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The Cost of Inaction for Young Children Globally: Workshop Summary (2014)

Chapter: 6 The Context of Families and Caregivers

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Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
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6

The Context of Families and Caregivers

As they grow and develop, children are affected by numerous contextual factors, most notably the family and caregivers that surround them. The condition of caregivers, particularly their mental health and economic well-being, can have a profound impact on growth and development outcomes of children. Speakers examined the influence of family and caregivers on children’s developmental potential, as well as possible ways to improve conditions for families and caregivers and, thus, for children.

MATERNAL MENTAL HEALTH1

Atif Rahman explained that depression is the second most common global disease burden in women, following infections and parasitic disease (Rahman, 2013), impacting approximately one out of five women in the perinatal period (Parsons et al., 2011). Depression is diagnosed by its symptoms, which include low mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration—all symptoms that profoundly affect maternal functioning. Depression can be chronic, leading to substantial impairments in the mother’s ability to care for her children. Also, depression can lead to mortality; suicide is a leading cause of mortality in women of child-bearing age.

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1 This section summarizes information presented by Atif Rahman, University of Liverpool.

Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×

He framed the problem of maternal depression by dispelling four myths, or states of denial (Rahman et al., 2013a):

  • Myth 1: Maternal depression is rare and occurs only in high income nations. This myth is grounded in the belief that developing countries have better social support networks. Rahman dispelled this myth, stating that the mean prevalence of perinatal depression in low- and middle-income countries was 18 to 23 percent (Fisher et al., 2012; Parsons et al., 2011). These rates, he noted, are quite high.
  • Myth 2: Maternal depression has no impact on children. Rahman argued that this myth has led to the neglect of maternal health. He explained there is strong evidence that links maternal depression to quality of care and child outcomes, including less adequate prenatal care, reduced breastfeeding, child undernutrition, child diarrhea, less adequate child health care, less responsive child care, disrupted mother–infant attachment, increased harsh discipline, reduced coping skills, and increased family stress (Rahman et al., 2013b; Wachs and Rahman, 2013).
  • Myth 3: Nothing can be done about maternal depression. This myth often stems from the fact that there are very few psychiatrists to support low-income populations. Rahman cited evidence that nonspecialists can effectively conduct successful interventions through community-based interventions and home visits. Rahman showed that simple interventions are effective (Rahman, 2013a), with improvements to the mother–child interaction, better cognitive development and growth, reduced diarrhea, and increased immunization rates.
  • Myth 4: Maternal mental health interventions cannot be integrated with other programs such as child programs and maternal health programs. Rahman cited evidence from his trial conducted in rural Pakistan (Rahman et al., 2008) that community health workers were still using techniques for intervention in maternal depression after a number of years, finding the techniques helpful and intuitive (Zafar et al., 2014). He also cited work that emphasized the “five pillars” approach: family support, empathic listening, guided discovery using pictures, behavioral activation, and problem solving that community health workers implemented. A pilot study has indicated that community health workers can be trained to help address maternal depression without much additional burden. The training improves the skill set of the community health workers, and the techniques are feasible and accepted (Zafar et al., 2014).
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×

Rahman concluded by stating the following:

  • Mental health problems, particularly depression, are common in women in the critical perinatal period.
  • Maternal depression is associated with negative outcomes in the child, especially growth and development.
  • Interventions for maternal psychosocial well-being can be delivered by nonspecialists, and therefore benefit both the mother and the child.
  • Strategies to combat maternal depression should be integrated with maternal and child health programs.

A participant noted that paternal health should also be studied.

THE CAREGIVING CONTEXT AND ITS INFLUENCE ON DEVELOPMENTAL OUTCOMES OF HIV-AFFECTED CHILDREN2

Amina Abubakar focused on the chronic stress conditions for children as the result of being infected and/or affected by HIV/AIDS. She stated that 90 percent of all children who are HIV positive live in sub-Saharan Africa, equaling 2.3 million children. More than 16 million children have been orphaned as the result of HIV/AIDS, and many others live with caregivers who are HIV positive (Cluver et al., 2013). Abubakar explained that, as the result of advances in antiviral medications, children with HIV are living longer lives. Now, she emphasized, those children need to thrive, not simply survive.

HIV-infected children lag behind in developmental areas, even when they are on medication and are medically stable. Abubakar explained that HIV-infected children tend to experience more neurocognitive delays, lag behind in educational outcomes, and can experience mental health problems (Abubakar et al., 2009; Devendra et al., 2013; Kamau et al., 2012). Similarly, HIV-affected children are also at risk of poor outcomes (Sherr et al., 2014), and this trend is stronger in resource-constrained areas (Le Doaré et al., 2012), likely the result of inadequate access resources.

Abubakar explained that there are many pathways to poor outcomes for children who are affected by HIV. She focused on caregiving and caregivers, noting that HIV causes multiple risk factors in caregiving. First, when ill, parents cannot bring in income due to lower participation rates in economic activities, and they also have more extensive medical expenses. This may lead to poverty. Children may also be responsible for

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2 This section summarizes information presented by Amina Abubakar, Centre for Geographic Medicine Research–Kenya Medical Research Institute.

Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×

caring for an ill parent. In certain communities, HIV has destroyed the standard support systems, leading to high levels of orphanhood. Finally, caregiver mental health problems, which can include depression and anxiety, are likely increased by the disease, and this is likely related to the stigma associated with the disease.

A study of Ugandan children ages 1 to 5 provided evidence for the adverse impacts of compromised caregiving, including behavioral problems for children (Busman et al., 2013). In describing this study, Abubakar pointed out that there remains a very small evidence base, and others have pointed out that the evidence on how to intervene is piecemeal (Sherr, 2011). This is particularly true for the youngest children. She suggested that more research can be done to understand the caregiving environments of HIV-infected or HIV-affected children.

The best solution, Abubakar proposed, is to address modifiable risk factors and focus on providing protective environments for children. Abubakar explained that in Kenya, HIV-infected children are enrolled in its comprehensive care system. For example, if a mother is HIV positive, then the entire family is tested. If a child is found to be uninfected, then the child is released from the comprehensive care program. However, research shows that the mental health and educational outcomes for such children are adversely affected (Abubakar, unpublished).

Abubakar emphasized the ability to enhance the potential of caregivers using psychosocial stimulation (Potterton et al., 2010). She suggested reaching families via community health workers. While these workers are not usually trained in mental health issues, they can be helpful nonetheless. With limited training, health workers can teach parents simple play techniques to enhance developmental outcomes for their children.

Results from a program in Mediational Intervention for Sensitizing Caregivers (MISC) also led to enhanced outcomes in terms of the mental health of the caregivers and improved caregiving practices (Boivin et al., 2013). Abubakar suggested examining factors that help parents succeed within a challenging context (such as poverty), and implementing those successful strategies with children and families infected and affected by HIV. The quality of child care is compromised when the caregiver is not doing well, either physically, mentally, or emotionally, Abubakar stated. She recommended investing to enhance the condition of caregivers, which would then promote the developmental potential of children affected by HIV.

A participant asked if the strategies for children with HIV could also be applied to children with autism, disabilities, or mental health issues. Abubakar said that interventions to support HIV-affected children could also translate to children with disabilities or other challenges, as they experience similar stresses. She pointed out that caregiver mental health

Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×

may be challenged in either circumstance. Also, she noted that any intervention program should be holistic in nature.

CAREGIVING AND OTHER CONTEXTUAL INFLUENCES ON EARLY CHILD DEVELOPMENT3

Patricia Kariger examined the context in which children develop, including the interactions among those contextual factors. Contextual influences range from near (family and community) to more distal (state, national, and global). While the more immediate influences are critical, distal levels set policies that can have a strong, if indirect, influence. Kariger emphasized the need to strengthen all levels for children to develop to their full potential. She cited evidence that shows children exposed to multiple risk factors exhibit developmental decline (Sameroff et al., 1993).

Kariger illustrated the influence of different variables by age, shown in Figure 6-1. In the figure, color saturation indicates the level of impor-

images

FIGURE 6-1 Importance of indicators as a function of age. Color saturation shows the importance of the variable. Indicators are organized from most proximal (lower on the y-axis) to more distal (higher on the y-axis).

SOURCE: Kariger, 2014.

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3 This section summarizes information presented by Patricia Kariger, University of California, Berkeley.

Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×

tance. She noted that proximal measurements, such as those for health and caregiving, are most critical in the early years (ages 0 to 3). Education and language and cognitive development are more critical in later childhood (ages 4 to 8). Other variables, such as those related to poverty and social protection, are equally critical throughout childhood, and these variables tend to be the more distal ones.

Kariger proposed several ways in which measures of the caregiving context can be improved:

  • Develop more comprehensive measures across the age span.
  • Measure the responsiveness of parents or caregivers.
  • Measure the quality of home-based care.
  • Identify a more developed way to screen for specific disabilities.
  • Monitor children’s exposure to violence and abuse.
  • Integrate measures across sectors.
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×
Page 33
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×
Page 34
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×
Page 35
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×
Page 36
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×
Page 37
Suggested Citation:"6 The Context of Families and Caregivers." Institute of Medicine and National Research Council. 2014. The Cost of Inaction for Young Children Globally: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18845.
×
Page 38
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The Cost of Inaction for Young Children Globally is the summary of a workshop hosted by the Institute of Medicine Forum on Investing in Young Children Globally in April 2014 to focus on investments in young children and the cost of inaction. Participants explored existing, new, and innovative science and research from around the world to translate this evidence into sound and strategic investments in policies and practices that will make a difference in the lives of children and their caregivers. This report discusses intersections across health, education, nutrition, living conditions, and social protection and how investments of economic, natural, social, and other resources can sustain or promote early childhood development and well-being.

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