Evidence of Impacts and Mechanisms as Vehicles of Dialog With Ethics
We are pleased to host for readers of our journal ‘Chronicles of Narrative Medicine’ an interview with Professor Sebastian Lipina, Director of the Applied Neurobiology Unit of the Medical Education and Clinical Investigation Center in Buenos Aires (Argentina).
Prof. Lipina is one of the most expert in the application of neuroscience, and his studies mainly investigate the correlation between poverty and the correct development of children and adolescents in the South of America. Since people living in poor conditions were actually one of the most common issues all over the world, affecting the economy of many different populations, in the Third World countries as well as in the Industrialized ones. Consequently, Prof. Lipina’s works could be very interesting not only to identify connections between financial conditions of families and the mental health in childhood but also to support Politicians from different nationalities to support needy people.
In occasion of the Congress of Chilean Pediatrics Society in Antofagasta, Chile (October 2018), ISTUD Foundation had the opportunity to meet Prof. Lipina and his studies, and to diffuse the Narrative Medicine potentials in the field of childhood health. Paola Chesi, project manager of the Healthcare Area of ISTUD Foundation, presented the methodology of Narrative Medicine, its application on pediatrics as carried out in the ISTUD projects CRESCERE, SOUND, and NASCERE PRIMA DEL TEMPO. The Congress was indeed a great opportunity to exchange cultures in scientific researches with the same aim while through different methodologies, as in this case.
The topic of this month is indeed the importance of deeply understand not only the clinical parameters of patients during the medical encounters but also the socio-demographics of people, to improve efficacy in terms of planning treatments, proving care at home, and to establish trusty doctor-patient relationships.
Here, the interview with Prof. Lipina is reported.
(1) Dear Professor, could you please briefly explain to our readers the known role of poverty in the children neuronal development?
In the last two decades, several researchers have begun the exploration of the influences of poverty on the activation of different neural networks through the administration of techniques of structural magnetic resonance imaging (MRI). For example, one study analyzed the associations of parenting practices and the level of home stimulation for learning on the neural morphology between middle childhood and adolescence. The results indicated that higher scores on a scale assessing parenting practices were associated with higher performance on a task demanding episodic memory processes and with smaller volumes of the hippocampus at the age 4. At the same time, they found that the association between levels of stimulation for learning at home –which was decreased in poor homes- with hippocampal volume was not verified at age 8. This evidence suggests that the quality of parenting influences the neural organization in these stages of development. Complementing this, a number of recent studies have found volumetric and cortical thickness variations in the hippocampus and amygdala of different populations of poor children and adolescents, and adults with children’s stories of poverty. In addition, several researchers found evidence of changes in the thickness, cortical surface, and connectivity of prefrontal, parietal, temporal and occipital neural networks, in children, adolescents and young adults from homes with different levels of poverty. Regarding the impact of poverty on performance at the level of neural activation using techniques of functional magnetic resonance imaging (fMRI), several studies have found variability in the patterns of frontal and parietal-occipital activation during the solution of tasks demanding phonological processing. This was verified in samples of children with ages between 5 and 8 years, and in adults with stories of reading difficulties who had grown up in poverty contexts. Other studies reported changes in the activation of prefrontal and limbic systems during the solution of tasks with demands of stress regulation in adults with histories of childhood poverty. Finally, it has also been verified that the complexity of the linguistic environment in rearing environments and levels of cortisol (a hormone associated with the activation of the stress regulatory system) were associated with both poverty, and with the activation of different prefrontal cortex areas during the performance of a learning test. Another series of recent studies on poverty influences on brain activity have applied techniques of electroencephalography. Evidence show differences in resting-state activation during the first year of life, in activation during the solution of tasks demanding inhibitory control in school-aged children, auditory attention in preschoolers and school-age children, and emotional processing during adolescence. At a behavioral level of organization, the influences of poverty on cognitive and emotional regulation and language development would be mediated by the quantity and quality of home stimulation of cognition and learning, and language environment during the early stages of development. In the last four years, several studies added evidence supporting this hypothesis at a neural level of analysis. For instance, the volume of gray matter and cortical thickness in frontal and temporal areas were identified as mediators of the association between income and academic performance between ages 4 and 18. In another study, the connectivity between hippocampus and amygdala was identified as a mediator of the association between income and depressive symptoms during the preschool stage, in poor children from ages 7 to 12. In addition, the connectivity between different neural networks involving several cortical areas was identified as a mediator between the number of years of education and cognitive control performance during adolescence.
The current neuroscientific studies in this area of stress regulation have gradually begun to incorporate the concepts and methodologies derived from advances in epigenetic and the analysis of neural activation. Different adverse experiences related to poverty during the early stages of development have been associated with a complex pattern of responses, which are assumed as mediators of increased susceptibility to the development of psychiatric disorders in adulthood. One of the hypotheses that are being discussed is that epigenetic changes in the encoding of glucocorticoids receptors would mediate the association between stress and cognitive and emotional regulation in adolescents with histories of child abuse. However, vulnerability and susceptibility to situations of moderate stress vary between individuals according to different epigenetic mechanisms and the possible presence of certain protective factors, such as relationships with sensitive adults. During the last decade appeared the first neuroimaging studies that began exploring how socioeconomic deprivation during childhood influences the response to stress in different stages of life. For instance, some studies evaluated the long-term impact of adverse conditions during childhood on adult performance in tasks tapping emotional processing of threatening faces. The results of these studies showed that children raised in adverse contexts showed increases in amygdala reactivity associated with decreased visual contact during interactions with adults.
(2) What are the main health and social factors connected to poverty?
The contemporary consensus about human development postulates that it is a process of continuous integration of interdependent events occurring at different levels of organization (i.e., biological, psychological, and cultural). This way of thinking considers each individual as a complex system made up of different elements that interact at genetic, neural, behavioral, and social levels, creating specific patterns of functioning and evolution in particular historical contexts. In this type of frameworks, human development consists of a series of interdependent contexts of development; each one has a specific pattern of material and symbolic exchanges among institutions and individuals. From the child’s perspective, the first context is that in which significant adults and institutions interact directly with her or him during everyday life activities (e.g., family, teachers, peers, schools, churches, NGOs, and neighborhood organizations). In turn, this developmental context is contained within another one in which people and institutions that deal with childcare interact, but without direct interaction with the child (e.g., parent-teacher meetings, which potentially influence parenting and educational practices). A third context, which contains the previous two, is that in which the social, cultural, and economic activities of each community take place (e.g., governmental agencies, trade unions, civic associations, businesses, industry, and media). Likewise, the cultural system of rules, beliefs, and values of each community contains all the previous developmental contexts as well as all the explicit and implicit conceptions of childhood, social equity, and sensitivity to the needs of human development. And each cultural system is contained in a biome, with its flora, fauna, and climate, which in turn are affected by human activity. Finally, all these developmental contexts interact in many different ways over the specific historical time of each community. Research findings are clear about the potential negative influences of poverty on brain development; however, they do not necessarily explain the mechanisms through which poverty generates its influences. The identification of such mechanisms of mediation is not easy because poverty is a complex phenomenon that involves many conditions that could influence brain development. This set of potential mediators shapes a virtual ecology of protective and risk factors of human development, involving multiple individual and environmental factors in all developmental the contexts and at different levels of the organization. Among such factors, the contemporary literature on developmental psychology and health sciences postulates the following as the most important: prenatal maternal health (nutrition, exposure to environmental toxic agents and drugs, environmental stressors); perinatal health (prematurity, birth weight); quality of early attachment; environmental stressors at home and schools; parenting and care quality and styles; early cognitive and learning stimulation at home, care centers, and schools; parents’ and teachers’ mental health; developmental disorders; family financial stress; access to social security and health systems; community resources; lack of social mobility; social, political, and financial crises; family, social, and cultural expectations about child development (e.g., discrimination, stigmatization, exclusion); and natural disasters.
(3) What are the main scientific, political, and social implications of these findings in the South American context?
The neuroscientific study of how poverty influences brain development is still at an early stage. However, after two decades of application of neuroimaging techniques and paradigms of neurocognitive functioning is possible to state that: (1) the different experiences of adversity related to poverty are associated with changes in the structure and function of neural systems related to cognitive and emotional regulation, language and learning skills; (2) these influence could happen at different times of human development; and (3) the hypothetical mechanisms through which these changes occur involve different factors related to childcare through the quality of language environments and cognitive stimulation and emotional support in home and educational contexts. However, as in any scientific endeavor, there are aspects of this area that need to continue its explorations to deepen understanding and avoid generating misconceptions that may adversely contaminate the social uses of this knowledge. One of such aspects is the interpretation of the results obtained by applying different neuroimaging techniques. For instance, a pattern of electrophysiological activity indicating differences in attentional processing that move away from what would be expected for children of the same age who do not live in poverty does not necessarily mean that such pattern corresponds to dysfunction or a deficit. Actually, this kind of evidence suggests that we would face an adaptive process, that indeed it would also be possible to modify by interventions, so it is necessary to improve the understanding of the contextual conditions that are associated with these adaptations. To foster such efforts could be productive to stimulate genuine interdisciplinary efforts devoted to integrating concepts of ecological psychology. In any case, it is not appropriate to communicate that such findings correspond to an immutable deficit condition. In the case of using techniques of neural structural analysis, this issue must be analyzed much more carefully, since the information is not obtained by analyzing the concomitant functional activity as in the case of EEG and fMRI techniques. However, it is possible to verify examples of social communication of these results that are problematic because they induce explicitly or implicitly notions that cannot be sustained with the available evidence and argue that poverty would generate immutable impacts. Other issues of importance in this area of study are the need to advance in the analysis of causality and to make efforts to avoid social communication of the correlational evidence as if it were causal. In this regard, it is necessary to advance in the design of longitudinal studies involving different levels of organization and multiple mediation analysis, to allow: (1) the identification of the differential effects of the accumulation and/or combination of several types of adversities throughout development; (2) the understanding about how different types of adversities modulate the efficiency of distinct neural networks; (3) the identification of periods of vulnerability and greater sensitivity to different types of adverse experiences; (4) the exploration of phenomena of mutability and immutability of the impacts; and (5) the design of valid measures to assess cognitive and emotional regulation in different stages of development.
(4) What are the possible interventions from decision makers, healthcare managers and providers of care to optimize the process of childhood development?
The field of neuroscience and poverty is still preliminary (the first empirical studies were published at the beginning of the last decade). This means that neuroscience knows too little about poverty to be of use in policy realms. Scientifically, we have only approached the surface of the poverty–brain associations, and many questions remain open. As one of the founders of this field asked recently (i.e., Martha Farah): “Which findings will replicate and generalize and which will not? What can we say with confidence about the mechanisms linking poverty and the brain? To what extent do the answers to these questions depend on specific dimensions of poverty (e.g., income, parental education, etc), or on poverty per se as opposed to gradations between higher levels of socioeconomic status? Are individuals’ ages, genders and genotypes part of the answer? Do the same mechanisms underlie socioeconomic disparities globally (i.e., do they apply in middle-income and low-income countries as well as in the high-income countries in which most of the research has been conducted? Do they vary across cultures or ethnicities or between urban and rural communities? There is little that we can now say with confidence. Thus, our knowledge of poverty and the brain remains quite limited. If we fail to appreciate the preliminary state of our knowledge, we risk the field’s credibility by promising too much and disappointing policy makers and funders. We also risk premature translation of research findings into policy, which could harm the very people in need of help”. In summary, until the field will mature enough to offer specific evidence-based suggestions and recommendations, those practitioners and policy-makers interested in promote health and improve the children living in poverty should explore what other disciplines such as epidemiology, pediatrics, developmental psychology, anthropology, sociology, and education have already made and suggested in the last decades regarding the interventions for poor populations.
(5) Since many studies have shown the efficient role of Narrative Medicine in the sensitization process about several healthcare issues, what is your consideration on applying this discipline to diffuse the importance of socio-demographic information among the main healthcare stakeholders?
I am not an expert in the health field nor the narrative medicine realm. However, since we are involved in projects in which we consider both the ability to produce narratives and their relationship to living conditions; and the analysis of the discourse content of the people with whom we develop our research (i.e., children, caregivers, teachers, policy-makers), we have learned the importance of considering the narratives to incorporate cultural relevance to our studies, as well as to improve our questions and intervention approaches. Considering this humble experience, I understand that applying this discipline to our studies is at least necessary.
Sebastián J. Lipina (Buenos Aires, Argentina, 1968). PhD in Psychology. Diploma in Social Sciences (FLACSO). Researcher of the National Council of Scientific and Technical Research (CONICET, Argentina). Director of the Unit of Applied Neurobiology (UNA, CEMIC-CONICET) Professor of the Seminar Childhood Poverty and Cognitive Development (UNSAM, Argentina). Fellow of the Center for Neuroscience and Society (CNS, University of Pennsylvania, USA) Codirector of the Mind, Brain and Education School (Ettore Majorana Foundation and Centre for Scientific Culture, Italy). Member of the IRB of CEMIC. Volunteer Researcher of the On-call Scientists Program (American Association for the Advancement of Science, USA). Consultant of the Panamerican Health Organization, UNICEF and UNDP.
