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Perspectives from international development assistance and from family programmes

The flagship role of early childhood development programmes
The UNICEF conceptual framework
Family factors and programmes that protect high-risk children
The effects of early intervention programmes
Impacts on family functioning or social health

The flagship role of early childhood development programmes

A number of programmes of various types have worked for many years with families in poverty. Social workers and home economists work with families, family planning with couples, and farming systems projects with households. Micro-enterprise programmes increasingly recognize the role of families as managers of strategic resources (Foss 1992). Nevertheless, until now, almost all of the pioneering work and literature on family programmes per se has been in the area of early childhood development.

Early childhood intervention family programmes take a two-generational approach, averting future poverty in the child's generation while improving family conditions in the present generation. They enter more intimately into the psychological environment of the family than other programme types, and they are based on evidence that interventions with children before the age of five have long-term benefits on rates of school completion, employment, teen pregnancy, and other indicators of family social health and economic development (Berrueta-Clement et al. 1984). This evidence supports a continuing focus on child development in multipurpose family initiatives.

Across the world, as early childhood development interventions start up, they show a progression from minimal to extensive family involvement (Simeonsson and Bailey 1990). Programmes are typically childcentred when they begin: they offer services directly to children, with the parent as passive observer. In a next step some parental involvement is encouraged, with a parent taking on the role of "teacher" and providing stimulation for the child. As programmes evolve, they typically recognize that community services also must be offered to the family, as a unit, to enable it to care for its children.

The movement towards greater family involvement probably has occurred in the majority of programme types. According to Weiss and Jacobs (1988), US programmes with different service objectives, in child health, child development, prenatal care, teen pregnancy prevention, and treatment of children with special needs, increasingly use similar models for involving the family. Community-based programmes in Indonesia and programmes in other developing countries based on the primary health care (PHC) concept have moved in very similar directions. According to Weiss and Jacobs (1988), these programmes:

1. Demonstrate an ecological approach to promoting child and adult growth by

(a) enhancing both the family's child-rearing capacity and the community context;

(b) building on and strengthening the interdependent relationships between the family and the community.

2. Are community-based and hence

(a) are sensitive to local needs and resources, even when government sponsored;

(b) use horizontal multilateral rather than vertical approaches to service delivery through creative use of volunteers, paraprofessionals, peer support, and social networks, in addition to professional services.

3. Provide services in the domains typically classified under the heading of "social support," including

(a) information;

(b) emotional and appraisal support (empathy, feedback, and reinforcement to adults in parenting roles, and access to other parents);

(c) instrumental support (referrals, transportation, etc.).

4. Emphasize prevention of mortality and of child and family dysfunctions.

These programmes, employing similar means to achieve overlapping ends, are likely to have a common set of outcomes that benefit families, such as enhanced parenting skills, reduced social isolation, and richer, more developmentally appropriate parent-child interactions.

In international child health and nutrition, such family-level outcomes are only beginning to become a part of the explicit goals of programmes in which they may have exerted beneficial effects for some time. During the 1980s, the international focus for children gradually shifted from child survival alone to child survival and development. The concept of vulnerable groups, which applied earlier to preschool children and to pregnant and lactating women, was extended to women and girl children. The family focus builds on development work in health, nutrition, population, agriculture, and rural development.

Myers (1992), writing for UNICEF in his book, The Twelve Who Survive, reviewed international development frameworks for child survival, health, nutrition, and development, with the child as the focus. These frameworks usually represent the family by the mother alone, although the word "parent" may be used instead. Some depict macro-systems of development inputs pointing through the mother to the child; others depict parent-child transactional relationships, and still others (Zeitlin, Ghassemi, and Mansour 1990) include the social system, the mother, and the child. Myers (1992) reported the following trends towards perspectives which increasingly engage with the micro-ecology of the family level in the fields of child survival, growth, and development:

1. From a definition of survival, growth, and development as states or conditions to considering them as processes.

2. From isolated emphasis on one or another dimension of child survival and development to a multidimensional and "integrated" view (Mosley and Chen 1984; L. Bennett, as cited in Myers 1992), to models including physical and psychosocial dimensions of development (Zeitlin, Ghassemi, and Mansour 1990).

3. From a one-way relationship between health or nutrition actions affecting early childhood development (Mosley and Chen 1984) to a two-way interactive relationship in which developmentally sensitive interactions affect health and nutritional status (Zeitlin, Ghassemi, and Mansour 1990).

4. From a view of the child as a passive recipient of "stimulation", or of other interventions, to the child as an actor, influencing the development process (Bronfenbrenner 1979; Super and Harkness 1987; Zeitlin, Ghassemi, and Mansour 1990).

5. From a "universal" definition of the goals and outcome of child development to a more culturally relative and sensitive view (Bronfenbrenner 1979; Super and Harkness 1987).

The emphasis on the family can be viewed as one more step in this process of integration and contextualization. It also is a step in the direction of respect for the social structures and the cultural integrity of the participants in the development process. These programmes move away from deficit and didactic models to partnerships in which all participants, parents, and professionals have expertise and support to share (Weiss and Jacobs 198X).

Myers speaks for our current effort to combine the "piecemeal thinking" of the various disciplines:

... we are victims of the age of specialization in which we live. Academic and bureaucratic divisions of labour cut the child into small pieces. The "whole single child," so often present in the rhetoric of child development, is slowly dissected in a series of unconnected, narrowly conceived analyses. Doctors, psychologists, nutritionists, sociologists, educators, anthropologists, economists, and others, each approach the topic from a distinct point of view. (Myers 1992, 49)

Our return to dealing with the whole child in the whole family may be viewed as a part of the de-differentiation that is characteristic of the postmodern era (Lash 1990). A corresponding process of integrating research disciplines also has occurred among the epidemiologists, nutritionists, economists, child psychologists, anthropologists, and other researchers who specialize in the problems of children in poverty. These researchers have become social science generalists, drawing across many disciplines for research techniques to flesh out the increasingly detailed and complete pictures that can be generated using data processing technology (see ch. 9).

The UNICEF conceptual framework

The UNICEF conceptual framework shown in figure 5.1 (Jonsson 1992) provides a basis for assessment, analysis, and action to improve child nutrition and development and is an effective tool for mobilizing communities and designing programmes. This framework deliberately leaves vague the ecological levels to permit emergence of different causal patterns in different context-specific circumstances. This flexibility permits specification of family-level variables, as one context of analysis. Accordingly, we drew on this framework in designing our latent variables for the analyses in chapter 9.

Fig. 5.1 Causes of malnutrition: the UNICEF model (source: Jonsson 1992)

Family factors and programmes that protect high-risk children

This section first reviews naturally occurring, informal, or family circumstances that protect children, followed by the formal circumstances established in intervention programmes designed for children alone or children and their families. We present evidence for the view of Meisels (1985) that,

The family and its sociocultural and economic context is the crucible in which forces for good and ill are transformed into developmental patterns for high risk and handicapped children in the first years of life. The evidence from a whole generation of research demonstrates that the quality of parents' behavior as caregivers and teachers makes a difference in the development of infants and young children. (Meisels 1985, 9)

Family factors linked to resilience and positive deviance

The literature on the caretaking correlates of optimal child development and the data on children who are invulnerable, resilient, or positive deviants (Rutter 1987; Werner 1990; Zeitlin, Ghassemi, and Mansour 1990) provide descriptions of the naturally occurring circumstances that protect children from the worst effects of the illness, absence, or death of a parent; of an unstimulating environment; or of the limitations of highly impoverished surroundings.

Of key importance to resilient children is at least one person who provides stable care, affection, and attention during the first years (Furstenberg 1976; Kellam, Ensminger, and Turner 1977; Crockenberg 1981; Werner and Smith 1982; Sheey 1987). Such a warm and stable relationship allows children to develop trust in others and to develop the secure sense that they are worthy of being loved. Loving grandparents, sibling caregivers, or friends and neighbours can supplement the care of overextended, absent, or dysfunctional parents.

There are also ways of caring for or raising children that tend to increase the children's ability to cope with problems. Longitudinal studies have shown that resilience in boys and girls is promoted by different parental behaviours (Werner and Smith 1982; Block and Gjerde 1986). Boys appear to be most resilient when they are raised in families that have more rules, structure, parental supervision, and a male role model, and where the expression of feelings is encouraged. Girls appear to do best where they are not overprotected, where they are encouraged to be independent and to take risks, and when they receive consistent emotional support from their primary caregiver.

Positive experiences in school also support resilient children. Rutter (1987) points out that schools that support high-risk children have high academic standards, offer incentives for good work, encourage performance with feedback and praise, and offer children opportunities to experience trust and responsibility. Supportive schools have a more organized and predictable environment, with clear rules, and defined student responsibilities. Teachers also may serve as positive role models and protective influences for highly stressed or disadvantaged children.

In developing countries, descriptions of resilient children are largely based on field observations rather than on longitudinal data. The protective factors that appear to be most common in developing countries (Dash and Dash 1982; Swaminathan 1986; International Development Research Center 1988; Colletta and Satoto 1989; Landers 1989; Zeitlin, Ghassemi, and Mansour 1990) include the following:

1. A high value placed on children and female commitment to mothering;

2. Emotional security and close bonding with mother;

3. Intense caretaking, high in tactile and verbal stimulation;

4. Sense of belonging fostered by involvement in a family-based social network with multiple family caregivers;

5. A wellstructured, organized, and clean home;

6. Learning by observing and interacting with adults;

7. Emphasis on selfreliance and self-help skills;

8. High manual dexterity and attentiveness to changes in the environment.

The effects of early intervention programmes

Programmes that provide services directly to children

There have been a number of reviews of the effects of early interventions on children (Simeonsson, Cooper, and Scheiner 1982; Halpern and Myers 1984; White and Casto 1985; Dunst 1986; Farran 1990; Myers 1992). Despite the considerable methodological flaws in the database, there are by now enough studies to allow us to draw conclusions for practice.

The majority of the studies reviewed focused on children at high risk for school problems, developmental delays, or problems in learning to read. The children studied also tended to be of low socioeconomic status and most were Black, though some studies included Hispanics and children in developing countries. While most studies were carried out in North America or Europe, two reviews (Halpern and Myers 1984; Myers 1992) considered the impact of programmes in developing countries.

From the data on children in developed countries, it may be concluded that when intervention services are provided directly to the child there is gain in school achievement and intelligence test performance. Intelligence test score gains are of the magnitude of up to one standard deviation (10-15 IQ points) in the short term. In developing countries (Myers and Hertenberg 1987) it may be concluded that most, if not all, early childhood intervention programmes have the effect of making children more alert, sociable, curious, and well prepared for primary school. Consistent with the findings from developed countries, children from the most deprived backgrounds (lower income, more socially distressed) tend to benefit the most from programme participation.

Data on the long-term impact of early intervention suggest that continued intervention is necessary for continued higher IQ scores but not for some improvements in school achievement. Data from the United States show that by five years of age, intervention children tend to score one-half standard deviation above control children; by the time they are seven years old and older there are no reported remaining intervention-control group differences in IQ scores, though a number of studies show decreased drop-out rates, fewer special education placements, and fewer grade retentions (Berrueta-Clement et al. 1984). Programmes in developing countries have not yet produced documentation of long-term effects beyond the third grade, but field experiences suggest that the readiness of the school to respond to more active and curious children is crucial in the process of maintaining the effects. While initial adjustment to school is better, the long-term impact seems to be overwhelmed by the limitations of the schools that the children enter.

While there are few data to suggest that preschool intervention, which is not continued into elementary school, has a long-term impact on IQ scores (Farran 1990), when the intervention is continued into the early elementary grades the effects are long lasting. Effects include intervention children both performing on grade level and graduating from high school at a higher rate than the controls (Becker and Gersten 1982; Meyer, Gersten, and Gutkin 1983; Gersten and Carnine 1984; Meyer 1984). Effective interventions tended to consist of improving the quality of the school day, for instance monitoring the teachers to make sure that classes receive academic instruction for 60 per cent of the school day (Farran 1990).

Programmes that provide services to families

Interest in family-based interventions has been spurred by the evidence that early interventions, when focused on the child alone, have a time-limited impact (Simeonsson, Cooper, and Scheiner 1982) and that a multifaceted approach appears to be more effective in both developed and developing countries (Farran 1990; Myers 1992).

Interventions focusing on providing services to children through their parents generally foster a partnership between the parent and programme on behalf of the child. In reviewing interventions nearly two decades ago, Bronfenbrenner (1979, 595) concluded that,

The involvement of the child's family as an active participant is critical to the success of any intervention program. Without such family involvement, any effects of intervention, at least in the cognitive sphere, appear to erode fairly rapidly once the program ends.

One approach to parental involvement considers the parent to be the primary teacher of the child, with the intervention team showing the parent how to work with the child. Home intervention programmes typically have used this approach, in which a paraprofessional home visitor makes a home visit, showing the parent how the child's development can be furthered if the parent engages the child in specific cognitive or language-based activities. These programmes have the advantages of keeping responsibility for children centred in the family, increasing the likelihood of long-term improvements through changes in parental behaviours, and providing services to children at a relatively low cost. As Myers (1992) points out, field experience with home visiting programmes suggests that they have the greatest impact if:

1. The learning is reinforced with occasional group meetings;

2. All family members, not just mothers, are involved;

3. The home visits focus on concrete problems and activities;

4. Parents are active participants in working out the details of the activities, rather than having the home visitor use a "cookbook" approach.

Another approach to parental involvement is to educate the parent about children and their development. Such parent education programmes tend to be training programmes in which the main goals are to direct changes in parental knowledge, attitudes, and behaviours. Bailey and Simeonsson (1990) summarize the outcome of research on parent training:

1. Parents can be taught to use correct and consistent educational interventions, behaviour management techniques, or therapeutic techniques.

2. Parent training programmes often result in desired changes in child behaviour and development.

3. Effective training includes modelling, practice, and specific feed back as well as a way of monitoring parental performance.

4. Long-term maintenance of changes in parental behaviour has not been adequately documented.

Seitz and Provence (1990, 423) review caregiver-focused models of early intervention, concluding that the following outcomes "appear open to influence through caregiver-focused early intervention":

1. Raising children's development and intelligence quotients (DQs and IQs);
2. Improving children's school adjustment;
3. Increasing maternal education;
4. Increasing spacing of subsequent child-bearing;
5. Improving the quality of parent-child interaction;
6. Improving parental responsiveness to children;
7. Improving children's socialization.

The evidence on direct training interventions with families seems convincing, that parents can be taught skills, knowledge, and techniques that facilitate their children's development. This instruction also is applicable to other children in the family and seems to be related to greater feelings of parental satisfaction and control (Myers and Hertenberg 1987). We also know, however, that the more negative circumstances the family suffers, the less they are able to benefit from a highly focused intervention programme. For such families, a more comprehensive system of community support and crisis interventions also may be necessary.

Impacts on family functioning or social health

Child-centred programmes with goals for family functioning

Although most programmes have targeted child outcomes only, Weiss (1988) lists four US programmes that have set goals for family economic selfsufficiency and one for life events stress. Evaluations of these programmes have measured educational advancement, employment and training, different sources of income, rate of subsequent births, quality of life, recent stressful experience, and high-risk status.

Programmes for handicapped children with special needs have pioneered the process of creating individualized family plans for meeting needs for nurturance and emotional support (Walker and Crocker 1988). Family preservation programmes that intervene with crisis counselling and programmes providing social support to teenage parents are models that need further investigation for international application. Weiss (1988) also calls for more investigation of the beneficial impact that family programmes have on service delivery systems, by increasing family-level demand for, and use of, a wide range of services.

Community-based interventions

In reviewing community-based early childhood interventions in the United States, Halpern (1990) concludes that community-based parenting programmes can influence maternal emotional responsiveness, affection, praise, appropriate control, and encouragement of child verbalization. The programmes are most effective when there is a strong focus on improving parenting knowledge and skills. When the focus is a more diffuse attempt to improve the parents' personal adjustment, there tend to be fewer significant gains for either the parent or the child. Halpern concludes that because the influence of these programmes on the child is indirect (mediated through the parent) there tend to be modest short-term effects on child development. We believe that this conclusion underestimates the potential for positive gain.

As noted above, the trend is towards community-based interventions, which most typically are neighbourhood based, employ workers from the local area, and attempt to improve overall family conditions to remove or decrease those circumstances known to be damaging to child development. To meet these goals, model programmes such as Parent-Child Center programs (PCC), the Parent-Child Development Centers (PCDs), and the Child and Family Resource Programs (CFRPs) have been run in the United States.

Myers (1992) looks at community-based programmes in developing countries, pointing out that general improvements in child survival and development hinge on improvements in the community that protects, nourishes, and challenges the young child. Community development approaches in developing countries tend to focus on improving family achievements in the basic task areas of income, food, health, shelter, and sanitation. Community development programmes favour the continuity and sustainability of programmes that are run for the community by the community. Such programmes also have the potential for improving life for everyone in the community, not just the children (Myers 1992).


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