Early child development programmes: further evidence for action
Authors: Maureen M Black, Kristen M Hurley
Journal: The Lancet Global Health (2016)

With the recognition that early child development lays the foundation for subsequent academic and social performance, economic productivity, and societal contributions, support for early child development programmes and policies has increased worldwide.1UNTransforming our world: the 2030 agenda for sustainable development. United Nations General Assembly, New York2015http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=EGoogle Scholar Longitudinal studies and neuroscientific evidence have shown that, during the formative periods of children's development, brain architecture and functioning are responsive to environmental conditions (both adversities and nurturance), which continue throughout life and into the subsequent generation.2Gertler P Heckman J Pinto R et al.Labor market returns to an early childhood stimulation intervention in Jamaica.Science. 2014; 344: 998-1001Crossref PubMed Scopus (290) Google Scholar, 3Johnson SB Riis JL Noble KG State of the art review: poverty and the developing brain.Pediatrics. 2016; 137: e20153075Crossref Scopus (310) Google Scholar, 4Walker SP Chang SM Wright A Osmond C Grantham-McGregor SM Early childhood stunting is associated with lower developmental levels in the subsequent generation of children.J Nutr. 2015; 145: 823-828Crossref PubMed Scopus (63) Google Scholar In response to the role of early child development in building human capacity, the Sustainable Development Goals (SDGs) include two targets for children younger than 5 years: meet developmental milestones (indicator 4.2.1) and participate in organised learning before primary school (indicator 4.2.1). The SDGs hold countries accountable for measuring and reporting on these targets. Attention to early child development programmes and policies is desperately needed because millions of young children in low-income and middle-income countries (LMICs) are not meeting SDG targets. Estimates based on population-level indicators of nutrition (stunting) and extreme poverty show that 39% of children younger than 5 years in LMICs are at risk of not reaching their developmental potential,5Grantham-McGregor S Cheung YB Cueto S Glewwe P Richter L Strupp B Developmental potential in the first 5 years for children in developing countries.Lancet. 2007; 369: 60-70Summary Full Text Full Text PDF PubMed Scopus (1973) Google Scholar and initial estimates from UNICEF's Early Childhood Development Index (ECDI) based on reports from nearly 100 000 caregivers show that 36·8% of children aged 3 and 4 years in LMICs do not achieve basic cognitive and socioemotional skills.6McCoy DC Peet ED Ezzati M et al.Early childhood developmental status in low-and middle-income countries: national, regional, and global prevalence estimates using predictive modeling.PLoS Med. 2016; 13: e1002034Crossref PubMed Scopus (258) Google Scholar ECDI scores are positively associated with caregiver–child joint activities such as reading, playing, listening to stories, counting, singing, or travelling outside of home, illustrating the centrality of the caregiving environment to child development.6McCoy DC Peet ED Ezzati M et al.Early childhood developmental status in low-and middle-income countries: national, regional, and global prevalence estimates using predictive modeling.PLoS Med. 2016; 13: e1002034Crossref PubMed Scopus (258) Google Scholar Caregiver–child activities are at the heart of many early child development programmes. One review7Elder JP Pequegnat W Ahmed S et al.Caregiver behaviour change for child survival and development in low-and middle-income countries: an examination of the evidence.J Health Commun. 2014; 19: 25-66Crossref PubMed Scopus (19) Google Scholar concluded that health-care workers in LMICs can implement effective strategies for caregiver behaviour change related to early child development. To be effective, strategies should address various aspects of caregiving (eg, feeding, communication, and play activities), include frequent contact with health-care workers (eg, twice per month), start early before the onset of dysfunctional caregiver–child interactions, and be of sufficient duration to enable caregivers to practise and normalise the behaviours (eg, 12 months).7Elder JP Pequegnat W Ahmed S et al.Caregiver behaviour change for child survival and development in low-and middle-income countries: an examination of the evidence.J Health Commun. 2014; 19: 25-66Crossref PubMed Scopus (19) Google Scholar, 8Walker S Chang S Effectiveness of parent support programmes in enhancing learning in the under-3 age group. Early Childhood Matters Magazine (The Hague).http://earlychildhoodmagazine.org/wp-content/uploads/2013/06/10-ECMnr120_Effectiveness-of-parent-support.pdDate: 2013Google Scholar In a Jamaican study with more than 20 years of follow-up, in adults (aged 25 years) who were stunted early in life, individuals who received caregiver–child enriched activities for 2 years through home visits had higher cognitive functioning; less anxiety, depression, and violence; and greater earnings than individuals who had been randomly assigned to the control group.2Gertler P Heckman J Pinto R et al.Labor market returns to an early childhood stimulation intervention in Jamaica.Science. 2014; 344: 998-1001Crossref PubMed Scopus (290) Google Scholar, 5Grantham-McGregor S Cheung YB Cueto S Glewwe P Richter L Strupp B Developmental potential in the first 5 years for children in developing countries.Lancet. 2007; 369: 60-70Summary Full Text Full Text PDF PubMed Scopus (1973) Google Scholar, 9Walker SP Chang SM Vera-Hernandez M Grantham-McGregor S Early childhood stimulation benefits adult competence and reduces violent behaviour.Pediatrics. 2011; 127: 849-857Crossref PubMed Scopus (155) Google Scholar Strategies to promote early child development are multidimensional, and include health, nutrition, care, early learning, and social protection. No single sector incorporates all dimensions; therefore early child development programmes are often fragmented, and beyond the responsibility of any single sector. With no sector ownership or advocacy, early child development programmes are at risk of not being used consistently across sectors and not incorporated into sustainable systems or national policies. The Care for Child Development Program (CCDP)10UNICEFCare for Child Development package. United Nations International Children's Emergency Fund, New York, NY2013http://www.unicef.org/earlychildhood/index_68195.htmlGoogle Scholar developed by UNICEF and WHO incorporates many necessary dimensions of early child development into a package that can be implemented through home visits by community health workers. The CCDP served as a basis for the Pakistan Early Development Study,11Yousafzai AK Rasheed MA Rizvi A Armstrong R Bhutta ZA Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial.Lancet. 2014; 384: 1282-1293Summary Full Text Full Text PDF PubMed Scopus (231) Google Scholar which is a powerful illustration that paid government workers (Lady Health Workers from the National Programme for Family Planning and Primary Healthcare) can successfully implement an integrated, home-based care (responsive stimulation) and nutrition programme over a 2 year period, with positive effects on children's development observed at 24 months. In The Lancet Global Health, Aisha Yousafzai and colleagues12Yousafzai AK Obradović J Rasheed MA et al.Effects of responsive stimulation and nutrition interventions on children's development and growth at age 4 years in a disadvantaged population in Pakistan: a longitudinal follow-up of a cluster-randomised factorial effectiveness trial.Lancet Glob Health. 2016; 4: e548-e558Summary Full Text Full Text PDF Scopus (110) Google Scholar now show that these effects extend to 4 years of age—2 years after the end of the formal intervention. In children at 4 years of age, the responsive stimulation intervention led to higher scores on measures of IQ, executive functioning, pre-academic skills, and pro-social behaviour, and to an enriched caregiving environment based on observations of caregiving behaviour and the home environment. There were several unexpected findings, mainly related to the absence of an effect of nutrition intervention on height and weight measurements and haemoglobin concentration, and the absence of synergistic benefits when both care and nutrition interventions were given together. One possible explanation is the low uptake of the micronutrient supplement, as previously reported.11Yousafzai AK Rasheed MA Rizvi A Armstrong R Bhutta ZA Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial.Lancet. 2014; 384: 1282-1293Summary Full Text Full Text PDF PubMed Scopus (231) Google Scholar To ensure that children's needs are addressed across multiple dimensions, future efforts should focus on strengthening interventions to promote children's nutrition that can be incorporated into responsive stimulation interventions. Findings from the trial by Yousafzai and colleagues11Yousafzai AK Rasheed MA Rizvi A Armstrong R Bhutta ZA Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial.Lancet. 2014; 384: 1282-1293Summary Full Text Full Text PDF PubMed Scopus (231) Google Scholar provide convincing evidence that early child development intervention can be successfully implemented by well trained and well supervised government health workers with effects that alter caregiver–child behaviour and are sustained through the preschool period. These findings contribute to the growing body of evidence that early child development programmes alter the course of children's development, even in the presence of chronic caregiver stress stemming from poverty, food insecurity, and persistent child undernutrition. Efforts such as the Global Action on Early Childhood Development launched by the World Bank and UNICEF13Kim JY Remarks by the World Bank group president Jim Yong Kim at the early childhood development event.http://www.worldbank.org/en/news/speech/2016/04/14/remarks-world-bank-group-president-jim-yong-kim-early-chilhood-developmentDate: April 14, 2016Google Scholar promote national programmes and policies to advance early child development. Ensuring that children achieve developmental skills early in life and have ongoing access to high-quality learning opportunities, as proposed by the SDG targets, will provide sustainable economic and social benefits that extend from individuals to nations. We declare no competing interests. Effects of responsive stimulation and nutrition interventions on children's development and growth at age 4 years in a disadvantaged population in Pakistan: a longitudinal follow-up of a cluster-randomised factorial effectiveness trialResponsive stimulation delivered in a community health service can improve child development and care, 2 years after the end of intervention. Future analyses of these data are needed to identify which children and families benefit more or less over time. Full-Text PDF Open Access