Christine PowellChristine PowellChild Development Research Group, Tropical Medicine Child Development Research Group, Tropical Medicine

Research Institute, UWI, Mona, JamaicaResearch Institute, UWI, Mona, Jamaica

Brain development most rapid and vulnerable Brain development most rapid and vulnerable from conception to 5 years. Modified by the from conception to 5 years. Modified by the quality of the environment.quality of the environment.

Undernutrition, iron deficiency, environmental Undernutrition, iron deficiency, environmental toxins, stress, poor stimulation and social toxins, stress, poor stimulation and social interaction can affect brain development and interaction can affect brain development and have lasting effects.have lasting effects.

Interventions can have lasting effects especially Interventions can have lasting effects especially if done earlyif done early

Interventions are more cost effective than at Interventions are more cost effective than at

other agesother ages Early cognitive ability & socio-emotional Early cognitive ability & socio-emotional

development are strong determinants of development are strong determinants of progress in school progress in school

Children who have better early development Children who have better early development are less likely to be retained in grade, to drop are less likely to be retained in grade, to drop out of school and are more likely to have better out of school and are more likely to have better school achievement scores school achievement scores

Stunting in childrenStunting in children

Several cross-sectional studies have shown Several cross-sectional studies have shown an association between stunting and poor an association between stunting and poor cognition or school achievement cognition or school achievement Children are less likely to be enrolled in Children are less likely to be enrolled in school or to enrol lateschool or to enrol lateAttain lower achievement levels or gradesAttain lower achievement levels or gradesHave poorer cognitive ability or achievement Have poorer cognitive ability or achievement scoresscores

Stunting in childrenStunting in children

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

Mean Developmental Quotients Mean Developmental Quotients on Griffiths Teston Griffiths Test

DQ

Age monthsAge months

Urban middle class Urban middle class n=78n=78

Urban poor Urban poor n=268n=268

Walker et al 1990Walker et al 1990

Can psychosocial stimulation Can psychosocial stimulation

interventions help?interventions help?

Several approaches Several approaches

Centre based – preschool mostly child Centre based – preschool mostly child focussedfocussed

Home visiting – parent and child focussedHome visiting – parent and child focussed Comprehensive ECD, health and nutritionComprehensive ECD, health and nutrition Individual counselling at health visitsIndividual counselling at health visits Parenting groups, at health centres or Parenting groups, at health centres or

community groupscommunity groups

Study DesignStudy Design

IncludedIncluded Studies with pre and post tests of child Studies with pre and post tests of child

developmentdevelopment Studies with matched controls Studies with matched controls Studies with randomised controlsStudies with randomised controls

Developed countries

Long term benefits from high quality early Long term benefits from high quality early interventioninterventionHigher verbal and math scoresHigher verbal and math scoresLess grade repetition and higher graduation Less grade repetition and higher graduation

ratesratesHigher employment and earningsHigher employment and earningsBetter health outcomesBetter health outcomesLess welfare dependencyLess welfare dependencyLower crime ratesLower crime rates

focus on mother & childfocus on mother & child mothers change sustainability mothers change sustainability focus on precise level of child’s developmentfocus on precise level of child’s development other siblings benefit other siblings benefit neighbourhood spreadneighbourhood spread lower costlower cost<3 years better at home<3 years better at home

Home-visiting ApproachHome-visiting Approach

Goals of visitGoals of visit

Increase mother’s ability to promote her Increase mother’s ability to promote her child’s development through playchild’s development through play

Improve mother-child interactionImprove mother-child interaction

Promote self esteem of mother and childPromote self esteem of mother and child

Encourage mother to continue activities Encourage mother to continue activities between visits and integrate into daily routinebetween visits and integrate into daily routine

Approach to visitApproach to visit

Emphasis on verbal interactionEmphasis on verbal interactionStructured curriculum centered around play Structured curriculum centered around play

activitiesactivitiesEnsure mother and child experience successEnsure mother and child experience successPraise for mother and childPraise for mother and child

• Focus on mother Focus on mother

• Home made toys • Paraprofessionals

Intensity of visits? Intensity of visits? Duration of program? Duration of program?

Effects of Effects of visiting frequency visiting frequency in in disadvantaged children disadvantaged children

DQ

Powell & Grantham-McGregor, 1989Powell & Grantham-McGregor, 1989

fortnightlyfortnightly

monthlymonthly

no visitsno visits

94

98

102

106

110

Pre-testPre-test Post-testPost-test

weeklyweekly

Duration Duration

Although benefits to development are seen Although benefits to development are seen within 6 months no evidence that these will be within 6 months no evidence that these will be sustained if intervention ends. sustained if intervention ends.

Studies demonstrating sustained benefits Studies demonstrating sustained benefits intervention continued for 18-24 months.intervention continued for 18-24 months.

Integrated with nutrition?Integrated with nutrition?

RCT of 20 Community Nutrition CentresRCT of 20 Community Nutrition Centres in Bangladesh in Bangladesh (Hamadani et al, 2006)Hamadani et al, 2006)

Visited homes 2 weekly for 1 yr

RCT of stimulation with malnourished Bangladeshi RCT of stimulation with malnourished Bangladeshi infants: Effect on mental development index (MDI)infants: Effect on mental development index (MDI)

78

80

82

84

86

88

90

92

94

Pre-test

Post-test

intervened malnourishedcontrol malnourished

adequately nourished

Rx p< .05

Hamadani et al, 2006Hamadani et al, 2006

MDI

Stunted Stunted 9-24 months 9-24 months RandomisedRandomised

(n=129)(n=129)

Control Supplement Stimulation BothControl Supplement Stimulation Both 3333 32 32 32 32 32 32

Jamaican study of supplementation Jamaican study of supplementation & stimulation& stimulation

Stimulation:Stimulation: Weekly 1hr home visits by Weekly 1hr home visits by community health aides. Play session with community health aides. Play session with mother and child. mother and child.

Focus onFocus on::• Enhancing maternal-Enhancing maternal-

child interactionschild interactions

• LanguageLanguage

• PraisePraise

• Showing mother how to Showing mother how to promote development promote development through playthrough play

Combined nutritional supplementation & Combined nutritional supplementation & stimulation with stunted children: RCTstimulation with stunted children: RCT

Non-stuntedNon-stunted

ControlControl

Grantham-McGregor et al, 1991Grantham-McGregor et al, 1991

Both RxsBoth Rxs

SupplementedSupplemented

StimulatedStimulated

DQ

Are benefits sustainable? Are benefits sustainable?

Follow-up at age 22 yearsFollow-up at age 22 years

The effects of early childhood stimulation on The effects of early childhood stimulation on economic, cognitive and social outcomeseconomic, cognitive and social outcomes

Measurements : IQ, education, employment, Measurements : IQ, education, employment, financial independence, family and social financial independence, family and social relationships, sexual relationships, drug use relationships, sexual relationships, drug use and violent behavior.and violent behavior.

Benefits of Stimulation at age 22yBenefits of Stimulation at age 22yIQIQ

p=0.003p=0.003

p=0.004p=0.004

p=0.02p=0.02

Benefits of Stimulation at age 22yBenefits of Stimulation at age 22yEducationEducation

p=.004p=.004

p=.014p=.014

p=.005p=.005

Benefits of Stimulation at age 22yBenefits of Stimulation at age 22yEducational attainmentEducational attainment

Significant increase in grade level attained – Significant increase in grade level attained – 0.5 grade, studies elsewhere suggest this will 0.5 grade, studies elsewhere suggest this will be associated with increased adult incomebe associated with increased adult income

Significantly more CXC examination passes Significantly more CXC examination passes 18.9% with 4 or more passes compared with 18.9% with 4 or more passes compared with 9.6% in no stimulation groups9.6% in no stimulation groups

Stimulation groups less likely to be expelled Stimulation groups less likely to be expelled from school from school

Benefits of Stimulation at age 22y Benefits of Stimulation at age 22y Psychological Functioning Psychological Functioning

p=.03p=.03 p=.05p=.05

Benefits of Stimulation at age 22y Benefits of Stimulation at age 22y Reduced violent behaviourReduced violent behaviour

p=.04p=.04p=.06p=.06

No significant benefits to:No significant benefits to:

family relationshipsfamily relationships

alcohol and drug usealcohol and drug use

teenage pregnanciesteenage pregnancies

community involvementcommunity involvement

Young adults who received early childhood Young adults who received early childhood stimulation through a parent and child stimulation through a parent and child focused home visiting programmefocused home visiting programme

better cognitive abilitybetter cognitive ability

better educational attainmentbetter educational attainment

better psychological functioningbetter psychological functioning

Less violent behaviourLess violent behaviour

Can stimulation be integratedCan stimulation be integrated into routine primary health care? into routine primary health care?

Home-visiting approach to early childhood Home-visiting approach to early childhood stimulation with parent and child focus has stimulation with parent and child focus has sustained benefits sustained benefits

Programme delivered by Community Health Programme delivered by Community Health aides employed to our research unitaides employed to our research unit

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

Sustainable approachSustainable approach

Health services provide most comprehensive Health services provide most comprehensive contact with children aged 0-3 years contact with children aged 0-3 years

Community Health Aides existing cadre of Community Health Aides existing cadre of staffstaff

Feasible to integrate early childhood Feasible to integrate early childhood stimulation into these services?stimulation into these services?

InterventionIntervention

• Clinic community health aides (CHA’s) Clinic community health aides (CHA’s) trained in psychosocial stimulationtrained in psychosocial stimulation

• Weekly home visiting with mothers and Weekly home visiting with mothers and childrenchildren

• Quality of sessions Quality of sessions maintained maintained maintained through maintained through regular supervisionregular supervision

Study DesignStudy Design

18 Nutrition Clinics18 Nutrition ClinicsRandomly assignedRandomly assigned

11 Intervention Clinics11 Intervention Clinics

- - 70 children70 children

7 Control Clinics7 Control Clinics

- 69 children- 69 children

65 children65 children 64 children64 children

5 lost5 lost 5 lost5 lost

Effect of Intervention by Primary Health Care Staff Effect of Intervention by Primary Health Care Staff on DQ of Moderately Malnourished Childrenon DQ of Moderately Malnourished Children

90

95

100

105

pre-test post-test

Control n=69 Control n=69

Intervened n=70Intervened n=70

Rx p<.001Rx p<.001

Powell et al, 2004Powell et al, 2004

DQ

Do the mothers benefit?Do the mothers benefit?

Change in Change in KnowledgeKnowledge of Mothers of of Mothers of Intervened and Control ChildrenIntervened and Control Children

Knowledge Knowledge

ScoreScore

p < .001p < .001

Change in Change in PracticesPractices of Mothers of of Mothers of Intervened and Control ChildrenIntervened and Control Children

Practices ScorePractices Score

p < .001p < .001

Change in Maternal Depression Change in Maternal Depression With InterventionWith Intervention

16

20

24

28

Pre-test Post-test

Baker et al , 2005Baker et al , 2005

Rx p < .05Rx p < .05

IntervenedIntervened

Control Control

DepressionDepression

SummarySummary The intervention was effective in improving the The intervention was effective in improving the

development of the children and their mothers' development of the children and their mothers' child rearing knowledge and practices.child rearing knowledge and practices.

It was feasible to use existing staff to integrate It was feasible to use existing staff to integrate child development activities into primary health child development activities into primary health care services for undernourished children. care services for undernourished children.

On average children were visited every 10-11 daysOn average children were visited every 10-11 days

Intervention with Intervention with term low birth weight infantsterm low birth weight infants

InterventionIntervention

Weekly 1 hour visits by CHAs for 8 weeks Weekly 1 hour visits by CHAs for 8 weeks from birth focused on improving maternal from birth focused on improving maternal responsiveness responsiveness

Weekly 1/2 hr visits from 7-24 months Weekly 1/2 hr visits from 7-24 months focused on helping the mothers become more focused on helping the mothers become more effective teachers of their children and effective teachers of their children and enhancing maternal-child interactions. enhancing maternal-child interactions.

Benefits of intervention Benefits of intervention for LBW infantsfor LBW infants

Better problem solving Better problem solving ability at 7 months LBWability at 7 months LBW

Infants more happy Infants more happy and cooperativeand cooperative

Higher developmental Higher developmental levels at 24 monthslevels at 24 months

Follow-up at age 6 yearsFollow-up at age 6 yearsSignificant benefits to performance IQ Significant benefits to performance IQ

(reasoning, problem solving) and memory(reasoning, problem solving) and memory

No benefits to languageNo benefits to language

Significant reduction in behaviour difficulties Significant reduction in behaviour difficulties (by maternal report on SDQ). May be (by maternal report on SDQ). May be important for transition to primary schoolimportant for transition to primary school

Other approaches

Other approaches to delivering Other approaches to delivering interventions for children 0-3 yearinterventions for children 0-3 year

Parenting programmesParenting programmes Individual counselling at health visitsIndividual counselling at health visits Parenting groups, at health centres or Parenting groups, at health centres or

community groupscommunity groups

WHO/UNICEF - Care for child WHO/UNICEF - Care for child developmentdevelopment

Key GoalsKey Goals

Target children aged from birth to 3 yearsTarget children aged from birth to 3 years Focus on children most at riskFocus on children most at risk Integrate interventions – health, nutrition Integrate interventions – health, nutrition

and stimulation and stimulation Improve knowledge and skills of mothers Improve knowledge and skills of mothers

and caregiversand caregivers

Guidelines and training for health care Guidelines and training for health care providers to counsel parents on how to providers to counsel parents on how to promote developmentpromote development

Counselling cards with age specific Counselling cards with age specific messages and activitiesmessages and activities

Individual counsellingIndividual counselling

Limited evaluation of CCD or other Limited evaluation of CCD or other individual counselling programmesindividual counselling programmes

Need to consider time and staff availability Need to consider time and staff availability at clinicsat clinics

Parent groupsParent groupsFew impact evaluationsFew impact evaluations

Study beginning to evaluate benefits of Study beginning to evaluate benefits of health centre based intervention with use of health centre based intervention with use of video messages followed by discussion and video messages followed by discussion and practicepractice

Integrating delivery with well Integrating delivery with well child visitschild visits

Only 6 - 8 contactsOnly 6 - 8 contactsLittle contact after 18 months Little contact after 18 months

how to reach children in second half of how to reach children in second half of 0-3y period0-3y period

What we knowWhat we know

Significant benefits from home visiting delivered by Significant benefits from home visiting delivered by CHAsCHAs

Weekly home visiting for 2 years had lasting Weekly home visiting for 2 years had lasting benefits to adulthoodbenefits to adulthood

Visits must be at least fortnightly to benefit Visits must be at least fortnightly to benefit developmentdevelopment

Home visiting can be integrated into health servicesHome visiting can be integrated into health services

Supervision is essential to maintain quality of visitsSupervision is essential to maintain quality of visits

What we need to knowWhat we need to know

Evaluation of other approaches to delivery of Evaluation of other approaches to delivery of parenting programmesparenting programmes

Is individual counseling feasible and effectiveIs individual counseling feasible and effective

Impact of parenting programmes delivered to Impact of parenting programmes delivered to groupsgroups

How to reach children 18-36 monthsHow to reach children 18-36 months