Early ChildhoodDevelopment

in South East Asia

Dr. Neena RainaRegional Advisor,

Child and Adolescent HealthWHO/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

03-012 Synaptic Density

Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

At Birth 6 Years Old 14 Years Old

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 schoolachievement and lower intelligence levels (Bundy, 1996; Hoddintott, et al., 2008)

Bogotá Project: Effects of supplementation and stimulation

on growth and weight (results at age 7)

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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 StudyGrantham-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

Jamaica Project:Effects of supplementation and stimulation on the mean development quotient of

stunted groups compared with non-stunted groups

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Development quotient includes practical reasoning, eye and hand coordination, hearing and speech, and performance. S.M. Grantham-McGregor, et al. (1991).

Jamaica Study:The effects of the stimulation intervention at age 17-18 years

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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

Key messages Lancet 2011Biological 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

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Tamis-LeMonda, et al. 2001

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

Optimal Investment Levels

Preschool School Post School

Age0

Mismatch between Investment and Opportunity

Cumulative Public Investment

Source: Carneiro & Heckman, Human Social Policy (2003)

Evidence

Age 1 week up to 6 months: Talk to your child and get a conversation going with sounds or gestures

Age 12 months up to 2 years:

Give your child things to stack up, and to put into containers and take out.

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?

• 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

Regional Strategy: WHO-SEARO

9 Jan 2010 35

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 areneeded and can be delivered together

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

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