Promoting Childhood Development

Globally Through Caregiving

Interventions
Maureen M. Black, PhD,a,b Susan P. Walker, PhD,c Orazio Attanasio, PhD,d Marta Rubio-Codina, PhD,e Costas Meghir, PhD,d
Jena D. Hamadani, MBBS, PhD,f Lia C. H. Fernald, PhD,g Alysse Kowalski, PhD, MPH,a Sally Grantham-McGregor, FRCP, MDh

Throughout the world, there has childhood and adolescence, and to neural plasticity and sensitivity to
been widespread recognition that become healthy, caring, and environmental interactions, leading to
children’s development is shaped by productive adults, assuming long-term negative consequences on
the cultural context and interactions responsibilities for their family, children’s health and development.11
that begin prenatally and extend community, and society. With The effects of poverty on the
throughout childhood.1,2 Children declines in child mortality5 and developing brain are mediated by
raised in stable and nurturing fertility over the past 30 years,6 caregiving behavior and stressful
settings that provide adequate resulting in smaller family sizes, experiences, illustrating the
nutrition, responsive caregiving, along with increases in early powerful potential of responsive
protection from adversities, and childcare7 and parents’ interest in caregiving.12,13
opportunities for learning, along with their young children’s learning
health and educational services, have opportunities,8 it is not surprising In the United States, between 2017
the best chance of reaching their full that The World Health Organization and 2020, 17% of children under 18
developmental potential.3,4 Nurturing and other international organizations years of age (12.6 million children)
interactions begin with families and regard investments in children as an lived in families with incomes below
extend to community programs and essential strategy to achieving the the poverty line ($26 246 for 2 adults
services, including childcare United National Sustainable and 2 children).14 Throughout the
providers, and to policies that shape Development Goals.1,9,10 world, hundreds of millions of
the macrosocial environment. children experience poverty and
Children’s early competencies can Poverty and environmental adverse experiences in their
prepare them to achieve increasingly deprivation disrupt children’s early communities or households that can
complex competencies throughout brain development during periods of disrupt their developmental

a
University of Maryland School of Medicine, Baltimore, Maryland; bRTI International, Research Triangle Park, North Carolina; cCaribbean Institute for Health Research, The University of the
West Indies, Kingston, Jamaica; dYale University, New Haven, Connecticut; eInter-American Development Bank, Washington, District of Columbia; fInternational Centre for Diarrhoeal Disease
Research, Bangladesh, Dhaka, Bangladesh; gUniversity of California, Berkeley, Berkeley, California; and hInstitute of Child Health, University College London, London, England

Dr Black was part of the Working Group for the supplement, conceptualized and designed the supplement, reviewed the paper included in the supplement, and drafted the
introductory manuscript. Drs Walker, Attanasio, Rubio-Codina, Meghir, Hamadani, Fernald, Kowalski, and Grantham-McGregor were part of the Working Group for the supplement,
conceptualized and designed the supplement, reviewed the papers included in the supplement, and reviewed and revised the introductory manuscript; and all authors approved the
final introductory manuscript as submitted and agree to be accountable for all aspects of the work.
This paper and supplement present the authors’ views and not those of the institutions they represent, including the Inter-American Development Bank, its board of directors, or the
countries they represent.
DOI: https://doi.org/10.1542/peds.2023-060221B
Accepted for publication Feb 17, 2023
Address correspondence to Maureen M. Black, PhD, Department of Pediatrics, University of Maryland School of Medicine, 737 W. Lombard St, Rm 161, Baltimore, Maryland 21201. E-mail: mblack@som.
umaryland.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2023 by the American Academy of Pediatrics
FUNDING: Funding for the supplement was provided by the New Venture Fund to the University of Maryland School of Medicine and the Jacobs Foundation to Yale University.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

PEDIATRICS Volume 151, number S2, May 2023:e2023060221B SUPPLEMENT ARTICLE

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 progress, preventing them from development and school readiness, nurturant and responsive
reaching their developmental particularly among children with caregivers,27,28 early childhood
potential.15 With unrealized human few resources.21,22 Building from a development programs strengthen
development, children’s ability to strong research base, these the capacity of parents and childcare
escape poverty and build fruitful programs have been implemented providers to give young children the
careers and satisfying lives as adults across the country, often with nurturing care needed to overcome
can be jeopardized. Poverty community-based partnerships early adversities and reach their
combined with caregiver stress can committed to supporting families developmental potential.7
undermine children’s exposure to and young children. Longitudinal studies show that the
nurturing and developmentally benefits of early intervention can be
enhancing interactions and Early childhood development maintained into adulthood with
opportunities. Globally, it is programs have also been developed positive impacts on adult
estimated that over 250 million and implemented in low- and psychological and economic
children under age 5 years are at middle-income countries (LMIC). functioning.24,29
risk for not meeting their The Jamaica Program developed by
developmental potential.3,16 Dr. Sally Grantham McGregor and This supplement originated as a
colleagues at the University of the tribute to Professor Sally Grantham-
The American Academy of Pediatrics West Indies in the 1970s is a McGregor for her innovative work
(AAP) is committed to the “optimal pioneering home visiting program and commitment to global early
physical, mental, and social health with demonstrated benefits that childhood development, including
and well-being for all infants, extend throughout childhood and the “Order of the British Empire”
children, adolescents, and young adolescence, resulting in better award for lifetime achievements.
adults.”17 AAP’s Council on Early employment and higher wages in The authors of this paper formed a
Childhood supports the health and adulthood.23,24 The Jamaica Program Working Group to organize a
wellbeing of young children; high- has been translated to “Reach Up supplement dedicated to promoting
quality community-based programs, Early Childhood Parenting global early childhood development.
Programme” (https://www. We invited over 50 established
including childcare, preschool, and
reachupandlearn.com/), known as authors from multiple institutions in
parenting programs; and cross-
“Reach Up,” and implemented in at high-, middle- and low-income
sectoral collaboration to promote
least 16 countries, some at scale. countries to submit concept notes
community-based early childhood
Consistent with the principles of that addressed the implementation
systems. These commitments are
nurturing care,3 Reach Up empha- of caregiving programs for infants
backed by both functional and
sizes a stable environment that pro- and young children in LMICs. We
neuroscientific evidence from early
vides protection from threats and reviewed 29 concept notes; scored
child development programs.
opportunities for learning through them based on 5 criteria relative to
Research programs, such as the
emotionally supportive and respon- global caregiving interventions
Infant Health and Development
sive relationships. These experiences (significance, innovation, authors,
Program, an intervention trial
have generated insights and lessons quality, and potential interest to
among low birth weight, premature
on how to effectively implement readers); and invited 20 authors to
infants, show stronger cognitive caregiving intervention programs at submit papers or commentaries.
effects at age 3 years among young scale.
children from lower versus higher- We received and reviewed 16
income families.18 Based on Findings from Reach Up,24 Care for papers and commentaries and
population projections, income gaps Child Development, developed by invited 14 authors to prepare
in IQ at age 3 years could be the World Health Organization and revised manuscripts for submission.
eliminated by programs that are UNICEF,25 and other home visiting The supplement relies on principles
universal or reach children at programs implemented among of equity and implementation
greatest need.19 Government infants and young children in low- science to extend beyond impact
programs, such as Head Start,20 and resource communities demonstrate evaluations and examine topics
programs from nonprofit the powerful impact of early relevant to scaling intervention
organizations, such as the Nurse intervention on children’s cognitive programs to reach the children and
Family Partnership and Parents as and socio-emotional development.26 families in LMICs at greatest need.
Teachers, show positive and Guided by bioecological theory and The papers address topics related to
sustained effects on children’s the recognition that children’s program quality, including children
cognitive and socio-emotional development is enhanced with in conflict and other extremely

S2 BLACK et al
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 difficult settings, integrating early and instant messages among to an existing parenting program in
intervention with other services, caregivers of young children rural Colombia and found benefits
delivering services remotely, and recruited from health centers in to childhood development and to
partnering with government Brazil and Jamaica who met risk caregiving practices, particularly
agencies, among others. criteria.33 Through a mixed methods maternal engagement, when quality
design, they documented the was high.38 Their observational
The initial commentary is written by positive effects of remote delivery of measure of quality has the potential
Professor Heckman, a Nobel laureate the intervention on caregiving to promote and maintain
in economics who demonstrated the practices. intervention quality at scale. In
economic benefits of investing in 2019, over 71 million children
early childhood development.30 His Although there have been multiple under age 5 had spent their entire
commentary highlights the central calls for integrated interventions,10 lives in crisis and conflict zones.
role of the family in building few have been implemented. Tofail Based on their experiences of
successful pathways for young et al implemented a group-delivered implementing adapted versions of
children. The first paper in the intervention in health facilities in Reach Up in crisis and conflict areas
supplement is a meta-analysis of 18 Bangladesh that addressed of Bangladesh, Syria, and Venezuela,
studies across 8 countries that childhood development, along with Wilton et al documented the
implemented the Reach Up program. maternal mental health.34 Their importance of cultural adaptation of
Jervis et al found benefits on findings of beneficial effects on interventions from a holistic
children’s development and home multiple domains of children’s perspective of children and
stimulation across 2 delivery development and improvements in caregivers, the inclusion of safety
strategies (home visits and small mothers’ depressive symptoms and and linkages to complementary
groups), implemented at varying caregiving illustrate the merits of services, and incorporating blended
levels of scale.31 This analysis group-delivery of integrated models and costing analyses.39
highlights how Reach Up has been interventions in health facilities. In
successfully implemented across an innovative design, Meghir et al Exposure to violence early in life
studied the timing and duration of can disrupt children’s brain
multiple settings and among diverse
interventions by comparing children development, increasing their risk
populations, even as a national
in India randomized to receive for socio-emotional problems.40 Two
program. In the second paper,
interventions delivered before age 3 papers in the supplement addressed
Hossain et al examined the effects of
and/or following age 3.35 violence prevention. Jensen et al
early childhood intervention among
Interventions among both age examined associations between
children in Bangladesh after 6 years
categories benefited children’s IQ intimate partner violence and harsh
and found sustained effects of
and school readiness. The finding child discipline in Rwanda.41 They
cognitive development among
that children receiving interventions implemented an intervention that
children without a history of
at both time periods did not reduced harsh discipline by
anemia.32 The anemic group did not
experience differential benefits increasing father engagement and
experience benefits either
requires additional investigation. parenting warmth among female
immediately following the
The Reach Up program has been caregivers, illustrating that violence
intervention or at the 6-year follow- implemented among approximately reduction can be effectively
up, suggesting that specialized 1500 children in an impoverished integrated into early childhood
interventions are necessary for region of Western China.36 Zhou et development programs to reduce
children with specific conditions, al found that the intervention was harsh discipline and intimate
such as anemia and disabilities. successfully implemented at scale, partner violence. Baker-Henningham
These findings add to the evidence with effect sizes that were et al used implementation science
on the sustainability of early comparable to those found among principles in the design,
intervention, as well as the harmful the original Jamaica Program. They implementation, and scaling of 2
effects of anemia. The coronavirus note the benefits of starting early violence-prevention caregiver-
disease 2019 pandemic disrupted and report on program costs. training programs for preschoolers
many early intervention programs. in Jamaica: a teacher-training
Smith et al evaluated the Although the importance of program program and a caregiving
development, adaptation, quality has been well established,37 program.42
implementation, and impact of a there has been limited attention to
remote version of Reach Up strategies to advance quality. Bernal The final paper in the supplement,
implemented through phone, text, et al developed quality enhancement by King et al, describes a protocol

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 for a cluster randomized trial to individually oriented home visiting contributions of Joshua Jeong, PhD
evaluate an integrated, multisector, services, recognizing the critical who assisted with the reviews of
multiplatform intervention to roles of families in nurturing their the manuscripts; the support of the
promote childhood development.43 children’s development. They have World Health Organization, UNICEF,
The intervention targets caregiving expanded and have successfully the World Bank Group, the Inter-
behaviors in the home and been delivered using diverse American Development Bank, and
community, and is delivered in methodologies – including groups, in other organizations that have sup-
partnership with the Royal diverse settings, including health ported research into the develop-
Government of Cambodia, centers, crisis and conflict areas, and ment of young children throughout
illustrating the engagement of local remote delivery, consistent with the the world.
governmental agencies. Recognizing AAP’s commitment of providing
the extension of caregiving from the high-quality community-based
home to community-based settings, programs for children. A primary ABBREVIATION
such as childcare, is critical with the strength of this collection is the
LMIC: low- and middle-income
global increases in women of child- inclusion of 79 authors, many of
countries
bearing age participating in the whom are directly involved with
work force.7 The supplement research and service within LMICs.
concludes with 2 commentaries. A primary limitation is that we may
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