Parental Health and Early Child Development
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The period from pregnancy to age 3 is when children are most susceptible to environmental influences. The period lays the foundation for health, well-being, learning, and productivity throughout a person’s whole life and has an impact on the health and well-being of the next generation. The biggest threats are extreme poverty, insecurity, gender inequities, violence, environmental toxins, and poor mental health. All of these things affect parental health.
Children’s early development requires nurturing care – defined as health, nutrition, security and safety, responsive caregiving, and early learning – provided by parent and child interactions and supported by an environment that enables these interactions. Early childhood development programs vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. To provide it, parents and their families – in all their diversity and all their forms, biological and social – need information, resources, and services.
Effective and sustainable interventions to improve developmental outcomes need to promote nurturing care and protection, be implemented as packages that target multiple risks, be applied at developmentally appropriate times during the life course, be of high quality, and build on existing delivery platforms to enhance feasibility of scaling-up and sustainability.
KeywordsEarly child development Nurturing care Developmental origins of health and disease Early mother infant interaction
The period from pregnancy to age 3 is when children are most susceptible to environmental influences (Shonkoff et al. 2012). The period lays the foundation for health, well-being, learning, and productivity throughout a person’s whole life and has an impact on the health and well-being of the next generation. The biggest threats are extreme poverty, insecurity, gender inequities, violence, environmental toxins, and poor mental health (Black et al. 2017). All of these affect parental health. The threats reduce these parental capacities to protect, support, and promote young children’s development. Children in the early developmental stage need nurturing care, the conditions that promote health, nutrition, security, safety, responsive caregiving, and opportunities for early learning (Lagercrantz 2016). Nurturing care is about children, their parents, and the places they interact.
Parents are at the center of nurturing care for young children. In the period from pregnancy to age 3, parents are the people most consistently present in children’s lives. As such, they are the primary providers of nurturing care. To provide it, parents and their families – in all their diversity and all their forms, biological and social – need information, resources, and services. Parents need to be included in programs that are designed to educate and support them in providing nurturing care (Richter et al. 2017). There are accumulating evidences that elucidate what strengthens parents’ capacity to support young children’s development. A facilitating environment is needed: policies, programs, and services that parents the knowledge and resources to provide nurturing care for young children. Community participation is a key part of this environment, which also needs to consider the diversity of children and families.
Early Child Development and Contributions of Parental Health
Developmental Origins of Health and Disease
Noncommunicable diseases (NCDs), mainly cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases, are responsible for 63% of global deaths. The Developmental Origins of Health and Disease (DOHaD) hypothesis was developed from the notion of fetal programming, initially proposed by Barker in the 1990s (Barker 1995, 2007), based on his observation on human epidemiology (Safi-Stibler and Gabory 2019). This concept postulates that the environment in which the individual finds himself/herself during his early development (pre-conceptional, in utero, and early postnatal periods) may have important consequences for his health, during his adult life, leading to NCDs. The literature about Developmental Origins of Health and Disease (DOHaD) studies is considerably growing. Maternal and paternal environment, during all the development of the individual from gametogenesis to weaning and beyond, as well as the psychosocial environment in childhood and teenage, can shape the adult and the elderly person’s susceptibility to her/his own environment and diseases. The different mechanisms by which the environment can model the epigenome: receptor signaling, energy metabolism, and signal mechanotransduction from extracellular matrix to chromatin. Then the epigenetic changes in response to maternal environment during the vulnerability time windows, gametogenesis, early development, placentation and fetal growth, and postnatal period are described with the specific example of overnutrition and food deprivation. The hope and effort carried by the epigenetic field in DOHaD is the possibility of reversibility, with an intervention proposed to the individual himself/herself. In the case of epigenetic changes in response to parental environment leading to the phenotype in the first hypothesis. Alternatively by taking care of parent-at-risk in the adequate time window, we could avoid the establishment of a deleterious epigenotype in the offspring, thus preventing the development of pathology. The question of the causal chain is therefore a crucial question we have to answer now. A final aspect is that it would be time to take a closer look, 30 years after the Barker’s hypothesis, at the health aspect in DOHaD. We could draw a parallel with the sociological concept of “salutogenesis” and suggest that certain foods or early behaviors that parents will provide to their children will help boost a “fitness” epigenome, helping therefore to break the vicious cycle of the NCDs pandemic.
Contributions of Perinatal Mental Health of Parents
There are some valuable researches regarding the effects of depression in fathers on child development. The Avon Longitudinal Study of Parents and Children (ALSPAC) study showed that paternal depression in the postnatal period could adversely affect emotional and behavioral outcomes in children aged 3.5 years and was associated with increased risk of conduct problems, especially in boys (Birmaher et al. 2009). Based on two other large longitudinal studies, paternal depressive symptoms during childhood were associated with depressive symptoms in their adolescent offspring, independent of the association between maternal and adolescent depressive symptoms (Boyce 2003). There is an association between depression in fathers during the postnatal period and subsequent depression in girls at age 18 years, and conduct problems in childhood seem to be a pathway for risk transmission between paternal depression and subsequent depression in adolescent offspring (Brent et al. 2014). These findings emphasize the importance of recognizing and treating depression in also fathers during the postnatal period.
Antenatal anxiety has been reported to be associated with various offspring problems, including both emotional and behavioral problems (Brent et al. 2015). Postnatal anxiety has been suggested to cause both psychological and somatic problems (Calhoun et al. 2015). Another study examining the role of PND and GAD symptom chronicity on children’s emotional and behavioral functioning at 24 months showed that maternal PND and GAD symptom severity were related to maternal report of child behavior problems and higher levels of emotional negativity (Chen and Weitzman 2005).
The Importance of Nurturing Care for Early Child Development
Nurturing care starts before birth, when mothers and other caregivers can start talking and singing to the fetus. By the end of the second trimester of pregnancy, the growing fetus can hear. And, from birth, the baby can recognize the mother’s voice. Early bonding is facilitated by skin-to-skin contact, breastfeeding, and the presence of a companion to support the mother. These also build the foundations for optimal nutrition, quality interactions, and care. Soon after birth, babies respond to faces, gentle touch and holding, as well as the soothing sound of baby talk. Parents soon learn to appreciate how babies respond to them, which is essential for the optimal development of the baby’s rapidly growing brain. Scientific findings from neuroscience and developmental psychology show that these caregiver-child interactions are highly beneficial for early childhood development, and have long-lasting effects. Starting from the first months, quality time with the baby, including smiling, touching, talking, storytelling, listening to music, sharing and reading books, and engaging in play, builds neural connections that strengthen the child’s brain (Gutierrez-Galve et al. 2019).
Nurturing care is necessary for all babies, but premature and low-birthweight babies (and babies with congenital conditions) need it even more. Unfortunately, they often get less of it. Parents need guidance in their interaction with these vulnerable babies, because these babies’ behavior and responses are often less predictable than others’. Without nurturing care, these infants are at risk of difficulties in their development. These difficulties can challenge caregivers who are already stressed by the birth of a so-called small baby. As a result, premature and low-birthweight babies may receive less attention and are sometimes neglected or maltreated, which puts them at greater risk of poor development. Health services and professionals need to give caregivers information and advice, and to support families, particularly ones with babies who are experiencing perinatal problems. Interventions during the neonatal period, such as kangaroo care, accompanied by specific, enhanced nurturing care at home, improve neonatal outcomes in small babies and have long-term beneficial effects throughout life. There would also be greater benefits for mothers and babies if health services gave parents information about how breast milk nurtures both the child and the parent-child relationship.
The mother’s nutrition during pregnancy affects her health and well-being, as well as the developing child’s nutrition and growth. Young children flourish on exclusive breastfeeding, from immediately after birth to the age of 6 months, together with skin-to-skin body contact (Charpak et al. 2017; Rollins et al. 2016). From the age of 6 months, young children need complementary foods that are frequent and diverse enough, which contain the micronutrients they need for the rapid growth of their body and brain (Black et al. 2008). This is in addition to breast milk and needs to be offered in a way that accommodates the social and emotional interaction involved in feeding a young child. And when children’s daily diet fails to support healthy growth, they need micronutrient supplements or treatment for malnutrition (including obesity). Food safety and family food security are essential for adequate nutrition.
Early Mother Infant Interaction
Responsive caregiving includes observing and responding to children’s movements, sounds, and gestures and verbal requests. It is the basis for protecting children against injury and the negative effects of adversity which are recognizing and responding to illness, enriched learning, and building trust and social relationships. Responsive caregiving also includes responsive feeding, which is especially important for low-weight or ill infants (Engle and Pelto 2011). Before young children learn to speak, the engagement between them and their caregivers is expressed through cuddling, eye contact, smiles, vocalizations, and gestures. These mutually enjoyable interactions create an emotional bond, which helps young children to understand the world around them and to learn about people, relationships, and language. These social interactions also stimulate connections in the brain.
Due to parental depression, limitations in their ability of synchrony, reflection, and emotional expression may affect infants’ emotional, behavioral, biological, and physiological profile. Infants of depressed parents tend to express less emotion, engage less in positive interactions, and elevated cortisol levels. These altered profiles may also constitute risk for intergenerational transmission.
Perinatal depression (PND) affects around 13% of mother (Stein and Harold 2015). Since infants are totally dependent on parents for their development, postnatal period has been a particular interest of clinical research and a critical focus on the benefits of early prevention and intervention. PND-mediated disturbances in parents’ emotional expression, regulation of emotions, and affective synchrony could adversely affect socio-emotional development of their offspring. Further, impairments in the parent-child reciprocal regulation of affect and the resulting difficulties in emotion regulation may contribute to vulnerability for development of psychopathology in children, especially in the presence of other risk factors such as insecure attachment and difficult temperament (Aktar et al. 2019). Those at particular risk of developing PND include women with a past history of depression, lack of social support, socioeconomic deprivation, or social isolation (Boyce 2003).
Good mental health and strong motivation are important for parents. They enable parents to recognize the child’s needs and respond appropriately, empathize with a young child’s experiences, and to manage their own emotions and their reactions to their baby’s dependence. Mental health problems among women who are pregnant or have recently given birth are among the most common causes of pregnancy-related morbidity. In resource-constrained low- and middle-income countries, the prevalence of common perinatal mental disorders including depressive, anxiety, and adjustment disorders is much higher than in high-income settings. That is because of risk factors such as socioeconomic stresses, unplanned pregnancy, being younger or unmarried, lacking the empathy and support of an intimate partner, being subject to violence, and having hostile in-laws. Protective factors include having more education and secure income-generating work and having a kind, trustworthy partner. Depression also affects fathers. Mental health problems affect emotions, concentration, judgment, and thinking. Depressed women are likely to have irritability and pessimism, as well as difficulty expressing warmth, affection, and pleasure. They are also likely to be preoccupied with worries and anxiety, including worries about infant care (Murray 1992). These influence their social interactions, including their interactions with the baby.
Risk and Protective Factors for Early Child Development
How to integrate nutrition and psychosocial stimulation programs at scale will be discussed in the next part.
Interventions for Parental Health and Early Child Development
For children to develop in the way that’s best for their whole lives, parents need to have time and resources for providing nurturing care. This is facilitated by enabling environments of policies, services, community, and family. Global policies encourage healthy environments and universal coverage. Countries’ social protection systems protect families and individuals when they face economic and social adversity. Health, education, and social welfare services provide parents with the necessary information and support, including specialized services for children with developmental difficulties. There are home visits for vulnerable families, giving them support, information, and assistance, and linking them with families and children who share their needs. And those who provide all this consider local attitudes, beliefs, and norms, in order to build on practices that are positive and to mitigate ones that are harmful for young children’s development. At each level, a conducive environment enables families and parents to provide nurturing care for young children. The program is designed for low-income mothers who have had no previous live births.
The Nurse Family Partnership program have three major goals: to improve the outcomes of pregnancy by helping women improve their prenatal health, to improve the child’s health and development by helping parents provide more sensitive and competent care of the child, and to improve parental health from life-course perspective by helping parents plan future pregnancies, complete their educations, and find work (Olds 2010).
There are also effective interventions for reducing depression and promoting maternal mental health. They are generally implemented by trained community health workers under professional supervision. Interventions designed to improve mothers’ mental health have a positive impact on infants’ health and development. And interventions to promote infants’ health and development have a positive effect on mothers’ mood. The effects on infant health and development appear to be stronger when interventions for mothers and babies are provided together. Interventions that improve parenting and the quality of the parent-child relationship have been shown to have long-lasting benefits on a range of both externalizing and internalizing symptoms of offspring. A randomized controlled trial indicated that, in addition to intensive treatment for persistent postnatal depression, additional specific parenting intervention such as video-feedback therapy could be effective for child development outcomes leading into the normal range (Stein et al. 2018). Another randomized controlled trial suggested that the relationship-focused behavioral coaching intervention by home visits of nurse in increasing maternal-infant relational effectiveness between depressed mothers and their infants during the first 9 months postpartum, where nurse taught mothers to identify and respond sensitively to their infant’s behavioral cues, increased in quality of mother-infant interaction and decreased in depression severity (Horowitz et al. 2013). Interventions targeting both parental psychopathology and parent-infant interactions appear promising in mitigating the risk of early intergenerational transmission (Aktar et al. 2019). The treatment of prenatal depression appears to have beneficial effects on offspring self-regulation, stress reactivity, and temperament. The combination of effective early interventions targeting parental depression and parent-infant relationship may significantly improve child outcomes, compared to the interventions addressing either parental psychopathology or parent-infant relationship in isolation.
New evidence supports a life-course perspective on childhood development primarily through advances in neuroscience and longitudinal follow-up approaches. Poverty and adverse childhood experiences have long-term physiological and epigenetic effects on brain development and cognition. The accumulation of adversities, beginning before conception and continuing throughout prenatal and early life, can disrupt brain development, attachment, and early learning. Developmental delays are evident in the first year, worsen during early childhood, and continue throughout life.
Children’s early development requires nurturing care – defined as health, nutrition, security and safety, responsive caregiving, and early learning – provided by parent and child interactions and supported by an environment that enables these interactions. Early childhood development programs vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential (Black et al. 2017). There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Coordinated multisectoral, multilevel programs might be necessary to reduce multiple adversities while enhancing protective factors.
Effective and sustainable interventions to improve developmental outcomes need to promote parents’ nurturing care and protection, be implemented as packages that target multiple risks for parents and child, be applied at developmentally appropriate times during the life course, be of high quality, and build on existing delivery platforms to enhance feasibility of scaling-up and sustainability.
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