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Case Studies and Scenarios

Case studies.

Each case study describes the real experience of a Registered Early Childhood Educator. Each one profiles a professional dilemma, incorporates participants with multiple perspectives and explores ethical complexities. Case studies may be used as a source for reflection and dialogue about RECE practice within the framework of the Code of Ethics and Standards of Practice​.

Scenarios are snapshots of experiences in the professional practice of a Registered Early Childhood Educator. Each scenario includes a series of questions meant to help RECEs reflect on the situation.

Case Study 1: Sara’s Confusing Behaviour

Case study 2: getting bumps and taking lumps, case study 3: no qualified staff, case study 4: denton’s birthday cupcakes, case study 5: new kid on the block, case study 6: new responsibilities and challenges, case study 7: valuing inclusivity and privacy, case study 8: balancing supervisory responsibilities, case study 9: once we were friends, ​​​​scenarios​​, communication and collaboration.

Barbara, an RECE, is working as a supply staff at various centres across the city. During her week at a centre where she helps out in two different rooms each day, she finds that her experience in the school-age program isn’t as straightforward as when she was in the toddler room. Barbara feels completely lost in this program.

Do You Really Know Who Your Friends Are?

Joe is an RECE at an elementary school and works with children between the ages of nine and 12 years old. One afternoon, he finds a group of children huddled around the computer giggling and whispering. Joe quickly discovers they’re going through his party photos on Facebook as one of the children’s parents recently added him as a friend.

Conflicting Approaches

Amina, an experienced RECE, has recently started a new position with a child care centre. She’s assigned to work in the infant room with two colleagues who have worked in the room together for ten years. As Amina settles into her new role, she is taken aback by some of the child care approaches taken by her colleagues.

What to do about Lisa?

Shane, an experienced supervisor at a child care centre, receives a complaint about an RECE who had roughly handled a child earlier that day. The interaction had been witnessed by a parent who confronted the RECE. After some words were exchanged, the RECE left in tears.

Duty to Report

Zoë works as an RECE in a drop-in program at a family support centre. She has a great rapport for a family over a 10-month period and beings to notice a change in the mom and child. One day, as the child is getting dressed to go home for the day, she notices something alarming and brings it to the attention of her supervisor.

Posting on Social Media

Allie, an RECE who has worked at the same child care centre for the last three years, recently started a private social media group to collaborate and discuss programming ideas. As the group takes a negative turn with rude and offensive comments, it’s brought to her supervisor’s attention.

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Casebook: Developmentally Appropriate Practice in Early Childhood Programs Serving Children from Birth Through Age 8

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About the book.

• Make connections to the fourth edition of Developmentally Appropriate Practice in Early Childhood Programs 
• Think critically about the influence of context on educator, child, and family actions 
• Discuss the effectiveness of the teaching practices and how they might be improved 
• Support your responses with evidence from the DAP position statement and book 
• Explore next steps beyond the case details 
• Apply the learning to your own situation 

Table of Contents

• Editors, Contributors, and Reviewers
• Introduction and Book Overview | Jennifer J. Chen and Dana Battaglia
• 1.1 Missed Opportunities: Relationship Building in Inclusive Classrooms | Julia Torquati
• 1.2 “My Name Is Not a Shame” | Kevin McGowan
• 1.3 Fostering Developmentally Appropriate Practice Through Virtual Family Connections | Lea Ann Christenson
• 1.4 Counting Collections in Community | Amy Schmidtke
• 1.5 The Joy Jar: Celebrating Kindness | Leah Schoenberg Muccio
• 1.6 Prioritizing Listening to and Learning from Families | Amy Schmidtke 
• 2.1 Julio’s Village: Early Childhood Education Supports for Teen Parents | Donna Kirkwood
• 2.2 Healthy Boundaries: Listening to Children and Learning from Families | Jovanna Archuleta
• 2.3 Roadmap of Family Engagement to Kindergarten: An Ecological Systems Approach | Marcela Andrés
• 2.4 Taking Trust for Granted? The Importance of Communication and Outreach in Family Partnerships | Suzanna Ewert
• 2.5 Book Reading: Learning About Migration and Our Family Stories | Sarah Rendón García 
• 3.1 Pairing Standardized Scale with Observation | Megan Schumaker-Murphy
• 3.2 The Power of Observing Jordan | Marsha Shigeyo Hawley and Barbara Abel
• 3.3 “But What Is My Child Learning?” | Janet Thompson and Jennifer Gonzalez
• 3.4 Drawing and Dialogue: Using Authentic Assessment to Understand Children’s Sense of Self and Observe Early Literacy Skills | Brandon L. Gilbert
• 3.5 The ABCs of Kindergarten Registration: Assessment, Background, and Collaboration Between Home and School | Bridget Amory
• 3.6 Creating Opportunities for Individualized Assessment Activities for Biliteracy Development | Esther Garza
• 3.7 Observing Second-Graders’ Vocabulary Development | Marie Ann Donovan
• 3.8 Writing Isn’t the Only Way! Multiple Means of Expressing Learning | Lee Ann Jungiv 
• 4.1 Engaging with Families to Individualize Teaching | Marie L. Masterson 
• 4.2 Tumbling Towers with Toddlers: Intention and Decision Making Over Blocks | Ron Grady  
• 4.3 What My Heart Holds: Exploring Identity with Preschool Learners | Cierra Kaler-Jones 
• 4.4 “I See a Really Big Gecko!” When Background Knowledge and Teaching Materials Don’t Match | Germaine Kaleilehua Tauati and Colleen E. Whittingham 
• 4.5 Using a Humanizing and Restorative Approach for Young Children to Develop Responsibility and Self-Regulation | Saili S. Kulkarni, Sunyoung Kim, and Nicola Holdman 
• 4.6 Joyful, Developmentally Appropriate Learning Environments for African American Youth | Lauren C. Mims, Addison Duane, LaKenya Johnson, and Erika Bocknek 
• 5.1 Using the Environment and Materials as Curriculum for Promoting Infants’ and Toddlers’ Exploration of Basic Cause-and-Effect Principles | Guadalupe Rivas 
• 5.2 Social Play Connections Among a Small Group of Preschoolers | Leah Catching 
• 5.3 Can Preschoolers Code? A Sneak Peek into a Developmentally Appropriate Coding Lesson | Olabisi Adesuyi-Fasuyi 
• 5.4 Everyday Gifts: Children Show Us the Path—We Observe and Scaffold | Martha Melgoza 
• 5.5 Learning to Conquer the Slide Through Persistence and Engaging in Social Interaction | Sueli Nunes 
• 5.6 “Sabes que todos los caracoles pueden tener bebés? Do You Know that All Snails Can Have Babies?” Supporting Children’s Emerging Interests in a Dual Language Preschool Classroom | Isauro M. Escamilla 
• 5.7 “Can We Read this One?” A Conversation About Book Selection in Kindergarten | Larissa Hsia-Wong  
• 6.1 Take a Chance on Coaching: It’s Worth It! | Lauren Bond 
• 6.2 It Started with a Friendship Parade | Angela Vargas 
• 6.3 The World Outside of the Classroom: Letting Your Voice Be Heard | Meghann Hickey 
• 7.1 Communication as a Two-Way Street? Creating Opportunities for Engagement During Meaningful Language Routines | Kameron C. Cardenv 
• 7.2 Eli Goes to Preschool: Inclusion for a Child with Autism Spectrum Disorder | Abby Hodges
• 7.3 Preschool Classroom Supports and Embedded Interventions with Coteaching | Racheal Kuperus and Desarae Orgo
• 7.4 Addressing Challenging Behavior Using the Pyramid Model | Ellie Bold
• 7.5 Dual Language or Disability? How Teachers Can Be the First to Help | Alyssa Brillante
• 7.6 Adapting and Modifying Instruction Using Reader’s Theater | Michelle Gonzalez
• 7.7 Supporting Children with Learning Disabilities in Mathematics: The Importance of Observation, Content Knowledge, and Context | Renee B. Whelan 
• 8.1 Facilitating a Child’s Transition from Home to Group Care Through the Use of Cultural Caring Routines | Josephine Ahmadein
• 8.2 Engaging Dual Language Learners in Conversation to Support Translanguaging During a Small Group Activity | Valeria Erdosi and Jennifer J. Chen
• 8.3 Incorporating Children’s Cultures and Languages in Learning Activities | Eleni Zgourou
• 8.4 Adapting Teaching Materials for Dual Language Learners to Reflect Their Home Languages and Cultures in a Math Lesson | Karen Nemeth
• 8.5 Studying Celestial Bodies: Science and Cultural Stories | Zeynep Isik-Ercan
• 8.6 Respecting Diverse Cultures and Languages by Sharing and Learning About Cultural Poems, Songs, and Stories From Others | Janis Strasser

Book Details

Faculty resources.

To access tips and resources for teaching the cases, please complete this brief form.  You’ll be able to download the items after you complete the form. 

Teacher Inquiry Group Resources

To access reflection questions to deepen your learning, please click here.

More DAP Resources

To read the position statement, access related resources, and stay up-to-the-minute on all things DAP, visit  NAEYC.org/resources/developmentally-appropriate-practice .

Pamela Brillante,  EdD, is professor in the Department of Special Education, Professional Counseling and Disability Studies, at William Paterson University. She has worked as an early childhood special educator, administrator, and New Jersey state specialist in early childhood special education. She is the author of the NAEYC book The Essentials: Supporting Young Children with Disabilities in the Classroom. Dr. Brillante continues to work with schools to develop high-quality inclusive early childhood programs. 

Jennifer J. Chen, EdD, is professor of early childhood and family studies at Kean University. She earned her doctorate from Harvard University. She has authored or coauthored more than 60 publications in early childhood education. Dr. Chen has received several awards, including the 2020 NAECTE Foundation Established Career Award for Research on ECTE, the 2021 Kean Presidential Excellence Award for Distinguished Scholarship, and the 2022 NJAECTE’s Distinguished Scholarship in ECTE/ECE Award. 

Stephany Cuevas, EdD, is assistant professor of education in the Attallah College of Educational Studies at Chapman University. Dr. Cuevas is an interdisciplinary education scholar whose research focuses on family engagement, Latinx families, and the postsecondary trajectories of first-generation students. She is the author of Apoyo Sacrifical, Sacrificial Support: How Undocumented Parents Get Their Children to College (Teachers College Press). 

Christyn Dundorf, PhD, has more than 30 years of experience in the early learning field as a teacher, administrator, and adult educator. She serves as codirector of Teaching Preschool Partners, a nonprofit organization working to grow playful learning and inquiry practices in school-based pre-K programs and infuse those practices up into the early grades.

Emily Brown Hoffman, PhD, is assistant professor in early childhood education at National Louis University in Chicago. She received her PhD from the University of Illinois at Chicago in Curriculum & Instruction, Literacy, Language, & Culture. Her focuses include emergent literacy, leadership, play and creativity, and school, family, and community partnerships. 

Daniel R. Meier, PhD, is professor of elementary education at San Francisco State University. His publications include Critical Issues in Infant-Toddler Language Development: Connecting Theory to Practice (editor), Supporting Literacies for Children of Color: A Strength-Based Approach to Preschool Literacy (author), and Learning Stories and Teacher Inquiry Groups: Reimagining Teaching and Assessment in Early Childhood Education (coauthor). 

Gayle Mindes, EdD, is professor emerita, DePaul University. She is the author of Assessing Young Children , fifth edition (with Lee Ann Jung), and Social Studies for Young Children: Preschool and Primary Curriculum Anchor, third edition (with Mark Newman). Dr. Mindes is also the editor of Teaching Young Children with Challenging Behaviors: Practical Strategies for Early Childhood Educators and Contemporary Challenges in Teaching Young Children: Meeting the Needs of All Students . 

Lisa R. Roy, EdD, is executive director for the Colorado Department of Early Childhood. Dr. Roy has supported families with young children for over 30 years, serving as the director of program development for the Buffett Early Childhood Institute, as the executive director of early childhood education for Denver Public Schools, and in various nonprofit and government roles.

Early Childhood Education: How to do a Child Case Study-Best Practice

• Creating an Annotated Bibliography
• Lesson Plans and Rubrics
• Children's literature
• Podcasts and Videos
• Cherie's Recommended Library
• Great Educational Articles
• Great Activities for Children
• Professionalism in the Field and in a College Classroom
• Professional Associations
• Pennsylvania Certification
• Manor's Early Childhood Faculty
• Manor Lesson Plan Format
• Manor APA Formatting, Reference, and Citation Policy for Education Classes
• Conducting a Literature Review for a Manor education class
• Manor College's Guide to Using EBSCO Effectively
• How to do a Child Case Study-Best Practice
• ED105: From Teacher Interview to Final Project
• Pennsylvania Initiatives

Description of Assignment

During your time at Manor, you will need to conduct a child case study. To do well, you will need to plan ahead and keep a schedule for observing the child. A case study at Manor typically includes the following components: 

• Three observations of the child: one qualitative, one quantitative, and one of your choice. 
• Three artifact collections and review: one qualitative, one quantitative, and one of your choice. 
• A Narrative

Within this tab, we will discuss how to complete all portions of the case study.  A copy of the rubric for the assignment is attached. 

• Case Study Rubric (Online)
• Case Study Rubric (Hybrid/F2F)

Qualitative and Quantitative Observation Tips

Remember your observation notes should provide the following detailed information about the child:

• child’s age,
• physical appearance,
• the setting, and
• any other important background information.

You should observe the child a minimum of 5 hours. Make sure you DO NOT use the child's real name in your observations. Always use a pseudo name for course assignments. 

You will use your observations to help write your narrative. When submitting your observations for the course please make sure they are typed so that they are legible for your instructor. This will help them provide feedback to you. 

Qualitative Observations

A qualitative observation is one in which you simply write down what you see using the anecdotal note format listed below. 

Quantitative Observations

A quantitative observation is one in which you will use some type of checklist to assess a child's skills. This can be a checklist that you create and/or one that you find on the web. A great choice of a checklist would be an Ounce Assessment and/or work sampling assessment depending on the age of the child. Below you will find some resources on finding checklists for this portion of the case study. If you are interested in using Ounce or Work Sampling, please see your program director for a copy. 

Remaining Objective 

For both qualitative and quantitative observations, you will only write down what your see and hear. Do not interpret your observation notes. Remain objective versus being subjective.

An example of an objective statement would be the following: "Johnny stacked three blocks vertically on top of a classroom table." or "When prompted by his teacher Johnny wrote his name but omitted the two N's in his name." 

An example of a subjective statement would be the following: "Johnny is happy because he was able to play with the block." or "Johnny omitted the two N's in his name on purpose." 

• Anecdotal Notes Form Form to use to record your observations.
• Guidelines for Writing Your Observations
• Tips for Writing Objective Observations
• Objective vs. Subjective

Qualitative and Quantitative Artifact Collection and Review Tips

For this section, you will collect artifacts from and/or on the child during the time you observe the child. Here is a list of the different types of artifacts you might collect: 

Potential Qualitative Artifacts 

• Photos of a child completing a task, during free play, and/or outdoors. 
• Samples of Artwork 
• Samples of writing 
• Products of child-led activities 

Potential Quantitative Artifacts 

• Checklist 
• Rating Scales
• Product Teacher-led activities 

Examples of Components of the Case Study

Here you will find a number of examples of components of the Case Study. Please use them as a guide as best practice for completing your Case Study assignment. 

• Qualitatitive Example 1
• Qualitatitive Example 2
• Quantitative Photo 1
• Qualitatitive Photo 1
• Quantitative Observation Example 1
• Artifact Photo 1
• Artifact Photo 2
• Artifact Photo 3
• Artifact Photo 4
• Artifact Sample Write-Up
• Case Study Narrative Example Although we do not expect you to have this many pages for your case study, pay close attention to how this case study is organized and written. The is an example of best practice.

Narrative Tips

The Narrative portion of your case study assignment should be written in APA style, double-spaced, and follow the format below:

• Introduction : Background information about the child (if any is known), setting, age, physical appearance, and other relevant details. There should be an overall feel for what this child and his/her family is like. Remember that the child’s neighborhood, school, community, etc all play a role in development, so make sure you accurately and fully describe this setting! --- 1 page
• Observations of Development :   The main body of your observations coupled with course material supporting whether or not the observed behavior was typical of the child’s age or not. Report behaviors and statements from both the child observation and from the parent/guardian interview— 1.5  pages
• Comment on Development: This is the portion of the paper where your professional analysis of your observations are shared. Based on your evidence, what can you generally state regarding the cognitive, social and emotional, and physical development of this child? Include both information from your observations and from your interview— 1.5 pages
• Conclusion: What are the relative strengths and weaknesses of the family, the child? What could this child benefit from? Make any final remarks regarding the child’s overall development in this section.— 1page
• Your Case Study Narrative should be a minimum of 5 pages.

Make sure to NOT to use the child’s real name in the Narrative Report. You should make reference to course material, information from your textbook, and class supplemental materials throughout the paper . 

Same rules apply in terms of writing in objective language and only using subjective minimally. REMEMBER to CHECK your grammar, spelling, and APA formatting before submitting to your instructor. It is imperative that you review the rubric of this assignment as well before completing it. 

Biggest Mistakes Students Make on this Assignment

Here is a list of the biggest mistakes that students make on this assignment: 

• Failing to start early . The case study assignment is one that you will submit in parts throughout the semester. It is important that you begin your observations on the case study before the first assignment is due. Waiting to the last minute will lead to a poor grade on this assignment, which historically has been the case for students who have completed this assignment. 
• Failing to utilize the rubrics. The rubrics provide students with guidelines on what components are necessary for the assignment. Often students will lose points because they simply read the descriptions of the assignment but did not pay attention to rubric portions of the assignment. 
• Failing to use APA formatting and proper grammar and spelling. It is imperative that you use spell check and/or other grammar checking software to ensure that your narrative is written well. Remember it must be in APA formatting so make sure that you review the tutorials available for you on our Lib Guide that will assess you in this area. 
• << Previous: Manor College's Guide to Using EBSCO Effectively
• Next: ED105: From Teacher Interview to Final Project >>
• Last Updated: Apr 3, 2024 2:53 PM
• URL: https://manor.libguides.com/ece

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• Case report
• Open access
• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

43k Accesses

2 Citations

1 Altmetric

Metrics details

Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Eager to Learn: Educating Our Preschoolers (2001)

Chapter: 9&#9;findings, conclusions, and recommendations, 9 findings, conclusions, and recommendations.

T HE RESEARCH ON EARLY CHILDHOOD learning and program effectiveness reviewed in this report provides some very powerful findings:

Young children are capable of understanding and actively building knowledge, and they are highly inclined to do so. While there are developmental constraints on children’s competence, those constraints serve as a ceiling below which there is enormous room for variation in growth, skill acquisition, and understanding.

Development is dependent on and responsive to experience, allowing children to grow far more quickly in domains in which a rich experiential base and guided exposure to complex thinking are available than in those where they receive no such support. Environment—including cultural context—exerts a large influence on both cognitive and emotional development. Genetic endowment is far more responsive to experience than was once thought. Rapid growth of the brain in the early years provides an opportunity for the environment to influence the physiology of development.

Education and care in the early years are two sides of the same coin. Research suggests that secure attachment improves

both social competence and the ability to exploit learning opportunities.

Furthermore, research on early childhood curricula and pedagogy has implications for how early childhood programs can effectively promote development:

Cognitive, social-emotional (mental health), and physical development are complementary, mutually supportive areas of growth all requiring active attention in the preschool years. Social skills and physical dexterity influence cognitive development, just as cognition plays a role in children’s social understanding and motor competence. All are therefore related to early learning and later academic achievement and are necessary domains of early childhood pedagogy.

Responsive interpersonal relationships with teachers nur ture young children’s dispositions to learn and their emerging abilities. Social competence and school achievement are influenced by the quality of early teacher-child relationships, and by teachers’ attentiveness to how the child approaches learning.

While no single curriculum or pedagogical approach can be identified as best, children who attend well-planned, high- quality early childhood programs in which curriculum aims are specified and integrated across domains tend to learn more and are better prepared to master the complex demands of formal schooling. Particular findings of relevance in this regard include the following:

Children who have a broad base of experience in domain-specific knowledge (for example, in mathematics or an area of science) move more rapidly in acquiring more complex skills

More extensive language development—such as a rich vocabulary and listening comprehension—is related to early literacy learning.

Children are better prepared for school when early childhood programs expose them to a variety of classroom structures, thought processes, and discourse patterns. This does not mean adopting the methods and curriculum of the elementary school; rather it is a matter of providing children with a mix of whole

class, small group, and individual interactions with teachers, the experience of different kinds of discourse patterns, and such mental strategies as categorizing, memorizing, reasoning, and metacognition.

While the committee does not endorse any particular cur riculum, the cognitive science literature suggests principles of learning that should be incorporated into any curriculum:

Teaching and learning will be most effective if they engage and build on children’s existing understandings.

Key concepts involved in each domain of preschool learning (e.g., representational systems in early literacy, the concept of quantity in mathematics, causation in the physical world) must go hand in hand with information and skill acquisition (e.g., identifying numbers and letters and acquiring information about the natural world).

Metacognitive skill development allows children to solve problems more effectively. Curricula that encourage children to reflect, predict, question, and hypothesize (examples: How many will there be after two numbers are added? What happens next in the story? Will it sink or float?) set them on course for effective, engaged learning.

young children who are living in circumstances that place them at greater risk of school failure—including poverty, low level of maternal education, maternal depression, and other fac tors that can limit their access to opportunities and resources that enhance learning and development—are much more likely to succeed in school if they attend well-planned, high-quality early childhood programs. Many children, especially those in low-income households, are served in child care programs of such low quality that learning and development are not enhanced and may even be jeopardized.

The importance of teacher responsiveness to children’s differences, knowledge of children’s learning processes and capabilities, and the multiple developmental goals that a quality pre-

school program must address simultaneously all point to the centrality of teacher education and preparation.

The professional development of teachers is related to the quality of early childhood programs, and program quality pre dicts developmental outcomes for children. Formal early childhood education and training has been linked consistently to positive caregiver behaviors. The strongest relationship is found between the number of years of education and training and the appropriateness of a teacher’s classroom behavior.

Programs found to be highly effective in the United States and exemplary programs abroad actively engage teachers and provide high-quality supervision. Teachers are trained and encouraged to reflect on their practice and on the responsiveness of their children to classroom activities, and to revise and plan their teaching accordingly.

Both class size and adult-child ratios are correlated with greater program effects. Low ratios of children to adults are associated with more extensive teacher-child interaction, more individualization, and less restrictive and controlling teacher behavior. Smaller group size has been associated with more child initiations, more opportunities for teachers to work on extending language, mediating children’s social interactions, and encouraging and supporting exploration and problem solving.

CONCLUSIONS AND RECOMMENDATIONS

What is now known about the potential of the early years, and of the promise of high-quality preschool programs to help realize that potential for all children, stands in stark contrast to practice in many—perhaps most—early childhood settings. How can we bring what we know to bear on what we do?

A committee of the National Research Council recently addressed that question with regard to K-12 education (National Research Council, 1999). While the focus of this report differs from theirs, the conceptual framework for using research knowledge to influence educational practice applies. In this model, the impact of research knowledge on classroom practice—the ultimate goal—is mediated through four arenas, as depicted in Fig-

FIGURE 9–1 Arenas through which research knowledge influences classroom practice.

ure 9–1 . When teachers are directly engaged in using research-based programs or curricula, the effect can be direct. This is the case in some model programs. But if research knowledge is to be used systematically in early childhood education and care programs, preservice and in-service education that effectively transmits that knowledge to those who staff the programs will be required.

While we have argued that the teacher is central, effective teachers work with curricula and teaching materials. In Chapter 5 we refer to exemplary curricula that incorporate research knowledge. Changing practice requires that teachers know about, and have access to, a store of teaching materials.

Quality preschool programs can be encouraged or thwarted by public policy. Regulations and standards can incorporate research knowledge to put a floor under program quality. Public funding and the rules that shape its availability can encourage quality above that floor, and can ensure accessibility to those most in need. And finally, program administrators and teachers, as well as policy makers, are ultimately accountable to parents and to the

public. Parents’ expectations of, and support for, preschool programs, as well as their participation in activities that support early development, can contribute to program success.

The chance of effectively changing early childhood education will increase if the four arenas that influence practice are addressed simultaneously and in a mutually supportive fashion. The committee’s recommendations address each of these four arenas of influence.

Professional Development

At the heart of the effort to promote quality preschool, from the committee’s perspective, is a substantial investment in the education and training of preschool teachers.

Recommendation 1: Each group of children in an early childhood education and care program should be assigned a teacher who has a bachelor’s degree with specialized education related to early childhood (e.g., developmental psychology, early childhood education, early childhood special education). Achieving this goal will require a significant public investment in the professional development of current and new teachers.

Sadly, there is a great disjunction between what is optimal pedagogically for children’s learning and development and the level of preparation that currently typifies early childhood educators. Progress toward a high-quality teaching force will require substantial public and private support and incentive systems, including innovative educational programs, scholarship and loan programs, and compensation commensurate with the expectations of college graduates.

Recommendation 2: Education programs for teachers should provide them with a stronger and more specific foundational knowledge of the development of children’s social and affective behavior, thinking, and language.

Few programs currently do. This foundation should be linked to teachers’ knowledge of mathematics, science, linguistics, literature, etc., as well as to instructional practices for young children.

Recommendation 3: Teacher education programs should require mastery of information on the pedagogy of teaching preschool-aged children, including:

Knowledge of teaching and learning and child development and how to integrate them into practice.

Information about how to provide rich conceptual experiences that promote growth in specific content areas, as well as particular areas of development, such as language (vocabulary) and cognition (reasoning).

Knowledge of effective teaching strategies, including organizing the environment and routines so as to promote activities that build social-emotional relationships in the classroom.

Knowledge of subject-matter content appropriate for preschool children and knowledge of professional standards in specific content areas.

Knowledge of assessment procedures (observation/performance records, work sampling, interview methods) that can be used to inform instruction.

Knowledge of the variability among children, in terms of teaching methods and strategies that may be required, including teaching children who do not speak English, children from various economic and regional contexts, and children with identified disabilities.

Ability to work with teams of professionals.

Appreciation of the parents’ role and knowledge of methods of collaboration with parents and families.

Appreciation of the need for appropriate strategies for accountability.

Recommendation 4: A critical component of preservice preparation should be a supervised, relevant student teaching or internship experience in which new teachers receive ongoing guidance and feedback from a qualified supervisor.

There are a number of models (e.g., National Council for Accreditation of Teacher Education) that suggest the value of this sort of supervised student teaching experience. A principal goal of this experience should be to develop the student teacher’s ability to integrate and apply the knowledge base in practice. Col-

laborative support by the teacher preparation institution and the field placement is essential. Supervision of this experience should be shared by a master teacher and a regular or clinical university faculty member.

Recommendation 5: All early childhood education and child care programs should have access to a qualified supervisor of early childhood education.

Teachers should be provided with opportunities to reflect on practice with qualified supervisors. This supervisor should be both an expert teacher of young children and an expert teacher mentor. Such supervisors are needed to provide in-service collaborative experiences, in-service materials (including interactive videodisc materials), and professional development opportunities directed toward improvement of early childhood pedagogy.

Recommendation 6: Federal and state departments of education, human services, and other agencies interested in young children and their families should initiate programs of research and development aimed at learning more about effective preparation of early childhood teachers.

Of particular concern are strategies directed toward bringing experienced early childhood educators, such as child care providers and prekindergarten and Head Start teachers, into compliance with standards for higher education and certification. Such programs should ensure that the field takes full advantage of the knowledge and expertise of existing staff and builds on diversity and strong community bonds represented in the current early childhood care and education work force. At the same time, it should assure that the fields of study described above are mastered by those in the existing workforce. These programs should include development of materials for early childhood professional education. Material development should entail cycles of field testing and revision to assure effectiveness.

Recommendation 7: The committee recommends the development of demonstration schools for professional development.

Many people, including professional educators of older chil-

dren, do not know what an early childhood program should look like, what should be taught, or the kind of pedagogical strategies that are most effective. Demonstration schools would provide contextual understanding of these issues.

The Department of Education should collaborate with universities in developing the demonstration schools and in using them as sites for ongoing research:

on the efficacy of various models, including pairing demonstration schools in partnership with community programs, and pairing researchers and in-service teachers with exemplary community-based programs;

to identify conditions under which the gains of mentoring, placement of pre-service teachers in demonstration schools, and supervised student teaching can be sustained once teachers move into community-based programs.

Educational Materials

Good teachers must be equipped with good curricula. The content of early childhood curricula should be organized systematically into a coherent program with overarching objectives integrated across content and developmental areas. They should include multiple activities, such as systematic exploration and representation, planning and problem solving, creative expression, oral expression, and the ability and willingness to listen to and incorporate information presented by a teacher, sociodramatic and exercise play, and arts activities.

Important curriculum areas are often omitted from early education programs, although there is research to support their inclusion (provided they are addressed in an appropriate manner). Methods of scientific investigation, number concepts, phonological awareness, cultural knowledge, languages, and computer technology all fall into this category.

Because children differ in so many respects, teaching strategies used with any curriculum, from the committee’s perspective, need to be flexibly adapted to meet the specific needs and prior knowledge and understanding of individual children. Embedded in the curriculum should be opportunities to assess children’s

prior understanding and mastery of the skills and knowledge being taught.

Teachers will also need to provide different levels of instruction in activities and use a range of techniques, including direct instruction, scaffolding, indirect instruction (taking advantage of moments of opportunity), and opportunities for children to learn on their own (self-directed learning). The committee believes it is particularly important to maintain children’s enthusiasm for learning by integrating their self-directed interests with the teacher-directed curriculum.

Recommendation 8: The committee recommends that the U.S. Department of Education, the U.S. Department of Health and Human Services, and their equivalents at the state level fund efforts to develop, design, field test, and evaluate curricula that incorporate what is known about learning and thinking in the early years, with companion assessment tools and teacher guides.

Each curriculum should emphasize what is known from research about children’s thinking and learning in the area it addresses. Activities should be included that enable children with different learning styles and strengths to learn.

Each curriculum should include a companion guide for teachers that explains the teaching goals, alerts the teacher to common misconceptions, and suggests ways in which the curriculum can be used flexibly for students at different developmental levels. In the teacher’s guide, the description of methods of assessment should be linked to instructional planning so that the information acquired in the process of assessment can be used as a basis for making pedagogical decisions at the level of both the group and the individual child.

Recommendation 9: The committee recommends that the U.S. Department of Education and the U.S. Department of Health and Human Services support the use of effective technology, including videodiscs for preschool teachers and Internet communication groups.

The process of early childhood education is one in which interaction between the adult/teacher and the child/student is the

most critical feature. Opportunities to see curriculum and pedagogy in action are likely to promote understanding of complexity and nuance not easily communicated in the written word. Internet communication groups could provide information on curricula, results of field tests, and opportunities for teachers using a common curriculum to discuss experiences, query each other, and share ideas.

States can play a significant role in promoting program quality with respect to both teacher preparation and curriculum and pedagogy.

Recommendation 10: All states should develop program standards for early childhood programs and monitor their implementation. These standards should recognize the variability in the development of young children and adapt kindergarten and primary programs, as well as preschool programs, to this diversity. This means, for instance, that kindergartens must be readied for children. In some schools, this will require smaller class sizes and professional development for teachers and administrators regarding appropriate teaching practice, so that teachers can meet the needs of individual children, rather than teaching to the “average” child. The standards should outline essential components and should include, but not be limited to, the following categories:

School-home relationships;

Class size and teacher-student ratios;

Specification of pedagogical goals, content, and methods;

Assessment for instructional improvement;

Educational requirements for early childhood educators; and

Monitoring quality/external accountability.

Recommendation 11: Because research has identified content that is appropriate and important for inclusion in early childhood programs, content standards should be developed

and evaluated regularly to ascertain whether they adhere to current scientific understanding of children’s learning.

The content standards should ensure that children have access to rich and varied opportunities to learn in areas that are now omitted from many curricula—such as phonological awareness, number concepts, methods of scientific investigation, cultural knowledge, and language.

Recommendation 12: A single career ladder for early childhood teachers, with differentiated pay levels, should be specified by each state.

This career ladder should include, at a minimum, teaching assistants (with child development associate certification), teachers (with bachelor’s degrees), and supervisors.

Recommendation 13: The committee recommends that the federal government fund well-planned, high-quality center-based preschool programs for all children at high risk of school failure.

Such programs can prevent school failure and significantly enhance learning and development in ways that benefit the entire society.

Policies that support the provision of quality preschool on a broad scale are unlikely without widespread public support. To engender that support, it is important for the public to understand both the potential of the preschool years, and the quality of programming required to realize that potential.

Recommendation 14: Organizations and government bodies concerned with the education of young children should actively promote public understanding of early childhood education and care.

Beliefs that are at odds with scientific understanding—that maturation automatically accounts for learning, for example, or that children can learn concrete skills only through drill and practice—must be challenged. Systematic and widespread public

education should be undertaken to increase public awareness of the importance of providing stimulating educational experiences in the lives of all young children. The message that the quality of children’s relationships with adult teachers and child care providers is critical in preparation for elementary school should be featured prominently in communication efforts. Parents and other caregivers, as well as the public, should be the targets of such efforts.

Recommendation 15: Early childhood programs and centers should build alliances with parents to cultivate complementary and mutually reinforcing environments for young children at home and at the center.

FUTURE RESEARCH NEEDS

Research on early learning, child development, and education can and has influenced the development of early childhood curriculum and pedagogy. But the influences are mutual. By evaluating outcomes of early childhood programs we have come to understand more about children’s development and capacities. The committee believes that continued research efforts along both these lines can expand understanding of early childhood education and care, and the ability to influence them for the better.

Research on Early Childhood Learning and Development

Although it is apparent that early experiences affect later ones, there are a number of important developmental questions to be studied regarding how, when, and which early experiences support development and learning.

Recommendation 16: The committee recommends a broad empirical research program to better understand:

The range of inputs that can contribute to supporting environments that nurture young children’s eagerness to learn;

Development of children’s capacities in the variety of cog-

nitive and socioemotional areas of importance in the preschool years, and the contexts that enhance that development;

The components of adult-child relationships that enhance the child’s development during the preschool years, and experiences affecting that development for good or for ill;

Variation in brain development, and its implications for sensory processing, attention, and regulation;

The implications of developmental disabilities for learning and development and effective approaches for working with children who have disabilities;

With regard to children whose home language is not English, the age and level of native language mastery that is desirable before a second language is introduced and the trajectory of second language development.

Research on Programs and Curricula

Recommendation 17: The next generation of research must examine more rigorously the characteristics of programs that produce beneficial outcomes for all children. In addition, research is needed on how programs can provide more helpful structures, curricula, and methods for children at high risk of educational difficulties, including children from low-income homes and communities, children whose home language is not English, and children with developmental and learning disabilities.

Much of the program research has focused on economically disadvantaged children because they were the targets of early childhood intervention efforts. But as child care becomes more widespread, it becomes more important to understand the components of early childhood education that have developmental benefits for all children.

With respect to disadvantaged children, we know that quality intervention programs are effective, but better understanding the features that make them effective will facilitate replication on a large scale. The Abecedarian program, for example, shows many developmental gains for the children who participate. But in addition to the educational activities, there is a health and nutrition component. And child care workers are paid at a level

comparable to local public school teachers, with a consequent low turnover rate in staff. Whether the program effect is caused by the education component, the health component, or stability of caregiver, or some necessary combination of the three, is not possible to assess. Research on programs for this population should pay careful attention to home-school partnerships and their effect, since this is an aspect of the programs that research suggests is important.

Research on programs for any population of children should examine such program variations as age groupings, adult-child ratios, curricula, class size, looping, and program duration. These questions can best be answered through random assignment, longitudinal studies. Such studies raise concerns because some children receive better services than others, and because they are expensive. However, random assignment between programs that have very similar quality features, but vary on a single dimension (a math curriculum, for example, or class size) would seem less controversial. The cost of conducting such research must, of course, be weighed against the benefits. Given the dramatic expansion in the hours that children spend in out-of-home care in the preschool years, new knowledge can have a very high payoff.

Research is also needed on the interplay between an individual child’s characteristics, the immediate contexts of the home and classroom, and the larger contexts of the formal school environment in developing and assessing curricula. An important line of research is emerging in this area and needs continued support.

Recommendation 18: A broad program of research and development should be undertaken to advance the state of the art of assessment in three areas: (1) classroom-based assessment to support learning (including studies of the impact of methods of instructional assessment on pedagogical technique and children’s learning), (2) assessment for diagnostic purposes, and (3) assessment of program quality for accountability and other reasons of public policy.

All assessments, and particularly assessments for accountability, must be used carefully and appropriately if they are to resolve, and not create, educational problems. Assessment of young

children poses greater challenges than people generally realize. The first five years of life are a time of incredible growth and learning, but the course of development is uneven and sporadic. The status of a child’s development as of any given day can change very rapidly. Consequently assessment results—in particular, standardized test scores that reflect a given point in time— can easily misrepresent children’s learning.

Assessment itself is in a state of flux. There is widespread dissatisfaction with traditional norm-referenced standardized tests, which are based on early 20th century psychological theory. There are a number of promising new approaches to assessment, among them variations on the clinical interview and performance assessment, but the field must be described as emergent. Much more research and development are needed for a productive fusion of assessment and instruction to occur and if the potential benefits of assessment for accountability are to be fully realized.

Research on Ways to Create Universal High Quality

The growing consensus regarding the importance of early education stands in stark contrast to the disparate system of care and education available to children in the United States in the preschool years. America’s programs for preschoolers vary widely in quality, content, organization, sponsorship, source of funding, relationship to the public schools, and government regulation.

As the nation moves toward voluntary universal early childhood programs, parents, and public officials face important policy choices, choices that should be informed by careful research.

Recommendation 19: Research to fully develop and evaluate alternatives for organizing, regulating, supporting, and financing early childhood programs should be conducted to provide an empirical base for the decisions being made.

Compare the effects of program variations on short-term and long-term outcomes, including studies of inclusion of children with disabilities and auspices of program regulation.

Examine preschool administration at local, county, and state levels to assess the relative quality of the administrative and support systems now in place.

Consider quality, infrastructure, and cost-effectiveness.

Review the evidence that should inform state standards and licensing, including limits on group size and square footage requirements.

Develop instruments and strategies to monitor the achievement of young children that meet state and national accountability requirements, respect young children’s unique learning and developmental needs, and do not interfere with teachers’ instructional decision making.

At a time when the importance of education to individual fulfillment and economic success has focused attention on the need to better prepare children for academic achievement, the research literature suggests ways to make gains toward that end. Parents are relying on child care and preschool programs in ever larger numbers. We know that the quality of the programs in which they leave their children matters. If there is a single critical component to quality, it rests in the relationship between the child and the teacher/caregiver, and in the ability of the adult to be responsive to the child. But responsiveness extends in many directions: to the child’s cognitive, social, emotional, and physical characteristics and development.

Much research still needs to be done. But from the committee’s perspective, the case for a substantial investment in a high-quality system of child care and preschool on the basis of what is already known is persuasive. Moreover, the considerable lead by other developed countries in the provision of quality preschool programs suggests that it can, indeed, be done on a large scale.

Clearly babies come into the world remarkably receptive to its wonders. Their alertness to sights, sounds, and even abstract concepts makes them inquisitive explorers—and learners—every waking minute. Well before formal schooling begins, children's early experiences lay the foundations for their later social behavior, emotional regulation, and literacy. Yet, for a variety of reasons, far too little attention is given to the quality of these crucial years. Outmoded theories, outdated facts, and undersized budgets all play a part in the uneven quality of early childhood programs throughout our country.

What will it take to provide better early education and care for our children between the ages of two and five? Eager to Learn explores this crucial question, synthesizing the newest research findings on how young children learn and the impact of early learning. Key discoveries in how young children learn are reviewed in language accessible to parents as well as educators: findings about the interplay of biology and environment, variations in learning among individuals and children from different social and economic groups, and the importance of health, safety, nutrition and interpersonal warmth to early learning. Perhaps most significant, the book documents how very early in life learning really begins. Valuable conclusions and recommendations are presented in the areas of the teacher-child relationship, the organization and content of curriculum, meeting the needs of those children most at risk of school failure, teacher preparation, assessment of teaching and learning, and more. The book discusses:

• Evidence for competing theories, models, and approaches in the field and a hard look at some day-to-day practices and activities generally used in preschool.
• The role of the teacher, the importance of peer interactions, and other relationships in the child's life.
• Learning needs of minority children, children with disabilities, and other special groups.
• Approaches to assessing young children's learning for the purposes of policy decisions, diagnosis of educational difficulties, and instructional planning.
• Preparation and continuing development of teachers.

Eager to Learn presents a comprehensive, coherent picture of early childhood learning, along with a clear path toward improving this important stage of life for all children.

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The Good that’s Within You: A Case Study of Early Childhood Curriculum Practice

• Published: 16 July 2021
• Volume 50 , pages 1047–1058, ( 2022 )

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• Daniel J. Castner   ORCID: orcid.org/0000-0001-6612-2092 1 ,
• Lacy Fajerstein 1 &
• Gretchen Butera 1  

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Few matters are of greater importance to high quality early childhood education than the content and mediation of curriculum. In spite of this, early childhood curriculum practices are rarely examined through the lens of curriculum theory. This research employs educational connoisseurship and criticism as a methodology to shed light upon the curriculum discourse and practices at one public elementary school in relation to one preschool classroom. The findings indicate multiple curriculum orientations subtly coexist at the school. We argue that identifying stakeholders' curriculum orientations and understanding how they operate in the context of a particular school provides a basis for more generative curriculum deliberations that make use of the strengths and recognize the limitations of disparate curricular traditions.

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Castner, D.J., Fajerstein, L. & Butera, G. The Good that’s Within You: A Case Study of Early Childhood Curriculum Practice. Early Childhood Educ J 50 , 1047–1058 (2022). https://doi.org/10.1007/s10643-021-01243-9

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• Published: 29 May 2024

A case–control study on pre-, peri-, and neonatal risk factors associated with autism spectrum disorder among Armenian children

• Meri Mkhitaryan 1 ,
• Tamara Avetisyan 2 , 3 ,
• Anna Mkhoyan 4 ,
• Larisa Avetisyan 2 , 5 &
• Konstantin Yenkoyan 1  

Scientific Reports volume  14 , Article number:  12308 ( 2024 ) Cite this article

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• Autism spectrum disorders
• Public health
• Risk factors

We aimed to investigate the role of pre-, peri- and neonatal risk factors in the development of autism spectrum disorder (ASD) among Armenian children with the goal of detecting and addressing modifiable risk factors to reduce ASD incidence. For this purpose a retrospective case–control study using a random proportional sample of Armenian children with ASD to assess associations between various factors and ASD was conducted. The study was approved by the local ethical committee, and parental written consent was obtained. A total of 168 children with ASD and 329 controls were included in the analysis. Multivariable logistic regression analysis revealed that male gender, maternal weight gain, use of MgB6, self-reported stress during the pregnancy, pregnancy with complications, as well as use of labor-inducing drugs were associated with a significant increase in the odds of ASD, whereas Duphaston use during pregnancy, the longer interpregnancy interval and birth height were associated with decreased odds of ASD. These findings are pertinent as many identified factors may be preventable or modifiable, underscoring the importance of timely and appropriate public health strategies aimed at disease prevention in pregnant women to reduce ASD incidence.

Introduction

Autism spectrum disorder is a neurodevelopmental disorder by the Diagnostic and Statistical Manual of Mental Disorders, the 5th Edition (DSM-5). It is identified by limited repeating patterns of behavior, activities, and interests, as well as impaired social interaction and communication 1 . A systematic review of research articles spanning from 2012 to 2021 indicates that the worldwide median prevalence of ASD in children stands at 1% 2 . Nevertheless, this reported percentage may not fully capture the actual prevalence of ASD in low- and middle-income nations, potentially leading to underestimations. In 2016, data compiled by the CDC's Autism and Developmental Disabilities Monitoring (ADDM) Network revealed that approximately one out of 54 children in the United States (one out of 34 boys and one out of 144 girls) received a diagnosis of ASD. This marks a ten percent increase from the reported rate of one out of 59 in 2014, a 105 percent increase from one out of 110 in 2006, and a 176 percent increase from one out of 150 in 2000 3 . According to the most recent update from the CDC’s ADDM Network, one out of 36 (2.8%) 8-year-old children has been diagnosed with ASD. These latest statistics exceed the 2018 findings, which indicated a rate of 1 in 44 (2.3%) 4 . To our understanding, there is no existing registry for ASD in the Republic of Armenia (RA). Additionally, there is no available data concerning the incidence and prevalence of ASD in the country.

The etiology of ASD remains unclear despite substantial research on the disorder; yet, important advances have been made in identifying some of the disorder's genetic and neurobiological underpinnings. It has been discovered that ASD is heritable, with environmental variables also being involved 5 , 6 , 7 . According to certain research, ASD is associated with both hereditary and environmental factors 5 , 8 , 9 . It is especially important to identify environmental risk factors because, unlike genetic risk factors, they can be prevented.

There are more than 20 pre-, peri- and neonatal risk factors associated with ASD 10 , 11 , 12 . Prenatal risk factors that have been associated with ASD involve parental age 13 , interpregnancy interval 14 , 15 , immune factors (such as autoimmune diseases, both viral and bacterial infections during pregnancy) 16 , 17 , medication use (especially antidepressants, anti-asthmatics, and anti-epileptics) 18 , 19 , 20 , maternal metabolic conditions (such as diabetes, gestational weight gain, and hypertension) 21 , 22 , 23 , and maternal dietary factors (such as folic acid and other supplement use, maternal iron (Fe) intake, as well as maternal vitamin D levels) 24 , 25 , 26 , 27 , 28 , 29 .

Numerous studies indicate that an increased risk of ASD is linked to several perinatal and neonatal factors. These factors include small gestational age or preterm birth, gestational small or large size, the use of labor and delivery drugs 30 , 31 , 32 , 33 . The risk of ASD associated with cesarean delivery is also a subject of continuous discussion 34 , 35 , 36 . Overall, there is no apparent link between assisted conception and a notably higher risk of ASD, however some particular therapies might make ASD more likely.

This study aimed to determine main pre-, peri- and neonatal risk factors linked to ASD among Armenian children. The following research questions were derived to address the objectives of the study:

What are the primary prenatal risk factors associated with the development of ASD among Armenian children?

How do perinatal factors such as maternal complications during childbirth, labor mode, labor interventions, use of labor-inducing drugs, contribute to the risk of ASD in Armenian children?

What neonatal factors, such as birth weight and gestational age, are linked to the likelihood of ASD diagnosis among Armenian children?

How do socio-demographic factors, such as parental education, gender of the child, number of kids in the family, sequence of the kid, influence the relationship between pre-, peri-, and neonatal risk factors and risk of ASD among Armenian children?

To the best of our knowledge, this was the first study of its kind conducted in Armenia that focused on a variety of factors linked to ASD.

The analysis encompassed a total sample of 497 participants, consisting of 168 children diagnosed with ASD and 329 children without ASD. The descriptive analysis revealed significant differences between the cases and controls on several socio demographic variables as well as prenatal, peri- and neonatal risk factors (see Tables 1 , 2 , 3 and 4 ).

The summary of socio demographic characteristics (Table 1 ). Among the cases (the ASD group), the distribution of gender of the child was significantly different to that in the control group. More specifically, while the distribution of male and female were balanced in the control group (52.89% and 47.11% respectively), the proportion of male children was significantly higher in the ASD group (82.14% and 17.86% respectively, p  < 0.01). Furthermore, the number of children in the families of cases and controls were slightly different. While the proportion of cases and controls who had two children were similar, families with one child were slightly higher in the ASD group compared to the control group (29.94% and 17.02% respectively, p  < 0.01). This picture is reversed with respect to the number of families with more than two children (16.17% and 29.79% respectively). A higher percentage of ASD cases are the first child in the family compared to controls (67.86% vs. 49.54%, p  < 0.01). The proportion of non-married families (those that reported to be single, widowed, divorced etc.) were higher in the ASD group compared to the control group (10.24% and 4.28% respectively, p  < 0.05). The distribution of the level of educational attainment of the parents were also different between the groups. More specifically, the prevalence of university degree among the cases were somewhat lower compared to that in the control group.

The summary of prenatal risk factors (Table 2 ). With respect to prenatal risk factors, there were significant differences between the cases and controls in interpregnancy intervals, self-reported complications and diseases, medication use, vitamin D levels, maternal weight gain, and the self-reported stress during pregnancy. More specifically, the cases had on average lower interpregnancy intervals compared to the controls (M = 12.9 and M = 23.7 months respectively, p  < 0.01). The cases more frequently reported to have had complications during the pregnancy compared to the controls (42.86% and 8.54% respectively, p  < 0.01). The prevalence of reported infectious diseases, other diseases and anemia during the pregnancy were also somewhat higher among the cases compared to the control group. The use of medications was higher among the cases compared to the control group (41.67% and 17.74% respectively, p  < 0.01). Various medications including vitamins, anticoagulants, Paracetamol, MgB6, Duphaston, iron preparation, No-spa, calcium preparation, antibiotics, and Utrogestan showed significant differences in usage between cases and controls (all p  < 0.05) (Table 3 ). The maternal weight gain among the cases was on average higher among the cases compared to the control group (M = 15.4 and M = 13.9 kg respectively, p  < 0.05). The self-reported stress was also more frequent among the cases compared to the controls (56.02 and 10.98% respectively, p  < 0.01). Specifically, comparing data on self-reported stress during different pregnancy periods, it was obvious that 47.06% of mothers of cases and 91.25% of mothers in the control group reported no stress experienced during pregnancy. During the first trimester, 14.38% of mothers with cases of autism reported stress, whereas only 0.94% of mothers in the control group reported stress. In the second trimester, 11.11% of mothers with cases of autism reported stress, compared to 4.06% of mothers in the control group. During the third trimester, 8.50% of mothers with cases of autism reported stress, while 1.88% of mothers in the control group reported stress. Across the entire pregnancy, 18.95% of mothers with cases of autism reported stress, compared to 1.88% of mothers in the control group. The differences in stress levels between the two groups were statistically significant, indicating a potential link between maternal stress during pregnancy and the odds of autism spectrum disorder in offspring.

The summary of perinatal and neonatal risk factors (Table 4 ). The interpretation of the data comparing various peri- and neonatal risk factors between cases (individuals with ASD) and controls (individuals without ASD) are shown below. 83.33% of cases and 91.77% of controls were born within 37–42 weeks of gestation, with a statistically significant difference ( p  < 0.05), whereas 16.67% of cases and 8.23% of controls were born either preterm (before 37 weeks) or post-term (after 42 weeks), also showing a significant difference. There was no statistically significant difference in birth weight between cases and controls (M = 3137.8 and M = 3176.9 g respectively, p  > 0.05). The mean birth height was slightly lower for cases compared to controls (M = 50.4 and M = 50.9 cm), with a statistically significant difference ( p  < 0.05). No statistically significant difference was reported regarding mode of labor. According to the data interventions during labor were reported more in ASD group compared to controls (39.76% and 17.23% respectively, p  < 0.01). Also, labor-inducing drugs were administered more in cases compared to the controls (39.76% and 21.04%, p  < 0.01).

The results of multivariable logistic regression

The multivariable logistic regression analysis indicated significant associations between sociodemographic, prenatal, perinatal and neonatal risk factors. More specifically, male children have 4 times higher odds of having ASD compared to female children (OR = 4.21, CI 2.33–7.63). Among prenatal factors, the maternal weight gain, use of MgB6, the self-reported stress during the pregnancy, as well as pregnancy with complications were associated with a significant increase in the odds of ASD, whereas use of Duphaston was associated with decreased odds of ASD (see Table 5 ). Additionally, the longer interpregnancy interval was associated with decreased odds of ASD diagnosis (OR = 0.708, CI 0.52–0.97). Among peri- and neonatal factors, use of labor-inducing drugs was associated with increase in the odds of ASD diagnosis (OR = 2.295, CI 1.3–4.1), while birth height showed association with decrease in odds (OR = 0.788, CI 0.6–1.0).

Our study provides comprehensive insights into the multifaceted nature of ASD, elucidating the intricate relationships between sociodemographic, prenatal, perinatal, and neonatal factors and ASD risk.

Our findings highlight significant gender disparities in ASD prevalence, with a notably higher proportion (4:1) of male children in the ASD group. This aligns with existing literature demonstrating a male predominance in ASD diagnosis 37 . Meanwhile, Loomes et al. reported 3:1 male-to-female ratio referring to a diagnostic gender bias, where girls meeting the criteria for ASD are at an elevated risk of not receiving a clinical diagnosis 38 . Furthermore, our study highlights the potential impact of family structure on the likelihood of ASD occurrence, indicating higher ASD rates among first-born children and in households where the parents are non-married (divorced, widowed, separated, etc.). A study conducted by Ugur et al. yielded comparable findings, suggesting that the prevalence of being the eldest child was higher in the ASD group compared to the control group 39 . Contrary to this, research conducted in the United States found no evidence to suggest that children diagnosed with ASD are more likely to live in households not composed of both their biological or adoptive parents compared to children without ASD 40 .

The association between prenatal risk factors and ASD risk underscores the importance of maternal health during pregnancy. Our findings suggest that factors such as lower IPIs, maternal complications and diseases during pregnancy, medication use, vitamin D levels, maternal weight gain and maternal self-reported stress during pregnancy may increase the odds of ASD in offspring. It is crucial to note that the higher number of firstborn children among cases compared to the control group could introduce bias when accurately estimating the association between IPI and ASD. Therefore, the coefficients of IPI should be interpreted cautiously. Despite this, we opted not to remove this variable from the model, as IPI is recognized as an important factor in existing literature. Several studies report different results regarding long and short IPIs and ASD risk 14 , 15 , 41 , 42 . The underlying reasons for the link between ASD and short and long IPIs may differ. Short IPIs could be associated with maternal nutrient depletion, stress, infertility, and inflammation, whereas long IPIs may be linked to infertility and related complications. According to our results the frequency of self-reported complications during pregnancy was notably higher among children with ASD compared to the controls. Additionally, there was a somewhat higher prevalence of reported infectious diseases, other illnesses, and anemia during pregnancy among the cases compared to the control group. Several previous investigations have associated maternal hospitalization resulting from infection during pregnancy with an elevated risk of ASD. This includes a substantial study involving over two million individuals, which indicated an increased risk associated with viral and bacterial infections during the prenatal period 12 , 17 . Furthermore, our study results indicate that medication usage during pregnancy was more common among the mothers of cases than the controls. Notably, various medications, including vitamins, anticoagulants, Paracetamol, MgB6, Duphaston, iron preparation, No-spa, calcium preparation, antibiotics, and Utrogestan (micronized progesterone), exhibited significant differences in usage between the cases and controls. According to the results of multiple logistic regression analysis use of MgB6 was associated with a significant increase in the odds of ASD, whereas use of Duphaston (Dydrogesterone), a progestin medication, was associated with decreased odds of ASD. Emphasizing the potential impact of additional variables in evaluating the link between Duphaston and ASD is essential. There is a possibility of factors overlooked in our study. However, after analyzing the included variables, no significant confounding effects were detected. This assessment involved scrutinizing the Cramer’s V value between Duphaston and other variables, and sequentially introducing new variables into the model to evaluate changes in the coefficients of Duphaston. In both cases, no significant confounding effects emerged. In contrast to our results certain researchers have shown that the use of supplements during pregnancy is linked to a decreased risk of ASD in offsprings compared to those whose mothers did not take supplements during pregnancy 43 , 44 . The results of an epidemiology study conducted by Li et al. have showed that prenatal progestin exposure was strongly associated with ASD prevalence, and the experiments in rats showed that prenatal consumption of progestin-contaminated seafood induced autism-like behavior 45 . On the other hand other authors suggest that insufficient maternal progesterone levels might contribute to both obstetrical complications and ASD development 46 . The observed association regarding MgB6 use could potentially be influenced by an unmeasured confounding variable in our study. This warrants further investigation and consideration in future research. Additionally, our study highlighted another modifiable risk factor for ASD that was significantly associated with higher odds of ASD: maternal gestational weight gain. This factor retained its significance even in the multivariable analysis. This finding is consistent with the results of several studies which have shown that maternal metabolic conditions like diabetes, gestational weight gain, and hypertension have been associated with mechanisms pertinent to ASD, such as oxidative stress, fetal hypoxia, and chronic inflammation 23 , 47 . These conditions can induce prolonged or acute hypoxia in the fetus, which might pose a substantial risk factor for neurodevelopmental disturbances.

Furthermore, our findings suggest that the self-reported stress during pregnancy was associated with a significant increase in the odds of ASD. When comparing self-reported stress levels during different pregnancy periods, a notable disparity emerged. The statistically significant differences in stress levels between the two groups were reported in all trimesters of pregnancy suggesting a potential correlation between maternal stress during pregnancy and the odds of autism spectrum disorder in offspring. Several authors report comparable findings suggesting that prenatal maternal stress show significant association with both autistic traits and Attention Deficit Hyperactivity Disorder (ADHD) behaviors 48 , 49 , 50 , 51 . Various mechanisms could be suggested to explain the link between prenatal stress and likelihood of ASD. For instance, stress during pregnancy can trigger physiological changes in the mother's body, such as increased cortisol levels and alterations in immune function, which may impact fetal development and contribute to the risk of ASD. Also, stress may affect placental function, leading to adverse changes in the transfer of nutrients and oxygen to the fetus. Furthermore, prenatal stress can influence gene expression in both the mother and the developing fetus. Certain genes involved in brain development and the stress response system may be affected, potentially increasing the risk of ASD. Additionally, maternal stress may influence parenting behaviors and interactions with the child after birth. High levels of maternal stress may affect the quality of caregiving, which in turn can impact the child's social and emotional development, potentially contributing to ASD risk. Lastly, stress during pregnancy could induce epigenetic modifications, which are alterations in gene expression that occur without changes in DNA sequence. These modifications might affect neurodevelopmental processes, making individuals more susceptible to ASD.

Our study reports notable statistical difference among cases and controls regarding gestational age. According to the results 16.67% of cases were born either preterm (before 37 weeks) or post-term (after 42 weeks), highlighting another significant distinction. Early gestational age is linked with unfavorable health consequences, such as developmental delays and subsequent intellectual impairments throughout childhood and adolescence. Similar results are reported by several authors as well 30 , 31 , 52 . According to our study results birth height was associated with decrease in odds of ASD, however there was no statistically significant difference in birth weight between cases and controls. Some authors demonstrated that infants with birth weights of < 2.5 kg were associated with ADHD and ASD 53 , 54 .

Other than the previously mentioned factors the results of our study have demonstrated that use of labor-inducing drugs was associated with increase in the odds of ASD. The study participants did not report or specify the type of used labor-inducing drugs. Recent investigations have indicated a potential correlation between the utilization of drugs during labor and delivery and the emergence of ASD 55 , 56 , especially given the increased usage of epidurals and labor-inducing medications in the past 30 years. However, conflicting findings exist, with some studies suggesting no link between the administration of labor-inducing drugs and the risk of ASD development 57 , 58 . Recent findings from Qiu et al. propose a potential link between maternal labor epidural analgesia and the risk of ASD in children, particularly when oxytocin was concurrently administered. However, oxytocin exposure in the absence of labor epidural analgesia did not show an association with ASD risk in children 59 . The potential link between the use of labor-inducing drugs and the risk of ASD is complex and not yet fully understood. However, several mechanisms have been proposed to explain this association: for example, labor-inducing drugs, such as oxytocin and prostaglandins, can affect hormonal levels in both the mother and the fetus. These hormonal changes may impact brain development and neural connectivity, potentially increasing the risk of ASD. In addition, labor induction may increase the risk of oxygen deprivation (hypoxia) during labor. Prolonged hypoxia during birth has been linked to adverse neurological outcomes, including an increased risk of neurodevelopmental disorders like ASD. Furthermore, labor induction can lead to an inflammatory response in both the mother and the fetus. This immune system activation may affect neurodevelopmental processes and contribute to the development of ASD. Overall, the relationship between labor-inducing drugs and ASD risk is multifactorial and likely involves interactions between genetic, environmental, and biological factors. Further research is needed to elucidate the specific mechanisms underlying this association.

To our knowledge this is the first study identifying potential pre-, peri- and neonatal risk factors associated with ASD in Armenia.

Limitations and strength

While our study possesses a retrospective design, a notable limitation, it depended on parental recall for details dating back several years. Additionally, the sample was not balanced in terms of gender, with more male children included, potentially introducing selection bias. Despite the relatively small sample size multivariable analysis using the presence or absence of ASD as the dependent variable was implemented to address potential confounding factors.

Nevertheless, our study included a representative sample of the Armenian ASD population, evaluating various factors in comparison with a randomly selected control group matched for age. All ASD diagnoses were made according to DSM-5 by professionals (psychiatrists, pediatricians, neurologists, speech therapists and developmental psychologists), and face-to-face interviews with parents at the time of the interview minimized the risk of information bias.

Our findings indicated that male gender, maternal weight gain, MgB6 usage, self-reported stress during pregnancy, pregnancy complications, and labor-inducing drugs were linked to a significant rise in ASD odds (Fig.  1 ). Conversely, the use of Duphaston during pregnancy, longer interpregnancy intervals, and higher birth height were associated with reduced odds of ASD (Fig.  1 ). These observations underpin the significance of regional investigations to uncover the unique environmental factors contributing to ASD. The implications are profound, as several identified factors may be preventable or adjustable, highlighting the urgency of implementing evidence-based practices and public health interventions. Emphasizing a culture of health promotion, screenings, timely diagnosis, and disease prevention strategies, particularly among pregnant women, holds promise for reducing ASD and related disorders. Moreover, further prospective and focused research is imperative to discern the interplay between various factors and gene-environment interactions that may serve as potential ASD risk factors. Enhanced understanding in this area could lead to earlier detection and improved ASD management. Future studies incorporating analyses of biological samples for genetic, epigenetic, and inflammatory markers will be pivotal in elucidating underlying mechanisms and ushering in a new phase of research focusing on modifiable risk factors for developmental disorders.

Sum up scheme showing prenatal, perinatal and neonatal factors which increase, as well as decrease the odds of ASD.

The study population comprised of 497 participants, of which 168 were children with ASD and 329 were typical development controls. The subject recruitment was done during 2021 to 2022. The controls and children with ASD were age matched (3–18 years). The subjects were formally diagnosed with ASD according to DSM-5 by professionals (pediatricians, neurologists, speech therapists and developmental psychologists). The children with ASD were recruited at MY WAY Educational and Rehabilitation Center in Yerevan. Inclusion criteria for cases were age between 3 and 18 years with ASD with diagnosis confirmed using DSM-V. Exclusion criteria for cases were other neurodevelopment disorders other than ASD. The control participants were randomly selected in the same period at Muratsan Hospital Complex. They were not known to have any neurodevelopmental or behavioral disruptions that might be related to ASD. The control group consisted exclusively of individuals diagnosed with simple conditions like flu or a simple routine physical examination.

Questionnaire and data collection

The self-reported questionnaire was completed via a face-to-face interview with the child’s parent. The questionnaire comprised three sections: various aspects of sociodemographic characteristics, prenatal risk factors, and perinatal/neonatal risk factors. Each section addressed specific questions related to these factors for comprehensive data collection. On average, the questionnaire was completed in about 15 to 20 min. The parent had the choice of accepting or refusing to complete the questionnaire. At the end of the process, the completed questionnaires were collected and sent for data entry by using SPSS 21 statistical software. The questionnaire was designed to acquire the information regarding risk factors of ASD. It consisted of different sections: sociodemographic characteristics (e.g., age, sex, family history of ASD, etc.), data on prenatal risk factors (e.g., pregnancy process, complications during pregnancy, infections during pregnancy, other diseases, stress, medication and supplement use during pregnancy, vitamin D level, etc.), questions related to maternal lifestyle risk factors (e.g., smoking, alcohol consumption, gestational weight gain). Respondents were also asked about peri- and neonatal risk factors, including gestational age, gestational size, the use of labor and delivery drugs, mode of delivery, etc.

Ethics disclosure

The study protocol was approved by the Ethics Committee (N 8–2/20; 27.11.2020) of Yerevan State Medical University in line with the principles set forth in the Declaration of Helsinki. Written informed consent was obtained from all the parents of the participants prior to data collection.

Statistical analysis

The data was processed and modelled in Python (version 3.11.6), an open- source software often used for data processing and modelling. The statistical analysis was performed by using the Statsmodels package (version 0.14.1) 60 .

Descriptive statistics were employed to summarize the characteristics of the study variables. Continuous variables were described using means and standard deviations, while categorical variables were presented as proportions. Prior to statistical analysis, numeric variables underwent standardization through the computation of z scores. To evaluate potential multicollinearity among predictor variables, the Variable Inflation Index (VIF) was computed. A predetermined threshold of 5 was established, and variables exceeding this threshold were considered indicative of multicollinearity. Bivariate analyses were conducted to explore associations between predictor variables and the outcome variable (presence or absence of autism diagnosis). T-tests were employed for continuous variables, while chi-squared tests were utilized for nominal and categorical variables. A multivariable logistic regression model was constructed to estimate the relationship between predictor variables and the outcome variable (autism diagnosis). Initially, a comprehensive strategy was employed by first fitting a null model and then iteratively introducing blocks of variables (e.g., socio demographic factors prenatal, peri- and neonatal factors). After introducing the new block of factors, a likelihood ratio test was conducted to evaluate the contribution of the added variables. If the p -value associated with the likelihood ratio test was insignificant ( p  > 0.05), the preference was given to a less complex model. In our analysis all added blocks had significant contribution to the overall fit of the model.

Subsequently, the significance of each variable was systematically assessed by applying a stepwise elimination technique whereby insignificant variables were progressively removed from the model. Similar to the above-mentioned process, at each step, a likelihood ratio test to evaluate the significance of the excluded variable was conducted. If the p -value associated with this test was found to be insignificant ( p  > 0.05), the adoption of a simpler model was favored. This iterative process allowed us to identify the most parsimonious model that retained statistically significant predictors while minimizing unnecessary complexity. Odds ratios (ORs) were computed, accompanied by 95% confidence intervals (CIs), to quantify the strength and direction of these associations.

Data availability

Data can be made available by the corresponding author upon reasonable request.

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Acknowledgements

We express our gratitude to all parents participated in the study.

This work was supported by Higher Education and Science Committee, Ministry of Education, Science, Culture and Sports of RA (24YSMU-CON-I-3AN and 23LCG-3A020), and YSMU.

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M.M. and K.Y. conceived the project; M.M., T.A., A.M., L.A. and K.Y. designed experiments, collected and analyzed data; M.M., T.A., A.M., L.A., and K.Y. wrote the draft; M.M., A.M., and K.Y. edited the manuscript. K.Y. obtained funding and supervised the study. All authors have read and agreed to the published version of the manuscript.

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Mkhitaryan, M., Avetisyan, T., Mkhoyan, A. et al. A case–control study on pre-, peri-, and neonatal risk factors associated with autism spectrum disorder among Armenian children. Sci Rep 14 , 12308 (2024). https://doi.org/10.1038/s41598-024-63240-3

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DOI : https://doi.org/10.1038/s41598-024-63240-3

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