CONCEPT OF STIMULATION & RECENT FINDINGS FROM A LONGITUDINAL STUDY

1. CONCEPT OF STIMULATION &RECENT FINDINGS FROM A LONGITUDINAL STUDY Dr. Shahnaz Vazir National Conference on “Early Learning: Status and The Way Forward” September 25th to 27th, 2013 IHC New Delhi

2. CONCEPT OF STIMULATION • ‘Responsive and increasingly complex developmentally appropriate interactions between caregivers and children that promote their emerging abilities, improve learning and enhance children’s development’ -Young, 2002, Landry et al, 2006). • Help infants and young children lagging behind in cognitive, language, socio-emotional development to catch up. • Advances in brain development indicate that provision of meaningful sustained challenging stimuli from birth can increase neural interconnectivity • Stimulated children can improve their abilities by strategies that offer age appropriate new learning opportunities

3. Why focus on infancy/early childhood? • Brain development rapid and vulnerable from conception to 3 years • Insults and interventions can have lasting effects • Interventions are more cost effective than at other ages • Cognitive ability & behavior on school entry predict academic success

5. Brain requires stimulation for synaptic growth

6. 2007 Lancet Series on Child Development • >200 million <5 y children in LAMI countries do not reach their developmental potential. • Most live in South Asia and Sub-Saharan Africa. • Prevalence data on early stunting & number of people living in absolute poverty can used as indicators of poor development as few national statistics on child development • Poor school performance/ drop out, subsequent low incomes, high fertility, poor care for their children contribute to the intergenerational transmission of poverty & illiteracy.

7. 2011 Lancet Series on Child Development • Inequality & early childhood risk factors for CD: • Stunting, inadequate cognitive stimulation, iodine deficiency, and iron deficiency anaemia. • Toxicity in the environment: intrauterine growth restriction, maternal depression, exposure to violence, malaria, diarrhoea, exposure to heavy metals. • Risks often occur together and cumulatively increase adverse effects on the development

8. 2011 Lancet Series on Child Development Strategies & effective interventions to promote CD: • Programs that provide direct learning experiences to children and families, • Targeted toward younger and disadvantaged children, • Of longer duration, high quality, and high intensity, • Integrated with family support, health, nutrition, or educational systems and services. • Despite convincing evidence, program coverage is low. MDGs of reducing poverty and ensuring primary school completion can be achieved by expansion of high quality, cost-effective early child development programs.

9. The Efficacy of an Integrated Feeding & Care Intervention Among 3 to 15 Months Old Children in Andhra Pradesh, IndiaINDO-US Program On MCHDR 3-R01-HD042219-02-04Funding: ICMR, NIH, UNICEF Indian Investigators US Investigators Dr. Shahnaz Vazir (PI) Dr. Margaret Bentley (PI) Dr. N. Balakrishna Dr. Patrice Engle Ms. Sylvia Fernandez Dr. Paula Griffiths Dr. UshaNaik Dr. Susan Johnson Dr. Hilary Creed-Kanashiro Dr. MonalShroff Carolina Population Center The University of North Carolina at Chapel Hill National Institute of Nutrition (ICMR) Hyderabad, India

10. To implement a randomized controlled behavioural intervention trial to assess effects of breastfeeding, complementary and responsive feeding education to caregivers, and promotion of developmental skills to improve infant growth & development. 3 Arm Study: 200 in each group, 60 villages, 600 mother-infant pairs Group 1 Control : no intervention, assessment only Group 2 Intervention for complementary feeding education Group 3 Intervention for complementary feeding plus responsive feeding and infant development OBJECTIVES Vazir S., P. Engle, N. Balakrishna, P.L. Griffiths, S.L. Johnson, H. Creed-Kanashiro, S. et al. 2013. Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers. MCN 9: 99-117.

11. Care for Development Module • Provides age-based recommendations for parents on • how to play (cognitive development) & communicate (language and social development) with their children from birth through 2 years of age, • possible solutions to problems that caregivers may have. • The Mother- Child Protection Card has C for D recommendations along with those for infant and young child feeding. • The C & D module should improve parents’ ability to support their children’s development, and • Link development with effective feeding practices, including responsive feeding.

12. Goals of child development intervention • Languagedevelopment • Increase total language • Encourage conversation • Help caregiver expand child’s play • Expand use of toys • Explore objects

13. Child development messages • Smile & look in your child’s eyes • Respond to child’s sounds, gestures and interests • Play simple games e.g. peek a boo • Talk to child and give names for things and people • Ask your child simple questions • Give time to explore objects / persons / things • Help your child find new things to do with toys • Explain and show children how to do things

15. Intervention through • Home visits by VLW • Flipcharts included culturally appropriate photographs & messages • Promote conversations and discussion • Tailored opportunities - motivation • ‘Tell me what you see’ in this picture • Checking questions: ‘Last time we talked about allowing your child to explore the food and self-feed…play…did you try this?’

16. Assessment Schedule

17. At 15 months mothers in group 3 report more stimulation than others * P < .05 No significant difference between Groups at 3 months (Baseline)

18. Change in total HOME by age of child 1<2 and 3

19. Change in caregiver responsivity by age of child 1<2 and 3

20. Change in learning opportunities by age of child 1<2 and 3 1<2<3 1<2 and 3

21. DQs vary by group NS 1 <3;2<3* Mental p=.018, 2<3 p=.07; motor not different

23. Results on Growth Group 2 compared to Group 1 had: • better improvement in haemoglobin from 3-15 months • less morbidity • higher HAZ at 15 m Group 3 compared to Group 1 had: • no sig differences on growth outcomes • better improvement in haemoglobin from 3-15 months • less morbidity

24. Results on Food Intake • Increases in maternal knowledge on infant feeding • Changes in behavior • Rice given more times per day (increase in energy as per RD) • Earlier introduction of animal products • Meat, liver, eggs (though in small amounts) • Earlier introduction of green leafy vegetables and fruits • Increases in amount of food consumed & nutrients but not equal to RDA

25. RESPONSE TO CHILD REFUSAL verbal/ non-verbal distractions “One more bite

26. Study recommendations for effective parenting interventions • Need for practice with children, for feedback, and rationale – not just information • Requires reinforcement on several channels • Strengthen, motivate and support caregiver to be positive about self and about child; build peer support • Toys, books, or household objects (to play) do help • Recommendations: • culturally appropriate stimulation • specific enough to understand and to do (formative research) • simple and not too many messages

28. STRATEGIES TO PROMOTE COGNITION AMONG LOW-INCOME RURAL INFANTS & PRESCHOOLERS IN INDIA:Micronutrient Supplementation & Early Learning Opportunities Research Team: PIs: Drs. Sesikeran & Maureen Black NIN: Drs. Shahnaz Vazir, K. Madhavan Nair, Radha Krishna, N. Balakrishna, Sylvia Fernandez Rao UMB: Drs. Kristen Hurley, Yan Wang, Larry Magder MI: Drs. Kim Harding, Lynnette Neufeld The Mathile Institute: Dr. Greg Reinhart

29. OBJECTIVE • To examine how innovative multiple micronutrient (MN) fortification strategies for infants and preschoolers combined with early learning opportunities impact children’s micronutrient status, growth and development through a randomized double-blind controlled trial in Nalgonda district of Andhra Pradesh, India.

30. MMN Fortification *MN products was determined by considering the level of MN deficiency among young children in India, the Indian RDA for each MN by age, and data from efficacy trials on the dose of MN required for changes in cognition.

31. Play and Communication Intervention • Infant Phase (Educational Flip Charts) • Trial informed by: • Care for Development (WHO, 2001) • Pakistan Early Development Study (Yousafzai, 2010) • Preschool Phase • No educational intervention • Rating of AWCs using Early Childhood Environmental Rating Scale, Modified (ECERS) Data collection completed and data analyses ongoing

32. CARE - A HAPPY LEARNING OPPORTUNITY THANK YOU