Every Child's Potential: Integrating Nutrition, Health, and Psychosocial Interventions to Promote Early Childhood Development

Agenda

* Presentation titles and times are subject to change.

Abstracts

Conceptual Overview of Integrated Interventions to Address Optimal Child Growth and Development
Maureen Black, PhD

There is growing evidence that the building blocks for long-term health and well-being are formed during the early years of life, often beginning prenatally. During these early years disparities in children's growth and development begin to appear, associated with poverty, general undernutrition, specific nutritional deficiencies, illnesses, environmental toxins and the lack of opportunities for stimulation, responsive relationships, and protection from harm. Children in low and middle-income countries are at high risk for disparities early in life that can interfere with their ability to benefit from school and other resources, and increase their vulnerability to negative academic, social, psychological, and health consequences. The loss of productive potential and the burden of illnesses affect not only individual children and families, but can have devastating effects on the social capital of communities and countries.
 
Evidence from nutrition interventions has shown that ensuring adequate nutrients early in life can protect children, promote their growth, and stimulate their motor, cognitive, and socio-emotional development. Evidence from early child development interventions has shown that providing high quality early child care, stimulation, and responsive interactions can prevent or ameliorate early disparities, enabling children to proceed along normal developmental trajectories ready to learn and to take advantage of social and community opportunities. Yet, in most cases, nutrition and early child development programs are introduced independently, responsible to different sectors, and with very little overlap.
 
The presentations in this special issue address a wide range of topics related to integrated early child development–nutrition interventions, ranging from the theoretical rationale to issues of planning, implementing, and evaluating integrated interventions; and extending to strategies to impact nutrition and early child development policies. Case studies of integrated interventions are included, along with "lessons learned" and recommendations for future research and implementation strategies. The goal is to identify the steps to encourage investment in full scale implementation of successful integrated interventions.

Economic Perspectives on Integrating Early Child Stimulation with Nutritional Interventions
Harold Alderman, PhD, International Food Policy Research Institute

There is a strongly-held view that there is a narrow window for effective nutritional interventions and a widely-known stylized depiction of age-dependent economic rates of returns to investments in cognitive and socio–emotional development. Both indicate critical periods in early life. Moreover, the fact that both the physical and cognitive development of a child in these early years of its life are highly dependent on child care practices and the characteristics of the care givers, such as their level of education or depression, motivates an interest in finding effective means to enhance stimulation in the context of nutritional programs, or vice versa. Nevertheless, there is relatively little evidence, to date, on how to align age-specific patterns of interventions and how to undertake cost-benefit analysis for integrated interventions. Thus, many core questions need further consideration in order to design integrated nutritional and stimulation programs. This presentation looks at some of these questions both from the standpoint of physical synergy—complimentary inputs, from an economic perspective—and from the perspective of managerial synergy in which joint management of programs reduces costs of delivery, even if no physical synergy might exist. The presentation also provides some guidelines as to how the economic returns from joint nutrition and stimulations programs might be estimated.

Measures and Indicators for Assessing Impact of Interventions Integrating Nutrition, Health, and Early Childhood Development
Edward A. Frongillo, PhD, Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC USA

When interventions integrating nutrition, health, and early childhood development are implemented, evaluation studies of effectiveness assessing intermediate and ultimate impacts on the four domains of food and nutrition, family care, health, and child development are needed. Such evaluations studies should aim to demonstrate impact, both benefits and potential harms, and to understand mechanisms through which impact has been achieved. This presentation reviews existing measures and indicators in order to suggest sets of measures and indicators suitable for use in evaluation studies of effectiveness of integrated interventions for children under 5 years. Within each of the four domains, multiple constructs and sub-constructs were considered. For each construct and sub-construct, we identified measures and indicators using several search processes, and then reviewed them in relation to four characteristics: validity, responsiveness to intervention inputs and activities, equivalence in constructs and items across contexts with appropriate adaptation, and feasibility to use in effectiveness studies. Suggested measures and indicators for each domain, construct, and sub-construct are tabulated and described. We discuss overall strengths and weaknesses of measures and indicators across the domains and constructs, further research establishing validity of measures, and guidance on the adaptation of measures to particular contexts.

Systematic Review on the Effects of Combining Child Development with Nutrition or Health Interventions on Children's Nutritional Status and Development
Sally McGregor, MBBS, MD, DPH, FRCP, University College London

We searched electronic data bases and agency reports, other published reviews and used personal contacts to identify trials including a child development component (psychosocial stimulation through home visiting, parent groups, parent counselling or centre based) combined with a health or nutrition component (e.g. growth monitoring, education on feeding, or nutritional supplementation) involving children under 5 years in low- or middle-income (LAMI) countries. Of 1533 studies initially identified we narrowed the pool to 21 because most did not fit the inclusion criteria. To be included in our review, studies must have had a non-intervened comparison group of similar socio-economic background. They must also include a child development outcome (cognitive, motor, school achievement, socio-emotional or behaviour) and a health or nutrition outcome (e.g. height/weight, haemoglobin) and present results with statistical analyses. Any study that was not a randomised controlled trial was rated by two of us for quality with the McMaster University Effective Public Health Practice Project Quality Assessment Tool and any rated "weak" were excluded. There remained 21 studies. We aimed to assess the impact of the separate interventions, their combined effect and any potential interaction.
 
Only 4 studies were designed to show independent effects of each intervention and combined effects with randomisation to 4 groups: nutritional supplementation, stimulation, both interventions and control. Three of these used macronutrient supplementation and showed no change in the effect of the independent interventions when combined (additive effects). One used zinc supplementation and there was a significant synergistic interaction with stimulation and zinc on child development. A further two randomised trials assessed the effect of one intervention and combined interventions In one trial the small benefit to linear growth from nutritional education was lost when stimulation was added, in the other the effects of stimulation remained when nutrition (micronutrients) was added.
 
The remaining studies only show the effects of combined treatment. Six studies added a child development component to a health or nutrition intervention. All showed benefits to child development outcomes one also showed a nutritional status benefits. In the other two studies adding micronutrients to meals at a preschool benefitted child development but not nutritional status and a centre-based preschool with meals benefited child development and growth compared with no intervention.
 
Finally, 7 studies were non-randomised evaluations of 8 large programs, all comprised centre-based components and most provided meals, one was mother's education groups only. Five showed benefits to child development one had no effect and two showed deficits. Only one benefited nutritional status consistently and that was a home visiting program whereas two showed some deficits. The implications of these findings are discussed.

Using UNICEF's Multi-Indicator Cluster Survey (MICS) Round 4 to study early childhood development outcomes
Oliver Petrovic, MD,MPH, UNICEF

Experience and scientific evidence has shown that several preconditions must co-exist to ensure that children get the best start in life and the opportunity to thrive: (i) effective and responsive care of the young child by the primary caregiver, family and community; (ii) access to and use of quality ECD and other basic social services for young children and (iii) a supportive policy environment in place. Situation analysis shows that: home environment is not conducive to optimal early childhood development; low access to early childhood care and education services (ECCE), marked with significant disparities and Policy and Programming Environment not supportive to ECD. The basic causes for hindering ECD programmes expansion and integration are lack of capacity to implement ECD policies / programmes, weak leadership and governance, lack of coordination mechanisms (essential in provision of ECD interventions), and a lack of data to design and monitor ECD progress. The root causes of all the issues listed above can be summarized in the lack of political will to invest in ECD; and existing exclusion and stigma of the most deprived young children and their families.

Systematic Seview of Implementation Processes to Deliver Integrated Programs
Aisha K. Yousafzai, PhD, Aga Khan University

This presentation reviews the implementation processes for interventions that integrate nutrition and psychosocial stimulation for children under five years of age in low- and middle-income countries. We examine the content of the program, the delivery strategy, intensity and duration, personnel training and supervision, compliance, and fidelity. This presentation complements the paper 'Systematic Review of Integrated Interventions: What Works and Does Not Work?' which addresses outcomes of integrated interventions. A systematic search of the Global Health Ovid database yielded 1020 articles of which 24 fit the criteria, and two further studies recently completed were reported on by author communication. Some of these articles describe efficacy studies where nutritional supplements or education along with psychosocial stimulation experiences or education were delivered directly to children or to caregivers of children. Other presentations describe large-scale programs such as conditional cash transfers in Latin America, Integrated Child Development Services' Anganwadi preschools in India, and World Bank collaborations with national governments in Africa. A summary table of the implementation processes of the 26 programs is included. We conclude with a set of recommendations summarizing what we know so far regarding best practices for integrative programs.

Formative Research Methods for Designing Culturally Appropriate, Integrated Vhild Nutrition and Development Interventions: An Overview
Margaret E. Bentley, PhD, RD University of North Carolina at Chapel Hill

Nutritional and developmental insults in the first few years of life have profound public health implications, including substantial contributions to neonatal, infant, and early childhood morbidity and mortality, as well as longer term impacts on cognitive development, school achievement, and worker productivity. Optimal development that can lead to the attainment of the individual's fullest potential therefore requires a combination of genetic capacity, adequate nutrition, psychosocial stimulation, and safe, clean physical environments. Researchers and policymakers have called for integrated child nutrition and development interventions for more than twenty years, yet there are only a handful of efficacy trials and even fewer examples of integrated interventions that have been taken to scale. While a critical component to the design of such interventions is formative research, there is a dearth of information in both the literature and policy arenas to guide this phase of the process. To move the field forward, this presentation first provides an overview of formative research methods with a focus on qualitative inquiry, a description of the critical domains to be assessed (infant and young child feeding, responsive feeding, and child development), and currently available resources. Application of these methods is provided through a real-world case study—the design of an integrated nutrition and child development efficacy trial in Andhra Pradesh, India. Recommendations for next steps are discussed, the most important of which is the need for a comprehensive set of formative guidelines for designing locally tailored, culturally appropriate integrated interventions.

Leveraging Families' Strengths, Paraprofessionals, and Bundled Services to Improve Child Outcome
Mark Tomlinson, PhD, Centre for Public Mental Health, Department of Psychology, Stellenbosch University, South Africa

Children are to be protected in intergenerational networks, with parents who have positive mood, resources to feed their children, and skills to promote early childhood development. Globally, more than 200 million children are raised annually without these resources. This article reviews the potential contributions of increasing coverage and penetration of services for these children, the opportunities created by bundling multiple services within one provider, the potential leveraging of paraprofessionals to deliver care, and mobilizing communities to support children in households at high risk for negative outcomes.

Understanding Care for Early Stimulation and Feeding Practices: The Building Blocks for a Sustainable and Feasible Intervention in India and Pakistan
Raghu Lingam, PhD MBChb , London School of Health and Tropical Medicine

SPRING, Sustainable Program Incorporating Nutrition & Games, is a program of research which aims to improve the survival, growth and development of children in areas of rural India and Pakistan delivered at scale through existing health systems.
 
The program, based on an extensive formative research, recognizes that different populations view and make sense of the world in diverse ways, and allows us to gain an insider's view of the factors that hinder or facilitate behaviour change. This presentation describes how families interact, play with and feed children, their expectations of growth and development and the perceived benefit, consequences, opportunities and barriers of adopting recommended feeding and developmental behaviours. Qualitative data were collected in 2011–2012 from communities purposively selected to reflect the diversity of the two study areas through 160 contacts with a range of respondents including pregnant and delivered women, grandmothers, fathers and community based workers. Methods used were in depth interviews, narratives and observations.
 
The presentation will report key findings and similarities and differences between the two sites will be highlighted. The implications of the findings for intervention design will be discussed.

Advantages and Disadvantages of Integration: Opportunities for Integrating Early Childhood Development (ECD) and Nutrition Programming
Ann M. DiGirolamo, PhD, MPH, CARE International

A growing body of evidence supports the notion that integrated programs addressing nutrition and stimulation provide stronger impacts on nutritional and developmental outcomes than either intervention alone. When translating evidence into practice, several advantages and challenges for integration can be noted. Combined interventions may be more efficient than separate interventions, because they are intended for the same population and make use of the same facilities, transportation and client contacts. In addition, for families, particularly for those most at risk, combined interventions can also lead to increased access to services. However, in order for integrated nutrition and ECD interventions to be successful, a variety of challenges must be addressed. These include work load of staff and supervisors, communication and coordination among different ministries and among staff in different sectors, and common language and measurement. It must be acknowledged at both the national and community levels that comprehensive, integrated care addressing both the physical and developmental needs of the child is key to promoting optimal health, growth and development for children. Emergencies present a unique opportunity for integrated services, but also present several unique challenges in addition to those mentioned above.

Water, Sanitation, and Hygiene (WASH), Nutrition and Early Child Development: A Critical Review and Conceptual Framework
Rebecca J. Stoltzfus, PhD, Cornell University

There is scarce research and programmatic evidence on the effect of poor water, sanitation and hygiene (WASH) conditions of the physical environment on early child cognitive, sensory–motor, and socio–emotional development. Furthermore, many common WASH interventions are not designed to protect babies in the first 1000 days of life. We review evidence on WASH, anemia and child growth, and provide a conceptual framework of pathways through which WASH affect child development; primarily through inflammation and stunting. Infants and young children in low income countries are frequently ingesting high quantities of fecal bacteria and pathogens through mouthing soiled fingers and play items, and the exploratory ingestion of soil and poultry feces. Frequent childhood infections from such exposures affect mother–child interaction and child feeding behavior, with cumulative negative consequences on growth and development. Furthermore, recent evidence suggest that chronic fecal–oral transmission of pathogenic and non-pathogenic microbes inflame the small intestine mucosal lining and result in a highly permeable gut, with impaired barrier and absorptive functions, and subsequent chronic immune stimulation. Evidence is mounting that these processes contribute to stunting and may also cause anemia, both well-described risk factors for deficits in child development. Current early child development research and programs lack proven interventions to provide a clean play and infant feeding environment in addition to established priorities of nutrition, stimulation and child protection. Solutions to this problem will require a combination of behavior change and appropriate technologies, designed for rugged environments and conducive to infant play and exploration. We propose the concept of "Baby WASH" as an additional component of early childhood development programs.

Rationale, Design, Methodology, and Sample Characteristics for an Integrated Child Development and Nutrition Intervention Among Infants in Rural India (PROJECT GROW SMART): A Randomized Controlled Study
K. Hurley, PhD, Department of International Health, Johns Hopkins Bloomberg School of Public Health

Background: More than 200 million children under five years of age from low-income and middle-income (LAMI) countries do not attain their developmental potential, largely due to poverty, nutritional deficiencies, and inadequate learning opportunities. While evidence suggest that addressing co-occurring risk factors such as lack of stimulation and micronutrient deficiencies simultaneously may produce maximum effects on child development, little is known about the effectiveness of such integrated programs. Project Grow Smart examines how innovative multiple micronutrient (MMN) fortification strategies for infants combined with early learning opportunities impact children's development. This presentation provides an overview of the study design, methodology and sample characteristics from baseline survey data and key lessons learned.
 
Method / Design: We recruited 497 mother–infant dyads into a double-blinded four-arm randomized controlled trial in rural India and randomly assigned them to receive: 1) MMN only 2) play and communication messages only; 3) MMN and play and communication messages; 4) placebo. Study outcomes include infant cognitive, motor, and social–emotional development. Mediators include infant micronutrient status and observed parent-child interactions. Data are also being collected on village-level resources, household assets and food security, maternal demographics, micronutrient status, mental health, parenting competence, feeding history and behaviors, and infant anthropometry, morbidity, and temperament.
 
Discussion: This study is timely and responds to the 2011 Lancet Series on Early Child Development in LAMI countries which identified the need to evaluate the effectiveness of approaches that combine early child development and nutrition interventions. Findings will generate new information to help guide large-scale policy and programs designed to reduce lost developmental, educational, and economic potential of children in resource poor setting.
 
Trial registration: NCT01660958

A Job Analysis of Community Health Workers in Context of Integrated Nutrition and Early Child Development
John Phuka, MBBS, University of Malawo

Background: With increasingly recognized role of Community Health Workers (CHWs) as a critical link in improving access to services and achieving many health care goals CHW are likely to participate or solely implement integration of children's nutrition, health and psychosocial development in low income countries like Malawi. Given the financial and human resources constraints in these developing countries, CHWs are expected to do more without necessarily receiving the needed support to do their jobs well or additional staffing support.
 
Objective: To evaluate the role of Malawian Community Health Workers in integrating children's nutrition, health and psychosocial development.
 
Methods: We conducted a qualitative study using key informant interviews, semi- structured and focus group discussions.
 
Findings: At least two Ministries, Ministry of Health (MoH) and Ministry of Gender and Social Welfare (MoGoW) have policy and organisational structure for implementing children's nutrition, health and stimulation in Malawi. However, coverage of community workers between the two Ministries is different. Despite strong policy guidance integration of children's nutrition, health and psychosocial stimulation is weak or non-existent and some activities depend on non-trained volunteers. Largely, CHW are not readily available to the community because of task shifting which is being implemented to cover staff shortage in other health care delivery departments. Re-organisation of the organisational structure, and provision of appropriate incentives and training may allow for the integrated activities.
 
Conclusion: Promotion and implementation of children's nutrition, health, psychosocial activities through introduction of care for child development package through community health workers (CHW) is possible but feasibility assessment with strong formative approach is needed.

Integration of a Scalable Maternal Psychosocial Well-being Component into a Child Development Intervention: Challenges and Opportunities
Atif Rahman, MD, PhD, University of Liverpool

Maternal Psychosocial Well-being (MPW) is a wide-ranging concept which encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem-solving) as well as the social (e.g., family and community support, empowerment, culture) aspects of motherhood. Child nutrition and development programs generally rely on the mother for their effective delivery, and there is strong evidence that poor MPW is associated with negative child nutrition and development outcomes. However, the field of MPW interventions has lagged behind, especially those that can be integrated into large-scale programs. Building on several years of research in Pakistan, we attempt to define MPW as it applies to child nutrition and development programs. We describe the development and piloting of an approach for MPW that has the potential for integration at scale in a combined nutrition and early child development program.

Cost Effectiveness of Responsive Stimulation and Nutrition Interventions Implemented in the Pakistan Early Child Development Scale Up (PEDS) Trial
Saima Gowani, EdM, Harvard University, Boston, Massachusetts, USA, PhD Candidate, Teachers College, Columbia University, New York, New York, USA

Early childhood programs have been heralded as a way to improve children's health and educational outcomes the world over. However, few studies in developing countries calculate the effectiveness of quality early childhood interventions. Even fewer estimate the costs associated with such programs. This study looks at the costs and effectiveness of a cluster randomized effectiveness trial on children followed from birth to 24 months in rural Sindh, Pakistan. Responsive stimulation and/or enhanced nutrition interventions were integrated in the Lady Health Worker Program. Outcomes suggested that children who receive responsive stimulation had significantly better development outcomes at 24 months than those that only received nutrition supplementation. A cost effectiveness analysis of the results verifies that early childhood interventions that include responsive stimulation are more cost effective than a nutrition intervention alone with respect to the promotion of early development. Approximate costs of responsive stimulation intervention integrated in an existing community based service providing basic health and nutrition care, is $3.75 per month per child. This presentation discusses these findings and considerations for future research.

Micronutrient Provision Among PAININ Beneficiaries
Florencia Lopez Boo, PhD, Inter American Development Bank

This presentation studies the cost-effectiveness of providing micronutrient supplements as part of an integrated early childhood development program in Nicaragua. Using a unique non-experimental longitudinal dataset from Nicaragua, we will estimate average treatment effects via propensity score matching techniques on the prevalence of anemia among disadvantaged children aged 0–3 years receiving micronutrient supplements. We will investigate whether the effects are sustained over time and whether there are differential impacts by child's age, dosage of micronutrient supplements, and program delivery modality. We find that the program seem to have reduced anemia by 9 percentage points (pp) overall and by 17 pp for children under 1. There are no differences by dosage (number of sachets) of micronutrients received, nor by program delivery mode. We calculated to cost–benefit ratio at a range between 2 and 4.24.

Advancing the Nutrition and ECD Policy Agenda: Indicators and Guidance
David Pelletier, PhD, Cornell University

A substantial body of scientific evidence demonstrates the developmental, health and social benefits of nutrition and early childhood development (ECD) interventions, and strong rationales exist for integrating these at the policy, programmatic and delivery levels. A priority and a challenge now is for national governments and development partners to strengthen investments, governance and quality implementation related to nutrition and ECD interventions. This presentation provides a set of frameworks and tools for advancing this policy agenda and illustrates their use in selected countries. One of these tools is the ECD component of the Systems Approach for Better Education Results (SABER). This tool identifies policy levers for strengthening the enabling environment, implementation and quality assurance related to ECD and provides indicators of the level of development in each of these three areas within a given country. A second tool is the Agenda Setting Framework, adapted from previous research in global health and nutrition, which provides process guidance and indicators for moving ECD and nutrition higher on national agendas. The broader application of these tools can guide and document the state of development of nutrition and ECD policies and actions at country level and provide the global community with a systematic basis for tracking progress and mobilizing assistance.
 
Coauthors: Michelle Neuman and Gretel Pelto

Strengthening Systems for Integrated Early Childhood Development Services: Cross-National Analyses of Governance
Pia Rebello Britto, PhD, Yale University

In recent years there has been a rise in services and programs for young children and families, many of which have been accompanied by rigorous evaluations demonstrating effectiveness. However, a majority of the world's youngest children still do not have access to quality early childhood development services. In part, the lack of inequitable services can be explained by poor systems level coordination, requiring a systematic approach to scaling up of programs. Our study seeks to explore the governance mechanisms required to strengthen coordination by using a comparative approach across multiple low and middle income country contexts. There is wide recognition of the interdependency between the factors implicated in system strengthening, such as capacity building, finance and costing, and governance; nevertheless, governance is critical because of the infrastructure support it provides to the system. In this presentation we present the results of an interdisciplinary study exploring the role of governance in improving equity, access and quality of ECD services in 2 low-income (Cambodia and Lao PDR) and 2 middle-income (Kenya and Peru) countries. The presentation will present results with implications for scale up of programs from a systems strengthening perspective with particular reference to coordination required for integrated ECD services in LMIC.

Integrating Early Child Development Programs into Health and Nutrition Services in Bangladesh: Its Benefits and Challenges
Jena Derakhshani Hamadani, PhD, International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh

Bangladesh is one of the poorest countries of the world with the highest population density. Its government recognizes the importance of early childhood development (ECD) and its immense educational and financial benefits hence it has incorporated ECD activities in its national plan of action. However ECD activities are not yet fully established in the country and only some sporadic programs are conducted with little or no evaluations.
 
In this presentation we present ECD programs that are integrated into health and nutrition services in Bangladesh. We found four evaluation reports of such programs and seven published research projects. We provide short reviews on coverage, methodology and effects of the published reports and share our experience of challenges faced and steps taken to solve them.
 
Overall, very few programs are based on scientific evidence and fewer are even evaluated. The research projects so far conducted are promising and there is sufficient evidence to confirm the prospect of integrating ECD activities into nutrition and health programs.
 
Suggestions are made on measures to overcome the implementation problems and on suitable methods to establish high quality ECD programs in Bangladesh and in other low and middle income countries, especially those in this subcontinent.

Issues in the Timing of Integrated Early Interventions: Contributions from Nutrition, Neuroscience and Psychological Research
Theodore D. Wachs, PhD, Purdue University

There is an increasingly large body of evidence documenting that children from low income families living in both high and low income countries have an elevated likelihood of being exposed to multiple biological and psychosocial risks that can significantly compromise their development. One implication of these findings is the importance of integrating and implementing multi-dimensional biological (e.g., nutritional supplementation) and psychosocial interventions (e.g., cognitive stimulation) to compensate for exposure to multiple risks and to promote development. In designing developmental interventions a critical and long-standing question is identifying the age period(s) in which interventions will have the strongest and longest lasting impact upon development. Attempts to answer this question are often framed in terms of either "critical periods" or "sensitive periods." Conceptually both critical and sensitive periods refer to time windows where the degree of potential plasticity in development is highest and the impact of exposure to normative experiences, developmentally facilitative experiences or developmental risks are particularly strong. However, in contrast to critical periods the time windows of sensitive periods are broader and there is continued, though reduced, plasticity both before and after the sensitive period.
 
The primary question addressed by this presentation is: can we identify optimal time (age) periods in which to provide integrated biological and psychosocial interventions to promote the development of children from low income families who are at risk for compromised development? To address our primary question we will review evidence from three relevant disciplines: nutrition, neuroscience and developmental psychology. Nutritional evidence will be used to identify age-linked domains of brain development that are most sensitive to protein and iron deficits or supplementation. Neuroscience evidence will be used to assess the importance of timing of exposures to environmental stressors for maintaining physiological integrity of the neuroendocrine and immune systems, both immediately and in the long-term. Psychological evidence will focus on the sensitivity of critical dimensions of cognitive and social–emotional development to exposure to contextual risk and protective influences at different ages. Integration of findings across these three disciplines will be used to draw conclusions about issues directly relevant to our primary question such as: are there different time periods that are optimal for biological versus psychological outcomes or interventions; how much residual plasticity is their outside of optimal intervention windows; are later occurring interventions necessary to maintain the impact of earlier interventions?

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