Around 90% of the children and adolescents in the world live in lower- and middle-income countries, where they make up around 50% of the population [1]. Studies have suggested that approximately 13% of children and adolescents worldwide suffer with some form of mental health problem or illness [2]. We can see that a large proportion of children living in lower- and middle-income countries do, or will struggle with mental health, so let’s look at why preventing and treating mental health problems is so important.

Why is Mental Health so important?

Mental health has been shown to have long-lasting effects from childhood into adulthood and is a fundamental aspect of having good health and wellbeing [3]. Poorer mental health has been found to be associated with delinquency and substance misuse in adolescents, as well as behavioural problems and social emotional problems in children [4]. Not only this, but mental health has also been shown to have an influence upon a person’s social and economic outcomes across their entire lifespan [4]. This creates a negative cycle. Those living under poverty have an increased risk of developing mental illness, and those living with mental illness are at an increased risk of remaining in, or moving into, poverty [5]. This reinforced the cycle of poverty. WHO Mental Health and Development reported the importance of mental health as a developmental issue for lower- and middle-income countries [6], so what interventions can be done in these countries?

How can Early Childhood Education Programmes benefit Mental Health?

Early Childhood Education (ECE) programmes have been found to benefit mental health in children in many different ways. ECE’s have been shown to aid in developing children’s cognition and language development, which support good mental health and wellbeing during a child’s development [7]. Not only this, but ECE’s also have been shown to help children’s self-regulation, and social-emotional skills. Improving a child’s social and emotional competence has been shown to greatly reduce the likelihood of mental health issues [8]. ECE’s have also been found to help with children’s self-esteem and school behaviour, along with decreasing school drop-out rates, which can lead to positive behaviours and improved academic performance which in turn has a positive effect upon mental health [9][10]. A study looking at ECE’s found that 75% of ECE programmes found short term benefits to child mental health [11].

There are many types of ECE which can be beneficial to mental health, such as:
                – Parenting Programmes
                – Centre Based Programmes
                – Educational Programmes
                – School Based Programmes

School-Based Programmes

Improving the teacher-student relationship can have a positive effect in the classroom, along with the mental health of both the teacher and the students. Increasing teacher skills has been shown to reduce anxiety and increase motivation inside the classroom [4]. One example of this is the Irie Classroom Toolbox [12]. The programme aimed to reduce aggression amongst the children within the classroom as well as reducing the violence to children from teachers, in Jamaican preschools. This would lead to both positive peer and positive teacher relations for children, which would be thought to improve mental health [13]. As a result of the programme, a reduce in teacher violence was found, alongside a reduce in class wide child aggression [12]. These benefits were also shown to be sustained for at least one school year.

This suggests that school-based programmes such as the Irie Classroom Toolbox can help the prevention of mental health problems in children, by reducing negative risk factors such as teacher violence, and by promoting positive factors such as social and emotional competence throughout the classroom. The Irie Classroom Toolbox is a low-cost intervention, which means it can be integrated into the school systems of lower- and middle-income countries more easily and gives a higher cost-benefit analysis. This means more children can be reached for a lower cost.

Parenting Programmes

Parenting programmes are hugely important for child mental health interventions, as child-parent relationships can have such a big impact on a child’s emotional and social development [11]. Improving a parent or caregiver’s behaviour in regard to a child can have a large impact upon said child’s mental health. Not only can an improved relationship help the child’s mental health, it can also have a positive impact upon parental mental health, especially maternal, through increased self-confidence and self-efficacy [14]. A trial in Iran looked at the prevention of a negative relationship between mother and child, and therefore the prevention of poor mental health for both [15]. Mother’s of 2 to 6-year olds were taught parenting skills and common mistakes made within parenting, for 2 hours a session, for two weeks. This led to a reduce in parent-child conflict and abuse, as mothers reported an improvement in the children’s behaviour [15]. This kind of preventative intervention which focuses on the mother-child relationship has a positive impact on the mental health of both parties.  

Conclusion

In summary, we can clearly see how mental health plays a big role in the wellbeing of children, especially those in lower- and middle-income countries, and why it is so important to protect children’s mental health [16]. It can also be seen how early childhood education programmes can be hugely beneficial to children’s mental health, particularly in lower- and middle-income countries where the cost of interventions is so important. Reducing the risk of mental health issues for a child means that they are less likely to carry those issues into adulthood, and therefore have more chance of breaking the cycle of poverty.

References

[1] Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta‐analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345-365.

[2] Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., … & Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801), 1515-1525.

[3] Patel, V., Flisher, A. J., Nikapota, A., & Malhotra, S. (2008). Promoting child and adolescent mental health in low and middle income countries. Journal of child psychology and psychiatry, 49(3), 313-334.

[4] Barry, M. M., Clarke, A. M., Jenkins, R., & Patel, V. (2013). A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC public health, 13(1), 835.

[5] Lund, C., De Silva, M., Plagerson, S., Cooper, S., Chisholm, D., Das, J., … & Patel, V. (2011). Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. The lancet, 378(9801), 1502-1514.

[6] WHO, M. (2010). health and development: Targeting people with mental health conditions as a vulnerable group.

[7] Lister-Sharp, D., Chapman, S., Stewart-Brown, S., & Sowden, A. (1999). Health promoting schools and health promotion in schools: two systematic reviews. In Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. Centre for Reviews and Dissemination (UK).

[8] Tennant, R., Goens, C., Barlow, J., Day, C., & Stewart-Brown, S. (2007). A systematic review of reviews of interventions to promote mental health and prevent mental health problems in children and young people. Journal of Public Mental Health, 6(1), 25.

[9] Weare, K., & Nind, M. (2011). Mental health promotion and problem prevention in schools: what does the evidence say?. Health promotion international, 26(suppl_1), i29-i69.

[10] Berlinski, S., Galiani, S., & Gertler, P. (2009). The effect of pre-primary education on primary school performance. Journal of public Economics, 93(1-2), 219-234.

[11] Baker-Henningham, H. (2014). The role of early childhood education programmes in the promotion of child and adolescent mental health in low-and middle-income countries. International journal of epidemiology, 43(2), 407-433.

[12] Baker-Henningham, H., Vera-Hernández, M., Alderman, H., & Walker, S. (2016). Irie Classroom Toolbox: a study protocol for a cluster-randomised trial of a universal violence prevention programme in Jamaican preschools. BMJ open, 6(5), e012166.

[13] Devries, K. M., Knight, L., Child, J. C., Mirembe, A., Nakuti, J., Jones, R., … & Walakira, E. (2015). The Good School Toolkit for reducing physical violence from school staff to primary school students: a cluster-randomised controlled trial in Uganda. The Lancet Global Health, 3(7), e378-e386.

[14] Cooper, P. J., Tomlinson, M., Swartz, L., Landman, M., Molteno, C., Stein, A., … & Murray, L. (2009). Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. Bmj, 338, b974.

[15] Oveisi, S., Ardabili, H. E., Dadds, M. R., Majdzadeh, R., Mohammadkhani, P., Rad, J. A., & Shahrivar, Z. (2010). Primary prevention of parent-child conflict and abuse in Iranian mothers: A randomized-controlled trial. Child Abuse & Neglect, 34(3), 206-213.

[16] Grantham-McGregor, S., Cheung, Y. B., Cueto, S., Glewwe, P., Richter, L., Strupp, B., & International Child Development Steering Group. (2007). Developmental potential in the first 5 years for children in developing countries. The lancet, 369(9555), 60-70.

Why are quality Early Childhood Education Programmes important?

It is well known that early childhood is a crucial period of a child’s life in terms of brain development. This means that increased exposure to risk factors, such as living in poverty, can have negative effects upon brain cognition and development that can severely impact a child for their whole life (1). When thinking about this, it is important to know that studies have shown early childhood education programs to improve the cognitive performance of children living in poverty (2). However, more than 200 million children living in lower- and middle-income countries are thought to not attain their development potential (1). This suggests that there is a strong need for quality early childhood education programs within lower- and middle-income countries, to ensure that risk factors are minimised, and children can reach their full potential. Not only this, but some early childhood education programs have been shown to lower the chances of a child growing up to be unemployed, which reduces the chances of that child living in poverty in the future – breaking the cycle of poverty (2).

What makes a good quality Early Childhood Education Programme?

 In short, a good quality early childhood education program in a lower- or middle-income country would have the following basics:

• A qualified, and motivated work force
• A suitable infrastructure for children
• Suitable teaching and learning resources
• An age and culturally appropriate curriculum

Arguably one of the most important of these factors is a skilled work force. Many studies have shown that early childhood education programs have a huge impact upon children when they are delivered by staff that have suitable knowledge and training (3). However, only 50% of pre-primary teachers in lower income countries are trained, which suggests that this is an area needing big improvements in order to ensure quality early childhood education programs worldwide (4).

Effective Parent Training Education Programmes

Effective Parent Training programs are very important, as parents are typically the main caregiver of the child for the first few years of life, but in lower- and middle-income countries parents may not have the skills or resources required to deliver adequate care. As a result of this, there is growing evidence that support from parent training programs helps to improve parent’s responsive caregiving, which therefore leads to an increase in the child’s development (5).

One example of an effective parent training program is the Reach Up Program. It was originally implemented in Jamaica but has also been shown to be transferable when adaptations are used. The goal of Reach Up is to help aid child development via building the mother/primary caregiver’s skills and responsive caregiving. Paraprofessionals attend workshops wherein they are trained, amongst other things, how to engage in play with the mother and child. These play sessions help to improve mother-child interactions, whilst helping to improve the child’s cognitive development. Play materials are left for the family, so that there is more exposure for the child. When Reach Up was implemented in Brazil and Zimbabwe, there was an 80% rate of positive comments from mothers, suggesting it was both helpful and well accepted (5).

Effective Centre Based Education Programmes

A school or centre based setting is an ideal setting for education interventions for young children, due to the large amount of time spent there for most children. It is also an easier way of reaching a higher number of children at once, as less professionals are needed to reach a bigger number of children. This means that less staff need to be trained, which can be particularly important in a lower- or middle-income country.

The Incredible Years program in Jamaica is a great example of an effective school-based program. It is an intervention which provided teachers already in the education system with training in classroom behaviour management, along with other important skills. It was found to have significant benefits to both the children’s behaviour within the classroom, and also the teacher’s behaviour towards the children. These benefits were still found to be sustained during a 6 month follow up, suggesting that the program was very effective. The program was also implemented using existing services and professionals, meaning it is more suitable for lower- and middle-income countries (6).

An example of an effective centre-based program is the What You Do with Baby Really Matters program that was delivered in health care centres in Jamaica. This kind of program is especially relevant for lower- and middle-income countries, as it successfully integrates an intervention into pre-existing services that most children and families already access. This allows for these kinds of programs to target the most disadvantaged, albeit at less intensity. The program consisted of nine 3-minute videos being shown to caregivers within a healthcare centre. The videos were relevant, relatable, easy to understand, motivating and credible to the parents. This was followed by the health care provider discussing the videos with the caregiver/s and encouraging them to attempt the behaviours seen in them at home with their children. Again, this type of program is much easier to produce on a wider scale, meaning that more children are likely to be helped, even if they are helped to a lesser extent than with a more intense, or one-on-one program (7).

What are the challenges to implementing high quality programs, especially at a wide scale?

Unfortunately, there are many challenges when you begin to look at how to implement these types of high-quality programs at a wider scale. The main challenge for lower- and middle-income countries is lack of money, and therefore inadequate funding and limited resources (8). Some other challenges include decentralized governance (9), and lack of coordination across sectors (10). However, whilst there are many challenges to widespread implementation, reducing intensity of programs and integrating them with pre-existing services is a great way to produce these programs at a wider scale more easily. It may be better to positively impact more children on a smaller level, than it might be to positively impact less children more intensely.

References

(1) Chang, S. M., Grantham-McGregor, S. M., Powell, C. A., Vera-Hernández, M., Lopez-Boo, F., Baker-Henningham, H., & Walker, S. P. (2015). Integrating a parenting intervention with routine primary health care: a cluster randomized trial. Pediatrics, 136(2), 272-280.

(2) Barnett, W. S. (1998). Long-term cognitive and academic effects of early childhood education on children in poverty. Preventive Medicine, 27(2), 204-207.

(3) Sylva, K., Melhuish, E., Sammons, P., Siraj-Blatchford, I., & Taggart, B. (2004). The effective provision of pre-school education (EPPE) project: Findings from pre-school to end of key stage 1.

(4) Early childhood education. (n.d.). Retrieved from https://www.unicef.org/education/early-childhood-education

(5) Smith, J. A., Baker-Henningham, H., Brentani, A., Mugweni, R., & Walker, S. P. (2018). Implementation of Reach Up early childhood parenting program: acceptability, appropriateness, and feasibility in Brazil and Zimbabwe. Ann NY Acad Sci, 1419(1), 120-140.

(6) Baker-Henningham, H., & Walker, S. (2018). Effect of transporting an evidence-based, violence prevention intervention to Jamaican preschools on teacher and class-wide child behaviour: a cluster randomised trial. Global Mental Health, 5.

(7) Walker, S. P., Powell, C., Chang, S. M., Baker-Henningham, H., Grantham-McGregor, S., & López-Boo, F. (2016). Parenting Programme in Health Centres: What You Do with Baby Really Matters. Implementation Manual.

(8) Bidwell, K., & Watine, L. (2014). Exploring early education programs in peri-urban settings in Africa. Accra, Ghana: UBS Optimus Foundation.

(9) Britto, P. R., Lye, S. J., Proulx, K., Yousafzai, A. K., Matthews, S. G., Vaivada, T., … & MacMillan, H. (2016). Advancing Early Childhood Development: from Science to Scale 2 Nurturing care: promoting early childhood development. safety (eg, routines and protection from harm), 3, 4.

(10) Samman, E. E., N. Presler-Marshall, T. Jones, C. Bhatkal, M. Melamed, M. Stavropoulou, and J. Wallace. 2016. Women’s Work: Mothers, Children and the Global Childcare Crisis. London: Overseas Development Institute.

When talking about conflict zones most places will usually talk about areas of armed conflict, however it can also include areas of disease epidemics, government collapse, or natural disaster such as places struck by tsunamis or hurricanes. However, for this post we will be talking about zones of armed conflict. Growing up in a conflict zone can be a huge risk for a child’s wellbeing and development, as it can possibly lead to separation from family, sexual trafficking and exploitation (1), as well as having physiological consequences such as anger, isolation and fear (2). Similarly, children growing up in areas of armed conflict will be faced with a much higher risk of malnutrition (3), as there is usually a decreased level of food and nutritional security in the area. Growing up in a lower- or middle-income area of conflict means there are more risk factors for a child’s development, and less protective ones. UNICEF have estimated that there are roughly 1 billion children living worldwide in an armed conflict zones, and that the majority of these areas are lower- and middle-income countries (4). Clearly, battling the risk factors to the development of children growing up within these areas should be a huge priority, and this post will discuss how this is being done, in conjunction with the Sustainable Development Goals.

Zero Hunger

The International Food Policy Research Institute estimates that around 112 million malnourished children are living in areas of conflict (5). Targeting hunger therefore is a huge area that could help to improve food security and nutrition in these areas.

A Micronutrient Powder Distribution Program in Bhutan, a lower-middle income country, aimed to reduce the risk of stunting by distributing single-dose sachet packets comprising of multiple minerals and vitamins that children (aged between 5 and 59 months) were thought to not be receiving daily (6). The children taking part in the intervention showed significant decreases in prevalence of stunting after the program. However, there was no control group measured, meaning that it cannot be known whether the program itself was the reason for the decrease. Nevertheless, the intervention was seen positively from the mothers of the children, as they reported seeing positive effects on health and energy. This kind of program that distributes micro-nutrients that are easy to integrate into the child’s home food, proves to be a cheaper and easier method of targeting hunger and malnutrition, and so may be more sustainable.

In Palestine, also a lower-middle income country, Food Assistance Programs have been trialed (7).These programs distribute food rations to children aged 6 to 59 months old in war zones, and found that after one year the prevalence of stunting, wasting and children who were underweight had lowered in comparison to children who had not been part of the program. Whilst the program found more significant results, it is much more expensive to implement.

Good Health and Wellbeing

There has been much evidence suggesting that children who grow up surrounded by war and conflict are more likely to have psychological problems later in life (8). This suggests that a focus on the psychosocial and mental development of these children is needed.

In Uganda, a lower income country in conflict, a program used Child-Centered Spaces (CCSs) to tackle the education, protection and psychosocial wellbeing of children. Children aged 3 to 6 years old that had participated in the CCSs reported being more likely to be safe both at home and within the community, had more positive social interactions both with adults and their peers, and learnt life skills that children not visiting CCSs were found not to have. Overall, it was reported that these children had a higher level of psychosocial wellbeing after visiting CCSs than their peers that did not. CCSs are not recommended as a standalone, as they have been found to work best when coupled with other interventions and programs, however they are a good foundation for bettering the health and wellbeing of children within conflict zones.

A trial in Bosnia, another upper-middle income country, looked at children aged 5 and 6 who were victims of war (9). The children and mothers attended short-term group-based psychosocial treatment, which focused on coping with problems and promoted a good, healthy mother-child relationship and interactions. The children within the treatment was compared to those who only had medical care, and it was found that the treatment had a modest positive effect upon the children’s weight gain, mental health and psychosocial functioning. The treatment is relatively simple and inexpensive to implement, as the leaders of the groups were 4 pre-school teachers and 1 medical student. One problem with this treatment is that whilst it may be low cost to do, it may be costly for the mothers to attend. It also brings up the problem of stigma, and how mothers may be less likely to attend such treatment as it may be seen as not very important during a conflict such as war.

In summary…

Overall, it is quite clear that the development and wellbeing of children growing up in conflict zones, especially within lower- and middle- income countries is extremely important, and that ways to benefit it are still developing. The early years of a child’s life sets out the foundations for their future, and so it is crucial to find programs and interventions that help these children, as they have so many risk factors facing them. Implementing Sustainable Development Goals into areas of conflict will not only help a sustainable future for the children, it will also help their growth and development.

References

1. van Leer, B. (2005). Foundation’s response to the tsunami. This publication has been a joint effort of the Bernard van Leer Foundation and the International Catholic Child Bureau. Our special thanks go to Margaret McCallin, our guest editor, without whom this edition would not have been possible.

2. Constandinides, D., Kamens, S., Marshoud, B., & Flefel, F. (2011). Research in ongoing conflict zones: Effects of a school-based intervention for Palestinian children. Peace and Conflict: Journal of Peace Psychology, 17(3), 270-302.

3. Carroll, G. J., Lama, S. D., Martinez-Brockman, J. L., & Pérez-Escamilla, R. (2017). Evaluation of nutrition interventions in children in conflict zones: a narrative review. Advances in Nutrition, 8(5), 770-779.

4. UNICEF., United Nations. Office of the Special Representative of the Secretary-General for Children, & Armed Conflict. (2009). Machel study 10-year strategic review: Children and conflict in a changing world. UNICEF.

5. Loewenberg, S. (2015). Conflicts worsen global hunger crisis. The Lancet, 386(10005), 1719-1721.

6. Bilukha, O., Howard, C., Wilkinson, C., Bamrah, S., & Husain, F. (2011). Effects of multimicronutrient home fortification on anemia and growth in Bhutanese refugee children. Food and nutrition bulletin, 32(3), 264-276.

7. Abdeen, Z., Greenough, P. G., Chandran, A., & Qasrawi, R. (2007). Assessment of the nutritional status of preschool-age children during the second Intifada in Palestine. Food and nutrition bulletin, 28(3), 274-282.

8. Cairns, E., & Dawes, A. (1996). Children: Ethnic and Political Violence‐a Commentary. Child Development, 67(1), 129-139.

9. Dybdahl, R. (2001). Children and mothers in war: an outcome study of a psychosocial intervention program. Child development, 72(4), 1214-1230.