SERIES

IZA DP No. 5282

PAPER

Early Childhood Stimulation Interventions in Developing Countries: A Comprehensive Literature Review

Helen Baker-Henningham Florencia Lopez Boo

DISCUSSION

October 2010

Forschungsinstitut zur Zukunft der Arbeit Institute for the Study of Labor

Early Childhood Stimulation Interventions in Developing Countries: A Comprehensive Literature Review

Helen Baker-Henningham
University of the West Indies, Mona

Florencia Lopez Boo

Inter-American Development Bank and IZA

Discussion Paper No. 5282 October 2010

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IZA Discussion Paper No. 5282 October 2010

ABSTRACT Early Childhood Stimulation Interventions in Developing Countries: A Comprehensive Literature Review*
This report reviews the effectiveness of early childhood stimulation interventions in developing countries. The report aims to answer the questions: What works in terms of early stimulation for young children in developing countries? For whom and under what conditions do these programs work and why do they work. The report is divided into several sections. Firstly, a brief discussion of the importance of early stimulation for young children in developing countries is provided. Secondly, the methods used to identify and characterize studies are provided and a review of randomized or quasi-experimental trials is presented. Thirdly, a review of the evidence for who benefits most from early interventions is presented followed by a review of program characteristics that affect the success of interventions and an examination of potential mechanisms through which interventions achieve their effects. Finally, recommendations for practice and future research are provided.

JEL Classification: Keywords:

J13, J18, J24

child development, early stimulation, mothers, parenting, developing countries

Corresponding author: Florencia Lopez Boo Social Protection and Health Division Inter-American Development Bank 1300 New York Ave. Washington, DC 20577 USA E-mail: florencial@iadb.org

The information and opinions presented in this paper are entirely those of the author(s), and no endorsement by the Inter-American Development Bank, its Board of Executive Directors, or the countries they represent is expressed or implied. The authors thank the comments from an anonymous peer-reviewer, Norbert Schady and Ferdinando Regalia.

Introduction: importance of early stimulation interventions for children in developing countries

-n this section( o"r main iss"es are introd"ced which provide a rationale or investing in earl! childhood stim"lation interventions in developing co"ntries# These iss"es incl"de% 13 the e)tent and nat"re o the problem( 23 the nat"re o child development incl"ding the importance o the earl! !ears( 43 the technolog! o skill ormation and 53 the centralit! o the amil! environment or optimal child development# Large n"mbers o children in developing co"ntries are e)posed to m"ltiple risk actors in the earl! !ears o li e incl"ding poor health( maln"trition and low levels o home stim"lation# +isk actors covar! 6 7 or e)ample( povert! covaries with low maternal ed"cation( teenage parenting( child "ndern"trition( low birth weight( high levels o maternal depression( "nsa e neighborhoods and low levels o stim"lation in the home3 6 and children e)posed to m"ltiple risk actors are at heightened risk or poor development# For e)ample( the n"mber o risk actors e)perienced b! children b! age 4 !ears in a 8"atemalan st"d! was associated with a linear decrease in cognition and school achievement in adolescence 78orman 9 0ollitt 1::;3# 8rantham-.c8regor and colleag"es 7200<3 estimate that over 200 million children "nder ive !ears o age in developing co"ntries are not reaching their developmental potential d"e to povert! and poor health and n"trition# These children are likel! to do poorl! at school and to have limited economic opport"nities in ad"lthood# This in t"rn perpet"ates the c!cle o povert! and contrib"tes to the intergenerational transmission o povert!( poor health and development# This loss o children=s developmental potential was estimated to lead to a 20> de icit in ad"lt income 78rantham-.c8regor et al# 200<3# Th"s in addition to perpet"ating social ine$"ities( poor development has serio"s implications or national development# ?hild development is m"lti-dimensional and incl"des cognitive-lang"age( sensor!-motor( and social-emotional domains( all o which are interdependent# @ltho"gh m"ch earl! literat"re oc"sed on the importance o earl! child cognition or later development( there is increasing recognition o the importance o non-cognitive domains in predicting children=s academic attainment( prod"ctivit! and social "nctioning in ad"lthood# ?hild development is also m"lti-determined being in l"enced b! an interaction between children=s genetic inheritance( biological state 7e#g# health and n"tritional stat"s3 and the

pro)imal 7e#g# $"alit! o maternal-child interaction3 and distal 7e#g# neighborhood characteristics3 environment 7&achs 20003# 1"ring the irst ew !ears o li e( rapid growth and development occ"r in all domains orming a strong o"ndation or learning later skills 72ational +esearch ?o"ncil -nstit"te o .edicine 20003# ?hildren living in disadvantaged environments are more likel! to be e)posed to biological and environmental risks which a ect brain growth and can lead to lasting changes in the developing brain=s str"ct"re and "nction# B! the ages o o"r to si) !ears( persistent gaps have emerged in children=s development in both cognitive and noncognitive domains between children rom disadvantaged backgro"nds and their more advantaged peers 7Heckman 200;3# There is a s"bstantial evidence base showing that e)pos"re to disadvantaged environments d"ring the irst ew !ears o li e is associated with man! negative o"tcomes in adolescence and ad"lthood incl"ding lower -A and academic attainment( increases in antisocial behavio"r and lower earnings in ad"lthood 7Heckman 9 .asterov 200<3# -n addition( c"m"lative e)pos"re to risk in earl! childhood is associated with poor health and chronic disease in ad"lthood indicating that health disparities also have their origins in earl! childhood 7Shonko et al# 200:3# 0robabl! most importantl! or the p"rposes o developing co"ntries= progressB a large bod! o research doc"ments that the social and economic s"ccess o investments in h"man capital in later childhood and adolescence will be in l"enced b! the cognitive and non-cognitive skills 7e#g# social and emotional skills3 that children bring to the task 7Hernstein 9 ."rra! 2005( ."rnane et al# 1::C( Heckman et al# 200;3# ?hildren with higher levels o the prere$"isite skills will bene it more whilst disadvantaged children will bene it less# F"rthermore( disadvantaged children are less likel! to take advantage o later learning opport"nities than their more advantaged peers as demonstrated or e)ample( b! greater school drop o"t amongst disadvantaged children in developing co"ntries 78rantham-.c8regor et al# 200<3# St"dies o skill ormation have shown that interventions in the earl! childhood !ears are one o the rare e)amples o interventions that are both e$"itable and e icient 6 that is( the interventions red"ce ine$"alities whilst also raising the prod"ctivit! o the societ! as a whole 7Heckman 200;B ?"nha et al# 20103# -nterventions starting later in li e re$"ire remediation o developmental de icits ca"sed b! earl! disadvantage and are more costl! and less e ective# *arl! interventions th"s increase the e icienc! o later interventions and the best res"lts are evident when e ective earl!

interventions ollowed b! high $"alit! interventions at later ages 7Heckman 200;3# ?"nha and colleag"es 7200C3 describe this phenomenon as the Dsel -prod"ctivit!= and Dcomplementarit!= o the learning process leading to a Dskill m"ltiplier= e ect# DSel -prod"ctivit!= re ers to the concept that skills learned at one stage o the learning process enhance learning at later stages# D?omplementarit!= means that earl! investments are most e ective when ollowed b! later investments# These two concepts lead to the notion that Eskill begets skillB learning begets learningF 7?"nha et al# 200C( pp#G03# *arl! investments have been shown to be partic"larl! important in terms o cognitive skills with investments at earl! ages !ielding m"ch larger ret"rns than investments at later ages as there is limited s"bstit"tabilit! across time periods 7?"nha et al# 20103# For non-cognitive skills there is larger scope to make "p earl! de icits beca"se earl! and late investments are more closel! s"bstit"table 7?"nha et al# 20103# This will have implications in the design o polic! interventions B"t what are the main determinants o child development' The negative e ects o disadvantaged environments in the earl! childhood !ears point to the importance o the amil! and the home environment or promoting optimal child development# Since the p"blication o the well-known ?oleman +eport 71:;;3( it has been recognized that ine$"alities in st"dent attainments are primaril! a res"lt o ine$"ities in amil! environments rather than school environments 7Heckman 200;3# F"rthermore( there is s"bstantial evidence rom developed co"ntries that earl! interventions that s"pport caregivers and provide developmentall! appropriate learning opport"nities or !o"ng children lead to signi icant bene its across m"ltiple o"tcomes in later li e( incl"ding higher cognition and school achievement( red"ced placement in special ed"cation classes( less grade retention( less crime and delin$"enc!( lower rates o teenage pregnanc! and increased earnings and less dependence on wel are in ad"lthood 7Heckman 9 .asterov 200<( Hoshikawa 1::C3# &alker and colleag"es 7200<3 identi ! inade$"ate cognitive stim"lation as one o the o"r most "rgent modi iable risk actors that are enco"ntered b! !o"ng children in developing co"ntries 7the other three "rgent risk actors identi ied were st"nting( iodine de icienc! and iron de icient anemia3 while *ngle and colleag"es 7200<3 provide evidence that earl! child development programs in developing co"ntries are s"ccess "l in promoting !o"ng children=s development( th"s preventing the loss o children=s developmental potential# The! s"ggest that the most e ective programs are those that Dprovide direct learning e)periences to children and amilies( are targeted towards !o"nger and disadvantaged children( are o longer

d"ration( high $"alit! and high intensit!( and are integrated with amil! s"pport( health( n"trition or ed"cational s!stems and services#= 7*ngle et al# 200<( pp# 22:3# There are two recent reviews o earl! childhood interventions globall!# 2ores 9 Barnett 720103 reviewed the evidence o the e ects o earl! childhood interventions cond"cted o"tside the ,S on child cognition( behavior( schooling and health# Thirt! interventions were identi ied and the average e ect size on child o"tcomes was 0#2; to 0#4:# *d"cational interventions and mi)ed n"trition and ed"cational interventions prod"ced the greatest bene its to children=s cognition 7e ect size 0#4C3 in comparison with cash trans er programs 7e ect size 0#1<3 or n"trition alone 70#2C3# *d"cational interventions also had the largest e ect size on schooling and behavioral o"tcomes altho"gh n"trition interventions had the largest impact on child health# -nterventions were e ective both in the short and over the long term e)cept or the health domain in which the e ect sizes decreased over time 7Fig"re 13# igure 1! "verall effect si#es of early childhood interventions on child cognition$ behavior$ schooling and health outcomes over the short and longer term
E ffect si#e
%!( %!' %!& %!2 %!1 %
Cognition )ehaviour Schooling * ealth

Short term

+ong term

Source: Nores & Barnett 2010 .a"lik 9 1armstadt 7200:3 cond"cted a descriptive review o the evidence or the e ectiveness o interventions targeting children in the birth to age three age range that "sed low cost stim"lation interventions incl"ding pla!( reading( m"sic and tactile stim"lation 7e#g# kangaroo care or preterm babies3# From their review the! concl"ded that pla!-based interventions and interventions that promoted shared reading were the most e ective and easible interventions or developing co"ntries# C

-n this paper we e)tend and complement 2ores 9 Barnett 720103 and .a"lik and 1armstadt 7200:3 in the ollowing wa!s# Firstl!( this paper is a more comprehensive review o st"dies rom low and middle income 7L@.-3 co"ntries# &e describe in detail 2G interventions rom L@.- co"ntries 6 onl! ten o these interventions are incl"ded the review b! 2ores 9 Barnett and ten are described in the paper b! .a"lik and 1armstadt# Secondl!( this review is oc"sed onl! on interventions that aim to promote children=s development thro"gh stim"lation( primaril! thro"gh parenting interventions# -nterventions largel! aimed at promoting child health 7e#g# kangaroo care3( n"trition onl! interventions and cash trans er programs have been e)cl"ded rom this review( as opposed to the earlier reviews# This allows or a more in-depth e)amination o iss"es that are important in earl! stim"lation interventions# Thirdl!( given the importance o the home environment and maternal well-being or !o"ng children=s development( we have e)tended the scope o this review to incl"de the bene its o intervention to caregivers# Finall!( in addition to investigating the e ect o earl! childhood interventions on child and maternal o"tcomes we e)amine iss"es relating to implementation 7e#g# what characterizes an e ective program( di erential e ectiveness o interventions( and the mechanism thro"gh which these interventions work3# These are important iss"es to be considered when scaling-"p e ective interventions#

,ethods
@ review o earl! stim"lation interventions or children aged birth to ive !ears( with a partic"lar oc"s on the birth to three !ear age gro"p was "ndertaken to acilitate an in-depth e)amination o pertinent aspects o the programmes# Studies were included if: The st"d! was cond"cted in a low or middle income co"ntr! @ reasonable comparison strateg! was emplo!ed 7e#g# randomized trial or $"asie)perimental eval"ation3 There was an e)plicit oc"s on improving child development andIor maternal o"tcomes#

The st"d! described a stim"lation intervention that occ"rred between pregnanc! and age 4 !ears andIor that described a stim"lation intervention in children aged 5-C that wo"ld be appropriate or children age 4 and "nder#

Studies were excluded if: The! dealt with preschool provision onl! in the age 4-C age range The! involved children in instit"tions or were speci icall! designed to be appropriate or a specialized gro"p o children e#g# kangaroo care or premat"re in ants and comm"nit! rehabilitation or disabled children# The ollowing databases were searched% .edline( 0s!chin o( *.B@S*( 8oogle Scholar and in addition hand searches o ke! articles and reviews were cond"cted and e)perts in the ield were contacted to identi ! "rther st"dies# The main oc"s o this report was on reviewing st"dies that had been p"blished in peer review Jo"rnals which primaril! consisted o e icac! st"dies# However( reports o large scale program eval"ations were also reviewed and in ormation on these were incl"ded i the! provided additional in ormation and insights not provided thro"gh the e icac! st"dies# The st"dies were reviewed or the e ects o earl! stim"lation interventions on child and maternal o"tcomes both conc"rrentl! and over the long term# ?hild o"tcomes were categorized as% 1# Child mental and motor development and/or IQ: meas"red b! standardized scales 2# Child behaviour: incl"des observed behavio"r( ratings b! teachers and parents( sel report and o icial records 4# Schooling: incl"ding school achievement( retention in grade( placement in special ed"cation and high school grad"ation 5# Nutritional status C# Health .aternal o"tcomes were categorized as% 1# Parenting: which incl"des observed parent child interaction( parenting attit"des( parenting knowledge( and stim"lation provided in the home# 2# Psychosocial function: incl"ding depression( an)iet!( sel -esteem as well as stresses and b" ers s"ch as social s"pport and chronic stressors#

<

4# Maternal life course: ed"cation( emplo!ment( child bearing( criminalit!( dr"g and alcohol ab"se or women=s stat"s in the home @n additional categor! o mother-child interaction was incl"ded to categorise o"tcomes that meas"red the s!nchron! between mother and child or that e)amined mother and child initiated interactions# 1etails o the sample( d"ration o the program( setting 7home visiting or centre based3( content o the intervention( personnel delivering the intervention( training provided to intervention sta and short and long term o"tcomes are given in tables 1 to C# The co"ntries in which the eval"ations were cond"cted were also classi ied "sing the &orld Bank classi ication o economies#

.eview of Studies
@ total o ort! ive Jo"rnal articles describing twent! si) st"dies o earl! stim"lation interventions or !o"ng children rom eleven developing co"ntries were identi ied# The st"dies were divided into ive categories according to the gro"p o children targeted andIor the primar! oc"s o the intervention# These ive categories are% 1# Stim"lation intervention in earl! in anc! with a primar! oc"s on promoting maternalchild interaction 2# Stim"lation interventions with disadvantaged children and their amilies 4# Stim"lation onl! interventions with "nderno"rished children and their amilies and 5# ?ombined stim"lation and n"trition programs# C# Stim"lation interventions with children at-risk d"e to health problems#

Stimulation Interventions in Early Infancy with a /rimary /romoting ,aternal Child Interaction

ocus on

Fo"r stim"lation interventions were identi ied in this categor! and all o"r were cond"cted in "pper-middle income co"ntries# The st"dies are described in detail in Tables 1# Three o the st"dies were randomized controlled trials and one "sed a well matched control gro"p# @ll o"r interventions involved promoting mothers= sensitive and responsive interactions with her in ant# The d"ration o the interventions varied rom one i t! min"te session to ; months o intervention and three o the interventions involved home visiting b! parapro essionals 7?ooper et al# 2002( 200:B 8ardner et al# 20043# -n these three interventions( the parapro essionals received initial training in the intervention( ongoing s"pervision was provided and a man"al was available to ens"re the stim"lation intervention was delivered with idelit!#

Child "utcomes Knl! one st"d! meas"red in ants= mental development and behavio"r - an eight week intervention starting at birth led to signi icant bene its on a problem-solving test and to in ants= cooperation and positive a ect d"ring the test session at age seven months 78ardner et al# 20043# Kne st"d!( involving si)teen home visits inishing when the in ants were ive months old led to signi icant bene its to in ant attachment stat"s at 1G months 7?ooper et al# 200:3# Knl! one intervention reported the e ect o intervention on growth and no bene its were o"nd 7?ooper et al# 20023# 2o st"dies incl"ded meas"res o bene its to children=s schooling or academic achievement as the ollow "p period did not e)tend into the school-age period# @lso( no child health o"tcomes were meas"red# ,aternal "utcomes Two st"dies investigated the e ect o intervention on parenting behavior and both o these st"dies were rom So"th @ rica and involved home visiting or the irst C-; months o the in ants= lives 7?ooper et al# 2002( 200:3 Signi icant bene its were reported in both st"dies and mothers participating in the intervention were o"nd to be more sensitive( less intr"sive and to show more positive a ect to their children at ; months 7?ooper et al# 2002( 200:3 and at 12 months 7?ooper et al# 200:3 and to be more responsive to their in ants cries at 1 month 7&endland-?arro et al# 1:::3 compared to mothers in the control gro"p# The two So"th @ rican :

st"dies also meas"red mother=s depressive s!mptoms and in one no signi icant bene its were o"nd at ; months 7?ooper et al# 20023 while in the second st"d!( intervention mothers reported signi icantl! ewer depressive s!mptoms at ; months b"t not at 12 months 7?ooper et al# 200:3# 2o st"dies incl"ded meas"res o maternal li e co"rse#

,aternal-Child Interaction Kne st"d!( rom Brazil( which involved one training session with the mother be ore discharge rom hospital 7&endland-?arro et al# 1:::3( meas"red the amo"nt o s!nchrono"s behavio"rs between mother and child one month later and signi icant bene its were o"nd or mother-in ant d!ads in the intervention gro"p#

Summary of Interventions in Early Infancy There are too ew st"dies to draw an! strong concl"sions abo"t the e ectiveness o stim"lation interventions in earl! in anc!# However( the evidence s"ggests that interventions that promote mothers= sensitivit! and responsiveness to her in ant earl! in li e can have signi icant bene its on mother=s parenting behavio"rs and it was enco"raging that in one st"d! bene its were also o"nd to in ant attachment one !ear a ter the end o the intervention# There is ins" icient evidence to determine i these interventions bene it children=s mental or motor development and the evidence o bene its to mothers= mental health is inconsistent#

10

0able 1: Stimulation Interventions in Early Infancy with a /rimary ocus on /romoting ,aternal-Child Interaction in Developing Countries Study So"th @ rica ?ooper et al# 2002 Uppermiddle income country Sample .others recr"ited in late pregnancy in a peri"rban settlement o"tside ?apetown with high "nemplo!ment and illiterac!# -ntervention gro"p % nL42 ?ontrol gro"p 7nL423% motherin ant d!ads matched on at least two o % maternal age( parit! and marital stat"s in an adJacent area Intervention Duration: ; months Conducted by: 0arapro essionals @daptation o the DHealth Misitor 0reventive -ntervention 0rogramme= incorporating ke! principles o the &orld Health Krganisation doc"ment% D-mproving the 0s!chosocial 1evelopment o ?hildren=# The intervention was delivered thro"gh home visiting and provided s"pport or the mother( enco"raged her in sensitive( responsive interactions with her in ant( sensitised the mother to her in ant=s abilities "sing the 2eonatal Behavio"ral @ssessment Sched"le and provided advice on management o sleep( cr!ing and eeding# -ntervention involved two antenatal visits( twice weekl! visits or 5 weeks postanatall!( weekl! or the ne)t G weeks( ortnightl! or a month and then monthl! or 2 months 6 a total o 20 visits# 0raining 0arapro essionals received initial training over a 5 month period and were provided with session b! session gro"p s"pervision b! an e)perience comm"nit! clinical ps!chologist# Short term effects @t ; months post part"m Child "utcomes Child ro!th: Signi icant e ect o intervention on child weight and height# ,aternal outcomes Parenting "mother#infant interaction$: -ntervention mothers were more sensitive in pla! and tended to show more positive a ect d"ring eeding# Pscychosocial function: 2o signi icant e ect o intervention on maternal mood#

11

0able 1 1continued2: Stimulation Interventions in Early Infancy with a /rimary ocus on /romoting ,aternal-Child Interaction in Developing Countries Study So"th @ rica ?ooper et al# 200: Uppermiddle income country Sample .other recr"ited in late pregnancy rom two areas o a peri-"rban settlement in So"th @ rica# Short term effects Child outcomes Infant attachment: Signi icantl! more in ants in the intervention gro"p -ntervention was similar to the ?ooper et al# 2002 were sec"rel! attached at 1G months than in the st"d! described above# control gro"p# 72o association was o"nd between mother-in ant .others were visited at home or 1 ho"r twice relationship o"tcomes and in ant attachment3# 550 pregnant antenatall!( weekl! or the irst eight postnatal women randoml! weeks( ortnightl! or the ne)t two months and ,aternal outcomes assigned to an monthl! or two months 6 a total o 1; visits Parenting: intervention inishing at in ant age C months# @t ; and 12 months( intervention mothers were more 7 nL2203 or sensitive and less intr"sive with their in ants 7e ect control gro"p 7n L 0raining sizes L appro) 0#2C3 22:3 See st"d! above b! ?ooper et al# 2002 Maternal Psychosocial function: Lower prevalence o depression in intervention @ttrition L 11-15> vers"s control gro"p at ; months 721> vs 2:> respectivel!3 and 12 months 71G> vs 2G>3 b"t not statisticall! signi icant# Less depressive s!mptoms among intervention mothers at ; and 12 months b"t di erences onl! signi icant at ; months# 71epression was not correlated with in ant attachment or mother-in ant relationship variables#3 Intervention Duration% C months Conducted by: 0arapro essionals

12

0able 1 1continued2: Stimulation Interventions in Early Infancy with a /rimary ocus on /romoting ,aternal-Child Interaction in Developing Countries Study 0orto @legre( Brazil &endlan d-?arro et al# 1::: Uppermiddle income country Sample 4G primiparo"s mothers and their full-term newborn infants 7with no health complications3 randoml! assigned to% -ntervention% nL1: or 0lacebo% nL1: 1< intervention and 1: control completed assessments Ningston( 150 term low birth /amaica weight 7LB&3 8ardner in ants randoml! et al# assigned to 2004 intervention 7* n L Upper<03 or control 7? n middle L <03# income country Intervention Duration: 1 session Conducted by: 0ro essional 7investigator3 -ntervention involved one C0 min"te session prior to hospital discharge# 1"ring the session mothers watched and disc"ssed a videotape showing in ormation abo"t newborn=s competence to interact( how to handle the in ant a ectionatel! and how to interact with the in ant# The placebo condition involved a C0 min"te session cond"cted in a similar manner to the intervention condition b"t oc"sing on basic caregiving skills 7e#g# h!giene3 and in ant health iss"es# 0raining 2ot speci ied Duration: G weeks Conducted by: parapro essionals 7comm"nit! health aides3 -ntervention involved weekl! home visits b! comm"nit! health aides o 1 ho"r d"ration rom birth to G weeks 0raining Health aides were given 1 week o training prior to cond"cting the intervention and were closel! s"pervised thro"gho"t the intervention period# Short term effects Effects after 1 month: ,other-child interaction -ntervention res"lted in greater re$"enc! o s!nchrono"s behavio"rs between mother and in ant especiall! vocal e)changes( looking at partner and ph!sical contact# -ntervention mothers were also more responsive to in ant cr!ing and to invol"ntar! responses 7e#g# sneezes( co"ghs( hicc"ps3#

Child outcomes at 3 months: Mental development: -ntervention bene ited problem solving on Dcover= means-end cognitive test b"t no signi icant bene its were o"nd or a 2nd problem-solving test 6 Ds"pport= means-end test# %ehavior: -ntervention signi icantl! bene ited in ants= cooperation and positive a ect d"ring the test session#

14

Stimulation Interventions with Disadvantaged Children and 0heir amilies

Twelve stim"lation interventions with disadvantaged children and their amilies in developing co"ntries were identi ied and two o these incl"ded children aged 5-C !ears# The st"dies are described in Table 2# Si) st"dies came rom "pper middle income co"ntries( three rom lowermiddle income co"ntries and three rom low income co"ntries# Knl! two o the st"dies "sed random assignment to the intervention or control condition 7/in et al# 200<( +ahman et al# 200G3 while the remaining ten "sed a $"asi-e)perimental design# The interventions varied in the age o the children on enrolment( d"ration o the intervention and the intensit! o the intervention# The maJorit! o the stim"lation interventions involved a home-visiting component altho"gh in several st"dies( the home visiting was also complemented b! a series o gro"p meetings with the mothers 7+ahman et al# 200G( *ickman et al# 2004( Nlein 9 +!e( 20053# Kne st"d! "sed gro"ps alone 7@bo"d 200<3( one involved co"nseling sessions d"ring a hospital visit 7*rtem et al# 200;3 and two involved centre based services or children altho"gh both these st"dies were primaril! targeting children over age 4 !ears and also incl"ded a parent training component 7&atanabe et al# 200C( Nagitcibasi et al# 2001( 200:3# -n si) o the twelve st"dies( the intervention was delivered b! trained parapro essionals( one st"d! "sed occ"pational therapists to r"n gro"p parent workshops and parapro essionals or the home visiting component 7*ickmann et al# 20043( in two st"dies pro essionals delivered the intervention 7*rtem et al# 200;( .agwaza 9 *dwards 1::13 and in three st"dies the $"ali ications o the intervention personnel were not provided 7&atanabe et al# 200C( /in et al# 200<( Sharma 9 2agar 200:3# The interventions also di ered in terms o the length o the intervention with one st"d! reporting an intervention over a two week period 7*rtem et al# 200;3 and three st"dies reporting an intervention lasting two !ears 70owell 9 .c8regor 1:G:( &atanabe et al# 200C( Nagitcibasi et al# 20013# The content o the interventions shared man! common characteristics and "s"all! involved showing the mother age appropriate activities to do with her child "sing low cost materials andIor items in the home( providing s"ggestions and activities to acilitate mother-child interaction andIor providing in ormation on n"trition( health care and child development#

15

Child "utcomes Child ental and otor !e"elopment

Ten st"dies meas"red children=s mental development and nine o"nd bene its# The onl! st"d! that showed no bene its was a parenting programme in Bangladesh which involved weekl! ed"cation sessions to gro"ps o mothers 7@bo"d 200<3# This st"d! involved primaril! gro"p disc"ssion and in ormation sharing and the a"thor s"ggested that the theoretical rather than practical nat"re o the intervention 7that is( the limited amo"nt o hands-on( practical activities andIor role pla!s3 ma! be one reason or the lack o bene its to child development# Knl! three st"dies meas"red children=s motor development 7Sharma 9 2agar 200:( *ickmann et al# 2004( /in et al# 200<3 and all o"nd bene its# Child Beha"ior Knl! three st"dies investigated the e ect o intervention on child behavio"r and all o"nd bene its 7.agwasa 9 *dwards( 1::1B Nlein 9 +!e 2005B Nagitcibasi et al# 200:3# -n So"th @ rica a 10-week intervention led to signi icant bene its to children=s task oriented behavio"r( positive social behavio"r and distractible behavio"r 7.agwasa 9 *dwards 1::13# -n T"rke!( mothers who had participated in a 2 !ear intervention involving ortnightl! gro"p meetings and ortnightl! home visits reported that their children were less aggressive 7Nagitcibasi et al# 20013 while in *thiopia( a 4 month intervention oc"sing on maternal child interaction led to signi icant bene its to mother reports o child behavio"r ; !ears a ter the end o the intervention# ?hildren in the intervention gro"p were less hostile and aggressive( less an)io"s( less h!peractive and less distractible "sing a standardized scale 7Nlein 9 +!e( 20053# Nutritional Status Knl! two st"dies incl"ded children=s n"tritional stat"s as an o"tcome and neither reported bene its o intervention on growth# S"rprisingl!( one st"d! reported that children in the intervention gro"p had lower weight or height than children in the control gro"p 7@bo"d 200<3# -n this st"d!( no pretest was cond"cted and hence it is possible that this di erence re lected children=s prior n"tritional stat"s# Child Schoolin# Knl! one st"d! incl"ded meas"res o school achievement and bene its were o"nd rom both ed"cational training and mother training or two !ears 7 rom age three to ive !ears3 to children=s 1C

school grades b"t not to scores on academic achievement tests over the short term and to school achievement at a ;-!ear ollow "p 7Nagitcibasi et al# 20013# There was also a trend or children whose mothers had received training to be more likel! to be enrolled in college at the 22 !ear ollow-"p 7Nagitcibasi et al# 200:3# Child $ealth 2o st"dies incl"ded meas"res o child health#

,aternal "utcomes %arentin# Si) st"dies eval"ated the e ect o stim"lation on one or more aspects o parenting and all o"nd bene its# Fo"r st"dies reported bene its to mothers= knowledge o child development 7+ahman et al# 200G( 0owell et al# 2005( @bo"d 200<( /in et al# 200<3( two reported bene its to mothers= sel reported practices 70owell et al# 2005( Nagitcibasi et al# 20013 and two reported bene its to the level o stim"lation in the home 7@bo"d 200<( *rtem et al# 200;3 %sychosocial &unction Two st"dies reported the e ect o stim"lation on maternal ps!chosocial "nction and in neither st"d! were an! bene its o"nd# -n /amaica( there were no signi icant di erences in maternal sel esteem between mothers who had participating in a home visiting program or one !ear and a control gro"p 70owell 20053 and in 0akistan( there was no bene it to mothers= mental distress rom a home visiting programme or ; months 7+ahman et al# 200G3# aternal 'ife Course Knl! one st"d! incl"ded o"tcome meas"res o bene its to maternal li e co"rse# -n T"rke!( mothers who had participated in an earl! stim"lation programme involving biweekl! gro"p meetings and biweekl! home visits reported signi icantl! higher stat"s within the home and better amil! relations si) !ears a ter the end o the intervention 7Nagitcibasi et al# 20013# other-Child (nteraction Kne st"d! investigated the e ect o intervention on mother-child interaction and signi icant bene its to str"ct"red observations o mother child interaction 7Nlein 9 +!e 20053#

1;

Summary of Stimulation Interventions with Disadvantaged Children and 0heir amilies The st"dies provide strong evidence that earl! stim"lation interventions can bene it children=s mental development and mothers= parenting practices over the short term# There is some evidence that stim"lation in earl! childhood can also have signi icant bene its to child behavio"r altho"gh onl! three st"dies e)amined this# There is no evidence rom these st"dies that earl! stim"lation can bene it children=s n"tritional stat"s or maternal ps!chosocial "nction altho"gh ew st"dies e)amined this# Similarl! it is not possible to draw an! concl"sions abo"t the bene its o earl! stim"lation to children=s schooling traJectories or maternal li e co"rse as onl! one st"d! e)amined these o"tcomes# Knl! two st"dies incl"ded a long term ollow-"p and hence the evidence or s"stained bene its rom earl! stim"lation is limited# However( both st"dies reported that some bene its o earl! stim"lation were maintained( one a ter ; !ears 7Nlein 9 +!e 20053 and one a ter 22 !ears 7Nagitcibasi et al# 200:3#

1<

0able 2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries Study +"ral 0akistan +ahman et al# 200G 'owermiddle income country Sample 5G villages randoml! assigned to an intervention or control condition# Intervention Duration: ; months Conducted by: parapro essionals DLearning thro"gh 0la!= 0rogram# ?onsists o a pictorial calendar depicting G s"ccessive stages o child development rom birth &omen in their last to 4 !ears with accompan!ing in ormation o child trimester o pla! and other activities that promote parental pregnanc! were involvement( learning and attachment# recr"ited @ training man"al is available or comm"nit! 7intervention% workers giving tips on how to cond"ct individ"al nL1;4B control% or gro"p sessions or parents "sing the calendar as nL15;3# a oc"s# -ntervention consisted o a hal da! workshop with small gro"p o mothers when in ants were 2 months old ollowed b! ortnightl! home visits lasting 1C-20 min"tes! 0raining Kne "ll-da! training workshop and a 1 ho"r re resher training session a ter 2 months# Kngoing monitoring and s"pervision provided# Short term effects ,aternal outcomes Parenting: Signi icant bene its o intervention to mother=s knowledge o child development# Mothers& psychosocial function: 2o signi icant bene its o intervention to maternal mental distress#

1G

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries
Study Ningston( /amaica 0owell 9 8rantham.c8regor( 1:G: Uppermiddle income country Sample St"d! 1 1C2 children aged 4-&% months o low S*S mothers allocated to 4 gro"ps# 14: ollowed "p% biweekl! 7n L 5:3( monthl! 7n L 5C3 0lacebo 7n L 5C3 St"d! 2 CG low S*S mothers and their children aged 14 5 &% months randomized to intervention 7* n L 2:3 or control 7? n L 2:3 Intervention Duration: 1 !ear and 2 !ears 72 separate samples3 Conducted by: 0arapro essionals Study 1 Biweekl! or monthl! visits or 2 !ears Study 2 &eekl! home visits or 1 !ear -ntervention involved home visits b! comm"nit! health aides d"ring which the mothers were shown activities to do with their child and a home made to! or a book was le t in the home# The placebo gro"p received to!s onl!# 0raining ?omm"nit! health aides received 1 week initial training and ongoing monitoring and s"pervision thro"gho"t the intervention period# Duration% 1 !ear Conducted by% parapro essionals 7!o"ng school leavers3 -ntervention involves weekl! home visits to demonstrate and teach mothers pla! activities the! can do with their children# 0arent meetings are also held and income generating proJects are s"pported# 0raining -nitial training ollowed b! hal -da! training sessions once per ortnight and ongoing s"pervision and monitoring# Short term effects Child outcomes Mental development: Study ' Biweekl! O monthl! L control on 1A and per ormance s"bscale Biweekl! L monthl! L control on hearing and speech and hand and e!e s"bscales Biweekl! L monthl! O control on 00MT 7receptive vocab"lar!3 Study ( -ntervention signi icantl! bene ited overall 1A on the 8ri iths test and hearing 9 speech and per ormance s"bscales 2o signi icant bene its were o"nd or the hand 9 e!e s"bscale -ntervention signi icantl! bene ited children=s receptive vocab"lar! meas"red b! the 0eabod! 0ict"re Mocab"lar! Test#

?larendon( r"ral /amaica 0owell( 2005 Uppermiddle income country

1;4 children aged 12 5 &% months allocated to intervention 7- nL:43 or control 7? n L <03 1:#;> attrition

Child outcomes Mental development: -ntervention bene ited children=s overall 1A( hand and e!e and per ormance s"bscales o the 8ri iths test 2o signi icant bene its o intervention were o"nd on the hearing and speech s"bscale o 8ri iths test Nutritional Status: 2o signi icant bene its to child growth# ,aternal "utcomes Parenting: -ntervention signi icantl! bene ited mothers= knowledge o child care and development 2o signi icant bene its o intervention on knowledge o health and n"trition 2o signi icant bene its to parenting practices # Psychosocial function: 2o signi icant bene its to parenting sel -esteem

1:

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries
Study +"ral Bangladesh @bo"d( 200< 'ow income country Sample 0ost test onl! intervention-control st"d! design# 22 villages which had received a parenting intervention in the previo"s !ear and 22 villages with no parenting intervention were recr"ited# .others o children aged 2!(-'!% years were recr"ited# -ntervention% nL1<0 ?ontrol% n L 1C: Intervention Duration: 1 !ear Conducted by: 0arapro essionals 0arenting programme -nternational# implemented thro"gh 0L@2 Short term effects Child outcomes Mental development: 2o signi icant bene its o intervention to children=s receptive vocab"lar!# 7B"t there was a gro"p ) se) interaction which showed that bo!s did better in the parenting gro"p and girls did worse3# Nutritional Status: ?hildren in parenting gro"p more likel! to have poorer weight or height# 2o signi icant di erences or weight or age# Health: -ntervention signi icantl! bene ited preventative health behavio"rs 7e#g# "sing a latrine3 ,aternal outcomes Parenting: -ntervention signi icantl! bene ited others knowledge o child development 7* ect size L 0#413# -ntervention signi icantl! bene ited stim"lation in the home 7* ect size L 0#453 7.others with more assets and mothers with at least one !ear o ed"cation bene ited more rom the intervention3# 2o signi icant bene its o the programme to mother=s comm"nication with child d"ring a pict"re-talking task# Child outcomes Mental and motor development: Signi icant bene its o intervention to mental and motor development inde) o the Ba!le! Scales o -n ant 1evelopment ,aternal outcomes Parenting: -ntervention signi icantl! bene ited stim"lation in the home#

0rogramme targeted mothers o children "nder 4 !ears and involved :0-min"te weekl! ed"cation sessions to gro"ps o mothers# Topics incl"ded common diseases( oral reh!dration sol"tions( h!giene( sanitation( breast eeding( weaning oods( micron"trient de iciencies( stages o cognitive and lang"age development( how to help children learn and enco"rage lang"age development( positive discipline( gender e$"alit! and child rights# 0raining 1< da!s basic training( o"r da!s a month s"pervision and monthl! re resher co"rses#

Himachal 0radesh( -ndia Sharma 9 2agar( 200: 'owermiddle income country

15C in ants aged birth to 16 months rom 2 villages in Himachal 0radesh# Kne village received intervention and the other village did not# -ntervention% nL;: ?ontrol% nL<;

Duration% 1G months Conducted by% not speci ied @ge appropriate to!s and pla! materials and s"ggested activities# .others provided with in ormation regarding providing a stim"lating home environment and "nderstanding children=s developmental milestone# 0raining 2ot speci ied

20

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries
Study 2ortheast Brazil *ickmann et al# 2004 Uppermiddle income country Sample Sample o 1C; children aged 1& months rom a larger cohort# -ntervention sites 7nL<G3% @ll children with a mental andIor motor development inde) P100 and e$"al n"mbers o children with an inde) o 101-11C# ?ontrol sites 7nL<G3% ?hildren matched or developmental inde) and se) with children in intervention site# Intervention Duration: C months Conducted by% occ"pational therapists with specializations in child development or workshops and parapro essionals or home visits# -ntervention involved workshops and home visits and involved a total o 15 contacts between 14 and 1< months o age% 11 home visits and 4 workshops# 1"ring the workshops mothers practiced pla!ing and interacting with children( made to!s rom discarded materials( and learned how to integrate stim"lation activities into reg"lar activities# 7+e reshments and transportation were provided3# Home visits involved showing the mother how to engage her child in pla! activities# 0raining 2ot speci ied Duration: 2 sessions over ; months Conducted by: ?o"nsellors 7$"ali ications not stated3 Two co"nseling sessions lasting 40-;0 min"tes "sing the &HK D?are or 1evelopment= g"idelines# .others were given a card 7.other=s ?ard3 depicting agespeci ic messages or promotion o e ective pla! and comm"nication between caregiver and child# The card was disc"ssed in the two co"nseling sessions "sing demonstration and practice# Sessions also involved disc"ssing obstacles and providing recommendations and help with problem solving iss"es relating to child development# 0raining 2ot speci ied Short term effects Child outcomes Mental and motor development: -ntervention signi icantl! bene ited child mental and motor development on the Ba!le! test 7* ect size L O 0#C3# ?hildren with -A P 100 bene ited more 7e ect sizeL13 than children with -A O 100 7e ect size L0#CC3#

+"ral ?hina /in et al# 200< 'owermiddle income country

Sample o 100 amilies with a child younger than 2 years rom < randoml! selected villages# Families randoml! allocated to intervention 7nLC03 or to a control condition 7nLC03#

Child outcomes Mental and motor development: -ntervention signi icantl! bene ited 8essell 1evelopment scores incl"ding the motor ( adaptive( lang"age and social scales 7* ect size L appro) 0#;<3# 7anal!sis did not control or covariates3 ,aternal outcomes Parenting: -ntervention mothers showed increased "nderstanding o the child development messages in the D.other=s ?ard= and more mothers in the intervention gro"p reported that the messages were easible than mothers in the control gro"p#

21

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries
Study @nkara( T"rke! *rtem et al# 200; Uppermiddle income country Sample Se$"entiall! cond"cted controlled trial# ?hildren aged 7 2' months attending clinic with minor or no illness -ntervention% nL120 ?ontrol% nL114 Low and middle income children living in @nkara were selected# Intervention Duration: 2 weeks Conducted by: 0ediatricians D?are or 1evelopment= intervention cond"cted b! pediatricians d"ring 2 clinic visits 1 week apart# The ?are or development intervention involves "sing an interview to assess how the caregiver pla!s and comm"nicates with her child and then disc"ssing appropriate strategies to promote positive mother-child interaction and appropriate pla! activities# .others were also enco"raged to read pict"re books to their child# 0raining 2ot speci ied So"th @ rica .agwaza 9 *dwards( 1::1 Uppermiddle income country :0 '-year old children rom low S*S amilies randoml! assigned to intervention 7nL403( home visits onl! 7nL403 or a control gro"p 7nL403 Duration% 10 weeks Conducted by% research assistants -ntervention involved a 10-week home visiting programme oc"sing on verbal stim"lation# The intervention involved role-pla!ing mother child interaction "sing pict"res and to!s to the mother and then asking the mother to "se the demonstrated techni$"es# .others were observed and eedback was given on their interaction# @ ter the eedback( mothers were again enco"raged to interact with their child and "rther eedback was given# The to!s andIor books were le t in the home and mothers were enco"raged to "se the material dail!# 0raining% *)tensive Short term effects * ects a ter 1 month% ,aternal outcomes Parenting: 2o signi icant di erences between intervention and control gro"ps on total stim"lation in the home 7HK.* scale3 Signi icantl! more amilies in the intervention gro"p had HK.* scores O 4G compared to the control gro"p# 7Signi icant predictors o HK.* were intervention gro"p( child age O;months and higher maternal ed"cation3# Signi icantl! more home-made to!s in intervention gro"p Signi icantl! more caregivers reported reading to their children in the intervention gro"p 2o signi icant di erences in compliance with medical treatment and illness o"tcomes# Child outcomes IQ: -ntervention signi icantl! bene ited child -A on the ?attell ?"lt"re Fair intelligence Test compared to the two comparison gro"ps# Child %ehaviour: -ntervention signi icantl! bene ited children=s task-oriented behavio"r( positive social behavio"r and distractible behavio"r#

22

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries
Study Nlein 9 +!e( 2005 *thiopia 'ow income country Sample 2 poor comm"nities in @ddis @baba( *thiopia# A"asi-e)perimental S!stematic random sampling o 5:IG:4 amilies rom one comm"nit! and 5<I1::< amilies in another comm"nit!# Two comm"nities randoml! assigned to intervention or control# Children were 1-& years old! Intervention Duration% 4 months Conducted by% 0arapro essionals 7b"t 12 !ears o schooling3 -ntervention involved DThe .ediational -ntervention or Sensitizing ?aregivers= 7.-S?3# The intervention involved videotaping maternal-child interactions and oc"sing on strengthening the positive aspects o the interaction# @lso role pla!s( presentation o good and bad e)amples o mediation and promoting generalization# Five home visits 71Q ho"rs each3 b! parapro essionals and ive gro"p meetings 72-4 ho"rs3 were held over a 4 month period# 0raining 0arapro essionals received weekl! or biweekl! training sessions or 2 months and the trainees had to pass practical and theoretical training criteria be ore commencing with the intervention# Short term effects Child outcomes Mental development: Signi icant bene its o intervention to child lang"age 1 !ear a ter the end o the intervention period# ,other-child interaction Signi icant bene its o intervention to mother-child interactions 7both parent and child initiated3 at 4 months and 1 !ear a ter the end o the intervention +ong term effects @t ; !ear ollow "p% Child outcomes Child %ehaviour: children in the intervention gro"p were rated b! their mothers as% Less hostile and aggressive( Less an)io"s Less h!peractive and Less distractible than children in the comparison gro"p ,other-child interaction Signi icant bene its o intervention to mother-child interactions#

24

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries Study Mietnam &atanabe et al# 200C 'ow income country Sample Intervention 414 children aged Duration: 4 !ears '-( years rom two Conducted by: not speci ied r"ral comm"nes# -ntervention involved strengthening e)isting Both comm"nes preschools thro"gh material s"pport and teacher had participated in training# a n"trition intervention rom 0arenting sessions were also instit"ted incl"ding 1 birth to three !ears# da! training seminars with ather and mothers Kne comm"ne with separatel! once a month or 10 months# poorer preschool acilities also @ local librar! was developed and pla! corners were received an *?1 promoted in homes# intervention when the children were 0raining aged 5-C !ears and 2ot speci ied one comm"ne did not# Short term effects Child outcomes IQ: -ntervention signi icantl! bene ited child -A on +aven=s 0rogressive matrices# St"nted children bene ited more than non-st"nted children 7* ect size 0#;1 and 0#0; respectivel!3#

25

0able 2 1continued2: Stimulation Interventions with Disadvantaged Children and 0heir amilies in Developing Countries
Country T"rke! Nagitcibasi et al# 2001( 200: Upper-middle income country Study Design 2CC children rom low S*S backgro"nds aged &-( years! ; gro"ps% 1# ?"stodial da! care 2# ?"stodial da! care and mother training 4# *d"cational da! care 5# *d"cational da! care 9 mother training C# 2o da! care ;# 2o da! care 9 mother training Intervention Duration: 2 !ears Conducted by: 0arapro essionals .other training involved ortnightl! home visits and ortnightl! gro"p meetings# 8ro"p meetings lasted appro) 1 ho"r and were cond"cted b! trained parapro essionals 7local coordinators3# .eetings incl"ded disc"ssions o topics related to child development 7e#g# n"trition( child health( child development( pla! activities( discipline( and preschool comm"nication3# Home visits were cond"cted b! Dmother=s aides similar in ed"cation and S*S to the mothers# The! delivered the materials to the mothers and demonstrated their "se# .other=s aides also visited mothers d"ring the gro"p meetings to demonstrate "se o the cognitive materials# 0raining Local coordinators received 1 week initial training program and periodic "rther training and eedback thro"gho"t the 2 !ears# .other=s aides were trained weekl! b! the local coordinators and their per ormance monitored Concurrent Effects @ ter 1 !ear% Child "utcomes IQ Signi icant bene its o ed"cational da! care and mother training on child -A# Schooling: 2o signi icant bene its o ed"cational da! care or mother training on academic achievement tests# Signi icant bene its o ed"cational da! care and mother training on school grades# %ehavior 2o signi icant bene its o ed"cational da! care or mother training on emotional problems or school adJ"stment# Signi icant bene its o mother training on child aggression# ,aternal outcomes Parenting: .others who had received training reported interacting with their child more( cond"cting more cognitivel! stim"lating activities and helping children with their homework more# .others who had received training reported "sing less p"nitive discipline methods# +ong-term Effects ; !ear ollow "p Child outcomes IQ: .other training and ed"cational da! care signi icantl! bene ited &-S?-+ vocab"lar! test# Schooling: .other training signi icantl! bene ited school achievement ,aternal outcomes )ife course: .other training signi icantl! bene ited mother=s stat"s in the amil! and general amil! relations# 22 year follow up Child outcomes IQ: 2o signi icant e ects o mother training or ed"cational da! care on child -A# Schooling: Trend or increased college attendance in the mother training gro"p# *nrichment bene ited bo!s more than girls# Socio#*conomic domain: 2o signi icant e ect o mother training on later emplo!ment# *d"cational da! care signi icantl! bene ited participants= occ"pational stat"s# ?hildren in the lowest $"artile or child -A on enrolment did not bene it rom earl! stim"lation#

2C

Stimulation "nly Interventions with 8ndernourished Children and 0heir amilies

Five st"dies describing stim"lation onl! interventions that speci icall! targeted "nderno"rished children and their amilies were identi ied- three rom /amaica 7an "pper middle income co"ntr!3 and two rom Bangladesh 7a low income co"ntr!3# The st"dies are described in Table 4# Three o the st"dies were randomized controlled trials 7Hamadani et al# 200;( 0owell et al# 2005( &alker et al# 20053 while two were $"asi-e)perimental 78rantham-.c8regor et al# 1:G<( 2ahar et al# 200:3# @ll st"dies involved home visiting altho"gh the st"d! b! Hamadani and colleag"es 7200;3 s"pplemented the home visiting with gro"p sessions with mothers# Two o the st"dies intervened with severel! malno"rished children and the stim"lation interventions began while the child was in hospital and was contin"ed a ter hospital discharge thro"gh home visiting 78rantham-.c8regor et al# 1:G<( 2ahar et al# 200:3# Two st"dies involved "nderno"rished children in the comm"nit! 7Hamadani et al# 200;( 0owell et al# 20053 and one st"d! children born term low birth weight# Fo"r o the st"dies intervened with children beginning at a relativel! wide age range 7e#g# rom age ;-25 months3 and in the st"d! with term low birth weight children the intervention started rom birth 7&alker et al# 20053 7This st"d! was also incl"ded in Table 13# @ll ive st"dies "sed a similar c"rric"l"m which involved demonstrating pla! activities to the mother and enco"raging her to do the activit! with her child# Home-made to!s and books were "sed in addition to items in the home# *mphasis was also placed on enco"raging positive maternal-child interactions and on b"ilding mothers= con idence and sel -esteem# The c"rric"l"m was delivered b! parapro essionals in all st"dies# The d"ration o the interventions varied rom ; months to 4 !ears#

Child "utcomes Child () @ll st"dies meas"red children=s mental development and all o"nd bene its# Two st"dies incl"ded a longer-term ollow "p# Severel! malno"rished children who had received stim"lation or three !ears were o"nd to have signi icantl! higher -A than non-stim"lated children 11 !ears a ter the end o the intervention 78rantham-.c8regor et al# 1::53( altho"gh their scores were

2;

signi icantl! below a matched gro"p o children who had not been "nderno"rished in earl! childhood 7Fig"re 23# igure 2! Developmental levels of severely malnourished 9amaican children until adolescence
DQ/IQ z-scores
1 1 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0 0 Admission Admission -0.2 -0.2 -0.4 -0.4 -0.6 -0.6 -0.8 -0.8 -1 -1

Ade"#atel$ no#rished

al. inter!ened

al. %on-inter!ened
2 5 ; G 10 12 15

@dm #1

Years from hospital

8rantham-.c8regor et al( 1::5

Low birth weight in ants born at term who had received stim"lation or two !ears had signi icantl! higher scores on per ormance -A and vis"al-spatial memor! than non-stim"lated in ants 7&alker et al# 20103 altho"gh no signi icant bene its were o"nd to "ll -A( receptive vocab"lar! or attention# ?onc"rrent bene its to children=s motor development were o"nd in two o the ive st"dies and both o these st"dies targeted children who were severel! malno"rished on enrolment 78rantham.c8regor et al# 1:G4( 2ahar et al# 200:3# Child Beha"ior Fo"r st"dies meas"red child behavior and three o"nd bene its# The st"d! b! 8rantham.c8regor and colleag"es 71:G<3 with severel! malno"rished children o"nd that( at the end o the three !ears o intervention( children who had not received stim"lation sta!ed closer to their mother and stopped pla! sooner than the children who had received stim"lation# The st"d! b! Hamadani and colleag"es 7200;3 with "nderweight children o"nd bene its to children behavio"r d"ring the developmental test session a ter one !ear o intervention# &alker and colleag"es 720103 reported bene its to children=s total behavior di ic"lties on the Strengths and 1i ic"lties

2<

A"estionnaire at age si) or children who had received 2 !ears o intervention starting at birth# 2ahar and colleag"es 7200:3 however o"nd no bene its o stim"lation to children=s behavio"r d"ring the developmental test session altho"gh this intervention lasted onl! si) months# Child Nutritional Status @ll ive st"dies meas"red e)amined the e ects o stim"lation on child growth and onl! one st"d! o"nd bene its# Severel! malno"rished children who received stim"lation or two weeks in hospital ollowed b! si) months o stim"lation thro"gh home-visiting had signi icantl! greater weight or age scores than a matched control gro"p 72ahar et al# 200:3# Child Schoolin# Two st"dies e)amined the e ects o stim"lation in earl! childhood on child schooling# 8rantham-.c8regor and colleag"es 71::53 o"nd no signi icant bene its eleven !ears a ter the end o the intervention period and &alker and colleag"es 720103 o"nd no bene its to children=s reading abilit! o"r !ears a ter the end o the intervention when the children were si) !ears old# Child $ealth 2o st"dies incl"ded child health o"tcomes#

,aternal "utcomes %arentin# Fo"r st"dies eval"ated the e ect o intervention on parenting and three o"nd bene its# Two st"dies o"nd bene its to mothers= knowledge o child development 7Hamadani et al# 200;( 0owell et al# 20053 and one also reported bene its to mother reports o parenting practices 70owell et al# 20053# Kne st"d! reported the bene its o intervention to the level o stim"lation provided in the home assessed thro"gh a combination o maternal report and direct observation 7&alker et al# 20053# However( 8rantham-.c8regor and colleag"es 71:G:3 o"nd no di erences in str"ct"red observations o maternal behavio"r between the intervention and control gro"ps# aternal %sychosocial &unction Kne st"d! eval"ated the e ect o intervention on maternal ps!chosocial "nction# @ randomized trial o a home-visiting intervention or "nderweight /amaican children cond"cted over one !ear res"lted in signi icant red"ctions in maternal depression 7Baker-Henningham et al# 200C3# 2G

aternal 'ife Course and

other-Child (nteraction

2o st"dies investigated the e ect o intervention on maternal li e-co"rse or maternal-child interaction#

Summary of Stimulation "nly Interventions with 8ndernourished Children The st"dies provide rob"st evidence that earl! stim"lation can bene it the mental development o "nderno"rished children over the short term# There is also some evidence that interventions with severel! malno"rished children bene it children=s conc"rrent motor development altho"gh the st"dies with moderatel! "nderno"rished children showed no bene its to child motor development# The evidence regarding child behavio"r is more mi)ed altho"gh interventions o s" icient d"ration 7at least 1 !ear3 have shown bene its# Knl! one st"d! o"nd bene its to child growth which s"ggests that stim"lation alone is "s"all! ins" icient to bene it the growth o "nderno"rished children and n"tritional s"pplementation is also re$"ired# There is ins" icient evidence rom the st"dies reviewed as to whether earl! stim"lation can bene it children=s schooling traJectories or child health# There is some evidence that mothers= parenting behavio"rs improve with earl! stim"lation thro"gh home visiting altho"gh this was not o"nd in one o the o"r st"dies that meas"red it# There is also some evidence o bene its to maternal mental health# Knl! one st"d! incl"ded long term o"tcomes and bene its to child cognition were s"stained#

2:

0able &: Stimulation "nly Interventions with 8ndernourished Children and 0heir amilies in Developing Countries Country /amaica Study Design 4 gro"ps in hospital aged 4 5 2' 8ranthammonths! .c8regor Control: severel! et al# 1:G4( malno"rished with 1:G<( 1:G:( standard care 7n L 1::5 1G3 1 !ear later% UpperIntervention: middle severel! income malno"rished with country stim"lation 7n L 1;3 Intervention +uration: 4 !ears Conducted 0arapro essionals Concurrent Effects Child outcomes Mental and motor development: 25 months a ter leaving hospital% the overall 1A o children in the intervention gro"p was signi icantl! better than the control gro"p# -ntervention children also had signi icantl! higher -A than control children ;0 9 <2 months a ter leaving hospital# %ehaviour: ?ontrol children sta!ed closer to mother and stopped pla! sooner than intervention children and a ter 4 !ears o st"d! ,aternal outcomes Parenting: 2o bene its o intervention to mothers= interaction with her child +ong-term Effects Child outcomes at 1' year follow-up IQ: -ntervention children had signi icantl! higher &-S? "ll scale -A 9 verbal s"bscale# 2o signi icant bene its o intervention to the &-S? per ormance s"bscale or to children=s per ormance on the 0eabod! 0ict"re Mocab"lar! Test# Schooling: 2o signi icant bene its o intervention to school achievement Nutritional status: 2o signi icant bene its o intervention to n"tritional stat"s at age 14 !ears

by:

-ntervention involved 1ail! pla! in hospital 9 4 !ears o home visits 71Iweek or 2 !ears and 1I ortnight or 4rd !ear3 0raining 0arapro essionals received one week o initial training and ongoing monitoring and s"pervision was provided#

40

0able & 1continued2: Stimulation "nly Interventions with 8ndernourished Children and 0heir amilies in Developing Countries
Study +"ral Bangladesh Hamadani al# 200; et Sample 20 comm"nit! n"trition centres randomized to intervention 7nL103 or control condition 7nL103# 20; "nderno"rished children 7P-2z scores &@R3 aged 42' months were enrolled# * nL105 ? nL102 Intervention Duration: 1 !ear Conducted by: 0arapro essionals &eekl! gro"p meetings at the n"trition centres or 10 months ollowed b! meetings ever! 2 weeks or 2 months# Topics incl"ded child development and pla!# -n addition( home visits twice a week or G months and weekl! or 5 months# 1"ring the home visits( the pla! leaders demonstrated pla! activities "sing home-made to!s and promoted positive mother-child interaction# @ll "nderno"rished children received standard n"trition care and s"pplementation# 0raining -nitial training not speci ied# Kngoing monitoring and s"pervision# Duration: ; months Conducted by: 0arapro essionals 1ail! 40 min"te gro"p meetings and individ"al 40 min"te pla! sessions or mothers and children or 2 weeks in hospital# 11 home visits over a ; month period when children were discharged rom hospital# 1"ring the home visits and hospital sessions mothers were shown how to "se ever!da! activities to promote child development and were also shown pla! activities with homemade to!s# 0raining 2 weeks initial training and ongoing monitoring and s"pervision# Short term effects Child "utcomes Mental and motor development: Signi icant bene its o intervention on the mental development inde) o the Ba!le! test 2o signi icant bene its o intervention on the ps!chomotor development inde) o the Ba!le! test 7b"t children who received more home visits had higher scores3# Nutrition: 2o signi icant e ect o intervention on growth %ehavior: Signi icant bene its o intervention to response to e)aminer( cooperation( emotional tone and vocalization# ,aternal outcomes Parenting: -ntervention had signi icant bene its to maternal knowledge o child rearing 2o signi icant bene its o intervention to maternal knowledge o health and h!giene Child outcomes: Mental and motor development: -ntervention signi icantl! bene ited children=s motor and mental development on the Ba!le! Scales o -n ant 1evelopment 7* ect size 0#C2 in mental development( 0#4< in motor development3# %ehavior 2o signi icant bene its o intervention to children=s behavio"r d"ring the developmental test session# Nutrition: Signi icant bene its o intervention to children=s weight or age#

'ow income country

1haka( Bangladesh 2ahar et al# 200: 'ow income country

Severel! malno"rished children aged 4-2' months: -ntervention gro"p 7nL<<3 ?ontrol gro"p 7nLC;3 Time-lagged controlled st"d! 6 control gro"p were st"died 1 !ear prior to the intervention gro"p# 44I<< intervention children ollowed "p 754>3# 4< o"t o C; control children ollowed "p 7;;>3#

41

0able & 1continued2: Stimulation "nly Interventions with 8ndernourished Children and 0heir amilies in Developing Countries
Study Ningston( /amaica 0owell et al# 2005 BakerHenningham et al# 200C Upper-middle income country Sample 14: "nderno"rished children 7P -1#Cz scores &@R3 aged :-&% months randomized b! clinic to intervention 7* n L <03 or control 7? n L ;:3 <#2> attrition Both gro"ps received standard n"trition and health care# Intervention Duration: 1 !ear Conducted by% 0arapro essionals -ntervention involved weekl! home visits b! comm"nit! health aides working in government health centres# The visits involved demonstrating pla! activities with mothers and disc"ssing parenting iss"es# Home made to!s and pict"res( low cost books and ho"sehold materials were "sed or the pla! activities# 0raining 0arapro essionals received one week o initial training and a two da! re resher training a ter ; months# Kngoing monitoring and s"pervision was provided# Short term effects Child outcomes Mental and motor development: Signi icant bene its o intervention to 8ri iths 1A and hearing 9 speech( hand 9 e!e and per ormance s"bscales# 7* ect size L 0#G on 1A3# 2o signi icant bene its to the motor s"bscale o the 8ri iths Test# Nutrition: 2o signi icant e ect o intervention on growth ,aternal outcomes Parenting: -ntervention signi icantl! bene ited parenting knowledge and parenting practices Psychosocial function: -ntervention signi icantl! bene ited maternal depressive s!mptoms 7* ect size L 0#543 .others receiving 50-C0 visits bene ited more than mothers receiving 2C-4: visits# .others receiving less than 2C visits were not signi icantl! di erent rom the control gro"p on depressive s!mptoms# ?hange in parenting knowledge and practices and change in depression did not mediate the e ect o intervention on child development#

42

0able & 1continued2: Stimulation "nly Interventions with 8ndernourished Children and 0heir amilies in Developing Countries
Study Ningston( /amaica &alker et al# 2005( 2010 Upper-middle income country Sample 150 term low birth weight 7LB&3 in ants randoml! assigned to intervention 7* n L <03 or control 7? n L <03# <> attrition at 25 months 22> attrition at ; !ears Intervention Duration% 2 !ears Conducted by% parapro essionals 7comm"nit! health aides3 -ntervention involved weekl! home visits b! comm"nit! health aides o 1 ho"r d"ration rom birth to G weeks ollowed b! weekl! home visits o 40 min"tes d"ration rom < to 25 months o age# 0la! activities were demonstrated to the mother and parenting s"pport and advice was provided# Home made to!s( books and ho"sehold items were "sed or the pla! activities# ?ontrol amilies were also visited weekl! at home and in ormation collected on child morbidit!# 0raining Health aides were given 1 week o training prior to cond"cting the intervention and were closel! s"pervised thro"gho"t the intervention period# Short term effects Child outcomes: Mental and motor development: ,t '- months: -ntervention bene ited overall 1A and per ormance s"bscale 2o signi icant bene its o intervention to motor( hearing and speech or hand and e!e s"bscales# ,t (. months: -ntervention bene ited children=s per ormance on the hand 9 e!e and per ormance s"bscales 2o signi icant bene its o intervention to overall 1A( or the motor and hearing and speech s"bscales# Nutrition: 2o signi icant bene its o intervention on child growth# ,aternal outcomes Parenting: -ntervention signi icantl! bene ited HK.* at 12 months# The e ect o intervention on child development was mediated in part b! the improvement in the home environment# +ong term effects Child outcomes Mental development: Signi icant bene its o intervention to per ormance -A 7e ect sizeL0#4G3 and vis"al-spatial memor! 7e ect sizeL0#C43 2o signi icant bene its o intervention to "ll -A( verbal -A( receptive vocab"lar!( attention and short term memor!# Schooling: 2o signi icant bene its o intervention to earl! reading abilit!# %ehavior: Signi icant bene its o intervention to total di ic"lties on the Strengths and 1i ic"lties A"estionnaire 7e ect sizeL0#53

44

Combined ;utrition and Stimulation Interventions with Children and 0heir amilies
Knl! three st"dies that e)amined the e ect o a combined n"trition and stim"lation intervention or !o"ng children were identi ied and all three were cond"cted in an "pper-middle income co"ntr! and involved a randomized design# The st"dies are described in detail in Table 5# The interventions were primaril! delivered b! parapro essionals in all three st"dies# -n one st"d!( the intervention was cond"cted over 2 !ears 78rantham-.c8regor et al# 1::13( in one over 4 !ears 7&aber et al# 1:G13 and one compared the e ect o di erent d"rations o intervention on child development 7.cNa! et al# 1:<G3# The age o the children also di ered with one st"d! recr"iting children age :-25 months 78rantham-.c8regor et al# 1::13( one recr"iting children rom birth 7&aber et al# 1:G13 and one recr"iting children between the ages o three to si) !ears 7.cNa! et al# 1:<G3# -n two st"dies the stim"lation intervention involved home-visiting b! parapro essionals 78rantham-.c8regor et al# 1::1( &aber et al# 1:G13 and the st"dies were designed to eval"ate the e ect o n"tritional s"pplementation alone( stim"lation alone( a combination o s"pplementation and stim"lation to a control gro"p who received neither s"pplementation nor stim"lation# -n one st"d!( children attended a centre based service which provided n"tritional s"pplementation and an ed"cational component and hence it is not possible to isolate the e ect o stim"lation alone 7.cNa! et al# 1:<G3# -n the latter st"d!( the d"ration o the intervention and the age o the child on enrolment varied#

Child "utcomes Child ental and otor !e"elopment

-n the two st"dies that incl"ded a stim"lation alone gro"p( signi icant bene its o stim"lation were o"nd to children=s mental development over the short term 78rantham-.c8regor et al# 1::1( &aber et al# 1:G13# -n /amaica( the bene its o stim"lation to child -A were s"stained "ntil age 1<-1G !ears 7&alker et al# 200C3# ?onc"rrent bene its o stim"lation were also o"nd to children=s motor development in these two st"dies 78rantham-.c8regor et al# 1::1( &aber et al# 1:G13# 2"tritional s"pplementation bene ited children=s motor and mental development over the short term in the /amaican and Bogota st"dies# -n /amaica( some bene it o s"pplementation to child -A was still evident at age <-G !ears 7especiall! or children o mothers with higher verbal

45

-A3( b"t these bene its were not maintained at age 11-12 !ears 7&alker et al# 20003 or at age 1<1G !ears 7&alker et al# 200C3# -n ?ali( ?olombia( the child -A scores were higher with greater d"ration o the combined stim"lation and s"pplementation intervention at age G !ears 7.cNa! et al# 1:<G3# Child *eha"ior -n the /amaica st"d! no bene its to child behavio"r rom earl! stim"lation were o"nd or str"ct"red observations o child activit! levels( amo"nt o e)ploration and a ect a ter ; months o intervention 7.eeks-8ardner 1::C( 1:::3( or or parent reports o behavio"r at age 11-12 !ears 7?hang et al# 20023# However( signi icant bene its were o"nd to participants= sel -reports o mental health at age 1<-1G !ears# @dolescents who had participated in the stim"lation intervention in earl! childhood were less depressed( less an)io"s( and had higher sel -esteem than adolescents who had not received stim"lation 7&alker et al# 200;3# The! also had less parentreported attention problems 7&alker et al# 200;3# -n Bogota( ?olombia( in ants receiving stim"lation cried less at age 5 months than in ants who did not receive stim"lation 7.ora et al# 1:<:3# There were no bene its o s"pplementation to child behavio"r at an! time point in the /amaican st"d!# -n Bogota( s"pplemented children were less apathetic at age 5 months 7.ora et al# 1:<:3# Child Schoolin# @ll st"dies e)amined the e ect o intervention on child schooling# -n /amaica( no signi icant bene its o stim"lation were o"nd to children=s school achievement at age 11-12 !ears 7?hang et al# 20023( b"t at age 1<-1G !ears( adolescents who had received stim"lation per ormed better on an ed"cational reading test 7&alker et al# 200C3 and there was a trend towards stim"lation red"cing the likelihood o dropping o"t o school and o being s"spended or e)pelled rom school 7&alker et al# 200;3# There were no bene its o s"pplementation to school achievement or schooling traJectories at an! time point# -n Bogota( earl! stim"lation led to a signi icant e ect on reading readiness or bo!s onl! 4Q !ears a ter the end o the intervention while s"pplementation bene ited children with mothers with more ps!chological reso"rces 7S"per et al# 1::13#

4C

-n ?ali( ?olombia there was a dose response relationship between the lengths o time children had participated in the combined n"trition and stim"lation intervention and their rates o school ail"re and grade level achieved 7.cNa! 9 .cNa! 1:G43# Child Nutritional Status -n the /amaica st"d!( no bene it to child growth rom stim"lation was o"nd at an! age# S"pplementation bene ited child growth conc"rrentl! and !o"nger children bene ited most 7&alker et al# 1::13 b"t the e ects were not s"stained and no bene its o s"pplementation were o"nd at age <-G !ears 7&alker et al# 1::;3 or 11-12 !ears 7&alker et al# 20003# -n Bogota( ?olombia( no bene its to child growth were o"nd at age 4( b"t at age ; stim"lation bene ited children=s height or age 7S"per et al# 1::03# The a"thors s"ggested that mothers receiving the home visiting intervention ma! have adopted better eeding practices res"lting in improved n"tritional stat"s o the children# -n the ?ali( ?olombia st"d!( height and weight gain increased in a dose response manner with the lengths o time children had been e)posed to the combined stim"lation and n"tritional s"pplementation intervention 7.cNa! et al# 1:<G3( b"t these bene its to n"tritional stat"s were no longer evident at age 10 !ears 70erez-*scamilla 9 0ollitt 1::C3# Child $ealth 2one o the st"dies e)amined the e ect o intervention on child health#

,aternal "utcomes %arentin# Two st"dies incl"ded meas"res o parenting# -n /amaica( no bene its o stim"lation or s"pplementation were o"nd to mothers= interaction with the child at home a ter si) months o intervention 7.eeks-8ardner et al# 1:::3# -n Bogota( ?olombia( mothers= receiving home visits were more attentive and responsive with their in ants at 5 months than mothers in the comparison gro"ps 7.ora et al# 1:<:3 while no bene its were o"nd rom s"pplementation alone# aternal %sychosocial &unction 2o st"dies investigated the e ect o stim"lation on maternal ps!chosocial "nction#

4;

aternal 'ife Course and

aternal-Child (nteraction

2one o the st"dies incl"ded meas"res o maternal li e co"rse or mother-child interaction#

Summary of Combined ;utrition and Stimulation Interventions The st"dies reviewed in this section indicate that earl! stim"lation with or witho"t n"tritional s"pplementation bene its children=s mental development over the short term and that these bene its are s"stained over time# @ltho"gh there is limited evidence o bene its to children=s school achievement( bene its were o"nd to children=s schooling traJectories 7e#g# school ail"re( grade level achieved and school s"spensions and e)p"lsions3# There is ins" icient evidence to draw an! concl"sions abo"t the e ects o combined n"trition and stim"lation programmes on child behavio"r altho"gh it was also enco"raging that earl! stim"lation or two !ears in earl! childhood prod"ced signi icant bene its to mental health in adolescence 7&alker et al# 200;3# There is also ins" icient evidence to make an! concl"sions regarding the e ect o these interventions on maternal o"tcomes# 2"tritional s"pplementation alone is ins" icient to prod"ce long term gains to children=s development and behavio"r or to mothers= parenting behavior in the short-term#

4<

0able ': Combined ;utrition and Stimulation Interventions with Children and 0heir amilies in Developing Countries
Country /amaica ?hang et al# 2002 8rantham.c8regor et al( 1::1( 1::< .eeks8ardner et al# 1::C( 1::: &alker et al# 1::1( 1::;( 2000( 200C( 200; Uppermiddle income country Study Design 12: st"nted children age :-2' months randomized to 5 gro"ps% 1# s"pplementation 2# stim"lation 4# s"pplement 9 stim"lation 5# placebo Intervention Duration: 2 !ears Conducted by: 0arapro essionals Supplementation: 1kg milk based orm"laIweek giving <C0 kcal( 20g protein dail! Placebo: home visits onl! Stimulation: &eekl! home visits 0la! activities were demonstrated to the mother and parenting s"pport and advice was provided# Home made to!s( books and ho"sehold items were "sed or the pla! activities# 0raining 0arapro essionals received one week o initial training and ongoing monitoring and s"pervision was provided# Concurrent Effects Child outcomes IQ at (. months: S"pplementation bene ited 1A( per ormance and locomotor s"bscales Stim"lation bene ited 1A and all 5 s"bscales% 7motor( hearing and speech( hand and e!e and per ormance s"bscales3 Stim"lation and s"pplementation had an additive e ect %ehavior "after / months of intervention$: 2o bene its o s"pplementation or stim"lation a ter ; months o intervention Nutritional status at (. months: S"pplementation bene ited height and weight and there was a signi icant s"pplementation ) age interaction with !o"nger children bene iting the most# Stim"lation had no e ect on growth# ,aternal outcomes Parenting: 2o bene its o s"pplementation or stim"lation to mothers= interaction with child a ter ; months o intervention# +ong-term Effects Child outcomes +t ,-- years: IQ S"pplementation and stim"lation bene ited signi icantl! more tests than wo"ld be e)pected b! chance b"t no signi icant di erences on an! one test# Stim"lation also bene ited percept"al motor "nction# Nutritional status: 2o bene its o s"pplementation or stim"lation on growth were o"nd# +t 11-12 years: IQ: 2o bene it rom s"pplementation Stim"lation had bene its in reasoning 7+aven=s matrices3( vocab"lar! and -A on the &-S?-+ and verbal b"t not per ormance s"bscale# Schooling: 2o signi icant bene its on school achievement# Nutritional status: 2o bene its o s"pplementation or stim"lation on growth were o"nd# +t 1,-1- years: 2o bene its rom s"pplementation on an! meas"res IQ: Signi icant bene its o stim"lation on "ll scale -A( 00MT( verbal analogies test and reading tests 7* ect sizes 0#5 to 0#;3# 2o signi icant bene its to working memor!( mathematics and non-verbal reasoning# Schooling: 0articipants who received stim"lation had similar school drop o"t rates to the non-st"nted gro"p whereas signi icantl! more previo"sl! st"nted who did not receive stim"lation dropped o"t o school# Trend towards stim"lated participants to be less likel! to be s"spended rom school or to be e)pelled# Mental Health: Signi icant bene its o stim"lation to an)iet!( depression( sel -esteem and attention de icit 7* ect sizes 0#5-0#5:3# Trend towards less oppositional behavior b! parent report# 2o signi icant bene its to antisocial behavior or h!peractivit!#

4G

0able ' 1continued2: Combined ;utrition and Stimulation Interventions with Children and 0heir amilies in Developing Countries
Country BogotS( ?olombia &aber et al# 1:G1B S"per et al# 1::0B S"per et al# 1::1B .ora et al# 1:<:( 1:G1 Upper-middle income country Study Design High risk amilies randomized to ; gro"ps% @% control gro"p B# S"pplement rom ;-4; months ?# S"pplement rom pregnanc! to ; months 1# S"pplement rom pregnanc! to 4; months *0 .aternal ed"cation rom birth-4; months 10 S"pplementation rom pregnanc! to 4; months T * above# Children aged from birth to &4 months Intervention Duration: 4 !ears Conducted 0arapro essional Concurrent Effects Child outcomes IQ: S"pplement bene ited all o the 8ri ith=s s"bscales and total 1A# Stim"lation bene ited hearing and speech s"bscale onl! at 4; months Child behavior: @t 5 months( s"pplemented children less apathetic# -n ants receiving stim"lation cried less Nutritional status: 2o e ect o stim"lation on growth at age 4 ,aternal outcomes Parenting: 2o bene its o s"pplementation to maternal behavior# .others in ed"cation gro"p more attentive and responsive at 5 months +ong-0erm Effects Child outcomes Schooling: 4Q !ears a ter intervention( s"pplementation bene ited scores on reading readiness primaril! or children with mothers with more ps!chological reso"rces# 2o bene it on arithmetic or knowledge 4Q !ears a ter intervention( stim"lation had a marginall! signi icant e ect on reading readiness or bo!s onl!# Nutritional status: Stim"lation bene ited height or age at age ;#

by:

Supplement GC; kcalsIda! 4G#5g protein T vitamins 9 minerals 4-; months 12CgIwk o skimmed milk T vegetable and protein mi)t"re ;-12 months 1 lb whole dr! milk 2C0g o high protein vegetable mi) T iron O12mths ;24 kcals T 20g proteinIda! T vitamins 9 minerals Stim"lation involved training mothers d"ring home visits# Home visitors worked directl! with children and promoted positive mother-child interactions# .aterials available in the homes were "sed to oster child e)ploration# 0raining 2ot speci ied

4:

0able ' 1continued2: Combined ;utrition and Stimulation Interventions with Children and 0heir amilies in Developing Countries
Country ?ali( ?olombia .cNa! et al# 1:<G .cNa! 9 .cNa! 1:G4 0erez-*scamilla 0ollitt( 1::C Upper-middle country 9 income Children aged from &-4 years Study Design 401 "nderno"rished children strati ied b! neighborhood areas randomized to C treatments beginning at di erent ages# Intervention Duration: Mariable Conducted by: ?hild care workers 7ed"cation level not speci ied3 Treatment involved combined health( n"trition and stim"lation C da!sIwk or ; ho"rs at centre# 5 ho"rs were devoted to ed"cation and 2 ho"rs to health( n"trition and h!giene# *1a L <C 6G5 months *1b L as T1a with prior s"pplementation *2 L ;4 6 G5 months *4 L C2 6 G5 months *5 L 52 6 G5 months S"pplement provided at least <C> o +1@ or protein and calorie T vitamins and minerals# Stim"lation involved a str"ct"red c"rric"l"m to promote children=s cognitive( lang"age( social and ps!chomotor skills# -nvolved ;-G directed activities I da! and one longer session or individ"al proJects designed to enco"rage child e)perimentation and decision making# 0raining 2ot speci ied Concurrent Effects Child outcomes IQ: 8eneral cognitive abilit! improved with treatment in a dose-response manner# S"pplementation and health care alone had no signi icant e ect Nutritional status: Height and weight gain also increased with treatment in a dose-response manner# +ong-term Effects Child outcomes IQ: -A scores meas"red on the Stan ord-Binet were higher with greater d"ration o treatment at age G !ears Schooling: Lower rates o school ail"re and higher grade level with increasing intervention "p to age 10# Nutritional status: @t age 10 !ears( e ects o intervention on child n"tritional stat"s were no longer evident

50

Stimulation Interventions for Children At-.is< due to *ealth /roblems

Three st"dies that e)amined the e ect o a stim"lation intervention or children at-risk d"e to health problems were identi ied and all "tilized a randomized design# Kne st"d! was cond"cted in an "pper-middle income co"ntr! and two in lower middle income co"ntries# Two st"dies intervened with children rom birth( one st"d! rom ?hina with preterm in ants 7Bao et al# 1:::3 and one st"d! rom -ndia with in ants discharged rom a special care neonatal n"rser! 72air et al# 200:3# The third st"d! involved earl! stim"lation or children in ected with H-M 70otterton et al# 20103# -n two st"dies the intervention was primaril! delivered b! pro essionals in a hospital clinic setting 72air et al# 200:( 0otterton et al# 20103 and the caregivers were asked to cond"ct stim"lation activities at home# -n two st"dies( the intervention was cond"cted over 1 !ear 72air et al# 200:( 0otterton et al# 20103( and in one over 2 !ears 7Bao et al# 1:::3# The st"dies are described in detail in Table C#

Child "utcomes Child ental and otor !e"elopment

@ll three st"dies meas"red children=s mental and motor development and all o"nd bene its to mental development and two reported bene its to motor development 72air et al# 200:( 0otterton et al# 20103# The st"d! b! Bao and colleag"es o"nd no bene its to the motor development o children born preterm a ter an intervention lasting two !ears# -n the st"d! with in ants discharged rom a special care n"rser!( some bene its o intervention were s"stained at one !ear ollow-"p 72air et al# 200:3# -n the st"d! with children in ected with H-M( altho"gh signi icant bene its o intervention were o"nd( the children in the intervention gro"p contin"ed to be severel! developmentall! dela!ed 70otterton et al# 20103# Child Nutritional Status Two st"dies incl"ded meas"res o child n"tritional stat"s 72air et al# 200:( 0otterton et al# 20103# -n the st"d! with children discharged rom a special care n"rser! signi icant bene its were o"nd to child weight and height a ter one !ear o intervention and signi icant bene its to child length were o"nd at the one !ear ollow-"p 72air et al# 200:3# 2o signi icant bene its o stim"lation to children=s n"tritional stat"s were o"nd in the So"th @ rican st"d! with H-M-in ected children 70otterton et al# 20103# 51

Child Beha"ior. Schoolin# and $ealth 2one o the st"dies e)amined the e ect o intervention on child behavior schooling or health#

,aternal "utcomes 2one o the st"dies incl"ded meas"res o maternal o"tcomes# Summary of Stimulation Interventions for Children At-.is< Due to *ealth /roblems These st"dies show that earl! stim"lation with children at-risk d"e to health problems in developing co"ntries bene its children=s mental development over the short term# There is some evidence that children=s motor development also bene its altho"gh this was onl! o"nd in two o the three st"dies# -n one st"d!( earl! stim"lation with at-risk neonates or the 1st !ear o li e also bene ited children=s n"tritional stat"s# There is no evidence on the e ect o these interventions on child behavior( schooling or health or on maternal o"tcomes#

52

0able (: Stimulation Interventions with Children at .is< Due to *ealth /roblems in Developing Countries
Study ?hina Bao et 1::: Sample 104 preterm in ants 72G-4;#: weeks gestation3 randoml! assigned to intervention 7nLC23 or a conventional care condition 7C13# Intervention Duration: 2 !ears Conducted by: parapro essionals .others were trained to cond"ct activities to promote children=s motor( cognitive and speech development and their social behavior# *d"cational to!s were also provided# Duration: 1 !ear Conducted by: 0ro essionals 7occ"pational therapists3 -ntervention involved training mothers individ"all! and in gro"ps in earl! stim"lation in the hospital# -t is "nclear how man! training sessions the mothers attended# .onthl! ollow-"p visits at home were "sed to monitor compliance altho"gh it is not clear whether mothers were also provided with assistance in implementing the intervention d"ring these visits# 0raining 2ot speci ied Short term effects Child outcomes Mental and motor development: Signi icant bene its o intervention to children=s mental development inde) at age 1G and 25 months# 2o signi icant bene its o intervention to children=s motor development#

al#

Lower-middle income co"ntr!

So"th -ndia 2air et al# 200: 'ower-middle income country

G00 babies discharged rom special care neonatal n"rser! randomized to an -ntervention gro"p 7nL5003 or control gro"p 7nL5003 G4> ollowed "p at end o intervention :2> ollowed "p one !ear a ter the end o the intervention

Child outcomes: Mental and motor development: Signi icant bene its a ter 1 !ear o intervention to mental development 7e ect sizeL0#4G3 and motor development 7e ect sizeL0#503 on the Ba!le! Scales o -n ant 1evelopment# @t one !ear ollow "p( signi icant bene its o intervention were o"nd or children=s mental development 7e ect sizeL0#213 and motor development 7e ect sizeL0#2C3# Nutritional status: Signi icant bene its to child weight 7e ect size L 0#23 and length 7e ect sizeL0#213 a ter 1 !ear o intervention and no signi icant bene its to head circ"m erence# @t one !ear ollow "p( signi icant bene its were o"nd or child length 7e ect sizeL0#213# 2o signi icant bene its to child weight or head circ"m erence#

54

0able ( 1continued2: Stimulation Interventions with Children at .is< Due to *ealth /roblems in Developing Countries
Study Soweto( So"th @ rica 0otterton al# 2010 et Sample 122 H-M positive children aged less than 2= years randomized to an intervention gro"p 7nL;03 or control gro"p 7nL;23 54I;0 intervention ollowed "p 7<2>3 5:I;2 control children ollowed "p 7<:>3 Intervention Duration: 1 !ear Conducted by: 0ro essionals 7ph!siotherapist3 -ntervention involved provision o a basic home stim"lation program which was individ"alized or each child and was based on the concerns and priorities o the caregiver and the res"lts o a developmental test# The program was str"ct"red aro"nd activities o dail! living and other activities that co"ld be incorporated into the amil!=s dail! ro"tine# ?aregivers were advised in the "se o this program d"ring 4 monthl! clinic visits# 0raining 2ot speci ied Short term effects Child "utcomes Mental and motor development: Signi icant bene its o intervention to mental and motor development on the Ba!le! Scales o -n ant 1evelopment# Nutritional status: 2o signi icant bene its o intervention to child height or age( weight or age( weight or height or head circ"m erence#

Upper-middle income country

55

"verall Summary of the )enefits of Early Stimulation Interventions Taken as a whole( the st"dies reviewed indicate that earl! stim"lation interventions or !o"ng children prod"ce signi icant bene its to children=s mental development 720I21 st"dies o"nd bene its3 and there is some evidence that children=s motor development also bene its 7<I12 st"dies o"nd bene its3# There is also reasonable strong evidence or bene its to children=s behavio"r 7:I10 st"dies o"nd bene its3 and some evidence o bene its to children=s schooling( especiall! children=s schooling traJectories 75IC st"dies o"nd bene its3# The st"dies reviewed indicate that earl! stim"lation interventions do not generall! lead to bene its to children=s n"tritional stat"s 7onl! 5I14 st"dies o"nd bene its3 and none o the st"dies incl"ded child health o"tcomes# -n terms o maternal o"tcomes( there is also reasonabl! strong evidence that mothers= parenting knowledge and skills can improve with earl! stim"lation interventions 715I1; st"dies o"nd bene its3# The evidence as to whether there are bene its to maternal ps!chosocial "nction is inconsistent 7onl! 2IC st"dies o"nd bene its3 and ma! depend on the amo"nt and t!pe o s"pport provided or the mother thro"gh the intervention# There is ins" icient evidence as to whether earl! stim"lation interventions can bene it maternal li e co"rse 7onl! one st"d! incl"ded an! meas"res o this and bene its were o"nd or mothers= stat"s in the amil!3# Knl! seven st"dies had a longer-term ollow-"p and all seven reported s"stained bene its# Bene its were o"nd or a broad arra! o o"tcomes incl"ding maternal reports o child behavio"r 7Nlein 9 +!e 2005( &alker et al# 20103( child cognition 7Nagitcibasi et al# 2001( 8rantham.c8regor et al# 1::5( 1::<( &alker et al# 2000( 200C( &alker et al# 2010( .cNa! et al# 1:<G3( children=s academic achievement 7Nagitcibasi et al# 2001( S"per et al# 1::1( &alker et al# 200C3( child schooling traJectories 7.cNa! 9 .cNa! 1:G4( &alker et al# 200;3 and participants= mental health in adolescence 7&alker et al# 200;3# The st"dies reviewed th"s show that stim"lation interventions with !o"ng children and their amilies can have signi icant bene its to children=s development and to parenting behaviors when implemented in a range o di erent c"lt"ral and economic conte)ts and when delivered b! parapro essional or pro essional sta # However( the st"dies reviewed were all e icac! st"dies involving relativel! small sample sizes and or the most part cond"cted "nder the close s"pervision o research sta # -n man! st"dies( e)tensive training and s"pervision was provided

5C

or the persons delivering the intervention to ens"re high $"alit! and idelit! o intervention deliver!# &hen s"ch programs are taken to scale( implementation iss"es 7 or e)ample( lower levels o monitoring and s"pervision( higher sta t"rn-over( lower availabilit! o reso"rces3 ma! lead to an atten"ation o the bene its to child and maternal o"tcomes# However( there is some evidence rom large scale eval"ations o earl! child development programs in developing co"ntries that signi icant bene its to child development are possible# Two s"ch eval"ations are described in table ; overlea # For e)ample( an integrated child health( n"trition and development intervention or children aged birth to o"r !ears in the 0hilippines showed bene its to children=s mental and motor development( social and emotional skills( and child n"tritional stat"s with average e ect sizes across all o"tcomes o 0#5CS1# Bene its to children=s mental development 7incl"ding cognition and receptive and e)pressive lang"age3 averaged 1#02S1 which is larger than o"nd in most e icac! trials# Kther e)amples o large scale programs promoting child development are incl"ded in the ollowing sections i the! incl"ded anal!ses on the di erential e ectiveness o interventions( i the! investigated what program characteristics a ect the s"ccess o interventions or i the! incl"ded in ormation on cost e ectiveness#

5;

0able 4: E>amples of large scale programme evaluations of stimulation interventions in developing countries Study
0hilippines @rmecin et al# 200;

Sample
;;:4 children aged %' years on enrollment 5(150 rom program areas 2(4C: rom nonprogram areas

Intervention
?omprehensive earl! child development program integrated "sing a m"lti-sectoral approach# -ncl"ded oc"s on child heath( n"trition and development# Services incl"ded centre based services 7e#g# da! care centers( preschools( health stations3 and home-based services 7e#g# amil! da! care programs( home visits3#

Short term effects

Child "utcomes IQ: Signi icant bene its rom intervention or cognitive skills 7e ect sizeL0#CC3( e)pressive lang"age 7e ect sizeL1#0:3( receptive lang"age 7e ect sizeL1#543( gross motor skills 7e ect sizeL0#<:3( sel -help skills 7e ect sizeL0#443 and ine motor skills 7e ect sizeL0#;C3# 0rogram impacts increase with d"ration# Bene its most prono"nced or children below age o"r at time o inal s"rve! 7age 2-4 at enrollment3 and or children who had been e)posed to the program or O 1< months# %ehavior: Signi icant bene its to social-emotional skills 7e ect size 0#CC3# Nutrition: Signi icant bene its rom intervention or weight or height 7e ect sizeL0#243 and proportion wasted 7e ect sizeL0#013# 2o signi icant bene its on proportion st"nted and height or age Signi icant di erences avoring non-program areas were o"nd or proportion anemic and hemoglobin co"nt# Health: 2o signi icant bene its on percentage with worms or diarrhea# Child outcomes .eas"red gross and ine motor skills( lang"age-a"ditor! skills( ps!chosocial skills# 0ositive e ects are o"nd or children who participated or at least < months and the e ects are stronger with longer d"ration# *stimated cost-bene it ratios to range rom 1#< to 4#<#

Bolivia Behrman et al# 2004

11:G children aged 432 months rom poor( "rban areas#

0-1- program 70ro!ecto 1esarrollo -n antil3#

-ntegral

de

1a! care( n"trition and ed"cational services to children# ?hild attend "ll time da! care in gro"ps o "p to 1C children 7sta %child ratio L 1%C3 # <0> o children=s n"tritional needs are s"pplied thro"gh the da! care service# @lso involves health and n"trition monitoring and ed"cational activit! programming#

5<

?ho )enefits ,ost rom Early Interventions

St"dies were also reviewed or evidence as to whether earl! stim"lation interventions bene it certain s"bgro"ps o children andIor amilies more than others# @ disc"ssion o who bene its most rom stim"lation interventions is disc"ssed below# Child () The evidence or whether child -A moderates the e ect o intervention is con licting# -n Brazil( children with a mental development score o 100 or less on the Ba!le! Scales o -n ant 1evelopment bene ited more than children with a mental development score above 100 7*ickmann et al# 20043# -n 0er"( it was reported that o the children participating in the 0roJect 0+K2*- 7which involves ed"cational da! care incl"ding n"trition or 4-C !ear old children3( the children with lower developmental levels at pretest bene ited more 7&HK( 1:::3 However( in T"rke!( children in the lowest $"artile or -A on enrollment did not bene it rom earl! stim"lation in the orm o an ed"cational centre-based intervention or mother training 7Nagitcibasi et al# 200:3# Child /ender Bene its have been reported to be speci ic or bo!s and girls and it is o ten the gender most disadvantaged in that pop"lation on the o"tcome in $"estion that bene it# For e)ample( in the eval"ation o the -ntegrated ?hild 1evelopment Service 7-?1S3 in -ndia 7?hat"rvedi et al# 1:G<3( it was o"nd that the positive e ect o the intervention on school enrolment was or girls onl! as most o the bo!s in the control gro"p were enrolled in school# Similarl!( the -?1S was o"nd to bene it non-verbal reasoning in girls onl! 7&HK( 1:::3# -n Bogota( bo!s bene ited more rom earl! stim"lation on a reading readiness test 4Q !ears a ter the end o the intervention 7S"per et al# 1::03# -n a st"d! in Bangladesh a rather p"zzling res"lt was o"nd - bo!s in intervention villages per ormed better on a vocab"lar! test than bo!s rom control villages b"t girls per ormed worse 7@bo"d 200<3# However( the st"d! was $"asi-e)perimental rather than randomized and there were no pretest scores so it is di ic"lt to interpret the res"lts#

5G

&amily Bac0#round .!ers 71::23 reviewed the e ect o earl! childhood ed"cation on schooling in developing co"ntries and reported that the greatest di erences between children in intervention and control gro"p were o"nd or the most disadvantaged# For e)ample( in a st"d! in o"rteen r"ral villages in -ndia( school dropo"t b! grade 4 was m"ch greater or children who had not participated in the -ntegrated ?hild 1evelopment Services 7-?1S3 in the lower and middle castes than or children in the lower and middle castes who had attended the -?1S# However( no di erence was o"nd among children in the higher castes 7Fig"re 43# igure &! School drop out for children with and without e>perience in ICDS according to caste

IC D S n on -IC D S
'% &% 2% 1% %

h ig h er ca ste
&rom $ers' 1((2

m id d le ca ste

low er ca ste

-n .!anmar the earl! childhood care and development program involves a parenting component or amilies o children aged rom birth to ive !ears and a centre-based component or three to ive !ear old children# @n eval"ation o this program b! Save the ?hildren 720053 showed that the program increased the chance o school enrollment or all children b"t that the gains were greatest or children rom the poorest $"artile 7Fig"re 53#

5:

igure '! School enrollment rates for children with and without early childhood education e>perience in ,yanmar by socio-economic status

@
1%% :% 6% 3% 4% (%
Aood

Intervened Control

air

/ oor

/ oorest

)ocio-economic )tat#s

The bene it o stim"lation to the most disadvantaged is analogo"s to indings rom st"dies o n"tritional s"pplementation# For e)ample( in a 8"atemalan st"d! comparing the e ect o a high calorie and protein s"pplement to a low calorie s"pplement( children rom low S*S amilies bene ited the most in terms o cognition at age 5-C !ears and on school achievement in adolescence 70ollitt et al# 1::43 7Fig"re C3# igure (! +ong term effect of high calorie and protein supplement on vocabulary by SES in Auatemala

Vocabulary

2 9 2 7 2 5 2 3 2 1 1 9 1 7 1 5
0 20 40
SES
/ ollitt et al 1::&

hi+h calorie , protein lo* calorie

60

80

1 00

For maternal o"tcomes a di erent res"lt is o ten o"nd# -n Bangladesh( mothers with more assets and with higher levels o ed"cation bene ited more rom an intervention involving weekl! gro"p workshops in terms o the level o stim"lation provided in the home 7@bo"d 200<3# The intervention was disc"ssion based and did not involve a signi icant amo"nt o role-pla! and

C0

practice activities and hence it is perhaps not s"rprising that more advantaged mothers were more able to "nderstand and appl! the strategies than less advantaged mothers# This inding that more ed"cated mothers bene it more rom stim"lation interventions has however also been o"nd in a st"d! with disabled children in Mietnam 7Shin et al# 200:3 and in a st"d! describing the e ect o a n"trition ed"cation program in 0er" 7+obert et al# 200;3# *d"cated mothers have been shown to have better recall o intervention messages 7+obert et al# 200;3 and have also been o"nd to be more compliant 71e So"za et al# 200;3# Similarl!( there is some evidence that children o mothers with higher -A bene it most rom n"tritional s"pplementation d"ring the irst ew !ears o li e# For e)ample( among st"nted children receiving s"pplementation in earl! childhood( onl! those children o mothers with higher -A showed bene it on tests o percept"al-motor "nction at age <-G !ears 78rantham.c8regor et al( 1::<3# Similarl!( in Bogota( among children with mothers with more ps!chological reso"rces( those receiving s"pplementation bene ited more in tests o reading readiness 4Q !ears a ter the end o the intervention period 7S"per et al# 1::13# Child Biomedical or Nutritional Status @ll o the interventions with "nderno"rished and term low birth weight children( the interventions described with preterm in ants 7Bao et al# 1:::3 and in ants discharged rom a special care neonatal n"rser! 72air et al# 200:3 and the intervention with H-M in ected children 70otterton et al# 20103 showed bene its to child development indicating that children with compromised n"tritional andIor biomedical stat"s can bene it rom appropriate earl! interventions# There is some evidence that children who are biologicall! v"lnerable bene it more rom earl! stim"lation# For e)ample( in Mietnam( st"nted children bene ited more on the +aven=s 0rogressive .atrices -A test rom a two !ear intervention that involved strengthening earl! childhood ed"cation in their comm"ne than their non-st"nted co"nterparts 7&atanabe et al# 200C3# aternal %sychosocial &unction There is limited evidence rom developing co"ntries as to whether maternal ps!chosocial "nction moderates the e ect o intervention# -n /amaica( there was no evidence that maternal depressive s!mptoms a ected the o"tcome o the intervention and children o mothers with var!ing levels o depressive s!mptoms bene ited rom the intervention 7Baker-Henningham et al# 200C3# -n So"th @ rica( maternal depression at ; and 12 months was not correlated with

C1

conc"rrent maternal sensitivit! and responsiveness or with in ant attachment at 1G months 7?ooper et al# 200:3# Summary of ?ho )enefits ,ost rom Early Stimulation Interventions The evidence s"ggests that earl! childhood stim"lation interventions generall! bene it those children who are most v"lnerable# The review o non-,S earl! childhood interventions b! 2ores 9 Barnett 720103 also concl"ded that there was some evidence that more disadvantaged children bene ited more rom the interventions 7which incl"ded cash trans er( n"tritional( ed"cational and mi)ed interventions3 than more advantaged children( partic"larl! or schooling and n"tritional o"tcomes# This is also consistent with evidence rom the ,S 7Barnett 9 Bel ield 200;3# However( contrar! res"lts are o"nd or maternal ed"cation and there is some evidence that mothers with higher levels o ed"cation bene it more rom earl! stim"lation interventions and that the! "nderstand the material better( are more able to implement the strategies the! learn and are more compliant# Less ed"cated mothers ma! need more intensive interventions andIor interventions that involve more demonstration( practice activities and role-pla!s to ens"re the! are able to translate the messages into concrete action#

/rogram Characteristics Affecting Success

The literat"re was also reviewed to identi ! program characteristics that impact on the e ectiveness o earl! stim"lation interventions on child and maternal o"tcomes# Intensity The intensit! o the intervention has been o"nd in several st"dies to a ect the s"ccess o the intervention# @ st"d! in /amaica investigated the e ectiveness o di ering intensities o a home visiting intervention 70owell 9 8rantham-.c8regor 1:G:3# The intervention involved home visits or 2 !ears b! parapro essionals in which home made to!s and books were bro"ght to the home and the caregivers shown age appropriate activities to do with their child# ?hildren receiving weekl! visits were compared with those receiving ortnightl! and monthl! visits and a non-visited control gro"p# The gains in child development were o"nd to increase with increased re$"enc! o visiting 7Fig"re ;3#

C2

igure 4! Effects of different visiting freBuency on child DC in 9amaica

DC

11%
wee<ly

1%4
fortnightly

1%2
monthly

:6
no visits

:' pre-test
/owell D Arantham-,cAregor$ 1:6:

post-test

-n Bangladesh( a stim"lation intervention or "nderno"rished children that involved gro"p meetings and home visits led to no signi icant bene its to motor developmentB however( bene its were greater or children who received more visits 7Hamadani et al# 200;3# @ similar trend has been reported or maternal o"tcomes 6 a home visiting intervention in /amaica over 1 !ear led to signi icant bene its to maternal depressive s!mptoms# .others who received ort! or more visits d"ring the !ear bene ited more than mothers receiving 2C-4: visitsB no bene its were o"nd or mother receiving less than 2C visits 7Baker-Henningham et al# 200C3# Cuality &e wo"ld e)pect that the $"alit! o the program wo"ld be an important actor in l"encing o"tcomes and !et ew proJects have e)amined this iss"e# The maJorit! o st"dies reviewed or this report invested signi icant reso"rces in sta training and sta were provided with initial training in the intervention( ollowed b! ongoing s"pervision and monitoring# -n addition( an intervention man"al was "s"all! available which doc"mented the intervention in detail# ,nder these conditions( the maJorit! o programs were o"nd to be e ective# &hen programs go to scale( the degree o training( monitoring and s"pervision o ten decreases and maintaining idelit! o implementation o the intervention becomes more challenging# -n ?olombia( DHomes o &ell-Being= are s"pported in which comm"nit! mothers 7parapro essionals3 look a ter "p to 1C children aged 2 to C !ears# ?hildren are ed( their growth is monitored and ed"cational activities are cond"cted# However( an eval"ation o the program

C4

reported that in the maJorit! o da! care homes the ood was not prepared ade$"atel!( the ho"ses were o ten in poor condition and in over 2C> o the homes( the comm"nit! mothers did not plan an! pedagogical activities 7&HK( 1:::3# -n a m"lti-variate anal!sis e)amining the e ect o $"alit! on children=s development no relationship was o"nd between d"ration o time in the program and the risk stat"s o the children# There was however a small( b"t signi icant association 7r L #1<3 between program $"alit! and child well-being in terms o n"trition( health and ps!chosocial development# -n addition( the proportion o children with a developmental dela! was lower in homes r"n b! the more e)perienced comm"nit! mothers# These res"lts s"ggest that the $"alit! o the program was more important in predicting child development than the $"antit! o e)pos"re the child received# -n optimal conditions( both $"alit! and $"antit! are likel! to be related to child o"tcomes# 0iming There is limited evidence rom the literat"re as to the optim"m time to begin an intervention or !o"ng children and their amilies# Timing is "s"all! con o"nded with d"ration# +ame! and +ame! 71::G3 s"mmarize evidence rom the global earl! ed"cation literat"re and concl"de that programs which begin earliest and contin"e longest prod"ce the greatest e ects altho"gh the! cite onl! child- oc"sed( centre-based services to s"pport their view# -n the 0hilippines 7@rmecin et al# 200;3( a large scale eval"ation o the earl! childhood program showed that children bene ited more i the! had been enrolled in the program at age two to three !ears compared to children enrolled at a later age# Ho"nger children were also o"nd to bene it more in an eval"ation o the +oving ?aregivers= home visiting program in St# L"cia 6 the cognitive development o children aged ;-1G months at program start was enhanced b! the program whereas no bene its were o"nd or the cognitive development o children aged 1G-40 months at program start 7?aribbean ?hild S"pport -nitiative 200G3# *vidence or optimal timing or earl! stim"lation is also available rom st"dies involving children in severel! deprived environments s"ch as instit"tions and these st"dies ind that that the !o"nger the child is when the! are removed rom these environments into appropriate oster care( the better the o"tcome - with partial evidence that children in the irst two !ears o li e do better than children ostered later 72elson et al# 200<3# There is also some evidence that irst two !ears o li e is most sensitive to the e ects o "ndern"trition 78rantham-.c8regor 9 Baker-Henningham 200C3# -n a recent review o earl! childhood interventions( which incl"ded cash trans er( n"tritional( ed"cational C5

and mi)ed interventions( 2ores 9 Barnett 720103 reported that programs that target in ants and toddlers alone and pre-N children alone prod"ced larger bene its than programs that targeted both ages at the same time# This ma! re lect di erences in the characteristics o the program rather than the age o the children as interventions that target a speci ic age range are likel! to be more oc"sed than those that target children over a wider age range# Duration The d"ration o the intervention has also been shown to be related to child o"tcomes# -n the st"d! in ?ali( ?olombia( treatment involved rom one to o"r : month interventions o a combined health( n"trition and stim"lation intervention at a da! care centre and one gro"p which received health and n"trition onl!( prior to one : month combined intervention# @t age < !ears( the combined intervention improved general cognitive abilit! in proportion to the n"mber o treatment periods received 7Fig"re <3# ?hildren receiving treatment also per ormed better than a gro"p o ade$"atel! no"rished children rom the same neighborhoods b"t per ormed worse than children rom high S*S backgro"nds# @t ollow "p( one and two !ears a ter the end o the intervention( the -A o the children was also directl! related to the d"ration o intervention 7.cNa! et al# 1:<G3# Height and weight gain were also directl! related to the d"ration o the intervention thro"gho"t the st"d! period 70erez-*scamilla 9 0ollitt 1::C3# igure 3! Dose 5response effect on child cognition of a combined health$ nutrition and stimulation intervention in Cali$ Colombia

IQ
11% 1%( 1%% :( :% 6( 6% 3(

HS% middle class T0% 0 treatment T1% 1 treatment period T2% 2 treatment periods T4% 4 treatment periods T5% 5 treatment periods

*S

0%

01

02

0&

0'

.cNa! et al( 1:<G

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Large scale eval"ations have also shown the importance o s" icent d"ration# -n the 0hillipines( children who had been e)posed to the earl! childhood program or more than seventeen months bene ited more in terms o -A scores and in Bolivia( positive e ects on child development o an ed"cational da! care program or ;-<2 month old children rom poor "rban areas were onl! o"nd or children who had participated or at least seven months and the e ects were stronger with longer d"ration 7Behrman et al# 20043# The review o non-,S earl! childhood interventions b! 2ores 9 Barnett 720103 also o"nd partial evidence to s"ggest that interventions that lasted over 1 !ear prod"ced greater bene its than interventions lasting less than one !ear# /ersonnel Delivering the Intervention The maJorit! o st"dies reviewed or this report involved interventions that were cond"cted b! parapro essionals 71;I22 o the st"dies that reported the $"ali ications o the personel3# -t is enco"raging that interventions cond"cted b! parapro essionals prod"ced these widespread bene its to children and mothers in developing co"ntries as the cost o "sing pro essionals wo"ld be prohibitive in man! co"ntries# This is contrar! to res"lts rom the ,S which indicate that home-visiting interventions cond"cted b! parapro essionals are largel! ine ective and that pro essionals are re$"ired or optimal o"tcomes 7Klds 9 Nitzman 1::43# -t sho"ld be noted however( that training and s"pervision o sta is likel! to be ke! to s"ccess "l interventions and as mentioned previo"sl!( the maJorit! o st"dies paid close attention to these aspects o the intervention# ,ode of Delivery *arl! stim"lation interventions can be delivered thro"gh a variet! o modalities incl"ding homevisiting( gro"p parent meetings( ed"cational da! care provision( child development messages integrated into ro"tine health care visits andIor thro"gh media interventions# For this report( no st"d! was identi ied that investigated the e ectiveness o di erent modes o deliver! and the maJorit! o st"dies "sed a home-visiting approach which was s"pplemented with parent gro"p meetings in some st"dies# 2o peer reviewed Jo"rnal articles describing the impact o ed"cational da! care provision or children aged rom birth to three were identi ied altho"gh there are several large scale programs that have "sed this approach 7e#g# 0+K2*- in 0er" described in &HK( 1:::3# -t is likel! that the most e ective and appropriate deliver! mode will var! across c"lt"res and across conte)ts# For e)ample( gro"p sessions in n"trition centres with mothers o

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"nderno"rished children was a easible strateg! in r"ral Bangladesh 7Hamadani et al# 200;3( b"t was not appropriate in "rban /amaica where comm"nit! violence( inade$"ate transportation and strict clinic dress codes were some o the actors that led to poor attendance 7Baker 20043# Similarl!( improving the $"alit! o da! care ma! be partic"larl! important in areas where a high proportion o children attend da! care acilities b"t centre-based services wo"ld appropriate in pop"lations where the maJorit! o !o"ng children are cared or at home# ocus of Intervention *arl! stim"lation interventions can be child- oc"sed 7e#g# ed"cational da! care3( parent- oc"sed 7parent gro"p meetings3 or Joint oc"sed 7intervention intervenes directl! with the child and the parent3# The maJorit! o the interventions reviewed or this report involved a home visiting component 71GI2; st"dies3 and seven o those eighteen st"dies also cond"cted gro"p parenting sessions# -n addition( two st"dies combined centre-based services with a parent training component 7&atanabe et al# 200C( Nagitcibasi et al# 2001( 200:3# -n all o these st"dies there was a Joint oc"s on both the parent and the child( with ed"cational activities involving home-made to!s and books or the child and parenting s"pport or the mother# Hence the interventions oc"ssed not onl! on the !o"ng child=s development b"t also on the well-being o the mother and the amil!# This Joint oc"s is likel! to be an important actor in e)plaining the s"ccess o the programmes# *vidence rom st"dies in the ,S s"ggests that home visiting interventions are less e ective than centre based services or promoting child o"tcomes 7+ame! 9 +ame! 1::G3 b"t man! o the ,S home-visiting programmes were mainl! parent oc"sed and did not have a strong child- oc"sed component# ,ethods 8sed in Intervention There is some evidence rom the st"dies reviewed that active involvement o the mother in the intervention leads to better o"tcomes# -t is recommended that the intervention activel! involves the mother in cond"cting the stim"lation activities with appropriate eedback and that the mother is enco"raged to contin"e the activities on a dail! basis# -nterventions "sing disc"ssion and in ormation sharing onl! have been shown to be less e ective 7@bo"d 200<3 and hands-on practical activities are recommended# -n addition( the maJorit! o the interventions "sed low cost materials 7 or e)ample( home-made to!s( books and pict"res andIor items in the home3 to be less

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promote child pla!( rather than "sing store-bo"ght to!s and books which wo"ld be cost prohibitive in most developing co"ntries# Summary of /rogramme Characteristics Affecting Success The available evidence s"ggests that programs o high $"alit! programs delivered with higher intensit! and over a longer d"ration are most e ective# There is limited evidence abo"t the most appropriate mode o deliver! and this ma! var! across conte)t# Stim"lation interventions have been shown to be more e ective i started at a !o"nger age altho"gh there is no evidence as to whether interventions starting at birth or in the irst ew months o li e are more or less e ective than interventions that start in later in anc!# -nterventions can be delivered e ectivel! b! parapro essionals with appropriate s"pervision and there is some s"ggestion that the! are more e ective i the! target both the mother and the child# @ctive involvement o the mother in the intervention is important and in ormation sharing and disc"ssion based interventions are likel! to be ine ective( especiall! with mothers living in disadvantaged circ"mstances and mothers with low levels o ed"cation#

)y ?hat ,echanisms Do Early Stimulation Interventions *ave 0heir Effects

Few st"dies have e)amined the mechanism thro"gh which stim"lation interventions have their e ects# Several mechanisms are possible# Firstl!( stim"lation d"ring the irst three !ears o li e help to prevent changes to brain str"ct"re and ne"rological pathwa!s associated with the stress "l in l"ences aced b! children living in disdavantaged circ"mstances 7Shonko et al# 200:3# Secondl!( earl! stim"lation programmes have been shown to bene it mothers= parenting behavio"r( mother-child interaction and the level o stim"lation provided in the home and stim"lation in the home has been shown to be an independent predictor o children=s mental development in developing co"ntries in several st"dies 7Hamadani et al# 2010( Santos et al# 200G3 partic"lar! or children who are more v"lnerable or disadvantaged 7Barros et al# 200:( 8rantham.c8regor et al# 1::G3# Kne st"d!( a home visiting intervention with term low birth weight children in /amaica( did demonstrate that the bene its to child development were partiall! mediated b! the levels o stim"lation in the home 7&alker et al# 20053# *arl! stim"lation programmes has also been shown to lead to bene its to maternal mental health which is a risk actor or poor child development 7&achs et al# 200:3# However( two st"dies have e)amined

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whether changes in maternal depression were associated with change in child development 7Baker-Henningham et al# 200C3 or child attachment 7?ooper et al# 200:3 and in neither st"d! was the e ect o intervention mediated b! the red"ction in maternal depressive s!mptoms# *arl! stim"lation ma! also bene it children b! enhancing their abilit! to bene it rom other ed"cational opport"nities( or e)ample( b! boosting their school readiness skills so that the! are more able to bene it rom school#

0he Cost of Early Childhood Education /rograms

The cost o earl! childhood care and development programs is obvio"sl! an important consideration or reso"rce poor co"ntries# @ cost-bene it anal!sis o the 0err! 0reschool 0rogram in the ,S estimated that or ever! dollar invested in the program( U12#:0 have been saved in terms o ed"cation( wel are and the criminal J"stice s!stem 7Bel ield et al# 200;3# However( Barnett 71::<3 points o"t that the costs o earl! childhood ed"cation programs in high income co"ntries are o ten C-10 times the per capita gross national prod"ct o low income co"ntries and ma! be even more# -n addition( the percentage o children aged 0 to ; !ears o age is m"ch higher in low income co"ntries and hence &estern models o *?* will not be inanciall! easible# Ho"ng 71::C3 gives some e)amples o costing data% the -?1S in -ndia is estimated to cost one i teenth o the minim"m wage( the 0+K2*- program in 0er" costs one o"rteenth o the minim"m wage while a program o parent ed"cation in ?hile costs one i th o the minim"m wage per child# Behrman and colleag"es 720043 estimated the cost-bene it ratios to range rom 1#< to 4#< or the 0-1- program in Bolivia which involves da! care( n"trition and ed"cational services to children aged ;-<2 months in poor r"ral areas# The costs o earl! childhood stim"lation interventions in low income co"ntries have not been s!stematicall! e)amined and the relative costs o di erent service options are "nclear# The coverage o s"ch programs remains low and the costs to be borne b! amilies high and hence services are "nlikel! to be accessible to Dat risk= amilies# The challenge is to design services which are o s" icient $"alit! to make an impact and which are targeted to the children who need them most#

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Conclusions and .ecommendations

The evidence cited in this report indicates that earl! stim"lation interventions are e ective in improving child and maternal o"tcomes and these bene its are likel! to be s"stained over the long term# -nterventions sho"ld target !o"nger and more disadvantaged children and their amilies and sho"ld involve active involvement o the children=s caregivers# -nterventions sho"ld also promote the well-being o amilies as a whole( partic"larl! the mothers# -nterventions o higher $"alit!( greater intensit! and o longer d"ration are likel! to be the most e ective# F"rther research is re$"ired to determine the optimal age or starting earl! childhood interventions or ma)im"m cost-e ectiveness# .ore research is also re$"ired to identi ! the relative e ectiveness o di erent modes o deliver!# For e)ample( gro"p parenting sessions ma! be a cost-e ective method o service deliver! b"t this approach has not been properl! eval"ated# 0rograms also need to incl"de meas"res o cost so that the cost-e ectiveness and cost-bene it o earl! stim"lation interventions can be calc"lated# This is important or changing government polic! and or advocating or more "nds to be channeled into earl! childhood intervention services# -denti !ing mechanisms or wider dissemination o evidence based earl! childhood stim"lation interventions so that the! are s"stained thro"gh ro"tine "nding so"rces while maintaining their e ectiveness is also important to ens"re broad and contin"ed access to these services# Finall! more long-term ollow "p st"dies o earl! childhood stim"lation interventions are re$"ired with a broad range o meas"res incl"ding child schooling traJectories( academic achievement and economic prod"ctivit! in ad"lthood and participants= behavioral o"tcomes( mental health and li e co"rse# .ore eval"ations o the e ects o interventions on mothers= wellbeing and li e co"rse wo"ld also be bene icial in order to delineate the scope o potential o"tcomes rom earl! childhood interventions#

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Nlein( 0#( 9 +!e( H# 720053# -nteraction-oriented earl! intervention in *thiopia% The .ediational -ntervention or Sensitizing ?aregivers 7.-S?3 @pproach# (nfants and ?oun# Children( 1<( 450-4C5# .agwaza( @#( 9 *dwards( S# 71::13# @n eval"ation o an integrated parent-e ectiveness training and children=s enrichment program or disadvantaged amilies# South +frican @ournal of %sycholo#y( 21( 21-2C# .a"lik( 0N#( 1armstadt( 8L# 7200:3# ?omm"nit!-based interventions to optimize earl! childhood development in low reso"rce settings# 1ournal of %erinatolo#y( 2:( C41-C52# .cNa!( @#( 9 .cNa!( H# 71:G43# 0rimar! school progress a ter preschool e)perience% tro"blesome iss"es in the cond"ct o ollow-"p research and indings rom the ?ali( ?olombia st"d!# -n N# Ning 9 +# .e!ers 7*ds#3( %re"entin# school failure: the relationship *etween preschool and primary education7 7pp# 4;-523# Kttawa% -nternational 1evelopment +esearch ?enter# .cNa!( H#( Sinisterra( L#( .cNa!( @#( 8omez( H#( 9 Lloreda( 0# 71:<G3# -mproving cognitive abilit! in chronicall! deprived children# Science( 200( 2<0-2<G# .eeks-8ardner( /#( 8rantham-.c8regor( S#( ?hang( S# 71::C3# @ctivit! and behavio"ral development in st"nted and non-st"nted children and response to n"tritional s"pplementation# Child !e"elopment. ;;( 1<GC-1<:<# .eeks-8ardner( /#( 8rantham-.c8regor( S#( Himes( /#( 9 ?hang( S# 71:::3# Behavior and development o st"nted and non-st"nted /amaican children# 1ournal of Child %sycholo#y and %sychiatry. 50( G1:-G2<# .ora( /#( ?lement( /#( ?hristiansen( 2#( Krtiz( 2#( M"ori( L#( 9 &agner( .# 71:<:3# 2"tritional s"pplementation( earl! stim"lation and child development# -n% Brozek / 7*d#3 Behavioral e ects o energ! and protein de icits# 1H*& 0"b# no# 72-H3 <:-1:0; 7pp# 2CC-2;:3# .ora( /#( 8"illeramo( .#( Sellers( S#( 9 Krtiz( 2# 71:G13# 2"trition( social environment and cognitive per ormance o disadvantaged ?olombian children at three !ears# Nutrition in $ealth and !isease and (nternal !e"elopment: Symposia from the A(( (nternational Con#ress of Nutrition( 504-520# ."rnane( +#( &illett( /# 9 Lev!( F# 71::C3# The 8rowing -mportance o ?ognitive Skills in &age 1etermination# 3e"iew of 9conomics and Statistics( <<( 2C162;;#

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.!ers( +# 71::23# The twelve who s"rvive% Stren#thenin# pro#rammes of early child de"elopment in the third world7 +o"tledge( London( ,N# 2ahar( B#( Hamadani( /#( @hmed( T#( To ail( F#( +ahman( @#( H"da S#( 9 8rantham-.c8regor( S# 7200:3# * ects o ps!chosocial stim"lation on growth and development o severel! malno"rished children in a n"trition "nit in Bangladesh# 9uropean 1ournal of Clinical Nutrition( ;4( <2C-41# 2air( .N?#( 0hilip( *#( /e!aseelan( L#( 8eorge( B#( .atthews( S#( 9 0adma( N# 7200:3# * ect o child development centre model earl! stim"lation among at-risk babies 6 @ randomized controlled trial# (ndian %ediatrics. 5;( S20-S2;# 2ational +esearch ?o"ncil and -nstit"te o .edicine# 720003 &rom neurons to nei#h*orhoods7 >he science of early child de"elopment7 2ational @cadem! 0ress( &ashington 1#?# 2elson( ?#( Reanah( ?#( Fo)( 2#( .arshall( 0#( Sm!ke( @#( 9 8"thrie( 1# 7200<3# ?ognitive +ecover! in Sociall! 1eprived Ho"ng ?hildren% The B"charest *arl! -ntervention 0roJect# Science( 41G( 1:4<-1:50# 2ores( .#( 9 Barnett( S# 720103# Bene its o earl! childhood interventions across the world% 7,nder3 -nvesting in the ver! !o"ng# 9conomics of 9ducation 3e"iew( 2:( 2<1-2G2# Klds( 1#( 9 Nitzman( H# 71::43# +eview o research on home visiting or pregnant women and parents o !o"ng children# >he &uture of Children( 4( C4-:2# 0erez-*scamilla( +#( 9 0ollitt( *# 71::C3# 8rowth improvements in children above 4 !ears o age% The ?ali st"d!# 1ournal of Nutrition( 12C( GGC-G:4# 0ollitt( *#( 8orman( N#( *ngle( 0#( .artorell( +#( 9 +ivera( /# 71::43# *arl! s"pplementar! eeding and cognition# Society for 3esearch in Child !e"elopment. CG( .onograph 2o# <# 0otterton( /#( Steward( @#( ?ooper( 0#( 9 Becker( 0# 720103# The e ect o a basic home stim"lation program on the development o !o"ng children in ected with H-M# !e"elopmental edicine and Child Neurolo#y. C2( C5<-CC1# 0owell( ?# 720053# @n eval"ation o the +oving ?aregivers 0rogram o the +"ral Famil! S"pport Krganisation( .a! 0en( ?larendon( /amaica# ,2-?*F( /amaica% Unpu*lished report# 0owell( ?#( Baker-Henningham( H#( &alker( S#( 8erna!( /#( 9 8rantham-.c8regor( S# 720053# Feasibilit! o integrating earl! stim"lation into primar! care or "nderno"rished /amaican children% ?l"ster randomized controlled trial# British edical 1ournal( 42:( G:#

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0owell( ?#( 9 8rantham-.c8regor( S# 71:G:3# Home visiting o var!ing re$"enc! and child development# %aediatrics( G5713( 1C<-1;5# +ahman( @#( -$bal( R#( +oberts( ?#( 9 H"sain( 2# 7200G3# ?l"ster randomized trial to s"pport earl! development o children in a low-income co"ntr!# Child: care. health and de"elopment( 4C713( C;-;2# +ahman( @#( .alik( @#( Sikander( S#( +oberts( ?#( 9 ?reed( F# 7200G3# ?ognitive behavior therap!based intervention b! comm"nit! health workers or mothers with depression and their in ants in r"ral 0akistan% @ cl"ster-randomized controlled trial# 'ancet( 4<2( :02-:0:# +ame!( ?#( 9 +ame!( S# 71::G3# *arl! intervention and earl! e)perience# +merican %sycholo#ist C4( 10:-120# +obert( +#( 8ittelsohn( /#( ?reed-Nanashiro( H#( 0enn!( .#( ?a"l ield( L#( 2arro( .#( 9 Black( +# 7200;3# 0rocess eval"ation determines the pathwa! o s"ccess or a health center-delivered n"trition ed"cation intervention or in ants in Tr"Jillo( 0er"# 1ournal of Nutrition. 14;( ;45;51# Santos( 1#( @ssis( @#( Bastos( @#( Santos( L#( Santos( ?#( Strina( @#( 0rado( .#( @lmeida-Filho( 2#( +odrig"es( L#( 9 Barreto( .# 7200G3# 1eterminants o cognitive "nction in childhood% @ cohort st"d! in a middle income conte)t# B C %u*lic $ealth. G( 202# Save the ?hildren# 720053# + %ositi"e (mpact: + Study from ?hildhood ?are and 1evelopment# Sharma( S#( 9 2agar( S# 7200:3# -n l"ence o home environment on ps!chomotor development o in ants in Nangra district o Himachal 0radesh# 1ournal of Social Sciences( 21( 22C-22:# Shin( /#( 2han( 2#( Lee( S#( ?rittenden( N#( For!( .#( 9 Hong( H# 7200:3# The e ects o a homebased intervention or !o"ng children with intellect"al disabilities in Mietnam# 1ournal of (ntellectual !isa*ility 3esearch. C4( 44:-4C2# Shonko ( /#( Bo!ce( &T#( 9 .c*wen( B# 7200:3# 2e"roscience( molec"lar biolog!( and the childhood roots o health disparities% B"ilding a new ramework or health promotion and disease prevention# 1ournal of the +merican edical +ssociation( 401( 22C2-22C:# ood s"pplementation and S"per( ?#( Herrera( .#( 9 .ora( /# 71::03# Long term e ects o maln"trition# Child !e"elopment( ;1( 2:-5:# yanmar of the 9ffects for Children. their &amilies and Communities7 &estport( ?T% Save the ?hildren Federation( *arl!

ps!chosocial intervention on the ph!sical growth o ?olombian in ants at risk o

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S"per( ?#( Herrera( .#( .ora( /# 71::13# ?ognitive o"tcomes o earl! n"tritional intervention in the Bogota st"d!# +*stracts of the meetin# of the Society for 3esearch in Child !e"elopment. Seattle7 &aber( 1#( M"ori( L#( Krtiz( 2#( ?lement( /#( ?hristiansen( 2#( .ora( /#( +eed( +#( 9 8"illermo .# 71:G13# 2"tritional s"pplementation( maternal ed"cation and cognitive development o in ants at risk or maln"trition# +merican 1ournal of Clinical Nutrition( 45( <:<-G04# &achs( T# 720003 Necessary *ut not sufficient: the role of indi"idual and multiple influences on human de"elopment7 @merican 0s!chological @ssociation 0ress( &ashington 1#?# &achs( T#( Black( .#( 9 *ngle( 0# 7200:3# .aternal depression% @ global threat to children=s health( development and behavior and to h"man rights# Child !e"elopment %erspecti"es. 4( C1-C:# &alker( S#( ?hang( S#( 0owell ?#( 9 8rantham-.c8regor( S# 720053# 0s!chosocial intervention improves the development o term low birth weight in ants# 1ournal of Nutrition( 145( 151<-1524# &alker( S#( ?hang( S#( 0owell( ?#( 9 8rantham-.c8regor( S# 7200C3# * ects o earl! childhood ps!chosocial stim"lation and n"tritional s"pplementation on cognition and ed"cation in growth-st"nted /amaican children% 0rospective cohort st"d!# 'ancet( 4;;( 1G05-1G0<# &alker( S#( ?hang( S#( 0owell( ?#( Simono ( *#( 9 8rantham-.c8regor( S# 7200;3# * ects o ps!chosocial stim"lation and dietar! s"pplementation in earl! childhood on ps!chosocial "nctioning in late adolescence% Follow-"p o randomized controlled trial# British 1ournal( 444( 5<2# doi%10#114;IbmJ#4GG:<#CCC20G#2F# &alker( S#( ?hang( S#( Ho"nger( 2#( 9 8rantham-.c8regor( S# 720103# The e ect o ps!chosocial stim"lation on cognition and behavior at ; !ears in a cohort o term( low-birthweight /amaican children# !e"elopmental edicine and Child Neurolo#y( C2( e15G-1C5# &alker( S#( 8rantham-.c8regor( S#( Himes( /#( 0owell( ?#( 9 ?hang( S# 71::;3# *arl! childhood s"pplementation does not bene it the long term growth o st"nted children in /amaica# 1ournal of Nutrition( 12;( 401<-4025# &alker( S#( 8rantham-.c8regor( S#( 0owell( ?#( 9 ?hang( S# 720003# * ects o growth restriction in earl! childhood on growth( -A and cognition at age 11 to 12 !ears and the bene its o n"tritional s"pplementation and ps!chosocial stim"lation# 1ournal of %ediatrics( 14<( 4;51# edical

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&alker( S#( 0owell( ?#( 8rantham-.c8regor( S#( Himes( /#( 9 ?hang( S# 71::13# 2"tritional s"pplementation( ps!chosocial stim"lation and growth o st"nted children% The /amaican st"d!# +merican 1ournal of Clinical Nutrition( C5( ;52-;5G# &alker( S#( &achs( T#( 8ardner( /#( Lozo ( B#( &asserman( 8#( 0ollitt( *#( ?arter( /#( 9 the -nternational ?hild 1evelopment Steering 8ro"p# 7200<3# ?hild development% risk actors or adverse o"tcomes in developing co"ntries# 'ancet( 4;:( 15C-1C<# &antanabe N#( Flores +#( F"Jiwara /#( 9 Tran L# 7200C3# *arl! childhood development interventions and cognitive development o !o"ng children in r"ral Mietnam# >he 1ournal of Nutrition( 14C( 1:1G-1:2C# &endland-?arro( /#( 0iccinini ?#( .illar( &# 71:::3# The role o an earl! intervention on enhancing the $"alit! o mother-in ant interaction# Child !e"elopmentB <0( <14-<21# &HK# 71:::3# >he Critical 'in07 (nter"entions for physical #rowth and psycholo#ical de"elopment7 + re"iew7 8eneva% 1epartment o ?hild and @dolescent Health( &orld Health Krganisation# Hoshikawa( H# 71::C3# Long term e ects o earl! childhood programs on social o"tcomes and delin$"enc!# &uture of Children. C( C1-<C# Ho"ng( .# 71::C3# (n"estin# in youn# children7 &ashington( 1#?#% &orld Bank#

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