Integrating Early Childhood Development (ECD) Activities .

Interventions with stunted children: RCTDQ110Non-stunteddownward spiral that creates or exacerbates malnutritionand poor health.19 The longer term consequences forthe child may include behaviour problems, cognitivedelay and poor academic performance, and childhooddepression.20Both ine6 mo12 mo18 mo24 moGrantham-McGregor et al, 1991Figure 3: The stronger effect of stimulation alone overnutrition alone on development. 14HOW WILL COMBINING FOOD AND EARLYCHILDHOOD DEVELOPMENT ACTIVITIES HELPCHILD GROWTH AND DEVELOPMENT?There is an increasing amount of evidence from lowresource settings that programmes to improve infantstimulation and enhance parenting have a beneficial effecton children’s long term mental health.12 They have additiveeffects when combined with nutrition programmes. Theyimprove children’s growth and developmental outcomesin the long term. For example in a study of the impact ofproviding food supplements and stimulation to stunted andnon stunted 9-24 month old children in Jamaica, the stuntedchildren who received both interventions weekly over a twoyear period had higher developmental scores than thosewho received neither intervention, or only the nutritionintervention. Significantly the group of children whoreceived stimulation on its own or stimulation combinedwith food, showed enduring cognitive benefits, whichwere still evident at age seventeen. These benefits had notendured in the children who received nutrition alone.13There is also evidence that, in socially adverseenvironments, depressed mothers (both those with clinicaldepression and depressive symptoms) are more likely tohave undernourished children with poor health. 15 16 17 18One possible mechanism is that mothers with depressivesymptoms are less engaged and involved with theirchildren, play with them less and are less responsive totheir needs. The neglected baby becomes more apatheticand irritable and less able to engage their mother. In thelonger-term, undernourished children may contributeto maternal depression because mothers experienceincreased feelings of guilt and incompetence. There is aThe most vulnerable parents and children are found inthe harshest environments, particularly after naturaldisasters, in conflict and post conflict areas, droughtaffected regions, and in refugee and IDP camps. Inthese emergencies the established networks of carethat normally protect the health, safety and security ofthe child are disrupted, and food is scarce. Displaced,exhausted parents are less able to provide the stimulation,nurturance and care that their infants need. Mothers areparticularly vulnerable to depression in these areas. 21 Itis likely that the combined interactive effects that occurin such settings contribute to poor outcomes in children.These connections are illustrated in figure 4.There are multiple entry points to break the cycleillustrated above. (See figure 5). The obvious ones areproviding health and nutritional support for motherand child. These are the usual priorities in emergencies.Comprehensive sexual and reproductive healthprogrammes also provide support for the mother.Programmes that directly address maternal psychosocialneeds, including addressing previous traumatic events,and her security in the camp, her access to social support,will help her to be more responsive to her child. Whatis less well known is that infant stimulation programsdesigned to improve parental responsiveness, throughhome visits and group interventions, also directly improvematernal mood and wellbeing.22A review of 23 studies showed that programmes thatused mother to mother group support and home visits toimprove mother-child interaction also improved maternalmood, enhanced maternal wellbeing, and improved thechild’s nutritional status and growth outcomes, as themother became more responsive to the child’s needs.A randomized control study of a five month long grouppsychosocial intervention conducted with war-affectedmothers and slightly older children (average age 5 years)in post-conflict Bosnia showed both improved maternalmental health and child weight gain. The interventioncombined psycho-education and support to enhance thenatural coping of mothers and children who had sufferedtraumatic events, with a training to “promote sensitiveemotional expressive communication; promote enriching,stimulating interaction; and reactivate indigenouschildrearing practices.”234 Guidance note for integrating ECD activities into nutrition programmes in emergencies

The Vicious CirclesHow to improve the situationHungry babyApathetic/irritablebabySick babyMother neglects babyNo crying or crawlingfor foodHungry babyApathetic/irritablebabyNo crying or crawlingfor foodMother neglects babyImprovemother childinteractionOther smaller babydemanding attentionSick babyMother sick/tired/worried/depressed Poorly nourished babies may be:»» timid or irritable and easily upset»» harder to feed»» less active»» less likely to play and communicate»» less able to get the attention of theirmothers Mothers less likely to feed, play orcommunicate with them Mothers who are very worried andstressed by the problems of life may»» not pay attention to babies or be toointrusive»» not communicate with them»» not play with them Children become more apathetic orirritable in response and less likely todemand food when they need itAdd foodand medicalcareMother sick/tired/worried/depressedSupportmotherOther smaller babydemanding attentionFigure 4: How mother and infant problems in stressfulenvironments may interactFigure 5: Intervention pointsCombined interventions are likely to have the biggestimpact. Moreover programmes designed to enhance earlychildhood development may have multiple beneficialeffects: on child development, mother child interaction andmaternal mood. For these reasons WHO now advocatescombined psychosocial and nutritional programming infood shortage situations in order to address the physical,social, emotional, and intellectual developmental needsof the child and to enhance maternal well-being. 24 TheIASC Guidelines on Mental Health and PsychosocialSupport in Emergencies also recommend the integrationof psychosocial interventions such as ECD into nutritionalsupport,25 as do the INEE guidelines for Early ChildDevelopment in Emergencies.26 During food shortageemergencies, integrating simple early stimulation,learning and play activities with nutritional support iscrucially important to increase and sustain the impact on ayoung child’s health and nutritional status.WHAT MAKES FOR THE MOST EFFECTIVE EARLYCHILDHOOD DEVELOPMENT PROGRAMMES?In fact emergency nutrition programmes provide anideal opportunity to feed the body and to feed the mind.They are already widely recognised as an entry pointfor integrated, holistic care. When a mother or anothercaregiver brings the child for nutritional supplements theyusually receive education in multiple related domains:such as breastfeeding, good nutrition, weaning, hygienepromotion, looking after a sick child, HIV prevention,family planning and the importance of proper spacingbetween children. This is also the best time to teach theimportance of early childhood stimulation, responsiveparenting and to improve maternal knowledge of earlychild development. There is no stigma attached to servicesdelivered in this way and it is possible to reach a large,diverse group of vulnerable mothers and infants.There are some KEY LESSONS from the research. 27 28Early childhood development programmes should be integrated with existing family support, health,nutrition, or educational systems be targeted toward younger and disadvantagedchildren be high quality (whether formal or informal) include direct contact with children beginning in earlyin life provide direct learning experiences to children andfamilies, with opportunities for children to initiate theirown learning and exploration of their surroundingswith age-appropriate activities blend traditional child-rearing practices and culturalbeliefs with evidence-based approaches provide parents and child care workers with educationand support; including systematic curricula andtraining opportunities that use active strategiesto show and promote caregiving behaviours—e.g.practice, role play, or coaching to improve parent–childinteractionsHOW COULD EARLY CHILDHOOD DEVELOPMENTACTIVITIES BE INTEGRATED INTO EMERGENCYFEEDING PROGRAMMES?Emergency feeding programmes in famine affectedcountries take a variety of forms. Methods of deliverydiffer according to the political and geographical context,but contain many of the same core components. Theseinclude Supplementary Feeding Programmes (SFP) forundernourished children where families usually attendfortnightly to collect rations to supplement the child’s diet;Guidance note for integrating ECD activities into nutrition programmes in emergencies 5

Outreach Therapeutic Programmes (OTP) that supportboth acutely and moderately malnourished children on anoutpatient basis; and stabilization centres or therapeuticfeeding programmes where more severely malnourishedchildren, or children who are both malnourished and sick,are admitted with their caregivers to receive intensivecare. Children’s needs should be addressed throughthe provision of child friendly spaces and early childdevelopment centres which often incorporate nutritionalprogrammes.Below are some practical suggestions on how to integrateearly childhood development activities into these variouskinds of nutrition programmes. The training manuals,materials and human resources required are listed in theappendix.and caregivers to deliver health messages to promotegood hygiene, proper nutrition etc. Simple messages oninfant stimulation and early child development can bedelivered in the same way using large pictorial cards andinteractive methods. Some simple dos and don’ts are: 1. Integrate the key facts of the impact of early childhooddevelopment activities and simple messages on how to dothem into ALL nutritional materials: Currently stimulationand enhancing emotional responsiveness are not seenas an essential part of feeding activities and are rarelymentioned.29 Psychosocial activity is seen as a separatedomain associated with protection. This perception caneasily be changed by briefly flagging the topic and addingkey messages in all reports and training materials onnutrition. National and international Infant and Young ChildFeeding (IYCF) guidelines should always contain a sectionon this topic. This is already well done with other topicssuch as hygiene and childhood illnesses.2. One to one counseling** while weighing/assessing childand handing out supplements: All nutrition and associatedvolunteer staff who have direct contact with mothers canbe trained to provide simple health messages to give tothe mother while discussing other familiar topics. Forexample messages on the importance of breast feedingcan be combined with messages on how it provides theopportunity to show warmth and love and co

how to take turns and cooperate, learn rules, negotiate and resolve conflicts. In play parents and caregivers can model the best approaches to all the above and allow the child to experiment and explore safely on their own. Play also provides a space to try out multiple identities. Through fantasy and role playing children can master