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Identification of Modifiable Social and Behavioral Factors Associated With Childhood Cognitive Performance

Educational Objective To identify modifiable factors associated with childhood cognitive performance.
1 Credit CME
Key Points

Question  Are specific exposures associated with childhood cognitive performance and are inequities in these exposures associated with racial disparities in cognitive test scores?

Findings  In this cohort study of 1055 mother-child dyads, 24 of 155 prenatal and postnatal exposures were associated with childhood cognitive performance; models that included all of the exposures fully accounted for the racial disparities in cognitive test scores. Modifiable exposures included breastfeeding, parental educational levels, fostering of cognitive growth during mother-child interactions, parenting stress, and maternal reading ability, which together were associated with 0.5% of a standard deviation difference in cognitive test scores.

Meaning  The study’s results indicated that addressing inequities in the early environment could help to reduce racial disparities in childhood cognitive performance.


Importance  Inequities in social environments are likely associated with a large portion of racial disparities in childhood cognitive performance. Identification of the specific exposures associated with cognitive development is needed to inform prevention efforts.

Objective  To identify modifiable factors associated with childhood cognitive performance.

Design, Setting, and Participants  This longitudinal pregnancy cohort study included 1503 mother-child dyads who were enrolled in the University of Tennessee Health Science Center–Conditions Affecting Neurodevelopment and Learning in Early Life study between December 1, 2006, and July 31, 2011, and assessed annually until the children were aged 4 to 6 years. The analytic sample comprised 1055 mother-child dyads. A total of 155 prenatal, perinatal, and postnatal exposures were included to evaluate environment-wide associations. Participants comprised a community-based sample of pregnant women who were recruited between 16 weeks and 28 weeks of gestation from 4 hospitals in Shelby County, Tennessee. Women with high-risk pregnancies were excluded. Data were analyzed from June 1, 2018, to April 15, 2019.

Exposures  Individual and neighborhood socioeconomic position, family structure, maternal mental health, nutrition, delivery complications, birth outcomes, and parenting behaviors.

Main Outcomes and Measures  Child’s full-scale IQ measured by the Stanford-Binet Intelligence Scales, Fifth Edition, at age 4 to 6 years.

Results  Of 1055 children included in the analytic sample, 532 (50.4%) were female. Among mothers, the mean (SD) age was 26.0 (5.6) years; 676 mothers (64.1%) were Black, and 623 mothers (59.0%) had an educational level of high school or less. Twenty-four factors were retained in the least absolute shrinkage and selection operator regression analysis and full models adjusted for potential confounding. Associations were noted between child cognitive performance and parental education and breastfeeding; for each increase of 1.0 SD in exposure, positive associations were found with cognitive growth fostering from observed parent-child interactions (β = 1.12; 95% CI, 0.24-2.00) and maternal reading ability (β = 1.42; 95% CI, 0.16-2.68), and negative associations were found with parenting stress (β = −1.04; 95% CI, −1.86 to −0.21). A moderate increase in these beneficial exposures was associated with a notable improvement in estimated cognitive test scores using marginal means (0.5% of an SD). Black children experienced fewer beneficial cognitive performance exposures; in a model including all 24 exposures and covariates, no racial disparity was observed in cognitive performance (95% CIs for race included the null).

Conclusions and Relevance  The prospective analysis identified multiple beneficial and modifiable cognitive performance exposures that were associated with mean differences in cognitive performance by race. The findings from this observational study may help guide experimental studies focused on reducing racial disparities in childhood cognitive performance.

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Article Information

Accepted for Publication: June 2, 2020.

Corresponding Author: Kaja Z. LeWinn, ScD, MS, Weill Institute for Neurosciences, Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave, San Francisco, CA 94143 (kaja.lewinn@ucsf.edu).

Published Online: September 21, 2020. doi:10.1001/jamapediatrics.2020.2904

Author Contributions: Dr LeWinn and Ms Batra had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: LeWinn, Bush, Tylavsky, Rehkopf.

Acquisition, analysis, or interpretation of data: LeWinn, Bush, Batra, Tylavsky.

Drafting of the manuscript: LeWinn, Batra, Rehkopf.

Critical revision of the manuscript for important intellectual content: LeWinn, Bush, Tylavsky, Rehkopf.

Statistical analysis: LeWinn, Batra.

Obtained funding: LeWinn, Bush, Tylavsky.

Administrative, technical, or material support: LeWinn, Bush, Tylavsky.

Supervision: LeWinn, Rehkopf.

Conflict of Interest Disclosures: Dr LeWinn reported receiving grants from the Urban Child Institute during the conduct of the study. Dr Bush reported receiving grants from the University of California, San Francisco, and the Urban Child Institute during the conduct of the study. Dr Tylavsky reported receiving grants from the National Institutes of Health and the Urban Child Institute and during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by the Urban Child Institute in Memphis, Tennessee (Drs LeWinn, Bush, and Tylavsky); the Urban Child Institute also funded the Conditions Affecting Neurodevelopment and Learning in Early Life (CANDLE) study.

Role of the Funder/Sponsor: The Urban Child Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Robert Davis, MD, of the Center for Biomedical Informatics, University of Tennessee Health Science Center, and Nancy Adler, MD, of the Center for Health and Community, University of California, San Francisco, provided insightful comments and suggestions that greatly improved our manuscript. Neither contributor received compensation. We are grateful for the participation of families enrolled in the Conditions Affecting Neurodevelopment and Learning in Early Life (CANDLE), as well as the dedication of CANDLE research staff and investigators.

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