EI Talk: A Blog for Early
Childhood Professionals


Perinatal Depression in Latina Mothers

Early Childhood Interventions December 20, 2016

Mothers experiencing PD may fail to provide an enriching, developmentally supporting environment or developing a mutually beneficial relationship with their baby. A lack of toys, engaging language activities, and attention-provoking games during early stages of development may lead to poor cognitive and language development. In the long term, children of mothers with PD can show deficits in cognition, behavior, and academic performance (Bernard-Bonin, 2004). Children can demonstrate dysregulated attention, lower IQ than matched peers, and social and adaptive immaturities, and they are at higher risk for other challenges such as ADHD, anxiety, or depression) (Hay, Angold, Pawlby, Harold, & Sharp, 2003).

Often, PD is considered a condition that should be easy to “overcome” right?  Women often hear that it is a phase that will pass or they should just “buck-up” But, for most it is much more complicated.  Research indicates that the most successful antidote to Perinatal Depression is social support, such as home visits from family, friends, and professionals (McKee, 2001). Family therapy to teach coping strategies to the new mother, increase communication within the family about the illness, and foster resilience within the child can also be extremely helpful (Pearlstein, 2008). The active involvement of the father can be a very important buffer to provide support to the baby as well as the mother (McKee, 2001). Community organizations, including religious institutions and specialized programs, can provide further assistance. However, awareness of and access to these strategies is often inadequate, restricting women and families from using them. Even when accessibility does not pose a problem, many women experiencing PD will not accept the assistance given by community programs.

Data on prevalence of Perinatal Depression shows that certain demographics are more likely to experience PD. Due to the combination of risk factors the prevalence of PD in Latina mothers, is closer to 36%, which is significantly greater than the 12-20% national average (Baker-Ericzén, et. al., 2012). According to the US Census Bureau (2012), the majority of women giving birth are Latinas,  indicating that  there is a significant proportion of women who are at higher risk to experience PD. Additionally, Latinos in the U.S. are more likely to be low-income, have unwanted/unplanned pregnancies, and be single mothers. Latinos are also widely acknowledged to be far less likely to seek professionals regarding mental health concerns than are non-Hispanic whites (National Institute for Health Care Management, 2010). The combination of all of these factors makes the Latina mother population particularly worth considering for treatment options.

There are, however, intervention programs developed specifically for the Latina population.  For example, the Perinatal Mental Health (PMH) Project is a culturally sensitive, short-term telemedicine intervention (Baker-Ericzén, et. al. 2012). The PMH Project involves an initial screening by a physician to determine maternal depression, followed by enrollment in the telemedicine program by a mental health assistant. The telemedicine curriculum itself contains a variety of modules that are completed by the mother with the mental health assistant. The modules are designed with specific cultural sensitivities in mind, but the primary mode of communication is in English.  The modules focus on destigmatizing mental health problems, especially PD, and providing emotional support through cognitive-behavioral therapeutic strategies as well as coping and stress management techniques. The PMH plan was piloted in Southern California, and it found that contacting low-income, often single, Latina mothers by cell phone was an effective way of both transmitting culturally sensitive information about PD and providing resources to connect them with professionals (Baker-Ericzén, et. al. 2012).

Although its effects are still not fully understood by researchers, the PMH program was shown to be an innovative way to address problems with accessibility associated with clinics that were negatively perceived by many Latina mothers (Baker-Ericzén, et. al. 2012). Its large-scale effectiveness and long-term effects have not yet been determined, but this is certainly a program to consider furthering. Given the widespread prevalence of PD in Latina mothers, providers must find creative solutions to make treatment accessible to America’s increasingly diverse population.

References:

Baker-Ericzén, M. J., Connelly, C. D., Hazen, A. L., Dueñas, C., Landsverk, J. A., & Horwitz, S. M. (2012). A Collaborative Care Telemedicine Intervention to Overcome Treatment Barriers for Latina Women with Depression during the Perinatal Period. Families, Systems, & Health, 30.3, 224-40.

Bernard-Bonin, A. (2004). Maternal depression and child development. Paediatric Child Health, 9.8, 575-83.

Field, T. (2011). Prenatal depression effects on early development: A review. Infant Behavior and Development, 34, 1-14. doi: 10.1016/j.infbeh.2010.09.008

Hay, D.F., Angold, A., Pawlby, S., Harold, G.T., & Sharp, D. (2003). Pathways to Violence in the Children of Mothers Who Were Depressed Postpartum. Developmental Psychology, 39.6, 1083-94.

Mckee, M. (2001). Health-related Functional Status in Pregnancy: Relationship to Depression and Social Support in a Multi-ethnic Population. Obstetrics & Gynecology 97.6, 988-93.

National Institute for Health Care Management. (2010). Identifying and treating maternal depression: Strategies & considerations for health plans. NIHCM Foundation Issue Brief, June, 1–28.

Pearlstein, T. (2008). Perinatal depression: treatment options and dilemmas. Journal of Psychiatry & Neuroscience : JPN, 33(4), 302–318.

Phillips, M. L. (2011). Treating post-partum depression. American Psychological Association Monitor on Psychology, 42.2, 46. Retrieved from http://www.apa.org/monitor/2011/02/postpartum.aspx.

Teti, D. M., Gelfand, D. M., Messinger, D. S., & Isabella, R. (1995). Maternal depression and the quality of early attachment: An examination of infants, preschoolers, and their mothers. Developmental Psychology, 31(3), 364–376.

U.S. Census Bureau. (2004). Current populations survey, annual social and economic supplement: Ethnicity and ancestry statistics branch, population division. Retrieved from http://www.census.gov

Abby Lindsay (C’ 17)

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Implementing the Summer Food Service Program

Early Childhood Interventions December 09, 2016

Many families celebrate the advent of the summer school vacation with picnics to the beach and cookouts. Students and teachers alike are excited to take a break from classrooms and mandated testing. For families with children on free or reduced price lunch, summer vacation can be devastating. No school means no lunch or breakfast for millions of school-aged children. Summer vacations present a gap in the nutritional needs of low-income children. The Summer Food Service Program (SFSP) seeks to fill that gap.  Unfortunately, only one in seven children currently registered for the free and reduced price lunch program participates in SFSP (Facts on the Summer Food Service Program, n.d.).

Families who receive Supplemental Nutrition Assistance Program or SNAP benefits are automatically enrolled in free and reduced price lunch programs. The US Department of Agriculture (USDA) uses the federal poverty guidelines to determine eligibility for SNAP benefits. Attached are the USDA’s “Income Eligibility Guidelines” for the 2016-2017 school year (Income Eligibility Guidelines, 2016). For families not eligible for SNAP, there is a sliding scale for reduced price meals based on family income. These same families are eligible for services from SFSP (Facts on the Summer Food Service Program, n.d.).

During the summer, The Summer Food Service Program provides free meals and snacks to low-income children The program fed 3.2 million children a day during the month of July, 2014. The Summer Food Service Program is implemented in two ways. It can operate on an enrollment basis or as an open program. In order to be eligible for funding, a site must operate in a low-income neighborhood and serve a population consisting of at least 50% on free and reduced price lunch. Individual groups such as nonprofits, YMCA camps, and local governments can run a SFSP site. Usually an SFSP site also provides some sort of academic enrichment in addition to free meals and snacks.

There is an estimated 22 million children who receive free or reduced price lunch during the school year. Only 3.2 million of them participate in the Summer Food Service Program.  This may indicate that a significant number of children may be going hungry during the summer months, the SFSP is not operating in a satisfactory manner, or many families find it difficult to visit an SFSP site to obtain a meal because of the lack of transportation.

In the summer of 2015, the USDA proposed a program to help meet the nutritional needs of low-income seniors and people with disabilities who are unable to access community based resources. For the first time, the USDA is proposing that agencies that deliver groceries accept SNAP benefits, allowing them to deliver groceries to people who cannot travel to a grocery store.  A program like this has the potential to also impact the lives of low-income children who are unable to visit the SFSP sites.

The Obama administration has proposed a new program to help feed families during the summer. This program would give families eligible for free or reduced-price lunches an electronic benefit card. These cards would allow families to spend an extra $45 per child a week on groceries.  Such a program would erase the transportation difficulties associated with traveling to SFSP sites. It would also allow families to make independent choices in regards to their family diet. Unfortunately, this idea has yet to put into action due to Congressional inaction. Thus, millions of children may not be receiving nutritious meals. This is a perfect example of how Congress and the White House need to put aside differences to provide services that would benefit our country’s most vulnerable children.

References

Facts on the Summer Food Service Program. (n.d.). Food Research and Action Center. Retrieved from http://frac.org/pdf/sfsp_fact_sheet.pdf

Fessler, P. (2016). President Obama Wants More Funds to Feed Low-income Kids In Summer. Kosu. Retrieved from http://kosu.org/post/president-obama-wants-more-funds-feed-low-   income-kids-summer#stream/0

Income Eligibility Guidelines. (2016). Federal Register. Retrieved from         https://www.federalregister.gov/articles/2016/03/23/2016-06463/child-nutrition-           programs-income-eligibility-guidelines#h-8

Emma Hamstra (C’16)

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Letting “Homeless kids” just be “kids”: The role of play in alleviating toxic stress

Early Childhood Interventions September 26, 2016

Think back to when you were five years old. What was your home like? Where did you go to school? Who did you play with in your free time? Stereotypes about American childhood would lead one to expect the answers to those questions to bring back warm memories, and for many people this is the case. Childhood is a time to be remembered fondly, a time before life got hard. Unfortunately, the answers to those questions are complicated for a growing number of children. Child poverty is on the rise, and with that comes an increase in children experiencing homelessness.  Children who are homeless become invisible to society—sometimes even their teachers are unaware of the situations their students are facing. The effects of homelessness on young children are well-documented. I will highlight some of them here, but the main purpose of this post is to talk about an under-utilized early intervention strategy that is being used at the DC General Homeless Shelter: the power of play.

Homelessness in the District of Columbia is a pressing issue. DC is in the top ten list of states with the highest percentage of children under six experiencing homelessness at seven percent (7%). This means that one out of every fourteen children under six in DC are homeless. The numbers are staggering—there are over 600 children living in the largest shelter alone, not to mention those living in smaller shelters, in cars, or other temporary housing (Dvorak, 2013). It is well known that the early years of life are foundational to brain development, and homeless children have been shown to experience developmental delays and disabilities more than other children their age. For more information on early intervention strategies for homeless children, there is an excellent post on this blog about the issue.

While early childhood education and preschool programs are key to early intervention for homeless children, an area that is lacking in broader attention is the ability to simply experience childhood. Homeless children are forced to grow up fast. Parents and people who work with children experiencing homelessness express concern that those chidren are missing out on what is considered a “normal” childhood. When asked what her children needed most, one mother replied, “Play spaces. They need that room to play and just be kids. Not homeless kids. But kids” (Dvorak, 2013). Parents and specialists alike understand that play is not time off from learning, but a crucial part of the learning process. Through play, children learn social skills, communication, theory of mind, and gain a sense of belonging (ACT Government, 2016). Additionally, playtime can be an opportune time to observe children’s behavior and to detect signs of developmental delay in order to begin intervention as early as possible. Along with all of the other difficulties of homelessness, children experiencing homelessness have few opportunities for play. Shelters are not equipped for play, and more often than not the neighborhoods where homeless children live are not safe for play.

Here in DC, we are fortunate to be witnessing a movement to integrate play into early intervention. A groundbreaking program, the Homeless Children’s Playtime Project [HCPP], is opening up spaces for children to play under the supervision of caring volunteers. At DC General and several smaller shelters throughout the city, HCPP has established playrooms where for two hours a day, twice a week, children have the chance to just be kids. They can play in an unstructured environment without the stigma or misunderstanding they may face in the classroom. The serotonin released during play can serve as an antidote to high levels of cortisol produced under conditions of toxic stress (Dvorak, 2013). It also gives children the chance to develop positive relationships with adults—all volunteers undergo a background check and training to equip them to deal with the issues the homeless children face.

Parents and volunteers have offered much anecdotal evidence of the success of HCPP. I volunteered at DC General for several months and saw that it had a profound impact on many of the children I worked with. However, glowing reviews and celebratory newspaper articles are not enough. We need specialists and researchers to document the short and long-term benefits of HCPP. It is time to seriously consider play as an early intervention opportunity, and to figure out what works well and what does not. Only then can we know for sure whether play-based intervention strategies should be integrated into existing intervention strategies. Hopefully, a strategic plan for researching this program will bring it to the status of evidence-based practice. That way, other states can get funding to implement their own play programs for homeless children.

References

Benefits of Active Play. (2016). ACT Government. Government of Australia. Retrieved from http://www.health.act.gov.au/healthy-living/kids-play/active-play-everyday/benefits-active-play

Dvorak, P. (2013). For DC shelter’s 600 homeless children, a crucial source of fun and escape. The Washington Post. Early Care and Education for Young Children Experiencing Homelessness. (2014). National Center for Homeless Education. Early Childhood Homelessness in the United States: 50 State Profile. (2015). Administration for Children and Families.

McCoy-Roth, M., Marci, B., & Murphey, D. (2012). When the Bough Breaks: The Effects of Homelessness on Young Children. Child Trends. Retrieved from http://www.childtrends.org/publications/when-the-bough-breaks-the-effects-of-homelessness-on-young-children/

Claire Reardon (C’17)

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Zika and Microcephaly: Implications for Early Intervention Services in Brazil Part 2

Early Childhood Interventions February 22, 2016

In 2015, Zika virus infected an estimated one-half to over 1 million  people in Brazil. The outbreak was focused in the more rural Northeast part of the country, but the virus has spread through Brazil and surrounding countries (Hennessey, 2016). Zika infections are largely mild, and result in fever, rash, and joint pain. Hospitalization for the disease is rare (“Zika Virus,” 2016). However, since the start of the epidemic, the country has experienced a massive increase in suspected cases of microcephaly in infants. While the role of Zika in causing microcephaly in infants has not been established, the rate of microcephaly in infants rose from 0.5-2 cases per 10,000 to an estimated 99.7 cases per 10,000 in 2015 (Ventura, Maia, Bravo-Filho, Gois, & Belfort, 2016). Between mid-2015 and February 2016, 4783 children were suspected of having  microcephaly.  One thousand one hundred and three children have received comprehensive examinations (CT Scans, MRI) and 403 of these have received a conformational diagnosis of microcephaly (Victora, Schuler-Faccini, Matijasevich, Ribeiro, Pessoa, & Barros, 2016). The remaining 3670 have yet to complete full examinations. While it is likely that the increased prevalence of microcephaly is lower than currently estimated, the country is still experiencing a significant increase in children with microcephaly. For example, Pernambuco, a state in the Northeast region of Brazil, usually expects a maximum of 45 reported cases each year, but in 2015, 26 times that number (n=1170)were reported (Butler, 2016).

The rise in the number of children with microcephaly has significant implications for Brazil’s service system for children with disabilities. Microcephaly is usually caused by abnormal brain development, and puts children at risk for developmental delays, seizures, motor difficulties, and hearing and vision issues (CDC, 2016). Proper care of children with microcephaly requires not only medical imaging and evaluation for diagnosis, but comprehensive follow-up with a health care team, early intervention, and educational supports and services (Butler, 2016). Because of the multiple disabilities seen in children with microcephaly the children often need treatment for seizures, developmental disability, and ophthalmological and audiological disorders, and many children require speech, occupational, and physical therapy and special education to maximize their potential (American Academy of Neurology, 2009).

Numerous studies have shown that Early Childhood Development (ECD) and Early Intervention (EI) programs provide a wealth of benefits for children with disabilities and their families. A study of 70 ECD programs in the U.S. revealed that such programs yield positive effects on IQ and lead to better-developed abilities at the point of entry into school and greater achievement in the earlier school years (UNICEF, n.d.). Despite such facts, Brazil has a long history of being unable to provide high quality and equitable access to health and educational services for children with disabilities. Child development has historically been a low priority in health and education services in Brazil, and guidelines for care and integration of children with disabilities are not widely available (Eickman et al., 2003).

The discussion of Brazil’s capacity, or lack thereof, to help children with disabilities is ever more relevant with this increase in the number of children with microcephaly, no matter the cause. Early Intervention programs would serve as an important initial step in working with children with microcephaly and other developmental delays to help them reach their full potential. A great example of this in action is a project in Brazil that identified children between 0-3 years of age with developmental disabilities, and then enrolled them into community-based intervention programs with the aim of helping them reach their full potential. Mothers and fathers were taught how to interact with their children and provide developmentally appropriate care and stimulation to promote development, functional skills, and socialization (UNICEF, n.d.).  To capitalize on the benefits of early intervention, Brazil must make significant enhancements to an already fragile health care and intervention system for young children with disabilities:

  • increase public awareness about the rights of children with disabilities and systematically mobilize all sectors to create greater demand of appropriate services;
  • develop a robust community-based system of developmental services and supports for infants and toddlers with disabilities and delays;
  • develop strategies that allow greater flexibility in responding to the unique and various needs of children with disabilities;
  • address misconceptions, prejudices, and discriminatory practices that promote the exclusion of children with disabilities such as in schools;
  • expand a support system for parents to strengthen their capacity to demand rights and seek services; and
  • provide professional development so that teachers, therapists, and child care providers possess the skills and knowledge to serve children and families using evidence based practices (UNICEF, n.d.).

 Improvements in health care coverage have led to fewer disparities in health care access in Brazil, but the system’s strengths in primary care are not always reflected in specialized care availability. In 1988, Brazil established the Unified Health System (UHS), and currently more than 75% of the population relies exclusively on the system for access to health care. Primary care is provided for free at the point of service, and subsidies for heart surgery, medical imaging, lab diagnostics, vaccines, and many essential medicines increase access to necessary health care for much of the population. The UHS works with the Family Health Program, which employs teams of healthcare workers to provide primary care to over 97 million Brazilians in poor and isolated communities. Together, these services have helped to decrease regional and economic disparities in primary health care access.

However, disparities in access, especially for specialized services like early intervention, still exist. For example, Jurberg & Humphreys (2010) found three out of four children in a Southeast state did not receive appropriate intervention for their developmental disabilities. Access to care is likely lower in the more rural North and Northeast regions. Community health workers regularly perform home visits for primary and preventative care, but they rarely identify or refer children with disabilities to appropriate developmental services even when available (Paula, Ribeiro, Fombonne, & Mercadante, 2011). In Pernambuco, community health workers are not well-trained to diagnose or or treat children with developmental delays. A 2003 study found that developmental milestones were recorded only 1% of the time during visits, though growth and immunizations were well documented (Eickmann et al., 2003). However, children with microcephaly can be identified through simple head circumference measurements thus health workers and service providers should be readily prepared to make such assessments and subsequently provide referral to adequate services.

Equal access to education regardless of disability became constitutionally protected in Brazil after 2001, when a law required all children ages 7-14 to attend regular, rather than specialized, school. However, children with disabilities are still twice as likely to not attend school and four times more likely to be illiterate than children without disabilities (UNICEF Brazil, 2003). Most schools accept children with disabilities, but they do not always make full effort to integrate them. In 2000, only 21% of children with disabilities attending inclusive schools while 79% attended special schools (UNICEF Brazil, 2003). Public policies and guidelines for effective inclusion are not widely available, and specialized services for children are not easily accessible in many parts of the country (Silva, Goncalves, & Alvarenga, 2012).

Brazil’s system for intervention before school age is equally inadequate and the failings of the public health service are most intensely felt by families of children with microcephaly. Officials admit to their inability to provide children with appropriate services, which for children with microcephaly include intensive physical therapy, speech therapy and occupational therapy (Sandy, 2016). All of these are rarely, if ever, available to Brazilian families (Sandy, 2016). Jailson Correia, a regional health secretary, asserts that the government is “far from providing the high quality healthcare that Brazilians deserve” (Sandy, 2016). For families with children with disabilities, prejudice against those with disabilities remains as one of the biggest barriers to adequate access to services. According to the founder of the NGO Escola de Gente (translates to “School of the People”),

“When a disabled child is born in Brazil, the family is often alone… And they remain alone because of the lack of support from politicians and segregation from society” (Sandy, 2016).

Families often struggle to afford the necessary services, which include doctors and various modes of therapy, as they often find themselves receiving little to no aid from the state to help buffer the burden of costs.

In response to the rapidly rising incidence of children with microcephaly, the government of Brazil published a national plan for responding to the occurrence of microcephaly related to Zika virus infection, as well as national guidelines for early intervention of babies with microcephaly (Ministério de Saúde, 2016; “Saúde divulga diretriz nacional…”, 2016). But how prepared is Brazil to mobilize a support network, essentially overnight, for the 4,000 new and upcoming cases of microcephaly? To put this into perspective, it is estimated that DC’s early intervention system for children with disabilities supports about 700 families at any given time. In order to provide the adequate care, the system uses a network of about 500 service providers. Brazil’s government is faced with a serious problem. Current emphasis on prevention is appropriate, however, the government and civil society must address the growing public health and education crises facing Brazil. The reality is that the country now has more than 4,000 children with or at very high risk for having disabilities who will need a host of supports and services all at the same time.

Beyond the national response, the international response to the spread of Zika and the growth in microcephaly have been arguably minimal. For example, the World Health Organization released Zika: Strategic Response Framework & Joint Operations Plan (2016), only after widespread criticism of its very delayed response to the situation. Furthermore, though the framework claims to have “been developed to guide the international response to the current cluster of congenital malformations (microcephaly),” it is clear that the major focus is still on preventing further infections and not on managing existing cases of microcephaly (WHO, 2016). The same rings for all other major international health organizations, and little can be found on response strategies for aiding families of children with microcephaly.

It is time for Brazil, the international community, and civil society to recognize the needs of the children and families and begin creating a system of community based services and supports! 

References

  • American Academy of Neurology. (2009). Practice Parameter: Evaluation of the Child with Microcephaly [Chart]. Retrieved from https://www.aan.com/Guidelines/home/GetGuidelineContent/364
  • Butler, D. (2016). Zika virus: Brazil’s surge in small-headed babies questioned by report. Nature,doi:10.1038/nature.2016.19259
  • Centers for Disease Control and Prevention. (2016, January 29).  Facts about Microcephaly [Fact sheet]. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/ncbddd/birthdefects/microcephaly.html
  • Centers for Disease Control and Prevention (n.d.). Zika Virus. Retrieved February 5, 2016, from http://www.cdc.gov/zika/index.html.
  • Eickmann, S. H., Lima, A. C., Guerra, M. Q., Lima, M. C., Lira, P. I., Huttly, S. R., & Ashworth, A. (2003). Improved cognitive and motor development in a community-based intervention of psychosocial stimulation in northeast Brazil. Developmental Medicine and Child Neurology, 45(8), 536-541. doi:10.1017/S0012162203000987
  • Hennessey, M. (2016). Zika virus spreads to new areas—region of the Americas, May 2015–January 2016. MMWR. Morbidity and Mortality Weekly Report65.
  • Jurberg, C., & Humphreys, G. (2010). Brazil’s march towards universal coverage. Bulletin of the World Health Organization, 88(9), 646. doi:10.2471/BLT.10.020910
  • Ministério de Saúde. (2016). Protocolo de atenção à saúde e resposta à ocorrência de microcefalia relacionada à infecção pelo vírus Zika: plano nacional de enfrentamento à microcefalia. Retrieved from http://portalsaude.saude.gov.br/images/pdf/protocolo-sas-2.pdf.
  • Ministério de Saúde. (2016). Saúde divulga diretriz nacional para estimulação precoce de bebês com microcefalia. Retrieved from http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/21681-saude-divulga-diretriz-nacional-para-esimulacao-precoce-de-bebes-com-microcefalia.
  • Paula, C. S., Ribeiro, S. H., Fombonne, E., & Mercadante, M. T. (2011). Brief report: Prevalence of pervasive developmental disorder in Brazil: A pilot study. Journal of Autism and Developmental Disorders41(12), 1738-1742.
  • Sandy, Matt. (2016, February 5). In Brazil, stigma and poor care afflict microcephaly sufferers. Aljazeera America. Retrieved from
  • http://america.aljazeera.com/articles/2016/2/5/brazil-widespread-stigma-surrounds-microcephaly.html
  • Silva, F. T., Gonçalves, E. A. V., & Alvarenga, K. D. F. (2012). Inclusion of individuals with special needs in regular education: a literature review. Jornal da Sociedade Brasileira de Fonoaudiologia24(1), 96-103. PMID: 22460380
  • UNICEF. (n.d.). Early Childhood Development: The key to a full and productive life. Retrieved from http://www.unicef.org/dprk/ecd.pdf
  • UNICEF Brazil. (2003). Report on the situation of children and adolescents in Brazil. Retrieved from http://www.unicef.org/brazil/english/siab_english.pdf
  • Ventura, C. V., Maia, M., Bravo-Filho, V., Góis, A. L., & Belfort, R. (2016). Zika             virus in Brazil and macular atrophy in a child with microcephaly. The   Lancet387(10015), 228.
  • Victora, C.G., Schuler-Faccini, L., Matijasevich, A., Ribeiro, E., Pessoa, A., Barros, F.C. (2016). Microcephaly in Brazil: how to interpret reported numbers? The Lancet, 387(10019), 621-624. doi:10.1016/S0140-6736(16)00273-7
  • WHO. (2016). Zika: Strategic Response Framework & Joint Operations Plan. Retrieved from http://www.who.int/emergencies/zika-virus/strategic-response-framework.pdf?ua=1

Eleanor Birch and Jamie King (Georgetown University ’17)

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