Early Child Development: A Powerful Equalizer

Early Childhood Development : A Powerful Equalizer

Early Child Development :
A Powerful Equalizer
Final Report

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Prepared by
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Dr. Lori G. Irwin
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Dr. Arjumand Siddiqi
Dr. Clyde Hertzman

Early Child
Development :
A Powerful Equalizer

Final Report
for the World Health Organization’s
Commission on the Social Determinants of Health

Prepared by
Dr. Lori G. Irwin
Dr. Arjumand Siddiqi
Dr. Clyde Hertzman

March 2007

Glob a l
K HELP is a research institute within the For more information please contact:
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College for Interdisciplinary Studies at the Lori G. Irwin
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University of British Columbia. Human Early Learning Partnership (HELP)
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Director: Dr. Clyde Hertzman Vancouver, BC V6T 1Z3
Voice: 604.827.5395 Fax: 604.822.0640
Email: lori.irwin@ubc.ca
Website: www.earlylearning.ubc.ca/WHO
Mapping Portal: ecdportal.help.ubc.ca

acknowledgements 1

This summary report is based on a larger To our Commissioners, the Hon. Monique
document titled the Total Environment Begin, Stephen Lewis, Dr. William Foege, Dr.
Assessment Model of Early Child Alireza Marandi, and Dr. Denny Vågerö, we
Development (team-ecd) written by Dr. thank you for championing the recognition
Arjumand Siddiqi, Dr. Lori G. Irwin and of the importance of the social determinants
Dr. Clyde Hertzman for the Commission of health and for committing to moving this
on Social Determinants of Health. This work from knowledge to action.
summary represents the efforts and com- We would like to acknowledge the input
mitment of many people that contributed to we received from experts such as Dr. Alan
the team-ecd document. We would like Kikuchi-White, Dr. Alan Pence, and Dr. Ilgi
to gratefully acknowledge: the members Ertem.
of the Knowledge Network for Early Child We are also grateful to our colleagues
Development, Dr. S. Anandalakshmy, Dr. at the Human Early Learning Partnership
Marion Flett, Ms. Mary Gordon, Ms. Abeba (help) for their contributions to earlier
Habtom, Ms. Sarah Klaus, Dr. Ilona Koupil, versions of the team-ecd document Dr. Iraj
Dr. Cassie Landers, Dr. Beatriz Londoño Poureslami, Ms. Emily Hertzman, Ms. Robin
Soto, Dr. Helia Molina Milman, Dr. Bame Anderson and Dr. Stefania Maggi and to those
Nsamenang, Dr. Frank Oberklaid, Dr. Alaa colleagues whose unending support made
Ibrahim Shukrallah, Dr. Nurper Ulkuer, Dr. this work would possible: Ms. Jacqueline
Camer Vellani, Dr. Annah Wamae, and Dr. Smit-Alex, Ms. Leslie Fernandez, and Ms.
Mary Eming Young. Sophia Cosmadakis.
We would like to extend a special thanks Finally, we want to extend a special thank
to Dr. Meena Cabral de Mello, Senior Scientist, you to Ms. Karyn Huenemann for her edito-
World Health Organization Department of rial expertise and to Ms. Shannon Harvey for
Child and Adolescent Health and Technical her creative design.
Officer for Early Child Development, for
her input, review of previous drafts, and 1 This work was made possible through funding provided by the
commitment to this work. We would also Public Health Agency of Canada and undertaken as work for
the Early Child Development Knowledge Network established
like to thank the University College London
as part of the who Commission on the Social Determinants
Secretariat Members, Dr. Ruth Bell, Ms. of Health. The views presented in this report are those of the
Tanja Houweling, and the Geneva Secretariat authors and do not necessarily represent the decisions, policy or
views of who or Commissioners.
Glob a l
K Knowledge Network Coordinator, Ms. Sarah
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Simpson, whose patience and expertise has
wl
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ensured that our work integrates with the
broader goals of the Commission.
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Note: An updated version of this report
will be produced subsequent to an external
review process.

design: www.shhdesign.ca

Table of Contents

Abstract 3
Political Briefing 5
Executive Summary 7
Introduction 15
figure 1: team-ecd schematic 17
Methods 18
Results: team-ecd 19
Spheres of Influence
The Individual Child 19
The Family 21
Residential and Relational 26
Community
ecd Programmes and Services 28
Regional and National 33
figure 2 : edi vulnerability map 33
Global 37
Discussion and Recommendations 41
Conclusions 45
References 46
Appendix A: 53
Critical Appraisal of the Underlying Evidence
Appendix B: 55
Examples of ecd Programmes and Services
Appendix C: 61
Population-based Measurement of Early
Child Development from a National Perspective
Appendix D: 63
Children and Families in Global Perspective:
Discussion of and excerpts from Heymann’s
Forgotten Families

Early Child Development : A Powerful Equalizer

Abstract

This document synthesizes knowledge about ways in which government and civil society
opportunities to improve the state of early actors, from local to international, can work
child development (ecd) on a global scale. In in concert with families to provide equitable
Abstract
keeping with international policy standards, access to strong nurturant environments for
we define early childhood as the period from all children globally.
prenatal development to eight years of age.
What children experience during the early Key Words: early child development; equity;
years sets a critical foundation for their entire social determinants of health; lifecourse;
lifecourse. This is because ecd—including rights of the child
health, physical, social/emotional and
language/cognitive domains—strongly
influences basic learning, school success,
economic participation, social citizenry, and
health. Within the work of the Commission,
ecd has strong links to other social
determinants of health, particularly Urban
Settings, Gender, Globalization, and Health
Systems. Areas of common concern with
these determinants are discussed throughout
this document. Research confirms a strong
association between child survival and child
development, such that the child survival
and health agendas are indivisible from ecd.
Our developmental approach to the early
years includes the factors that affect child
health and survival, but goes beyond these
to consider how the early years can be used
to create thriving global citizens. Here, we
provide a framework for understanding the
environments (and their characteristics)
that play a significant role in influencing
early development. The evidence and its
interpretation is derived primarily from three
sources: 1) peer-reviewed scientific literature,
2) reports from governments, international
agencies, and civil society groups, and 3) a
Knowledge Network of experts in ecd that
is representative in both international and
inter-sectoral terms. The principal strategic
insight of this document is that the nurturant
qualities of the environments where children
grow up, live and learn—parents, caregivers,
family and community—will have the most
significant impact on their development. In
most situations, parents and caregivers cannot
provide strong nurturant environments
without help from local, regional, national,
and international agencies. We propose


Political Briefing
Early Child Development: protection policies that guarantee adequate
income for all, and allow parents and caregiv-
Investment in a Country’s Future
ers to effectively balance their time spent at
The early years of life are crucial in influ- home and work. Despite this knowledge, it is Political
encing a range of health and social outcomes estimated that at least 200 million children in Briefing
across the lifecourse. Research now shows developing countries alone are not reaching
that many challenges in adult society—mental their full potential.
health problems, obesity/stunting, heart Political leaders can play an important role
disease, criminality, competence in literacy in guaranteeing universal access to a range of
and numeracy—have their roots in early early child development services: parenting
childhood. Economists now argue on the basis and caregiver support, quality childcare,
of the available evidence that investment in primary healthcare, nutrition, education,
early childhood is the most powerful invest- and social protection. In the early years, the
ment a country can make, with returns over health care system has a pivotal role to play, as
the lifecourse many times the amount of the it is the point of first contact and can serve as
original investment. Governments can make a gateway to other early childhood services.
major and sustained improvements in society To be effective, services at all levels need to
by implementing policies that take note of this be better coordinated and to converge at the
powerful body of research while, at the same family and local community in a way that puts
time, fulfilling their obligations under the un the child at the centre.
Convention on the Rights of the Child. These kinds of family-friendly policies and
Research now shows that children’s early practices clearly benefit children and families,
environment has a vital impact on the way but they also result in economic benefits to
their brains develop. A baby is born with the larger society. Globally, those societies
billions of brain cells that represent lifelong that invest in children and families in the early
potential, but, to develop, these brain cells years—rich or poor—have the most literate
need to connect with each other. The more and numerate populations. These are the
stimulating the early environment, the more societies that have the best health status and
positive connections are formed in the brain lowest levels of health inequality in the world.
and the better the child thrives in all aspects Success in promoting early child develop-
of his or her life, in terms of physical development does not depend upon a society being
ment, emotional and social development, and wealthy. Because early child development
the ability to express themselves and acquire programs rely primarily on the skills of
knowledge. caregivers, the cost of effective programs
We know what kinds of environments varies with the wage structure of a society.
promote early child health and development. Regardless of their level of wealth, societies
While nutrition and physical growth are can make progress on early child development
basic, young children also need to spend their by allocating as little as $1.00 in this area for
time in caring, responsive environments that every $10.00 spent on health and education.
protect them from inappropriate disapproval Child Survival and Child Health agendas
and punishment. They need opportunities to are indivisible from Early Child Development.
explore their world, to play, and to learn how That is, taking a developmental perspective
to speak and listen to others. Parents and other on the early years provides an overarching
caregivers want to provide these opportunities framework of understanding that subsumes
for their children, but they need support from issues of survival and health. A healthy start in
community and government at all levels. For life gives each child an equal chance to thrive
example, children benefit when national and grow into an adult who makes a positive
governments adopt “family-friendly” social contribution to the community—economically
and socially.


Executive Summary

The early child period is considered to be cies, and civil society. These environments
the most important developmental phase and their characteristics are the determinants
throughout the lifespan. Healthy early child of ecd; in turn, ecd is a determinant of
Executive
development (ecd)—which includes the health, well-being, and learning skills across Summary
physical, social/emotional, and language/ the balance of the lifecourse.
cognitive domains of development, each The seeds of adult gender inequity are
equally important—strongly influences sewn in early childhood. In the early years,
well-being, obesity/stunting, mental gender equity issues—in particular, gender
health, heart disease, competence in literacy socialization, feeding practices, and access to
and numeracy, criminality, and economic schooling—are determinants of ecd. Early
participation throughout life. What happens gender inequity, when reinforced by power
to the child in the early years is critical for relations, biased norms and day-to-day
the child’s developmental trajectory and experiences in the family, school, com-
lifecourse. munity, and broader society, go on to have a
The principal strategic insight of this profound impact on adult gender inequity.
document is that the nurturant qualities of Gender equity from early childhood onwards
the environments where children grow up, influences human agency and empowerment
live and learn matter the most for their devel- in adulthood.
opment, yet parents cannot provide strong Economists now argue on the basis of the
nurturant environments without help from available evidence that investment in early
local, regional, national, and international childhood is the most powerful investment
agencies. Therefore, this report’s principal a country can make, with returns over the
contribution is to propose ways in which gov- lifecourse many times the size of the original
ernment and civil society actors, from local investment.
to international, can work in concert with The scope of the present report is fourfold:
families to provide equitable access to strong 1. To demonstrate which environments matter
nurturant environments for all children glob- most for children. This includes environments
ally. Recognizing the strong impact of ecd on from the most intimate (family) to the most
adult life, it is imperative that governments remote (global).
recognize that disparities in the nuturant 2 . To review which environmental configurations
environments required for healthy child are optimal for ecd, including aspects of
development will impact differentially on the environments that are economic, social, and
physical in nature.
outcome of different nations and societies.
In some societies, inequities in ecd translate 3. To determine the “contingency relationships”
that connect the broader socioeconomic
into vastly different life chances for children;
context of society to the quality of nurturing
in others, however, disparities in ecd reach a
in intimate environments such as families and
critical point, where they become a threat to communities.
peace and sustainable development.
4 . To highlight opportunities to foster nurturant
The early years are marked by the most conditions for children at multiple levels of
rapid development, especially of the central society (from family-level action to national
nervous system. The environmental condi- and global governmental action) and by
tions to which children are exposed in the multiple means (i.e. through programmatic
earliest years literally “sculpt” the developing implementation, to “child-centered” social and
brain. The environments that are respon- economic policy development).
sible for fostering nurturant conditions for In keeping with international policy stan-
children range from the intimate realm of the dards, early childhood is defined as the period
family to the broader socioeconomic context from prenatal development to eight years
shaped by governments, international agen- of age. The evidentiary base, as well as


interpretation of the body of evidence, is disadvantaged children are developmentally by parents and caregivers and the physical
derived from three primary sources: stronger than disadvantaged children in other conditions of the child’s surroundings), but
1) peer-reviewed scientific literature, nations, whereas, in all nations, children at also more distal factors that in various ways
2) reports from governments, international the higher ends of the socioeconomic spec- influence the child’s access to nurturant
agencies, and civil society groups, and trum tend to demonstrate relatively strong conditions (e.g., whether government policies
3) international experts in the field of ecd outcomes. provide families and communities with
(including the Commission on Social In this report we provide a framework sufficient income and employment, health
Executive
Determinants of Health, Knowledge Network for understanding the environments (and care resources, early childhood education, Summary
for ecd) that is representative in both interna- their characteristics) that play a significant safe neighborhoods, decent housing, etc.).
tional and inter-sectoral terms. role in providing nurturant conditions to While genetic predispositions and bio-
This evidence-based multiple-sourced all children in an equitable manner. The physical characteristics partially explain how
approach ensures that the conclusions and framework acts as a guide to understanding environment and experience shape ecd, the
recommendations of this report are borne the relationships between these environ- best evidence leads us to consider the child as
out of the perspectives of a diverse array ments, putting the child at the center of her a social actor who shapes and is in turn shaped
of stakeholders and broadly applicable to or his surroundings. The environments are by his or her environment. This is known as
societies throughout the world. not strictly hierarchical, but rather are truly the “transactional model,” which emphasizes
One guiding principle is an “equity-based interconnected. At the most intimate level is that the principal driving force of child
approach” to providing nurturant environ- the family environment. At a broader level are development is relationships. Because strong
ments for children everywhere. Multiple residential communities (such as neighbour- nurturant relationships can make for healthy
perspectives—from the provisions of human hoods), relational communities (such as those ecd, socioeconomic circumstances, despite
and child rights declarations to the realities based on religious or other social bonds), their importance, are not fate.
reflected by research evidence—make clear and the ecd service environment. Each of The family environment is the primary
the importance of equity. Programs and these environments (where the child actually source of experience for a child, both because
policies must create marked improvements in grows up, lives, and learns) is situated in a family members (or other primary caregivers)
the circumstances of societies’ most disad- broad socioeconomic context that is shaped provide the largest share of human contact
vantaged children, not just in absolute terms, by factors at the regional, national, and global with children and because families mediate a
Economists now argue on the but in comparison to the most advantaged level. child’s contact with the broader environment.
children as well.
basis of the available evidence What is now known is that, in every
The framework affirms the importance of Perhaps the most salient features of the family
a lifecourse perspective in decision-making environment are its social and economic
that investment in early society, inequities in socioeconomic regarding ecd. Actions taken at any of these resources. Family social resources include
resources result in inequities in ecd. The
childhood is the most powerful relationship is much more insidious than
environmental levels will affect children parenting skills and education, cultural prac-
not only in present day, but also throughout tices and approaches, intra-familial relations,
investment a country can make, solely differentiating the rich from the their lives. The framework also suggests that and the health status of family members.
poor; rather, any additional gain in social
with returns over the lifecourse and economic resources to a given family
historical time is critically influential for Economic resources include wealth, occu-
children; large institutional and structural pational status, and dwelling conditions.
many times the size of the results in commensurate gains in the devel- aspects of societies (e.g. government policy- The gradient effect of family resources on
opmental outcomes of the children in that
original investment. family. This step-wise relationship between
clusters, programs, and the like) matter for ecd is the most powerful explanation for
ecd, and these are “built” or “dismantled” differences in children’s well-being across
socioeconomic conditions and ecd is called a over long periods of time. societies. Young children need to spend their
“gradient effect.” However, some societies are Socioeconomic inequities in developmen- time in warm responsive environments that
more successful than others at “dulling” the tal outcomes result from inequities in the protect them from inappropriate disapproval
gradient effect, thus fostering greater equity. degree to which the experiences and environ- and punishment. They need opportunities to
Societies accomplish this by providing a range mental conditions for children are nurturant. explore their world, to play, and to learn how
of important resources to children as a right of Thus, all recommendations for action stem to speak and listen to others. Families want to
citizenship, rather than allowing them to be from one overarching goal: to improve the provide these opportunities for their chil-
a luxury for those families and communities nurturant qualities of the experiences children dren, but they need support from community
with sufficient purchasing power. have in the environments where they grow up, and government at all levels.
Importantly, an equity-based approach live, and learn. A broad array of experiences Children and their families are also
is also the successful path to creating high and environmental conditions matter. These shaped by the residential community (where
average ecd outcomes for a nation. Societies include those that are intimately connected the child and family live) and the relational
that demonstrate higher overall average to the child, and therefore readily identifiable communities (family social ties to those with
outcomes for children are those in which (e.g. the quality of time and care provided a common identity) in which they are embed-


ded. Residential and relational communities services that are readily transferable between
offer families multiple forms of support, places; however, many programme features
from tangible goods and services that assist require tailoring to the social, economic, and
with child rearing, to emotional connections cultural contexts in which they are found.
with others that are instrumental in the ecd services may be targeted to specific
well-being of children and their caregivers. At characteristics of children or families (e.g.,
the residential/locality level, both govern- low birth-weight babies or low-income
Executive
ments and grass-roots organizations also families), may occur only in some communi- Summary
play a highly influential role. Many resources ties and locales and not others, or may be more
available to children and families are provided comprehensively provided. Each of these is
on a community level through local recogni- also accompanied by their respective benefits
tion of deficits in resources, problem-solving, and drawbacks; however, the overarching
and ingenuity. There are, however, inequities goal of the global community should be to find
in ecd that are apparent between residential means of providing universal access to effective
communities, which must be addressed in a ecd programmes and services. Health care
systematic way. systems (hcss) are key to providing many
“Relational community” refers to the important ecd services. The hcs is in a
people, adults and children, who help form unique position to contribute to ecd, since
a child’s social identity: tribal, ethnic, hcss provide facilities and services that are
religious, and language/cultural. Often, this more widely accessible in many societies than
is not a geographically clustered community. any other form of human service, are already
Relational communities provide a source concerned with the health of individuals and
of social networks and collective efficacy, communities, employ trained professionals,
including instrumental, informational, and are a primary point of contact for child-
and emotional forms of support. However, bearing mothers.
discrimination, social exclusion, and other The influence of the regional and national
forms of subjugation are often directed at environments is fundamental in determining
groups defined by relational communities. the quality and accessibility of services and
The consequences of these forms of discrimi- resources to families and communities. They
nation (e.g., fewer economic resources) can are also salient for understanding the levels
result in discernable inequities. Moreover, of social organization at which inequalities in
relational communities can be sources of opportunity and outcome may be manifest,
gender socialization, both equitable and and the levels of organization at which action
non-equitable. Relational communities are can be taken to ameliorate inequities.
also embedded in the larger socio-political There are many interrelated aspects of
contexts of society; as such, reciprocal regional environments that may be significant
engagement with other relational groups, for ecd: physical (e.g., the degree of urbaniza-
civil society organizations, and governmental tion, the health status of the population),
bodies is a means of addressing the interests social, political, and economic. These aspects
and resource needs of their members. of the regional environment affect ecd
The availability of ecd programmes and through their influence on the family and
services to support children’s development neighbourhood, and on ecd services. In
during the early years is a crucial component contrast to more intimate environments, such
of an overall strategy for success in childhood. as the family, the significance of large envi-
ecd services may address one or more of the ronments, such as the region, is that regions
key developmental domains (i.e. language/ have an effect on large numbers of children.
cognitive, social/emotional, and physical Thus, changing the environment at this level
development). The quality and appropriate- can influence the lives of many children.
ness of services is a central consideration Much more research and accumulation of
in determining whether existing ecd knowledge is required regarding how regional
programmes improve outcomes for children. characteristics can be modified to positively
There are principles of ecd programmes and influence ecd.

0


The most salient feature of the national Rights in Early Childhood provisions of the
environment is its capacity to affect Convention on the Rights of the Child, as pre-
multiple determinants of ecd through conditions for international developmental
wealth creation, public spending, child- and assistance, are two mechanisms that can be
family-friendly policies, social protection, used. Analogous mechanisms have been used
and protection of basic rights. The chances effectively in other areas of international
that children will face extreme poverty, child development in the past.
Executive Abstract
Summary
labour, warfare, hiv/aids, being left in the Civil society groups are conceptualized as
care of a sibling, and so on, is determined, first being organized at, and acting on, all levels
and foremost, by the countries in which they of social organization, from local residential
are born. through global. The ability of civil society
At the level of the national environment, to act on behalf of children is a function of
comprehensive, inter-sectoral approaches the extent of “social capital” or connected-
to policy and decision-making work best for ness of citizens, and the support of political
ecd. Although ecd outcomes tend to be institutions in promoting expressions of civil
more favourable in wealthy countries than organization. When civil society is enabled,
poor ones, this is not always the case. It is clear there are many avenues through which they
that a commitment of 1.5–2.0% of gdp to can engage on behalf of children. Civil society
an effective mix of policies and programmes groups can initiate government, non-govern-
in the public sector can effectively support ment organization, and community action
children’s early development. Those nations on social determinants of ecd. They can
with less economic and political power are advocate on behalf of children to assure that
less free to determine their internal policy governments and international agencies adopt
agendas, and are more influenced by the policies that positively benefit children’s
interests of the international community, well-being. Finally, civil society groups are
including other nations and multilateral instrumental in organizing strategies at the
organizations. Notwithstanding this, most of local level to provide families and children
the recommendations in this report are within with effective delivery of ecd services, to
the capabilities of any national government improve the safety, cohesion, and efficacy of
that meets the international criteria for a residential environments, and to increase the
“competent authority.” capacity of local and relational communities
The global environment can influence ecd to better the lives of children. Although
through its effects on the policies of nations research on the direct effect of civil society on
as well as through the direct actions of a range ecd is limited, the strong statistical associa-
of relevant actors, including multilateral eco- tion between the strength of civil society and
nomic organizations, industry, multilateral human development in societies around the
development agencies, non-governmental globe leaves little doubt about its importance
development agencies, and civil society to ecd.
groups. A major feature of the global environ-
ment in relation to children’s well-being is
the element of power in economic, social, and
political terms. Power differentials between
types of actors, particularly between nations,
have many consequences, including the
ability of some nations (mainly resource-rich
ones) to influence the policies of other nations
(mainly resource-poor ones) to suit their
own interests. Although power differentials
may have invidious effects on ecd, they can
be exploited for the benefit of children, too.
Requiring a minimum level of government
spending on ecd and compliance with the


Introduction

The early child period is considered to be Lancet series on ecd estimates that there are
the most important developmental phase 559 million children under 5 in developing
throughout an individual’s lifespan. Healthy countries—including million who are
155
Introduction
early child development (ecd)—physical, stunted and 62 million who are not stunted
social–emotional, and language–cogni- but are living in poverty—for a total of over
tive—is fundamental to success and happiness 200 million children under five years of age
not only for the duration of childhood, but
throughout the lifecourse. ecd strongly influ-
ences well-being, obesity/stunting, mental
The agenda to improve child
health, heart disease, literacy and numeracy survival and health is indivisible
skills, criminality, and economic participa-
tion throughout life—all issues that have
from the agenda to improve early
profound implications for economic burden child development.
on countries. If the window of opportunity
presented by the early years is missed, it who are at extreme risk of impaired cognitive
becomes increasingly difficult, in terms of and social–emotional development. Most
both time and resources, to create a successful of these children—89 million—live in ten
lifecourse. Governments must recognize countries (India, Nigeria, China, Bangladesh,
that effective investments in the early years Ethiopia, Indonesia, Pakistan, Democratic
are a cornerstone of human development Republic of Congo, Uganda, and Tanzania)
and central to the successfulness of societies. that account for 1 45 million (66%) of the
Indeed, our planet provides no examples of 219 million disadvantaged children in the
highly successful societies among those who developing world. Many are likely to do poorly
have ignored development in the early years. It in school and subsequently as adults will likely
is therefore critical for governments, interna- have low incomes, high fertility, and provide
tional agencies, and civil society partners to poor health care, nutrition, and stimulation to
move from knowledge to action in ecd. their own children, thus contributing to the
intergenerational transmission of disadvantage
(Grantham-McGregor et. al., 2007). The loss of
Governments must recognize human potential that the above statistics repre-
that effective investments in sent is associated with more than “a 20% deficit
in adult income and will have implications for
the early years are a corner- national development” (Grantham-McGregor
stone of human development et. al., 2007, p. 67).
The overarching message of this report to
and central to the governments, international agencies, and civil
successfulness of societies. society partners is this: the agenda to improve
child survival and health is indivisible from
ecd is important in all countries, the agenda to improve ecd. That is, taking a
resource-rich and -poor alike, but special developmental perspective on the early years
attention needs be paid to the potential provides a comprehensive framework of under-
benefits to the resource-poor, where a child standing that subsumes issues of survival
has a four in ten chance of living in extreme and health. A healthy start in life gives each
poverty and 10.5 million children die before child an equal chance to thrive and grow into
age 5 from preventable diseases. Such children an adult who makes a positive contribution to
are likely to suffer from poor nutrition and the community—economically and socially.
poor health. They are also at high risk of never Accordingly, governments should adopt a
attending school (unesco 2007). The recent strategy of investing in ecd in order to meet


the Millennium Development Goals (mdgs) Child Rights agendas are indivisible from ecd. to shape children’s outcomes (Siddiqi, Irwin health, it becomes crucial here to address the
for poverty reduction, education, and health. Again, taking a developmental perspective on Hertzman, 2007). The team-ecd model factors influencing ecd itself. By expanding
the early years provides a framework of under- builds on a diverse literature, including the notion of environmental spheres of
standing that incorporates issues of survival previously described frameworks that have influence, adding a temporal component, and
Governments should adopt and health as well as education and rights. addressed ecd from a social environmental placing children’s well-being at its centre,
a strategy of investing in early perspective. These sources include Urie team-ecd offers the strongest means of
scope of work Bronfenbrenner’s Bioecological Model (1986); understanding (and therefore acting upon)
Introduction child development in order to developmental psychology perspectives on social determinants of ecd.
Introduction

meet the Millennium Develop- This work includes evidence related to infants ecd (Brooks-Gunn, Duncan Maritato,
and children, from prenatal development 1997); notions of “biological embedding” spheres of influence on early child
ment Goals for poverty reduc- through to eight years of age, specifically (Hertzman 1999); frameworks of under- development
tion, education, and health. considering how social determinants influence standing regarding social epidemiology and
health across the lifecourse. It is of relevance social determinants of health (Dahlgren In this schematic (see figure 1), a variety
Economists now argue on the basis of the to children on a global scale. We discuss the Whitehead, 1991; Emmons, 2003); research of interacting and interdependent spheres of
available evidence that investment in early limitations to the application of these ideas regarding social relations in human society influence are instrumental for development
childhood is the most powerful investment where appropriate. (Putnam, 2000; Weber, 1946); a vast in early childhood. They include the indi-
a country can make, with returns over the literature in the political economy domain vidual, family, and dwelling; residential and
life course many times the amount of the purpose (for a review of this literature, see Siddiqi, relational communities; ecd programmes
original investment. Globally, societies—rich Irwin Hertzman, 2007); and the World and services; and regional, national and global
or poor—that invest in children and families The purpose of this document is to Health Organization (who) Framework environments. In each sphere of influence,
in the early years have the most literate and synthesize knowledge to inform the csdh on Social Determinants of Health (Solari social, economic, cultural and gender factors
numerate populations. These are also the about opportunities to improve action on a Irwin, 2005). Because the who Equity Team affect its nurturant qualities.
societies that have the best health status and global scale in the area of ecd. The evidence framework considers ecd as a determinant of
lowest levels of health inequality in the world. assembled here focuses on priority associations
Societies with the most successful policies and between social determinants of health and figure 1: team-ecd
programmes for ecd spend approximately health inequities across different country schematic
1.5%–2.0% of gdp per year on it (oecd, 2006). contexts. It comments on the extent to
One study has estimated that every dollar which the social determinants of ecd can be
spent to help a child reach school age while acted upon; is intended to stimulate societal
thriving can generate up to $17 in benefits to debate on the opportunities for acting on
society over the following four decades (even social determinants of health and to inform
after controlling for inflation) (Schweinhart, the application and evaluation of policy
Barnes Weikart, 1993; Schweinhart, 2004). proposals and programmes in the area of
While the academic and grey literature ecd—nationally, across regions and globally.
provides compelling evidence about the The areas of focus for each of the Commission’s
importance of the early years, in practice, ecd Knowledge Networks—Globalization, Social
is not at the centre of international, national Exclusion, Health Systems, Gender, Urban
or local policies, programming and practice. Settings, Employment Conditions, Priority
Despite the strength of the evidence, adequate Public Health Conditions and Evidence
investments in ecd have been slow, particu- Measurement—are critical to understanding
larly, in resource-poor countries where the the social determination of ecd, and as such
greatest number of vulnerable children would are integral to this review.
benefit the most.
Within the work of the Commission on conceptual framework
Social Determinants of Health (csdh), ecd
has strong links to other social determinants The Total Environment Assessment Model
of health, particularly Urban Settings, Gender, of Early Child Development (team-ecd)
Globalization and Health Systems. Areas of has been developed for the csdh as a means
common concern with these determinants of framing the types of environments (and
are made clear, though implicit, throughout therefore experiences) that are integral
this document. Moreover, we argue that Child to healthy ecd, and linking these to the
Survival, Child Health, Education for All, and biological processes with which they interact

6


Methods Results: team-ecd
Spheres of Influence
The process of synthesizing the available personal experiences drawn from a wide
evidence raised the question of what counts variety of sources. While we have used the
as evidence. We paid attention to the quality highest quality research evidence available,
Methods influencing health and development over the Spheres of
of the source, the context of the research, we are also aware that not all high-quality The Individual Child long-term is known as biological embedding Influence:
the nuances of particular programmes and research is of practical significance or equally The Individual
The earliest years of life are characterized by (Hertzman, 1999).
populations served, and the ecological factors applicable in all global contexts. This multi- Child
associated with the studies. Accordingly, source, multi-method approach helped to the most important development that occurs nutrition
our evidentiary base is derived from three ensure that the conclusions and recommenda- in a human lifespan. There are several bases
primary sources: tions of this report are consistent with the for the bold and unequivocal nature of this Children’s optimal growth and development
1) peer-reviewed scientific literature, perspectives of a diverse array of stakeholders, statement. The early years are marked by the requires adequate nutrition, and receiving
and are broadly applicable to societies most rapid development, particularly of the adequate nutrition is a fundamental right
2) reports from governments, international
agencies, and civil society groups and throughout the world. central nervous system. The “critical periods” of children (see General Comment #7 on
We acknowledge both the limitations for the development of the brain almost the Convention on the Rights of the Child
3) international experts in ecd (including the
csdh Knowledge Network for ecd that is posed by many of these studies being focused exclusively occur during this time. During [crc] [United Nations Office of the High
representative in both international and inter- in resource-rich nations, and the many these early years, the experiences (e.g., good Commission for Human Rights (crc),
sectoral terms). challenges that limit the extent to which quality nutrition) and the environmental 1990]) and begins in utero with adequately
This Final Report is a summary of a broader experiences, programmes and research find- exposures (e.g., attachment to a caregiver) nourished mothers. During the first months
comprehensive evidence document entitled, ings from one global context 2 can be applied that a child receives will be instrumental in of life, breastfeeding plays an important role
like the model, team-ecd (Siddqi, Irwin to others. the successful development of early brain in providing children with the necessary
Hertzman, 2007), so when in-depth informa- function. Not only will the child be shaped nutrients. In fact, exclusive breastfeeding
tion is at issue, we to refer back to team-ecd. 2 Efforts aimed at universalization of knowledge and practices
by these experiences physiologically, but is thought to reduce the chances of early
Although there is a wealth of literature related have been based on dominant Anglo-American values, goals and the child will also shape these experiences. post-natal stunting (Smith et al., 2003).
to ecd, only a limited number of studies
norms (Nsamenang, 2005). Our best example of this is breast- The development that occurs in the early Breastfeeding carries with it the dual role
feeding. For many years in the past, European and American
focus upon ecd in resource-poor countries. organizations and corporate entities advocated for formula
years provides the essential building blocks of adequate nutrition and healthy infant
In addition, although we believe that qualita- feeding (Gussow, 1980). They have now introduced a global for a lifetime of success in many domains of development through stimulation and attach-
tive research findings contribute a unique
call for mothers to commit to “exclusive” breastfeeding for six life, including economic, social and physical ment as part of the breastfeeding process.
months (who, 2003). In this case, the value of breastfeeding
and important source of information to a in nations of Africa and Asia was already known through years
well-being. Despite what the evidence—both scientific
review such as this, the availability of studies of tradition and experience, but was trumped by “wisdoms” and traditional—tells us about adequate
employing qualitative methods was limited. biological embedding nutrition for infants and children, there are
There is also a heavy weighting of evidence in approximately 150 million children under the
the literature for “at risk” or special popula- The interaction that occurs between individ- age of five years in the developing world alone
tions, but these studies are also concentrated ual characteristics (genetic and physiologic) who suffer from malnourishment. Children
in resource-rich nations. and experiences and exposures drawn from who are malnourished are more likely to
We took a broad view of what literature the environment are basic to the development
was relevant to ecd (see Appendix A), of the child. The human brain, in particular, 150 million children under the age
investigating databases from multiple is the “master organ” of development. Early
disciplines, including medicine, developmen- in life, genetically programmed sensitive
of five years in the developing world
tal psychology, sociology, nursing, population periods occur in the brain, during which time alone suffer from malnourishment.
health, economics and anthropology. For the developing child is disproportionately
each, evidence that pertained to any aspect of sensitive to the influences of the external suffer the consequences of poor physical and
children’s well-being was included. In addi- environment (Barker, 1992; Bronfenbrenner, mental development; have poorer school
tion, papers addressing the interconnectivity 1986; Wadsworth, 1997). The interplay of performance (Pelto, Dickin Engle, 1999;
of family, residential, relational and broader the developing brain with the environment is Powell et al., 1998; Winicki Jemison,
societal contexts were reviewed, even when the driving force of development; its legacy 2003); be susceptible to the effects of infec-
these papers did not make direct reference is a unique configuration of synapses in the tion; have more severe diarrhoeal episodes;
to effects on children. Whenever possible we brain that influences cognitive, social and have a higher risk of pneumonia; have lower
used “causal evidence” in the scientific sense emotional functions thereafter. The process functioning immune systems; and often
and complemented it with practical and of early experience becoming solidified and have low levels of iodine, iron, protein and


evolves over time; it requires, at a minimum, a
thus energy, which can contribute to chronic and support for malnourished children and The Family
illness (unicef, 2006). As women remain their families—especially the most vulnerable safe environment and developmentally appro-
the primary caregivers for children, when children. priate resources. Stimulation (e.g., mothers The family is the primary influence on
they have greater influence in household and children playing with homemade toys) a child’s development (unicef, 2007)
decisions, women can significantly improve relationships has an independent effect on perceptual (“Family” is defined here as any group of
their children’s nutritional status (Smith et al, motor development outcomes among stunted people who dwell together, eat together,
2003). Educating women has also been shown Although adequate nutrition is essential for children, over and above nutritional supple- and participate in other daily home-based
Spheres of mentation (Grantham-McGregor et al., 1997). Spheres of
Influence:
not only to improve their children’s nutri- development, the quality of relationships activities together). The new crc General Influence:
The Individual tional status, but it also results in multiple is equally important for children’s develop- McArdle suggests that “play is marginal to the Comment #7 on Early Childhood restates the The Family
Child benefits for children by improving children’s ment. Existing literature leads us to consider plans of governments and local authorities” crc’s position on family as,
survival rates and school attendance (Smith et children as social actors (Boyden Levison, (2003, p. 512) and not viewed as a “serious”
the “fundamental group” and the “natural
al, 2003). 2000; Irwin, 2006; Irwin et al., 2007; Irwin activity. Potentially, one of the most efficient
environment” for growth and well-being but
Johnson, 2005; Mayall, 1996), who are strategies for improving ecd is to find ways to recognises that the concept of family extends
Nutritional deficiencies at all not only shaped by their environment but, convince parents and caregivers of the impor- well beyond the “nuclear” model. Parents and
in turn, shape it as well. A child’s individual tance of play and the ways they can promote it. caregivers are identified as principal actors in
stages of growth have long- development is transactional, reciprocal the construction of identity and the develop-
term damaging effects on the and mutually constituted. Young children ment of skills, knowledge and behaviours,
develop best in warm, responsive environ- and as duty-bearers in the realisation of the
intellectual and psychological ments that protect them from inappropriate key messages: the individual child young child’s rights. (gc7 para.15). (White,

development of children. disapproval and punishment, environments
2006, p. 2)

in which there are opportunities to explore 1. Health, nutrition, and well-being of Family members provide most environmental
Malnutrition is also implicated in more their world, to play, and to learn how to speak the mother is significant for the child’s stimuli for children, and families largely
than half of all child deaths worldwide. and listen to others (Ramey Ramey, 1998). development. control a child’s contact with the distal
Although this is a worrisome figure, it is Notwithstanding the complexity of ecd, 2 Three broad domains of develop- environment (Richter, 2004). The most
also essential to recognize that nutritional the many factors that influence ecd come ment—physical, social–emotional and salient features of the family environment
deficiencies at all stages of growth have down to these simple attributes of the child’s language–cognitive— are interconnected are its social and economic resources. Social
long-term damaging effects on the intel- and equally important.
day-to-day experience. Improving the quality resources include parenting skills and
lectual and psychological development of children’s day-to-day experience through 3. Children shape their environments as well education, cultural practices and approaches,
of children: unacceptable loss of human as being shaped by them.
relationships needs to be a primary goal of all intra-familial relations, and the health status
potential (Grantham-McGregor et al., 2007). initiatives regarding of parenting, childcare, 4 . Social determinants shape brain and of family members. Economic resources
Malnutrition is therefore one of the most biological development through their
and monitoring rights in early childhood under include wealth, occupational status and
influence on the qualities of stimulation,
important factors in poor development and the crc. dwelling conditions. Social and economic
support, and nurturance available to the
loss of development potential for children. We resources for children are highly intertwined,
child.
know that stunting as a result of chronic mal- the science of play yet imply different strategies for intervention
5. Play is critical for a child’s overall
nutrition is shaped by a complex combination
development.
of environmental, social and economic factors, The central role of play in children’s develop- relationships
which begin in utero and affect both physical ment is not always appreciated. Play processes
growth and mental development. Here is a influence synaptic formation and are linked A strong body of research demonstrates the
prime example of where child survival, food to secure attachment with caregivers and significance of primary caregivers (and by
security, ecd, education and gender equity relationships with other children. Play extension, families) on children’s long-term
agendas converge. It is essential to reduce provides an important socializing function, development (Shonkoff Phillips, 2000).
malnutrition globally, especially in 0 to 3 year beyond the merits of being physically active, Those factors that facilitate healthy social
olds, but this requires systematic action at in which children learn about and negotiate bonds and the character of caregiving
the local level in the areas of maternal health identity and the social subtleties of relation- practices that matter most for children are
(including adequate nutrition) and health care; ships (James, 1993). Play may vary according now well understood. A key requisite for
food security, with adequate micronutrient to individual children’s temperaments, healthy ecd is secure attachment to a trusted
intake; safe water; access to education for all; gender, culture or their families’ parenting caregiver with consistent caring, support
and protection from illness such as provided and caregiving practices, but the impact of and affection early in life (Bowlby, 1969).
by immunization programmes. While play on developmental processes is universal Securely attached infants and toddlers use
attention to these factors is important, it is across cultures (Bornstein et al., 1999). Play their emotional and physical security as a base
equally important to ensure the presence of can be structured or unstructured; it can be from which to explore their environment.
a systematic, community-based follow-up done alone, with a caregiver or in a group; it Successful attempts at exploration increase

0


the child’s self-confidence and encourage that are adverse for development (e.g., for their parents and siblings. Many children
more exploration. Thus, the child begins to crowded or slum living conditions, unsafe have experienced orphanhood or become the
learn about and master his or her environment neighborhoods) (Dipietro, 2000). ses can heads of their households due to the death of
and to gain in both competence and self- also influence children through its effects on their parents. In particular, this may influence
confidence. All families need some support to parental stress. Lower-income parents have girls’ development to a greater extent, since
learn how to develop and apply sensitivity and been found to be at increased risk for a variety they are more likely to bear the responsibility
responsiveness in their childcare practices. of forms of psychological distress, includ- of household matters, and may therefore
Spheres of
There are, however, both biological and ing negative feelings about self-worth and forego schooling (Richter, 2006). Here, we Influence:
environmental factors that can negatively depressive symptomatology. It is thought that call for recognition that programmes sup- The Family
impact on attachment. These include low birth this arises through a combination of greater porting the health of the caregivers of young
weight, malnutrition and infections, poverty exposure to negative life events and having children are also investments in ecd, and
and its associations, conflict and domestic fewer resources with which to cope with should be evaluated as such.
violence, and mental health problems such adverse life experiences (Shonkoff Phillips,
as maternal depression. In these instances, 2000). fathers
external support for families is particularly There is a demonstrated link between
important. socioeconomic circumstances and language The role of fathers as part of the family-level
and cognitive outcomes in young children, sphere should not be underestimated, and is
socioeconomic status based largely on the richness of the language often regrettably marginalized. The United
environment available to the child (Hart Nations Commission on the Status of Women
So consistent is the association between Risley, 1995). Family ses is also associated “[encourages] men to participate fully in all
socioeconomic status (ses) and a variety of with ability to provide other resources, such actions towards gender equality and [urges]
development and health outcomes throughout as health care and high-quality childcare, that the establishment of the principle of shared
the lifecourse, that it has been termed a exert a profound influence on developmental power and responsibility between women
“gradient effect.” The gradient effect of health (Hertzman Wiens, 1996). and men at home, in the community, in the
family resources on ecd is the most powerful workplace, and in the wider national and
The gradient effect of family explanation for differences in children’s family health international communities” (United Nations
well-being within societies, and these Office of the High Commission for Human
resources on ecd is the most resources profoundly affect all other aspects Family health conditions have a particularly Rights (uncsw), 2004, p.1). Certainly, this
powerful explanation for of the family environment (Siddiqi et al., in strong impact on ecd. Any chronic problem, includes the role of fathers in nurturing their
press). A recent study by Houweling, Casper, either physical or mental (especially of children (unicef, 1997). In fact, engaging and
differences in children’s well- et al. (2005) found a striking association the mother or primary caregiver), such as working effectively with fathers and other
being within societies, and these between socioeconomic status of families and intimate-partner violence (Anda et al., 2006; men who affect the well-being of children and
under-5 mortality in a population of children Fettelli et al., 1998), maternal depression families is now firmly emphasized in policy
resources profoundly affect all from 43 resource-poor countries. This same (Shonkoff Phillips, 2000), and chronic
, frameworks as a strategic requirement for all
other aspects of the family study suggested that, among these nations, illness, can have a deleterious effect on child children’s services (Fathers Direct, 2006).
socioeconomic inequality in child mortality development. In situations involving mater-
environment. was increasing (the gap was widening) as the nal depression, extreme poverty, or high gender
overall economies were growing. Family ses levels of family stress, important parent-child
has an impact on outcomes as diverse as low interactions may be impaired, resulting in Inequities within families may be significant
birth-weight, risk of dental carries, poorer fewer opportunities for learning experiences from the standpoint of the social determi-
cognitive test scores, difficulties with behav- in the home (Willms, 2003). The severity and nants of health, especially with respect to
iour and socialization, and increased odds of chronicity of maternal depression are predic- gender: “Women’s access to power at the
disengagement from school (Brooks-Gunn, tive of disturbances in child development household level has the most direct impact
Duncan Maritato, 1997). (nichd, 2002). on families and children … [through lack of
Social and economic resources influence A major health issue globally is the control over] allocation of resources for food,
ecd through several mechanisms. For prevalence of Human Immunodeficiency health care, schooling and other family neces-
instance, low levels of education and literacy Virus (hiv) among the adult population. sities” (unicef, 2007, p. 2 2). As a result,
affect the knowledge and skill-base of chil- The effect on children has been widespread, female children are more likely to receive
dren’s caregivers; feeding and breastfeeding from contracting the infection themselves less food, and to be denied essential health
practices also vary according to ses. Children (through transmission from mother to child), services and education. Household chores and
born into poor families are more likely to be to the phenomenon of children taking up caregiving keep adult women out of the paid
exposed to—and affected by—conditions adult roles within the family, such as caring labour force and girls out of school. Moreover,

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Early Child Development: A Powerful Equalizer

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