The Cost of Inaction
for Young Children Globally

Workshop Summary

Kimber Bogard and Maureen Mellody, Rapporteurs

Forum on Investing in Young Children Globally

Board on Children, Youth, and Families

Board on Global Health

       INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
                         OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This activity was supported by contracts between the National Academy of Sciences and the Accordia Global Health Foundation; the Aga Khan Founda- tion (unnumbered); Autism Speaks (unnumbered award); the Bernard van Leer Foundation (222-2012-043); The Bill & Melinda Gates Foundation (OPP1084405); Grand Challenges Canada (unnumbered); The William and Flora Hewlett Foun- dation (2013-9204); the Inter-American Development Bank (unnumbered); the Jacobs Foundation (2013-1079); National Institutes of Health–Fogarty Interna- tional Center, National Institute of Mental Health, and National Institute of Child Health and Human Development (HHSN26300051); the Nestlé Nutrition Institute (unnumbered); the Open Society Institute–Budapest (OR2013-10010); the Society for Research in Child Development (unnumbered); UNICEF (unnumbered); U.S. Centers for Disease Control and Prevention (200-2011-38807, TO #21); U.S. Depart- ment of State (SAQMMA14M0612); the Maria Cecilia Souto Vidigal Foundation (unnumbered); and the World Bank (unnumbered). The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13:  978-0-309-30775-8 International Standard Book Number-10:  0-309-30775-9 Additional copies of this workshop summary are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine) and National Research Council (NRC). 2014. The cost of inaction for young children globally: Workshop summary. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern- ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE ON INVESTING IN YOUNG CHILDREN GLOBALLY: THE COST OF INACTION—A WORKSHOP1 AMINA ABUBAKAR, Centre for Geographic Medicine Research– Kenya Medical Research Institute/Wellcome Trust Research Programme CONSTANZA ALARCÓN, Coordinator of the National Early Childhood Strategy, Presidency of the Republic, Colombia RAQUEL BERNAL, Associate Professor and Director of the Center for Research on Economic Development, Universidad de los Andes GILLIAN HUEBNER, Child Protection Technical Advisor, U.S. Agency for International Development JOAN LOMBARDI, Senior Advisor, Bernard van Leer Foundation FLORENCIA LOPEZ BOO, Social Protection Economist Senior Specialist, Inter-American Development Bank CHLOE O’GARA, Program Officer, Global Development and Population Program, The William and Flora Hewlett Foundation LORRAINE SHERR, Professor of Clinical and Health Psychology, University College, London ANDY SHIH, Senior Vice President, Scientific Affairs, Autism Speaks QUENTIN WODON, Adviser, Human Development Network, World Bank HIROKAZU YOSHIKAWA, Courtney Sale Ross University Professor of Globalization and Education, New York University IOM Staff SARAH M. TRACEY, Research Associate CHARLEE ALEXANDER, Research Assistant JOCELYN WIDMER, Mirzayan Fellow PAMELLA ATAYI, Administrative Assistant RACHAEL CLARK, Duke University Intern KIMBER BOGARD, Director, Board on Children, Youth, and Families PATRICK W. KELLEY, Director, Board on Global Health 1  Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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FORUM ON INVESTING IN YOUNG CHILDREN GLOBALLY1 ZULFIQAR A. BHUTTA (Co-Chair), Co-Director, SickKids Centre for Global Child Health, Toronto and Founding Director, Center of Excellence for Women and Child Health, Aga Khan University ANN MASTEN (Co-Chair), Distinguished McKnight University Professor, Institute of Child Development, University of Minnesota, Minneapolis J. LAWRENCE ABER, Willner Family Professor of Psychology and Public Policy, Steinhardt School of Culture, Education, and Human Development and University Professor, New York University AMINA ABUBAKAR, Centre for Geographic Medicine Research– Kenya Medical Research Institute/Wellcome Trust Research Programme CONSTANZA ALARCÓN, Coordinator of the National Early Childhood Strategy, Presidency of the Republic, Colombia NICOLE BEHNAM, Senior Orphans and Vulnerable Children Advisor, PEPFAR/Office of the U.S. Global AIDS Coordinator, U.S. Department of State RAQUEL BERNAL, Associate Professor and Director of the Center for Research on Economic Development, Universidad de los Andes PIA REBELLO BRITTO, Senior Advisor, Early Childhood Development Unit, UNICEF PAMELA Y. COLLINS, Director, Office for Research on Disparities and Director, Global Mental Health and Office of Rural Mental Health Research, National Institute of Mental Health GARY DARMSTADT, Senior Fellow, Global Development Division, The Bill & Melinda Gates Foundation ANGELA DIAZ, Jean C. and James W. Crystal Professor, Departments of Pediatrics and Preventive Medicine, Icahn School of Medicine at Mount Sinai and Director, Mount Sinai Adolescent Health Center RANA HAJJEH, Director, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, U.S. Centers for Disease Control and Prevention JODY HEYMANN, Dean, Fielding School of Public Health, University of California, Los Angeles GILLIAN HUEBNER, Child Protection Technical Advisor, U.S. Agency for International Development 1  Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the work- shop rapporteurs and the institution. vi

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VENITA KAUL, Director, School of Education Studies and Director, Center for Early Childhood Education and Development, Ambedkar University, Delhi SARAH KLAUS, Director, Early Childhood Program, London, Open Society Foundations VESNA KUTLESIC, Director, Office of Global Health, National Institute of Child Health and Human Development ALBERT LEE, Professor (Clinical), JC School of Public Health and Primary Care and Director, Centre for Health, Education, and Health Promotion, The Chinese University of Hong Kong JOAN LOMBARDI, Senior Advisor, Bernard van Leer Foundation FLORENCIA LOPEZ BOO, Social Protection Economist Senior Specialist, Inter-American Development Bank KOFI MARFO, Professor of Educational Psychology, Department of Psychological and Social Foundations, University of South Florida and Director of the Institute for Human Development at Aga Khan University MARK MILLER, Director, Division of International and Population Studies, Fogarty International Center HELIA MOLINA MILMAN, Professor in Public Health, Public Health Department, Pontificia Universidad Católica de Chile and Minister of Health, Chile TARYN MORRISSEY, Senior Advisor to the Deputy Assistant Secretary for Human Services Policy, Office of the Assistant Secretary for Planning and Evaluation CHLOE O’GARA, Program Officer, Global Development and Population Program, The William and Flora Hewlett Foundation ALAN PENCE, UNESCO Chair, Early Childhood, Education, Care and Development and Professor, School of Child and Youth Care, University of Victoria RUTH PEROU, Acting CDC Mental Health Coordinator, Program Performance and Evaluation Office, U.S. Centers for Disease Control and Prevention EDUARDO QUEIROZ, Executive Director, Maria Cecilia Souto Vidigal Foundation JOSE SAAVEDRA, Global Chief Medical Officer, Nestlé Nutrition LORRAINE SHERR, Professor of Clinical and Health Psychology, University College, London ANDY SHIH, Senior Vice President, Scientific Affairs, Autism Speaks KARLEE SILVER, President of Targeted Challenges, Grand Challenges Canada SIMON SOMMER, Head of Research, Jacobs Foundation vii

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REBECCA STOLTZFUS, Professor and Director, Program in International Nutrition, Program in Global Health, Cornell University TAHA E. TAHA, Professor, Epidemiology and Population, Family and Reproductive Health Sciences, Bloomberg School of Public Health, Johns Hopkins University LINDA ULQINI, Senior Program Officer, Aga Khan Foundation SUSAN WALKER, Professor of Nutrition and Director, Tropical Medicine Research Institute, Epidemiology Research Unit, University of the West Indies KELLY S. WILLIS, Executive Director, Accordia Foundation QUENTIN WODON, Adviser, Human Development Network, World Bank HIROKAZU YOSHIKAWA, Courtney Sale Ross University Professor of Globalization and Education, New York University viii

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BOARD ON CHILDREN, YOUTH, AND FAMILIES1 ANGELA DIAZ (Chair), Departments of Pediatrics and Preventive Medicine, Icahn School of Medicine at Mount Sinai SHARI BARKIN, Monroe Carell Jr. Children’s Hospital, Vanderbilt University THOMAS F. BOAT, College of Medicine, University of Cincinnati W. THOMAS BOYCE, Faculty of Medicine, University of British Columbia DAVID A. BRENT, Western Psychiatric Institute and University of Pittsburgh School of Medicine DAVID V. B. BRITT, Retired CEO, Sesame Workshop DEBBIE I. CHANG, Nemours Health and Prevention Services JANET M. CURRIE, Woodrow Wilson School of Public and International Affairs, Princeton University PATRICK H. DELEON, F. Edward Hebert School of Medicine and the Graduate School of Nursing, Uniformed Services University of the Health Sciences GARY W. EVANS, Department of Design and Environmental Analysis and Department of Human Development, Cornell University ELENA FUENTES-AFFLICK, University of California, San Francisco; and San Francisco General Hospital EUGENE E. GARCIA, Mary Lou Fulton Teachers’ College, Arizona State University J. DAVID HAWKINS, School of Social Work, University of Washington JEFFREY W. HUTCHINSON, Uniformed Services University of the Health Sciences JACQUELINE JONES, Early Childhood Education Specialist ANN S. MASTEN, Institute of Child Development, University of Minnesota VELMA McBRIDE MURRY, Peabody College, Vanderbilt University BRUCE S. McEWEN, The Rockefeller University PAMELA MORRIS, The Steinhardt School of Culture, Education, and Human Development, New York University TAHA E. TAHA, Bloomberg School of Public Health, Johns Hopkins University 1  Institute of Medicine and National Research Council boards do not review or approve individual products. The responsibility for the content of the workshop summary rests with the workshop rapporteurs and the institution. ix

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BOARD ON GLOBAL HEALTH1 THOMAS C. QUINN (Chair), National Institute of Allergies and Infectious Diseases, National Institutes of Health; and Johns Hopkins University School of Medicine JO IVEY BOUFFORD, New York Academy of Medicine CLAIRE V. BROOME, Department of Global Health, Rollins School of Public Health, Emory University JACQUELYN C. CAMPBELL, Johns Hopkins University School of Nursing THOMAS J. COATES, UCLA Program in Global Health and Division of Infectious Diseases at UCLA GARY DARMSTADT, Global Development Division, The Bill & Melinda Gates Foundation VALENTIN FUSTER, Wiener Cardiovascular Institute, Kravis Cardiovascular Health Center; and Mount Sinai School of Medicine, Mount Sinai Medical Center JACOB A. GAYLE, Community Affairs, Medtronic Foundation GLENDA E. GRAY, South African Medical Research Council STEPHEN W. HARGARTEN, Global Health Program, Medical College of Wisconsin PETER J. HOTEZ, Texas Children’s Hospital; Sabin Vaccine Institute; Texas Children’s Center for Vaccine Development; and National School of Tropical Medicine, Baylor College of Medicine CLARION JOHNSON, Private Consultant FITZHUGH MULLAN, Department of Health Policy, George Washington University GUY H. PALMER, School for Global Animal Health, Washington State University 1  Instituteof Medicine boards do not review or approve individual products. The re- sponsibility for the content of the workshop summary rests with the workshop rappor- teurs and the institution. x

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Reviewers This workshop summary has been reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integ- rity of the process. We wish to thank the following individuals for their review of this workshop summary: JERE R. BEHRMAN, University of Pennsylvania ALBERT LEE, The Chinese University of Hong Kong THEODORE D. WACHS, Purdue University SUSAN WALKER, University of the West Indies Although the reviewers listed above have provided many construc- tive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop sum- mary was overseen by Enriqueta Bond, President Emeritus, Burroughs Wellcome Fund. Appointed by the Institute of Medicine and the National Research Council, she was responsible for making certain that an inde- xi

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xii REVIEWERS pendent examination of this workshop summary was carried out in accor- dance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteurs and the institution.

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Acknowledgments The planning committee and project staff deeply appreciate many valuable contributions from individuals who assisted us with this project. First, we offer our profound thanks to all of the presenters and discussants at the workshop, who gave so generously of their time and expertise. These individuals are listed in full in the workshop agenda in Appendix B. We are also grateful to the many participants who attended the work- shop both in person and via the live webcast. The engagement of all those in attendance was robust and vital to the success of the event. In addition, the forum wishes to recognize the sponsors that sup- ported this activity. Financial support for this project was provided by the Accordia Global Health Foundation; the Aga Khan Foundation; Autism Speaks; the Bernard van Leer Foundation; The Bill & Melinda Gates Foundation; Grand Challenges Canada; The William and Flora Hewlett Foundation; the Inter-American Development Bank; the Jacobs Founda- tion; National Institutes of Health–Fogarty International Center, National Institute of Mental Health, and National Institute of Child Health and Human Development; the Nestlé Nutrition Institute; the Open Society Institute–Budapest; the Society for Research in Child Development; UNI- CEF; U.S. Centers for Disease Control and Prevention; U.S. Department of State; the Maria Cecilia Souto Vidigal Foundation; and the World Bank. xiii

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xiv ACKNOWLEDGMENTS A NOTE ABOUT THE COVER ART The Forum on Investing in Young Children Globally is committed to confronting the challenges and exploring the opportunities surrounding the global nature of integrating the science of health, education, nutrition, and social protection. One of the ways the forum has committed itself to being global in scope is through the workshops that occur in different regions throughout the world. The cover design is intended to embrace the diversity in place, culture, challenges, and opportunities associated with the forum activities at each of the workshops, but this global trajec- tory is done keeping in mind the momentum that comes in connecting these diverse locales to one another through the work of the forum. The bright orange dot represents the location of the workshop this report summarizes, and the lighter orange dots represent workshop locations across the first 3 years of the forum. The dotted orange line suggests that the forum will link what was gleaned from the convening activities from this workshop to the next. We would like to thank Jocelyn Widmer for her contributions to the cover design.

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Contents 1 OVERVIEW 1 Forum on Investing in Young Children Globally Overview, 1 Workshop Overview, 3 2 LINKING CHILDREN’S DEVELOPMENTAL POTENTIAL TO A NATION’S DEVELOPMENTAL POTENTIAL 7 3 THE SCIENCE OF DEVELOPMENTAL POTENTIAL 11 The Timing of Integrated Early Interventions: Nutrition, Stress, and Environmental Enrichment, 11 Developmental Potential and Child Disability, 13 Some Critical Gaps in the Current Science Base of Developmental Potential, 15 4 THE STATE OF THE WORLD’S YOUNG CHILDREN 19 Child Development from a Global Perspective, 19 State of Young Children in the Arab Region, 21  The Demographic and Health Surveys (DHS) Program and Children, 23 xv

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xvi CONTENTS 5 INEQUALITY AMONG CHILDREN IN REACHING THEIR DEVELOPMENTAL POTENTIAL 25 Inequalities and Two Generation Approaches, 25 Child Health and Nutrition and the Loss of Human Potential in India, 27 Growing Up Unequal: Trends in Global Inequality Among Children, 29 6 THE CONTEXT OF FAMILIES AND CAREGIVERS 33 Maternal Mental Health, 33 The Caregiving Context and Its Influence on Developmental Outcomes of HIV-Affected Children, 35 Caregiving and Other Contextual Influences on Early Child Development, 37 7 INDICATORS AND METRICS 39 Early Child Development: Measuring Results Beyond 2015, 39 Measuring Early Childhood Development in Low- and Middle-Income Countries: The MICS, 42 “Readiness to Learn” Assessment Project, 43 Early Childhood Rights Indicators (ECRI): A Rights-Based Approach to Enhancing Early Child Development, 44 8 INVESTING IN YOUNG CHILDREN AND THEIR CAREGIVERS 47 Policy Approaches to Supporting Children’s Development, 47 Investing Early and Return on Investment, 50 Continuity of Investments into Primary School, 52 9 BENEFIT–COST ANALYSIS OF INACTION 55 Costs of Inaction Versus Costs of Action for Investing in Young Children Globally, 55 A Comprehensive Country-Level Approach to Investing in Young Children: Colombia, 57 Investing in Young Children for High Returns, 60 REFERENCES 63 APPENDIXES A ACRONYMS 71 B WORKSHOP AGENDA 73 C PARTICIPANT BIOGRAPHIES 77