Transcript No Slide Title

Christine Powell
Child Development Research Group, Tropical Medicine
Research Institute, UWI, Mona, Jamaica
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
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
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
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
DQ
Mean Developmental Quotients
on Griffiths Test
Urban middle class
n=78
Urban poor
n=268
Age months
Walker et al 1990
Can psychosocial stimulation
interventions help?
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
Study Design
Included
 Studies with pre and post tests of child
development
 Studies with matched controls
 Studies with randomised controls
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
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
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
Approach to visit
 Emphasis on verbal interaction
 Structured curriculum centered around play
activities
 Ensure mother and child experience success
 Praise for mother and child
• Focus on mother
• Home made toys
• Paraprofessionals
Intensity of visits?
Duration of program?
DQ
110
Effects of visiting frequency in
disadvantaged children
weekly
106
fortnightly
102
monthly
98
no visits
94
Pre-test
Post-test
Powell & Grantham-McGregor, 1989
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.
Integrated with nutrition?
RCT of 20 Community Nutrition Centres
in Bangladesh (Hamadani et al, 2006)
Visited homes
2 weekly for 1 yr
RCT of stimulation with malnourished Bangladeshi
infants: Effect on mental development index (MDI)
MDI
94
92
90
88
86
84
82
80
78
intervened malnourished
control malnourished
adequately nourished
Rx p< .05
Pretest
Posttest
Hamadani et al, 2006
Jamaican study of supplementation
& stimulation
Stunted
9-24 months
Randomised
(n=129)
Control
33
Supplement
32
Stimulation
32
Both
32
Stimulation: Weekly 1hr home visits by
community health aides. Play session with
mother and child.
Focus on:
• Enhancing maternalchild interactions
• Language
• Praise
• Showing mother how to
promote development
through play
Combined nutritional supplementation &
stimulation with stunted children: RCT
DQ
Non-stunted
Both Rxs
Stimulated
Supplemented
Control
Grantham-McGregor et al, 1991
Questions
Are benefits sustainable?
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.
Benefits of Stimulation at age 22y
IQ
p=0.02
p=0.003
p=0.004
Benefits of Stimulation at age 22y
Education
p=.005
p=.004
p=.014
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
Benefits of Stimulation at age 22y
Psychological Functioning
p=.03
p=.05
Benefits of Stimulation at age 22y
Reduced violent behaviour
p=.06
p=.04
 No significant benefits to:
 family relationships
 alcohol and drug use
 teenage pregnancies
 community involvement
Summary
 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
Can stimulation be integrated
into routine primary health care?
Integration into services
 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?
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?
Intervention
• Clinic community health aides (CHA’s)
trained in psychosocial stimulation
• Weekly home visiting with mothers and
children
• Quality of sessions
maintained through
supervision
maintained
regular
Study Design
18 Nutrition Clinics
Randomly assigned
11 Intervention Clinics
7 Control Clinics
- 70 children
- 69 children
5 lost
65 children
5 lost
64 children
Effect of Intervention by Primary Health Care Staff
on DQ of Moderately Malnourished Children
DQ
105
Rx p<.001
100
Intervened n=70
95
Control n=69
90
pre-test
post-test
Powell et al, 2004
Do the mothers benefit?
Change in Knowledge of Mothers of
Intervened and Control Children
Knowledge
Score
p < .001
Change in Practices of Mothers of
Intervened and Control Children
Practices Score
p < .001
Change in Maternal Depression
With Intervention
Depression
Control
28
24
Rx p < .05
20
Intervened
16
Pre-test
Post-test
Baker et al , 2005
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
Intervention with
term low birth weight infants
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.
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
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
Other approaches
Other approaches to delivering
interventions for children 0-3 year
 Parenting programmes
 Individual counselling at health visits
 Parenting groups, at health centres or
community groups
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
 Guidelines and training for health care
providers to counsel parents on how to
promote development
 Counselling cards with age specific messages
and activities
Individual counselling
 Limited evaluation of CCD or other individual
counselling programmes
 Need to consider time and staff availability at
clinics
Parent groups
 Few impact evaluations
 Study beginning to evaluate benefits of health
centre based intervention with use of video
messages followed by discussion and
practice
Integrating delivery with well
child visits
 Only 6 - 8 contacts
 Little contact after 18 months
 how to reach children in second half of
0-3y period
What we know
 Significant benefits from home visiting delivered by
CHAs
 Weekly home visiting for 2 years had lasting
benefits to adulthood
 Visits must be at least fortnightly to benefit
development
 Home visiting can be integrated into health services
 Supervision is essential to maintain quality of visits
What we need to know
 Evaluation of other approaches to delivery of
parenting programmes
 Is individual counseling feasible and effective
 Impact of parenting programmes delivered to
groups
 How to reach children 18-36 months