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Journal ArticleDOI

Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world

TL;DR: The third in the Child Development Series as discussed by the authors assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential in developing countries by identifying four well-documented risks: stunting, iodine deficiency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence.
About: This article is published in The Lancet.The article was published on 2007-01-20 and is currently open access. It has received 927 citations till now. The article focuses on the topics: Child development & Millennium Development Goals.

Summary (5 min read)

Introduction

  • This is the third paper in a series that addresses the lost developmental, educational, and economic potential of more than 200 million children under the age of 5 years in developing countries.
  • The second paper identifi ed risks with the strongest evidence base and highest prevalence as stunting, iodine and iron deficiencies, and inadequate cognitive and social-emotional stimulation.
  • Less welldocumented, but with consistent epidemiological evidence, are risks related to social conditions (maternal depression and violence), environmental factors (lead and arsenic), and some infectious diseases (malaria and HIV).
  • The authors include only evaluations that report cognitive or social-emotional outcomes.
  • Early child development programmes 3 are designed to improve the survival, growth, and development of young children, prevent the occurrence of risks, and ameliorate the negative effects of risks.

Developing country interest in early child development programmes

  • Awareness of child development is increasing in developing countries.
  • The health sector has advocated for early child development programmes for children with low birth weight, 4 developmental delays, 5 and from low-income disadvantaged environments. [6] [7] [8].
  • Child development inform ation is often incorporated into growth monitoring charts.
  • Government-supported preschool programmes for child ren are increasing; in the past 15 years, at least 13 develop ing countries have instituted compulsory preschool or pre-primary programmes.
  • By 2005, the World Bank had financed loans to 52 developing countries for child develop ment programmes, for a total of US$1680 million, at least.

Search strategy

  • Databases searched were MEDLINE , Embase, Psych Info, the Cochrane Review, the Educational Resources Information Center (ERIC), the World Health Organization, the World Bank and the International Bureau of Education for UNESCO (United Nations Educational, Scientific and Cultural Organization), SIGLE (grey literature from Europe), LILACS (Latin American and Caribbean Health Services), and UNICEF.
  • The UNICEF and World Bank databases were searched and queries were sent to international organisations that may have had access to unpublished evaluations, including Plan International, Save the Children, Christian Children's Fund, Aga Khan Foundation, Bernard Van Leer Foundation, Consultative Group for Early Child Care and Development, and regional early child development networks.
  • 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 efficacy trials and programme evaluations have shown that improving the diets of pregnant women, infants, and toddlers can prevent stunting 11, 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.
  • 17 Conditional cash transfers provide funds dependant on behaviour, such as participation in nutrition monitoring and supplementation programmes.
  • 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.

Reducing iodine and iron defi ciencies

  • Assessments of efficacy trials and programmes of iodine interventions provide conclusive evidence of a signifi cant effect on cognition and behaviour.
  • Salt iodisation remains the most cost-eff ective way of delivering iodine and of substantially improving cognition.
  • 22 Iron supplementation to prevent anaemia in young children has positive eff ects on motor, social-emotional, and language development.
  • 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 success 1, 34, 35 Inadequate stimulation and interactions can aff ect child development through disrupting basic neural circuitry.
  • 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.
  • 49, 50 Cost-benefit ratios for seven programmes in developed countries ranged from 18 to 170.
  • 45 Programmes for disadvantaged children during early childhood have a better rate of return than programmes introduced later in life.

Table 1: Child-care centre programmes and parent-child interventions for child development in developing countries

  • The authors reviewed programmes implemented in developing countries since 1990 using six criteria: (a) randomised controlled trial or matched comparison group; (b) intervention before age 6 years; (c) eff ectiveness or programme evaluations (not efficacy trials); (d) child development assessed; (e) targeted disadvantaged children; and (f ) developing country.
  • 35 studies from developing countries were identified, of which 20 met the criteria (tables 1 and 2 and search strategy).
  • The programmes fell into three groups: centre-based early learning (N=8); parenting or parent-child (N=6); and comprehensive (N=6), including health and nutrition interventions.

Centre-based programmes

  • All eight evaluations recorded a substantial eff ect on children's cognitive development.
  • Preschools were pro vided in Guinea and Cape Verde, 52 Bangladesh, 53 Burma, 54 Nepal, 55 Vietnam, 56 and Colombia, 57 and pre-primary schools were expanded in Argentina.
  • 35 Most reported gains in noncognitive skills such as sociability, self-confi dence, willing ness to talk to adults, and motivation.
  • Longitudinal studies (Nepal, 55 Argentina, 35 Burma, 54 and Colombia 58 ) recorded improvements in the number of children entering school, age of entry, retention, and performance.

Parenting and parent-child programmes

  • In Jamaica, parenting practices improved when children and parents were actively involved in a home-visiting programme, but not when the parent component was limited to information sharing.
  • 60 In Bolivia, information and skill building about health, hygiene, nutrition, and development, linked with a literacy programme for indigenous women and home visits, resulted in higher test scores for participants' children than those of matched non-participants.
  • 63 Two programmes used group sessions with mothers.
  • In Turkey, where mothers practised skills to play with their children, there were short-term and long-term effects on child development.
  • 64 In Bangladesh, mothers' knowledge of child development and child rearing increased after information-based sessions, but there was no effect on child development, 65 perhaps because there were no practise or skill-based activities with families.

Comprehensive programmes

  • Six programme evaluations met the criteria for this group (table 2 ) and show the changes in programme models from 1975 to the late 1990s.
  • In the early 1990s, the PIDI (Proyecto Integral de Desarrollo Infantil) programme in Bolivia trained low-income urban women to run child care centres in their homes for malnourished children 6-72 months, and funded them to upgrade their homes, provide food for the centres, and run health and nutrition monitoring and educational activities.
  • 73 Communities within Adapted from data available in Armecin. 74 25 districts were divided into intervention and control.
  • Each intervention community could receive community grants for nutrition or early child development, and most chose nutrition.
  • After 2 years, there were substantial improvements in breastfeeding practices, growth rates in the youngest children, and parental attitudes and behaviour supporting early child development, but there were few effects on cognitive development of children aged 35-6 years, possibly because of the low intensity of the intervention.

Factors consistently associated with programme eff ectiveness

  • Numerous factors are associated with success of interventional programmes (panel 1).
  • 57, 58 Evaluations from Guinea, Cape Verde, and Bangladesh recorded associations between multiple measures of preschool quality and children's cognitive performance.
  • 79, 80 Programmes that have assessed intensity report a linear relation between frequency of home visits and improvements in child development.
  • 81 Benefi cial eff ects of combined programmes have been found on efficiency of delivery, cost savings, and eff ect.
  • In the past few years, there has been a resurgence of early child development programmes, almost to their former level.

Social risks

  • There have been few evaluations of social protection interventions designed to mitigate the effects of social risks (eg, maternal depression, exposure to domestic and community violence, and stigma and loss due to HIV/AIDS) on children from developing countries.
  • 91 In Jamaica, mothers' depression scores declined after participating in a parenting intervention, similar to evidence from developed countries showing that teaching mothers practical caregiving skills has benefi cial effects for both mothers and children. [94] [95] [96].
  • Violence toward young children often occurs through excessive corporal punishment, child abuse and neglect, and exposure to violence.
  • There are few programmes directed toward young children in developing countries, and no evaluations were located.
  • 102 Interventions for younger children aff ected by AIDS, such as home visiting, support for families, ensuring access to care, and community-based child care are limited in scale and have not been rigorously assessed.

Environmental risks

  • The evidence that environmental toxins such as lead and arsenic can compromise child development 103,104 is a major reason for reducing exposure.
  • Chelation, even oral chelation 105 or the removal of lead from children's blood and bone stores, although successfully reducing body burden, has not resulted in improvements in children's developmental functioning.
  • Mitigation programmes (including provisions of deep water-wells and education) successfully reduce arsenic concentrations in exposed individuals, but there are no findings on whether they result in improvements in child development.
  • System atically preventing exposure is probably a more eff ective and efficient strategy than treatment, but the challenge is the extensiveness of environmental toxin exposure.

Infectious risks

  • Severe malaria and HIV/AIDS have been associated with poor child development.
  • 2 Effective malaria prevention and control include insecticide treated bednets and artemisinin based combination therapies.
  • 10 Until recently, coverage of treated bednets for children under 5 years of age was estimated at less than 5%, 106 but countries are now rapidly scaling up coverage, with around 50 million nets expected to be delivered in 2006 and some countries expected to exceed the Abuja targets in 2006.
  • 107 benefits to later cognitive abilities following chemo prophylaxis before the age of 6 years have been reported.
  • 108 Mother-to-child transmission of HIV can be prevented, but in 2005, only 9% of pregnant women in low-income and middle-income countries received services to prevent transmission to their newborn babies, and only 92% of HIV-positive pregnant women received prophylactic antiretrovirals.

Investing in early child development programmes

  • Government investment is low.
  • Programme coverage is negatively associated with countries' general poverty index (figure 5 ), leaving the poorest countries with almost no investment in early child development.
  • 110 Jaramillo and Mingat 111 estimate that in Africa, an increase in the preschool gross enrolment rate to 40% during the next decade could reduce repetition rates and increase the proportion of grade 1 students who reach grade 5 from 65% to 78%.
  • There are human rights and economic reasons to invest in child development programmes (panel 3).
  • 114 Recent estimates of benefit-to-cost ratios for interventions for early child development yield ratios substantially above 1 in developing countries, 115 and in developed countries.

Reducing disparities

  • Achievement differences in children from diff erent socio economic groups widen over time.
  • Aggregate average benefit is the product of the range of individual benefits times the programme coverage.
  • If coverage was not expanded randomly and the hardest cases were left for last, the lines probably would be less steep as coverage became very high.
  • Analyses across the two data sets found that with 90% coverage, an increase of 1 SD in pre-school cognitive skills is associated with an aggregate benefit of around two-thirds to more than one grade of additional schooling (figure 7 has the derivation of estimated benefits).

Integration of early child development programmes into other systems

  • Policy decisions on programmes often span multiple ministries (eg, health, education, welfare) and need coordination across sectors.
  • In the Congo, surveyed parents reported that they would like more information about their children's development in their health visits, 125 and in the USA, incorporating developmental counselling into primary care has improved quality of care and parenting practices.
  • Linking early development programmes administered through the health system with programmes in the educational system increases the likelihood of building intervention follow-up for children at risk.
  • 127 In Cuba, the Educate your Child programme covers 98% of young children.

Conclusion

  • Effective interventions are available to reduce the developmental loss currently estimated to aff ect more than 200 million children under 5 years of age in developing countries, by promoting child development and preventing or ameliorating developmental loss.
  • The most effective interventions are comprehensive pro grammes for younger and disadvantaged children and families that are of adequate duration, intensity, quality, and are integrated with health and nutrition services.
  • The papers in this series show that early interventions promote child development and prevent or ameliorate developmental loss.
  • The response, particularly in the poorest countries, has been slow.
  • Children's rights are threatened by the failure of countries to develop their human capital, resulting from the lack of attention to early development.

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References
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Journal ArticleDOI
TL;DR: Two factors with available worldwide data—the prevalence of early childhood stunting and the number of people living in absolute poverty—are identified as indicators of poor development and show that both indicators are closely associated with poor cognitive and educational performance in children.

2,942 citations

Journal ArticleDOI
30 Jun 2006-Science
TL;DR: Evidence on the effects of early environments on child, adolescent, and adult achievement and how early inputs strongly affect the productivity of later inputs is summarized.
Abstract: This paper summarizes evidence on the effects of early environments on child, adolescent, and adult achievement. Life cycle skill formation is a dynamic process in which early inputs strongly affect the productivity of later inputs.

2,882 citations

Journal ArticleDOI
TL;DR: Environmental lead exposure in children who have maximal blood lead levels < 7.5 μg/dL is associated with intellectual deficits, and an inverse relationship between blood lead concentration and IQ score is found.
Abstract: Lead is a confirmed neurotoxin, but questions remain about lead-associated intellectual deficits at blood lead levels < 10 µg/dL and whether lower exposures are, for a given change in exposure, associated with greater deficits. The objective of this study was to examine the association of intelligence test scores and blood lead concentration, especially for children who had maximal measured blood lead levels < 10 µg/dL. We examined data collected from 1,333 children who participated in seven international population-based longitudinal cohort studies, followed from birth or infancy until 5‐10 years of age. The full-scale IQ score was the primary outcome measure. The geometric mean blood lead concentration of the children peaked at 17.8 µg/dL and declined to 9.4 µg/dL by 5‐7 years of age; 244 (18%) children had a maximal blood lead concentration < 10 µg/dL, and 103 (8%) had a maximal blood lead concentration < 7.5 µg/dL. After adjustment for covariates, we found an inverse relationship between blood lead concentration and IQ score. Using a loglinear model, we found a 6.9 IQ point decrement [95% confidence interval (CI), 4.2‐9.4] associated with an increase in concurrent blood lead levels from 2.4 to 30 µg/dL. The estimated IQ point decrements associated with an increase in blood lead from 2.4 to 10 µg/dL, 10 to 20 µg/dL, and 20 to 30 µg/dL were 3.9 (95% CI, 2.4‐5.3), 1.9 (95% CI, 1.2‐2.6), and 1.1 (95% CI, 0.7‐1.5), respectively. For a given increase in blood lead, the lead-associated intellectual decrement for children with a maximal blood lead level < 7.5 µg/dL was significantly greater than that observed for those with a maximal blood lead level ≥ 7.5 µg/dL (p = 0.015). We conclude that environmental lead exposure in children who have maximal blood lead levels < 7.5 µg/dL is asso

1,945 citations

Journal ArticleDOI
TL;DR: The evidence is sufficient to warrant interventions for malaria, intrauterine growth restriction, maternal depression, exposure to violence, and exposure to heavy metals, including iron deficiency anaemia.

1,869 citations

Journal ArticleDOI
14 Oct 1998-JAMA
TL;DR: This program of prenatal and early childhood home visitation by nurses can reduce reported serious antisocial behavior and emergent use of substances on the part of adolescents born into high-risk families.
Abstract: Context.— A program of home visitation by nurses has been shown to affect the rates of maternal welfare dependence, criminality, problems due to use of substances, and child abuse and neglect. However, the long-term effects of this program on children’s antisocial behavior have not been examined. Objective.— To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on children’s antisocial behavior. Design.— Fifteen-year follow-up of a randomized trial. Interviews were conducted with the adolescents and their biological mothers or custodial parents. Setting.— Semirural community in New York. Participants.— Between April 1978 and September 1980, 500 consecutive pregnant women with no previous live births were recruited, and 400 were enrolled. A total of 315 adolescent offspring participated in a follow-up study when they were 15 years old; 280 (89%) were born to white mothers, 195 (62%) to unmarried mothers, 151 (48%) to mothers younger than 19 years, and 186 (59%) to mothers from households of low socioeconomic status at the time of registration during pregnancy. Intervention.— Families in the groups that received home visits had an average of 9 (range, 0-16) home visits during pregnancy and 23 (range, 0-59) home visits from birth through the child’s second birthday. The control groups received standard prenatal and well-child care in a clinic. Main Outcome Measures.— Children’s self-reports of running away, arrests, convictions, being sentenced to youth corrections, initiation of sexual intercourse, number of sex partners, and use of illegal substances; school records of suspensions; teachers’ reports of children’s disruptive behavior in school; and parents’ reports of the children’s arrests and behavioral problems related to the children’s use of alcohol and other drugs. Results.— Adolescents born to women who received nurse visits during pregnancy and postnatally and who were unmarried and from households of low socioeconomic status (risk factors for antisocial behavior), in contrast with those in the comparison groups, reported fewer instances (incidence) of running away (0.24 vs 0.60; P = .003), fewer arrests (0.20 vs 0.45; P = .03), fewer convictions and violations of probation (0.09 vs 0.47; P,.001), fewer lifetime sex partners (0.92 vs 2.48; P = .003), fewer cigarettes smoked per day (1.50 vs 2.50; P = .10), and fewer days having consumed alcohol in the last 6 months (1.09 vs 2.49; P = .03). Parents of nurse-visited children reported that their children had fewer behavioral problems related to use of alcohol and other drugs (0.15 vs 0.34; P = .08). There were no program effects on other behavioral problems. Conclusions.— This program of prenatal and early childhood home visitation by nurses can reduce reported serious antisocial behavior and emergent use of substances on the part of adolescents born into high-risk families. JAMA. 1998;280:1238-1244 JUVENILE CRIME is a significant problem in the United States. In 1996, law enforcement agencies made 2.9 million arrests of juveniles (children ,18 years). Moreover, 19% of all arrests and 19% of all violent crime arrests were accounted for by juveniles. Although the number of juvenile Violent Crime Index arrests (ie, for murder, forcible rape, robbery, and aggravated assault) declined in both 1995 and 1996, the rate in 1996 was still 60% higher than the 1987 level. 1

1,052 citations

Frequently Asked Questions (1)
Q1. What are the contributions in this paper?

This paper is the third in the Child Development Series. This paper assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential. The most effective early child development programmes provide direct learning experiences to children and families, are targeted toward younger and disadvantaged children, are of longer duration, high quality, and high intensity, and are integrated with family support, health, nutrition, or educational systems and services. The first paper showed that more than 200 million children under 5 years of age in developing countries do not reach their developmental potential. The second paper identifi ed four well-documented risks: stunting, iodine defi ciency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence: maternal depression, violence exposure, environmental contamination, and malaria.