulness in-
terventions to shape the brain and, in turn, behavior.
Mindfulness in Schools
Mindfulness practice is being used successfully in schools. Sibinga and colleagues46
studied a mindfulness-based stress reduction intervention compared with a health ed-
ucation program in 300 middle school children. This RCT showed significantly lower
levels of somatization, depression, negative affect, negative coping, rumination,
self-hostility, and post-traumatic symptoms compared with control. These effects
do not seem limited to older children because a pilot study of mindfulness training
in primary schools by Vickery and colleagues47 showed that children 7 to 9 years of
age like mindfulness and wish to continue the practice. Additionally, they found
that, relative to controls, the intervention group had decreased negative affect and
increased meta-cognition as reported by their teachers. An RCT of a 12-week
mindfulness-based Kindness Curriculum was studied in 68 public preschool children,
demonstrating improvements in social competence and higher report card grades in
areas of learning, health, and social-emotional development.48 Mindfulness interven-
tions have shown profound effects in older children, studies in younger children show
that they like it, and even preschool children have seen positive effects from the
practice.
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Preschool Prevention, Assessment, and Intervention 617
intervention trial showed positive results for ADHD.49 In the near future, more robust
randomized clinical trial data will be available because RCTs evaluating meditation
versus medication50 and family-based mindfulness for ADHD51 are under way. Mind-
fulness interventions are showing promise in other disorders as well. A pilot study of
mindfulness-based stress reduction for Tourette syndrome and chronic tic disorders
showed improvement in tic severity and tic-related impairment in 59% of the sub-
jects.52 Mindful parenting decreased aggression and increased social behavior in
case studies of children with developmental disabilities.53
Wellness Prescription
Meditate for 5 sessions of 2 to 3 minutes daily. Meditate together as a family. Once
parents have developed a meditation practice, they can begin teaching the basics
of belly-breathing and focusing on the breath to even very young children.
MUSIC
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618 Hudziak & Archangeli
Listening to music in pregnant women is associated with decreased stress and anx-
iety, and improved sleep quality, again demonstrating the interrelatedness of these
wellness interventions and their family-wide effects.64
Wellness Prescription
The authors advise learning how to play an instrument and playing it 1 hour a day for
2 years. Listen to music together as a family and consider incorporating classical com-
posers such as Bach because there is some evidence suggesting benefits on heart-
rate variability.65
PARENT TRAINING
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Preschool Prevention, Assessment, and Intervention 619
and Dutil3 reviewed the contribution of poor sleep to obesity in adolescents and found
that multiple systematic reviews and meta-analyses demonstrate increased risk for
obesity with poor sleep, with increased risk for the shortest durations. Furthermore,
they characterize the interrelatedness of sleep with many of the domains discussed.
Aerobic activity and diet can improve sleep quality and poor sleep can reduce physical
activity due to fatigue and increased food intake. Additionally, screen time has been
shown to disrupt sleep. In addition to its effects on physical activity and sleep, televi-
sion exposure increases the incidence and the persistence of externalizing problems
in preschool children.72 Santisteban and colleagues73 demonstrated that reading
mediated lower risk for aggression in both boys and girls. A recent RCT of a combined
parent training and shared reading intervention showed significant improvement in
parenting behaviors, child behaviors, and language development of the children in
the intervention group.74
Wellness Prescription
All parents should be educated on the principles of parent management training. Chil-
dren with sleep disturbances should engage in behavioral interventions around sleep.
Screen time should be limited and shared reading encouraged. The authors recom-
mend a 1:1 ratio of minutes spent reading to minutes of screen time allowed.
SUMMARY
The future of prevention and treatment of emotional and behavioral problems in the
preschool population is centered on growing knowledge of the developing brain
and how shaping the home environment through supporting family health, and
shaping the school environment by supporting community health, can modify the tra-
jectory of young children’s lives. The first step in this journey is adopting a family-
based approach as a discipline in which strengths and weaknesses of parents are
assessed; partnership is created via motivational interviewing to build on their
strengths; and, when needed, parents accept care for their own emotional-
behavioral needs. Through parent training for all parents, clinicians can help assure
that the knowledge, skills, and attitudes necessary to raise healthy children are widely
disseminated. By identifying and treating existing emotional-behavioral, substance
use, and general medical problems in parents, clinicians can contribute to better over-
all parental health and place parents in a better place to actualize the lessons in parent
training. When parents are doing well, they will be able to learn more easily and apply
these lessons in their children’s lives.
The real power of this approach is the day-to-day benefit of working with parents of
young children in prescriptive health promotion. Not only do these prescriptions bring
families closer together (exercising together, meditating together, eating, reading, pro-
ducing music together), the emerging neuroscience literature provides evidence that
each of these improves overall general cognitive and emotional-behavioral health.
This article provided several examples of such prescriptions and advised health
care professionals to encourage and incentivize parents to follow these paths with
the goal of working as a team to build healthier preschool brains and, it is hoped, alter
the arc of possibilities for all children. Healthy diets, regular exercise, adequate sleep,
regular reading, mindful meditation practiced by parents and children, learning an in-
strument, and several different forms of parent training are all promising avenues for
addressing the needs of this population. Improvement in an area can synergistically
lead to improvement in other areas, supporting the authors’ recommendation that
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620 Hudziak & Archangeli
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