Prevalence of mental health problems that children in low and middle income countries face

Mental illness accounts for approximately 14% of the global burden of disease¹⁸. Depression and anxiety are some of the leading causes of disability worldwide¹⁸. Mental health problems affect 10-20% of children and adolescents worldwide and a majority of them come from LMICs⁶. These conditions often develop in children during their childhood and adolescence years and if left untreated can cause negative effects to their social functioning skills¹⁸. Other long term outcomes include adult criminal violence, drug misuse, school failure, teenage pregnancy and unemployment³. Mental illness in low and middle-income countries (LMICs) is a global concern as over 80% of those with mental disorders reside in these countries and their youth population are the ones most vulnerable⁸. Many LMICs are affected by armed conflict, violence and natural disasters, which significantly affects the mental development and well-being of the population’s children¹¹. Additionally, children in LMICs have a greater risk of developing depression, anxiety and post-traumatic stress disorder (PTSD)¹¹ due to living in harsh environments. Availability and access to mental health services for children have been found to be limited and inadequate¹⁴.

Why are early childhood interventions important in the promotion of children’s mental well-being? 

Interventions to improve child development, prevent mental health problems and promote well-being should be a global health priority. This is because, experiences in early childhood have a long-term effects on the child’s brain function, cognition and psychosocial functioning¹. Exposure to adverse environments during a child’s first few years of life have been shown to predict lower IQ levels and academic achievement, increase anti-social behaviour, lower economic productivity and poor health and chronic disease in adulthood⁵. Therefore, the foundations for a stable adult physical and mental health must be laid during the early childhood years. Quality of parenting and child IQ have been found to be effective protective factors for children growing up under disadvantaged circumstances⁷. Quality of parenting is determined by the skills, knowledge and mental health of the caregiver¹⁷. Studies have found that maternal depression negatively affects parenting quality and child development¹⁵. On the other hand, the quality of early childhood classroom environment is seen as both a risk and protective factor for child behaviour management and adjustment. There is evidence showing the benefits of early childhood interventions such as promoting children’s cognitive development and sustaining it over a period of time². Interventions aimed at improving children’s nutrition and educational outcomes in LMICs, have also been found to strongly benefit their cognitive development and improved their educational outcomes¹⁰. Literacy programmes have also been found to have had an unanticipated benefit on children’s mental health by reducing feelings of hopelessness⁸.

How are children’s mental health problems treated in low and middle-income countries?

• Choose the interventions that have displayed clear benefits¹²
• Parent training and centre-based programmes
• Interventions should also be culturally appropriate and economically feasible⁴
• From 10 weeks to 3 years or more
• Target group (e.g. prenatal, new-born, infants over 6 months and children between 3-6 years)
• Risk status of mothers (e.g. HIV infected) 
• Interventions that incorporate hand-on-practice, role-play, supportive feedback, practice activities have been shown to be effective in changing the caregivers’ behaviour¹
• Health status of the child (e.g. stunted, anaemic or undernourished)
• Delivered by paraprofessionals
• A manual with a structured curriculum, training guide and monitoring instruments are important for maintaining quality of intervention¹
• Paraprofessionals are able to deliver interventions at a high level of quality provided that they receive adequate training and supervision¹
• Benefits to child mental health were observed:
• Reduced anxiety, depression, anti-social behaviour in adulthood¹⁶
• Another study looked into the effects of attending a high quality preschool programme as compared to a low quality preschool programme. The intervention involved educational activities, nutrition and physical exercise activities. As a result the researchers found:
• A reduction in schizotypal personality, (b) cognitive disorganisation, (c) conduct disorder, (d) psychotic behaviour, (e) motor excess at 17 years and (f) reduced criminal offending at 23 years¹³.

Conclusions 

• Mental illness accounts for approximately 14% of the global burden of disease
• Mental health problems affect 10-20% of children and adolescents worldwide and a majority of them come from LMICs
• Many LMICs are affected by armed conflict, violence and natural disasters, which significantly affects the mental development and well-being of the population’s children
• Interventions to improve child development, prevent mental health problems and promote well-being should be a global health priority
• This is because, experiences in early childhood have a long-term effects on the child’s brain function, cognition and psychosocial functioning
• Therefore, the foundations for a stable adult physical and mental health must be laid during the early childhood years. Quality of parenting and child IQ have been found to be effective protective factors for children growing up under disadvantaged circumstances
• Some of the ways that early childhood interventions are being implemented in LMICs to combat mental health problems include:
• Implementing interventions that ‘works’ or display clear benefits
• Can be either parent training programmes and centre-based programmes
• Interventions are delivered by paraprofessionals that are trained and supervised 

References used:

1. Baker-Henningham, H. (2013). The role of early childhood education programmes in the promotion of child and adolescent mental health in low- and middle-income countries. International Journal Of Epidemiology, 43(2), 407-433. doi: 10.1093/ije/dyt226
2. Engle, P., Fernald, L., Alderman, H., Behrman, J., O’Gara, C., & Yousafzai, A. et al. (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 378(9799), 1339-1353. doi: 10.1016/s0140-6736(11)60889-1
3. Fergusson, D., John Horwood, L., & Ridder, E. (2005). Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal Of Child Psychology And Psychiatry, 46(8), 837-849. doi: 10.1111/j.1469-7610.2004.00387.x
4. Grantham-McGregor, S., Powell, C., Walker, S., & Himes, J. (1991). Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study. The Lancet, 338(8758), 1-5. doi: 10.1016/0140-6736(91)90001-6
5. Heckman, J., & Masterov, D. (2007). The Productivity Argument for Investing in Young Children. Review Of Agricultural Economics, 29(3), 446-493. doi: 10.1111/j.1467-9353.2007.00359.x
6. Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., & Omigbodun, O. et al. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801), 1515-1525. doi: 10.1016/s0140-6736(11)60827-1
7. Masten, A. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56(3), 227-238. doi: 10.1037/0003-066x.56.3.227
8. Patel, V., & Kleinman, A. (2003). Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, 609-615.
9. Patel, V., Flisher, A., Nikapota, A., & Malhotra, S. (2008). Promoting child and adolescent mental health in low and middle income countries. Journal Of Child Psychology And Psychiatry, 49(3), 313-334. doi: 10.1111/j.1469-7610.2007.01824.x
10. Pelto, G., Dickin, K., & Engle, P. (1999). A Critical Link- Interventions for Physical Growth and Psychological Development. Nutritional Anthropology, 22(2), 21-27. doi: 10.1525/nua.1999.22.2.21
11. Punamäki, R. (2002). The uninvited guest of war enters childhood: Developmental and personality aspects of war and military violence. Traumatology, 8(3), 181-204. doi: 10.1177/153476560200800305
12. Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet, 372(9642), 902-909. doi: 10.1016/s0140-6736(08)61400-2
13. Raine, A., Mellingen, K., Liu, J., Venables, P., & Mednick, S. (2003). Effects of Environmental Enrichment at Ages 3–5 Years on Schizotypal Personality and Antisocial Behavior at Ages 17 and 23 Years. American Journal Of Psychiatry, 160(9), 1627-1635. doi: 10.1176/appi.ajp.160.9.1627
14. Saxena, S., Lora, A., Morris, J., Berrino, A., Esparza, P., & Barrett, T. et al. (2011). Focus on Global Mental Health: Mental Health Services in 42 Low- and Middle-Income Countries: A WHO-AIMS Cross-National Analysis. Psychiatric Services, 62(2), 123-125. doi: 10.1176/ps.62.2.pss6202_0123
15. Wachs, T., Black, M., & Engle, P. (2009). Maternal Depression: A Global Threat to Children’s Health, Development, and Behavior and to Human Rights. Child Development Perspectives, 3(1), 51-59. doi: 10.1111/j.1750-8606.2008.00077.x
16. Walker, S., Chang, S., Vera-Hernandez, M., & Grantham-McGregor, S. (2011). Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior. PEDIATRICS, 127(5), 849-857. doi: 10.1542/peds.2010-2231
17. Walker, S., Wachs, T., Grantham-McGregor, S., Black, M., Nelson, C., & Huffman, S. et al. (2011). Inequality in early childhood: risk and protective factors for early child development. The Lancet, 378(9799), 1325-1338. doi: 10.1016/s0140-6736(11)60555-2
18. Yatham, S., Sivathasan, S., Yoon, R., da Silva, T., & Ravindran, A. (2018). Depression, anxiety, and post-traumatic stress disorder among youth in low and middle income countries: A review of prevalence and treatment interventions. Asian Journal Of Psychiatry, 38, 78-91. doi: 10.1016/j.ajp.2017.10.029

PPP-4020, Global Early Childhood, Blog 2

The Situation in Rural Bangladesh

In rural Bangladesh around 48% of children aged less than five years are moderately to severely malnourished¹. Malnutrition has been found to be a strong predictor of low cognitive and language development in Bangladesh^6,8. Children that were found to have received stimulation together with food supplements exhibited better mental development in the long term³. Yet with all this information, parents are often uninformed about the needs of child stimulation to enhance their mental development⁴. This is where parent training programme comes in and fills in the gaps by providing parents with new information and new parenting practices. A survey found that half of the mothers in rural Bangladesh had no education and most were unaware of the importance of fostering curiosity and self-confidence in children⁵. Based on the survey, mothers also reported “giving their child nutritious foods” and “teaching their child to talk” as ways of promoting mental development. However, providing opportunities for play and conversation were rarely mentioned. Through home-observations and maternal recall, children were found to have spent many hours by themselves. Despite the evidence of children being malnourished and not receiving adequate stimulation, parents still want their child to excel at school. 

Early Childhood Education Programmes

The need for high quality early childhood education (ECE) has never been greater. Some of the short- and long-term benefits for children that participate in high-quality ECE include: (a) better quality of life and healthy behaviours, (b) lower crime rate, (c) higher education attainment and (d) increased knowledge for mothers that participate in parent training programmes². A substantial body of evidence has demonstrated the critical importance of the first three years of a child life and how development during this period may make or break the child’s future¹⁴. Brain development is heavily influenced by the experiences and interactions that the child has during this period, thus stabling the foundation for future learning⁷.

To foster (a) conditions that optimise child growth and development and (b) mother-child interaction for the purposes of stimulation and nutrition¹. Parents need to be involved when targeting child development because their sensitive responsiveness is crucial to secure attachment and its multiple consequences¹⁰. With regards to children that are at risk for poor language and cognitive development, opportunities for stimulation and learning must be created at home if they do not attend pre-school¹. 

Services are aiming at taking a preventative stance by seeking not only to reduce the impact of risk factors on child development, but also to increase that of protective factors, by reinforcing the parenting role¹². Weekly sessions are often conducted and headed by trained staff members called facilitators. These sessions are often attended by mothers. The topics that commonly discussed and taught to mothers include common diseases, hygiene, sanitation, breastfeeding and micronutrient deficiencies. Parents are also taught ways on how they can help with their child’s learning. On top of that, parents are also shown ways on how they can (a) encourage their child’s language development. Topics regarding positive discipline, gender equality and children rights are also discussed in parent training programmes. Although parenting practices are the main focus in parent training programmes, the main underlying focus is still to improve the health, growth and development of children. 

Some of the characteristics of high quality programmes include provisions of a clear and structured curriculum, which includes demonstrations, rehearsals and repeated practice with feedback and ongoing supervision. Studies have found that training programmes have a higher chance of changing behaviours if they incorporate principles such as providing (a) information, (b) opportunities to observe role models, (c) practice the skills taught to them, (d) participatory problem solving and (e) a minimum of 14 hours contact¹³. These behaviour change strategies are also commonly used in parent training programmes (i.e. provision of information, advice, demonstration and community support)¹¹. This study also found that, parents that participated in the parent training programme experienced enhanced social motivation to participate in activities. 

How can the Quality of ECEs be Improved?

Some of the components that are necessary to increase the quality of ECE programmes include:

(a) Having a trained and stable workforce – Workforce plays a vital role when it comes to delivering quality ECE programmes. With regards to LMICs, the workforce will probably be made up paraprofessionals therefore, adequate training must be provided to ensure programmes can be conducted smoothly. 

(b) Effective leadership – Quality ECE programmes should also be supervised under a leader. Relating back to LMICs, this would be in the form of supervisors. Supervisor will be expected to train and manage their paraprofessionals. This is by giving them adequate training and also providing an avenue to discuss problems that may arise while the programmes are being conducted. 

(c) Age-appropriate curriculum – Programmes should also try to have age-appropriate curriculums. However, paraprofessionals or professionals conducting these programmes must also try to notice and see if any child is left behind in the curriculum or advancing at a greater pace than their peers. However, this may not be the case in some situations as some programmes are made to cater to a more general audience due to financial and staff constraints. 

(d) Comprehensive and engaging activities for both parent and child that are attending the programme  – In an ideal world where funding and manpower might not be an issue, programmes should be very comprehensive and very engaging for both the parent and the child. Though, this is not the case when programmes are implemented in LMICs. However, to a certain degree, parents and children do find the activities engaging. This is displayed through the benefits that both parent and child experience after attending the programme.  

(e) Adopting a continuous quality improvement system – Programmes must monitor, reflect and revise practices and policies to ensure that quality is maintained. Besides measuring children’s developmental and wellbeing outcomes, programmes can also assess how each staff member is performing and use the data collected to make necessary improvements. 

Conclusions

(a) Around 48% of children living in rural Bangladesh are found to be moderately to severely malnourished and parents are often uninformed about the mental development needs of their child

(c) The need for quality ECE programmes have never been greater as several studies have reported both parent and child reaping short- and long-term benefits

(d) One of the goals of ECEs is to reduce the impact of risk factors on child development and to increase the protective factors, this is done through the involvement of both the parent and the child

 (f) Methods of improving ECE programme quality include having (a) a trained and stable workforce, (b) effective leadership roles, (c) curriculum catering to all age groups, (d) comprehensive and engaging activities for both parent and child and (e) a continuous quality improvement system

Reference used:

1. Aboud, F. (2006). Evaluation of an early childhood preschool program in rural Bangladesh. Early Childhood Research Quarterly, 21(1), 46-60. doi: 10.1016/j.ecresq.2006.01.008
2. Garcıa, J. L., Heckman, J. J., Leaf, D. E., & Prados, M. J. (2017). The life-cycle benefits of an influential early childhood program. University of Chicago, Department of Economics.
3. Grantham-McGregor, S., Walker, S., Chang, S., & Powell, C. (1997). Effects of early childhood supplementation with and without stimulation on later development in stunted Jamaican children. The American Journal Of Clinical Nutrition, 66(2), 247-253. doi: 10.1093/ajcn/66.2.247
4. Guldan, G., Zeitlin, M., Beiser, A., Super, C., Gershoff, S., & Datta, S. (1993). Maternal education and child feeding practices in rural Bangladesh. Social Science & Medicine, 36(7), 925-935. doi: 10.1016/0277-9536(93)90084-h
5. Haider, S. J., Ali, M., Chowdhury, S., Kabir, M., Akhter, R., Islam, N., & Paul, D. (2001). Baseline survey of caregivers kap on early childhood development in Bangladesh. Dhaka, Bangladesh: Research Evaluation Associates for Development (READ) for UNICEF Bangladesh.
6. Hamadani, J., Huda, S., Khatun, F., & Grantham-McGregor, S. (2006). Psychosocial Stimulation Improves the Development of Undernourished Children in Rural Bangladesh. The Journal Of Nutrition, 136(10), 2645-2652. doi: 10.1093/jn/136.10.2645
7. Harvard University Center on the Developing Child, “InBrief: The Science of Early Childhood Development” (2007). Retrieved 1 March 2020, from https://developingchild.harvard.edu/resources/inbrief-science-of-ecd/
8. Huda, S., Grantham-McGregor, S., Rahman, K., & Tomkins, A. (1999). Biochemical Hypothyroidism Secondary to Iodine Deficiency Is Associated with Poor School  
9. Achievement and Cognition in Bangladeshi Children. The Journal Of Nutrition, 129(5), 980-987. doi: 10.1093/jn/129.5.980
10. NICHD Early Child Care Research Network. (1997). The Effects of Infant Child Care on Infant‐Mother Attachment Security: Results of the NICHD Study of Early Child Care NICHD Early Child Care Research Network. Child development, 68(5), 860-879.
11. Penny, M., Creed-Kanashiro, H., Robert, R., Narro, M., Caulfield, L., & Black, R. (2005). Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomised controlled trial. The Lancet, 365(9474), 1863-1872. doi: 10.1016/s0140-6736(05)66426-4
12. Rodrigo, M., Almeida, A., Spiel, C., & Koops, W. (2012). Introduction: Evidence-based parent education programmes to promote positive parenting. European Journal Of Developmental Psychology, 9(1), 2-10. doi: 10.1080/17405629.2011.631282
13. Sweet, M., & Appelbaum, M. (2004). Is Home Visiting an Effective Strategy? A Meta-Analytic Review of Home Visiting Programs for Families With Young Children. Child Development, 75(5), 1435-1456. doi: 10.1111/j.1467-8624.2004.00750.x
14. Yoshikawa, H., Weiland, C., Brooks-Gunn, J., Burchinal, M. R., Espinosa, L. M., Gormley, W. T., … & Zaslow, M. J. (2013). Investing in our future: The evidence base on preschool education.

Children living in conflict zones

Throughout the world, there are children living in war zones that are experiencing psychological consequences due to exposure of violence. Children that are exposed to the adverse effects of wars have a higher chance of developing mental health problems⁽²²⁾. Palestinian children in the occupied Palestinian territories (oPt) have been exposed to high levels of violence, including military raids, imprisonment, home demolitions, personal injury and suffered the death of loved ones⁽²³⁾.

Statistics from studies report that 48% of children had personally experienced or witnessed political violence while 93% reported not feeling unsafe and vulnerable to attacks, 52% of children also reported that they felt their parents could not protect them from all the violence that was occurring⁽²⁴⁾. Children living in high conflict zones have also been found to exhibit higher levels of aggression, violence and revenge seeking behaviours⁽²⁵⁾. These behaviours are likely due to (a) having inadequate social support systems, (b) perception of self-unworthiness, (c) the belief that surrounding adults are non-trustful and (d) the presence of various threatening and unsafe social institutions⁽²⁵⁾.

Wars have also often lead to famine which in turn affects the nutrition that these children receive. A study conducted in war-torn Bosnia found that children’s diets were insufficient in quality and quantity⁽²⁶⁾. Preschool children are often the ones at the most risk of suffering nutritional deficit in time of conflict⁽²⁷⁾. 

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In this blog post we will be taking a look at how early childhood interventions can impact the lives of children living in – areas of high conflict – low and middle income countries (LMIC). We will then be taking a look at how these early childhood programmes/interventions can help meet certain Sustainable Developmental Goals (SDGs).

Why are Early Childhood Interventions important?

First off, you must be wondering why is the need for early childhood interventions so crucial or maybe perhaps why global child development is such an important issue. Findings suggests that 219 million (39%) children younger than 5 years in LMICs are at the risk of not reaching their developmental potential⁽¹⁾. Children that are exposed to poverty and adverse events are more likely to have long-term physiological effects on brain development and cognition^(2,3). Evidence has shown that adverse exposures pose the greatest harm from the period of conception up to 3 years⁽⁴⁾. 

Can something be done to elevate these circumstances?

However, these adverse effects can be mitigated by early interventions. Some of the benefits of early childhood interventions include: increase in adult wage earnings⁽⁵⁾, reductions in violence, depressive symptoms and social inhibition⁽⁶⁾ and increased long-term educational consequences⁽⁷⁾.

Children are able to reach their developmental potential through acquiring developmental competencies for academic, behavioural, socio-emotional and economic accomplishments. Moreover, multiple factors can influence the acquisition of these developmental competencies. Such factors include: mental and physical health, security and safety, early learning and being in a responsive caregiving environment. All of these factors play an integral role in nurturing care as they interact among each other. 

Nurturing care is described as a home environment that is (a) sensitive to a child’s health and nutritional needs, (b) responsive, (c) emotionally supportive and developmentally stimulating and appropriate, with opportunities for play and exploration with protection from adversities⁽⁸⁾. Studies have also found positive effects of nurturing care on children’s health, growth and development⁽⁹⁾. Nurturing care has also been found to reduce the damaging effects of low socioeconomic status on children’s brain development⁽¹⁰⁾. Nurturing care also extends beyond care provided by families and includes community caregivers and support for families.

Examples of Early Childhood Interventions being implemented

With all the details out of the way, you might be wondering how are all these early childhood programmes implemented. Well some of the activities implemented in early childhood programmes include (a) home activities and (b) centre-based child care and preschool. With regards to home activities, low-cost activities such as storytelling and singing, and playing with everyday household objects while exposing young children to new experiences are used to promote and stimulate early learning and development⁽¹¹⁾.

Televisions and other medias have also been used to increase access of early childhood programmes. An example of television being used specifically targeting children is Sesame Street. A meta-analysis that looked at more than 10,000 children from 15 countries found an increase in children’s (a) literacy and numeracy skills, (b) health and safety, (c) social reasoning skills and (d) positive attitude towards others⁽¹²⁾. 

With regards to centre-based child care and preschool programmes, a study found that children under 5 years in LMIC benefitted from child care programmes⁽¹³⁾. However, not all child care programmes are equal as some have been seen to potentially cause more harm than good if it is of poor quality⁽¹⁴⁾. Quality child care programmes can be described as having good (a) infrastructure, (b) caregiver training, (c) caregiver-child ratios , (d) caregiver-child interactions and (e) lots of opportunities for play and exploration⁽¹⁾. On the other hand, attending preschool has been shown to positively predict children’s future performance in primary school⁽¹⁵⁾. There is an observed increase in positive effects of preschool attendance when education and nutrition programmes are implanted side-by-side⁽¹⁶⁾.

Interventions implemented from as early as conception

Interventions can also be implemented from as early as conception⁽¹⁷⁾. These interventions place a great focus on the health of the mother. Interventions during this period include:

• Iodine supplementation (before or during pregnancy)⁽¹⁸⁾
• Magnesium sulphate supplementation for women at risk of preterm birth⁽¹⁹⁾ 
• Providing a balanced energy and protein diet with the inclusion of micronutrients⁽²⁰⁾
• Reducing maternal depression⁽²¹⁾

What are Sustainable Development Goals (SDGs)?

Now that we have discussed some of the effects of early childhood interventions, we can focus on how these interventions can contribute to achieving the SDGs. You might be wondering by now, what are SDGs? They are a set of goals that provides a blueprint for peace and prosperity for people and the planet, now and into the future. In general, SDGs are basically “call for actions” for countries be it developed or developing. Several of these goals focus on the development of children’s physical and mental – health and well-being. There are in total 17 goals that make up the SDGs (click here to have a look at the entire SDGs list). The impact of early childhood interventions can help achieve some of these goals. However, for this blog only a few of these goals will be mentioned and discussed as not all are related to early childhood interventions. Some of the SDGs that are relevant to the effects of early childhood interventions are SDG 1, 2, 3, 4, 5, 10 and 16.

Early Childhood Interventions can contribute towards achieving SDGs by:

• Ensuring healthy lives by promoting well-being for all at all ages (Target 3)
• Human development from early childhood (Target 4.2)
• Early childhood development through primary and secondary schooling (Target 4.1)
• Providing technical and vocational education and university (Target 4.3)
• Enhancing acquisition of skills and knowledge to promote sustainable development (Target 4.7)
• Preparing the youth for employment and entrepreneurship (Target 4.4)
• Ending all forms of discrimination against all women and girls everywhere (Target 5.1)
• Ending abuse, exploitation, trafficking and all forms of violence against and torture of children (Target 16.2)

References used:

1. Black, M., Walker, S., Fernald, L., Andersen, C., DiGirolamo, A., & Lu, C. et al. (2016). Early childhood development coming of age: science through the life course. The Lancet, 389(10064), 77-90. doi: 10.1016/s0140-6736(16)31389-7
2. Shonkoff, J., Garner, A., Siegel, B., Dobbins, M., Earls, M., & Garner, A. et al. (2011). The Lifelong Effects of Early Childhood Adversity and Toxic Stress. PEDIATRICS, 129(1), e232-e246. doi: 10.1542/peds.2011-2663
3. Walker, S., Wachs, T., Grantham-McGregor, S., Black, M., Nelson, C., & Huffman, S. et al. (2011). Inequality in early childhood: risk and protective factors for early child development. The Lancet, 378(9799), 1325-1338. doi: 10.1016/s01406736(11)60555-2
4. Richter, L., Daelmans, B., Lombardi, J., Heymann, J., Boo, F., & Behrman, J. et al. (2017). Investing in the foundation of sustainable development: pathways to scale up for early childhood development. The Lancet, 389(10064), 103-118. doi: 10.1016/s0140-6736(16)31698-1
5. Hoddinott, J., Maluccio, J., Behrman, J., Flores, R., & Martorell, R. (2008). Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. The Lancet, 371(9610), 411-416. doi: 10.1016/s0140-6736(08)60205-6
6. Walker, S., Chang, S., Vera-Hernandez, M., & Grantham-McGregor, S. (2011). Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior. PEDIATRICS, 127(5), 849-857. doi: 10.1542/peds.2010-2231
7. Maluccio, J., Hoddinott, J., Behrman, J., Martorell, R., Quisumbing, A., & Stein, A. (2006). The Impact of Nutrition during Early Childhood on Education among Guatemalan Adults. SSRN Electronic Journal. doi: 10.2139/ssrn.946107
8. Black, M., & Aboud, F. (2011). Responsive Feeding Is Embedded in a Theoretical Framework of Responsive Parenting. The Journal Of Nutrition, 141(3), 490-494. doi: 10.3945/jn.110.129973
9. Bradley, R., & Putnick, D. (2012). Housing Quality and Access to Material and Learning Resources Within the Home Environment in Developing Countries. Child Development, 83(1), 76-91. doi: 10.1111/j.1467-8624.2011.01674.x
10. Noble, K., Houston, S., Brito, N., Bartsch, H., Kan, E., & Kuperman, J. et al. (2015). Family income, parental education and brain structure in children and adolescents. Nature Neuroscience, 18(5), 773-778. doi: 10.1038/nn.3983
11. Barros, A., Matijasevich, A., Santos, I., & Halpern, R. (2009). Child development in a birth cohort: effect of child stimulation is stronger in less educated mothers. International Journal Of Epidemiology, 39(1), 285-294. doi: 10.1093/ije/dyp272
12. Mares, M., & Pan, Z. (2013). Effects of Sesame Street: A meta-analysis of children’s learning in 15 countries. Journal Of Applied Developmental Psychology, 34(3), 140-151. doi: 10.1016/j.appdev.2013.01.001
13. Leroy, J., Gadsden, P., & Guijarro, M. (2012). The impact of daycare programmes on child health, nutrition and development in developing countries: a systematic review. Journal Of Development Effectiveness, 4(3), 472-496. doi: 10.1080/19439342.2011.639457
14. Grantham-McGregor, S., Fernald, L., Kagawa, R., & Walker, S. (2013). Effects of integrated child development and nutrition interventions on child development and nutritional status. Annals Of The New York Academy Of Sciences, 1308(1), 11-32. doi: 10.1111/nyas.12284
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