1. Christine Powell Child Development Research Group, Tropical Medicine Research Institute, UWI, Mona, Jamaica

2. Why focus on early childhood?  Brain development most rapid and vulnerable from conception to 5 years. Modified by the quality of the environment.  Undernutrition, iron deficiency, environmental toxins, stress, poor stimulation and social interaction can affect brain development and have lasting effects.  Interventions can have lasting effects especially if done early

3. Why focus on early childhood?  Interventions are more cost effective than at other ages  Early cognitive ability & socio-emotional development are strong determinants of progress in school  Children who have better early development are less likely to be retained in grade, to drop out of school and are more likely to have better school achievement scores

4. Stunting in children Several cross-sectional studies have shown an association between stunting and poor cognition or school achievement  Children are less likely to be enrolled in school or to enrol late  Attain lower achievement levels or grades  Have poorer cognitive ability or achievement scores

5. Stunting in children Longitudinal studies have also shown that children who are stunted before age 3 years show poorer levels of cognition, school achievement and IQ up to age 18 years.  Indonesia & South Africa – cognitive tests at 7 years  Peru – cognition at 9 years  Philippines – IQ at 8 and 11 years  Jamaica – school achievement and cognition at 17-18 years  Brazil – attained grade at 18 years  Guatemala – schooling and IQ 18-26 years

6. Mean Developmental Quotients on Griffiths Test DQ Age months Urban middle class n=78 Urban poor n=268 Walker et al 1990

7. Can psychosocial stimulation interventions help?

8. Several approaches Centre based – preschool mostly child focussed Centre based – preschool mostly child focussed Home visiting – parent and child focussed Home visiting – parent and child focussed Comprehensive ECD, health and nutrition Comprehensive ECD, health and nutrition Individual counselling at health visits Individual counselling at health visits Parenting groups, at health centres or community groups Parenting groups, at health centres or community groups

9. Study Design Included Studies with pre and post tests of child development Studies with pre and post tests of child development Studies with matched controls Studies with matched controls Studies with randomised controls Studies with randomised controls

10. Developed countries Long term benefits from high quality early intervention Higher verbal and math scores Higher verbal and math scores Less grade repetition and higher graduation rates Less grade repetition and higher graduation rates Higher employment and earnings Higher employment and earnings Better health outcomes Better health outcomes Less welfare dependency Less welfare dependency Lower crime rates Lower crime rates

11.  focus on mother & child  mothers change sustainability  focus on precise level of child’s development  other siblings benefit  neighbourhood spread  lower cost  <3 years better at home Home-visiting Approach Home-visiting Approach

12. Goals of visit Increase mother’s ability to promote her child’s development through play Increase mother’s ability to promote her child’s development through play Improve mother-child interaction Improve mother-child interaction Promote self esteem of mother and child Promote self esteem of mother and child Encourage mother to continue activities between visits and integrate into daily routine Encourage mother to continue activities between visits and integrate into daily routine

13. Approach to visit Emphasis on verbal interaction Emphasis on verbal interaction Structured curriculum centered around play activities Structured curriculum centered around play activities Ensure mother and child experience success Ensure mother and child experience success Praise for mother and child Praise for mother and child

14. Focus on mother Focus on mother

15. Home made toys Paraprofessionals

17. Intensity of visits? Duration of program?

18. Effects of visiting frequency in disadvantaged children DQ Powell & Grantham-McGregor, 1989 fortnightly monthly no visits 94 98 102 106 110Pre-testPost-test weekly

19. Duration Although benefits to development are seen within 6 months no evidence that these will be sustained if intervention ends. Although benefits to development are seen within 6 months no evidence that these will be sustained if intervention ends. Studies demonstrating sustained benefits intervention continued for 18-24 months. Studies demonstrating sustained benefits intervention continued for 18-24 months.

20. Integrated with nutrition?

21. RCT of 20 Community Nutrition Centres in Bangladesh Hamadani et al, 2006) in Bangladesh ( Hamadani et al, 2006) Visited homes 2 weekly for 1 yr

22. RCT of stimulation with malnourished Bangladeshi infants: Effect on mental development index (MDI) Rx p<.05 Hamadani et al, 2006 MDI

23. Stunted 9-24 months Randomised (n=129) Control Supplement Stimulation Both 33 32 32 32 33 32 32 32 Jamaican study of supplementation & stimulation

24. Stimulation: Weekly 1hr home visits by community health aides. Play session with mother and child. Focus on: Enhancing maternal- child interactionsEnhancing maternal- child interactions LanguageLanguage PraisePraise Showing mother how to promote development through playShowing mother how to promote development through play

25. Combined nutritional supplementation & stimulation with stunted children: RCT Non-stuntedControl Grantham-McGregor et al, 1991 Both Rxs Supplemented Stimulated DQ

26. Questions Are benefits sustainable?

27. Follow-up at age 22 years The effects of early childhood stimulation on economic, cognitive and social outcomes The effects of early childhood stimulation on economic, cognitive and social outcomes Measurements : IQ, education, employment, financial independence, family and social relationships, sexual relationships, drug use and violent behavior. Measurements : IQ, education, employment, financial independence, family and social relationships, sexual relationships, drug use and violent behavior.

28. Benefits of Stimulation at age 22y IQ p=0.003 p=0.004 p=0.02

29. Benefits of Stimulation at age 22y Education p=.004 p=.014 p=.005

30. Benefits of Stimulation at age 22y Educational attainment  Significant increase in grade level attained – 0.5 grade, studies elsewhere suggest this will be associated with increased adult income  Significantly more CXC examination passes 18.9% with 4 or more passes compared with 9.6% in no stimulation groups  Stimulation groups less likely to be expelled from school

31. Benefits of Stimulation at age 22y Psychological Functioning p=.03 p=.05

32. Benefits of Stimulation at age 22y Reduced violent behaviour p=.04 p=.06

33. No significant benefits to: No significant benefits to:  family relationships  alcohol and drug use  teenage pregnancies  community involvement

34. Summary Young adults who received early childhood stimulation through a parent and child focused home visiting programme Young adults who received early childhood stimulation through a parent and child focused home visiting programme  better cognitive ability  better educational attainment  better psychological functioning  Less violent behaviour

35. Can stimulation be integrated into routine primary health care? into routine primary health care?

36. Integration into services Home-visiting approach to early childhood stimulation with parent and child focus has sustained benefits Home-visiting approach to early childhood stimulation with parent and child focus has sustained benefits Programme delivered by Community Health aides employed to our research unit Programme delivered by Community Health aides employed to our research unit Can the programme be effectively delivered to more high risk children by integrating with existing services? Can the programme be effectively delivered to more high risk children by integrating with existing services?

37. Sustainable approach Health services provide most comprehensive contact with children aged 0-3 years Health services provide most comprehensive contact with children aged 0-3 years Community Health Aides existing cadre of staff Community Health Aides existing cadre of staff Feasible to integrate early childhood stimulation into these services? Feasible to integrate early childhood stimulation into these services?

38. Intervention Clinic community health aides (CHA’s) trained in psychosocial stimulationClinic community health aides (CHA’s) trained in psychosocial stimulation Weekly home visiting with mothers and childrenWeekly home visiting with mothers and children Quality of sessions maintained maintained through regular supervisionQuality of sessions maintained maintained through regular supervision

39. Study Design 18 Nutrition Clinics Randomly assigned 11 Intervention Clinics - 70 children - 70 children 7 Control Clinics - 69 children - 69 children 65 children 64 children 5 lost

40. Effect of Intervention by Primary Health Care Staff on DQ of Moderately Malnourished Children Control n=69 Intervened n=70 Rx p<.001 Powell et al, 2004 DQ

41. Do the mothers benefit?

42. Change in Knowledge of Mothers of Intervened and Control Children KnowledgeScore p <.001

43. Change in Practices of Mothers of Intervened and Control Children Practices Score p <.001

44. Change in Maternal Depression With Intervention Baker et al, 2005 Rx p <.05 Intervened Control Depression

45. Summary  The intervention was effective in improving the development of the children and their mothers' child rearing knowledge and practices.  It was feasible to use existing staff to integrate child development activities into primary health care services for undernourished children.  On average children were visited every 10-11 days

47. Intervention with term low birth weight infants

48. Intervention Weekly 1 hour visits by CHAs for 8 weeks from birth focused on improving maternal responsiveness Weekly 1 hour visits by CHAs for 8 weeks from birth focused on improving maternal responsiveness Weekly 1/2 hr visits from 7-24 months focused on helping the mothers become more effective teachers of their children and enhancing maternal-child interactions. Weekly 1/2 hr visits from 7-24 months focused on helping the mothers become more effective teachers of their children and enhancing maternal-child interactions.

49. Benefits of intervention for LBW infants Better problem solving ability at 7 months LBW Better problem solving ability at 7 months LBW Infants more happy and cooperative Infants more happy and cooperative Higher developmental levels at 24 months Higher developmental levels at 24 months

50. Follow-up at age 6 years Significant benefits to performance IQ (reasoning, problem solving) and memory Significant benefits to performance IQ (reasoning, problem solving) and memory No benefits to language No benefits to language Significant reduction in behaviour difficulties (by maternal report on SDQ). May be important for transition to primary school Significant reduction in behaviour difficulties (by maternal report on SDQ). May be important for transition to primary school

51. Other approaches

52. Other approaches to delivering interventions for children 0-3 year Parenting programmes Parenting programmes  Individual counselling at health visits  Parenting groups, at health centres or community groups

53. WHO/UNICEF - Care for child development Key Goals  Target children aged from birth to 3 years  Focus on children most at risk  Integrate interventions – health, nutrition and stimulation  Improve knowledge and skills of mothers and caregivers

54. Guidelines and training for health care providers to counsel parents on how to promote development Guidelines and training for health care providers to counsel parents on how to promote development Counselling cards with age specific messages and activities Counselling cards with age specific messages and activities

55. Individual counselling Limited evaluation of CCD or other individual counselling programmes Limited evaluation of CCD or other individual counselling programmes Need to consider time and staff availability at clinics Need to consider time and staff availability at clinics

56. Parent groups Few impact evaluations Few impact evaluations Study beginning to evaluate benefits of health centre based intervention with use of video messages followed by discussion and practice Study beginning to evaluate benefits of health centre based intervention with use of video messages followed by discussion and practice

57. Integrating delivery with well child visits Only 6 - 8 contacts Only 6 - 8 contacts Little contact after 18 months Little contact after 18 months  how to reach children in second half of 0-3y period

58. What we know Significant benefits from home visiting delivered by CHAs Significant benefits from home visiting delivered by CHAs Weekly home visiting for 2 years had lasting benefits to adulthood Weekly home visiting for 2 years had lasting benefits to adulthood Visits must be at least fortnightly to benefit development Visits must be at least fortnightly to benefit development Home visiting can be integrated into health services Home visiting can be integrated into health services Supervision is essential to maintain quality of visits Supervision is essential to maintain quality of visits

59. What we need to know Evaluation of other approaches to delivery of parenting programmes Evaluation of other approaches to delivery of parenting programmes Is individual counseling feasible and effective Is individual counseling feasible and effective Impact of parenting programmes delivered to groups Impact of parenting programmes delivered to groups How to reach children 18-36 months How to reach children 18-36 months