7

Combining the Science of
Child Development with
Quality Measurement to Support
Early Childhood Programs and Policies

According to Abbie Raikes,¹ who provided the keynote talk, early childhood development has made its global debut in the United Nations Sustainable Development Goals (UN SDGs). Target 4.2 of UN SDG Goal 4 on education explicitly recognizes early childhood care and education as a necessary part of a child’s holistic development and well-being.² Moving forward, it will be necessary to ensure understanding that development starts at birth, as well as ensuring the importance of integrating preprimary programs; parenting programs; and health, education, and nutrition programs, she said.

Raikes views measurement as an important element to track trends and investments at the population level. The question then becomes how to translate these components into feasible measurements at scale. Measurement can encourage developmentally informed practice by describing children’s development at key transitions such as formal entry into school. It can also describe the link between context and outcomes, she said. Perhaps most importantly, Raikes emphasized how measurement holds stakeholders accountable for improving children’s environments and development, and that measurement can promote equity. As pre-

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¹ Abbie Raikes is the technical development lead for the Measuring Early Learning Quality and Outcomes Project at UNICEF.

² Target 4.2 states: “By 2030, ensure that all girls and boys have access to quality early childhood development, care and preprimary education so that they are ready for primary education.” For more information, visit http://www.un.org/sustainabledevelopment/education (accessed April 1, 2016).

sented in Box 7-1, Raikes offered several principles that should be considered when developing measurement tools.

Raikes presented two projects addressing the question of measurement at scale. The first is a project by the World Health Organization (WHO)—with support from the Bernard van Leer Foundation—to develop a set of global indicators for child development from birth to age 3. The WHO project will field test and recommend a set of indicators to assess child development at the population level across the 0 to 3 age group. The second project taking the issue of measurement at scale is the Measuring Early Learning and Quality Outcomes Project. This project is a collaboration between UNICEF, the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Bank, and the Brookings Institution, with support from the Children’s Investment Fund Foundation and several other partners. Phase 1 of the project, “consensus to country action,” has three goals: (1) convene expert groups on quality, child development, and learning; (2) develop and pretest two new tools (child development and learning, and quality) that are conceptually linked; and (3) conduct institutional assessments on scaling the assessment. Raikes noted that although two tools were developed from this project, the main goal was to create a method for defining a common core.

Looking to the future, Raikes provided three goals for using “collective measurement expertise.” She said the first goal should be integrating measurement to put forth a vision for measurement for children from birth through age 8. Next, researchers should work to create systems of measurement with countries participating in more than one effort. Finally,

she said that governments should partner with local or regional research hubs to improve measurement over time.

THE AGES AND STAGES QUESTIONNAIRE: INVENTORY

Hollie Hix-Small provided an overview of the Ages and Stages Questionnaire: Inventory (ASQ: I), a direct child assessment instrument that targets children ages 1 to 36 months and evaluates progress over time. This measure was developed from the Ages and Stages Questionnaire (ASQ) items in 2006 at the University of Oregon.³ It has been studied in Kenya, Madagascar, Taiwan, and with indigenous populations in the United States, and is now available for wider research use, said Hix-Small.⁴

Hix-Small said that the ASQ and the ASQ: I vary in many ways. While the ASQ is a screening tool meant to identify children 1 to 66 months old who are at risk of having developmental delays or disabilities, the ASQ: I is a progress monitoring tool that is currently available for children ages 1 to 36 months. Because the ASQ: I offers a continuous measure with age-appropriate starting points, parents or evaluators can start with survey questions appropriate for the developmental stage of the child. Hix-Small noted that in this way, the ASQ: I offers more flexibility than the ASQ and accounts for special cases such as a 6-month-old who is functioning more like a 3-month-old.

According to Hix-Small, parents are very involved in the administration of the ASQ: I; they respond to questions from survey administrators about their children’s progress and actively elicit skills from their children. She said that some workshop participants might think that parents in low- and middle-income countries cannot answer questions about their child’s development in a reliable and valid manner, but emerging research suggests parents are more than capable of answering these questions (Abubakar et al., 2010). In fact, in Madagascar, Hix-Small said that parents have underreported their children’s development.

Hix-Small said the ASQ items have been translated into more than 37 languages and can be administered in two formats—with items grouped by domain and items grouped by activities. She explained that it is possible to arrange culturally appropriate activities that are more authentic and natural for the child and to collect data through observation. Hix-Small also said that this tool has several policy implications. First, ASQ: I is a low-cost and change-sensitive way to monitor child outcomes. It is

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³ For more information on the Ages and Stages Questionnaire, please visit: http://agesandstages.com/products-services/asq3 (accessed April 4, 2016).

⁴ An adapted version of the instrument was used in India, Indonesia, Peru, and Senegal (Fernald et al., 2012).

also a technically sound tool to monitor change across developmental domains, she noted. Hix-Small said program implementers can use the ASQ: I to improve programming, accountability to donors, and increase parent awareness of child outcomes. Finally, policy makers can use the tool as a more robust measure of child progress allowing for program comparisons on child outcomes. Looking ahead, Hix-Small recommended additional research in the following areas: administration methods in varying regional and cultural contexts; item “functioning” within and between populations; additional concurrent validity studies; and development of country-specific percentile ranges.

THE GUIDE FOR MONITORING CHILD DEVELOPMENT

Krishnamurthy presented the Guide for Monitoring Child Development (GMCD), a clinical, open-ended evaluation and intervention to enhance developmental monitoring, support, and management of developmental difficulties. This tool, which has been in development by Ilgi Ertem and colleagues at Ankara University in Turkey since 1995 (Ertem et al., 2008), aims to catalyze provider–caregiver partnerships, and advance approaches to early childhood development and developmental difficulties in health systems. Krishnamurthy said the tool addresses two barriers to accessing children in low- and middle-income countries (LMICs): a lack of caregiver training in early childhood development and a lack of internationally standardized tools. The GMCD, as outlined by Krishnamurthy, reflects a bioecological theory; monitors and supports, rather than screens; and identifies and addresses risk factors.

Krishnamurthy presented examples of the questions asked in the guide (see Box 7-2). The first question is the only closed question; the remain-

ing questions are open-ended and are aimed at generating a dialogue between the administrator and the parent. The guide is composed of 10 questions, the last 2 of which address maternal depression and other risk factors, instituting the “support” component of the guide. Krishnamurthy says that although the guide takes only 15 minutes to complete, in some instances, this is the first opportunity the caregiver has had to talk about her child’s development. Many caregivers end the discussion feeling reassured that they can discuss their child’s development with a health care provider, according to Krishnamurthy.

Krishnamurthy said that the International GMCD was completed in May 2015. Researchers worked in Argentina, India, South Africa, and Turkey for 5 years to determine if development in healthy children is similar in different countries and if these similarities can be used to develop an open-access international GMCD that does not require standardization.⁵ More than 20,000 children enrolled over the course of 5 years and 3 phases (standardization for years 1–3; establishment of validity during years 3 and 4; and implementation, years 4 and 5). Based on preliminary analyses, findings showed that developmental milestones from age 0 to 42 months were attained at similar ages (by both sexes) in different countries by children without known health risks.

THE INTERNATIONAL DEVELOPMENT AND EARLY LEARNING ASSESSMENT

Ivelina Borisova presented Save the Children’s International Development and Early Learning Assessment (IDELA),⁶ a direct child assessment instrument that targets children aged 3.5 to 6.5 years (see Box 7-3). IDELA measures motor development, emergent language and literacy, emergent math/numeracy, and socioemotional development, as well as approaches to learning. According to Borisova, IDELA includes cross-cutting elements such as motivation, persistence at completing tasks, and self-regulation. The assessment takes 30 minutes to administer per child and includes 24 items across the four domains. To ensure that children do not feel like they are being assessed, tasks in IDELA are designed to be play based and interactive.

Flexibility is built into IDELA, said Borisova. The tool can be contextualized at the national level or regional level and can account for linguistic

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⁵ The International GMCD was developed in partnership between Ankara University, Centro Rosarino de Estudios Perinatales, Ummeed Child Development Center, University of Pretoria, and Yale University.

⁶ At the time of the workshop, Ivelina Borisova was director, Early Childhood Development Impact and Innovations at Save the Children.

differences, depending on the country’s level of diversity. Further, optional subscales accompany the core items. This means that countries making a big push on health and hygiene practices in preschool can add additional questions for this target, she said. Additionally, optional upward extensions can be added to many of the subscales to avoid “ceiling effects” in the more urban, middle-income, and highly developed populations. According to Borisova, countries can also add culturally or context-specific items to the core IDELA items. She said that to date, most countries take this option. In discussing adaptation of the tool, Borisova stated that Save the Children has a systematic process for introducing IDELA in new countries and has been successful in introducing a generic assessment into unique settings and making the tool work across diverse populations. In fact the tool has been used in 28 countries to date. She believes the flexibility IDELA offers is something that creates global linkages between countries and contexts while remaining a standardized tool for comparison.

Data collected through the administration of IDELA alongside a simple caregiver questionnaire can show disparities between children from various backgrounds. In Ethiopia for example, children from higher socioeconomic status have significantly higher literacy scores than counterparts with low socioeconomic status, 53 percent compared to 35 percent (Pisani et al., 2015). Similar disparities were found in skill variation in Bhutan for urban (40 percent) versus rural children (28 percent) (Dowd et al., under review) (see Figure 7-1).

In assessing skill variation in Mali, IDELA data showed that children with literate mothers scored higher than children with illiterate mothers

in numeracy (42 percent compared to 34 percent) and socioemotional development (49 percent compared to 42 percent) (Thera et al., 2015).

Borisova also highlighted differences between children who have access to early childhood services and those who do not, and how these data can affect policy. Findings from IDELA show that in Ethiopia, children with access to high-quality early childhood programming have significant skill gains compared to children who receive standard programming offered through the government (39 percent gains compared to 10 percent gains) (Amente et al., 2013). Further, Borisova discussed the compounded disadvantage children can face on school readiness skills. In a national school readiness study in Bhutan, the difference in school readiness skills between children attending an early childhood development program and those who did not was, on average, only 6 percent

(27 percent for early childhood development attendees versus 21 percent for nonattendees). However, when an added factor was added, such as socioeconomic status, the gap in skills widened significantly, and children from low-income families not attending preschool scored almost 20 percentage points lower compared to peers from wealthier families attending preschool (Dowd et al., under review).

Borisova closed by discussing the need for multipartner engagement at the national level to make the best use of the tool and the data it can offer ministries and relevant stakeholders. She presented implications for practice and policy, as provided in Box 7-4.

THE VIOLENCE AGAINST CHILDREN SURVEYS AND THE THRIVES TECHNICAL PACKAGE

Ruth Perou presented the U.S. Centers for Disease Control and Prevention’s (CDC’s) Violence Against Children Surveys (VACS), nationally representative household surveys of children and young adults ages 13 to 24.⁷ In addition to the surveys, which address topics such as gender attitudes, witnessing violence, violence perpetration, and health outcomes, the surveys are accompanied by a THRIVES technical package to protect children from violence and adversity (see Box 7-5).

According to Perou, despite that many countries are unaware of the extent of violence against their children, studies have shown that exposure to violence during childhood can increase vulnerability to a number

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⁷ Ruth Perou is a behavioral scientist at the U.S. Centers for Disease Control and Prevention.

of mental and physical health problems such as depression, unwanted pregnancy, cardiovascular disease, diabetes, and human immunodeficiency virus (HIV). Perou said the VACS and accompanying technical package were developed to estimate the extent of violence around the world, stimulate prevention and response efforts, and monitor progress. To date, the CDC has implemented VACS in 16 countries, and demand from other countries has been very high, said Perou.

Perou presented the latest data from the VACS. Findings show that in eight VACS countries, 4 to 38 percent of girls and 6 to 21 percent of boys aged 18 to 24 experienced sexual violence prior to turning 18 (Sumner et al., 2015) (see Figure 7-2). In seven VACS countries, 42 to 66 percent of girls and 52 to 76 percent of boys experienced physical violence before age 18 (Sumner et al., 2015) (see Figure 7-3). Research also shows associations between exposure to childhood sexual violence and increased risk of negative health conditions and behavior such as HIV, sexually transmitted diseases, pregnancy complications, alcohol use, suicidal ideation, and depression (Reza et al., 2009). According to Perou, most individuals reporting physical or sexual violence did not receive services for their abuse (Sumner et al., 2015); very few ever sought services. This may be due to a lack of services, being unaware services exist, or stigma, according to Perou.

Findings from the VACS have provided data to help countries respond to physical and sexual abuse as well as develop and launch violence prevention programs, said Perou. The THRIVES technical package includes programs and policies that are effective in preventing violence. Country-level responses have included legislation; school-based curricula about violence; service provision strategies; and an increase in workforce capacity of clinicians, police, social workers, and teachers.

A GLOBAL PERSPECTIVE ON MEASUREMENT: IMPLICATIONS FOR POLICY

Emily Vargas-Baron provided her perspective on early childhood policy and the various programmatic implications that accompany these policies in the era of the UN SDGs.⁸ She believes some countries will try to achieve improved child development by using future measurement capacities of the UN SDGs. However, countries will likely create many additional indicators and targets that fit their national contexts. This will result in what Vargas-Baron referred to as a “patchwork quilt” of efforts around the world in which some countries follow the global indicators and their targets and others may not do so.

Vargas-Baron highlighted that many countries do have one or more policy instruments for early childhood development. At the time of the workshop, 75 countries had instruments, 10 more were reported to have them, and 23 were preparing them. Of these countries, Vargas-Barón said that 60 percent were LMICs. She did note that while many countries had instruments, not all of them included indicators, effectively making them more similar to “policy statements” than true national early childhood development policies or strategic plans. For those countries whose instruments include indicators, the indicators are predominantly operational or process indicators with inputs and outputs that are essential for policy implementation, said Vargas-Baron. According to a recent study, relatively few of the indicators used in early childhood development policies were outcome indicators, which is problematic (Vargas-Baron and Schipper, 2012). She said that it is critically important to develop a system to measure early childhood development outcomes and to use those outcomes for planning purposes.

While the United Nations Millennium Development Goals (UN MDGs) lacked an early childhood development goal, Vargas-Baron highlighted several UN SDGs that include targets related to early childhood development and early childhood intervention (see Box 7-6 for a full list). She said that these targets provide an opportunity to establish early childhood development and early childhood intervention indicators, noting that while this likely will not be achieved in the first round of indicators, specialists working on the UN MDGs took 4 years to complete and adopt their full list of indicators for use around the world.

Vargas-Baron summarized what she believes to be several key issues. First, she said that early childhood learning is not the same as early childhood development; learning is a subset of development, and researchers and decision makers need to take a broader view of child development.

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⁸ Emily Vargas-Baron is director of the RISE Institute in the United States.

For example, 1 to 2 years of preprimary education and school readiness is not all encompassing of child development, which includes child health, nutrition, sanitation, education, protection, and child rights. Second, she stated that of necessity, national, intracountry, regional, and municipal needs must come before international needs. Countries will vary in their relative emphasis on topics such as fragile birth status; malnutrition and chronic illness; disabilities; and high-risk status and child protection. She also said that in most countries where she has worked, countries are very interested in having good indicators and measures for child development, but sometimes they lack the requisite expertise to develop them. Vargas-Baron said that countries further along in using effective measures might offer technical assistance to set indicators, measures, and targets, and validate instruments.

Vargas-Baron noted some challenges moving forward. She said that early childhood development and early childhood intervention specialists will need to include early childhood and marginalized populations in the development of UN SDG indices such as the social progress index, the People’s Report Card, and others. Such efforts rarely include early childhood development in their international indices.

Additionally, she said that policy makers and policy researchers should be invited to participate in the development of indicators to offer nations guidance in developing national UN SDG plans. To offer this guidance, Vargas-Barón said a measurement research agenda should include population-level assessment of child development by age bands, parenting behaviors, assessment of the quality of early childhood development and early childhood intervention programs, and child equity.

CLOSING REMARKS

At the conclusion of the workshop, Liana Ghent remarked that the workshop provided a number of practical suggestions to bridge the gaps between research, policy, and practice.⁹ For her, close cooperation and shared learning between these fields will promote cross-sectorial cooperation and coordination. She linked some messages from the workshop to the International Step by Step Assocation (ISSA) regional membership association that focuses on Europe and Central Asia. First, Ghent said the workshop has helped to inform ISSA’s Early Childhood Workforce Initiative, a partnership with Results for Development, which targets competencies, standards, support for improvement, and empowering the early childhood workforce. Ghent emphasized that issues discussed in the workshop will continue to be explored in ISSA’s Conference 2016¹⁰: Early Childhood in Times of Rapid Change, during which ideas will be taken further, including how to define meaningful learning during times of rapid change. According to Ghent, the iYCG Forum will benefit the global early childhood community if it continues to link to regional networks, as it did in its partnership with the ISSA and the Open Society Foundations for the workshop in Prague.

In her closing remarks, Klaus stated that one thread tied together all of the presentations relating to children at the margins: the importance of data in raising awareness and making inequality visible. She highlighted an Open Society Foundations report drawing attention to the lack of data on Roma entitled, No Data—No Progress (McDonald and Negrin, 2010). This report could have easily been called No Data—No Problem, she said, because for many, if they do not see a problem, it does not exist. She thanked presenters for demonstrating the myriad ways marginalization affects child development and for motivating participants to take action through scientific and programmatic developments.

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⁹ Liana Ghent is executive director of the ISSA.

¹⁰ See http://www.issa.nl/content/save-date-issas-2016-conference (accessed April 4, 2016).

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