Introductory Statement
Although in recent years there has been a dramatic decrease in
child mortality in low-income countries, many surviving children continue to
have poor psychosocial and cognitive development. There are extremely limited
data on the size of the problem, but it is likely that millions of young
children are failing to reach their potential in development. They
subsequently are unable to benefit fully from schooling and to become
productive citizens. This failure has implications both for the individuals
and for national development.
A workshop held in 1991 in Jamaica [1] concluded that there
was substantial evidence that poor health and nutrition detrimentally affected
children's development. However, good health and nutrition alone were
insufficient to promote optimal child development, and quality of the
psychosocial environment was also important. It was the need to look at the
children's development in a holistic way and take an integrated approach to
child services that stimulated the subcommittee on Nutrition and Mental Health
of the Institute of Child Health, London University, and UNICEF, New York to
plan another workshop. The aim of the event was to sensitize senior managers
and policy makers to the need for development of programmes that integrated
child development, health, and nutrition activities.
The resulting workshop was held at Wye College, Kent, in the
United Kingdom, on April 4-8, 1998, and was attended by researchers active in
the field of nutrition and child development, UNICEF programme officers from
regional and country offices, and representatives from other international
agencies and non-governmental organizations. The papers in this issue were
presented at the workshop. These papers review the nature of child development
and factors that affect it, including health, nutrition, and the environment.
The problems in measuring child development and identifying at-risk children
are discussed. Case studies of integrated programmes and studies from
developing countries are also included. Finally, the economic implications of
such programmes are considered.
Following the Wye meeting, a small group of researchers met at
UNICEF's request in New York and wrote a short summary of the scientific
evidence on the nature and determinants of child development and their
implications for interventions. This summary can be found in this issue after
this introductory statement. It is hoped that this issue will contribute to
further work on designing and implementing integrated programmes for the
promotion of child development in developing countries.
Several people contributed to the planning of the meetings,
including David Alnwick, Roger Shrimpton, Ludmila Lhotska, and Marjorie
Newman-Williams from UNICEF, and Andrew Tomkins from the Centre for
International Child Health, University College, London. Ernesto Pollitt from
the University of California, Davis, was particularly helpful in planning the
scientific programme. The meeting was funded by UNICEF with a contribution
from the International Union of Nutritional Sciences
Sally Grantham-McGregor Editor
Introduction
At the request of UNICEF, a summary was prepared of the
scientific evidence on the nature and determinants of child development and
their implications for programmatic interventions with young children. This
summary is given below and reflects the views of the authors. We have included
well-established points that we think are important as well as adding
information that is new both theoretically and empirically
The size of the problem
No figures exist on the number of children with developmental
delays (lags in mental, motor, social, and emotional development compared with
reference criteria) as a result of poor health and nutrition and poor
environments. However, 39% of children under five years of age in low-income
countries are growth retarded. Growth retardation is a marker for both
disadvantaged environments and developmental risk, and hence it is likely that
at least this proportion of children will have poor developmental outcomes.
The size of the problem is obviously enormous, but more data are urgently
required
The nature of early childhood development
Child development is multidimensional. These dimensions, which
are interdependent, include social, emotional, cognitive, and motor
performance, as well as patterns of behaviour and health and nutritional
status.
The optimal development of children refers to their ability to
acquire culturally relevant skills and behaviours that allow them to function
effectively in their current context as well as adapt successfully when their
current context changes.
Development is multidetermined, varying as a function of
nutritional and biomedical status, genetic inheritance, and social and
cultural context.
Undernutrition, poor health, and non-optimal caregiving affect
a broad range of outcomes, including cognitive, motor, psychosocial, and
affective development. For example, children are naturally motivated to
explore and to attempt to master their environment. Under nutrition, poor
health, and non-optimal caregiving tend to reduce these motivations, which may
inhibit development.
The early years of life are essential as the foundation for
later development. However, the impact of past and concurrent under nutrition,
poor health, and nonoptimal caregiving is not confined to these years.
Children's development is essentially cumulative in nature.
Some developmental trajectories can be made better or worse as
a function of influences encountered past the early years
Determinants of child development
The number of risk factors has a cumulative or interactive
impact on child development.
The effect of risk factors varies with the age of the child,
and their effects, or the results of interventions, may have delayed and not
immediate impact.
When resources are limited, the highest-risk individuals in a
population should be targeted for intervention. However, it is important to
realize that the highest-risk individuals in a population may occur relatively
infrequently. Focusing solely on these individuals may not have a large impact
on the community. Further, some communities may have such a high prevalence of
multiple risk factors (e.g., orphaned children, famine, widespread maternal
illiteracy) that the whole population should be targeted. Risk can be assessed
at both the individual and the community or ecological level (table 1).
It is important to understand the prevalence of risk and
protective factors in a population in order to plan effective resource
utilization. Thus, the first step in planning any programme of services should
be to conduct an assessment of the prevalence of protective and risk
factors.
Programmatic actions
Programme characteristics and content.
The timing, duration, and breadth of an intervention modify
its effect. Generally, the earlier and the longer the interventions, the
larger the developmental benefits. This is true for both the initial and the
later size of the effect as well as for its duration. If timing and duration
are held constant, multifocal interventions (e.g., health, nutrition, and
optimal child care) will yield larger and more sustained benefits than
unifocal interventions (e.g., supplementary feeding). This statement is
particularly valid when the interventions begin past the child's postnatal
growth spurt of the brain. Short-term and unifocal interventions that begin
during the later pre-school period will do little to repair the damage from a
history of malnutrition, poor health, and less than optimal caretaking. The
merit of late interventions, even during the school years, is to prevent or
remedy the adverse effects of concurrent health and nutrition problems that
often interfere with learning and performance.
The more frequent the contact and the more intense the
intervention, the more likely the children will benefit. Ideally, there should
be an integration of maternal and child health services and early childhood
development programmes.
Interventions may not benefit all domains of development. As
programmes are implemented in communities, they should be monitored carefully.
Before going to scale these programmes should be expanded in a staged manner,
and it is critical to take into account culture, ecology, language, and
demographic factors, among others, and to devise interventions that reflect
these variables. Rather than simply adopting already existing approaches,
there is an urgent need for evaluations of varied approaches to intervention
and methods of delivering these services.
Recommendations of programme type (e.g., homebased,
centre-based, or a combination) are dependent on the availability of several
critical variables, such as responsible caregivers in the home, safety of the
home, quality of caregiving in the centre, and stability, support, and
training of caregivers in the centre. In general, centre-based programmes are
not recommended for children from birth to three years of age except when the
child is an orphan, the mother is in full-time employment, there is no
suitable adult caregiver in the home, or there is extreme family disruption or
child abuse and neglect.
Actions taken to facilitate child development in addition to
nutrition and health interventions should contain at a minimum the following:
age-appropriate responses of adults; stable relationships with adult
caregivers; supporting the child's development of language through labelling,
encouraging the child's vocalizations, expanding, explaining, and two-way
conversations; providing an environment for the child to explore safely;
providing interesting play materials and books that reflect the child's
everyday experiences; warm, affectionate behaviour and positive affect;
sensitive and responsive behaviour to the child's signals; play activities
with peers and adults.
Many children with disabilities can respond productively to
the same developmental interventions as children without disabilities and
should be included in such intervention efforts. Children who have been
injured as a result of war are also included among those with disabilities.
Parents
Actions should be taken to strengthen the parent's or
caregiver's sense of effectiveness as a promoter of child development.
Interventions with parental and non-parental caregivers are
needed to help them use developmental materials appropriately, to provide
challenging activities at the appropriate level of difficulty in which the
child can be successful, to become increasingly involved with their children,
to respond verbally to the child's vocalizations, to be responsive to the
child's emotional needs, and to avoid physical punishment as a standard
child-rearing practice.
Parents or caregivers should be taught how to integrate child
development activities into activities of daily living as much as possible.
Involving other family members in these activities has the potential to
increase their impact.
Training
Another critical element of programme expansion is systematic
and continuous training and supervision for both professional and
paraprofessional staff. The success of the programme is highly dependent on
the preparation and supervision of staff at all levels. Paraprofessionals need
to be given field-based training to be closely affiliated with the communities
in which they work, and should have credibility with the families in their
communities. Health and medical professionals should receive inservice
training to enable them to appreciate and provide necessary support for
paraprofessionals and professionals working in child development activities.
Evaluation and assessment
Larger-scale studies of effectiveness with careful evaluation
of process and impact need to be conducted.
All programme evaluations should begin by specifying programme
objectives and documenting that programme activities are delivered.
Adaptation of existing direct (developmental scales and
cognitive tests) and indirect (e. g., parent's report) assessments of child
development in children 18 months to 6 years of age (focusing on psychomotor,
gross motor, reasoning, language, and adaptive tasks, including social and
emotional behaviour) can be used to evaluate programme success when the
programmes are intended to promote and enhance these outcomes. .
There is need for an investment of resources to develop new
instruments and improve existing instruments intended to assess children's
cognitive and noncognitive development below the age of three years. This is
particularly true for large-scale evaluations of programme interventions.
Further research on the use of parental reports and other approaches,
including brief observations, is needed.
Process measures of developmental interventions are critical
for continuous improvement of programmes and for providing assessment of the
strengths and weaknesses of programme practices (e.g., children's and parent's
responsiveness to the intervention, children's level of development and change
over time, parental level of participation, and factors that inhibit
participation). Such process measures can also serve the function of teachmg
parents and other caregivers about their children and providing them with
information about how to modify their behaviour with their children. Simple
checklists, combined with training and supervision, can be used for this
purpose
TABLE 1. Examples of community or ecological risk factors and
individual risk factors
