Early Child Development : A Powerful Equalizer Final Report G l o b a l K n o w l e d g e f o r E a r l y C h i l d D e v e l o p m e n t Lori G. Irwin Arjumand Siddiqi Clyde Hertzman Early Child Development : A Power 7ul Equalizer Final Report ,or the World Health Organization 9s Commission on the Social Determinants o, Health Prepared by Lori G. Irwin , Ph.D., RN Arjumand Siddiqi , Sc.D., MPH Dr.
Clyde Hertzman , MD, M.Sc., FRCPC June 2007 acknowledgements\xa 1 This summary report is based on a larger document titled the Total Environment Assessment Model o; Early Child Development (team-ecd) written by Arjumand Siddiqi, Lori G. Irwin and Clyde Hertzman ;or the Commission on Social Determinants o; Health. This summary represents the e;;orts and commitment o; many people that contributed to the team- ecd document.
We would like to grate;ully acknowledge: the members o; the Knowledge Network ;or Early Child Development, S. Anandalakshmy, Marion Flett, Mary Gordon, Abeba Habtom, Sarah Klaus, Ilona Koupil, Cassie Landers, Beatriz Londoño Soto, Helia Molina Milman, Bame Nsamenang, Frank Oberklaid, Alaa Ibrahim Shukrallah, Nurper Ulkuer, ... more. less.
Camer Vellani, Annah Wamae, and Mary Eming Young. We would like to extend a special thanks to Meena Cabral de Mello, Senior Scientist, World Health Organization Department o; Child and Adolescent Health and Technical O; cer ;or Early Child Development, ;or her input, review o; previous dra;ts, and commitment to this work.<br><br> We would also like to thank the University College London Secretariat Members, Ruth Bell, Tanja Houweling, and the Geneva Secretariat Knowledge Network Coordinator, Sarah Simpson, whose patience and expertise has ensured that our work integrates with the broader goals o; the Commission. To our Commissioners, the Hon. Monique Begin, Stephen Lewis, William Foege, Alireza Marandi, and Denny Vågerö, we thank you ;or championing the recognition o; the importance o; the social determinants o; health and ;or committing to moving this work ;rom knowledge to action.<br><br> We would like to acknowledge the input we received ;rom experts such as Alan Kikuchi-White, Alan Pence, and Ilgi Ertem. We are also grate;ul to our colleagues at the Human Early Learning Partnership ( help ) ;or their contributions to earlier versions o; the team-ecd document Iraj Poureslami, Emily Hertzman, Robin Anderson, Eric Hertzman (cartographer) and Ste;ania Maggi and to those colleagues whose unending support made this work would pos- sible: Jacqueline Smit Alex, Leslie Fernandez, and Sophia Cosmadakis. Finally, we want to extend a special thank you to Karyn Huenemann ;or her editorial expertise, to Maria LeRose ;or her ability to synthesise complex in;ormation and make it accessible to a broad audience (www.barlett- lerose.ca), to Shannon Harvey ;or her creative design, and to Betty Beck ;or her prepress/ production expertise.<br><br> 1 This work was made possible through ;unding provided by the Public Health Agency o; Canada and undertaken as work ;or the Early Child Development Knowledge Network established as part o; the who Commission on the Social Determinants o; Health. The views presented in this report are those o; the authors and do not necessarily represent the decisions, policy or views o; who or Commissioners. Note: This report has undergone an external review process.<br><br> G l o b a l K n o w l e d g e ; o r E a r l y C h i l d D e v e l o p m e n t design:\xashannon @ shhdesign.ca\xa production:\xabettyandjan.com Table o, Contents Abstract 3 Political Brie ng 5 Executive Summary 7 Introduction 15 figure\xa 1 :\xateam-ecd\xaschematic\xa 17 \xa Methods 18 Results: team-ecd 19 Spheres o, Infuence The Individual Child 19 The Family 21 Residential and Relational 26 Community ecd Programmes and Services 28 Regional and National 33 figure\xa 2 :\xaedi\xavulnerability\xamap\xa 35 Global 37 Discussion and Recommendations 41 Conclusions 45 Re,erences 46 Appendix A: 53 Critical Appraisal o, the Underlying Evidence Appendix B: 55 Examples o, ecd Programmes and Services Appendix C: 61 Population-based Measurement o, Early Child Development ,rom a National Perspective Appendix D: 63 Children and Families in Global Perspective: Discussion o, and excerpts ,rom Heymann 9s Forgotten Families Early Child Development : A Power,ul Equalizer \x9 Abstract Abstract This document synthesizes knowledge about opportunities to improve the state o; early child development ( ecd ) on a global scale. In keeping with international policy standards, we de ne early childhood as the period ;rom prenatal development to eight years o; age. What children experience during the early years sets a critical %oundation %or their entire li%ecourse .<br><br> This is because ecd 4including the physical, social/emotional and language/ cognitive domains 4strongly infuences basic learning, school success, economic participation, social citizenry, and health. Within the work o; the Commission, ecd has strong links to other social determinants o; health, particularly Urban Settings, Gender, Globalization, and Health Systems. Areas o; common concern with these determinants are discussed throughout this document.<br><br> Research con rms a strong association between child survival and child development, such that the child survival and health agendas are indivisible ;rom ecd . Our developmental approach to the early years includes the ;actors that a;;ect child health and survival, but goes beyond these to consider how the early years can be used to create thriving global citizens. Here, we provide a ;ramework ;or understanding the environments (and their characteristics) that play a signi cant role in infuencing early development.<br><br> The evidence and its interpretation is derived primarily ;rom three sources: 1 ) peer-reviewed scienti c literature, 2 ) reports ;rom governments, international agencies, and civil society groups, and 3 ) a Knowledge Network o; experts in ecd that is representative in both international and inter-sectoral terms. The principal strategic insight o; this document is that the nurturant qualities o; the environments where children grow up, live and learn 4parents, caregivers, ;amily and community 4will have the most signi cant impact on their development. In most situations, parents and caregivers cannot provide strong nurturant environments without help ;rom local, regional, national, and international agencies.<br><br> We propose ways in which government and civil society actors, ;rom local to international, can work in concert with ;amilies to provide equitable access to strong nurturant environments ;or all children globally. Key Words: early child development; equity; social determinants o) health; li)ecourse; rights o) the child Early Child Development : A Power,ul Equalizer \xb Political Brie ng Early Child Development: Investment in a Country 9s Future The early years o; li;e are crucial in infu- encing a range o; health and social outcomes across the li;ecourse. Research now shows that many challenges in adult society 4mental health problems, obesity/stunting, heart disease, criminality, competence in literacy and numeracy 4have their roots in early childhood.<br><br> Economists now assert on the basis o; the available evidence that investment in early childhood is the most power;ul investment a country can make, with returns over the li;ecourse many times the amount o; the original investment. Governments can make major and sustained improvements in society by implementing policies that take note o; this power;ul body o; research while, at the same time, ;ul lling their obligations under the un Convention on the Rights o; the Child. Research now shows that children 9s early environment has a vital impact on the way their brains develop.<br><br> A baby is born with billions o; brain cells that represent li;elong potential, but, to develop, these brain cells need to connect with each other. The more stimulating the early environment (social interaction), the more positive connections are ;ormed in the brain and the better the child thrives in all aspects o; his or her li;e, in terms o; physical development, emotional and social development, and the ability to express themselves and acquire knowledge. We know what kinds o; environments promote early child health and development.<br><br> While nutrition and physical growth are basic, young children also need to spend their time in caring, responsive environments that protect them ;rom inappropriate disapproval and punishment. They need opportunities to explore their world, to play, and to learn how to speak and listen to others. Parents and other caregivers want to provide these opportunities %or their children, but they need support %rom community and government at all levels.<br><br> For example, children bene t when national governments adopt c;amily-;riendly d social protection policies that guarantee adequate income ;or all, maternity bene ts, nancial support ;or the ultra-poor, and allow parents and caregivers to e;;ectively balance their time spent at home and work. Despite this knowledge, it is estimated that at least 200 million children in developing countries alone are not reaching their %ull potential. Political leaders can play an important role in guaranteeing universal access to a range o% early child development services: parenting and caregiver support, quality childcare, primary healthcare, nutrition, education, and social protection.<br><br> In the early years, the health care system has a pivotal role to play, as it is the point o; rst contact and can serve as a gateway to other early childhood services. To be e;;ective, services at all levels need to be better coordinated and to converge at the ;amily and local community in a way that puts the child at the centre. These kinds o; ;amily-;riendly policies and practices clearly bene t children and ;amilies, but they also result in economic bene ts to the larger society.<br><br> Globally, those societies that invest in children and ;amilies in the early years 4rich or poor 4have the most literate and numerate populations. These are the societies that have the best health status and lowest levels o; health inequality in the world. Success in promoting early child develop- ment does not depend upon a society being wealthy.<br><br> Because early child development programs rely primarily on the skills o; caregivers, the cost o; e;;ective programs varies with the wage structure o; a society. Regardless o; their level o; wealth, societies can make progress on early child development by allocating as little as $1 . 00 in this area ;or every $10 .<br><br> 00 spent on health and education. Child Survival and Child Health agendas are indivisible %rom Early Child Development. That is, taking a developmental perspective on the early years provides an overarching %ramework o% understanding that subsumes issues o% survival and health.<br><br> A healthy start in li%e gives each child an equal chance to thrive and grow into an adult who makes a positive contribution to the community 4economically and socially. Political Brie ng Early Child Development : A Power,ul Equalizer \xd Executive Summary The early child period is considered to be the most important developmental phase throughout the li;espan. Healthy early child development ( ecd ) 4which includes the physical, social/emotional, and language/ cognitive domains o; development, each equally important 4strongly infuences well-being, obesity/stunting, mental health, heart disease, competence in literacy and numeracy, criminality, and economic participation throughout li;e.<br><br> What happens to the child in the early years is critical ;or the child 9s developmental trajectory and li;ecourse. The principal strategic insight o; this document is that the nurturant qualities o; the environments where children grow up, live and learn matter the most ;or their devel- opment, yet parents cannot provide strong nurturant environments without help ;rom local, regional, national, and international agencies. There;ore, this report 9s principal contribution is to propose ways in which gov- ernment and civil society actors, ;rom local to international, can work in concert with ;amilies to provide equitable access to strong nurturant environments ;or all children glob- ally.<br><br> Recognizing the strong impact o; ecd on adult li;e, it is imperative that governments recognize that disparities in the nuturant environments required ;or healthy child development will impact di;;erentially on the outcome o; di;;erent nations and societies. In some societies, inequities in ecd translate into vastly di;;erent li;e chances ;or children; in others, however, disparities in ecd reach a critical point, where they become a threat to peace and sustainable development. The early years are marked by the most rapid development, especially o; the central nervous system.<br><br> The environmental condi- tions to which children are exposed including the quality o% relationships and language environment in the earliest years literally csculpt d the developing brain. The environ- ments that are responsible ;or ;ostering nurturant conditions ;or children range ;rom the intimate realm o; the ;amily to the broader socioeconomic context shaped by governments, international agencies, and civil society. These environments and their characteristics are the determinants o; ecd ; in turn, ecd is a determinant o; health, well- being, and learning skills across the balance o; the li;ecourse.<br><br> The seeds o; adult gender inequity are sewn in early childhood. In the early years, gender equity issues 4in particular, gender socialization, ;eeding practices, and access to schooling 4are determinants o; ecd . Early gender inequity, when rein;orced by power relations, biased norms and day-to-day experiences in the ;amily, school, com- munity, and broader society, go on to have a pro;ound impact on adult gender inequity.<br><br> Gender equity ;rom early childhood onwards infuences human agency and empowerment in adulthood. Economists now assert on the basis o; the available evidence that investment in early childhood is the most power;ul investment a country can make, with returns over the li;ecourse many times the size o; the original investment. The scope o; the present report is ;our;old: 1 .<br><br> To demonstrate which environments matter most ;or children. This includes environments ;rom the most intimate (;amily) to the most remote (global). 2 .<br><br> To review which environmental con gurations are optimal ;or ecd , including aspects o; environments that are economic, social, and physical in nature. 3 . To determine the ccontingency relationships d that connect the broader socioeconomic context o; society to the quality o; nurturing in intimate environments such as ;amilies and communities.<br><br> 4 . To highlight opportunities to ;oster nurturant conditions ;or children at multiple levels o; society (;rom ;amily-level action to national and global governmental action) and by multiple means (i.e. through programmatic implementation, to cchild-centered d social and economic policy development).<br><br> In keeping with international policy stan- dards, early childhood is de ned as the period Executive Summary \xe Early Child Development : A Power,ul Equalizer \xf that demonstrate higher overall average outcomes ;or children are those in which disadvantaged children are developmentally stronger than disadvantaged children in other nations, whereas, in all nations, children at the higher ends o; the socioeconomic spec- trum tend to demonstrate relatively strong outcomes. In this report we provide a ;ramework ;or understanding the environments (and their characteristics) that play a signi cant role in providing nurturant conditions to all children in an equitable manner. The ;ramework acts as a guide to understanding the relationships between these environ- ments, putting the child at the center o; her or his surroundings.<br><br> The environments are not strictly hierarchical, but rather are truly interconnected. At the most intimate level is the ;amily environment. At a broader level are residential communities (such as neighbour- hoods), relational communities (such as those based on religious or other social bonds), and the ecd service environment.<br><br> Each o; these environments (where the child actually grows up, lives, and learns) is situated in a broad socioeconomic context that is shaped by ;actors at the regional, national, and global level. The ;ramework a; rms the importance o; a li;ecourse perspective in decision-making regarding ecd . Actions taken at any o; these environmental levels will a;;ect children not only in present day, but also throughout their lives.<br><br> The ;ramework also suggests that historical time is critically infuential ;or children; large institutional and structural aspects o; societies (e.g. government policy- clusters, programs, and the like) matter ;or ecd , and these are cbuilt d or cdismantled d over long periods o; time. Socioeconomic inequities in developmen- tal outcomes result ;rom inequities in the degree to which the experiences and environ- mental conditions ;or children are nurturant.<br><br> Thus, all recommendations %or action stem %rom one overarching goal: to improve the nurturant qualities o% the experiences children have in the environments where they grow up, live, and learn. A broad array o; experiences and environmental conditions matter. These include those that are intimately connected to the child, and there;ore readily identi able (e.g.<br><br> the quality o; time and care provided by parents and caregivers and the physical conditions o; the child 9s surroundings), but also more distal ;actors that in various ways infuence the child 9s access to nurturant conditions (e.g., whether government policies provide ;amilies and communities with su; cient income and employment, health care resources, early childhood education, sa;e neighborhoods, decent housing, etc.). While genetic predispositions and bio- physical characteristics partially explain how environment and experience shape ecd , the best evidence leads us to consider the child as a social actor who shapes and is in turn shaped by his or her environment. This is known as the ctransactional model, d which emphasizes that the principal driving ;orce o; child development is relationships.<br><br> Because strong nurturant relationships can make ;or healthy ecd , socioeconomic circumstances, despite their importance, are not %ate. The %amily environment is the primary source o; experience ;or a child, both because ;amily members (or other primary caregivers) provide the largest share o; human contact with children and because ;amilies mediate a child 9s contact with the broader environment. Perhaps the most salient ;eatures o; the ;amily environment are its social and economic resources.<br><br> Family social resources include parenting skills and education, cultural prac- tices and approaches, intra-;amilial relations, and the health status o; ;amily members. Economic resources include wealth, occu- pational status, and dwelling conditions. The gradient e;;ect o; ;amily resources on ecd is the most power;ul explanation ;or di;;erences in children 9s well-being across societies.<br><br> Young children need to spend their time in warm responsive environments that protect them ;rom inappropriate disapproval and punishment. They need opportunities to explore their world, to play, and to learn how to speak and listen to others. Families want to provide these opportunities ;or their chil- dren, but they need support ;rom community and government at all levels.<br><br> Children and their ;amilies are also shaped by the residential community (where the child and ;amily live) and the relational Executive Summary ;rom prenatal development to eight years o; age. The evidentiary base, as well as interpretation o; the body o; evidence, is derived ;rom three primary sources: 1 ) peer-reviewed scienti c literature, 2 ) reports ;rom governments, international agencies, and civil society groups, and 3 ) international experts in the eld o; ecd (including the Commission on Social Determinants o; Health, Knowledge Network ;or ecd ) that is representative in both interna- tional and inter-sectoral terms. This evidence-based multiple-sourced approach ensures that the conclusions and recommendations o; this report are borne out o; the perspectives o; a diverse array o; stakeholders and broadly applicable to societies throughout the world.<br><br> One guiding principle is an cequity-based approach d to providing nurturant environ- ments %or children everywhere. Multiple perspectives 4;rom the provisions o; human and child rights declarations to the realities refected by research evidence 4make clear the importance o; equity. Programs and policies must create marked improvements in the circumstances o; societies 9 most disad- vantaged children, not just in absolute terms, but in comparison to the most advantaged children as well.<br><br> What is now known is that, in every society, inequities in socioeconomic resources result in inequities in ecd . The relationship is much more insidious than solely di;;erentiating the rich ;rom the poor; rather, any additional gain in social and economic resources to a given ;amily results in commensurate gains in the devel- opmental outcomes o; the children in that ;amily. This step-wise relationship between socioeconomic conditions and ecd is called a cgradient e;;ect. d However, some societies are more success;ul than others at cdulling d the gradient e;;ect, thus ;ostering greater equity.<br><br> Societies accomplish this by providing a range o; important resources to children as a right o; citizenship, rather than allowing them to be a luxury ;or those ;amilies and communities with su; cient purchasing power. Importantly, an equity-based approach is also the success;ul path to creating high average ecd outcomes ;or a nation. Societies Economists now assert on the basis o% the available evidence that investment in early childhood is the most power%ul investment a country can make, with returns over the li%ecourse many times the size o% the original investment.<br><br> 10 Early Child Development : A Power,ul Equalizer 11 communities (;amily social ties to those with a common identity) in which they are embed- ded. Residential and relational communities o;;er ;amilies multiple ;orms o; support, ;rom tangible goods and services that assist with child rearing, to emotional connections with others that are instrumental in the well-being o; children and their caregivers. At the residential/locality level, both govern- ments and grass-roots organizations also play a highly infuential role.<br><br> Many resources available to children and ;amilies are provided on a community level through local recogni- tion o; de cits in resources, problem-solving, and ingenuity. There are, however, inequities in ecd that are apparent between residential communities, which must be addressed in a systematic way. cRelational community d re;ers to the people, adults and children, who help ;orm a child 9s social identity: tribal, ethnic, religious, and language/cultural.<br><br> O;ten, this is not a geographically clustered community. Relational communities provide a source o; social networks and collective e; cacy, including instrumental, in;ormational, and emotional ;orms o; support. However, discrimination, social exclusion, and other ;orms o; subjugation are o;ten directed at groups de ned by relational communities.<br><br> The consequences o; these ;orms o; discrimi- nation (e.g., ;ewer economic resources) can result in discernable inequities. Moreover, relational communities can be sources o; gender socialization, both equitable and non-equitable. Relational communities are also embedded in the larger socio-political contexts o; society; as such, reciprocal engagement with other relational groups, civil society organizations, and governmental bodies is a means o; addressing the interests and resource needs o; their members.<br><br> The availability o; ecd programmes and services to support children 9s development during the early years is a crucial component o; an overall strategy ;or success in childhood. ecd services may address one or more o; the key developmental domains (i.e. language/ cognitive, social/emotional, and physical development).<br><br> The quality and appropriate- ness o; services is a central consideration in determining whether existing ecd programmes improve outcomes ;or children. There are principles o; ecd programmes and services that are readily trans;erable between places; however, many programme ;eatures require tailoring to the social, economic, and cultural contexts in which they are ;ound. ecd services may be targeted to speci c characteristics o; children or ;amilies (e.g., low birth-weight babies or low-income ;amilies), may occur only in some communi- ties and locales and not others, or may be more comprehensively provided.<br><br> Each o; these is also accompanied by their respective bene ts and drawbacks; however, the overarching goal o% the global community should be to fnd means o% providing universal access to e%%ective ecd programmes and services. Health care systems ( hcs s) are key to providing many important ecd services. The hcs is in a unique position to contribute to ecd , since hcs s provide ;acilities and services that are more widely accessible in many societies than any other ;orm o; human service, are already concerned with the health o; individuals and communities, employ trained pro;essionals, and are a primary point o; contact ;or child- bearing mothers.<br><br> The infuence o; the regional and national environments is ;undamental in determining the quality and accessibility o; services and resources to ;amilies and communities. They are also salient ;or understanding the levels o; social organization at which inequalities in opportunity and outcome may be mani;est, and the levels o; organization at which action can be taken to ameliorate inequities. There are many interrelated aspects o; regional environments that may be signi cant ;or ecd : physical (e.g., the degree o; urbaniza- tion, the health status o; the population), social, political, and economic.<br><br> These aspects o; the regional environment a;;ect ecd through their infuence on the ;amily and neighbourhood, and on ecd services. In contrast to more intimate environments, such as the ;amily, the signi cance o; large envi- ronments, such as the region, is that regions have an e;;ect on large numbers o; children. Thus, changing the environment at this level can infuence the lives o; many children.<br><br> Much more research and accumulation o; knowledge is required regarding how regional Executive Summary 12 Early Child Development : A Power,ul Equalizer 1\x9 Abstract characteristics can be modi ed to positively infuence ecd . The most salient ;eature o; the national environment is its capacity to a;;ect multiple determinants o; ecd through wealth creation, public spending, child- and ;amily-;riendly policies, social protection, and protection o; basic rights. The chances that children will %ace extreme poverty, child labour, war%are, hiv/aids, being le%t in the care o% a sibling, and so on, is determined, frst and %oremost, by the countries in which they are born.<br><br> At the level o; the national environment, comprehensive, inter-sectoral approaches to policy and decision-making work best ;or ecd . Although ecd outcomes tend to be more ;avourable in wealthy countries than poor ones, this is not always the case. It is clear that a commitment o; 1 .<br><br> 5 3 2 . 0 % o; gdp to an e;;ective mix o; policies and programmes in the public sector can e;;ectively support children 9s early development. Those nations with less economic and political power are less ;ree to determine their internal policy agendas, and are more infuenced by the interests o; the international community, including other nations and multilateral organizations.<br><br> Notwithstanding this, most o% the recommendations in this report are within the capabilities o% any national government that meets the international criteria %or a ccompetent authority. d The global environment can infuence ecd through its e;;ects on the policies o; nations as well as through the direct actions o; a range o; relevant actors, including multilateral eco- nomic organizations, industry, multilateral development agencies, non-governmental development agencies, and civil society groups. A major ;eature o; the global environ- ment in relation to children 9s well-being is the element o; power in economic, social, and political terms. Power di;;erentials between types o; actors, particularly between nations, have many consequences, including the ability o; some nations (mainly resource-rich ones) to infuence the policies o; other nations (mainly resource-poor ones) to suit their own interests.<br><br> Although power di;;erentials may have invidious e;;ects on ecd , they can be exploited ;or the bene t o; children, too. Requiring a minimum level o% government spending on ecd and compliance with the Rights in Early Childhood provisions o% the Convention on the Rights o% the Child, as pre- conditions %or international developmental assistance, are two mechanisms that can be used. Analogous mechanisms have been used e;;ectively in other areas o; international development in the past.<br><br> Civil society groups are conceptualized as being organized at, and acting on, all levels o; social organization, ;rom local residential through global. The ability o; civil society to act on behal; o; children is a ;unction o; the extent o; csocial capital d or connected- ness o; citizens, and the support o; political institutions in promoting expressions o; civil organization. When civil society is enabled, there are many avenues through which they can engage on behal; o; children.<br><br> Civil society groups can initiate government, non-govern- ment organization, and community action on social determinants o; ecd . They can advocate on behal; o; children to assure that governments and international agencies adopt policies that positively bene t children 9s well-being. Finally, civil society groups are instrumental in organizing strategies at the local level to provide ;amilies and children with e;;ective delivery o; ecd services, to improve the sa;ety, cohesion, and e; cacy o; residential environments, and to increase the capacity o; local and relational communities to better the lives o; children.<br><br> Although research on the direct e%%ect o% civil society on ecd is limited, the strong statistical associa- tion between the strength o% civil society and human development in societies around the globe leaves little doubt about its importance to ecd . Executive Summary Early Child Development : A Power,ul Equalizer 1\xb Introduction The early child period is considered to be the most important developmental phase throughout an individual 9s li;espan. Healthy early child development ( ecd ) 4physical, social 3emotional, and language 3cogni- tive 4is ;undamental to success and happiness not only ;or the duration o; childhood, but throughout the li;ecourse.<br><br> ecd strongly infu- ences well-being, obesity/stunting, mental health, heart disease, literacy and numeracy skills, criminality, and economic participa- tion throughout li;e 4all issues that have pro;ound implications ;or economic burden on countries. I; the window o; opportunity presented by the early years is missed, it becomes increasingly di; cult, in terms o; both time and resources, to create a success;ul li;ecourse. Governments must recognize that e;;ective investments in the early years are a cornerstone o; human development and central to the success;ulness o; societies.<br><br> Indeed, our planet provides no examples o; highly success;ul societies among those who have ignored development in the early years. It is there;ore critical ;or governments, interna- tional agencies, and civil society partners to move ;rom knowledge to action in ecd . We base this report on the assumption that every child has a basic right to a name and a national- ity but we know that many children the world over are not registered at birth.<br><br> ecd is important in all countries, resource-rich and -poor alike, but special attention needs be paid to the potential bene ts to the resource-poor, where a child has a ;our in ten chance o; living in extreme poverty and 10 . 5 million children die be;ore age 5 . Such children are likely to su;;er ;rom poor nutrition and poor health.<br><br> They are also at high risk o; never attending school ( unesco 2007 ). The recent Lancet series on ecd esti- mates that there are 559 million children under 5 in developing countries 4including \x9 155 million who are stunted and 62 million who are not stunted but are living in poverty 4;or a total o; over 200 \x9 million children under ve years o; age who are at extreme risk o; impaired cognitive and social 3emotional development. Most o; these children 4 89 million 4live in ten countries (India, Nigeria, China, Bangladesh, Ethiopia, Indonesia, Pakistan, Democratic Republic o; Congo, Uganda, and Tanzania) that account ;or 145 million ( 66 %) o; the 219 million disadvantaged children in the developing world.<br><br> Many are likely to do poorly in school and subsequently as adults will likely have low incomes, high ;ertility, and provide poor health care, nutrition, and stimulation to their own children, thus contributing to the intergenerational transmission o; disadvantage (Grantham-McGregor et. al., 2007 ). The loss o; human potential that the above statistics repre- sent is associated with more than ca 20 % de cit in adult income and will have implications ;or national development d (Grantham-McGregor et.<br><br> al., 2007 , p. 67 ). The overarching message o; this report to governments, international agencies, and civil society partners is this: the agenda to improve child survival and health is indivisible ;rom the agenda to improve ecd .<br><br> That is, taking a developmental perspective on the early years provides a comprehensive ;ramework o; under- standing that subsumes issues o; survival and health. A healthy start in li;e gives each child an equal chance to thrive and grow into an adult who makes a positive contribution to Introduction Governments must recognize that e%%ective investments in the early years are a corner- stone o% human development and central to the success%ulness o% societies. The agenda to improve child survival and health is indivisible %rom the agenda to improve early child development.<br><br> 16 Early Child Development : A Power,ul Equalizer 1\xd to healthy ecd , and linking these to the biological processes with which they interact to shape children 9s outcomes (Siddiqi, Irwin & Hertzman, 2007 ). The team-ecd model builds on a diverse literature, including previously described ;rameworks that have addressed ecd ;rom a social environmental perspective. These sources include Urie Bron;enbrenner 9s Bioecological Model ( 1986 ); developmental psychology perspectives on ecd (Brooks-Gunn, Duncan & Maritato, 1997 ); notions o; cbiological embedding d (Hertzman 1999 ); ;rameworks o; under- standing regarding social epidemiology and social determinants o; health (Dahlgren & Whitehead, 1991 ; Emmons, 2003 ); research regarding social relations in human society (Putnam, 2000 ; Weber, 1946 ); a vast literature in the political economy domain (;or a review o; this literature, see Siddiqi, Irwin & Hertzman, 2007 ); and the World Health Organization ( who ) Framework on Social Determinants o; Health (Solari & Irwin, 2005 ).<br><br> Because the who Equity Team Introduction ;ramework considers ecd as a determinant o; health, it becomes crucial here to address the ;actors infuencing ecd itsel;. By expanding the notion o; environmental spheres o; infuence, adding a temporal component, and placing children 9s well-being at its centre, team-ecd o;;ers the strongest means o; understanding (and there;ore acting upon) social determinants o; ecd . spheres\xaof\xainfluence\xaon\xaearly\xachild\xa development In this schematic (see figure 1 ), a variety o; interacting and interdependent spheres o; infuence are instrumental ;or development in early childhood.<br><br> They include the indi- vidual, ;amily, and dwelling; residential and relational communities; ecd programmes and services; and regional, national and global environments. In each sphere o; infuence, social, economic, cultural and gender ;actors a;;ect its nurturant qualities. figure\xa 1 :\xateam-ecd\xa schematic are made clear, though implicit, throughout this document.<br><br> Moreover, we argue that Child Survival, Child Health, Education ;or All, and Child Rights agendas are indivisible ;rom ecd . Again, taking a developmental perspective on the early years provides a ;ramework o; under- standing that incorporates issues o; survival and health as well as education and rights. scope\xaof\xawork This work includes evidence related to in;ants and children, ;rom prenatal development through to eight years o; age, speci cally considering how social determinants infuence health across the li;ecourse.<br><br> It is o; relevance to children on a global scale. We discuss the limitations to the application o; these ideas where appropriate. purpose The purpose o; this document is to synthesize knowledge to in;orm the csdh about opportunities to improve action on a global scale in the area o; ecd .<br><br> The evidence assembled here ;ocuses on priority associations between social determinants o; health and health inequities across di;;erent country contexts. It comments on the extent to which the social determinants o; ecd can be acted upon; is intended to stimulate societal debate on the opportunities ;or acting on social determinants o; health and to in;orm the application and evaluation o; policy proposals and programmes in the area o; ecd 4nationally, across regions and globally. The areas o; ;ocus ;or each o; the Commission 9s Knowledge Networks 4Globalization, Social Exclusion, Health Systems, Gender, Urban Settings, Employment Conditions, Priority Public Health Conditions and Evidence & Measurement 4are critical to understanding the social determination o; ecd , and as such are integral to this review.<br><br> conceptual\xaframework The Total Environment Assessment Model o; Early Child Development ( team-ecd ) has been developed ;or the csdh as a means o; ;raming the types o; environments (and there;ore experiences) that are integral the community 4economically and socially. Accordingly, governments should adopt a strategy o; investing in ecd in order to meet the Millennium Development Goals ( mdg s) ;or poverty reduction, education, and health. Economists now argue on the basis o; the available evidence that investment in early childhood is the most power;ul investment a country can make, with returns over the li;e course many times the amount o; the original investment.<br><br> Globally, societies 4rich or poor 4that invest in children and ;amilies in the early years have the most literate and numerate populations. These are also the societies that have the best health status and lowest levels o; health inequality in the world. Societies with the most success;ul policies and programmes ;or ecd spend approximately 1 .<br><br> 5 % 3 2 . 0 % o; gdp per year on it ( oecd , 2006 ). One study has estimated that every dollar spent to help a child reach school age while thriving can generate up to $ 17 in bene ts to society over the ;ollowing ;our decades (even a;ter controlling ;or infation) (Schweinhart, Barnes & Weikart, 1993 ; Schweinhart, 2004 ).<br><br> While the academic and grey literature provides compelling evidence about the importance o; the early years, in practice, ecd is not at the centre o; international, national or local policies, programming and practice. Despite the strength o; the evidence, adequate investments in ecd have been slow, particu- larly, in resource-poor countries where the greatest number o; vulnerable children would bene t the most. Within the work o; the Commission on Social Determinants o; Health ( csdh ), ecd has strong links to other social determinants o; health, particularly Urban Settings, Gender, Globalization and Health Systems.<br><br> Areas o; common concern with these determinants Introduction Governments should adopt a strategy o% investing in early child development in order to meet the Millennium Develop- ment Goals %or poverty reduc- tion, education, and health. G l o b a l E c o l o g i c a l , C o r p o r a t e / E c o n o m i c , P o l i c y , P o l i t i c a l a n d S o c i a l E n v i r o n m e n t s N a t i o n a l H e a l t h S t a t u s , E c o l o g i c a l , E c o n o m i c , P o l i c y , P o l i t i c a l & S o c i a l E n v i r o n m e n t s R e g i o n a l H e a l t h S t a t u s , E c o l o g i c a l , E c o n o m i c , P o l i c y , P o l i t i c a l & S o c i a l E n v i r o n m e n t s R e s i d e n t i a l C o m m u n i t y H e a l t h S t a t u s a n d C u l t u r a l , E c o n o m i c , S e r v i c e & S o c i a l E n v i r o n m e n t s F a m i l y , C u l t u r a l , E c o n o m i c , & S o c i a l E n v i r o n m e n t , G e n d e r R o l e s , F a m il y H e a l t h S t a t u s a n d D w e l l i n g E n v i r o n m e n t Individual Brain and Biological Development Genetics, Age, Sex, Gender ECD Programmes and Services Relational Community (Tribe, Religion, etc.) Health Status, Gender Socialization, Cultural Environment and Socioeconomic Status & Resources Civil Society Institutional / Historical Time 1\xe Early Child Development : A Power,ul Equalizer 1\xf Results: team-ecd\xa Spheres o, Infuence The Individual Child The earliest years o; li;e are characterized by the most important development that occurs in a human li;espan. There are several bases ;or the bold and unequivocal nature o; this statement.<br><br> The early years are marked by the most rapid development, particularly o; the central nervous system. The csensitive periods d ;or the development o; the brain almost exclusively occur during this time. During these early years, the experiences (e.g., good quality nutrition) and the environmen- tal exposures (e.g., attachment to a caregiver) that a child receives will be instrumental in the success;ul development o; early brain ;unction.<br><br> Not only will the child be shaped by these experiences physiologically, but the child will also shape these experiences. The development that occurs in the early years provides the essential building blocks ;or a li;etime o; success in many domains o; li;e, including economic, social and physical well-being. biological\xaembedding The interaction that occurs between individ- ual characteristics (genetic and physiologic) and experiences and exposures drawn ;rom the environment are basic to the development o; the child.<br><br> The human brain, in particular, is the cmaster organ d o; development. Early in li;e, genetically programmed sensitive periods occur in the brain, during which time the developing child is disproportionately sensitive to the infuences o; the external environment (Barker, 1992 ; Bron;enbrenner, 1986 ; Wadsworth, 1997 ). The interplay o% the developing brain with the environment is the driving %orce o% development ; its legacy is a unique con guration o; synapses in the brain that infuences and is infuenced by cognitive, social and emotional ;unctions therea;ter.<br><br> The process o; early experience becoming solidi- Spheres o 7 Infuence: The Individual Child ed and infuencing health and development over the long-term is known as biological embedding (Hertzman, 1999 ). nutrition Children 9s optimal growth and development requires adequate nutrition, and receiving adequate nutrition is a ;undamental right o; children (see General Comment # 7 on the Convention on the Rights o; the Child [ crc ] [United Nations O; ce o; the High Commission ;or Human Rights, 1990 ]) and begins in utero with adequately nourished mothers. During the rst months o; li;e, breast;eeding plays a critical role in providing children with the necessary nutrients.<br><br> In ;act, exclusive breast;eeding is thought to reduce the chances o; early post-natal stunting (Smith et al., 2003 ). Breast;eeding carries with it the dual role o; adequate nutrition and healthy in;ant development through stimulation and attachment as part o; the breast;eeding process. Despite what the evidence 4both scienti c and traditional 4tells us about adequate nutrition ;or in;ants and children, there are approxi- mately 150 million children under the age o; ve years in the developing world alone who su;;er ;rom malnourishment.<br><br> Children who are malnourished are more likely to su;;er the consequences o; poor physical and mental development; have poorer school per;ormance (Pelto, Dickin & Engle, 1999 ; Powell et al., 1998 ; Winicki & Jemison, 2003 ); be susceptible to the e;;ects o; in;ec- tion; have more severe diarrhoeal episodes; have a higher risk o; pneumonia; have lower ;unctioning immune systems; and o;ten have low levels o; iodine, iron, protein and 150 million children under the age o% fve years in the developing world alone su%%er %rom malnourishment. personal experiences drawn ;rom a wide variety o; sources. While we have used the highest quality research evidence available, we are also aware that not all high-quality research is o; practical signi cance or equally applicable in all global contexts.<br><br> This multi- source, multi-method approach helped to ensure that the conclusions and recommenda- tions o; this report are consistent with the perspectives o; a diverse array o; stakeholders, and are broadly applicable to societies throughout the world. We acknowledge both the limitations posed by many o; these studies being ;ocused in resource-rich nations, and the many challenges that limit the extent to which experiences, programmes and research nd- ings ;rom one global context 2 can be applied to others. Methods The process o; synthesizing the available evidence raised the question o; what counts as evidence.<br><br> We paid attention to the quality o; the source, the context o; the research, the nuances o; particular programmes and populations served, and the ecological ;actors associated with the studies. Accordingly, our evidentiary base is derived ;rom three primary sources: 1 ) peer-reviewed scienti c literature, 2 ) reports ;rom governments, international agencies, and civil society groups and 3 ) international experts in ecd (including the csdh Knowledge Network ;or ecd that is representative in both international and inter- sectoral terms). This Final Report is a summary o; a broader comprehensive evidence document entitled, like the model, team-ecd (Siddqi, Irwin & Hertzman, 2007 ), so when in-depth in;orma- tion is at issue, we to re;er back to team-ecd .<br><br> Although there is a wealth o; literature related to ecd , only a limited number o; studies ;ocus upon ecd in resource-poor countries. In addition, although we believe that qualita- tive research ndings contribute a unique and important source o; in;ormation to a review such as this, the availability o; studies employing qualitative methods was limited. There is also a heavy weighting o; evidence in the literature ;or cat risk d or special popula- tions, but these studies are also concentrated in resource-rich nations.<br><br> We took a broad view o; what literature was relevant to ecd (see Appendix A), investigating databases ;rom multiple disciplines, including medicine, developmen- tal psychology, sociology, nursing, population health, economics and anthropology. For each, evidence that pertained to any aspect o; children 9s well-being was included. In addi- tion, papers addressing the interconnectivity o; ;amily, residential, relational and broader societal contexts were reviewed, even when these papers did not make direct re;erence to e;;ects on children.<br><br> Whenever possible we used ccausal evidence d in the scienti c sense and complemented it with practical and Methods 2 E;;orts aimed at universalization o; knowledge and practices have been based on dominant Anglo-American values, goals and norms (Nsamenang, 2005 ). Our best example o; this is breast- ;eeding. For many years in the past, European and American organizations and corporate entities advocated ;or ;ormula ;eeding (Gussow, 1980 ).<br><br> They have now introduced a global call ;or mothers to commit to cexclusive d breast;eeding ;or six months ( who , 2003 ). In this case, the value o; breast;eeding in nations o; A;rica and Asia was already known through years o; tradition and experience, but was trumped by cwisdoms d imported ;rom Europe and America. 20 Early Child Development : A Power,ul Equalizer 21 The Family The ;amily 3 is the primary infuence on a child 9s development ( unicef , 2007 ) ( cFamily d is de ned here as any group o; people who dwell together, eat together, and participate in other daily home-based activities together).<br><br> The new crc General Comment # 7 on Early Childhood restates the crc 9s position on ;amily as, the c;undamental group d and the cnatural environment d ;or growth and well-being but recognises that the concept o; ;amily extends well beyond the cnuclear d model. Parents and caregivers are identi ed as principal actors in the construction o; identity and the develop- ment o; skills, knowledge and behaviours, and as duty-bearers in the realisation o; the young child 9s rights. Family members provide most environmental stimuli ;or children, and ;amilies largely control a child 9s contact with the distal environment (Richter, 2004 ).<br><br> The most salient ;eatures o; the ;amily environment are its social and economic resources. Social resources include parenting skills and education, cultural practices and approaches, intra-;amilial relations, and the health status o; ;amily members. Economic resources include wealth, occupational status and dwelling conditions.<br><br> Social and economic resources ;or children are highly intertwined, yet imply di;;erent strategies ;or intervention relationships\xa A strong body o; research demonstrates the signi cance o; primary caregivers (and by extension, ;amilies) on children 9s long-term development (Shonko;; & Phillips, 2000 ). Those ;actors that ;acilitate healthy social bonds and the character o; caregiving practices that matter most ;or children are now well understood. A key requisite ;or healthy ecd is secure attachment to a trusted caregiver with consistent caring, support and a;;ection early in li;e (Bowlby, 1969 ).<br><br> Securely attached in;ants and toddlers use key\xamessages:\xathe\xaindividual\xachild 1. Health, nutrition, and well-being o; the mother are signi cant ;or the child 9s development. 2.<br><br> Three broad domains o; develop- ment 4physical, social 3emotional and language 3cognitive 4are interconnected and equally important. 3. Children shape their environments as well as being shaped by them.<br><br> 4. Social determinants shape brain and biological development through their infuence on the qualities o; stimulation, support, and nurturance available to the child. 5.<br><br> Play is critical ;or a child 9s overall development. Spheres o 7 Infuence: The Family evolves over time; it requires, at a minimum, a sa;e environment and developmentally appropriate resources. Stimulation (e.g., mothers and children playing with home- made toys with a ;ocus on guided learning and exploration) has an independent e;;ect on perceptual motor development outcomes among stunted children, over and above nutritional supplementation (Grantham- McGregor et al., 1997 ).<br><br> McArdle suggests that cplay is marginal to the plans o; governments and local authorities d ( 2003 , p. 512 ) and not viewed as a cserious d activity. Potentially, one o% the most e%fcient strategies %or improving ecd is to fnd ways to convince parents and caregivers o% the importance o% play and the ways they can promote it.<br><br> thus energy, which can contribute to chronic illness ( unicef , 2006 ). As women remain the primary caregivers ;or children, when they have greater infuence in household decisions, women can signi cantly improve their children 9s nutritional status (Smith et al, 2003 ). Educating women has also been shown not only to improve their children 9s nutri- tional status, but it also results in multiple bene ts ;or children by improving children 9s survival rates and school attendance (Smith et al, 2003 ).<br><br> Malnutrition is also implicated in more than hal; o; all child deaths worldwide. In addition to its devastating impact on child mortality, nutritional de ciencies especially ;or children under three years old have long-term damaging e;;ects on the intellectual and psychological development o; children: unacceptable loss o; human potential (Grantham-McGregor et al., 2007 ). Malnutrition is there;ore one o; the most important ;actors in poor development and loss o; development potential ;or children.<br><br> We know that stunting as a result o; chronic mal- nutrition is shaped by a complex combination o; environmental, social and economic ;actors, which begin in utero and a;;ect both physical growth and mental development. Here is a prime example o% where child survival, %ood security, ecd , education and gender equity agendas converge. It is essential to reduce malnutrition globally, especially in 0 to 3 year olds, but this requires systematic action at the local level in the areas o; maternal health (including adequate nutrition) and health care; ;ood security, with adequate micronutrient intake; sa;e water; access to education ;or all; and protection ;rom illness such as provided by immunization programmes.<br><br> While attention to these ;actors is important, it is equally important to ensure the presence o; a systematic, community-based ;ollow-up Spheres o 7 Infuence: The Individual Child Nutritional defciencies at all stages o% growth have long- term damaging e%%ects on the intellectual and psychological development o% children. and support ;or malnourished children and their ;amilies 4especially the most vulnerable children. relationships Although adequate nutrition is essential ;or development, the quality o; relationships is equally important ;or children 9s develop- ment.<br><br> Existing literature leads us to consider children as social actors (Boyden & Levison, 2000 ; Irwin, 2006 ; Irwin et al., 2007 ; Irwin & Johnson, 2005 ; Mayall, 1996 ), who are not only shaped by their environment but, in turn, shape it as well. A child 9s individual development is transactional, reciprocal and mutually constituted. Young children develop best in warm, responsive environ- ments that protect them ;rom inappropriate disapproval and punishment, environments in which there are opportunities to explore their world, to play, and to learn how to speak and listen to others (Ramey & Ramey, 1998 ).<br><br> Notwithstanding the complexity o; ecd , the many ;actors that infuence ecd come down to these simple attributes o; the child 9s day-to-day experience. Improving the quality o% children 9s day-to-day experience through relationships needs to be a primary goal o% all initiatives regarding o% parenting, childcare, and monitoring rights in early childhood under the crc . the\xascience\xaof\xaplay The central role o; play in children 9s develop- ment is not always appreciated.<br><br> Play processes infuence synaptic ;ormation and are linked to secure attachment with caregivers and relationships with other children. Play provides an important socializing ;unction, beyond the merits o; being physically active, in which children learn about and negotiate identity and the social subtleties o; relation- ships (James, 1993 ). Play may vary according to individual children 9s temperaments, gender, culture or their ;amilies 9 parenting and caregiving practices, but the impact o; play on developmental processes is universal across cultures (Bornstein et al., 1999 ).<br><br> Play can be structured or unstructured; it can be done alone, with a caregiver or in a group; it 3 While in this section we ;ocus our attention on c;amily d broadly de ned, we want to emphasize the importance o; connectedness to kin an kith and relational communities ;or support and stimulation. 22 Early Child Development : A Power,ul Equalizer 2\x9 born into poor ;amilies are more likely to be exposed to 4and a;;ected by 4conditions that are adverse ;or development (e.g., crowded or slum living conditions, unsa;e neighborhoods) (Dipietro, 2000 ). s es can also infuence children through its e;;ects on parental stress.<br><br> Lower-income parents have been ;ound to be at increased risk ;or a variety o; ;orms o; psychological distress, includ- ing negative ;eelings about sel;-worth and depressive symptomatology. It is thought that this arises through a combination o; greater exposure to negative li;e events and having ;ewer resources with which to cope with adverse li;e experiences (Shonko;; & Phillips, 2000 ). There is a demonstrated link between socioeconomic circumstances and language and cognitive outcomes in young children, based largely on the richness o; the language environment available to the child (Hart & Risley, 1995 ).<br><br> Family ses is also associated with ability to provide other resources, such as health care and high-quality childcare, that exert a pro;ound infuence on developmental health (Hertzman & Wiens, 1996 ). family\xahealth Family health conditions have a particularly strong impact on ecd . Any chronic problem, either physical or mental (especially o; the mother or primary caregiver), such as intimate-partner violence (Anda et al., 2006 ; Fettelli et al., 1998 ), maternal depression (Patel, DeSouza, & Rodrigues, 2003 ; Shonko;; & Phillips, 2000 ), and chronic illness, can have a deleterious e;;ect on child development.<br><br> In situations involving mater- nal depression, extreme poverty, or high levels o; ;amily stress, important parent-child interactions may be impaired, resulting in ;ewer opportunities ;or learning experiences in the home (Willms, 2003 ). The severity and chronicity o; maternal depression are predic- tive o; disturbances in child development ( nichd, 2002 ). A major health issue globally is the prevalence o; Human Immunode ciency Virus ( hiv ) among the adult population.<br><br> The e;;ect on children has been widespread, ;rom contracting the in;ection themselves (through transmission ;rom mother to child), to the phenomenon o; children taking up adult roles within the ;amily, such as caring ;or their parents and siblings. Many children have experienced orphanhood or become the heads o; their households due to the death o; their parents. In particular, this may infuence girls 9 development to a greater extent, since they are more likely to bear the responsibility o; household matters, and may there;ore ;orego schooling (Richter & Foster, 2006 ).<br><br> Here, we call %or recognition that programmes supporting the health o% the caregivers o% young children are also investments in ecd , and should be evaluated as such. fathers The role o; ;athers as part o; the ;amily-level sphere should not be underestimated, and is o;ten regrettably marginalized. The United Nations Commission on the Status o; Women c[encourages] men to participate ;ully in all actions towards gender equality and [urges] the establishment o; the principle o; shared power and responsibility between women and men at home, in the community, in the workplace, and in the wider national and international communities d (United Nations O; ce o; the High Commission ;or Human Rights ( uncsw), 2004, p.<br><br> 1 ). Certainly, this includes the role o; ;athers in nurturing their children ( unicef, 1997 ). In ;act, engaging and working e;;ectively with ;athers and other men who a;;ect the well-being o; children and ;amilies is now rmly emphasized in policy ;rameworks as a strategic requirement ;or all children 9s services (Fathers Direct, 2006 ).<br><br> gender Inequities within ;amilies may be signi cant ;rom the standpoint o; the social determi- nants o; health, especially with respect to gender: cWomen 9s access to power at the household level has the most direct impact on ;amilies and children & [through lack o; control over] allocation o; resources ;or ;ood, health care, schooling and other ;amily neces- sities d ( unicef, 2007 , p. 22 ). As a result, ;emale children are more likely to receive less ;ood, and to be denied essential health Spheres o 7 Infuence: The Family their emotional and physical security as a base ;rom which to explore their environment.<br><br> Success;ul attempts at exploration increase the child 9s sel;-con dence and encourage more exploration. Thus, the child begins to learn about and master his or her environment and to gain in both competence and sel;- con dence. All ;amilies need some support to learn how to develop and be sensitive and responsive in their childcare practices.<br><br> There are, however, both biological and environ- mental ;actors that can negatively impact on attachment. These include low birth weight, malnutrition and in;ections, poverty and its associations, confict and domestic violence, and mental health problems such as maternal depression. In these instances, external support ;or ;amilies is particularly important.<br><br> socioeconomic\xastatus So consistent is the association between socioeconomic status ( ses ) and a variety o; development and health outcomes throughout the li;ecourse, that it has been termed a cgradient e;;ect. d The gradient e;;ect o; ;amily resources on ecd is the most power;ul explanation ;or di;;erences in children 9s well-being within societies, and these resources pro;oundly a;;ect all other aspects o; the ;amily environment (Siddiqi et al., in press). A recent study by Houweling, Casper, et al. (2005 ) ;ound a striking association between socioeconomic status o; ;amilies and under- 5 mortality in a population o; children ;rom 43 resource-poor countries.<br><br> This same study suggested that, among these nations, socioeconomic inequality in child mortality was increasing (the gap was widening) as the overall economies were growing. Family ses has an impact on outcomes as diverse as low birth-weight, risk o; dental carries, poorer cognitive test scores, di; culties with behav- iour and socialization, and increased odds o; disengagement ;rom school (Brooks-Gunn, Duncan & Maritato, 1997 ). Social and economic resources infuence ecd through several mechanisms.<br><br> For instance, low levels o; education and literacy a;;ect the knowledge and skill-base o; chil- dren 9s caregivers; ;eeding and breast;eeding practices also vary according to s es . Children The gradient e%%ect o% %amily resources on ecd is the most power%ul explanation %or di%%erences in children 9s well- being within societies, and these resources pro%oundly a%%ect all other aspects o% the %amily environment. 24 Early Child Development : A Power,ul Equalizer 2\xb Spheres o 7 Infuence: The Family exposed to unsa;e working conditions.<br><br> Public provision o; quality, a;;ordable childcare is part o; the solution to this problem. resilience Many ;amilies that ;ace daily challenges because o; their socioeconomic disadvantages are nevertheless able to create the essential nurturant environments ;or their children. Resilience re;ers to the capacity o; a child to thrive, despite growing up ;acing adversity.<br><br> Bartley 9s review o; research on thi