Wednesday, April 16, 2014

Measuring Contextual Influences on Early Child Development

Patricia KarigerApril 17, 2014

Investing in Young Child Children Globally

Contextual Influences on Early DevelopmentContextual Influences on Early Development

KARIGER: Talking points for presentation: Measuring Contextual Influences on Early Child Development

Slide 1: Graphic of environmental influences on ECD. Child development results from interactions between the child, and the child’s environments, over time. Environments refer to those which are immediate and proximal to the child (such as family and community environments, including schools, health providers, religious or spiritual centers, etc.) as well as those which are more distal, such as state and national policies and governance; regional unions (EU, African Union), and global doctrines agreed to by the country (such as UN Convention on the Rights of the Child).

Contextual Influences on Early Development

FamilyCommunity

State

Nation/Region

World

Slide 2: Graphic of environmental influences on ECD by sector, across environments. Various evidence-based policies, programs and services are implemented across these levels of the environment to support early child development, although few, if any, are implemented at a global level. None are implemented consistently across countries, but some common sectors that include provisions to benefit early child development include: economic investments in strengthening household capacities to support families, especially in times of need; legal policies to ensure rights of the child and ensure protection to families and children; promotion of health and nutrition services for pregnant women, families and young children; education and ECD programs; other social welfare services to support women and families with young children.

Contextual Influences on Early Development

Family Community State Nation/Region World

Econo

mic Sup

ports

/

Protec

tions

Social and Child Protection

Health and Nutrition ServicesEducation and Care Services

Judicial Protectio

n

Social Welfare Services

Slides 3-5: Brief summary graphic (table?) of ECD indicators widely used by agency, that map on to sectors presented in previous slides. Many existing indicators of early child development are collected at various levels, across countries, but not consistently. That is: not all are collected across countries, and not all use the same definition (for example, poverty is not well-defined). This can be used to point out gaps.

Slides 6-12: Gaps in measurement of ECD factors that may benefit promoting/investing in child development-related policies (recognizing these may vary across countries):

6. How to measure responsive parenting (including responsive feeding) in 0-8 years

Adapted from Bronfenbrenner, 1986

International Declarations

Policies, Investments

Capacities, Implementation

Local Institutions

Relationships, Resources

Wednesday, April 16, 2014

Contextual Influences on Early DevelopmentContextual Influences on Early Development

Family Community State Nation/Region World

Econo

mic Sup

ports

/

Protec

tions

Social and Child Protection

Health and Nutrition ServicesEducation and Care Services

Judicial Protectio

n

Social Welfare Services

Wednesday, April 16, 2014

Engle et al, 2007 The Lancet

•Development is influenced by both biological and environmental risk factors. Environmental risks include:• Socio-cultural factors: gender inequity, low levels of maternal education• Psychosocial risks: parenting factors, maternal health, household

environment (from Walker et al 2007; 2011, The Lancet)

Early child development Promote child development

Prevent risks Ameliorate negative e!ects of risks

Poverty

Biological risk factors

Psychosocial risk factors

Child development

School performance

Economic performance

Intergenerational transmission

CNS development and function

Sensori-motor

Cognition-language

Social-emotional

Figure !: Conceptual model of how interventions can a!ect early child development

30 developing countries had policies on early child development,10 and UNICEF was assisting governments in supporting parenting programmes in 60 countries.10

Despite this interest, there have been few systematic evaluations of early child development programmes in developing countries.

Early child development programmes Improving food intake and reducing stunting Both e!cacy trials and programme evaluations have shown that improving the diets of pregnant women, infants, and toddlers can prevent stunting11,12 and result in better motor and mental development.2,13,14 Food supplementation during the first 2–3 years of life improves cognition at 3 years of age and beyond.13,15 One trial showed an improvement in motor development with exclusive breastfeeding.16 The longest follow-up duration is from Guatemala, where supplementation before age 3 years showed benefi cial e"ects on schooling, reading, and intelligence tests during adulthood (25–42 years).17

Conditional cash transfers provide funds dependant on behaviour, such as participation in nutrition monitoring and supplementation programmes.18 Evidence from a conditional cash transfer programme in Mexico for more than 20 million people showed that transfers to women plus direct nutritional supplements for young children and nutrition education19 were associated with children’s improved growth and motor development.18,20 Conversely, analysis of such a transfer programme in Brazil noted that recipient children grew slower than non-recipients, perhaps because families feared that benefits would be discontinued if their child grew well.21

Reducing iodine and iron defi ciencies Assessments of e!cacy trials and programmes of iodine interventions provide conclusive evidence of a signifi cant e"ect on cognition and behaviour.2 Salt iodisation remains the most cost-e" ective way of delivering iodine and of substantially improving cognition. At least 30

developing countries have reached the 2005 goal of sustainable elimination of iodine defi ciency through universal salt iodisation:10 69% of households consume iodised salt, with rates of 86% in Latin America, 85% in east Asia, but only 47% in central Europe and central Asia.10

Iron deficiency anaemia impedes child development.2

Detrimental e"ects in infants and toddlers might not be readily reversed by iron therapy, suggesting the need for a preventive approach.22 Iron supplementation to prevent anaemia in young children has positive e" ects on motor, social-emotional, and language development.2 Inno-vations for iron supplementation include: micro encap-sulated ferrous fumarate plus ascorbic acid supplied as sprinkles added to complementary foods;23 growing plant varieties with higher iron content;24 removing phytates from plants that inhibit iron absorption; soaking maize flour in excess water with phytase and decanting the water before cooking the fl our;25 and new iron fortifi cation methods that eliminate aftertaste, reduce risk of excess intake, and maintain bioavailability.26,27 These approaches are promising for the reduction of iron defi ciency and anaemia in young children.26,27 A 6-month trial in South Africa assessed the e"ect of iron and other micronutrient-fortified maize porridge on infant development and reported better motor development in the fortifi ed porridge group than the non-fortifi ed group.28

Concerns have been raised about giving iron supple-ments to iron replete infants, eg, decreased linear growth29,30 or increased hospitalisations and death in a malarial region.31 These issues should be studied further and need to be considered in public health programming.

Stimulation combined with nutrition and health programmes Stimulation occurs through responsive and increasingly complex developmentally appropriate interactions (matched to the child’s emerging abilities) between caregivers and children that enhance child develop-ment.32,33 Both cognitive and social-emotional skills provide the basis for later academic and employment success1,34,35

Inadequate stimulation and interactions can a" ect child development through disrupting basic neural circuitry. Neural disruptions are measured through stress hormones,36 brain images,37 and event-related potentials.38

Early stimulation may enhance neurocognitive processing and brain functioning, particularly for premature infants.39

The e"ects of early stimulation are also evident in the dramatic improvements in child development in undernourished, institution-raised children adopted into middle-class homes. A study of Korean girls adopted into middle-class families illustrates the synergistic e" ects of malnutrition and environmental deprivation on children’s intelligence.40,41 IQ scores of children adopted after 2 years of age and with a history of malnutrition scored worse than equally malnourished children adopted at less than age 2 years (figure 2), but both were close to average.

Socio-culturalfactors

Conceptual Model: Risk and Development

Cumulative Environmental Risk and Cognitive Development at Age 4

Sameroff et al 1993

WPPSI125

Raw Scores ~Q- Adjust for Covariate

FIG. 5.-risk groups.

0 1 2 3 4 5 6 7-8Multiple Risk Score

-Mean 4-year TQ scores, and means adjusted for covariation of mother TQ, within multiple

125

120

115

110

105

100

95

90

85

80

75

FIG. 6.risk groups.

WISC-R

-.iji • ^

\ \ h -

""̂ K~ Raw Scores ~D" Adjust for Covariate

\ . s z'

1 \ 1 1—6 7-90 1 2 3 4 5

Multiple Risk Score-Mean T3-year TQ scores, and means adjusted for covariation of mother TQ, within multiple

91

Engle et al, 2007 The Lancet

Early child development Promote child development

Prevent risks Ameliorate negative e!ects of risks

Poverty

Biological risk factors

Psychosocial risk factors

Child development

School performance

Economic performance

Intergenerational transmission

CNS development and function

Sensori-motor

Cognition-language

Social-emotional

Figure !: Conceptual model of how interventions can a!ect early child development

30 developing countries had policies on early child development,10 and UNICEF was assisting governments in supporting parenting programmes in 60 countries.10

Despite this interest, there have been few systematic evaluations of early child development programmes in developing countries.

Early child development programmes Improving food intake and reducing stunting Both e!cacy trials and programme evaluations have shown that improving the diets of pregnant women, infants, and toddlers can prevent stunting11,12 and result in better motor and mental development.2,13,14 Food supplementation during the first 2–3 years of life improves cognition at 3 years of age and beyond.13,15 One trial showed an improvement in motor development with exclusive breastfeeding.16 The longest follow-up duration is from Guatemala, where supplementation before age 3 years showed benefi cial e"ects on schooling, reading, and intelligence tests during adulthood (25–42 years).17

Conditional cash transfers provide funds dependant on behaviour, such as participation in nutrition monitoring and supplementation programmes.18 Evidence from a conditional cash transfer programme in Mexico for more than 20 million people showed that transfers to women plus direct nutritional supplements for young children and nutrition education19 were associated with children’s improved growth and motor development.18,20 Conversely, analysis of such a transfer programme in Brazil noted that recipient children grew slower than non-recipients, perhaps because families feared that benefits would be discontinued if their child grew well.21

Reducing iodine and iron defi ciencies Assessments of e!cacy trials and programmes of iodine interventions provide conclusive evidence of a signifi cant e"ect on cognition and behaviour.2 Salt iodisation remains the most cost-e" ective way of delivering iodine and of substantially improving cognition. At least 30

developing countries have reached the 2005 goal of sustainable elimination of iodine defi ciency through universal salt iodisation:10 69% of households consume iodised salt, with rates of 86% in Latin America, 85% in east Asia, but only 47% in central Europe and central Asia.10

Iron deficiency anaemia impedes child development.2

Detrimental e"ects in infants and toddlers might not be readily reversed by iron therapy, suggesting the need for a preventive approach.22 Iron supplementation to prevent anaemia in young children has positive e" ects on motor, social-emotional, and language development.2 Inno-vations for iron supplementation include: micro encap-sulated ferrous fumarate plus ascorbic acid supplied as sprinkles added to complementary foods;23 growing plant varieties with higher iron content;24 removing phytates from plants that inhibit iron absorption; soaking maize flour in excess water with phytase and decanting the water before cooking the fl our;25 and new iron fortifi cation methods that eliminate aftertaste, reduce risk of excess intake, and maintain bioavailability.26,27 These approaches are promising for the reduction of iron defi ciency and anaemia in young children.26,27 A 6-month trial in South Africa assessed the e"ect of iron and other micronutrient-fortified maize porridge on infant development and reported better motor development in the fortifi ed porridge group than the non-fortifi ed group.28

Concerns have been raised about giving iron supple-ments to iron replete infants, eg, decreased linear growth29,30 or increased hospitalisations and death in a malarial region.31 These issues should be studied further and need to be considered in public health programming.

Stimulation combined with nutrition and health programmes Stimulation occurs through responsive and increasingly complex developmentally appropriate interactions (matched to the child’s emerging abilities) between caregivers and children that enhance child develop-ment.32,33 Both cognitive and social-emotional skills provide the basis for later academic and employment success1,34,35

Inadequate stimulation and interactions can a" ect child development through disrupting basic neural circuitry. Neural disruptions are measured through stress hormones,36 brain images,37 and event-related potentials.38

Early stimulation may enhance neurocognitive processing and brain functioning, particularly for premature infants.39

The e"ects of early stimulation are also evident in the dramatic improvements in child development in undernourished, institution-raised children adopted into middle-class homes. A study of Korean girls adopted into middle-class families illustrates the synergistic e" ects of malnutrition and environmental deprivation on children’s intelligence.40,41 IQ scores of children adopted after 2 years of age and with a history of malnutrition scored worse than equally malnourished children adopted at less than age 2 years (figure 2), but both were close to average.

Socio-culturalfactors

•Early interventions can help children reach their potential by preventing risks, and by ameliorating the effects of risks

Conceptual Model: Risk and Development

Early interventions: Promote development Prevent risks Ameliorate effects of risks

Global Environmental Risks: What the Evidence Tells Us

• Studies reviewed in Walker et al (2007; 2011), The Lancet

• Key risk factors prioritized were those which:

• Are widely prevalent in the lives of children 0-5 years in low- and middle-income countries

• Affect child developmental outcomes (cognition, language, etc.)

• Are modifiable with interventions

• Environmental, contextual or psychosocial risk factors include:

• Lack of cognitive stimulation/support for learning

• Maternal depression

• Exposure to violence

• Institutionalization

Why Develop Indicators to Assess Children, Family and Environment?

• Population-level measures of children and their environments will:

• Help nations prioritize investment in various sectors

• Help nations evaluate programs and services

• Allow comparisons of families and environments across countries and regions

• Help provide a more complete picture of young children’s lives

• Population-level measures of children and their environments are feasible:

• Indices or items can be added to existing surveys administered to parents, teachers or government officials

Criteria for Indicators

• It’s imperative to use well-defined, evidence-based, reliable and valid indicators that are also:

• Universally meaningful

• Easy to measure and interpret

• Malleable; capable of showing change

• Able to be addressed by programs or services

• Presented in a format easily understood by stakeholders who can effect change

Which Indicators Currently Exist?Overview of Existing Indicators

• What indicators currently exist?

United Nations!"#$%&'()%*+,-$'.)&'/$,%)"

Cultural Organization

Commissioned by UNESCO within the framework of the Holistic Early Childhood Development Index

The Review of Care, Education and

Child Development Indicators in Early Childhood

United Nations

Cultural Organization

Commissioned by UNESCO within the framework of the Holistic Early Childhood Development Index

The Review of Health and Nutrition Indicators

in Early Childhood

United Nations

Cultural Organization

Commissioned by UNESCO within the framework of the Holistic Early Childhood Development Index

The Review of Policy and Planning Indicators

in Early Childhood

United Nations

Cultural Organization

Commissioned by UNESCO within the framework of the Holistic Early Childhood Development Index

The Review of Legal Protection Indicators

in Early Childhood

United Nations

Cultural Organization

Commissioned by UNESCO within the framework of the Holistic Early Childhood Development Index

The Review of Social Protection Indicators

in Early Childhood

Wednesday, April 16, 2014

http://www.unesco.org/new/en/education/themes/strengthening-education-systems/early-childhood/monitoring-and-evaluation/holistic-ecdindex/

Examples of Indicators Used by Organizations

USAID UNICEF UNESCO WHOPoverty/Wealth Index X X X

Child Protection X X XMaternal DepressionEducation/Early Care X X XEarly Development X X

Institutionalized Children?

Exposure to Violence?Household Support

for Learning X

Child Health/Nutrition X X X X

Measurement Across Indicators by AgeImportant to Measure Comprehensively

Household Support for Learning

Birth Age 8

Proximal

Distal

Health and Nutrition

Age 4

Maternal Caregiving Practices (Health & Nutrition)

Education and Care Services

Language/Cognitive/Social-emotional Development

Social Protection

Poverty Alleviation

Thursday, April 17, 2014

How Can Measurement be Improved?

• More comprehensive measurement of children across 0-8 years

• Measures on responsive parenting spanning age range, including responsive feeding and support for early primary students

• Understanding the quality of care provided by multiple caregivers or home-based care providers

How Can Measurement be Improved?

• Screening for specific disabilities

• Institutionalized children

• Maternal depression

• Monitoring exposure to domestic violence, abuse, community violence and war/unrest

• Efforts to link measures and indicators across sectors

Recent Advancements and Efforts to Improve Measurement of Early Indicators

• UNESCO’s Holistic Early Child Development Index

• USAID’s Center on Children in Adversity

• Guide for Monitoring Child Development. I. Ertem; B. Forsyth. Turkey, India, South Africa, Argentina.

• Malawi Development Assessment Tool. M. Gladstone et al. Malawi, Mali, The Gambia, Burkina Faso.

• Developmental Milestones Checklist. A. Abu-Bakar et al. Kenya, West Africa.

• Global Child Development Group. Exploring creation of 0-3 child development tool.

Conclusions

• Great interest and energies directed at ECD indicators

• Cross-organizational efforts should be shared, coordinated

• Creation of single source for accessing indices and indicators?

• Agreement and support on core set of indicators, with optionals