1. Early Childhood Development in South East Asia
Dr. Neena Raina
Regional Advisor,
Child and Adolescent Health
WHO/SEARO

2. Are you aware that At birth there are 1 billion brain cells
Brain of a six month old is half and that at 8 years is 90% that of an adult in weight
Most of the synaptic connections (wiring) takes place during the early years of life. Rewiring cannot take place later in life
Maturity of brain is characterized by pruning . Excess of neurons and synapses are eliminated. This pruning is guided by the environment during the early years of life

3. Rethinking of the brain
Old thinking
New thinking
Brain development depends on the genes
Experiences before 3 years age have a limited impact on later development and personality
Secure relationship with a caregiver helps early development and learning
Brain development is linear
Early brain development is slow as compared to an adult
Brain development depends on the interaction between genes and the experiences
Early experiences influence architecture of the brain and extent of adult capacity
Secure relationship with a care giver affects early development and wiring of brain
Brain development is maximal in early years (including pregnancy)
Brain is twice as active at three as compared to college student

4. Synaptic Density At Birth 6 Years Old 14 Years Old 03-012
There are an estimated 1000 trillion synapses at 8 months age. A pruning takes place and brain forgets and loses synapses that are not used. Detailed analysis of the patterns of nerve connection that form from birth to age 14 have been carried out. This slide which comes from the work of Huttenlocher shows the connections amongst the neurons at birth is not intense but that by the age of 6 the connection density is considerable. By the age of 14, the connection pattern is still greater than at birth but is less intense. The weak pathways have been cut out. This process is referred to as the wiring and sculpting of the brain. The wiring of neurons in the brain is hugely influenced by stimulation and the use of these neuron pathways. Thus, as you age, pathways that are not intensely used will disappear. What this evidence does show you is that the early period of life has a significant effect on the wiring and sculpting of the brain.
Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

5. This PET scan of the brain of a normal child show regions of high activity shown in red and low shown in blue and black . At birth only primitive structures such as the brain stem shown in the center are fully functional. In regions are the temporal lobes on the top early childhood experiences wire the circuit.

6. PET scan of an abused brain shows severe deprivation in early infancy Black areas are predominant. Such children suffer emotional and cognitive problems

7. Stunting is associated with
Reversing the developmental effects associated with stunting (low height for age)
31% of children under 5 years of age in developing countries are stunted (SOWC 2007), 46% in India (Status of the World’s Children 2006)
Stunting is associated with
Poor developmental attainment in young children (Walker, et al., 2007)
Up to 46% less income earned as adults due to poorer school achievement and lower intelligence levels (Bundy, 1996; Hoddintott, et al., 2008) 7

8. Bogotá Project: Effects of supplementation and stimulation on growth and weight (results at age 7)
Van der Gaag, J. School Performance and Physical Growth of Underprivileged Children: Results of the Bogotá Project at Seven Years. (1983). World Bank, Washington D.C.

9. Bogotá study (continued)
At age 7, children who had received supplementation and stimulation in early childhood
Physical growth: Less than 20% were stunted, compared to 50% in the control group
Development:
Better reading readiness scores
Better mathematics scores and basic knowledge (preschool achievement test scores)
Results especially strong for chidren of fathers of low to moderate levels of education and literacy (a proxy for SES)

10. The Jamaica Study Grantham-McGregor, et al. , 1991
Looked at the effects of nutritional supplementation and psychosocial stimulation on stunted children aged 9-24 months
An experimental intervention study
129 children from poor neighboorhoods were randomly assigned to four groups:
Control
Supplemented only
Stimulated only
Supplemented plus stimulated
And a matched comparison group of non-stunted children 10

11. Jamaica Project: Effects of supplementation and stimulation on the mean development quotient of stunted groups compared with non-stunted groups
Development quotient includes practical reasoning, eye and hand coordination, hearing and speech, and performance. S.M. Grantham-McGregor, et al. (1991). 11

12. Jamaica Study: The effects of the stimulation intervention at age 17-18 years
p (significance)
0.1
.001
.01
.05
.02 .1
.02
standard scores
UNICEF
Walker, et al. (2005) 12 12

13. Findings from the Lancet series on child development (2007)
An estimated over 200 million children under age 5 are not developing their full potential
The cost in economic potential is 20-29% of each adult worker’s income per year
The best documented risks are stunting, iron deficiency, iodine deficiency, and lack of stimulation
Poor growth and poor development are closely related 13

14. Key messages Lancet 2011
Biological and psychosocial risks affects the developing brain. Risks are poverty, malnutrition and lack of stimulation. Breast feeding, cognitive stimulation and maternal education are important to tackle the risks. Inequalities in child development begin prenatally and in the first years of life, and increase over time. Reducing inequalities requires early integrated interventions that reduce risks and promote child development. The most effective and cost-efficient time to prevent inequalities is early in life. Parenting interventions and center-based programmes (preschools) can improve children’s development. Quality in Early Child Development programmes can be maximized through design, curriculum, parent involvement, and training and supervision for workers Increasing preschool enrolment in each low- and middle-income country would result in a benefit of between US $10 - $34 billion

15. Sensitivity (Care giver)
The caregiver is aware of the infant’s signals and interprets them accurately
The caregiver accepts the child’s interests, gives physical affection, is positive
To be sensitive, the caregiver must be able to
Regard the child as a separate person
See things from the child’s point of view

16. Responsiveness of the care giver
The response of the mother depends on, or is triggered by, the child’s signal This should be recognized early and matched by a response by the care giver
To be responsive, the caregiver must be sensitive

17. Responsiveness to child language affects language development
Tamis-LeMonda, et al. 2001 17

18. Sensitivity and responsiveness (care giver) :
To be effective in caring for a young child—sick or well, e.g.:
Breastfeed on demand, feed responsively
Protect a child from imminent harm
Recognize and seek care when the child is sick
See cause and effect in the environment and in social relationships
Learn to speak, solve problems

19. Attachment
Primarily a process of the infant forming a relationship with his or her mother (infant to mother): attachment is reinforced by the responses of the mother (or other primary caregiver)
Occurs in first two years of life, but especially between 2 and 7 months of age
Child develops a personal communication system with the primary caregiver……by receiving an appropriate response from the caregiver

20. Consequences of poor attachment
A break leads to:
Confusion (‘lost in a strange country without an interpreter’)
Lack of trust
Increasing rage or depression
Shutting down—’non-organic failure to thrive’
When there is no primary caretaker, child attaches to things, environment, routines, etc. and has difficulty adapting to any change

21. Bonding
The process of a mother forming a relationship with her new infant (mother to infant)
Begins during the first few hours after birth

22. High risk conditions for bonding
Mother
Separated from infant for a period after birth
Poor health, for example, as many as 40% of mothers are depressed after delivery,
Characteristics of child
About a quarter of low birth weight babies were abused and failure to bond was the reason)
-children with illness or undernourished children frequently are abused due to lack of bonding

23. ECD and long term effects
In an unstimulating, emotionally and physically unsupportive environment their brain development is affected in adverse ways. Many problems in adult life have their origins in pathways that begin in childhood.
In the short term, ECD influences ‘readiness for school’. Over the first and the second decade of life it influences school success, social success or rejection, stunting, early criminality and the prospects for a successful transition to citizenship.

24. ECD and long term effects
By the third and fourth decade of life it influences mental health (depression and anxiety disorders), physical health (obesity, blood pressure, heart disease, non-insulin dependent diabetes), and socioeconomic mobility.
From the fifth decade onward, it influences a wide range of chronic diseases as well as the prospect of healthy aging

25. Why invest in early childhood development ?
At the most basic level it improves child survival
ECD helps development, goes beyond survival, builds social capital with return of seven times
Helps to break the intergeneration cycle of poverty and malnutrition
Contributes to reduction of gender inequities
ECD builds social capital
Helps build community networks to improve self care
First line of defense in dealing with developmental delays and disability

26. Mismatch between Investment and Opportunity
Preschool
School
Post School
Age
Evidence
Cumulative Public Investment
Optimal Investment Levels
Source: Carneiro & Heckman, Human Social Policy (2003)

27. Age 1 week up to 6 months: Talk to your child and get a conversation going with sounds or gestures
The first example is the recommendation for children age up to 6 months:
Communicate with your child. Talk to your child and get a conversation going with sounds or gestures.
Even with these still pictures you have an idea of how this mother gets a conversation going with her young child, even before the child is able to speak. Activities to imitate and communicate with her child help the mother interact responsively. They also prepare the child for learning language and the skills that form the basis for later social cooperation.

28. Age 12 months up to 2 years:
Give your child things to stack up, and to put into containers and take out.
Another example, the recommendation for play for the child age 12 months to 2 years, is:
Give your child things to stack up, and to put into containers and take out.
When the health worker counsels the mother on care, she gives the mother a chance to try-out a recommended activity. Here the health worker encourages the mothers to help their children stack the cups or put things into bowls.
Around this activity, the mother interacts with her child. The health worker praises her, reinforcing this interaction. For example: See how your child enjoys playing with you. You are helping your child learn.
In our experience with the course so far, we have seen mothers who interacted very little with their children until they were given a concrete play activity to do. The goal is to use this activity, like stacking cups, to try to change or improve her interaction with her child during the consultation. And help the mother to see ways she can help her child learn. 28

30. Adults are children’s first teachers

33. What can be achieved through CCD
Reduction in deaths
Children will be healthier
Improved nutritional status
School readiness, improved performance in school
Greater adult productivity and income
The gains are maximal if CCD can be focused on underprivileged groups in the society

34. Why ECD should be in the Health Sector?
Regional Strategy: WHO-SEARO
Why ECD should be in the Health Sector?
Health: Overall well being
Established MCH services: to support the critical period from prenatal period to first three years of life
Synergy of good care and mother-child interaction for survival, growth, and development
Tradition of health care providers as advisors for families

35. Entry points in Health Care System
9 Jan 2010
Entry points in Health Care System
Sick child visit (e.g. IMNCI)
Well-baby clinics
Prenatal and newborn services (e.g. breastfeeding support)
Nutrition clinics or feeding programmes
Child care centers
Mothers, groups
Home visits: Community health workers
Special services for children at risk
Care and nutrition intervention, both are
needed and can be delivered together
Health system offers several opportunities for promoting ECD
Whenever the caregivers of young children (especially < 3 years) come in contact with health care providers they should receive age-appropriate guidance for promoting ECD
9 Jan 2010
WHO- PEDICON

36. More Opportunities in Health Sector
Home Visits for Newborn Care:
Community Health Workers to visit homes for supporting post-natal care
Community Case Management:
Treatment of diarrhea and pneumonia
Counselling on feeding and immunization
Opportunity to integrate ECD activities

37. STRATEGIC DIRECTIONS Goal:
To ensure that all children are able develop their full potential, recognizing that development is integrally related to child health and nutrition.
Improving one without improving the other will not achieve the goal for ECD: A benefit for society

38. STRATEGIC DIRECTIONS All families receive information and guidance
Special care given to disadvantaged and special needs children
ECD incorporated at each level of the health system
Child health policies
Community health programmes
Health care facility
Goals should be to improve the well being of children during their most vulnerable period. This includes social, emotional, cognitive, and physical development. The means of doing that include providing families with guidance, providing additional support to families with disadvantaged children.
How should this be done? Embed ECD At three levels: at the community level, through the community health programs; at the facility level, through advice and guidance to families and special attention to disadvantaged children; and at the higher level, through child health policies.

39. IMPLEMENTING ECD AT SCALE
Advocacy for ECD with Policy makers
Define the Vision and Goals for ECD in country
Set up Coordinating Mechanism
Develop Costed Plans
Pilot programme models - Scale up
Monitoring and evaluation plan

40. THANK YOU