Cumulative Risks, Early development and emerging Academic Trajectories (CREATE) 2016-2018

Principal Investigators: Janean Dilworth Bart, MS, PhD & Kristen Malecki, MPH, PhD

Funding: UW2020, $289,188 was awarded in total

Study Aim: 

Brain development occurs rapidly in early childhood, making it a time when the child is at an increased vulnerability to the negative effects of psychosocial and environmental stress, as well as being exceptionally receptive to high quality interventions. Despite the sensitivity of this time, there are few studies that examine how a child’s simultaneous exposure to psychosocial, chemical, and non-chemical stressors affect academic readiness (self-regulation and language deficits). Even fewer studies include biomarkers of stress and inflammation.

The CREATE study will look at the exposure to psychosocial, chemical, and non-chemical stressors in tandem with the biomarkers of stress and inflammation that will be assessed by urine cortisol, creatinine, norepinephrine and epinephrine, IL-6, and CRP inflammatory markers.

This study has three main aims. Aim one is to identify sources of chemical and non-chemical stress in preschool-age children. This will be done by establishing a time-activity modeling protocol for assessing multiple personal exposures to indoor and outdoor fine particulate matter [PM2.5] and noise among 60 3-4 years old children. The second aim is to develop an integrative child cumulative risk score to include chemical, non-chemical, and psychological stress. This includes factors such as household chaos, parenting quality, caregiver psychological distress, language environment quality, indoor and outdoor sources of PM2.5, and noise. The final aim is to determine associations between cumulative risk, inflammation, and indicators of academic readiness (SR and language) among 3-4 years old children. The first hypothesis is that children facing an increased number of combined stressors from exposure to social and environmental risks will have lower academic readiness scores. The second hypothesis is that the unique profiles of aggregate chemical, nonchemical, and psychosocial domain scores will be associated with self-regulation (model I), and verbal ability (model II), and these relationships are partially mediated by inflammation.

More About the Study:

Participants were recruited from Madison WI area preschools. At the child’s school, their parent/guardian fills out the consent and eligibility screener and the questionnaires regarding the child’s health, demographic information, PHQ-2, and CES-D. The home appointment is then scheduled.

The next two visits occur at the child’s home, with the field staff setting up the LENA, the stationary air monitor, and the personal air monitor. The second at home visit consists of the field staff collecting the LENA and air monitors, the urine sample (and potentially the hair and cheek swab). The final meeting can occur at either the child’s home or preschool (though preferably it would be at home), the field staff measures physical measurements and lung function, and learning assessments.

Survey data was collected on paper, using two devices, and using Qualtrics.

Psychosocial stress was measured using the Home Observation for Measurement of the Environment (HOME) Inventory, Early Childhood Version, which was filled out by the field staff. Household chaos was measured with Chaos, Hubbub, and Order Scale, and Caregiver depression was identified using the Center for Epidemiological Studies-Depression Scale. Both were filled out by the caregiver.

The two devices used were the Language Environment Analysis (LENA) system that recorded 16 hours of the child’s auditory environment, and a small, personal monitoring device that measured air quality by estimating fine particulate matter.

The online platform used to complete the CAFÉ questionnaire was Qualitrics, on a tablet provided by the field staff.

Urine samples were collected in the child’s home. Some participants also gave cheek swabs and hair samples.

SHOW Services Leveraged

  • Participant recruitment
    • Invited N=67
      • N=26 children participated
    • Eligibility Criteria: child is 3 or 4 years old and has at least 1 parent available to participate (only 1 parent is allowed to participate with the child), English language proficiency of both parent and child
    • New recruitment of non-SHOW participants via various preschools in the Madison WI area
  • Human and Environmental Biospecimen Collection
  • Physical Measurements
  • In-person interviewing
  • Data cleaning


This study led to a publication in the International Journal of Environmental Research & Public Health.

Conclusions drawn: Real-time data collection of air quality and noise using wearables on 3- to 4-year-old children presents many challenges, which are among the top reasons prior studies have not attempted to do so. For example, we found that children wearing backpacks during a 24-h period is tolerable for one day, but beyond that, many children are not comfortable or willing to wear backpacks. We also found that children may become overly curious and try to tamper with equipment. Moreover, urine sample collection among recently potty-trained (or in-training) children is a daunting task outside of a clinical setting. However, our feasibility study demonstrates these perceived barriers to data collection on 3- to 4-year-old children can be overcome. The success of this study can largely be attributed to the interdisciplinary team of experts from child development, environmental epidemiology, and environmental engineering that came together to develop and continually adapt a well-thought-out protocol and study design. The feasibility of our study has important relevance for future research and intervention work. Future directions with the CREATE feasibility study will be to integrate key lessons learned from this feasibility study into a larger longitudinal design spanning several years throughout childhood and adolescence and will take lessons learned from this feasibility pilot in terms of recruitment strategies, study design, and protocol implementation.

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