Psychosocial stimulation, maternal role and mental development of stunted

children: The Tanah Datar – Indonesia Nutrition and Cognitive Development

Study

Rina Hasniyanti*, Fasli Jalal**, Nur Indrawaty Lipoeto**

*Padang Health Politechnic, Ministry of health, West Sumatra, Indonesia

**Dept of Nutrition, Faculty of Medicine, Andalas University, Indonesia

Abstract
Stunting is associated with poor cognitive and mental development. However,
psychosocial stimulation has been shown to reduce the effect. This study aimed to
determine the relationship between psychosocial stimulation, maternal education,
maternal knowledge, parenting methods, and health status with the levels of
psychomotor and mental development of stunted children aged 6 to 12 months in
Tanah Datar District of West Sumatra, Indonesia.
This study used a quantitative approach with a cross sectional design.
Anthropometric assessment was used to 265 infants aged 6-12 months from 9
villages to get 89 stunted children from the district. Psychosocial stimulation was
assessed using HOME scale, maternal education, maternal knowledge, parenting
methods, and health status were reported by participants using interviewer-
administered questionnaires. Psychomotor and mental development indexes were
assessed through interviews and observations using the Bayley Scale Infant
Development (BSID).
Stunting prevalence in this study was 36.6%. The results of the study showed
that 30.3% and 38.2% of the stunted children had deficits in mental development
index and psychomotor development index respectively according to BSID. Maternal
knowledge and education had significantly relationship with psychomotor and
mental development of stunted children. Other factors such as diarrhea and upper
respiratory infection events, parenting methods and psychosocial stimulation did not
significantly associated with psychomotor and mental development of the children.
Psychosocial stimulation to the stunted infant aged 6-12 months had not yet
had effect to the levels of psychomotor and mental development. However, maternal
role is important for the development.

Key words: stunting, psychosocial stimulation, maternal role, Mental Development

Index, Psychomotor Development Index

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Background

Stunting takes place primarily due to chronic undernutrition and infectious

diseases. Stunting was found as high as 35% in Indonesia (Riskesdas, 2010).
Stunting during the early period of life is critical, because the first few years in life
are particularly important period in human development. The beginning of
development of cognitive abilities is gained in this period (Mendez and Adair, 1999;
Grantham Mcgregor, 2007).
Stunting during infancy and early childhood is adversely affect cognitive
development. Crookston et al (2010) found that stunted children in aged 6 and 18
months, and were followed up at age 4.5 to 6 years old, have had lower intellectual
ability than children who were not stunted. Kar et al (2008) conducted a study on
children aged 5-7 years found significant differences on cognitive development
between stunted children and not stunting. A study in Vietnam reported an increase
by a standard deviation of height for age Z score (HAZ) leads to an increase by one
fourth of a standard deviation of the log score of language ability (Le Thuc Duc,
2009). These were previously confirmed by other studies (Mendez MA and Adair
LS, 1999; Walker SP et al, 2005; Grantham McGregor et al, 2007, Grantham
Mcgregor, S, 2007).
Psychosocial stimulation in early childhood had significant benefits in the
improvement of stunted children’s psychological development. Stunted children who
received stimulation had levels of anxiety, depressive syndrome and self esteem
similar to those of the nonstunted children (Walker SP et al, 2006). Maternal role is
the key in providing psychosocial stimulation. Improvement of maternal education
will increase the possibility of catch-up growth and levels of cognition in later
adolescence (Crookston et al, 2010).
We conducted a cross sectional study to determine relationship between mental and
psychomotor development index of stunted children with psychosocial stimulation
provided by mothers, maternal education, parenting methods and health status.

Methods

This was a cross sectional study, conducted from December 2011 to June
2012 at Districts of Tanah Datar of West Sumatra Province in Indonesia. Ethical
reviews were conducted by The Ethics Committee of Medical Faculty of Andalas
University, Indonesia.

Participants
We randomly selected 265 infants aged 6 to 12 months from 9 villages in the
District of Tanah Datar. Screening of stunted children was done by applying
anthropometric assessment to all children. Anthropometric measurements were done
at Centre of Health Services (Posyandu) in each hamlet. The presence of stunting
was defined as a height-for-age Z-score (HAZ) based on the World Health
Organization reference data. Severe early stunting was defined as HAZ ˂-3;
moderate stunting as HAZ ˂-2 and ≥-3.

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Data collection
Private interviews were administered in each house to collect data on characteristics
of the children and their mothers, maternal education and nutrition knowledge, health
status and parenting methods.
Knowledge is measured using questionnaires and summing the scores of food and
parenting knowledge and categorized into less if score <60% and good if the total
score of ≥ 60%. Maternal education were divided into two categories, ≤12 years (low
education level) and >12 years (high education level). The health status of the
infants is the incidence of diarrhea and acute respiratory infections (ARI) during the
last 30 days that need treatment to health services. Parenting methods was assessed
using questionnaire that included questions on breastfeeding, food supplementary,
feeding practices and food sanitation practices. All variables were given scores,
calculation was based on the maximum value, comprising of less (<60%) and good
(≥ 60%).
We assessed psychosocial stimulation by using HOME Scale developed by Caldwell
and Bradley (1984). For children 0-3 years old, 45 observations was conducted
which was divided into 6 subscales: 1) parental responsivity, 2) acceptance of child,
3) organization of the environment, 4) learning material, 5) parental involvement,
and 6) variety in experience. Scale below 25 is considered low, above ≥25 normal.
Translation and validation of Home Scale measurement was done by other study in
Indonesia (Masrul, 2005). Measurement of psychosocial stimulation was conducted
through private interviews and observations.

Mental Development Index (MDI) and Psychomotor Development Index (PDI)

The Bayley Scale of Infant Development (BSID) was used to assess MDI and PDI.
The tests were performed by trained psychologists. Mental development was
measured using 51 items to evaluate several types of abilities: sensory/perceptual
acuities, discriminations, and response; acquisition of object constancy; memory
learning and problem solving; vocalization and beginning of verbal communication;
basis of abstract thinking; habituation; and mental mapping. Psychomotor
Development Index was measured using 44 items to assess the degree of body
control, large muscle coordination, finer manipulatory skills of the hands and fingers,
dynamic movement, postural imitation, and the ability to recognize objects by sense
of touch. In Indonesia, BSID had been used by several studies (Pollit E, 1996;
Masrul, 2005). We used the translation verse of BSID modified by the previous
studies. The index score <85 is low, and normal if the index score is ≥ 85.

Processing and Data Analysis

Mean test scores were calculated for children classified by stunting status;
differences in scores were assessed using t tests (to compare two groups) or chi-
square tests (for three or more groups). Linear regression was used to assess the
relationship between stunting and test performances.

Results

Participants characteristics
We found 89 out of 265 children (33.58%) were stunted, of these 31% were severe
stunted. The average of z score was -2.41 SD. The study was done to the children of
6 – 9 months with the average age was 9.5 months. Most of the children had good
level of psychomotoric development (61.8%) and good level of motoric development

3
(69,7%). There was no differences in MDI and PDI between those had diarrhea
(23%) and acute respiratory infection (46%) with who had no diarrhea nor ARI.
There were no differences in MDI and PDI index between those who received good
parenting patterns and optimal psychostimulation from the mothers. However, length
of education of the mothers had a significant relationship to MDI (p=0.01) but not to
PDI (p=0.28). Mothers knowledge of food, parenting methods, sanitation had also
significant relationship with both MDI (p=0.02) and PDI (p=0.02).

Table 1. Participant characteristics

Characteristics n=89 MDI PDI

1. Health Status
a. Diarrhea 21 (23,6 %) p=0.31 p=0.81
b. ARI 43 (48,3 %) p=0.48 p=0.69
4. Parenting
a. Good 66 (74,2 %) p=0.80 p=0.06
b. Less 23 (25,8 %)
5. Psychosocial stimulation
a. Good 48 (53,9 %) p=0.98 p=0.42
b. Less 41 (46,1 %)
6. Mother Length of education
a. > 9 year 55 (61,8 %) p=0.01 p=0.28
b. < 9 year 34 (38,2 %)

7. Maternal Knowlegde
a. Good 44 (49,4 %) p=0.02 p=0.02
b. Less 45 (50,6 %)

Factors Affecting the Development of Mental and Psychomotor

All variables were analyze using logistic regression analysis to determine the
most influence factors in psychomotor development of the stunted children as shown
table 2. Table 3 above shows that the significant factors related to the child's motor
development was stunted parenting and maternal nutrition knowledge. The results of
the analysis found the odds ratio (OR) of maternal nutrition knowledge factor was
2.837 (95% CI :1,134-7, 095), means a child with a good maternal nutrition
knowledge there is an opportunity to have normal motor development 2.8 times
compared to children with maternal nutrition knowledge less.

Table 3. Factors Affecting Psychomotor Development Index

Variabel B P Wald OR 95 % CI
Diarrhea 0.310 0,591 1,364 0,439-4,238
ARI -0.286 0,541 0,751 0,300-1,879
Psychosocial stimulation 0.459 0,323 1,582 0,636-3,935
Parenting pattern 0,877 0,088 2,403 0,878-6,579
Maternal Knowledge 1,043 0,026 2,837 1,134-7,095
Constant -0,635 0,172
P value = 0,009
-2 Log Likelihood = 108,916

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 Tabel 4 Factors Affecting Mental Development Index

Variabel B P Wald OR 95 % CI
Psychosocial stimulation 0,241 0,631 1,273 0,476-3,402
ARI -0,377 0,451 0,686 0,258-1,827
Parenting pattern -0,525 0,363 0,592 0,191-1,832
Diare -0,780 0,215 0,458 0,133-1,574
Mother Nutrition Knowledge1,190 0,016 3,288 1,249-8,657
Constant
P value = 0,013
-2 Log Likelihood = 103.014

Table 4 above shows that the significant factors related to the child's mental
development is stunted maternal nutrition knowledge. The results of the analysis
found the odds ratio (OR) was 3.288 (95% CI :1,249-8, 657), means a child with a
good maternal nutrition knowledge there is an opportunity to have a normal mental
development 3.2 times compared to children with a mother's nutritional knowledge is
lacking.
Paxson and Schady in 2007 to test the children's cognitive Ecuador, Spain
with the Peabody Picture Vocabulary Test and found that cognitive scores are higher
in children who have this level of knowledge economy and a better mother (5).

DISCUSSION

The result of this study found 89 out of 265 children (36.6%) aged 6 to 9
months were stunted. Child stunting in this study obtained by screening in 265
children aged 6-12 months in 9 villages were selected by measuring the length of its
body. The results obtained for 36.6% stunted children. Almost the same as research
Leenstra T et al in 2005 in Kenya which found pre-school age children stunting rate
of 35% (11). Duc also said that one in three children in developing countries are
malnourished or short (underweight and stunted) (5).

Mental Development of Children's Stunting

Measuring a child's development is limited to mental development as
measured by the Mental Development Index (MDI) and psychomotor development
as measured by Psycomotor Development Index (PDI). Mental development is a
mental process that includes an understanding of the world, knowledge discovery,
making comparisons, thinking and understanding (13).
Based on MDI measurements obtained results of this study that the lowest
percentage rate of mental development is slow stunting of 30.3%. Almost the same
results Masrul (2005) who found the proportion of children aged 6-12 months who
experienced slow growth indicator based MDI was 14.4%. Cohort studies conducted

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by Walker et al in 2007 found stunted children aged 9-24 months have more
depressive symptoms than children not stunted after the age of 17 years (14).
Alderman et al (2007) found that children in rural Zimbabwe who did
improvement of nutritional status (height-for-age index) during the pre-school, it will
affect his performance in school. In Tanzania in 2009 also found that malnourished
children associated with tardiness to school and the graduation (6)
Based on the results of focus group discussions and observations made in the
mothers during the study child stunting, maternal health behavior research in this
area has generally been quite good, stunting the child's mother was willing and
understand parenting, the water source for day-to-day guaranteed and affordable
health care. IHC crowded visited by mothers, whether for immunization, growth
monitoring and health information from the counseling is done. Health Center / pustu
/ polindes / poskestri already exist in every districts so that people are not difficult to
get health care.

Stunting Children's motor development

The development is the development of psychomotor control body
movements through coordinated activities between the central nervous system,
peripheral nerves and muscles (13). Measurements obtained PDI percentage stunting
a child's motor development is slow at 38.2%. Masrul study (2005) found the
proportion of children aged 6-12 months who experienced slow progress by
indicators PDI was 18.8%.
The results showed more number of levels of motor and mental development
were normal child stunting compared to the slow, possible causes are complex
factors, such as the conceptual framework of this research, child development is
influenced by direct and indirect factors. The immediate cause of nutrient intake
were not examined (one of the drawbacks of this study) are likely to cause the child
stunting normal development, in addition to indirect causes such as parenting, access
to health services and environmental health is good. Most of the mothers had given
parenting and psychosocial stimulation in both children, which amounted to 53.9%
and 74.2%.

Factors most associated with motor and mental development Child Stunting
Based on the results of multivariate analysis performed as contained in Table
4, it is known that factors associated with motor and mental development of stunted
children is parenting and maternal nutrition knowledge. The results of the analysis
found the odds ratio (OR) of maternal nutrition knowledge factor was 2.837 (95% CI
:1,134-7, 095), means a child with a good maternal nutrition knowledge there are
opportunities to have children with normal motor development of children 2.8 times
compared with the nutritional knowledge mother less. The factors that most
influence on motor development stunted child is the mother's nutritional knowledge
with p = 0.009.
These results contrast with the findings of Yuliana (2002), which may explain
variations in psychosocial stimulation motor development of children at 24.2% by F
test results that showed a P value of 0.000 (significant p <0.05). While other factors
such as eating parenting, maternal nutrition knowledge, respiratory illness, family
size and the other is meaningless. Similar to the results of research Herawati (2005),
that the determinant factor is the change in the change scores PDI scores
psychosocial stimulation (R ² = 0.216). Further research Herawati (2005) suggests

6
that one factor that correlated significantly with the development of children aged 6-
12 months PDI is a mother's nutritional knowledge.
Based on these results, the level of maternal nutrition knowledge is not much
different between the less and a good, where the only question about the usefulness
of the nutrients are a small part answered correctly. The question of the nutrients
needed by the body and monitoring the development of children, the average can be
answered correctly by the mother, because the mother was used to come and listen to
posyandu counseling so she has understood the needs of their children and the
importance of monitoring children's development. Mothers in the study area is quite
active comes to posyandu.

CONCLUSION

Characteristics of child stunting were found were an average age of 9.4

months and most of the male sex, while the mother of the child stunting is
characteristic of an average age of 29 years and a few old women with less than 9
years of education.
The percentage of good maternal nutrition knowledge more than the mother's
nutritional knowledge is lacking, the percentage incidence of diarrhea was less than
the incidence of respiratory infections, as well as the percentage of parenting and
psychosocial stimulation were both more than less. A small percentage of motor and
mental development of stunted children is slow. Factors that play a role in
influencing the child's motor development was stunted maternal nutrition knowledge.
The discovery of positive deviance in child stunting mothers who have mental and
motor development of children of normal feeding, providing meals to children how
to play so that children like to eat. The efforts that have been made in improving
motor and mental development is stunted children of pregnant women hold classes,
toddler classes and counseling mothers on posyandu.

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NIIL Ibu design the study, supervisor data collection, write the manuscript

RH collect and analyze data collection , write the manuscript

M analyze data, read manuscript