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Biennial Report of the Director
National Institutes of Health Fiscal Years 2006 & 2007



Summary of Research Activities by Disease Categories

Life Stages, Human Development, and Rehabilitation

In 1961, Dr. Robert Guthrie, a pediatrician and microbiologist, developed a simple test, using a “heel-stick” drop of blood, to detect phenylketonuria (PKU) in newborn infants. This rare, inherited disease interferes with the body’s capacity to metabolize protein. Unless treated almost immediately with a special diet, PKU progressively derails a child’s intellectual development. Children with untreated PKU may appear healthy as newborns, but by age 3 to 6 months, they begin to lose interest in their surroundings, and by 1 year of age, their intellectual function is irreversibly impaired. Dr. Guthrie’s discovery has allowed for rapid, inexpensive screening of all infants at birth. Those identified with PKU can be started on the preventive diet and escape the disorder’s permanent damaging effects. Building on Dr. Guthrie’s discovery, NIH-supported scientists developed an additional newborn screening test, this time for congenital hypothyroidism. Like PKU, this condition may not be apparent at birth, but unless simple preventive treatment begins almost immediately in affected infants, irreversible damage to the developing brain occurs within months. All states now mandate newborn PKU and hypothyroidism screening, and the developmental disability associated with these two disorders has all but disappeared in the United States.

Introduction
From before conception through old age, complex biological processes interacting with physical and psychosocial factors in an environment determine health and functioning at any given life stage and provide the foundation of the next stage. NIH research in this area encompasses the formation and development of cells, tissues, organs and organ systems, as well as the physical, cognitive, and behavioral characteristics of the child, adolescent, and adult in his or her environment. Although developmental processes proceed most rapidly in gestation and the early years of childhood, they continue throughout the course of life.

This area of research includes studies of normative processes of growth, maturation, and aging. Understanding “what goes right” developmentally at each life stage is critical to discovering how to protect and enhance human health and functioning. Knowledge from such normative research also is essential to understanding the role of developmental vulnerabilities in the origins, expression, prevention, and treatment of illness and injury. For example, understanding the normal brain immaturity of adolescents is essential to understanding aberrant behaviors of youth and developing interventions that will work for them. Similarly, understanding normal, progressive maturation and functional decline in relation to disease processes is key to discovering better interventions to extend healthy active years of life. At all life stages, normative data on physical and psychosocial development are critical to designing effective rehabilitative interventions.

Individuals may experience underdeveloped, lost, damaged, or deteriorated function during any of the life stages. Medical rehabilitation research is the study of physiologic mechanisms, methods of treatment, and devices that serve to improve, restore, or replace these functions. This research includes translating new knowledge into medical, behavioral, psychological, social, and technological interventions to optimize impaired functioning. A key aspect of medical rehabilitation research is its focus on the effects of functional impairment on the whole person, rather than on a single organ system. Thus, it views the person in the context of a system of interacting variables, including psychosocial, organic, and environmental.

By necessity, the scope of NIH research on life stages, human development, and rehabilitation is broad. Dynamic, ongoing interactions among developmental processes and physical and psychosocial environmental factors are implicated in a wide range of disorders and disabilities. Research in this area includes basic, clinical, epidemiological, and translational studies of normative processes and of many chronic diseases such as cancer, obesity, osteoporosis, and cardiovascular and metabolic disorders. Also included is research on mental illness, addiction, and cognitive disabilities such as intellectual disability, autism, and Alzheimer's disease. Whereas the section “Chronic Diseases and Organ Systems” in this report addresses these conditions generally, this section focuses on life stage and developmental dimensions of chronic and other conditions and on rehabilitative interventions.

NIH Institutes dedicated to specific disorders and organ systems incorporate life stages and developmental perspectives into their research initiatives and projects. For example, NCI supports research on how cancer risk and therapies may differ in children, adults, and the elderly. Among NIDCR's research priorities are studies of genetic and environmental interactions that may explain disfiguring birth defects of the head, face, and mouth. NINR and NIAAA strategic plans incorporate a life-course approach.

As the Institute with statutory responsibility for child health and human development research, NICHD conducts and supports research programs in reproductive health and the developmental processes that begin before conception and continue through gestation, birth, infancy, childhood, and adolescence. As the Institute charged with research on aging, NIA conducts and supports research on both the maintenance and loss of functions during the aging process, diseases associated with aging, and the problems and needs of older individuals and their caregivers. NINR conducts research focused on establishing a scientific basis for patient care across all life stages and is designated the lead NIH Institute for end-of-life research. NIEHS focuses on the influences of environmental agents on the development and progression of human disease.

Mission-specific rehabilitation research is supported by 18 Institutes, including NIA, NIBIB, NICHD, NIDCR, and NINDS. A focal point for this area is the National Center on Medical Rehabilitation Research, within NICHD, which emphasizes the rehabilitation and lifelong care of people with physical disabilities resulting from injury, stroke, and other disorders.

Burden of Illness and Related Health Statistics

Because of the wide range of disorders studied in NIH life stages, human development, and rehabilitation research, data on the health and economic costs of specific conditions are presented throughout this report. This section presents selected examples of general data on lifetime burdens of illness and on burdens at the beginning and later stages of life.

Lifetime Burden
From birth to death, per-person health care costs in the United States have been estimated to average $316,579 in 2000 dollars. Of this total, an estimated 7.8 percent of health care costs accrue from birth to age 20, 12.5 percent between ages 20 and 39, 31.0 percent between ages 40 and 64, and 48.6 percent, or almost half of all lifetime health care expenditures, after age 65.80 Between 1992 and 1996, 22 percent of all medical expenditures for the period after age 65 occurred in the last year of life.81 Although rates of self-reported disability in people age 65 and older have been declining in recent years, any cost savings from this trend may be offset by the burgeoning growth of this population as a proportion of U.S. residents.82 Between 2000 and 2050, the proportion of this older population is expected to increase from 5.9 percent to 11.6 percent of U.S. residents.

Early Origins of Disease and Disability
Preterm birth and the associated problem of low birth weight signal the potential for significant developmental problems that may originate in the prenatal period, or even before, as a result of a family's genetic makeup and its environmental exposures.83 Preliminary data indicate that in 2004-2005, 12.7 percent of U.S. births were preterm, a rate that has risen 20 percent since 1990. Infants born with low birth weight in 2005 comprised 8.2 percent of births, an increase of more than 20 percent since the mid-1980s.84

Although medical advances and supportive environments enable increasing numbers of preterm infants to survive and to “catch up” developmentally in childhood, the health and economic burdens associated with these births begin immediately and may last a lifetime. In 2001, costs for preterm, low-birth-weight hospital admissions were $5.8 billion in the United States, or 47 percent of the costs of all hospital stays of infants.85 Preterm birth accounts for one of five children with intellectual disability, one of three children with vision impairment, and almost half of children with cerebral palsy. For an individual with intellectual disability, lifetime costs of medical care, special education, residential care, lost wages, and other associated expenditures are estimated to be $1,014,000 in 2003 dollars.86

Later Emergence of Disease and Disability
Aging comprises a set of dynamic biological, physiological, and psychosocial processes and systems that are interactive and independent and that result in wide variations in health outcomes and functioning. For some individuals, sensory, cognitive, and physical capacities continue at remarkably high levels for decades. For others, increasing age is accompanied by a significant, progressive decline in almost all physiological functions and a significantly increased risk of age-related chronic diseases and disability. Recent estimates indicate that approximately 80 percent of all individuals in the United States who are 65 years or older have at least one chronic condition, and 50 percent have at least two.87

The marked variability among older adults in aging processes and disease burden may be explained in part by risks incurred in earlier decades. For example, periods of rapid tissue growth in gestation, early childhood, adolescence, and during pregnancy may be periods of heightened risk to later-emerging cancers.88 Low birth weight is related to increased risk in adults for cardiovascular disease, such as myocardial infarction, stroke, and hypertension.89 Maternal diabetes during pregnancy may increase the risk of diabetes and obesity in offspring.90 Prenatal influences also may increase risks of osteoporosis91 and Alzheimer's disease.92 In each case, discovering effective interventions at early stages in life could contribute to lower burdens of disease and disability associated with aging.

NIH Funding for Life Stages, Human Development, and Rehabilitation Research

In FYs 2006 and 2007, NIH funding for rehabilitation research was $324 million and $344 million respectively. Currently, NIH does not collect trans-NIH funding data on the category of life stages and human development research. The table at the end of this chapter indicates some of the research areas involved in this investment (see “Estimates of Funding for Various Diseases, Conditions, and Research Areas”).

Summary of NIH Activities
The goal of life stages, human development, and rehabilitation research is to enable people to achieve a full lifespan with the best health and function at every life stage. Understanding complex developmental pathways to health or illness throughout life is critical to creating new ways to prevent disease and disability before they become symptomatic—or even preempting the disease process before it starts. Developmental stages also are an important consideration in rehabilitation research. For example, differences between age groups such as physical size, physiological processes, psychosocial trajectories, and expected lifespan must be taken into account in planning rehabilitation for an individual. A central goal of research is to provide the scientific evidence needed to support developmentally appropriate rehabilitation plans.

The fundamental concepts of developmental science, such as “developmental windows,” can be brought to bear whether a research project focuses primarily on normative development, multiple life stages, a specific life stage, or rehabilitation. These “windows” are periods in the life of a cell, a fetus, a child, or an adult when the normal processes of growth and maturation may be more sensitive to the effects of external factors, often referred to as “environmental influences.” Because human development progresses in a multifaceted environment, scientists study a wide range of external factors that could have adverse or protective effects on human health and functioning. This research might examine the effects of physical agents such as, for example, diet, exercise, pesticides, industrial chemicals, or mold. But it also might investigate the influences on health and development of factors such as parenting styles, family structure, education, community social norms and economic status, and/or intergenerational influences.

Normative Research

Scientists' efforts to identify and understand interactions among developmental processes and external factors are being accelerated by powerful new technologies. For example, advanced imaging technologies are being used to create a robust database of normal brain development during childhood and adolescence. The resulting data will enable scientists to better understand the atypical developmental processes associated with autism, intellectual disability, and other developmental disorders. Novel analytic techniques developed in genomics research have created new research opportunities in the emerging field of epigenetics. This new field builds on discoveries that the timing of gene functions—the “on” and “off” switches that control myriad biological processes—can be altered without changing the structural DNA “coding” of a gene. The health effects of these subtle and potentially reversible alterations may be transient or may persist and even be passed down from parent to child. One new NIH initiative in developmental epigenetics focuses on alterations in gene expression that may occur spontaneously or in response to environmental exposures well before birth. Multiple initiatives, comprising a Roadmap Epigenomics Initiative, are intended to develop comprehensive reference maps of the epigenome and to develop new analytic technologies.

In other normative research, a long-term study of women before, during, and after menopause is designed to improve understanding of the health effects, psychosocial influences, and subsequent health consequences of this major life stage for women. Extended studies of older populations are enabling scientists to disentangle the effects of disease from the normal aging process.

Discoveries by NIH-supported scientists conducting normative research have enabled them to preempt the development of cleft palates in experimental mice that were bred to manifest this disabling defect. Having identified a protein that influences the development of certain undifferentiated cells in the embryo, scientists then identified the critical point in normal embryonic development of the palate, or roof of the mouth. They subsequently manipulated the protein at that point in development to reverse the initiation of the clefting process in the mice.

Multistage Research

NIH research encompassing multiple developmental or life stages seeks to understand what factors early in life may contribute to health or to health risks in later life (see also the section “Epidemiological and Longitudinal Studies” in Chapter 3). This conceptual model builds on seminal “life course” studies that found clues to the origins of adult chronic diseases in the earliest period of human life-gestation. The first life course studies linked the risk of heart disease, stroke, hypertension, and diabetes in adults to adaptation of the fetus to inadequate nutrient supply in utero.93

NIH research examples in this section illustrate how the life-course research model has expanded to include a greater number of developmental stages and a wider array of potentially influential environmental factors. For example, the National Children's Study (NCS) is designed to enroll women who intend to become pregnant and to follow their pregnancies and then their children from birth to age 21. Investigators will use multiple techniques to examine many aspects of the children's lives over time—from family genetics, to the constructed environment of neighborhoods and schools, to chemical exposures linked to the atmosphere, food, and water supplies. The overall NCS goal is to understand the relationships among multiple exposures and multiple health outcomes. NIH also is collaborating with the Norwegian National Public Health Institute in a long-term prospective cohort study of pregnant women and their children, in which a variety of exposure and health variables will be investigated.

Other studies encompassing more than one life or developmental stage investigate specific factors and/or specific health outcomes. For example, investigators within a consortium of NIH-supported research centers study a range of prenatal to adult environmental exposures that may predispose a woman to breast cancer. NIH-supported scientists use longitudinal studies, imaging and genetics tools, and animal studies to examine the contribution of in utero drug exposure to emotional and cognitive development and to vulnerability to later substance abuse and other mental disorders. Research on the long-term safety of fetal and infant exposure to anti-HIV (antiretroviral) drugs, administered to prevent HIV transmission from an infected woman to her child, is one of numerous NIH research efforts in HIV/AIDS. Cohorts of long-term cancer survivors, including those treated in childhood and at other life stages, are being followed to identify the health and developmental effects of cancer drugs and radiation treatments. Known adverse effects include damage to heart muscles; neurocognitive problems; reproductive health problems, including infertility; pain; and second malignancies, as well as anxiety and depression, discrimination in employment and insurance, and general quality of life. This “survivorship” research ultimately seeks to optimize physiological, psychosocial, and functional outcomes for cancer survivors and their families.

Stage-Specific Research

NIH research that focuses on a single life stage seeks to understand the developmental vulnerabilities of that stage and their implications for risk of disease or disability and for effective interventions. For example, sensitivity of the rapidly developing fetus and the newborn to a variety of inborn and external risk factors is the subject of extensive NIH-supported research efforts. Included in this research are ongoing research programs on stillbirth, preterm birth, SIDS, fetal alcohol syndrome, and birth defects. In one study, scientists found that preterm infants could go home earlier from neonatal intensive care units if their parents received an educational and behavioral intervention that began shortly after their child's admission to the unit and continued after the child went home. During the intervention, fathers as well as mothers learned about the appearance and characteristics of preterm infants and how best to parent their child. This research also found that the intervention lessened mothers' anxiety, depression, and overall parenting stress and increased fathers' involvement in infant care.

School-age children are an important research population because habits that can protect an individual's health, or increase his or her risk of later disease or disability, may be established in this developmental period. Examples of this research include testing a middle-school intervention to lower the risk of developing type 2 diabetes in children as they approach adolescence. Once considered an “adult” disease, type 2 diabetes increasingly is seen in children as rates of pediatric obesity continue to rise. To investigate the potential of the school environment to promote the adoption of long-term healthy behaviors, the experimental program is testing the effects of offering healthier food choices in school cafeterias and vending machines, lengthening and intensifying periods of physical activity, and deploying communication campaigns. In another example, scientists have developed a large body of evidence about how children learn to read and are now investigating differences in how children learn math and science. Research into learning processes for children both with and without learning disabilities permits the development of evidence-based teaching methods so that children with a range of abilities can learn these critical subjects. Major developmental disabilities in children, including intellectual disability and autism, also are the subject of ongoing research.

Adolescence, the developmental period in which the immature brain and teenage social contexts may explain risk-taking behaviors, is another focal point of life stages and human development research. Carefully designed studies on teen and college-age substance-abusing behaviors and teen driving are providing the scientific basis for new interventions. Studies of the unique challenges in clinical management of youth with HIV or at risk of infection, and of pharmacological therapies for young people with depression and suicide risk, are yielding important guidance for clinicians. Models for delivering needed services to youth with mental illness as they transition to adulthood are being tested.

Another significant area of stage-specific research encompasses the period in which couples start families. Reproductive health research includes expanding fundamental knowledge of processes that underlie human reproduction, investigating ways to alleviate human infertility, and developing and testing new contraceptive options for men and women. Basic, clinical, and translational studies aim to increase understanding of normal reproduction and reproductive pathophysiology and to develop more effective strategies for diagnosing, treating, and preventing conditions that compromise reproductive health. To advance research in this area, the NIH sponsors training programs for reproductive health researchers, including obstetricians and gynecologists.

As individuals age, interactions among normal aging processes and risks acquired early in life and/or cumulatively over the course of life may heighten their vulnerability to disease and disability. For example, many conditions that emerge or worsen in aging individuals are characterized by inflammation, which leads over time to changes in cell tissue and organ structure and function. These changes may contribute to frailty, independent of overt disease, and also may increase susceptibility to, and rate of progression in, chronic diseases. NIH-supported projects include studies of vascular inflammation and neurotoxicity in the aging brain and inflammatory response to loss of sleep. The breadth of NIH research in aging processes is illustrated by an initiative on the psychological mechanisms that guide economic decisions of older people and the underlying neurobiological pathways of their economic behaviors. End-of-life studies focusing on enhancing communications among individuals, families, and clinicians and on measuring care outcomes are intended to enable those involved to better manage this experience. An NIH state-of-the-science conference on end-of-life care and publication of conference proceedings were designed to survey and assess recent advances and to chart additional new directions for this area of research.

Rehabilitation Research

Rehabilitative interventions to enable individuals to gain or recover functions lost to illness or injury may be needed at any life stage. Research in this area recognizes the need for specialized approaches for infants and children at the beginning of the developmental span, for mature adults, and for older people experiencing cumulative effects of normal aging processes and chronic disease. For example, the decline in disability among older people raises questions of whether and how this trend can be maintained or even accelerated. Enabling older people to maintain their health and independence for as long as possible is a major goal of NIH-supported rehabilitation research. Among efforts to reach that goal are projects that are developing and testing exercise and motor-learning interventions for adults who have experienced stroke, hip fracture, and other chronic debilitating diseases and conditions. An important priority in this research is translating findings from the clinical research setting into effective and accessible rehabilitative programs based in communities.

In other rehabilitation research, NIH-supported scientists are applying the newest technology to hasten recovery from and lessen disabling effects of disease and injury. Multiple research projects are focused on novel technologies to supplement or restore lost nervous system functions. Examples include studies to develop devices designed to restore the capacity of people with spinal cord injuries to stand and to control bowel and bladder function. Scientists also are investigating technologies to control seizures as well as brain-machine interfaces to allow persons with paralysis to control devices directly with their brains. To improve rehabilitation for upper-limb paralysis, NIH is supporting the development of robotic exoskeletons that could ultimately provide therapies for stroke patients in their homes and elsewhere. To expand the mobility of soldiers and others who have lost limbs to injury, NIH-funded research includes studies of a new “intelligent” artificial knee joint. Investigators also are developing ways to implant an artificial limb directly onto the bone of a residual limb, eliminating the need for irritation- and infection-prone socket devices. Even more technologically advanced options for replacing irretrievably injured body parts may one day result from pioneering research in tissue regeneration.

Notable Examples of NIH Activity
Key for Bulleted Items:
E = Supported through Extramural research
I = Supported through Intramural research
O = Other (e.g., (policy, planning, and communication)
COE = Supported through a congressionally mandated Center of Excellence program
GPRA Goal = Concerns progress tracked under the Government Performance and Results Act

Normative Research

Developmental Epigenetics: This rapidly evolving area of research examines how nonstructural changes in gene expression during normal developmental processes can influence health outcomes across the generations. NIH is expanding its research in this area to help scientists learn how typical epigenetic changes and variations occur at the molecular level, starting well before birth. Understanding these epigenetic changes—how they are inherited and passed on to subsequent generations and what factors influence them—could hold the scientific key to understanding and modifying certain factors that lead to a number of diseases or conditions, from obesity to heart disease.
  • This example also appears in Chapter 3: Molecular Biology and Basic Sciences.
  • (I) (NICHD)
Researchers Report Chemical Rescue of Cleft Palate in Mice: A growing understanding of the multiple roles played by the enzyme GSK3 has enabled scientists to realize that this protein molecule has a role in determining the developmental fates of certain undifferentiated cells in the embryo. A few years ago, this realization led a team of scientists to develop a technique that prompts small molecules directly to turn GSK3 on and/or off with a high degree of precision at different stages of fetal development. In the March 1 issue of the journal Nature, NIH-supported scientists and their colleagues reported using this on-off technique to determine the critical developmental period of the palate, or roof of the mouth, in mice. Remarkably, the researchers showed that, by turning GSK3 back on in pregnant mice during this key developmental window, their embryos in most cases corrected their developing cleft palates. As they reported, five out of nine mouse pups had complete reversal of the developing cleft, and another newborn had a partial rescue of the cleft. As the authors noted, “New approaches to rescuing selected developmental defects require detailed knowledge of timing and levels of protein expression; our studies provide an improved method for defining these experimental conditions in vivo.” MRI Study of Normal Brain Development: Understanding healthy brain development is essential to finding the causes of many childhood disorders, including those related to intellectual and developmental disabilities, mental illness, drug abuse, and pediatric neurological diseases. NIH is creating the Nation's first database of MRI measurements and analytical tools, as well as clinical and behavioral data, to understand normal brain development in approximately 500 children from across the Nation. This large-scale longitudinal study uses several state-of-the-art brain imaging technologies. The data will be disseminated as a Web-based, user-friendly resource to the scientific community. Study of Normal Brain Development: The NIH Intramural Research Program is conducting studies to explore brain development with MRI in healthy children and adolescents. Recent studies have addressed differences in brain structure related to risk for Alzheimer's disease and sex differences in brain development trajectories. National Longitudinal Study of Adolescent Health (Add Health): Several NIH Institutes are supporting this study, which integrates biomedical, behavioral, and social science data to discover the pathways that lead to health and/or disease in adulthood. The NIH initially funded Add Health in 1994 as a social science study of the causes of adolescent health problems and health-related behaviors. As the cohort of adolescents has moved into early adulthood, the study's focus has shifted to the environmental, behavioral, and biological pathways that lead to the development of adult chronic disease. The study initially incorporated measurements of social environments—peer groups, families, schools, and neighborhoods—that could affect health and also incorporated a sibling-pair design that facilitated quantitative genetic studies. Most recently, in collaboration with other Federal offices, NIH funded a new wave of interviews that will include the collection of genetic data and biological markers of disease processes, as well as basic social, individual, and behavioral data. The new design was developed by a collaborative team representing the fields of epidemiology, cardiology, psychology, sociology, behavioral genetics, nutrition, biostatistics, anthropology, medicine, molecular virology, statistics, and survey research. Study of Women's Health Across the Nation (SWAN): The goal of SWAN is to characterize the biological processes, health effects, psychosocial influences, and sequelae of the pre- to peri- to postmenopausal transition in ethnically diverse cohorts. Now in its 14th year, SWAN involves seven clinical field sites supported by a central reproductive hormone laboratory, a coordinating center, an advisory panel, and a repository of blood, urine, and DNA specimens. Used in numerous studies, SWAN data have resulted in important findings. For example, changes in bone density occur from premenopause through late perimenopause; premenopausal women have a significantly lower prevalence of forgetfulness than do women at later menopausal stages; and a high body mass index (BMI) is not only associated with insulin resistance, which dramatically increases the risk of cardiovascular disease, but also with different menopausal hormonal patterns relative to normal BMI.
  • (E) (NIA, NINR, NCCAM, NICHD, NIMH, ORWH)
Baltimore Longitudinal Study of Aging (BLSA): In 2008, NIA will celebrate the 50th anniversary of the BLSA, America's longest-running scientific study of human aging. More than 1,400 men and women ranging in age from the 20s to the 90s have been study volunteers. The BLSA has generated significant findings to elucidate the normal course of aging and disentangle the effects of disease from the normal aging process. Health and Retirement Study (HRS): The HRS is the leading source of combined data on the health and financial circumstances of Americans over age 50 and is a valuable resource to follow and predict trends and help inform policies for an aging America. Now in its 14th year, the study follows more than 20,000 people at 2-year intervals and provides researchers with an invaluable, growing body of multidisciplinary data on the older Americans' physical and mental health, insurance coverage, finances, family support systems, work status, and retirement planning. Managed under a cooperative agreement between NIH and the University of Michigan, the study was expanded in 2006 to include additional key constructs in cognitive aging. A substudy will provide the first estimates of cognitive impairment and dementia based on nationally representative data and validation of survey measures. HRS staff will also assemble information on sample and questionnaire design, computer-assisted interview programming, interviewer performance, and data dissemination to improve the quality of data collected and provide an incentive for international partners to follow a harmonized design that will maximize the potential for cross-national behavioral and social research on aging.

Life Stages Research

The National Children's Study (NCS): The NCS promises to be one of the richest information resources available for answering questions related to children's health and development and will form the basis of child health guidance, interventions, and policy for generations to come. The landmark study will examine the effects of environmental influences on the health and development of more than 100,000 children across the United States, following them from before birth until age 21. This extensive research effort will examine factors ranging from those in the natural and manmade environment to basic biological, genetic, social, and cultural influences. By studying children through their different phases of growth and development, researchers will be better able to understand the role of these factors in both health and disease. Specifically, NCS will identify factors underlying conditions ranging from prematurity to developmental disabilities, asthma, autism, obesity, and more. The study is led by a consortium of Federal agencies, including NICHD and NIEHS, CDC, and the Environmental Protection Agency. Environmental Health of Mothers and Babies: the Norwegian Mother and Child Cohort Study: NIH is participating in the Norwegian Mother and Child Cohort Study, which provides a valuable opportunity to assess the role of environmental exposures in the health of women and their children. The Norwegian Mother and Child Cohort Study, or MoBa, (den norske Mor and barn-undersØkelsen) is an ongoing, long-term, prospective cohort study of 100,000 pregnant Norwegian women and their children. In collaboration with the Norwegian National Public Health Institute (NIPH), NIH is supporting the collection of additional biologic specimens from the pregnant women. These specimens will be used for the measurement of environmental exposures. A variety of exposure and health variables on babies, mothers, and fathers are collected. Records from the cohort study will also be linked to routine national health registries. The Role of Development in Drug Abuse Vulnerability: NIH supports a number of longitudinal studies at various stages of development, following cohorts over extended time frames. Information is gathered on children's cognitive and emotional development, as well as their vulnerability to addiction later in life. These studies have been critical to estimate, for example, the contribution of in utero drug exposure on emotional and cognitive development, vulnerability to substance abuse, and other mental disorders. This knowledge, together with animal studies that provide complementary and validating information while minimizing the confounding factors that are likely to play a role in prenatal effects of drug exposure in humans, will help us to mitigate the deleterious impact of substance abuse on the developing fetus. With regard to later developmental stages, the application of modern brain imaging technologies has generated unprecedented structural and functional views of the dynamic changes occurring in the developing brain (from childhood to early adulthood). The discovery of these changes has been critical to understanding the role of brain development in decision-making processes and responses to stimuli, including early exposure to drugs. Such studies have suggested, for example, that an unbalanced communication between volitional control and emotional circuits may explain some of the impulsive reactions typical of adolescents, who tend to engage in risky behaviors and are at heightened risk for developing addictions. Collectively, these longitudinal studies, using new imaging and genetics tools, promise a greatly enhanced ability to interpret the effects of myriad environmental variables (e.g., quality of parenting, drug exposure, socioeconomic status, and neighborhood characteristics) on brain development and behavior. Transdisciplinary Tobacco Use Research Centers: Multiple Institutes at NIH are co-funding seven collaborative, transdisciplinary centers to identify familial, early childhood, and lifetime psychosocial pathways related to smoking initiation, use, cessation, and patterns of dependence. Research on genetics of addiction, physiological biomarkers, and the use of advanced imaging techniques can lead to individualized and community approaches for tobacco prevention and treatment. This model demonstrates the feasibility and benefits of scientific collaboration across disciplines and public-private partnerships. The Centers for Transdisciplinary Research on Energetics and Cancer (TREC):These centers foster collaboration among transdisciplinary teams of scientists to accelerate progress toward reducing cancer incidence, morbidity, and mortality associated with obesity, low physical activity, and poor diet. The biology and genetics of the many factors that influence diet, physical activity, and obesity across the stages of life are applied to behavioral, sociocultural, and environmental factors, and transdisciplinary training opportunities are provided for scientists. The TREC initiative is interfacing with a number of established NCI initiatives in the area of diet, physical activity, and weight and is integrated with the NIH Obesity Research Task Force Strategic Plan. HIV/AIDS Epidemiological and Long-Term Cohort Studies, Cohorts, and Networks: NIH supports epidemiological HIV research through a wide range of studies, cohorts, and networks that contributes to our understanding of risk factors that lead to HIV transmission and disease progression. Established in 2005, the International Epidemiologic Databases to Evaluate AIDS (IeDEA) compiles data from NIH-funded international HIV research to answer population-level questions about HIV variants and resistance, HIV pathogenesis in different settings, success of antiretroviral therapy, treatment history of HIV in different populations, success of prevention strategies, and vaccines. The Pediatric HIV/AIDS Cohort Study (PHACS) network, established in 2005, addresses two critical pediatric HIV research questions: (1) the long-term safety of fetal and infant exposure to prophylactic antiretroviral chemotherapy and (2) the effects of perinatally acquired HIV infection in adolescents. The Women's Interagency HIV Study (WIHS) and the Multicenter AIDS Cohort Study (MACS) are the two largest observational studies of HIV/AIDS in women and homosexual or bisexual men, respectively, in the United States. These studies exceed the scope of clinical care diagnostics and laboratory analysis on both HIV-infected and, importantly, HIV-negative controls, which allows for novel research on HIV spread, how the disease progresses, and how it can best be treated. The groups focus on contemporary questions such as the interactions among HIV infection, aging, and long-term treatment; cardiovascular disease; and host genetics and its influence on susceptibility to infection, disease progression, and response to therapy. Childhood Cancer Survivors Study (CCSS): Although survival rates from childhood cancers are encouraging, researchers have found that these young survivors may particularly suffer from the late effects of treatment. In 2006, CCSS researchers documented serious long-term health issues in adults after radiation for childhood cancers. These findings will change treatment regimen guidelines for current childhood cancers and also have implications for individuals from the study who are now adults. The Children's Oncology Group (COG) has prepared a resource for physicians, “Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers.” Long-Term Cancer Survivors Research Initiatives: The population of cancer patients surviving more than 5 years continues to grow across life stages, from children through senior adults. These research initiatives focus on the physiological and psychosocial effects of treatment and medical interventions to promote positive outcomes in survivors and their families. Important early findings suggest long latencies for treatment-related effects, highlighting the need for extended follow up, early identification, and intervention before complications become more serious. Implications include the length and quality of survival and the ongoing burden of illness and costs. Developmental Windows of Vulnerability to Environmental Exposures: The Breast Cancer and Environment Research Centers supported by NIH function as a consortium to study the impact of prenatal to adult environmental exposures that may predispose a woman to breast cancer. The centers bring together basic scientists, epidemiologists, research translational units, and community advocates within and across the centers to investigate mammary gland development in animals and young girls to determine vulnerability to environmental agents that may influence breast cancer development in adulthood. The overall goals of the BCERC are to develop public health messages to educate young girls and women who are at high risk of breast cancer about the role of specific environmental stressors in breast cancer and how to reduce exposures to those stressors. These public health messages will be based on the integration of basic biological, toxicological, and epidemiological data.
  • For more information, see https://www.bcerc.org
  • This example also appears in Chapter 2: Cancer.
  • (E) (NIEHS, NCI)
Population Research: Given the Nation's increasing diversity and changing demographics, it is critical to understand how trends in areas such as immigration, fertility, marriage patterns, and family formation affect the well-being of children and families. NIH research in these areas allows policymakers and program planners to better address public health needs. For instance:
  • The Fragile Families and Child Well-Being Study follows children born to unmarried parents to assess how economic resources, father involvement, and parenting practices affect children's development.

  • The New Immigrant Survey follows the first nationally representative sample of legal immigrants to the United States, providing accurate data on legal immigrants' employment, lifestyles, health, and schooling before and after entering the country.

  • The National Longitudinal Survey of Youth (1979 cohort) continues to assess the work, educational, and family experiences of a nationally representative cohort of young men and women who were 14-22 years old when they were first studied in 1979. T he study also follows children born to female participants up through age 20, creating the opportunity to study intergenerational influences on child development, health behaviors, and educational attainment.
Brain Disorders in the Developing World: Research Across the Lifespan: Brain disorders are the leading contributor to years lived with disability in all regions of the world, with the exception of sub-Saharan Africa. This program boosts research in the developing world on childhood disorders such as cerebral palsy and epilepsy, on mental illnesses such as depression and schizophrenia, and on degenerative disorders such as stroke and Alzheimer's disease. Under this program, U.S. investigators and their foreign collaborators are studying the neurocognitive consequences of HIV/AIDS, the relationship between zinc nutrition and brain development, and the neurological disorders stemming from treatable infectious causes, such as cerebral malaria, cisticercosis, TB, and bacterial sepsis. Nonalcoholic Steatohepatitis (NASH) Clinical Research Network: NASH is strongly associated with obesity and type 2 diabetes, conditions that have increased dramatically in recent decades. Network research addresses GPRA Goal SRO-4.3. The Network is conducting a randomized clinical trial to evaluate the safety and efficacy of the insulin-sensitizing drug pioglitazone or vitamin E compared with placebo for the treatment of nondiabetic adults with NASH. Also, in a separate trial in children, the network is comparing the insulin-sensitizing drug metformin, vitamin E, and placebo in treating nonalcoholic fatty liver disease. Acute Liver Failure Study Groups: The adult and pediatric Acute Liver Failure Study Groups address the problem of acute liver failure due to drugs or other factors. The Groups' research has provided knowledge and tools for managing the clinical and public health burden of acute liver failure. In 2002, the adult study group highlighted a dramatic increase in liver injury due to the over-the-counter pain reliever acetaminophen. The groups then developed a serum-based assay to detect acetaminophen-induced acute liver failure in adults and children. Current studies are testing potential therapies to improve survival in patients with acute liver failure. Comprehensive Assessment of Long-Term Effects of Reducing Intake of Energy (CALERIE): A large body of research in animals indicates that substantially reducing caloric intake while maintaining optimal nutrition results in significant increase in lifespan. The CALERIE study will help to determine whether these beneficial effects extend to humans. Results from pilot studies demonstrate that overweight people who cut their calories by 25 percent for 6 months have reduced fasting insulin levels and core body temperature, two markers that may be associated with increased longevity in humans. A long-term study began in January 2007.

Stage-Specific Research

Fertility and Infertility: As the CDC has stated, “for many couples who wish to start a family, the dream is not easily realized.” For about 2.1 million married couples who reported not using contraception, the women were still unable to become pregnant after 1 year. NIH supports research to better understand the basic processes underlying human reproduction and to directly alleviate infertility and reproductive disorders. Much of this effort involves translating rapidly emerging laboratory research into clinical applications. Scientists are working to determine how certain gynecological conditions, such as polycystic ovary syndrome and endometriosis, and certain diseases and disorders of the male reproductive system affect fertility. Some evolving and exciting fertility research is applying cryopreservation technology to the freezing of human eggs to preserve fertility in women undergoing cancer treatment. Scientists are also exploring the link between obesity and fertility and assessing the long-term impact of using assistive reproductive technologies.
  • (E) (NICHD, ORWH)
Women's Reproductive Health Research Career Development Program: The ORWH cosponsored with NICHD the funding of 20 institutional career development awards designed to increase the number of obstetricians and gynecologists conducting research in women's health. Pregnancy and Perinatology: NIH continues to support a portfolio of research on high-risk pregnancies and poor pregnancy outcomes, including preterm labor and birth, fetal disorders, SIDS, poor maternal health, and stillbirth. Much of this research is conducted through centers and networks that bring together researchers from different disciplines and allow them to study larger numbers of patients. For example, NIH recently created two research networks on premature birth and on stillbirth. The Genomic and Proteomic Network for Premature Birth Research aims to accelerate research in the area of premature birth by providing researchers with the latest technology and methods. The Stillbirth Collaborative Research Network aims to identify the causes of stillbirth so that new interventions can be developed to prevent these tragic outcomes.
  • (E) (NICHD)
Prenatal Alcohol, SIDS, and Stillbirth (PASS) Research Network: After a 3-year feasibility study, NIH established this multidisciplinary consortium to determine the role of prenatal alcohol exposure and other maternal risk factors in the incidence and etiology of SIDS, stillbirth, and fetal alcohol syndrome, all of which are devastating pregnancy outcomes. The PASS study will follow 12,000 pregnant, high-risk, American Indian and South African women and their infants prospectively until the infants are 12 months old. Maternal, fetal, and infant measures and tissues will be obtained for analysis. Potential Therapy for Children Afflicted with Progeria Syndrome: : Hutchinson-Gilford Progeria Syndrome (HGPS) is a genetic disorder of accelerated aging. In addition to other symptoms of aging, HGPS patients suffer from accelerated cardiovascular disease and often die in their teen or even preteen years from heart-related illnesses. No treatments are currently available for HGPS; however, recent work led by NHGRI researchers indicates that farnesyltransferase inhibitors (FTIs), a class of drugs originally developed to treat cancer by blocking the growth of tumor cells, are capable of reversing the effects of the defective HGPS protein, lamin A. Ongoing studies in a mouse model have validated the results of preliminary experiments, and a clinical trial of FTIs in children with progeria began in 2007. In FY 2008, researchers plan on expanding the study to investigate whether FTIs are capable of reversing the detrimental effects after progression of the cardiovascular anomalies that are seen in the mouse model. The development of biological assays to assess the effects of FTI treatment on the patients' cells is in progress to monitor the potential beneficial effects of the clinical trial. In addition, it has been demonstrated that the progerin protein is present in small amounts in normal aging tissues. The investigation of this phenomenon is being pursued as a contributory factor to the normal aging process. Newborn Screening: Screening and treating newborns for phenylketonuria (PKU) and hypothyroidism have virtually eliminated these conditions as a cause of mental retardation in the United States. A new, trans-NIH collaborative effort will build on this success to develop a new generation of microchips and related technologies that should enable screening programs across the Nation to rapidly test newborns for hundreds of genetic conditions in a single test using one drop of an infant's blood. Complementing the technology development is an initiative to stimulate development of new treatments for such conditions as short chain Acyl CoA dehydrogenase deficiency (SCAD), tyrosinemia, and the genetic causes of hearing loss with the promise of significantly reducing the lifelong health burden of these and other conditions.
  • This example also appears in Chapter 3: Technology Development
  • (E) (NICHD, NIDCD, NIDDK)
Discovering the Causes of Nonsyndromic Cleft Lip and Cleft Palate: For nearly 60 years, NIH has supported scientific investigation of causes and interventions for cleft lip and cleft palate, which are among the most common birth defects. In recent years, advances in technology made it possible for scientists to directly sequence genes suspected of contributing to cleft lip and/or palate. NIH grantees and their associates have used this approach to identify genetic mutations accounting for up to 13 percent of cases of cleft lip and/or palate. One of the most recent advances occurred in March 2007, when the scientists reported sequencing the coding regions of 12 members of the fibroblast growth factor (FGF) and FGF receptor gene families and finding seven mutations that may contribute to as much as 5 percent of nonsyndromic cleft lip and/or palate. The group followed up by generating three-dimensional computer models of the FGF proteins that predicted how the altered amino acids would affect their normal shape and function. In a separate finding, NIH-supported scientists reported that women who carry a fetus whose DNA lacks both copies of a gene involved in detoxifying cigarette smoke substantially increase their baby's chances of being born with a cleft lip and/or palate if they smoke. About a quarter of babies of European ancestry and up to 60 percent of those of Asian ancestry lack both copies of the gene, called GSTT1. The scientists calculated that if a pregnant woman smokes 15 cigarettes or more per day, the chances of her GSTT1-lacking fetus developing a cleft increase by nearly 20-fold. Globally, about 12 million women each year smoke through their pregnancies. This finding provides additional motivation for expectant mothers to follow existing advice not to smoke. Other work conducted by NIH scientists looking at occupational exposures of parents suggest that exposures in certain occupations may influence the risk of orofacial clefting in offspring. Specific exposures accompanying these occupations warrant exploration. Craniofacial Birth Defects or Syndromes: Craniofacial defects are among the most common of all birth defects. Birth defects and developmental disorders can be isolated or may be part of complex hereditary diseases or syndromes. Cleft lip and cleft palate are among the more common birth defects in the United States, occurring in about 1 to 2 of 1,000 births. Numerous other disorders with oral and craniofacial manifestations, such as ectodermal dysplasias, Treacher Collins syndrome, and Apert's syndrome, though considerably more rare than cleft lip and cleft palate, also have serious lifetime functional, esthetic, and social consequences. These disorders are often devastating to parents and children alike. Surgery, dental care, psychological counseling, and rehabilitation may help ameliorate the problems, but often at a great cost and over many years. In fact, the lifetime cost of treating the children born each year with cleft lip or cleft palate is estimated to be $697 million. NIH is actively pursuing knowledge to prevent future defects as well as treat those who are currently affected. Exciting advances in genetic studies are shedding light on the genes that are important in forming the head and face, how these genes function, and how they interact with environmental, nutritional, and behavioral factors. Such information may ultimately provide the knowledge necessary for prenatal diagnosis, the development of methods to prevent craniofacial birth defects, and the basis for developing better treatments. The development of biocompatible, naturally derived materials and biodegradable scaffolds offers new hope for the treatment of defects resulting from craniofacial birth defects or syndromes. Understanding the Causes and Conceiving New Treatments for Craniosynostosis: Craniosynostosis arises when one or more of the fibrous sutures between the six cranial bones prematurely fuse and lock sections of the skull tightly into place. Because the brain continues to grow during early childhood, craniosynostosis, if left untreated, can distort the shape of the skull and portions of the face, as well as cause hearing loss, blindness, and/or intellectual disability. To better understand the causes of craniosynostosis, a team of NIH-supported researchers study the fusion of cranial sutures in mice. They suspect that the premature fusion involves alterations in the normal biochemical interplay between embryonic tissue, called mesenchyme, from which the cranial sutures form, and a thin fibrous layer of tissue, called the dura mater, that lies beneath it. The scientists also have found that different regions of the dura mater send different developmental signals to the overlying mesenchyme. Defining in fine detail the signals between the mesenchyme and the dura mater could provide the intellectual basis for discovering and developing noninvasive biological approaches to control craniosynostosis. NIH-supported researchers have made an important step in this direction. They isolated mesenchymal cells derived from cranial sutures in two different areas of the skull, cultured each group of cells separately, and later analyzed their gene expression patterns. The scientists found clear differences in the patterns of genes expressed among the two populations of mesenchymal cells. To their knowledge, this marks the first glimpse of the genetic programs that are wired into mesenchymal cells derived from cranial sutures. This line of research potentially opens a new chapter in understanding the causes of and conceiving new treatments for cranial synostosis. Cesarean Delivery Versus Vaginal Birth: The rate of cesarean delivery has risen dramatically over the past two decades; in fact, cesarean delivery currently ranks as the most commonly performed surgical procedure in the United States. More research is needed to determine how frequently cesarean deliveries are scheduled for women without medical indications for the procedure, and how these “maternal request” deliveries compare with vaginal delivery in terms of child and maternal health outcomes. Currently, NIH is supporting a Cesarean Registry through the Maternal-Fetal Medicine Units Network. Among other findings, the registry data showed that women who gave birth to a child vaginally, after a previous cesarean delivery of twins or triplets, were not at higher risk for complications during labor and delivery.
  • NIH Consens State Sci Statements. 2006;23:1-29, PMID: 17308552
  • Varner M for the NICHD MFMU Network, The MFMU Cesarean Registry: VBAC success and complication rates following one previous cesarean for multifetal gestation. Abstract for the Society for Maternal-Fetal Medicine Annual Meeting 2006.
  • (E) (NICHD)
Maternal Oral Health and Obstetric Outcomes: In recent years, evidence has suggested that a pregnant woman with periodontal (gum) disease might be at increased risk for premature birth. Two similar but not identical NIH-supported trials evaluate this possibility. Conducting more than one large clinical trial on this important public health question will cast a wide enough investigational net to determine which, if any, women are at risk. One study, called the Obstetrics and Periodontal Therapy Trial (OPT), recently concluded that periodontal treatment during pregnancy is safe for mother and baby but does not significantly lower preterm birth risk. The Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) study is ongoing. Study Shows Child's Weight Can Be Influenced by Mother Before and During Pregnancy: NIH-supported researchers found that a child's weight may be influenced by its mother even before the child is born. In a study of more than 3,000 children, scientists found that children of mothers who were obese before pregnancy were more likely to be overweight by 3 years of age. In addition, children born to African American or Hispanic mothers or to mothers who smoked during pregnancy were at greater risk for becoming overweight. These findings indicate the need to develop creative and effective strategies to promote healthy nutritional habits in prospective mothers as a way of reducing later health problems in their children. NICU Program Reduces Premature Infants' Length of Stay and Improves Parents' Mental Health Outcomes: In a randomized, controlled clinical trial, NIH-funded investigators tested an educational program, called Creating Opportunities for Parental Empowerment (COPE), among parents of premature infants. An estimated half a million premature infants are born in the United States each year. Most require hospitalization in a newborn intensive care unit, and their parents often suffer high levels of stress, anxiety, and depression. Compared with controls, parents who participated in the COPE program reported better understanding of the behaviors to expect from their infants and displayed more positive parent-infant interactions. Mothers had lower anxiety, depression, and overall parenting stress, and fathers were more involved in the infants' care. Infants of COPE parents averaged 3.8 fewer days in the neonatal intensive care unit than the control infants, which translated to a savings of roughly $5,000 per infant. Trial to Reduce the Incidence of Type 1 Diabetes for Those Genetically at Risk (TRIGR): Researchers are conducting a study to determine whether the onset of type 1 diabetes mellitus can be delayed or prevented by weaning genetically susceptible infants to Nutramigen®, a hydrolysate of cow milk protein, instead of to a standard cow milk-based infant formula. Earlier studies in animal models have shown that hydrolyzed protein diets prevented the onset of type 1 diabetes. TRIGR is the first large effort designed to ascertain whether a simple nutritional intervention during infancy can delay or prevent the onset of type 1 diabetes in children who are at high genetic risk for the disease. Enrollment for the study was recently completed, totaling more than 2,000 children from 15 countries. Childhood and Maternal Obesity: As the maternal and childhood obesity epidemic grows, researchers are trying to understand the interaction among the many complex biological and behavioral factors that contribute to this rise, identify the long-term impact on mother and child, and develop effective interventions to reverse these trends. NIH obesity research, which includes a range of racial and ethnic groups, is examining topics such as:
  • Basic research on the physiology, psychology, and genetics of obesity in children
  • Developing working definitions of the metabolic syndrome in children and adolescents
  • Linking maternal obesity, reproductive health, and pregnancy to adverse health outcomes
  • Behavioral intervention trials in schools, the home, and the community
  • This example also appears in Chapter 2: Chronic Diseases and Organ Systems.
  • (E, I) (NICHD, NCCAM, NCI, NCMHD, NHLBI, NIDCR, NIDDK, NINR, OBSSR, ODP)
Diabetes Research in Children Network (DirecNet): The risk of hypoglycemia is now the main obstacle to successfully managing type 1 diabetes mellitus in children of all ages. Severe hypoglycemia can lead to seizures or unconsciousness. In 2001, NIH established DirecNet to assess the accuracy and efficacy of continuous glucose monitoring devices, evaluate the effectiveness of the devices as tools to help control blood sugar levels, and determine the incidence of hypoglycemia. DirecNet also focuses on possible changes in neurocognitive function in children with type 1 diabetes who have frequent bouts of hypoglycemia. The network was recently renewed to use new tools to evaluate factors and mechanisms contributing to hypoglycemia, such as exercise and diet. The goal is to continue to improve management of type 1 diabetes and prevent hypoglycemia by “closing the loop” between measuring glucose levels and delivering insulin. HEALTHY: The HEALTHY multicenter clinical trial aims to prevent risk factors for type 2 diabetes in middle-school children. A pilot study for HEALTHY found that an alarmingly high 15 percent of students in middle schools enrolling mainly minority youth had three major risk factors for diabetes; about half of the children were overweight. These data suggest that middle schools are appropriate targets for efforts to decrease risk for obesity and diabetes. In the full-scale HEALTHY trial, 42 enrolled middle schools receive the intervention, which includes changes to school food service and physical education classes, behavior change, and communications campaigns. More than 80 percent of the enrolled students are from minority populations. Studies of Diabetes in Youth: Previously known as a disease of adults, type 2 diabetes is increasingly being observed in youth. The Treatment Options for Type 2 Diabetes in Youth study is comparing three different treatment strategies for children with the disease. The SEARCH for Diabetes in Youth Study is providing key data on childhood diabetes incidence and prevalence. SEARCH estimated that 1 of every 523 youths had physician-diagnosed diabetes in 2001. Although type 2 diabetes is increasing in children over 10, particularly minorities, type 1 diabetes accounts for most new cases, with an estimated 15,000 youths diagnosed annually. The Environmental Determinants of Diabetes in the Young: Understanding the environmental factors, such as infectious agents or diet, that can trigger type 1 diabetes in genetically susceptible individuals is crucial to developing prevention strategies. To address this knowledge gap, NIH established The Environmental Determinants of Diabetes in the Young (TEDDY) consortium. This international consortium is enrolling newborns and following them until age 15 to identify environmental triggers for type 1 diabetes. The study is amassing the largest set of data and samples in the world for newborns at risk for type 1 diabetes.
  • For more information, seehttps://teddy.epi.usf.edu
  • This information also appears in Chapter 3: Epidemiological and Longitudinal Studies.
  • (E) (NIDDK, NIAID, NIEHS, CDC, and the Juvenile Diabetes Research Foundation)
Longitudinal Assessment of Bariatric Surgery (LABS): The multicenter, NIH-funded LABS consortium is analyzing the risks and benefits of bariatric surgery as a treatment for extreme obesity in adults. Because bariatric surgery is also sometimes used in clinical practice as a treatment for severely obese adolescents, NIH is also supporting an observational study of teens already scheduled for surgery, Teen-LABS, to collect data to help determine whether it is an appropriate treatment option for extremely obese adolescents. Bone Health: NIH researchers established reference curves for bone mineral content and density in children. The early findings are now available according to age, sex, and race and can be used to help identify children with bone deficits and to monitor changes in bone in response to chronic diseases or therapies. Early study findings showed that bone minerals continue to accrue beyond the teenage years, so the study will continue as the adolescent participants approach young adulthood. In another study, NIH scientists discovered two genes for osteogenesis imperfecta, or brittle bone disease. The genes affect how collagen, an important building block for bone, is formed. Although there is no treatment for the disorder, the findings allow researchers to test families who have lost a child to osteogenesis imperfecta for the presence of the defective genes. Never Too Early—The Milk Matters Campaign: The risk for osteoporosis actually starts in childhood. Thus, NIH supports a public health campaign to help increase calcium consumption among children and teens, ages 11 to 15, a time of critical bone growth. Milk Matters is designed to educate parents, teachers, and health care providers about how most tweens and teens are not getting enough calcium their diets. The campaign features materials and publications in English and Spanish. Learning Math and Science: Educators, university leaders, and scientists have called for evidence-based interventions to improve U.S. students' understanding and achievement in mathematics and science. NIH's long-standing research efforts on individual differences in learning, how children learn to read, and specific learning disabilities enable it to play a leading role in improving understanding and developing these interventions. For example, NIH Mathematics and Science Cognition and Learning program supports both basic and intervention research in all aspects of mathematical thinking and problem solving, as well as in scientific reasoning, learning, and discovery. In partnership with the Department of Education, NIH participates in a national mathematics and science initiative and advises on the best use of scientifically based research on teaching and learning these critical subjects.
  • (E) (NICHD)
Intellectual and Developmental Disabilities: Intellectual and developmental disabilities have serious, lifelong effects on cognitive and adaptive development. NIH supports research to improve functioning for individuals who have intellectual and development disabilities and to understand the underlying genetic processes to prevent these conditions. For example, NIH supports 14 Mental Retardation/Developmental Disabilities Research Centers to advance diagnosis, prevention, treatment, and amelioration of intellectual and developmental disabilities. Because the centers have developed core research resources in genetics, proteomics, and clinical infrastructure, they also provide support for researchers in the Fragile X Syndrome Research Centers, Rare Disease Cooperative Centers, and Autism Centers. In addition to these centers, NIH supports research to better understand the neurobiology and genetics that underlie the cognitive and behavioral processes in persons with Down's syndrome and other intellectual and developmental disabilities. National Database for Autism Research (NDAR): The NDAR is a collaborative biomedical informatics system being created by NIH to provide a national resource to support and accelerate research in autism.
  • For more information, see https://ndar.nih.gov
  • This example also appears in Chapter 2: Neuroscience and Disorders of the Nervous System and Chapter 3: Disease Registries, Databases, and Biomedical Information Systems.
  • (I, E) (NIMH, NICHD, NINDS, NIEHS, NIDCD, CIT)
Teen Driving: Over one-third of teenage deaths are due to motor vehicle accidents. NIH-supported researchers recently completed a study demonstrating that teen drivers' behavior often became more risky in the presence of teen passengers. The researchers found that teenage drivers—both males and females—were more likely to tailgate and exceed the speed limit if there was a teenage male passenger in the front seat. Conversely, male teenagers were less likely to tailgate or exceed the speed limit when a teenage female was in the front passenger seat. To determine why the presence of teen passengers influenced these behaviors, NIH researchers are designing a study that will involve placing electronic monitoring equipment in vehicles with teen drivers. After learning the specific reasons for the risky behavior, researchers can then work to develop ways to prevent it. Underage Drinking Research Initiative: In 2004, NIH launched this ongoing initiative with the goal of obtaining a more complete and integrated scientific understanding of the environmental, biobehavioral, and genetic factors that promote initiation, maintenance, and acceleration of alcohol use among youth, as well as factors that influence the progression to harmful use, abuse, and dependence, all framed within the context of overall development. Activities and achievements in 2007 include:
  • Provided the scientific foundation for The Surgeon General's Call to Action to Prevent and Reduce Underage Drinking (released March 6, 2007) and for the ongoing work of the Interagency Coordinating Committee on Preventing Underage Drinking
  • Convened scientific meetings of experts, including the Underage Steering Committee, which met four times over a 2-year period; a Meeting on Diagnosis of Alcohol Use Disorders among Youth (April 2006); and a Meeting on Screening for Child and Adolescent Drinking and AUDs among Youth (June 2007)
  • Issued three RFAs, including “Underage Drinking: Building Health Care System Responses” (four projects awarded in FY 2006), “Impact of Adolescent Drinking on the Developing Brain” (five projects awarded in FY 2007), and “Alcohol, Puberty and Adolescent Brain Development” (three projects awarded in FY 2007)
  • Published Alcohol Research and Health, Volume 28, Number 3, “Alcohol and Development in Youth: A Multidisciplinary Overview”
  • Published a supplement of seven developmentally focused papers covering a broad range of underage drinking topics (accepted for the journal Pediatrics).
The Rapid Response Program: In April 2002, the Task Force on College Drinking released its seminal report, “A Call to Action: Changing the Culture of Drinking at U.S. Colleges.” As part of its college focus, NIH initiated support of collaborations between university personnel who have responsibility for alcohol programs on various campuses and established college drinking researchers to implement and evaluate programs to reduce underage alcohol use and its consequences. These programs include:
  • RFA AA-03-008: “Research Partnership Awards for Rapid Response to College Drinking Problems.” Five U01 (cooperative agreement) 5-year grants were awarded in December 2002.
  • PAR-03-133: “Rapid Response to College Drinking Problems. ” Fifteen 3- year grants were awarded in June 2003. This rapid funding mechanism (U18, cooperative agreement) supports timely research on interventions to prevent or reduce alcohol-related problems among college students. It was intended to support studies of services or interventions that could capitalize on “natural experiments” (e.g., unanticipated adverse events, policy changes, new media campaigns, campus-community coalitions, etc.). Each U18 grantee was required to partner with a U01 grantee. Together, these pairs, working with NIH Scientific Staff Collaborators, jointly design, develop, implement, and evaluate college drinking projects on their campuses.

    • This example also appears in Chapter 3: Epidemiological and Longitudinal Studies.
    • (E) (NIAAA)
Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN): Although one-third to one-half of new HIV infections occur among adolescents and young adults, researchers know little about how the complex physiological changes associated with adolescence impact the transmission dynamics and course of HIV infection. NIH is supporting a national clinical research network to address the unique challenges and clinical management needs of HIV-positive youth and those at risk of infection. Researchers in this network are building the capacity to develop and conduct selected biomedical, behavioral, and community-based studies, including vaccine and microbicide trials to ensure that the needs of high-risk teens are considered as treatment and prevention interventions are being developed.
  • For more information, see https://www.atnonline.org
  • This example also appears in Chapter 2: Infectious Diseases and Biodefense.
  • (E) (NICHD, NIDA, NIMH)
Adolescent Depression and Suicide: NIH continues to support research on the treatment of depression during adolescence, including the concern that certain antidepressant medications, called selective serotonin reuptake inhibitors, can increase the risk of suicide. NIH supported a recent meta-analysis of studies on this subject that found that the benefits of antidepressant medication for children and adolescents with major depressive disorder and anxiety disorders likely outweighed any potential risks. Interventions and Services for Youth with Mental Illness Who Are Transitioning to Adulthood: The transition to adulthood for youth with mental illness is often a period in which care is compromised, with a host of negative outcomes. In 2006, NIH launched an initiative to stimulate research on refining and testing interventions in service delivery models for youth transitioning to adulthood. Four applications were funded. Alzheimer's Disease Neuroimaging Initiative (ADNI): ADNI is an innovative public-private partnership for examining the potential for serial MRI, PET, or other biomarkers to measure earlier and with greater sensitivity the development and progression of mild cognitive impairment and Alzheimer's disease. Early results suggest that researchers may be able to reduce the costs associated with clinical trials by improving imaging and biomarker analysis. One ADNI study found that a standard model can be used to monitor the performance of MRI scanners at multiple clinical sites, ensuring the accuracy of the MRI images. In another study, investigators compared changes over time in PET scans of brain glucose metabolism in people with normal cognition, mild cognitive impairment, and Alzheimer's disease and found that scans correlated with symptoms of each condition and that images were consistent across sites, suggesting the validity of PET scans for monitoring the effectiveness of therapies in future clinical trials. More than 200 researchers have already accessed a public database containing thousands of brain images and related clinical data obtained through blood and cerebrospinal fluid analyses. Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE): This recent multicenter study in community-dwelling seniors showed that certain mental exercises can offset expected declines in thinking skills of older adults and show promise for maintaining the cognitive abilities needed for tasks such as shopping, making meals, and handling finances. The ACTIVE study is the first randomized, controlled trial to demonstrate long-lasting, positive effects of brief cognitive training in older adults. Although training did not improve the participants' ability to tackle other everyday tasks, their cognitive skills declined less than with untrained seniors. Additional research is needed to translate these findings from the laboratory into interventions that prove effective at home. Lifestyle Interventions and Independence for Elders: Results of several studies have suggested that physical exercise may prevent physical disability, including impaired mobility, in both healthy and frail older adults. To develop definitive evidence regarding the effectiveness of such interventions, NIH designed the Lifestyle Interventions and Independence for Elders (LIFE-P) pilot study, a clinical trial that tested the effects of a physical activity program versus a health education program in preventing major disability. The study involved 424 participants age 70 to 89 who were at risk of disability. These individuals were followed for at least 1 year at four locations around the country: Wake Forest University School of Medicine in Winston Salem, North Carolina; the University of Pittsburgh in Pennsylvania; the Cooper Institute in Dallas, Texas; and Stanford University in Palo Alto, California. At various points in the physical exercise intervention, study participants were tested for their performance on a battery of lower-extremity function tests and the time required for them to walk 400 meters. At the end of the study, participants in the intervention group demonstrated significant improvement over controls. This successful pilot study was completed in 2005 and showed both feasibility and positive preliminary data to permit the design and consideration of a large-scale clinical trial.
  • (I, E) (NIA)
Inflammation in the Elderly: Inflammatory processes, particularly those mediating chronic inflammation, have been implicated as predictors or initiators of or contributors to a number of chronic diseases and conditions of aging. NIH currently supports research to determine relationships of age-related changes in inflammation and inflammatory mediators to physiologic and pathophysiologic aging changes, risks and progression of age-related morbidity and disability, and changes in tissue and organ function. Funded projects include studies of vascular inflammation and neurotoxicity in the aging brain and inflammatory responses to sleep loss. Neuroeconomics of Aging: Scientists in the emerging field of neuroeconomics seek to explain the psychological mechanisms that guide economic decisions and the neurobiological pathways that underlie them. NIH is currently supporting research to examine the social, emotional, cognitive, and motivational processes and neurobiological pathways of economic behavior as they (1) influence social, financial, and health-related decisions affecting the well-being of middle-aged and older adults and (2) inform the development and refinement of integrative economic theories of utility, learning, and strategic choice relevant to aging. National Long-Term Care Survey (NLTCS): NLTCS is an ongoing longitudinal study supported by NIA to examine changes in the health and functional status of older Americans and track health expenditures. The study is one of the Nation's preeminent resources for understanding and analyzing national disability trends and other demographic trends to inform public health policy. Efforts are currently under way to make the d ata publicly available. Improving Communication About End-of-Life Care in the ICU Reduces Symptoms of Stress, Anxiety, and Depression in Family Members: A clinical trial supported in part by NIH found that an intervention to improve communication between intensive care unit clinicians and family members of a dying patient significantly reduced feelings of stress, anxiety, and depression in the family members. In the randomized controlled trial, researchers examined communication guidelines that follow the mnemonic VALUE: to Value what the family members said, Acknowledge their emotions, Listen, Understand the patient as a person, and Elicit family member questions. From interviews conducted 3 months after the death of the patient, family members in the VALUE group were found to have lower scores for stress, anxiety, and depression than those in the customary-practice group. The finding indicated that improving communication in end-of-life family conferences in the intensive care unit helped family members express their views and emotions, accept a more realistic goal of care, and improve their long-term psychological outcomes. Improving End-of-Life Care: Special Supplement to the Journal of Palliative Medicine: FY 2005, NIH sponsored the State-of-the-Science Conference on Improving End-of-Life Care. This conference addressed the current state of end-of-life care and proposed important new directions for end-of-life research. Key conclusions to emerge from the conference included: the rapid increase in older adults facing the need for end-of-life care requires the development of research infrastructure to better examine end-of-life issues; enhanced communication between patients, families, and providers is crucial to end-of-life care; and improved outcome measures are needed to better conduct end-of-life research. In FY 2006, a special issue of the Journal of Palliative Medicine presented a series of papers developed from this workshop on a wide variety of topics. The supplement includes articles on measuring end-of-life care outcomes; analyzing racial, cultural, and ethnic factors that influence end-of-life care; improving care for dying children and their families; and examining factors in the health care system that influence end-of-life care. Centers in Self-Management or End-of-Life Research: Future progress in improving the ability of those with chronic disease at all stages of life to manage their own illness, as well as improving the care of patients at the end of life, will require the development of enhanced research capacity, in terms of both people and institutions. In early 2007, NIH solicited applications for the Centers in Self-Management or End-of-Life Research. These Centers are expected to enhance research and training capacity for interdisciplinary, biobehavioral efforts in end-of-life and self-management science.

Rehabilitation Research

Neural Prosthesis Program: Neural prosthetic devices restore or supplement nervous system functions that have been lost through disease or injury, allowing people with disabilities to lead fuller and more productive lives. The NINDS Neural Prosthesis program pioneered the development of this technology beginning more than 35 years ago. The program has, directly or indirectly, catalyzed the development of cochlear implants for the hearing impaired, respiratory and hand grasp devices for people with spinal cord injuries, and deep brain stimulation for patients with Parkinson's disease, among other contributions. Current work aims to restore standing and voluntary bowel and bladder control after spinal cord injury, to allow paralyzed persons to control devices directly from their brains, and to control seizures. Ongoing research also seeks to improve cochlear implants and to advance deep brain stimulation, which may be applicable to many brain disorders. Through the years, the program has fostered the development of a robust research community, now including private-sector companies, and represents a cooperative effort among several NIH Institutes, which coordinate their efforts with programs now under way in the Department of Veterans Affairs and DoD. Upper Limb Rehabilitation: To improve the process of restoring function in the upper limbs, NIH is developing robotic exoskeletons for rehabilitation of upper-extremity paralysis. Recent studies demonstrate that practicing tasks repetitively with feedback can enhance recovery of arm function for selected populations of stroke survivors. This type of practice typically requires the assistance of a trained physical therapist. However, the development of low-cost robotic exoskeletons holds the promise of providing therapeutic activities at home and in a variety of settings to help a wider range of stroke patients improve functioning more efficiently.
  • (E) (NICHD, NIBIB) (GPRA Goal)
High-Tech Replacements for Damaged Limbs: NIH is investing strategically to develop improved prosthetic devices that can help soldiers and other individuals who have lost limbs resume normal activities. The latest developments and research activities include a new, “intelligent” artificial knee joint that enables a user's lower-leg prosthesis to adjust automatically to hills, stairs, and other variable surfaces, offering greater mobility. Scientists are also working on developing a prototype “bionic arm,” controlled by microprocessors that read signals through nerves that have been rerouted from the neck to the chest. Investigators are also seeking ways to implant an artificial limb directly into the bone of the residual limb, doing away with the need for a socket device, which often causes painful, chronic irritation. New Medical Adhesive Boasts Unique Wet-Dry Abilities: One day, tissue engineering will make it possible to regenerate lost facial components. Until then, victims of massive craniofacial trauma or extensive surgeries due to cancer often must depend on maxillofacial prosthetics to provide the form and function needed to resume their day-to-day lives. Current adhesives are not always retentive over long periods or changing conditions. The loss of retention can result in visible margins or even dislodgement of the prosthesis. Now NIH-supported scientists report they have merged two of nature's most elegant strategies for wet and dry adhesion. As reported in Nature, the scientists designed a synthetic material that starts with the dry adhesive properties of the gecko lizard and supplements it with the underwater adhesive properties of a mussel. The hybrid material, which they call a geckel nanoadhesive, proved in initial testing to be adherent under dry and wet conditions and also adhered much longer under both extremes than previous gecko-based synthetic adhesives, a major issue in this area of research. According to the authors, their findings mark the first time that two polar opposite adhesion strategies in nature have been merged into a manmade reversible adhesive. It is envisioned that the new adhesive will be used for many medical applications, including enhancing the retention of oral and maxillofacial prosthetics. Engineering Stem Cells to Repair or Replace Damaged Tissues: Guiding a person's own stem cells to repair or replace damaged tissues with healthy tissue is the goal of multiple NIH-supported tissue engineering projects. For example, one team previously reported success creating three-dimensional mandibular (jaw) joints using rodent tissue; their continuing work on the project addresses pragmatic questions that must be answered in order to create functional human joints. Other teams are working on regeneration of the temporomandibular disk, which acts as a cushion between the bony components of the jaw joint and on the tissue engineering of skeletal muscle. Tissue engineering holds great promise for regeneration or replacement of dental, oral, and craniofacial structures lost due to trauma, disease, or congenital anomalies. The progress seen in this area will also inform tissue engineering solutions for degeneration in other articular surfaces, such as knee, hip, and shoulder joints. Maintaining Physical Function in Older Populations: Chronic disability among older Americans has dropped dramatically, and the rate of decline has accelerated during the past two decades, according to recent analysis of data from the NIH National Long-Term Care Survey (NLTCS), which examined disability changes within three age groups (65-74, 75-84, and 85+) and found that the prevalence of chronic disability among people age 65 and older fell from 26.5 percent in 1982 to 19 percent in 2004/2005. The proportion of people without disabilities increased the most in the oldest age group, rising by 32.6 percent among those age 85 and older. The findings suggest that older Americans' health and function continue to improve at a critical time in the aging of the population. The question of how best to maintain and accelerate the trend of declining disability, especially in the face of increasing rates of obesity, will be addressed at a workshop sponsored by the National Academies and commissioned by NIH. NIH currently supports large, multidisciplinary research programs that focus, in part, on rehabilitation research for older people. For example, one of the Claude D. Pepper Older Americans Independence Centers conducts exercise and motor learning-based rehabilitation research to optimize the recovery of older adults who have suffered a stroke, hip fracture, or other chronic debilitating disease and translate these findings into effective community-based rehabilitation programs (see Chapter 4). The Edward R. Roybal Centers for Applied Gerontology conduct applied research to keep older persons independent, active, and productive in later life. International Collaborative Trauma and Injury Research Training Program: Each year, more than 5 million deaths and countless disabilities result from injuries. This program is strengthening the scientific expertise in developing countries in human injury-related research and funds 11 collaborations between institutions in high-income countries and low- or middle-income countries. These collaborations support research training in applied science, the epidemiology of risk factors, acute care and survival, rehabilitation, and long-term mental health consequences of trauma and injury. The program is also supported by the World Health Organization, the Pan American Health Organization, and CDC. Cochlear Implants: One of the more groundbreaking biomedical achievements in the last 30 years has been the cochlear implant, an electronic device that provides a sense of sound to individuals who are profoundly deaf or severely hard-of-hearing. Cochlear implants process sounds from the environment and directly stimulate the auditory nerve, bypassing damaged portions of the inner ear. Nearly 100,000 individuals worldwide have been fitted with cochlear implants. In the United States, approximately 22,000 adults and nearly 15,000 children have received them. Derived in part from NIH-funded research that dates back to the early 1970s and continues today, this remarkable technology has enabled deaf and severely hard-of-hearing individuals to enjoy an enhanced quality of life. NIH-supported scientists showed that profoundly deaf children who receive cochlear implants at an early age develop language skills at a rate comparable to that of children with normal hearing. They also found that the benefits of the cochlear implant in children far outweigh its costs. Scientists can now study the large groups of children who were identified early for hearing loss and use this knowledge to document how treatments such as cochlear implants can lead to improved speech and language acquisition, academic performance, and economic outcomes for these children.
NIH Strategic Plans Pertaining to Life Stages, Human Development, and Rehabilitation Research
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
    Branch Reports to Council with Future Scientific Directions:
National Cancer Institute (NCI) National Institute of Dental and Craniofacial Research (NIDCR) National Institute on Aging (NIA) National Institute on Drug Abuse (NIDA) National Institute on Deafness and Other Communication Disorders (NIDCD) National Institute on Alcohol Abuse and Alcoholism (NIAAA)
    Recommendations of the NIAAA Extramural Advisory Board (EAB)
National Institute of Nursing Research (NINR) Office of Dietary Supplements (ODS) Trans-NIH Strategic Plans 80Alemayehu B, Warner KE. Health Serv Res 2004;39:627-42, PMID: 15149482
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