Early Childhood Development in South East Asia Dr. Neena Raina Regional Advisor, Child and Adolescent Health WHO/SEARO

Are you aware that At birth there are 1 billion brain cells Brain of a six month old is half and that at 8 years is 90% that of an adult in weight Most of the synaptic connections (wiring) takes place during the early years of life. Rewiring cannot take place later in life Maturity of brain is characterized by pruning . Excess of neurons and synapses are eliminated. This pruning is guided by the environment during the early years of life

Rethinking of the brain Old thinking New thinking Brain development depends on the genes Experiences before 3 years age have a limited impact on later development and personality Secure relationship with a caregiver helps early development and learning Brain development is linear Early brain development is slow as compared to an adult Brain development depends on the interaction between genes and the experiences Early experiences influence architecture of the brain and extent of adult capacity Secure relationship with a care giver affects early development and wiring of brain Brain development is maximal in early years (including pregnancy) Brain is twice as active at three as compared to college student

Synaptic Density At Birth 6 Years Old 14 Years Old 03-012 There are an estimated 1000 trillion synapses at 8 months age. A pruning takes place and brain forgets and loses synapses that are not used. Detailed analysis of the patterns of nerve connection that form from birth to age 14 have been carried out. This slide which comes from the work of Huttenlocher shows the connections amongst the neurons at birth is not intense but that by the age of 6 the connection density is considerable. By the age of 14, the connection pattern is still greater than at birth but is less intense. The weak pathways have been cut out. This process is referred to as the wiring and sculpting of the brain. The wiring of neurons in the brain is hugely influenced by stimulation and the use of these neuron pathways. Thus, as you age, pathways that are not intensely used will disappear. What this evidence does show you is that the early period of life has a significant effect on the wiring and sculpting of the brain. Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

This PET scan of the brain of a normal child show regions of high activity shown in red and low shown in blue and black . At birth only primitive structures such as the brain stem shown in the center are fully functional. In regions are the temporal lobes on the top early childhood experiences wire the circuit.

PET scan of an abused brain shows severe deprivation in early infancy Black areas are predominant. Such children suffer emotional and cognitive problems

Stunting is associated with Reversing the developmental effects associated with stunting (low height for age) 31% of children under 5 years of age in developing countries are stunted (SOWC 2007), 46% in India (Status of the World’s Children 2006) Stunting is associated with Poor developmental attainment in young children (Walker, et al., 2007) Up to 46% less income earned as adults due to poorer school achievement and lower intelligence levels (Bundy, 1996; Hoddintott, et al., 2008) 7

Bogotá Project: Effects of supplementation and stimulation on growth and weight (results at age 7) Van der Gaag, J. School Performance and Physical Growth of Underprivileged Children: Results of the Bogotá Project at Seven Years. (1983). World Bank, Washington D.C.

Bogotá study (continued) At age 7, children who had received supplementation and stimulation in early childhood Physical growth: Less than 20% were stunted, compared to 50% in the control group Development: Better reading readiness scores Better mathematics scores and basic knowledge (preschool achievement test scores) Results especially strong for chidren of fathers of low to moderate levels of education and literacy (a proxy for SES)

The Jamaica Study Grantham-McGregor, et al. , 1991 Looked at the effects of nutritional supplementation and psychosocial stimulation on stunted children aged 9-24 months An experimental intervention study 129 children from poor neighboorhoods were randomly assigned to four groups: Control Supplemented only Stimulated only Supplemented plus stimulated And a matched comparison group of non-stunted children 10

Jamaica Project: Effects of supplementation and stimulation on the mean development quotient of stunted groups compared with non-stunted groups Development quotient includes practical reasoning, eye and hand coordination, hearing and speech, and performance. S.M. Grantham-McGregor, et al. (1991). 11

Jamaica Study: The effects of the stimulation intervention at age 17-18 years p (significance) 0.1 .001 .01 .05 .02 .1 .02 standard scores UNICEF Walker, et al. (2005) 12 12

Findings from the Lancet series on child development (2007) An estimated over 200 million children under age 5 are not developing their full potential The cost in economic potential is 20-29% of each adult worker’s income per year The best documented risks are stunting, iron deficiency, iodine deficiency, and lack of stimulation Poor growth and poor development are closely related 13

Key messages Lancet 2011 Biological and psychosocial risks affects the developing brain. Risks are poverty, malnutrition and lack of stimulation. Breast feeding, cognitive stimulation and maternal education are important to tackle the risks. Inequalities in child development begin prenatally and in the first years of life, and increase over time. Reducing inequalities requires early integrated interventions that reduce risks and promote child development. The most effective and cost-efficient time to prevent inequalities is early in life. Parenting interventions and center-based programmes (preschools) can improve children’s development. Quality in Early Child Development programmes can be maximized through design, curriculum, parent involvement, and training and supervision for workers Increasing preschool enrolment in each low- and middle-income country would result in a benefit of between US $10 - $34 billion

Sensitivity (Care giver) The caregiver is aware of the infant’s signals and interprets them accurately The caregiver accepts the child’s interests, gives physical affection, is positive To be sensitive, the caregiver must be able to Regard the child as a separate person See things from the child’s point of view

Responsiveness of the care giver The response of the mother depends on, or is triggered by, the child’s signal This should be recognized early and matched by a response by the care giver To be responsive, the caregiver must be sensitive

Responsiveness to child language affects language development Tamis-LeMonda, et al. 2001 17

Sensitivity and responsiveness (care giver) : To be effective in caring for a young child—sick or well, e.g.: Breastfeed on demand, feed responsively Protect a child from imminent harm Recognize and seek care when the child is sick See cause and effect in the environment and in social relationships Learn to speak, solve problems

Attachment Primarily a process of the infant forming a relationship with his or her mother (infant to mother): attachment is reinforced by the responses of the mother (or other primary caregiver) Occurs in first two years of life, but especially between 2 and 7 months of age Child develops a personal communication system with the primary caregiver……by receiving an appropriate response from the caregiver

Consequences of poor attachment A break leads to: Confusion (‘lost in a strange country without an interpreter’) Lack of trust Increasing rage or depression Shutting down—’non-organic failure to thrive’ When there is no primary caretaker, child attaches to things, environment, routines, etc. and has difficulty adapting to any change

Bonding The process of a mother forming a relationship with her new infant (mother to infant) Begins during the first few hours after birth

High risk conditions for bonding Mother Separated from infant for a period after birth Poor health, for example, as many as 40% of mothers are depressed after delivery, Characteristics of child About a quarter of low birth weight babies were abused and failure to bond was the reason) -children with illness or undernourished children frequently are abused due to lack of bonding

ECD and long term effects In an unstimulating, emotionally and physically unsupportive environment their brain development is affected in adverse ways. Many problems in adult life have their origins in pathways that begin in childhood. In the short term, ECD influences ‘readiness for school’. Over the first and the second decade of life it influences school success, social success or rejection, stunting, early criminality and the prospects for a successful transition to citizenship.

ECD and long term effects By the third and fourth decade of life it influences mental health (depression and anxiety disorders), physical health (obesity, blood pressure, heart disease, non-insulin dependent diabetes), and socioeconomic mobility. From the fifth decade onward, it influences a wide range of chronic diseases as well as the prospect of healthy aging

Why invest in early childhood development ? At the most basic level it improves child survival ECD helps development, goes beyond survival, builds social capital with return of seven times Helps to break the intergeneration cycle of poverty and malnutrition Contributes to reduction of gender inequities ECD builds social capital Helps build community networks to improve self care First line of defense in dealing with developmental delays and disability

Mismatch between Investment and Opportunity Preschool School Post School Age Evidence Cumulative Public Investment Optimal Investment Levels Source: Carneiro & Heckman, Human Social Policy (2003)

Age 1 week up to 6 months: Talk to your child and get a conversation going with sounds or gestures The first example is the recommendation for children age up to 6 months: Communicate with your child. Talk to your child and get a conversation going with sounds or gestures. Even with these still pictures you have an idea of how this mother gets a conversation going with her young child, even before the child is able to speak. Activities to imitate and communicate with her child help the mother interact responsively. They also prepare the child for learning language and the skills that form the basis for later social cooperation.

Age 12 months up to 2 years: Give your child things to stack up, and to put into containers and take out. Another example, the recommendation for play for the child age 12 months to 2 years, is: Give your child things to stack up, and to put into containers and take out. When the health worker counsels the mother on care, she gives the mother a chance to try-out a recommended activity. Here the health worker encourages the mothers to help their children stack the cups or put things into bowls. Around this activity, the mother interacts with her child. The health worker praises her, reinforcing this interaction. For example: See how your child enjoys playing with you. You are helping your child learn. In our experience with the course so far, we have seen mothers who interacted very little with their children until they were given a concrete play activity to do. The goal is to use this activity, like stacking cups, to try to change or improve her interaction with her child during the consultation. And help the mother to see ways she can help her child learn. 28

Adults are children’s first teachers

What can be achieved through CCD Reduction in deaths Children will be healthier Improved nutritional status School readiness, improved performance in school Greater adult productivity and income The gains are maximal if CCD can be focused on underprivileged groups in the society

Why ECD should be in the Health Sector? Regional Strategy: WHO-SEARO Why ECD should be in the Health Sector? Health: Overall well being Established MCH services: to support the critical period from prenatal period to first three years of life Synergy of good care and mother-child interaction for survival, growth, and development Tradition of health care providers as advisors for families

Entry points in Health Care System 9 Jan 2010 Entry points in Health Care System Sick child visit (e.g. IMNCI) Well-baby clinics Prenatal and newborn services (e.g. breastfeeding support) Nutrition clinics or feeding programmes Child care centers Mothers, groups Home visits: Community health workers Special services for children at risk Care and nutrition intervention, both are needed and can be delivered together Health system offers several opportunities for promoting ECD Whenever the caregivers of young children (especially < 3 years) come in contact with health care providers they should receive age-appropriate guidance for promoting ECD 9 Jan 2010 WHO- PEDICON

More Opportunities in Health Sector Home Visits for Newborn Care: Community Health Workers to visit homes for supporting post-natal care Community Case Management: Treatment of diarrhea and pneumonia Counselling on feeding and immunization Opportunity to integrate ECD activities

STRATEGIC DIRECTIONS Goal: To ensure that all children are able develop their full potential, recognizing that development is integrally related to child health and nutrition. Improving one without improving the other will not achieve the goal for ECD: A benefit for society

STRATEGIC DIRECTIONS All families receive information and guidance Special care given to disadvantaged and special needs children ECD incorporated at each level of the health system Child health policies Community health programmes Health care facility Goals should be to improve the well being of children during their most vulnerable period. This includes social, emotional, cognitive, and physical development. The means of doing that include providing families with guidance, providing additional support to families with disadvantaged children. How should this be done? Embed ECD At three levels: at the community level, through the community health programs; at the facility level, through advice and guidance to families and special attention to disadvantaged children; and at the higher level, through child health policies.

IMPLEMENTING ECD AT SCALE Advocacy for ECD with Policy makers Define the Vision and Goals for ECD in country Set up Coordinating Mechanism Develop Costed Plans Pilot programme models - Scale up Monitoring and evaluation plan

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