COACHING THE CARERS

A groundbreaking study offers undeniable proof that the fight against inequality starts with moms

Children born into poverty start at a big disadvantage. To thrive, they need food, shelter, and health care. But a growing body of evidence shows there are other ways to help close the vast gap in development between poor kids and their wealthier peers—singing, talking, and playing with them.

If this sounds obvious or inconsequential, it’s not. Dealing with the stress of poverty makes it hard for many parents to establish critical bonds with their babies—bonds that lay the foundations for learning, emotional regulation, and relationships. Poor parents are “focused on survival and illness and food and health care,” says Sally Grantham-McGregor, an emeritus professor of international child health at University College London and University of the West Indies. “There’s no time to play with children—it seems frivolous.”

But playing with babies turns out to be anything but frivolous. Grantham-McGregor and her colleagues have spent more than 40 years pioneering research which showed just how much supporting mothers in the earliest days of a child’s life can directly benefit that child. In the 1970s, Grantham-McGregor and Christine Powell, from the University of the West Indies, began a research project aimed at helping young children from poor backgrounds and their moms in Kingston, Jamaica. They designed programs that sent doctors and nurses to visit mothers every week in their homes for two years, bringing toys and books that would help parents become better teachers to their babies and to increase stimulation and play.

The resulting studies found that children whose mothers received coaching made significant developmental gains, and not just in the short term. Twenty-two years later, the kids from one group who had received those home visits as young children not only had higher scores on tests of reading, math, and general knowledge, they had stayed in school longer. They were less likely to exhibit violent behavior, less likely to experience depression, and had better social skills. They also earned 25% more on average than a control group of kids whose mothers had not received the coaching.

The highly influential Jamaica studies have influenced the way many countries think about investing in early childhood development. Brazil, Guatemala, Zimbabwe, Bolivia, Peru, Colombia, Bangladesh, and India are all trying parent coaching programs—many based on the Jamaica model. It’s easy to see why some countries are embracing such an approach. After all, it’s in every country’s best interest to ensure that its most disadvantaged citizens get the support they need to live productive, fulfilling lives.

 “If we want to attack poverty, the place to start is very early in life.” “If we want to attack poverty, the place to start is very early in life,” says Paul Gertler, an economist who studied the long-term effects of the Jamaica program. Research shows that poverty affects a young child’s development on multiple levels, from their cognitive and educational performance to their physical health and social and emotional development. Compared to the cost of unemployment benefits or other social safety net programs, “getting it right to start with is cheaper.”

To tackle the lasting effects that inequality can have on a child’s life, we have to start early. The work of Grantham-McGregor and her team in Jamaica offers some of the best evidence we have about what governments can do to support families in an effort to close the intractable gap between rich and poor children everywhere.

The Jamaica experiments

Much as caregivers in poor countries typically want their children to succeed, it’s not necessarily obvious that a key way to do this is to talk and sing to babies, respond to them when they cry, and find other ways to engage them with the world. Consider a 2012 nationally representative survey in Brazil, which asked mothers, 52% of whom were college educated, what things were most important for the development of their children up to three years of age: only 19% mentioned playing and walking, 18% said receiving attention from adults, and 12% picked receiving affection.

The Jamaica studies showed how much these things matter. Through randomized controlled trials supporting poor, often uneducated mothers, the programs dramatically improved children’s development. (The effect sizes have been described as “astounding.”) It expanded the scope of helping poor children from health and nutrition to stimulation and responsiveness.

While the earliest studies used health professionals as home visitors and relatively expensive toys and materials, Grantham-McGregor and Powell quickly changed the program’s model to save money, using community health workers instead of doctors and nurses and homemade toys. Over the course of seven studies, they also experimented with different levels of frequency for the home visits and worked with babies experiencing different kinds of deprivation, including severely malnourished infants and children who had been born at a low birth weight.

They found that the effects of early intervention were both long-lasting and complex. One study tracked 129 stunted childrenthat is, babies smaller than well-nourished children of the same age and gender, who show persistent developmental delays as they grow up. Researchers followed a group of children and mothers that received weekly home visits for two years, as well as other groups of children, including a control group. The study then tracked the children’s development for up to 22 years.

The benefits of the intervention seemed to vary as the children grew up. After two years, the infants in the visiting group showed significant developmental gains. They actually caught up to kids who were not stunted—an enormous victory.

 “Jamaica was so important because it shows us the potential of what can be done, the importance of stimulation, and that impacts can be long lasting.” Over time, however, some of the effects seem to fade or fluctuate. At 7 to 8 years of age, the mean IQ from the intervention group was no higher than that of the control group. By age 11 to 12, the children who had been in the home visiting group had significantly higher IQs than the control group, but showed no significant improvements in behavior or school achievement. Then, when researchers tested the intervention group again at age 22, they found a battery of benefits—from higher income to better social skills and less violent tendencies.

Many researchers might have given up when the effects of the early intervention programs seemed to fade. But the benefits resurfaced with a bang, proving that programs that coach mothers can bring about lasting, significant, long-term results. In 2016, Grantham-McGregor and Smith published research in the Journal of Applied Research on Children exploring 12 published trials in five different countries, all of which were based on the original findings of the Jamaica program.

“Jamaica was so important because it shows us the potential of what can be done, the importance of stimulation, and that impacts can be long lasting,” says Amanda Devercelli, global lead for early childhood development at the World Bank. The challenge lay in taking Jamaica’s small program with big effects and making it accessible to the millions of poor families who need it.

The brain science behind nurturing care

In the years since the Jamaica studies, the science underscoring the critical opportunities and risks of early childhood has exploded. Neuroscience revealed the incredible plasticity of the early brain, showing that the foundations for learning as well as children’s social, emotional, and moral development start as early as pregnancy, and spike in a baby’s earliest years. Like a house, children’s brains need strong foundations. Their brains cannot fully develop without responsive caregiving; people who help them form deep and trusting attachments; and stimulation. Stress during a child’s early years, whether from poverty, malnutrition, neglect, or abuse, can negatively affect their nervous system in ways that can create lifelong problems with learning, behavior, and physical and mental health.

A foundational tenet of nurturing care is the importance of serve and return, which refers to adults’ responses to a child’s attempts at communication—from crying and babbling to gazing and smiling. According to the National Scientific Council (pdf) on the Developing Child and the Center for the Developing Child at Harvard, “The interactive influences of genes and experience literally shape the architecture of the developing brain, and the active ingredient is the ‘serve and return’ nature of children’s engagement in relationships with their parents and other caregivers in their family or community.”

The neurobiology of early childhood presents a challenge to policymakers. Until fairly recently, policy makers focused their dollars and attention for children on education, usually starting around age five. But five years old is too late. Research shows that developmental deficits between richer and poorer children can show up in kids as young as seven months. By the time children are in school, the gaps between advantaged children and disadvantaged ones are already enormous. School tends to exacerbate those rifts.

“It’s fairy well-established that how well a child has developed cognitively —language development, socially, emotionally—when they enter school will determine to a large extent how well they do in school, and that will have repercussions in adulthood including the intergenerational cycle of poverty,” says Grantham-McGregor. This means the bigger a developmental deficit is early on, the harder it is for poor kids to catch up.

Grantham-McGregor is excited about the developments in neuroscience. But she’s emphatic that it’s already well-established that mothers from disadvantaged homes benefit from this kind of help. “The brain research is exciting and it’s helpful because people pay attention,” she said. “It’s good for advocacy, but we were doing these programs before this data came out. And we’re still doing them.”

Expanding the lessons of Jamaica

Economists have joined the neuroscientists, arguing—with data—that investing in early childhood is the most cost-effective way to affect long-term outcomes like education and employment.

James Heckman runs the Center for the Economics of Human Development at the University of Chicago, and won the Nobel prize in 2000 for his work in micro-econometrics. He has since focused on applying his work to early childhood, including analyzing of the Jamaica research. He estimates that the best investment any policy-maker can make is in the earliest years of childhood, because these interventions have the highest payoffs.

“The highest rate of return in early childhood development comes from investing as early as possible, from birth through age five, in disadvantaged families,” Heckman said in 2012. “Starting at age three or four is too little too late, as it fails to recognize that skills beget skills in a complementary and dynamic way.”

 “We know from developmental science that families are the biggest builders of skills and abilities in their children in the earliest years.” The key, it seems, is ensuring that families have the support and tools they need to bond with young children and provide them with engaging environments. “We know from developmental science that families are the biggest builders of skills and abilities in their children in the earliest years,” Heckman tells Quartz. “Jamaica shows that simple but effective parental education can produce better child outcomes.”

Jamaica-inspired programs now exist all over the world, as do hundreds of other parenting programs. The biggest issue they face? How to get the strongest outcomes in the most affordable way. In a sense, Jamaica set the bar uncomfortably high for this, due to its small size and the fact that the home visitors were highly trained, and the coaching quite intensive.

“Our challenge now is to take what we learned from Jamaica and design programs that are affordable and feasible in many diverse low-income settings,” says Devercelli from the World Bank.

One study in Colombia looked at whether a more affordable, and scalable, version of the Jamaica program could produce the same effects. It used a large sample, studying 1,420 children aged 12-24 months and their primary caregivers in 96 municipalities, and tied the implementation of the home visits to an existing social protection program, conditional cash transfers. The results showed positive and significant effects on cognition and language, though smaller than the effects in Jamaica, as would be expected.

Meanwhile, in 2012, the Peruvian government implemented Cuna Mas, a home-visiting program based on many of the materials and foundations used in Jamaica and perhaps the best example of Jamaica operating at scale. The program has reached over 90,000 Peruvian families. Early research shows positive and significant effects on children’s cognition and language, as well as parenting practices, although the effects are smaller than in either Jamaica or Colombia.

“As you scale, the impacts are smaller,” says Marta Rubio Codina, a senior economist at the Inter-American Development Bank. Reducing costs to make the programs more affordable for governments means that quality can suffer. The goal, she says, is to figure out how to minimize those compromises. “My bet is that we have to invest in the workforce: training the home visitors and training their mentors.”

To help other countries develop and measure their own programs, an international collaboration of academics headed by the Jamaican group at the University of the West Indies developed Reach Up and Learn, a web-package of materials and curriculum and training manuals which are being used in places from Colombia, India, Peru, and Brazil. One challenge: making sure the curriculum reflects the country’s culture, including local games, rhymes, songs, and stories.

“Adapting to culture is a lot of work,” says Grantham-McGregor. Pretend games taught to parents may need to be adapted—going to the field to work, or spinning wool, depending on common occupations. Local artists also need to redraw pictures to reflect a given culture’s typical housing, landscape, and style of dress, among other things.

Countries are experimenting with other variations on the program. Bangladesh has built a strong body of evidence that Jamaica-type programs are effective. They are experimenting with small groups of mothers visiting health workers in clinics, rather than having workers come to their homes.

As the long-term benefits of such programs materialize, early childhood advocates are urging governments to find more ways to support mothers and families. In 2016, the Lancet published a series of articles on early childhood, highlighting the unique opportunity the early years offer to policy-makers. Writing for the Lancet, Pia Britto, an advisor to Unicef, wrote that we now know the critical importance of “nurturing care,” which she defines as a set of interrelated concepts around caregiving ranging from hygiene to stimulation (talking, singing, playing), responsiveness (early bonding, secure attachment, trust, and sensitive communication), and safety (routines and protection from harm).

“The single most powerful context for nurturing care is the immediate home and care settings of young children often provided by mothers, but also by fathers and other family members, as well as by child-care services,” Britto writes. Thanks to the Jamaica experiments, the world has increasingly accepted this fundamental truth: The best way to help poor kids is to start early, and give mothers and families the support they need.

Hannah Yi contributed additional reporting to this story. This reporting is part of a series supported by a grant from the Bernard van Leer Foundation.

Correction: This story was corrected to reflect that it was Christine Powell, not Joanne Smith, who was part of the original research team in Jamaica in the 1970s.

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