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Ciencias Psicológicas
versión impresa ISSN 1688-4094versión On-line ISSN 1688-4221
Cienc. Psicol. vol.19 no.1 Montevideo 2025 Epub 01-Jun-2025
https://doi.org/10.22235/cp.v19i1.3974
Original Articles
Risk and protective factors for the development of children aged 0 to 6 years in Brazil: A systematic review
1
http://orcid.org/0000-0003-4504-7665
2
http://orcid.org/0000-0001-5868-5901
1 Universidade Federal do Paraná, Brasil, thaismessiasg@gmail.com
2 Universidade Federal do Paraná, Brasil
3 Universidade Federal do Paraná, Brasil
4 Universidade Federal do Paraná, Brasil
This study aimed to examine the biopsychosocial factors that impact the child development in Brazil through a systematic review. The methodology adopted the PRISMA protocol and used a detailed search strategy in major databases. It selected empirical articles published between 2012 and 2024 that included samples of Brazilian children from 0 to 6 years old, describing risk and protective variables using standardized instruments for development assessment. The analysis resulted in the selection of 43 empirical studies, identifying 66 risk and protective factors, of which 78.78 % were classified as risks. The main risk factors identified were socioeconomic vulnerability, preterm birth and male sex. The findings suggest that variables such as maternal education and socioeconomic level are significantly associated with child development, serving as risk or protective factors depending on the context. The analysis underscores the need for early, multidisciplinary interventions to strengthen protective factors and reduce risks. It also suggests expanding research on protective factors. The results highlight the importance of biopsychosocial factors in child development, emphasizing the need for integrated policies in health, education, and social assistance to enhance human development from childhood and reduce inequalities.
Keywords: child development; neuropsychology; adverse childhood experiences
Este estudo objetivou examinar os fatores biopsicossociais que impactam o desenvolvimento de crianças no Brasil, por meio de uma revisão sistemática. A metodologia adotou o protocolo PRISMA, com uma estratégia de busca detalhada nas principais bases de dados, selecionando artigos empíricos publicados entre 2012 e 2024 que incluíam amostras de crianças brasileiras de 0 a 6 anos e que descreviam variáveis de risco e proteção utilizando instrumentos padronizados de avaliação do desenvolvimento infantil (DI). A análise resultou na seleção de 43 estudos empíricos, identificando 66 fatores de risco e proteção, dos quais 78,78 % foram classificados como riscos. Os principais fatores de risco identificados foram: vulnerabilidade socioeconômica, nascimento pré-termo e sexo masculino. Os achados sugerem que variáveis como escolaridade materna e nível socioeconômico estão significativamente associadas ao DI, servindo como fatores de risco ou proteção dependendo do contexto. A análise sublinha a necessidade de intervenções precoces e multidisciplinares para fortalecer fatores protetivos e reduzir riscos, além de sugerir a expansão das pesquisas sobre fatores de proteção. Os resultados apontam a importância dos fatores biopsicossociais no DI, destacando a necessidade de políticas integradas em saúde, educação e assistência social para potencializar o desenvolvimento humano desde a infância e diminuir desigualdades.
Palavras-chave: desenvolvimento infantil; neuropsicologia; experiências adversas da infância
Este estudio tuvo como objetivo examinar los factores biopsicosociales que impactan el desarrollo de los niños en Brasil, a través de una revisión sistemática. La metodología adoptó el protocolo PRISMA, con una estrategia de búsqueda detallada en las principales bases de datos, seleccionó artículos empíricos publicados entre 2012 y 2024 que incluían muestras de niños brasileños de 0 a 6 años y que describían variables de riesgo y protección utilizando instrumentos estandarizados de evaluación del desarrollo infantil. El análisis condujo a la selección de 43 estudios empíricos, se identificaron 66 factores de riesgo y protección, de los cuales el 78.78 % se clasificaron como riesgos. Los principales factores de riesgo identificados fueron: vulnerabilidad socioeconómica, nacimiento prematuro y sexo masculino. Los hallazgos sugieren que variables como la educación materna y el nivel socioeconómico están significativamente asociadas al desarrollo infantil y sirven como factores de riesgo o protección dependiendo del contexto. El análisis subraya la necesidad de intervenciones tempranas y multidisciplinares para fortalecer factores protectores y reducir riesgos, además de sugerir la expansión de las investigaciones sobre factores protectores. Se señala la importancia de los factores biopsicosociales en el desarrollo infantil, se destaca la necesidad de políticas integradas en salud, educación y asistencia social para potenciar el desarrollo humano desde la infancia y disminuir las desigualdades.
Palabras clave: desarrollo infantil; neuropsicología; experiencias adversas de la infancia
Child Development (CD) is a dynamic process and the result of a set of interconnected factors, with a highlight on biologic, genetic, psychologic, social, and environmental factors, which might have a negative or positive impact on each other (Mancini et al., 2004; Pilz & Schermann, 2007). In general, CD can be understood as a complex transformation, dynamic and characterized by the progressive achievement of cognitive, motor, behavioral, emotional, and psychosocial skills (Costa et al., 2015; Miranda & Malloy-Dini, 2018; Papalia et al., 2013). During a child’s early years, the nervous system presents greater brain plasticity compared to later developmental stages. Thus, during early childhood, the brain is equipped with high capacity for recovery, in addition to organic and functional reorganization (Gazzaniga et al., 2018; Semrud-Clikeman & Elisson, 2011).
Risk factors are understood as biological and environmental factors that are related to an increase in the probability for the occurrence of negative symptoms or adverse outcomes in an individual’s life (Kraemer et al., 2005). Children that live in stressful contexts, for instance, demonstrate more elevated levels of cortisol, the hormone involved in the regulation of stress, than children that are not exposed to these factors (Slopen et al., 2014). Cortisol is linked to specific areas of the central nervous system, such as memory, learning, emotions and the immunologic system (Shonkoff et al., 2012). Within developmental psychology, there is widespread use of multiple indicators to understand risk factors. Concerning such aspect, previous research have defended the view that exposure to multiple risk factors rather than a single factor present different consequences in development, with a highlight on negative effects in the analysis of cumulative risk (Kraemer et al., 2005; Rutter, 1981; Sameroff, 2006). On the other hand, protective factors are individual or social mechanisms that mitigate or neutralize the negative effects of the risk factors. Thus, they are regarded as positive promoters of development (Haggerty, 1996; Rutter, 2006).
From a globalized perspective, children exposed to risk conditions must be monitored by health, education, and social service professionals. Monitoring children is critically important because, based on the identification of possible delays in any domain, it becomes possible to produce a specialized assessment in order to investigate possible alterations in development (Hassano, 2011). These processes must be addressed by multidisciplinary, interdisciplinary, or transdisciplinary teams in order to strengthen protective factors during the confrontation of adverse situations that may compromise full development (Valiati et al., 2011). Early intervention proves relevant because it significantly improves these children’s quality of life and reduces the risk for delays in development and alterations in learning (Walker et al., 2011).
The Child and Adolescent Statute (Estatuto da Criança e do Adolescente - ECA) is Brazil’s legal framework for the comprehensive protective of children and adolescents. This legislation guarantees that all individuals in this age group enjoy the full range of fundamental rights intrinsic to human dignity, enabling the development of their physical, mental, moral, spiritual, and social potential in conditions of freedom and dignity (Law No. 8.069, 1990). According to an estimate by the Instituto Brasileiro de Geografia e Estatística (IBGE), or Brazilian Institute of Geography and Statistics, in August of 2022, there are about 215 million residents in Brazil. 19 million (8.83 %) are children aged from 0 to 6 years (IBGE, 2022). In low- and middle-income countries, it is estimated that more than 250 million children under the age of five may not reach their full developmental potential, mainly due to risk factors such as poverty, nutritional deficits, and inadequate learning conditions (Black et al., 2017; Grantham-McGregor et al., 2007; McCoy et al., 2016; Walker et al., 2007). Development in early childhood was included in the global agenda of the United Nations as one of the goals of the Sustainable Development Objectives (SDO) for the promotion of quality development for all children (Black et al., 2017; United Nations, 2023). Monitoring CD is a priority in the current Brazilian health context and a major concern for parents and legal guardians. It aims to identify problems in the developmental process of children and adolescents, and to correct and/or mitigate their adverse biopsychosocial effects (Amorim et al., 2009; A. M. Ribeiro et al., 2010; D. G. Ribeiro et al., 2014b; Santa Maria-Mengel & Linhares, 2007). One of the priorities for future research aimed at reducing early childhood developmental inequalities in low- and middle-income countries is to identify protective factors that promote adequate child development (Walker et al., 2011).
In light of this, understanding how biopsychosocial risk and protective factors interact and relate to child development (CD). In Brazil, although some evidence exists regarding these determinants (Maia & Williams, 2005; Morais et al., 2016), there is still a lack of studies that systematically integrate protective factors and CD domains within the national context. Thus, it becomes necessary to compile updated evidence on the main biopsychosocial factors that influence the development of Brazilian children. This more integrative approach provides a solid basis for the formulation and improvement of early interventions and intersectoral public policies, as recommended by The Legal Framework for Early Childhood (Marco Legal da Primeira Infância) (Law No. 13.257/2016) and other national guidelines for the full benefit of children such as the Happy Child Program (Programa Criança Feliz) (Decree no. 8.869, 2016; and altered by Decree no. 9.579, 2018).
In view of this gap, the present study aims to investigate biopsychosocial risk and protective factors associated with CD in Brazilian children aged 0 to 6 years, based on a systematic review of national literature.
Method
The use of methods for systematic review in this study followed the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol (Page et al., 2021). The PECO strategy was used to identify the Population (P), Exposure (E), Comparison (C, when applicable), and Outcomes (O) to be assessed. The objective was to investigate, in Brazilian children aged 0 to 6 years (P), the identification of risk and protective factors associated with child development (E), in order to evaluate their impact on developmental outcomes (O). For the selection and extraction of the articles, two researchers conducted electronic searches for original works, initially in April of 2022 and, subsequently, in March of 2025, in the following data bases: Scopus, LILACS, Scielo, PubMed Central, PsycINFO and Web of Science, with the following search strategy: ("risk factor*" OR "protective factor*" OR "biopsychosocial factor*") AND ("psychological" OR "social" OR "biological" OR "cognition" OR "emotional" OR "intelligence" OR "language development" OR “language” OR "motor development") AND ("preschool child" OR "child development" OR "child behavior" OR "infant behavior"). The second one had the objective to update and amplify the comprehension of the systematic review, including the Scopus data base and articles published until 2024. The complete electronic search strategy can be found in this article’s Appendix A. According to eligibility criteria, researchers included: (a) empirical articles; (b) articles in English, Spanish, or Portuguese; (c) articles published between 2012 and 2024; (d) a sample of Brazilian children aged 0 to 6 years; (e) description of risk and protective variables in CD; (f) the use of standardized instruments for the assessment of CD. The exclusion criteria were: (a) lack of clarity in the description of the instrument used in the assessment of CD; (b) literature review articles and meta-analyses; (c) articles rated as having a high risk of bias.
First, the articles were imported into the Rayyan Software. After the identification of duplicated articles, they were removed from the data bases. The process of identification and selection of relevant articles was realized by means of a reading of the title and abstract by two researchers working independently by the blinded model, with a verification whether they fit into the inclusion or exclusion criteria. Articles classified as accepted or accepted with restrictions by both independent researchers were included into the sample. When researchers disagreed on the inclusion of an article into the sample, the methods used in such studies were read by the two researchers together in an online conference in order to reach a consensus whether the article should be included or not, without the need for a third researcher. In order to verify the agreement between the two researchers, Cohen’s Kappa coefficient was calculated in statistical analysis (Cohen, 1960), which indicated almost perfect agreement among the judges (k = .81, p < .001; agreement = 97 %) (Landis & Koch, 1977).
The data extraction process was carried out independently by two authors, who retrieved and fully reviewed the articles included in the review. After this phase, researchers realized a conference for checking collected and general agreement among authors. The results were imported into an Excel worksheet, which made it possible to collect all data that were relevant for the interpretation of studies.
Assessment of the methodologic quality of the included studies
The checklist for methodologic, critical assessment by the Joanna Briggs Institute (JBI) (Aromataris & Munn, 2020) was used for the assessment of bias risk in the studies that were included in this research work. Thus, it was possible to verify the methodologic quality of observational, cross-sectional, Longitudinal, quasi-experimental, and randomized experimental studies. The risk for bias refers to the extent to which a study might be systematically incorrect or present distortions in its results due to failure in design, in realization, or in analysis (Aromataris & Munn, 2020). The Joanna Briggs Institute (JBI) checklist is widely used in the assessment of bias risk in systematic reviews, considering issues such as clarity in selection criteria, integrity in randomizing methods, completeness in the follow-up of participants, and precision in measurement of outcomes. The JBI is equipped with separate tools for the assessment of research works according to outline, cross-sectional (8 criteria), Longitudinal studies (11 criteria), quasi-experimental (9 criteria) and controlled randomized essays (13 criteria). The analysis of the methodologic quality of each study was independently realized by two authors and divergencies were resolved through discussion within the review team. Researchers attributed 0 (absence/insufficiency) or 1 (satisfactory presence) for each item in the checklists. Scores were counted and, later on, the studies were classified as low bias risk by means of the minimum scoring and the absence of failures in items that are considered critical, according to outlining (Information on the detailed description of the critical items can be obtained in the Appendix A). Given that risk and protective factors are complex, multifactorial, and often interdependent, there is a need for studies to adopt robust strategies for controlling confounding variables, in order to produce more accurate and theoretically grounded results. This approach guaranteed balance between methodological rigor and feasibility of inclusion of studies that were conducted in applied contexts, which led to the selection of research works with enough scientific validity to sustain the review conclusions. Later, there was the Kappa calculation, indicating the almost perfect agreement among the judges regarding the investigated items (k = 0,80, p < 0,001; agreement = 94 %) (Landis & Koch, 1977).
Results
The selection of articles was conducted in accordance with the flowchart presented in Figure 1. Concerning the identification of studies by database, consultation by means of the search strategy resulted in 4127 articles. After removing duplicates, screening for eligibility by peers, and assessing risk of bias, a total of 43 articles were included in this systematic review.
Table 1 shows the characteristics of the studies that were included in this review. Considering the division of Brazil into five geographical regions (IBGE, 1992), it was possible to verify that the samples in the studies were collected under the following regional distribution: North (n = 1), Northeast (n = 6), Mid-west (n = 3), South (n = 14), Southeast (n = 19). Thus, the southeast was the region of 44.18 % of the studies, and the state of São Paulo was the one with the greatest number of studies included in this review (n = 13; 30.23 %).
It was found that 62.80 % of the included samples used a cross-sectional design (n = 27) (Table 1). The results of the risk of bias assessment for each included article, based on the JBI checklist (Aromataris & Munn, 2020), are also presented in Table 1. The average total scores and item-by-item analyses are provided in the table available in the Appendix A. The most frequently observed sources of bias in cross-sectional studies were related to the reliability and validity of outcome measurement, as well as the use of strategies to control for confounding factors during the conduct of the study. These were followed by issues in the objective description of sample participants, including demographic characteristics and time frame. In Longitudinal studies, concerns regarding the validity or reliability of outcome measurement were the most frequently identified sources of bias. After that, researchers found the adopted measurements for the management of the confusion factors and presented the reasons why there was a loss participant follow-up and how such data was explored. Based on the analyses, in general the most relevant limitations that were found in the studies include the research design, lack of reliability in the collection of data, which is especially linked to the fact that the studies do not indicate who was responsible for such phase or whether there was any training, in addition to inadequacy in the adoption of measurements for the adjustment of confusion variables.
The total number of participants across all studies was 36,365 (SD = 1,324.56). Table 1 also presents the age range of the assessed populations in months, based on chronological age-and, in some studies, corrected age-when referring to children born preterm, with the data reported separately. Table 1 . . also includes the mean and standard deviation of children’s ages (in months) at the time of assessment for each study, sample size, percentage of boys in each sample, and the instruments used to assess development. The most frequently used instrument was the Bayley Scales of Infant Development (39.53 %, n = 17), followed by the Developmental Screening Test (Denver-II) (18.60 %, n = 8).
The variables of CD risk and protective were categorized in accordance with the biological, psychological or social domain. Table 2 . . provides a detailed description of the groups of categories that were identified in the studies as elements of risk and protective for CD. Overall, researchers identified 66 types of risk and protective variables. 78.78 % (n = 52) were identified as risk factors, with a predominance in the biological domain (36.36 %, n = 24), followed by the social (34.84 %, n = 23) and psychological domains (7.57 %, n = 5). Regarding protective factors, the percentage was 13.63 % (n= 9) of social variables, 6.06 % (n = 4) of biological variables and 1.51% (n = 1) of psychological variables.
The risk factor referring to socio-economic vulnerability/low income was the most frequently reported variable across all studies, corresponding to 19.69 % (n = 13), followed by the preterm birth, biological risk factor, representing 15.15 % (n = 10) and the male sex with 13.63 % (n = 9). Regarding psychological factors, among the five identified psychological risk variables, the most recurrent risk variable was the mother with mental disorder 6.06 % (n = 4). Among the protective factors, stimulating maternal interaction and practices was the most frequently cited protective factor, representing 12.12 % (n = 8), followed by breastfeeding 6.06 % (n = 4).
Note: N: Number; SD: Standard Deviation; NI: indicates data that was not provided or that could not be extracted; TG: Total Group; EG: Experimental Group; CG: Control Group; CA: Chronological Age; ICO: Corrected Age; EG1: Experimental Group 1; CG1: Control Group 1; EG2: Experimental Group 2; CG2: Control Group 2; G1: Group 1; G2: Group 2; G3: Group 3; A1: Assessment 1; A2: Assessment 2; GNC: Group of mothers that did not smoke tobacco or drink alcohol during pregnancy; GAC: Group of mothers that only drank alcohol during pregnancy; GTC: Group of mothers that only smoked tobacco during pregnancy; GACTC: Group of mothers that simultaneously drank alcohol and smoked tobacco during pregnancy; PA: Pará; RR: Roraima; BA: Bahia; CE: Ceará; PB: Paraíba; PE: Pernambuco; RN: Rio Grande do Norte; GO: Goiás; MT: Mato Grosso; PR: Paraná; SC: Santa Catarina; RS: Rio Grande do Sul; MG: Minas Gerais; SP: São Paulo; RJ: Rio de Janeiro; The abbreviations of the instruments used to assess child development, behavior, and risk/protective factors are detailed in the tables provided in the Appendix A. *Joanna Briggs Institute (JBI) Checklist; **Instruments for assessing CD.
Note: N: Number of occurrences. *weight at birth < 1,500 g, 5-minute Apgar < 7, gestational age < 32 weeks and congenital malformations; Ϯ Scoring from 0 to 8 consisting of: Preterm birth, low weight at birth, 5-minute Apgar score < 7, Breastfeeding < 3 months, fewer than 6 prenatal consultations and more than three hospitalizations due to health complications; Composite score ranging from 0 to 8, consisting of: Low economic class, Low maternity schooling, Maternity during adolescence, Single/divorced marital status and high levels of parental stress
Biological risk factors
Preterm birth (PTB) and/or low birth weight (LBW)
The PTB has been associated with delay in neuropsychomotor development (Fink et al., 2018), especially in cognitive domains (Orioli et al., 2024;), gross and fine motor skills (Panceri et al., 2020; Saccani et al., 2013; A. C. Zago et al., 2023) and sensory processing (Machado et al., 2019). It was possible to observe a reduction in the development scores for PTB children and children with LBW (< 2500g) (Caldas et al., 2014; Fernandes et al., 2012). The LBW also demonstrated strong association with low neuropsychomotor scores (L. B. Araujo et al., 2017; Hass et al., 2023; Orioli et al., 2024; Panceri et al., 2020; A. C. Zago et al., 2023) and risk of delay in development (Kofke et al., 2022).
Prolonged mechanical ventilation, periventricular hemorrhage, low Apgar scores, and periventricular leukomalacia were negatively associated with global developmental outcomes in preterm infants (Panceri et al., 2020). Bronchopulmonary dysplasia and periventricular leukomalacia emerged as predictors of motor, cognitive, and adaptive behavior deficits (Fernandes et al., 2012). Prolonged time in the Neonatal ICU was the most relevant negative predictor of PTB motor and cognitive development (Hass et al., 2023). Clinical neonatal sepsis increased the risk for neuromotor alterations at the age of twelve months for premature infants with very low weight (Ferreira et al., 2014). The Neonatal Near Miss events was associated to all domains of development (Aristizábal et al., 2023).
Male sex
The male sex was a major predictor of low Intelligence Quotient (IQ) at the age of six years, even after controlling for confounding factors (Camargo-Figuera et al., 2014). Boys born small for gestational age demonstrated poorer physical and neuropsychological performance (Fink et al., 2018). Yamaguchi et al. (2019) found that boys were 1.65 times more likely to present questionable development, even after controlling for contextual variables. Correia et al. (2019) observed a higher risk of developmental delay among boys, particularly in the domains of motor skills, problem-solving, and social skills, especially after 36 months of age. Boys showed cognitive (Pereira et al., 2016), motor (Fernandes et al., 2012; Góes et al., 2015), language (Fernandes et al., 2012; Góes et al., 2015), and socio-emotional deficits (Fernandes et al., 2012), as well as impairments in perceptual-motor skills (E. M. M. Santos et al., 2020) and in the personal-social domain among those exposed to SARS-CoV-2 at 12 months of age (C. A. D. Santos et al., 2024).
Type of delivery
While Caldas et al. (2014), Pinheiro et al. (2024) and A. C. Zago et al. (2023) pointed at the cesarean section as a variable associated to lower results in development, A. C. D. Silva et al. (2015) observed a higher risk among children born via vaginal delivery.
Height Deficits
Low height in the first year of life was associated with IQ deficits (Camargo-Figuera et al., 2014). Height-for-age was significantly predicted by biological factors, such as birth weight and number of prenatal visits (Neves et al., 2016). Birth length was significantly associated with poor motor performance in twelve-month-old preterm infants (Panceri et al., 2020).
Intrauterine exposure to SARS-CoV-2
Children whose mothers were infected during the first trimester of pregnancy were 2.15 times more likely to be classified as having possible developmental delays at 12 months of age, compared to those whose mothers were infected during the third trimester (Pinheiro et al., 2024). Similarly, researchers identified a threefold increased risk of neurodevelopmental delays in children with intrauterine exposure to the virus, with statistically significant associations even after controlling for prematurity, sex, and maternal depression (C. A. D. Santos et al., 2024). Alterations observed in brain imaging exams were also associated with lower developmental scores (C. A. D. Santos et al., 2024). The highest prevalence of motor and socio-emotional delays, as well as inflexibility, was observed in the group exposed to SARS-CoV-2 (P. Y. F. Silva et al., 2023).
Adverse neonatal and perinatal clinical conditions
A study with a sample of children born to adolescent or young adult mothers identified prolonged neonatal ICU hospitalization as an independent risk factor for global developmental delay (Kofke et al., 2022). In another study, conducted with preterm children, researchers found an association between periventricular hemorrhage and developmental deficits (Caldas et al., 2014). Neonatal pneumonia was also shown to negatively affect language development (Góes et al., 2015), and the presence of clinical pathologies in childhood was associated with lower motor performance (Silva, J. et al., 2015). The use of phototherapy increased the likelihood of developmental alterations in children older than 12 months (A. C. D. Silva et al., 2015). While investigating twin-twin transfusion syndrome (TTTS), D. Campos et al. (2016) identified that cardiopulmonary diseases and donor twin status were associated with delays in fine motor skills and expressive language. Deficits in head circumference during the first year of life were associated with an increased risk of low IQ (Camargo-Figuera et al., 2014).
Simultaneous exposure to alcohol and tobacco during pregnancy increased the risk of children being classified as emerging/at risk by 2.81 times (Negrão et al., 2020), and parental tobacco use was associated with lower IQ scores (Camargo-Figuera et al., 2014). Finally, J. A. T. Santos et al. (2024) found that children with a high Biopsychosocial Risk Index (BRI) presented lower developmental scores, particularly in fine motor skills.
Psychological risk factors
The presence of maternal mental disorders, including depression, anxiety, and psychological distress, was associated with delays in children’s cognitive, motor, emotional, and social development (Pinheiro et al., 2024; D. G. Ribeiro et al., 2014a; H. A. L. Rocha et al., 2021; Shephard et al., 2019). Children exposed to multiple adverse childhood experiences (ACEs), and whose mothers were victims of intimate partner violence, showed delays across all developmental domains (H. A. L. Rocha et al., 2021). In a study of adolescent mothers living in poverty, maternal ADHD symptoms were associated with increased absolute and relative theta power in infants’ brain oscillatory activity (Shephard et al., 2019). A negative maternal perception of the child’s health was also associated with lower IQ scores (Camargo-Figuera et al., 2014).
Social risk factors
Socioeconomic vulnerability and food insecurity
Studies have pointed to a strong association between economically disadvantaged contexts and delays in neuropsychomotor development (L. B. Araujo et al., 2017), particularly in the cognitive (Fernandes et al., 2012; Hass et al., 2023; Neves et al., 2016; Panceri et al., 2020), language (Caldas et al., 2014; Hass et al., 2023; Neves et al., 2016; Panceri et al., 2020; Tella et al., 2018), and motor domains (Panceri et al., 2020; Pereira et al., 2016; Saccani et al., 2013; Tella et al., 2018), as well as in perceptual-motor skills (E. M. M. Santos et al., 2020). Low household income was associated with an increased risk of delays in expressive communication among infants with twin-twin transfusion syndrome (D. Campos et al., 2016). In addition, low family income emerged as a significant predictor of low IQ (Camargo-Figuera et al., 2014). Children from families with low monthly income, lower socioeconomic status, and food insecurity were at greater risk for delays across multiple developmental domains (Correia et al., 2019).
Low parental education
Low maternal education was associated with deficits in cognition (Camargo-Figuera et al., 2014; Panceri et al., 2020; Shephard et al., 2019; Tella et al., 2018), language (Lima & Cáceres-Assenço, 2022; Panceri et al., 2020; Tella et al., 2018), and motor skills (Panceri et al., 2020). Higher maternal education was linked to greater engagement in home-based stimulation, especially among children with biological risk factors (Abreu et al., 2024). E. V. Silva et al. (2024) found that maternal education was the most important variable in predicting CD, followed by paternal education.
Unfavorable family, environmental and institutional conditions
Situations such as single-parent families (L. B. Araujo et al., 2017; Góes et al., 2015), multiparity (Kofke et al., 2022), overcrowding at home (Camargo-Figuera et al., 2014) and precarious habitations (Neves et al., 2016) and poor-quality neighborhoods (Neves et al., 2016) were linked to low development scores. Racial and social inequalities were also highlighted: children whose both parents were not white (Camargo-Figuera et al., 2014) belonged children identified as Black or ethnic/racial groups (Sánchez-Luquez et al., 2024) presented greater risk for delay. Recent exposure to community violence was associated to lower scores for self-regulation, externalizing problems and deficits in global development (McCoy et al., 2024). Attendance to nurseries after the first year of life was negatively associated with motor development (Saccani et al., 2013) whereas children who attended the CEI part-time presented a significantly increased risk for developmental concerns in comparison to children who attended the institution full-time (Yamaguchi et al., 2019). Not going to school was a significant predictor of low perception-motor skills in children aged 4 to 5 years (E. M. M. Santos et al., 2020). The unemployment of a child’s parents was linked to lower IQ scores (Camargo-Figuera et al., 2014). The high in risk factors to form the Social Risk Index (SRI), was related to loss especially in the language and social behavior domains (J. A. T. Santos et al., 2024). Finally, the precocious use of digital media with non-educational content, without adult mediation and with multiple screens was significantly associated with low cognitive scores for children after their 12th month of life (Pedrotti et al., 2024).
Biological protective factors
Breastfeeding, especially when it is exclusive (at hospital release) or prolonged, was presented as a protective factor for cognitive and language development (Camargo-Figuera et al., 2014; Hass et al., 2023; Kofke et al., 2022; Orioli et al.,2024). Child cognitive maturity presented itself as a predictor for motor cognition (Caruzzo et al., 2020). The practice of physical activities during pregnancy, provided evidence that physically active women were more likely to have children with better scores in neuropsychomotor development at twelve months of age (Domingues et al., 2014). Advanced maternal age also emerged as a protective factor that was associated to improved gross motor skills (Abreu et al., 2024).
Psychological protective factors
Stimulating parental practices, including home interaction (Abreu et al., 2024; Neves et al., 2016; D. G. Ribeiro et al., 2014b), playing that involves movement for the baby (Saccani et al., 2013), encouragement to take on challenging postures (Pereira et al., 2016) and better emotional/verbal responses (Fatori et al., 2021) were positively associated with motor, cognitive, and expressive language development. Cognitive stimulation was positively associated with IQ at the age of 6 years, regardless of genetic predisposition (Sánchez-Luquez et al., 2024). Interventions based on the reading of materials out loud by parents and their children promoted significant gains in receptive language and enhanced the quality of mother-child interactions in the home context (Weisleder et al., 2018).
Social protective factors
The variety of stimuli in the home environment significantly benefits cognitive and motor development in small children, including premature infants (Abreu et al., 2024; Hass et al., 2023). The larger quantity of toys and diversity of home physical space were significantly associated with higher cognitive scores (Pereira et al., 2016). The participation of nurseries in the first year of life and access to health services, such as the Family Health Strategy (FHS) (Estratégia Saúde da Família (ESF)), are important support networks for monitoring and for precocious stimulation (A. C. D. Silva et al., 2015). In the family realm, having a mother that worked outside the home was associated with better CD results (D. G. Ribeiro et al., 2014a). Parents’ knowledge of CD also stood out as a protective factor for development, even though it was partial (Hass et al., 2023). In the context of the Covid-19 pandemic, it was possible to observe that children who were submitted to less rigorous social distance presented better performance in gross motor activities (Abreu et al., 2024). Structured interventions focusing on family support, such as home visit programs for adolescent mothers, demonstrated positive effects in the development of expressive language as well as in the indicators of home environment quality (Fatori et al., 2021).
Discussion
This study aimed to analyze the relationship between biopsychosocial risk and protective factors and CD during early childhood, using a sample of Brazilian children.
There is a notable predominance of social and biological risk factors-such as socioeconomic vulnerability, preterm birth, and male sex-and their association with neuropsychomotor developmental delays. It is possible to verify that, although biological factors are strongly associated to risk of developmental delay, social risk factors such as low parental income and education stand out as the most consistent determinants across the analyzed studies. Moreover, the negative impact of these risks is amplified when combined with psychosocial factors such as maternal mental disorders, exposure to violence, low levels of stimulation at home and, more recently, the direct and indirect effects of the Covid-19 pandemic. On the other hand, the review also verified that responsive parental practices, stimulating home environments, prolonged breastfeeding, early interventions based on the family, and integrated public policies (such as home visits and conditional cash transfers) serve as robust and protective factors capable of promoting positive developmental trajectories even in contexts marked by multiple risk factors.
The systematization of these findings makes an original contribution to the field by compiling recent national evidence. It reinforces the importance of intersectoral public policies that not only address clinical and perinatal conditions but also act directly to reduce social inequalities and to strengthen families as key environments for promoting development in early childhood.
Furthermore, the results in this systematic review support existing evidence that biopsychosocial factors might generate a negative or a positive impact in the development of Brazilian children, thus being classified as risk factors or protective factors for CD, respectively. These results are also consistent with the findings of studies conducted by Formiga (2009), Caldas et al. (2014) and D. M. Araujo et al. (2020) when it comes to the multifactorial characteristic of the development process and of the cumulative concept of risk and protective. It is important to emphasize that the analyzed variables do not inherently constitute risk or protective factors. Rather, their classification depends on the multifactorial context in which they occur, and they may acquire different valences depending on the specific context and established combinations (Pérez-López & Sánchez-Caravaca, 2008). To illustrate this, the review data indicate that variables such as maternal education and socioeconomic level are associated with CD, where lower levels were identified as risk factors, while higher levels were described as protective factors during early childhood.
Socioeconomic vulnerability emerged as one of the most frequently examined variables in the studies included in this systematic review, highlighting its central role in the multiplicity of risks CD. It reinforces the additive and intensifying nature of social risks when combined with biological vulnerabilities. Studies have shown that children who were exposed to multiple layers of social disadvantages presented higher risk of developmental delays, even when born at term and without clinical complications (Camargo-Figuera et al., 2014; Correia et al., 2019). According to Duncan and Brooks-Gunn (2000), chronic poverty was considered an impact factor that was more persistent and detrimental factor to cognitive and motor development than temporary exposure to economic hardship. Poverty, low maternal education, precarious housing conditions and family environment with low-stimulation are adversities that negatively affect CD (Black et al., 2018; Camargo-Figuera et al., 2014; Correia et al., 2019; Hass et al., 2023; Neves et al., 2016; Venancio et al., 2022; Walker et al., 2011). These disparities might contribute to the perpetuation of the poverty cycle into adulthood (Lu et al., 2020; Sania et al., 2019; Venancio et al., 2022; Walker et al, 2007, Walker et al., 2011). According to Walker et al. (2011), there is a significant inequality in the development of programs and public policies for early childhood in underdeveloped and emerging countries. The authors also emphasize the importance of such initiatives in supporting children living in social vulnerability across the globe, with the aim of mitigating global disparities.
The male sex variable was frequently associated with poorer developmental outcomes. Studies such as the ones by Fernandes et al. (2012) and Fink et al. (2018) demonstrated that preterm boys or those small for gestational age exhibited lower neuropsychomotor results when compared to girls under the same conditions. Similarly, boys living in poverty presented a higher risk of developmental delays, supporting the hypothesis that the male sex functions as an indicator of greater sensitivity to adverse contexts rather than as an isolated causal determinant (Correia et al., 2019; Camargo-Figueira et al., 2014; E. M. M. Santos et al., 2020). Explanations based on cultural expectations and different standards for caretaking according to gender have been proposed to account for these findings (Correia et al., 2019; E. M. M. Santos et al., 2020). Therefore, although the male sex was widely cited as being associated with developmental delay risks, its interpretation must not be based on direct causality, but rather viewed as a marker of population-level vulnerability (Camargo-Figuera et al., 2014). Its significance must be regarded in relation to environmental and social contexts. This finding reinforces the importance of developing gender-sensitive approaches in CD promotion policies, viewing sex not as an inherent difference but as an indicator of specific needs (Camargo-Figuera et al., 2014).
According to the classification by the World Health Organization (WHO) (2015), preterm infants are those born before 37 weeks of gestation, while those born between 37 and 42 weeks are considered full-term. The high number of studies on preterm birth (PTB) in Brazil, compared to other identified risk factors, may be related to the fact that the country ranks among the ten nations with the highest number of preterm births worldwide (WHO, 2018). Between 2012 and 2022, a total of 3,530,568 preterm births were recorded in Brazil (Ministério da Saúde, 2024). It is also important to highlight that the cost of PTB for the Brazilian public health system exceeds R$ 8 billion per year (J. O. Campos et al., 2020). It is well known that children born preterm may exhibit subtle developmental disturbances, even in the absence of severe neurological disorders (Ballot et al., 2012; Brown et al., 2014; Guerra et al., 2014). These findings justify and reinforce the need for studies that promote preventive measures against PTB, as well as sustained attention and continued advances in mitigating its impact.
Factors such as PTB, low parental education, and LBW were associated with lower CD scores in early childhood. These findings corroborate the meta-analysis conducted by Sania et al. (2019), which aimed to assess the magnitude of the relationship between risk factors and cognitive, motor, and language development in children under seven years of age living in low- and middle-income countries. This study was among the first to report statistically significant associations between lack of access to clean drinking water and basic sanitation and poorer cognitive development in children. It also identified additional risk variables, such as short maternal stature and childhood anemia. Despite the relevance of these findings, our review did not identify these specific risk factors; instead, they appeared broadly categorized under socioeconomic vulnerability and inadequate infrastructure. This discrepancy may be related to differences in eligibility criteria, as the study by Sania et al. (2019) included a global sample. However, these data point to a lack of studies using Brazilian samples that examine the association between these variables and early childhood development (an alarming gap for a developing country). Therefore, future research should investigate the relationship between lack of access to clean water and basic sanitation and CD. According to the Sanitation Ranking published by Instituto Trata Brasil in partnership with GO Associados (2022), based on data from SNIS 2020, more than 35 million Brazilians lack access to treated water, 100 million are not served by sewage collection systems, and only 50% of sewage is treated in the country.
According to the 2023 report by the Food and Agriculture Organization of the United Nations (FAO), there has been an increase in hunger indicators and limited access to adequate food in Brazil. According to 2022 data, approximately 70.3 million individuals experienced moderate situations of food insecurity, meaning they faced difficulties in accessing sufficient food (FAO, 2023). In addition, it was identified that 21.1 million Brazilian people suffered from serious food insecurity between 2020 and 2022 (FAO, 2023). These findings also reflect the period of the COVID-19 pandemic, which marked a critical scenario of risk to CD, exacerbating preexisting inequalities and vulnerabilities across all Brazilian regions.
Social distance measures directly affected the routines of families by reducing access to healthcare, education, and psychosocial support services (Figueiredo et al., 2021). Studies such as those by P. Y. F. Silva et al. (2023) and Pedrotti et al. (2024) demonstrated that the deprivation of social interaction, increased parental stress, and the replacement of family engagement with excessive screen time has been associated with deficits in the motor and cognitive development of young children. These findings are corroborated by Murray et al. (2023), who reported psychosocial and economic risks resulting from the COVID-19 pandemic, with a direct effect on the mental health of caregivers and children, and the intensification of pre-existing inequalities. Furthermore, the research indicated that for children whose mothers were infected by the SARS-CoV-2 virus during their intrauterine period, exhibited greater developmental delays (Pinheiro et al., 2024; C. A. D. Santos et al., 2024; P. Y. F. Silva et al., 2023). The results by Orioli et al. (2024), with a sample of newborns who were exposed to SARS-CoV-2 in the perinatal period, show that COVID-19 was not a risk factor for intrauterine growth restriction, but it was possible to verify that the rate of premature births on the sample was 46.3 %, which, according to the authors, is possibly the result of the impact of COVID-19 on maternal health. Additionally, it was verified that PTB (gestational age < 36 weeks) was the greatest risk for cognitive development. There is a clear need for further research in this area to better understand the biological, social, and psychological impacts of the COVID-19 pandemic, considering the characteristics of the different regions of Brazil, on the development of Brazilian children and on their families' quality of life, especially during early childhood, which is a period when children build the foundations for subsequent phases of development. It is also a period in which children are particularly sensitive and responsive to interventions (Black et al., 2017; Walker et al., 2011).
A divergence was observed regarding the type of delivery. Some studies indicated that birth by cesarean section was associated with lower developmental scores (Caldas et al., 2014; Pinheiro et al., 2024; A. C. Zago et al., 2023 ). However, A. C. D. Silva et al. (2015) identified vaginal delivery as a contradictory risk factor. These discrepancies suggest that the type of delivery alone does not determine developmental outcomes; rather, that the associated clinical and perinatal contexts must be taken into account (A. C. D. Silva et al., 2015). Thus, future studies should control for confounding variables, such as the quality of obstetric care and neonatal complications, in order to clarify the relationship between delivery type and neuropsychomotor developmental delays.
Regarding protective factors, the data show a significant decline across all domains when compared to risk factors, highlighting a scarcity of studies that emphasize the perspective of fostering development rather than merely avoiding risks. Notably, in the context of protective factors, the social domain appears to surpass the biological domain. Overall, the studies included in this systematic review highlight a range of strategies to promote CD. Among these, the orientation of families toward early stimulation practices, including responsive interactions, enriched environments, and structured parental support interventions, all of which emerged as important factors in mitigating the negative effects of biopsychosocial risks (Abreu et al., 2024; Fatori et al., 2021; Hass et al., 2023; Neves et al., 2016; D. G. Ribeiro et al., 2014b; Weisleder et al., 2018). However, there remains a shortage of studies focusing on protective factors, particularly longitudinal studies aimed at early interventions that promote resilience, as supported by previous national reviews (Maia & Williams, 2005; Morais et al., 2016).
Among the limitations of the present study, it is worth mentioning the absence of a registered review protocol and the lack of quantitative analyses. In addition, the included studies exhibited substantial heterogeneity, with most adopting a cross-sectional design and statistical approaches that did not allow for the assessment of causal relationships between the studied variables. It is important to highlight the need for future research with the following characteristics: expanded measurement of the impact of COVID-19 on the development of Brazilian children in early childhood; investigations into how risk factors, such as inadequate sanitation and screen time, affect development; studies focused on protective factors for early childhood development and the effectiveness of intervention models as mechanisms to promote human potential; and meta-analyses aimed at measuring the relative weight (valence) of risk and protective factors, in order to provide guidance for inter-, multi-, and transdisciplinary teams in designing and implementing early intervention strategies for CD.
Risk and protective factors are understood through the analysis of multiple variables, such as the social context, and socioeconomic, environmental, cultural, family, and genetic factors, as a consequence, they are not studied in isolation (Black et al., 2017; Walker et al., 2011). Therefore, it is essential that risk and protective factors be examined by multidisciplinary and interdisciplinary teams, while considering the diverse conditions that are involved and the impact of these relationships in the lives of individuals. In addition, the promotion of research aiming at the understanding of protective factors for the development of biopsychosocial dimensions would lead to early interventions designed to create opportunities for mitigating the negative effects of risk factors, and consequently, significantly altering the quality of life of individuals and their families, as well as promote preventive health policies.
Conclusion
In conclusion, the evidence gathered in this systematic review indicates that a range of biopsychosocial risk factors contributes to disparities in the development of Brazilian children. Although research on protective factors for child development remains limited in comparison to studies on risk factors, the findings highlight key variables that function as enhancers, promoters, and protectors during early childhood.
Comprehensive care for Brazilian children is structured under the aegis of health, education, and social action, which aim to promote the conditions necessary for achieving their full developmental potential. Thus, ongoing assessment and monitoring of CD by different fields of knowledge is considered an important mechanism for management, especially during the period of greatest neural plasticity: early childhood (Black et al., 2017; Walker et al., 2011). Through such efforts, it is possible to identify developmental adversities at an early stage and promote actions that prevent, minimize, or eradicate negative effects. In this context, it is necessary to recognize the complexity of human relations from childhood onward, from biological, psychological, and social perspectives. Therefore, interventions that focus on the reduction of risk factors might enhance the realization of human potential when it comes to CD in early childhood, which extends into adult life and the next generation (Walker et al., 2011). Thus, investment in public policies for family, education, healthcare, and community environments might alter the trajectory of social inequalities that continue to cause suffering in the lives of Brazilian children and their families, ultimately contributing to improved quality of life.
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Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
How to cite: Messias, T. da G., Krainski, K. J., Felipin, L. F., & Riechi, T. I. J. de S. (2025). Risk and protective factors for the development of children aged 0 to 6 years in Brazil: A systematic review. Ciencias Psicológicas, 19(1), e-3974. https://doi.org/10.22235/cp.v19i1.3974
Authors’ contribution (CRediT Taxonomy): 1. Conceptualization; 2. Data curation; 3. Formal Analysis; 4. Funding acquisition; 5. Investigation; 6. Methodology; 7. Project administration; 8. Resources; 9. Software; 10. Supervision; 11. Validation; 12. Visualization; 13. Writing: original draft; 14. Writing: review & editing. T. da G. M. F. has contributed in 1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14; K. J. K. in 2, 3, 5, 6, 9, 11, 14; L. F. F. in 2, 5, 6, 12, 13; T. I. J. de Sá R. in 1, 7, 10, 11, 14.
Appendix A
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Table A1: Search Strategies in Scientific Databases for Studies on Risk and Protective Factors for Child Development
Note: The last search was conducted on March 20, 2024, and was limited to the title, abstract, and/or keywords of the articles. Filters were used in order to restrict results to only scientific articles reviewed by peers, in accordance with inclusion criteria such as publication year (2014-2024), language (English, Spanish, or Portuguese), and studies involving human subjects.
Note:*The items correspond to the checklist, according to each delineation, available in Critical Appraisal Tools on the JBI page, which can be accessed at https://jbi.global/critical-appraisal-tools
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Received: March 23, 2024; Accepted: April 26, 2025
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