Significance Of Reaching Under Threes: Empirical Evidence

1. Significance Of Reaching Under Threes: Empirical Evidence 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 Urban middle class n=78 Urban poor n=268 Age months Walker et al 1990

7. Can psychosocial stimulation interventions help?

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

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

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

11. Home-visiting Approach • 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

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

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

14. Focus on mother

15. Home made toys • Paraprofessionals

17. Intensity of visits? Duration of program?

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

19. Duration • 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.

20. Integrated with nutrition?

21. RCT of 20 Community Nutrition Centres 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) MDI Rx p< .05 Hamadani et al, 2006

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

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

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

26. Questions Are benefits sustainable?

27. Follow-up at age 22 years • 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.

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

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

30. Benefits of Stimulation at age 22yEducational 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: • family relationships • alcohol and drug use • teenage pregnancies • community involvement

34. 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 Summary

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

36. 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 Can the programme be effectively delivered to more high risk children by integrating with existing services? Integration into services

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

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

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

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

41. Do the mothers benefit?

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

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

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

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

46. Starting intervention at birth

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 1/2 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 • Infants more happy and cooperative • Higher developmental levels at 24 months

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