Networklearning invites all its friends and colleagues to take a little time to think about their country and its children under the age of five.

Why? Because these little kids are the future of the nation. If they are not reaching their full potential, the whole country loses out.

Worldwide, more than 200 million children under the age of 5 years are not fulfilling their potential for growth, intelligence, or emotional development. Infants and toddlers growing up in poverty are exposed to poor sanitation, large family size, a lack of stimulation, and fewer household resources. As they grow up, children living in poverty in the developing world grow up to have seriously lower wages than do others. Their own children will suffer the same lack of resources, so the effect of poverty continues. Early childhood is a period of rapid change and physiological development. It is a period critical for intervention.

In September 2011, the Lancet (a British health journal) published an issue that follows up on previous work that looked at early childhood development in developing countries: you can read it in full here (in difficult language!). UNICEF seems to be the major agency behind these initiatives.

Up to now, heath workers have focused on the more obvious factors that lead to small children not meeting their full potential. Most of the readers will be fully aware of the first three. They are each reviewed in the Lancet papers:

1. poor diet for the mothers during pregnancy

2. poor diet during the childrens' first years

3. lack of mental stimulation

4. specific deficiencies such as iron and iodine.
The text refers to evidence from studies in Chile, India, Mexico, and Zanzibar that showed poorer development in understanding, motor, and social-emotional skills associated with iron-deficiency anaemia in infancy, or in the preschool period. The presence and effect of other environmental toxins are scarcely reported.

Recent research emphasises the importance of all of these factors, but in addition adds:

5. malaria: longitudinal studies with school-aged children from Brazil and Mali have shown associations between attacks of malaria (with or without symptoms) and poorer academic performance. Randomised clinical trials of chemo-prophylaxis in schoolchildren showed significant benefits to language, mathematics, and attendance in Sri Lanka, and to attention in Kenya.

6. exposure to lead: recent evidence from Poland has shown that prenatal exposure to very low concentrations of lead can result in poor mental development in young children. Evidence from low-income and middle-income countries on the effect of other toxins on early child development is inconsistent or sparse.

7. HIV infection: an estimated 2·1 million children younger than 15 years are living with HIV; however, only 28% of children in low-income and middle-income countries who need anti-retroviral drugs, actually receive them. HIV infection affects brain development, leading to poorer understanding (cognition).

8. depression in mothers: there is a high incidence of maternal depressive symptoms in many low-income and middle-income countries. Maternal depressive symptoms are everywhere negatively associated with early child development and the quality of parenting skills. In Bangladesh, maternal depressive symptoms were associated with infant stunting, perhaps related to a style of care-giving which is unresponsive. Risk factors for maternal depression, such as poverty, low education, high stress, lack of empowerment, and poor social support, are also risk factors for poor child development, suggesting that the relationship between maternal depression and slowed early child development is at a number of levels with different factors adding to each other. There is evidence that symptoms of maternal depression can be effectively treated in low-income and middle-income countries – even where resources are restricted and treatment is given through community health workers. This evidence points to the need for early identification of the depression, followed by community programmes to reduce the risk of bad consequences for mothers and children.

9. disability: in a survey of disability in 18 low-income and middle-income countries, 23% of children aged 2-9 years had, or were at risk for disabilities. Besides being a marker for problems around development, childhood disabilities often reduce the child's access to school or health services. Although interventions can lead to better functioning in children with disabilities, few have been assessed in low-income and middle-income countries.

A review of interventions in the South found that if interactive group therapy is provided for parents of children with disabilities, most develop more positive attitudes. Mother-and-child groups clearly help; in Bangladesh, for example, training the parents about child development benefited children with cerebral palsy.

10. institutionalisation (the damaging effects of long-term care in orphanages or hospitals): at least 2 million children are institutionalised in non-parental-type residential care. This is probably an underestimate because of under-reporting and lack of information for some regions. Use of orphanages and other institutional care seems to be increasing. Although the response of children to institutionalisation varies, many show long-term developmental problems. Institutional care which starts early in life increases the children's risk for bad effects, including poor growth, ill-health, attachment disorders, attention disorders, poorer functioning intelligence, anxiety, and autistic-like behaviour.

11. exposure to violence in the family or surroundings. Estimates suggest that 300 million children younger than 5 years have been exposed to violence. This means societal or community violence such as events in the last five years in many low-income and middle-income countries. Young children exposed to violence show insecure attachments, increased risk of behaviour problems, reduced levels of helpful social behaviour, and increased aggressive behaviour. The bad consequences might result from disruptions to family structure and function, things that test parents' child-rearing skills, and that reduce the children's ability to regulate their own emotions.

Studies from Israel and Palestine have identified strategies that can reduce stress reactions for young children. The effect of exposure to violence can be reduced by the right reactions from the parents and by calm family routines; however, violence can continue to disrupt the quality of parenting.

So which of these factors are playing a role in the communities in which you work?

If comparisons are made inside countries (in Europe, Ethiopia, India and elsewhere), children of richer families are more than twice as likely to go to pre-school and have good stimulation at home than the kids of the poorest; by the age of five they can speak significantly better (between 0.5 and 1.5.STDs).

Protective factors: these are the factors which protect children against the worst effects of all the bad influences – especially,

• education of their mothers and

• exclusive breast-feeding for the first few months. In Brazil, boys breastfed for at least 9 months attained 0·5-0.8 school grades more by the age of 18 than boys breastfed for less than one month. In the same population, an analysis of the effect of the grade level attained on the income of the child when adult, suggests that this difference corresponds to a 10-15% difference in income.

Strategies for intervention: early childhood is the time when we can most effectively counter the inequalities in every country, especially for the poorest children. Programmes in early childhood seem to offer high returns for the investment. What seems to work best:

1. programmes that work with other disciplines. The problems that are affecting small children are many and interlinked; interventions must be the same. Health workers must work with educators and with researchers

2. programmes of high quality, maximised by paying attention to design, a structured and evidence based curriculum, practice for parents, systematic training for childcare workers, monitoring and assessment, governance, and supervision.

3. programmes that help parents and link to pre-school programmes: these improve especially the emotional development of small children These good Parenting Programmes are ones that promote parent-child interactions, improve responsiveness in feeding infants and young children, increase attachment, encourage learning, include book reading and play activities; use positive discipline, and encourage problem-solving related to children's development, care, and feeding. They may be delivered and supported through health programmes, home visits, community groups, regular clinic visits and media; in addition they are often combined with other components.

Example: The Gambia Parental Education Programme; Nearly 50% of the rural people are extremely poor. And 60% of the poor are under 20. Researchers did Basic KAP studies and FGDs into physical & psychological aspects of child care; they identified relevant services inc. the PHC, MCH, WATSAN structures; there was a National Nutrition intervention in place, the BFCI, a community-based programme emphasising exclusive breastfeeding; this was used as a natural entry point. The existing Village Support Groups (VSGs) and Traditional Communicators, selected by their respective communities, became key actors. 69 communities were covered. For the evaluation 43 intervention and 27 control communities were randomly selected and surveyed.

Evaluation: many parents/care-givers in both the experimental and control communities have been able to build on their traditional child rearing knowledge and practices and demonstrated improvement in skills In the communities with the programme, more of the parents (around 10% more than in the controls) gave exclusive breastfeeding and introduced complementary food at an appropriate age. Other improvements: cleaner food preparation and storage; use of the safest water source and/or filters; use of chamber pots for small children; latrines; collection and dumping of waste matter; a more positive attitude of parents towards disabled children; more parents(93% v 88%) having friendly interactions with their children; more child-play encouraged, alone and with other children; a decrease in using corporal punishment (56% v 67%); more making of culturally relevant toys and encouraging play with toys; parents mentioning that toys make their children concentrate, develop fine motor skills, think, communicate with each other, share, and above all be creative.

4. With parents, the effects are larger when there are active strategies to show and promote care-giving behaviours
― eg, practice, role play, or coaching to improve parent-child interactions.

Example: Hassan & Halford looked at a Better Parenting Programme in Jordan. 337,parents, mostly mothers (94%) were randomly assigned to an experimental group or a control group. Over time, participants in the experimental group (but not the control group) improved on parenting knowledge, spending time playing and reading books with their children, using more explanations during the course of disciplining their child, and accurately perceiving behaviours that constitute child neglect.

5. programmes that increase pre-school enrollment and which target especially the most vulnerable & those at highest risk;

6. childrens' educational media;

7. the combination of early childhood development with conditional cash transfer programmes (CCT);

Example: In Mexico a CCT programme was started, Oportunidades. This was a conditional cash transfer programme with the goal of improving options for poor families through interventions in health, nutrition, and education. Families enrolled in CCT programmes receive cash in exchange for complying with certain conditions - preventive health requirements and nutrition supplementation, education, and monitoring. Early enrolment reduced behavioural problems for all children in the early versus late treatment group. An additional 18 months of the programme before the age of three for children whose mothers had no formal education showed up when they were eight to ten for example in improved child growth of about 1·5 cm assessed as height-for-age. The money itself also had significant effects on most outcomes, adding to existing evidence for interventions in early childhood.

Conclusion

• It is estimated that if either 20% or 50% of small children could be enrolled in pre-school the benefit-to-cost ratio would be either 6 to 4, or 17 to 6.
• Unless governments allocate more resources to quality early child development programmes for the poorest people in the population, economic differences will continue and widen.

We ask each reader to work out whether and how they could improve the situation of small children in the area in which they work.

• Are you in front-line services?
• Can you encourage longer breast-feeding, play-groups or better malaria control?
• Can you spend time once a week with a group of mothers, helping them improve their skills? We urge you to start small, but to start.
• Or are you in a position to promote the cause of early childhood development – to be an Advocate for their needs and their potential? Then become as informed as possible and download our Key Information Sheet on Advocacy.