Cognitive, psychosocial, and behaviour gains at age 31 years from the Jamaica early childhood stimulation trial

8-Year Follow-up of a Maternal Education Trial in a Low-Resource Setting

OBJECTIVES

Nutrition and stimulation interventions promote early childhood development, but little is known about their long-term benefits in low- and middle-income countries. We conducted a follow-up study of a cluster-randomized maternal education trial performed in children aged 6 to 8 months to assess the sustainability of developmental benefits after 8 years.

METHODS

The education intervention lasted 6 months and consisted of nutrition, hygiene, sanitation, and child stimulation aspects. We assessed child processing and cognitive abilities using the Kaufman Assessment Battery for Children Second Edition (KABC-II) and attention and inhibitory control using the Test of Variables of Attention after 8 years. The original trial included 511 mother-child pairs (intervention, n = 263; control, n = 248), whereas in the current study, 361 (71%; intervention, n = 185; control, n = 176) pairs were available for analyses.

RESULTS

The intervention group scored higher than the controls (all P < .001) on all 5 KABC-II subscales and on the KABC-II global score (mean difference: 14; 95% confidence interval, 12-16; P < .001). For all 5 Test of Variables of Attention variables, the intervention group scored higher than the controls on both the visual and auditory tasks (all P < .05). Because the intervention was delivered as a package, a limitation is that we cannot pinpoint the individual contribution of each component (nutrition, hygiene, and stimulation) to the developmental benefits.

CONCLUSIONS

The intervention group consistently scored markedly higher on both neuropsychological tests. Thus, even 8 years after the original maternal education intervention, the developmental benefits that we observed at child age of 1, 2, and 3 years, were sustained.

Gene-environment pathways to cognitive intelligence and psychotic-like experiences in children

In children, psychotic-like experiences (PLEs) are related to risk of psychosis, schizophrenia, and other mental disorders. Maladaptive cognitive functioning, influenced by genetic and environmental factors, is hypothesized to mediate the relationship between these factors and childhood PLEs. Using large-scale longitudinal data, we tested the relationships of genetic and environmental factors (such as familial and neighborhood environment) with cognitive intelligence and their relationships with current and future PLEs in children. We leveraged large-scale multimodal data of 6,602 children from the Adolescent Brain and Cognitive Development Study. Linear mixed model and a novel structural equation modeling (SEM) method that allows estimation of both components and factors were used to estimate the joint effects of cognitive phenotypes polygenic scores (PGSs), familial and neighborhood socioeconomic status (SES), and supportive environment on NIH Toolbox cognitive intelligence and PLEs. We adjusted for ethnicity (genetically defined), schizophrenia PGS, and additionally unobserved confounders (using computational confound modeling). Our findings indicate that lower cognitive intelligence and higher PLEs are significantly associated with lower PGSs for cognitive phenotypes, lower familial SES, lower neighborhood SES, and less supportive environments. Specifically, cognitive intelligence mediates the effects of these factors on PLEs, with supportive parenting and positive school environments showing the strongest impact on reducing PLEs. This study underscores the influence of genetic and environmental factors on PLEs through their effects on cognitive intelligence. Our findings have policy implications in that improving school and family environments and promoting local economic development may enhance cognitive and mental health in children.

High doses of a national preschool program are associated with the long-term mitigation of adverse outcomes in cognitive development and life satisfaction among children who experience early stunting: a multi-site longitudinal study in Vietnam

Background

Stunting (low height-for-age) is a marker of cumulative developmental disadvantage that can also contribute to impaired cognitive development and poor psychological wellbeing. Several interventions designed to preserve stunted children's developmental potential through increasing their cognitive stimulation have proven to be effective. However, their resource-intensive nature limits their sustainability and scalability in the low-and middle-income countries in which 98% of stunted children live. The current study had three aims: to identify the domains of developmental disadvantage associated with stunting at 5 years of age in the Vietnamese context; to examine the relationship between Vietnamese children's stunting status at 5 years of age, the dose of the national preschool program they received, and their cognitive skills and psychological well-being at 4 ages; and to determine whether some doses of the national preschool program were associated with the mitigation of adverse cognitive and wellbeing outcomes among stunted children.

Method

The Young Lives Study in Vietnam (n = 2,000; 31 sites) provided archival data that allowed calculation of the approximate dose (in hours) of the preschool program received by children, and longitudinal data on children's growth (1, 5, 8, 12, and 15 years), receptive vocabulary (5, 8, 12 and 15 years), reading skills, mathematics skills and life satisfaction (each at 8, 12, and 15 years).

Results

Stunting at 5 years of age was associated with diverse aspects of financial and social disadvantage, greater exposure to health risks, lower preventive health care, and constraints on maternal care. Scores for all cognitive variables at all ages were positively associated with preschool dose and negatively associated with stunted growth at 5 years of age. That is, effects associated with stunting and preschool dose at 5 years of age continued to be found during the subsequent 10 years. High doses of preschool education (3,000 h or more) were associated with the mitigation of adverse outcomes for most cognitive variables at most ages.

Conclusion

The current findings raise the possibility that generic preschool programs delivered at high dose may provide a scalable and sustainable intervention to support the life opportunities of children who experience early stunting.

The contribution of epidemiology to the understanding of neurodevelopmental disabilities

Epidemiological approaches have played an important role in creating better understanding of developmental disabilities by delineating their frequency in populations and changes in their frequency over time, by identifying etiological factors, and by documenting pathways to prevention. Both cerebral palsy (CP) and mild intellectual disability are declining in frequency in high-income countries. The diagnosis of autism spectrum disorder has increased in recent decades, but much of this increase is a result of changing approaches to ascertainment and recording. Epidemiological studies have found that most CP is not of birth-asphyxial origin, that most febrile seizures do not pose a major risk for epilepsy, and that folic acid deficiency may contribute to developmental disabilities apart from its effect on neural tube defects. Epidemiological research has shown that an important fraction of neural tube defects and virtually all cases of Reye syndrome are preventable, and recent trials have shown ways to prevent CP. Early psychoeducational interventions in children at risk for mild intellectual disability are an effective and valuable societal investment. Very large population-based studies starting in pregnancy have been launched in Norway, Denmark, and Japan in recent years and these and other population studies promise to continue the epidemiological contribution to a better understanding of developmental disabilities.

Art at the Start: A controlled trial and close observation of parent-infant art therapy intervention

This two-part study seeks to evidence art therapy intervention for parent-infant attachment relationships, looking at improvements to wellbeing and relationships. Study one was a controlled trial with 105 participating parent/caregivers and their infants (0-3-years), identified due to concerns about their relationship. They were quasi-randomized to attend a 12-week art therapy group or treatment as usual. Measures focused on parents' wellbeing and their perceptions of their relationship with their infant. In study 2 we analyzed video footage from the first and penultimate sessions of a sample of 37 dyads, looking for observable changes in the different channels of communication upon which attachments are predicated. The controlled trial showed intervention participants had significantly improved parental wellbeing, significant increases in attachment warmth and significant decreases in intrusion. This contrasted with the control sample who showed a significant decrease in wellbeing, stable warmth, and significant increases in intrusion. The observation study showed that there was a significant increase in the communicative behaviors from the parents to the infant which would support attachments between the first and penultimate sessions. We conclude that these results make a robust case for the inclusion of art therapy within the range of interventions available for at risk early relationships.

Using lessons learnt from key stakeholders to increase support for scaling the Reach Up Early Childhood Parenting program

Introduction

Sustainable implementation of early childhood programs requires resources, materials and methods that are adaptable, scalable and feasible for delivery through multiple sectors. Additional or modified program resources may be required to meet emerging needs, as programs go to scale. An active and effective monitoring, evaluation and learning (MEL) process may enable programs to be responsive to demands. The Reach Up: Early Childhood Parenting program, is designed primarily for disadvantaged children under 4 years of age in low- and middle-income countries (LMICs) to promote their development through playful caregiver interactions. The curriculum, training manuals and other materials and resources support implementers in the adaptation of the intervention, implementation, workforce training, monitoring and evaluation. This paper reports on how data collected from key informants drove modifications to program processes, materials and resources.

Methods

We conducted in-depth interviews with 14 key informants (including program managers, lead trainers, academics, consultants and workforce personnel) on their experiences with Reach Up across 15 LMICs where the program has been implemented. We also reviewed written records generated from (i) structured small group discussions at a Knowledge Exchange meeting of 31 Reach Up partners and (ii) notes from working groups formed at the meeting and tasked to continue working post-meeting to find solutions to support ongoing implementation. The transcripts from the in-depth interviews and the meeting records were analysed using thematic analysis with a mixture of pre-defined categories and data-driven sub-themes.

Results

The main findings indicated that there was a need to: (i) develop advocacy and communication resources and materials to aid prospective implementers and other stakeholders, to make decisions for implementation, (ii) revise and/or add to the content and format of the curriculum and add content in the training and other supporting manuals and (iii) enhance the training process.

Conclusion

The feedback from the key global partners informed the development of new knowledge materials, resources and processes and modifications to existing program materials and resources. These will help to support advocacy, ongoing implementations, and the process of transitioning the Reach Up early childhood intervention to scale.

Promoting early childhood development in Viet Nam: cost-effectiveness analysis alongside a cluster-randomised trial

BACKGROUND

Economic evaluations are critical to ensure effective resource use to implement and scale up child development interventions. This study aimed to estimate the cost-effectiveness of a multicomponent early childhood development intervention in rural Viet Nam.

METHODS

We did a cost-effectiveness study alongside a cluster-randomised trial with a 30-month time horizon. The study included 669 mothers from 42 communes in the intervention group, and 576 mothers from 42 communes in the control group. Mothers in the intervention group attended Learning Clubs sessions from mid-pregnancy to 12 months after delivery. The primary outcomes were child cognitive, language, motor, and social-emotional development at age 2 years. In this analysis, we estimated the incremental cost-effectiveness ratios (ICERs) of the intervention compared with the usual standard of care from the service provider and household perspectives. We used non-parametric bootstrapping to examine uncertainty, and applied a 3% discount rate.

FINDINGS

The total intervention cost was US$169 898 (start-up cost $133 692 and recurrent cost $36 206). The recurrent cost per child was $58 (1 341 741 Vietnamese dong). Considering the recurrent cost alone, the base-case ICER was $14 and mean ICER of 1000 bootstrap samples was $14 (95% CI -0·48 to 30) per cognitive development score gained with a 3% discount rate to costs. The ICER per language and motor development score gained was $22 and $20, respectively, with a 3% discount rate to costs.

INTERPRETATION

The intervention was cost-effective: the ICER per child cognitive development score gained was 0·5% of Viet Nam's gross domestic product per capita, alongside other benefits in language and motor development. This finding supports the scaling up of this intervention in similar socioeconomic settings.

FUNDING

Australian National Health and Medical Research Council and Grand Challenges Canada.

TRANSLATION

For the Vietnamese translation of the abstract see Supplementary Materials section.

Parenting Promotes Social Mobility Within and Across Generations

This paper compares early childhood enrichment programs that promote social mobility for disadvantaged children within and across generations. Instead of conducting a standard meta-analysis, we present a harmonized primary data analysis of programs that shape current policy. Our analysis is a template for rigorous syntheses and comparisons across programs. We analyze new long-run life-cycle data collected for iconic programs when participants are middle-aged and their children are in their twenties. The iconic programs are omnibus in nature and offer many services to children and their parents. We compare them with relatively low-cost more focused home-visiting programs. Successful interventions target both children and their caregivers. They engage caregivers and improve the home lives of children. They permanently boost cognitive and non-cognitive skills. Participants in programs that enrich home environments grow up with better skills, jobs, earnings, marital stability, and health, as well as reduced participation in crime. Long-run monetized gains are substantially greater than program costs for the iconic programs. We investigate the mechanisms promoting successful family lives for participants and report intergenerational effects on their children. A study of focused home-visiting programs that target parents enables us to isolate a crucial component of successful programs: they activate and promote parenting skills of child caregivers. The home-visiting programs we analyze produce outcomes comparable to those of the iconic omnibus programs. National implementation of the programs with long-run follow up that we analyze would substantially shrink the overall US Black-White earnings gap.

Early Stimulation and Enhanced Preschool: A Randomized Trial

OBJECTIVES

To estimate the impacts of 2 interventions, early stimulation (ES) for children aged <3 years and enhanced preschool (EP) for children aged 3+ years, and their interactions.

METHODS

In Odisha, India, 192 villages were randomly assigned to ES or to no ES. Within each village, about 8 mothers with children initially aged 7 to 16 months were enrolled, receiving ES or no ES accordingly (n = 1449). Subsequently, when children were aged ∼3 years, the villages were rerandomized to either EP at Anganwadi centers or no EP. This yielded 4 groups: (1) ES and EP, (2) only ES, (3) only EP, and (4) no intervention. Trained Anganwadi workers ran the EP. Primary outcomes, measured at baseline and follow-up after ∼1 year, were children's IQ (summarizing cognition, language, and executive functioning) and school readiness (SR). Secondary outcomes were home environments, caregivers' child-development knowledge. and preschool quality.

RESULTS

Fifteen months after ES ended, onlyES had a sustained benefit on IQ (0.18 SD, P <.04) and on SR (0.13 SD, P <.08). Only EP improved IQ (0.17 SD, P <.04) and SR (0.24 SD, P <.01). Receiving both interventions improved IQ (0.24 SD, P <.01) and SR (0.21 SD, P <.01). No statistically significant interactions between the 2 interventions were observed.

CONCLUSIONS

Both ES and EP increased IQ and SR. Only ES impacts were sustained for 15 months. Only EP resulted in considerable catch-up for children who did not receive only ES. The absence of significant complementarities should be investigated further because of its profound policy implications.

Six-Year Follow-up of Childhood Stimulation on Development of Children With and Without Anemia

BACKGROUND AND OBJECTIVES

Previously, in 30 Bangladeshi villages, 2 groups of children with iron-deficiency anemia (IDA) and nonanemic (NA) iron sufficiency aged 6 to 24 months participated in 2 parallel cluster randomized controlled trials of the effect of psychosocial stimulation on neurodevelopment. The intervention was composed of weekly play sessions at home for 9 months. All children with anemia received iron treatment of 6 months. The intervention improved the mental development of NA but not IDA groups. Six years after end line when the children were aged 8 to 9 years, we aimed to determine if benefits were sustained in the NA group or late-onset benefits emerged in the IDA group.

METHODS

We relocated 372 (90%) of the initial 412 children from all the clusters (villages), and assessed their IQ with the Wechsler Abbreviated Scale of Intelligence-II, motor development, and school achievement including math, spelling, and reading. Analyses were by intention-to-treat, adjusting for clustering.

RESULTS

There was a significant interaction between anemia groups (IDA/NA) and intervention on IQ. The intervention benefitted the NA group's Full-Scale IQ (effect size, 0.43 [95% confidence interval, 0.08-0.79]) and Perceptual Reasoning Index (effect size, 0.48 [95% confidence interval, 0.08-0.89]) but did not affect the IDA group's outcomes. No other outcomes were significant.

CONCLUSIONS

The benefits from early childhood psychosocial stimulation on the NA group's IQ, 6 years after intervention ended, adds to the limited evidence on the sustainability of benefits in low- and middle-income countries. Reasons for lack of effect in children with anemia are unknown.

Executive functioning skills and their environmental predictors among pre-school aged children in South Africa and The Gambia

Executive functions (EFs) in early childhood are predictors of later developmental outcomes and school readiness. Much of the research on EFs and their psychosocial correlates has been conducted in high-income, minority world countries, which represent a small and biased portion of children globally. The aim of this study is to examine EFs among children aged 3-5 years in two African countries, South Africa (SA) and The Gambia (GM), and to explore shared and distinct predictors of EFs in these settings. The SA sample (N = 243, 51.9% female) was recruited from low-income communities within the Cape Town Metropolitan area. In GM, participants (N = 171, 49.7% female) were recruited from the rural West Kiang region. EFs, working memory (WM), inhibitory control (IC) and cognitive flexibility (CF), were measured using tablet-based tasks. Associations between EF task performance and indicators of socioeconomic status (household assets, caregiver education) and family enrichment factors (enrichment activities, diversity of caregivers) were assessed. Participants in SA scored higher on all EF tasks, but children in both sites predominantly scored within the expected range for their age. There were no associations between EFs and household or familial variables in SA, except for a trend-level association between caregiver education and CF. Patterns were similar in GM, where there was a trend-level association between WM and enrichment activities but no other relationships. We challenge the postulation that children in low-income settings have poorer EFs, simply due to lower socioeconomic status, but highlight the need to identify predictors of EFs in diverse, global settings. RESEARCH HIGHLIGHTS: Assessed Executive Functioning (EF) skills and their psychosocial predictors among pre-school aged children (aged 3-5 years) in two African settings (The Gambia and South Africa). On average, children within each setting performed within the expected range for their age, although children in South Africa had higher scores across tasks. There was little evidence of any association between socioeconomic variables and EFs in either site. Enrichment activities were marginally associated with better working memory in The Gambia, and caregiver education with cognitive flexibility in South Africa, both associations were trend-level significance.

The Reach Up Parenting Program, Child Development, and Maternal Depression: A Meta-analysis

BACKGROUND AND OBJECTIVES

Evidence is needed on effective approaches to build parents' ability to promote child development feasible in low- and middle-income countries. Our objective was to synthesize impact of the Reach Up early childhood parenting program in several low- and middle-income countries and examine moderation by family and implementation characteristics.

METHODS

Systematic search using PubMed and Academic Search Elite/EBSCO Host. Randomized controlled trials of the Reach Up program from 1985 to February 2022 were selected. Data were extracted by 2 independent researchers. Primary outcomes were child cognitive, language, and motor development. Secondary outcomes were home stimulation and maternal depressive symptoms. We synthesized pooled effect sizes using random effect inverse-variance weighting and effect modification by testing pooled subgroup effect estimates using the χ2 test for heterogeneity.

RESULTS

Average effect size across 18 studies ranged from 0.49 (95% confidence interval [CI] 0.32 to 0.66) for cognition, 0.38 (CI 0.24 to 0.51) for language, 0.27 (CI 0.13 to 0.40) for motor development, 0.37 (CI 0.21 to 0.54) for home stimulation, and -0.09 (CI -0.19 to 0.01) for maternal depressive symptoms. Impacts were larger in studies targeted to undernourished children, with mean enrollment older than age 12 months and intervention duration 6 to 12 months. Quality of evidence assessed with the Cochrane Assessment of Risk of Bias and GRADE system was moderate. Instruments used to assess child development varied. In moderator analyses, some subgroups included few studies.

CONCLUSIONS

Reach Up benefits child development and home stimulation and is adaptable across cultures and delivery methods. Child and implementation characteristics modified the effects, with implications for scaling.

Urban-rural differences in the relationship between stunting, preschool attendance, home learning support, and school readiness: A study in Côte d'Ivoire

Background

Stunted physical growth during early childhood is a marker of chronic undernutrition, and the adverse life circumstances that underlie it. These have the potential to disrupt normal brain development and the acquisition of foundational cognitive, language, social and motor skills. Stunting is prevalent in most low-and middle-income countries. Because the prevention of stunting requires large-scale structural and attitudinal changes, several psycho-educational interventions have been developed to mitigate the adverse association between early stunting and skill development. However, the resource-intensive nature of custom-designed interventions limit their sustainability and scalability in resource-limited settings. This study explored the possibility that available resources that promote positive development (existing preschool education programs, and no- or low-cost home-based learning activities and resources) may protect against any negative association between stunting and the acquisition of foundational skills required for academic learning and adaptation at school.

Method

Data for 36-to 59-month-old children (n = 3,522; M = 46.7 months; 51.2% male; 74.1% rural) were drawn from the most recent Multiple Indicator Cluster Survey conducted in Côte d'Ivoire (MICS5, 2016). Stunting was assessed using the WHO Child Growth Standards. Preschool attendance and home learning activities and resources were assessed by maternal report. School readiness was assessed using the 8-item form of the Early Child Development Index (ECDI).

Results

A high percentage of children met the criteria for stunting (28.5%; 19.7% moderate; 8.8% severe). There were marked urban-rural differences in the prevalence of stunting, rates of preschool attendance, home learning activities and resources, children's school readiness scores, and the relationships between stunting, the protective factors and school readiness scores. These urban-rural differences in ECDI scores could be fully explained by differences between these settings in stunting and the protective factors. However, only two protective factors (access to books and home-based activities that promote learning) made independent contributions to variance in ECDI scores. There was tentative evidence that stunted children whose homes provided highly diverse learning activities and multiple types of learning resources were more likely than those who did not to have a high level of school readiness.

Conclusion

Capitalizing on the existing practices of families that show positive deviance in caregiving may provide a basis for culturally appropriate, low-cost interventions to improve school readiness among children in low- and middle-income countries, including children with stunted growth.

Editorial: Prevention is the best cure

In this issue of Journal of Child Psychology and Psychiatry, many interesting research findings converge to suggest that prevention and early intervention strategies can be the key to building healthier societies with happier people. Across different societies, we observe that scientific attention and practice is becoming more evenly divided between the traditionally dominant focus on clinical disorders and residential treatments on the one hand and a burgeoning focus on prevention and resilience in ambulant settings and younger populations on the other hand.

The Use of Peabody Tool in the Assessment of Passive Vocabulary in Preschoolers

<p style="text-align: justify;">The purpose of this study was to evaluate the experience of using the Peabody Picture Vocabulary tool to assess receptive vocabulary in preschoolers. The study involved 619 Russian-speaking children aged 3&ndash;7 years (M=67.80, SD=13.73), 48.3% of whom were boys. The Peabody Picture Vocabulary test-IV (form A) was used in the study. The article analyzed differences between children of different age groups from 3.5 to 7.5 years with a step of six months. It was found that there were significant differences in the ceiling items, the total number of errors, and the raw scores in children of different age groups. No gender differences were found. An analysis of the children's performance of series and individual tasks showed that the complexity of the tasks was unevenly distributed. As a result, the methodology in its current form does not work quite as it was intended by its creators: Moscow preschoolers go through a lot of series and spend a lot of time on the implementation of the methodology, which is due to differences in the lexical systems between Russian and English. In this regard, the tool is not optimal for use in its current form; the authors of the article propose to design a local tool for the assessment of the receptive vocabulary in Russian preschoolers.</p>