Discussion Paper
Beyond Survival:
The Case for Investing in Young Children
Globally
G. Huebner, N. Boothby, J. L. Aber, G. L. Darmstadt, A. Diaz, A. S. Masten, H.
Yoshikawa, I. Redlener, A. Emmel, M. Pitt, L. Arnold, B. Barber, B. Berman, R.
Blum, M. Canavera, J. Eckerle, N. A. Fox, J. L. Gibbons, S. W. Hargarten, C.
Landers, C. A. Nelson III, S. D. Pollak, V. Rauh, M. Samson, F. Ssewamala, N. St
Clair, L. Stark, R. Waldman, M. Wessells, S. L. Wilson, and C. H. Zeanah
June 16, 2016
Beyond Survival:
The Case for Investing in Young Children Globally
G. Huebner, N. Boothby, J. L. Aber, G. Darmstadt, A. Diaz, A. S. Masten, H.
Yoshikawa, I. Redlener, A. Emmel, M. Pitt, L. Arnold, B. Barber, B. Berman, R.
Blum, M. Canavera, J. Eckerle, N. A. Fox, J. L. Gibbons, S. W. Hargarten, C.
Landers, C. A. Nelson III, S. D. Pollack, V. Rauh, M. Samson, F. Ssewamala, N. St
Clair, L. Stark, R. Waldman, M. Wessells, S. L. Wilson, and C. H. Zeanah
EXECUTIVE SUMMARY
Investing in young children1 globally is a primary means of achieving sustainable
human, social, and economic development, all of which are vital to ensuring
international peace and security. Strategic investments in children have been
recognized by the world’s leaders in their recent adoption of the Sustainable
Development Goals, which aim to further peace, end global poverty, and ensure that all
human beings can fulfill their potential in dignity (United Nations, 2015). For the first
time, early childhood development is acknowledged as a critical part of the global
development agenda. Although child development is explicitly referenced under the new
education goal, it is naturally linked to other goals—reducing poverty, improving health
and nutrition, promoting equality for girls and women, and reducing violence (United
Nations, 2015). Indeed, coordinated, evidence-based investments must be made across
sectors to ensure that more and more children not only survive but also thrive.
This paper is a call to action, informed by science from multiple disciplines. We
hope it will help to close the gap between what is known and what is done to support
the development of children globally and, in turn, sustainable progress for communities
and nations.
The cost of inaction is enormous (IOM/NRC, 2014). Currently, an estimated 5.9
million children die before their fifth birthday (UNICEF, 2016); 159 million children under
age 5 are stunted (UNICEF, 2015); at least 200 million children fail to reach their
developmental potential each year (Grantham-McGregor et al., 2007); and 1 billion
children experience violence annually (Hillis et al., 2016). As a result, countries lose up
to about 30 percent in adult productivity every year (Grantham-McGregor et al., 2007).
Meanwhile, return on investments during the prenatal and early childhood years
average between 7 and 10 percent greater than investments made at older ages
(Carneiro and Heckman, 2003). Although there are other opportunities to enhance
human development, cost-effective strategic investments made during children’s early
years can mitigate the deleterious effects of poverty, social inequality, and
discrimination, ultimately resulting in long-lasting gains that reap benefits for children
and youth, families, communities, and nations (Carneiro and Heckman, 2003).
Over the course of the last two decades, this knowledge has begun to infiltrate
U.S. domestic policy and programs (IOM, 2000). Yet, investing in young children’s
1
The UN defines the early childhood period as beginning prenatally through age 8.
1
developmental potential has been a more difficult proposition to sell in some U.S.
foreign assistance policy and program circles. The science is clear—and globally
applicable—and successful programs have been piloted and brought to scale, both
within the United States and internationally. Early investment in young children’s
development appears to trigger a multiplier effect, with positive outcomes ricocheting
across multiple sectors over the long term. Nevertheless, the compelling case for
investment continues to be lost in translation.
The U.S. government spends more than $30 billion on foreign assistance2 and
has been at the front line of cutting-edge investments in development for decades. Still,
many policies and programs—not to mention the funding to support them—have not
kept up with the science that underscores the critical importance of investing early and
holistically to ensure healthy and productive lives and communities.
Currently, U.S. government foreign assistance remains fragmented, with little
focus on or cross-sectoral funding for holistic child development and with limited
mechanisms in place to ensure effective coordination across sectors. Without a
proactive effort to integrate programs for young children, harmonize implementation,
and synchronize the measurement of results, program and outcome siloes are created,
and an important opportunity to maximize results for children is lost. Young children’s
needs and risks are multidimensional. Tackling one issue at a time, divorced from a
more complex reality, is ultimately a disservice to time- and resource-strapped
vulnerable families. Young children require integrated support, including health,
nutrition, education, care, and protection. The science explains why. By turning attention
and resources toward coordinated investments and delivery platforms, it is possible to
close the gap between what is known and what is done to support young children
globally.
BEYOND SURVIVAL: EXPANDING THE VISION
Evidence-based, results-oriented, coordinated, and effectively monitored international
development assistance works. The success of the “child survival revolution” is an
important example. In the past two decades alone, child deaths have fallen dramatically,
from 12 million in 1990 to 5.9 million in 2015 (UNICEF, 2016). This significant progress
is largely due to strategic investments, high-impact interventions, and tools for child
survival, notably new vaccines and improved health care practices. Shared targets and
coordinated interventions on the part of global public and private partners have ensured
that the momentum is maintained.
The success of the child survival revolution is inextricably linked to the focused
attention and dedicated funding it has rightfully received for decades from the global
development community and donors, including the U.S. government. In 2014, total
global development assistance for maternal, newborn, and child health (MNCH) was
approximately $9.6 billion, around $1 billion less than the amount provided for
HIV/AIDS. Of this total, $3.0 billion was allocated to maternal health. The other $6.6
billion focused on child health activities. Since 1990, the U.S. government has
2
According to ForeignAssistance.gov, $33.9 billion is planned in foreign aid in fiscal year 2017. The website offers
a breakdown of expenditures by sector and country.
2
consistently served as the largest source of development assistance for global health.
Across MNCH sources, the United States was the origin of 20.8 percent of all MNCH
funding in 2014, 72.1 percent of which was channeled through U.S. bilateral aid
agencies. Other channels in receipt of substantial U.S. government support for MNCH
were UN agencies (8.8 percent, or $177 million), nongovernmental organizations and
foundations (7.4 percent, or $148 million), and Gavi, the vaccine alliance (8.9 percent,
or $179 million) (IHME, 2014).
Despite this sustained investment and hard-earned progress in reducing
preventable childhood deaths, approximately 200 million children under age 5 survive,
but fail to thrive. This figure represents 30 times the number of children who die before
they reach their fifth birthday and is a population requiring urgent attention (GranthamMcGregor, 2007). Spending early childhood in the midst of extreme poverty and
experiencing significant deprivation, violence, and/or neglect results in devastating
consequences throughout the life cycle and profound repercussions for society. These
200 million children live below the poverty line and/or are stunted. They attend school
for fewer years—or not at all. They are disproportionately affected by violence and are
more likely to be exploited. All these factors limit their future ability to live healthy and
productive lives, obtain gainful employment, and contribute to their communities and
families, perpetuating a multigenerational cycle of poverty. As a result, countries where
these 200 million children live have an estimated 30 percent loss in adult productivity
and are prone to instability and conflict (Grantham-McGregor, 2007).
If we are serious about eradicating poverty and fostering equity, we must aim
higher. Ensuring survival is a crucial first step, of course, but this should be our
minimum standard for success. The campaign to save lives will be incomplete if the
future prospects of those who survive remain constrained by factors that, with the right
attention and focus, could be effectively addressed (Shonkoff et al., 2012). Indeed,
improving outcomes for those who survive the scourge of childhood deprivation and
illness should be seen as a compelling priority from the standpoint of human rights,
sustainable economic and social development, and global security.
The fact is, children develop holistically. As whole human beings, we do not first
survive physically and then develop intellectually, socially, and emotionally. The
processes of growth and development are by nature interrelated, interdependent, and
mutually reinforcing. Yet, international assistance for children in developing countries is
rarely holistic. As a foreign assistance community committed to achieving sustainable
human, social, and economic development and international security, we have
separated children according to the category of their vulnerability and intervened in line
with sectoral predispositions, legislative mandates, and associated funding streams.
Yet, this segregated, fragmented approach to sustainable development does not offer
the greatest return on investment.
Established and emerging science continues to demonstrate that to promote
“child thrival” successfully, investments and services must be coordinated and
integrated where possible, concurrently addressing the health, nutrition, development,
education, and protection needs of children, beginning prenatally and, better yet, during
the preconception period.3 This knowledge can inform innovative strategies to address
3
For instance, the National Scientific Council on the Developing Child is a multidisciplinary, multiuniversity
collaboration committed to closing the gap between what we know and what we do to promote successful learning,
3
child survival and well-being across domains, leading to improved outcomes for children
over the long term as they venture into adulthood in ways that did not exist even 10
years ago (Shonkoff et al., 2012). Focusing on integrated investments and interventions
for children ages 0-8 aims to create a multiplier effect, building a solid foundation to
support long-term development and scaffolding for opportunities across domains.
Child survival can no longer be a sufficient goal. A moral and economic
imperative exists to build on the successes of the last two decades and achieve a future
for the world’s children that envisions healthy and productive lives beyond survival.
FROM NEURONS TO NATIONS: BUILDING THE ARCHITECTURE FOR THE
FUTURE
Frederick Douglass, an African American social reformer and statesman is said to have
written, “It is easier to build strong children than to repair broken men.” This statement
not only sounds good; it is biologically true and sensible from an economic perspective
as well.
Major advances in neuroscience, molecular biology, genomics, psychology,
sociology, and other fields have helped us to understand the significance of early
experiences on lifelong health and development. To analyze what science tells us about
this critical period, the National Academies’ Board on Children, Youth, and Families4
established the Committee on Integrating the Science of Early Childhood Development
in 1997. The committee was charged with reviewing what is known about the nature of
early development and the role of early experiences and to discuss the implications of
this knowledge base for policy, practice, and further research.
From Neurons to Neighborhoods is the product of this two-and-a-half-year
project during which a top-tier scientific committee analyzed and evaluated the
extensive, multidisciplinary, and complex science of early human development (IOM,
2000). The committee examined how early experiences affect all aspects of
development, from the neural circuitry of the growing brain, to the expanding network of
a young person’s social relationships, to the enduring and changing values of the
society in which caregivers raise children. The committee addressed the critical need to
use knowledge about early childhood to maximize the nation’s human capital and to
nurture, protect, and ensure the health and holistic well-being of all children.
The committee’s work was the beginning of a sustained and concerted effort to
bridge the gap between what is known and what is done to promote sound physical and
mental health and successful learning for all young children in the United States.
Following the impactful From Neurons to Neighborhoods consensus study, the National
Scientific Council on the Developing Child was formed to generate, analyze, and
integrate scientific knowledge to educate policy makers, civic leaders, and the general
adaptive behavior, and sound physical and mental health for all young children. Established in 2003, the council
translates science to build public will that transcends political partisanship and recognizes the complementary
responsibilities of family, community, workplace, and government to promote child well-being. See
http://developingchild.harvard.edu/science/national-scientific-council-on-the-developing-child/. The Forum on
Investing in Young Children Globally was launched in 2014. The forum is a 3-year effort that aims to integrate
knowledge with action in regions around the world to inform evidenced-based, strategic investments in young
children. See http://www.nationalacademies.org/hmd/activities/children/investingyoungchildrenglobally.aspx.
4
See http://sites.nationalacademies.org/DBASSE/BCYF/index.htm.
4
public about the rapidly growing science of early childhood development and its
underlying neurobiology.
Part of this effort has centered on building awareness on how early experiences
affect the development of brain architecture, which provides the foundation for all future
learning, behavior, and health. “Just as a weak foundation compromises the quality and
strength of a house, adverse experiences early in life can impair brain architecture, with
negative effects lasting into adulthood” (National Scientific Council on the Developing
Child, 2007). Neural connections are made at a significant speed in a child’s early
years, and the quality of these connections is affected by the child’s environment,
including nutrition, interaction with caregivers (National Scientific Council on the
Developing Child, 2004), and exposure to adversity, or toxic stress (National Scientific
Council on the Developing Child, 2005/2014).
As one commentator put it simply: “Childhood is not Las Vegas. What happens in
childhood does not stay in childhood” (Eloundou-Enyegue, 2014). The experiences
children have in their early lives—and the environments in which they have them—exert
a lifelong impact. These experiences shape the developing brain architecture and
influence how and what genes are expressed over time. This dynamic process affects
whether children grow up to be healthy, productive members of society (National
Scientific Council on the Developing Child, 2010b). This is not to suggest that
compromised beginnings cannot be turned around. Indeed, children’s resilience is a
powerful reality, achieved when protective factors—particularly a stable and committed
relationship with a supportive parent, caregiver, or other adult—outweigh other risks
(Masten, 2014; Center on the Developing Child at Harvard University, 2015). The
neurobiology of brain development clearly shows that it is easier, more efficient, and
more cost-effective to build strong beginnings than it is to facilitate repairs later in life,
when brain architecture is less malleable (see Figure 1).
FIGURE 1: The ability to change brains decreases over time.
SOURCE: Center on the Developing Child at Harvard University (n.d).
5
In addition to the important advances made in better understanding the
neurobiological elements of early childhood, James J. Heckman, a Nobel Laureate in
Economics, has shown that rates of return on investments made during the prenatal
and early childhood years average between 7 and 10 percent greater than investments
made at older ages (see Figure 2) (Carneiro and Heckman, 2003; Heckman, 2008).
Heckman’s cutting-edge work with a consortium of economists, psychologists,
statisticians, and neuroscientists shows that early childhood development directly
influences economic, health, and social outcomes for individuals and society. His work
has demonstrated how adverse early environments create deficits in skills and abilities
that drive down productivity and increase social costs—thereby adding to financial
deficits borne by the public (Heckman, undated).
FIGURE 2: Rate of return on investment
SOURCE: Heckman (2008).
As a result of this growing knowledge, over the past two decades we have seen
a nationwide groundswell of interest in the critical early years. “In many ways, the 1990s
represented an awakening of federal action on child care and early childhood issues
that had been slow to evolve in the earlier decades. Emerging evidence and important
state and legislative action laid the groundwork for many of the policy issues and
debates we see today” (Lombardi et al., 2016). There is now widespread recognition in
the United States that what happens during the early childhood period can either
contribute to children’s healthy development or set the stage for problems in school and
throughout life, taking a long-term economic toll on individuals, families, communities,
and even the nation. Bipartisan legislation supporting early childhood policies and
programs has been passed in dozens of states, and nearly every state has some kind of
6
early childhood agenda (Center on the Developing Child at Harvard University, 2014).
Following on progress made under previous administrations (Lombardi et al., 2016),
President Obama noted the science of early childhood in several of his State of the
Union addresses, making a clear connection between strategic investments in young
people and the progress of our nation (Center on the Developing Child at Harvard
University, 2014). The president’s budget for fiscal year 2017 prioritizes early
investments in children, including $1.2 billion to expand early intervention and preschool
programs, $9.6 billion for Head Start, and $15 billion in new funding over the next 10
years to extend and expand evidence-based, voluntary home visiting programs, which
enable nurses, social workers, and other professionals to support new and expectant
parents (U.S. Office of Management and Budget, 2016).
Unfortunately, these connections have not been emphasized or prioritized in U.S.
foreign policy or assistance programs (U.S. Department of State, 2015; U.S. Office of
Management and Budget, 2016).5 Nevertheless, the science that has informed U.S.
domestic policies and programs is now being examined at a global level. Of note, the
National Academy of Sciences—established by an Act of Congress in 1863 and
charged with providing independent, objective advice to the nation on matters related to
science and technology—established a Forum on Investing in Young Children Globally
in 2014.6 The forum, a collaboration between the Board on Global Health and the Board
on Children, Youth, and Families, aims to integrate knowledge with action in regions
around the world to inform evidenced-based, strategic investments in young children. Its
main objectives are to explore global integrated science of healthy child development
through age 8; share models of program implementation at scale and financing across
social protection, education, health, and nutrition in various country settings; promote
global dialogue on investing in young children; and catalyze opportunities for
intersectoral coordination at local, national, and global levels. Just as the National
Academy of Science’s From Neurons to Neighborhoods considered the connection
between investments in young children and the ability of American children, families,
and communities to prosper, the organization is now dedicated to ensuring that decision
makers around the world use the best science and evidence for investing to optimize
the well-being of children and their lifelong potential—from neurons to nations,7 so to
speak.
The convergence of the biological, developmental, and economic sciences
continues to remind us that the clock is always ticking and the cost of inaction continues
to rise as time passes (Center on the Developing Child at Harvard University, 2014).
Despite the fundamental principles of biology and human development—or, human
The Quadrennial Diplomacy and Development Review provides a blueprint for advancing America’s interests in
global security, inclusive economic growth, climate change, accountable governance, and freedom for all. As a joint
effort of the Department of State and the U.S. Agency for International Development, the review identifies major
global and operational trends that constitute threats or opportunities and delineates priorities and reforms to ensure
our civilian institutions are in the strongest position to shape and respond to a rapidly changing world.
6
See http://www.nationalacademies.org/hmd/activities/children/investingyoungchildrenglobally.aspx.
7
Jack Shonkoff (Harvard Graduate School of Education; Harvard Medical School; Harvard School of Public
Health), Charles A. Nelson (Harvard School of Public Health), and Holly Schindler (Harvard Graduate School of
Education) taught an undergraduate course titled “From Neurons to Nations: The Science of Early Childhood
Development and the Foundations of a Successful Society.” See http://isites.harvard.edu/course/colgsas-81179.
5
7
capital formation (Heckman, 2007)—the critical importance of timely and integrated
early intervention is often overlooked in our international development and child policies
and programs. It is time that our programs, policies, and investments more closely
correspond with the established science. It is the best and most cost-effective means to
ensure that children, families, communities, and nations catch up with their
developmental potential.
RECOGNIZING THE MULTIDIMENSIONALITY OF CHILDREN’S WELL-BEING
Investments in child health and well-being are a cornerstone for productive adulthood
and robust communities and societies. Promoting healthy and holistic child development
is an investment in a country’s future workforce and ability to thrive economically.
Ensuring that all children, including the most vulnerable living at the margins of society,
have the best first chance in life is a tried-and-true means to stabilize individuals,
communities, and societies over the long term.
Risk factors affecting healthy child development are complex and manifold,
including undernutrition, toxic stress, and lack of access to life-saving vaccines,
nurturing care, protection, and opportunities to learn (Evans et al., 2013; Wachs and
Rahman, 2013). U.S. international assistance programs have typically focused on single
risks or categories of vulnerability—for example, responding to the devastating impacts
of HIV/AIDS or malaria, natural disasters or human conflict, exposure to violence,
exploitation, or human rights violations such as child marriage. These diverse efforts to
support and protect children have produced substantial benefits, though the diffused
approach has also resulted in fragmented responses. Siloed interventions lead to siloed
outcomes. By focusing on only a single element of the burden of risks, the effect on
outcomes is diminished (Singer, 2014). Science has shown that coordinated,
multifaceted, and evidence-based action can help ensure that children in adversity
benefit fully from policies and services and achieve better outcomes over the long term
(Boothby et al., 2012).
Co-locating and integrating services where possible; maximizing home visiting
programs to address issues related to health, nutrition, and parent-child interactions;
and creating effective referral mechanisms to close gaps between sectoral interventions
and providers go a long way in ensuring that vulnerable children and families have the
support they need to succeed. Table 1 summarizes elements of a holistic package of
services for young children and their caregivers. While many programs focus on
particular intervention or sectoral areas, noting the interlinkages within and across
sectors is critical to ensuring children’s well-being across domains.
8
TABLE 1 Elements of a Holistic Package for Young Children and Their Caregivers8
Maternal, Newborn and Child Health
Reproductive health and family
planning
Maternal education
Antenatal visits
Skilled assistance during childbirth
Immediate and exclusive
breastfeeding for 6 months
Complementary and responsive
feeding
Immunizations
Deworming
Regular check-ins with health care
providers
Growth monitoring and promotion
Timely diagnosis and treatment of
disease
Screening for developmental
delays and disabilities
Access to safe water, sanitation,
and hygiene/handwashing
Early Childhood Care and Education
Opportunities for play, learning,
education, and interaction with
responsive adults in safe
environments
Child-centered spaces in the
community
Equitable access to quality
preprimary education, including for
children with developmental delays
and disabilities and children from
marginalized groups
Continuity with quality primary
education
Parenting skills and caregiver
support, focusing on early
stimulation, growth, and
development
Nutrition
Counseling on adequate diet and
appropriate nutrition during
pregnancy
Iron-folic acid for pregnant mothers
Complementary feeding
Optimal feeding practices,
including responsive feeding and
stimulation
Micronutrient supplementation and
fortification
Therapeutic zinc supplementation
for diarrhea
Protection from Violence and Neglect
Education related to positive
parenting, safe discipline, and the
effects of violence on child health
and development
Household economic
strengthening coupled with
building of parenting skills;
promotion of gender equality to
prevent violence against women
and girls
Reduced access to and use of
alcohol, illegal drugs, and weapons
Legal protections that prevent and
respond to violent and neglectful
behavior
Services for victims and
perpetrators
Social norms and behavior change
This chart draws from similar depictions that present key interventions by sector and/or age, including “Figure 1:
25 Key Interventions for Young Children and Their Families” in Denboba et al. (2014), p. 3.
8
9
Caregiver Support
Parental leave
Quality and affordable child care
Parenting skills and caregiver
support
Prevention and treatment of
maternal depression
Referral mechanisms for support
services
Safety Net
Birth registration
Social service, child welfare, and
protection systems, including
effective case management
Household economic
strengthening
Prevention of family-child
separation and support for familybased alternative care
Maternal, Newborn, and Child Health
Science challenges the fundamental nature of programmatic stovepipes. For instance,
there is growing international consensus within the public health community that early
development is part of overall child health and is necessary for future prosperity. As far
as long-term child outcomes are concerned, a narrow focus on child survival is
insufficient. Maternal, newborn, and child health programs must also promote children’s
developmental potential.
In 2013, Dr. Margaret Chan, director general of the World Health Organization
(WHO), emphasized three areas critical for healthy child development: (1) stable,
responsive, and nurturing caregiving with opportunities to learn; (2) safe and supportive
physical environments; and (3) appropriate nutrition (Chan, 2013). Indeed, many of the
strategies that support child development are the same as those that prevent morbidity
and mortality (Engle et al., 2011; Jensen et al., 2015). Such interventions enhance and
are absolutely consistent with the child survival agenda.
Primary and community health workers may be the first and only service
providers to have contact with children during the first few years of life (Engle et al.,
2013). Services targeting women and young children—family planning, prenatal care,
safe birth practices, neonatal survival strategies, breastfeeding support, growthmonitoring, immunizations—allow opportunities for introducing behaviors and practices
that encourage healthy child development. As the WHO director general has stated,
“The health sector therefore has a unique responsibility, because it has the greatest
reach to children and their families during pregnancy, birth, and early childhood. The
evidence is compelling to expand the child survival agenda to encompass child
development” (Chan, 2013).
Indeed, strategies to prevent mortality in the first month of life—deaths that
account for about half of all deaths in children under 5 years—are significant not only for
survival but also for human capacity. “Failure to improve birth outcomes by 2035 will
result in an estimated 116 million deaths, 99 million survivors with disability or lost
development potential, and millions of adults at increased risk of non-communicable
diseases after low birth weight. In the post-2015 era, improvements in child survival,
development, and human capital depend on ensuring a healthy start for every newborn
baby—the citizens and workforce of the future” (Lawn et al., 2014, p. 9938).
10
Foundations for healthy child development include many of the best practices
that support child survival, including planned pregnancy and skilled assistance during
childbirth; exclusive breastfeeding in the first six months of life followed by appropriate
complementary and responsive feeding; timely diagnosis and treatment of infections
and diseases; and preventive interventions, including vaccinations and regular checkins with health care providers (Table 1). Nevertheless, these health practices, though
critical for every child’s well-being, are insufficient on their own and must be reinforced
with informed action across sectors (Chan, 2013).
Recognizing the need to equip health care workers with skills to promote holistic
and healthy child development, UNICEF and WHO together created Care for Child
Development, a landmark intervention that was originally developed in the late 1990s as
part of the regular child health visits as specified in the WHO/UNICEF strategy of
Integrated Management of Childhood Illnesses (UNICEF and WHO, 2012). Since then,
other initiatives have sought to integrate child survival, primary care, and child
development, including Accelerated Childhood Survival and Development, Infant Young
Child Feeding, and Maternal and Newborn Health Care. The Care for Child
Development intervention provides information and recommendations for cognitive
stimulation and social support to young children through sensitive and responsive
caregiver-child interactions. It also guides health workers and other counselors as they
help families build stronger relationships with their children and solve problems in caring
for their children at home. These basic care-giving skills contribute to the survival, as
well as the healthy growth and development, of young children (Elder et al., 2014).
Efforts to strengthen the capacities of vulnerable families to meet their children’s
health and developmental needs in the midst of poverty or serious threat suggest two
pathways. The first requires improved access to and utilization of preventive health
services and treatment. The second requires bolstering children’s protective factors and
capacity for resilience. Both involve supporting parents’ and caregivers’ ability to
respond appropriately to children facing deprivation or distress. “The biology of
adversity and resilience demonstrates that significant stressors, beginning in utero and
continuing throughout the early years, can lead to early demise or produce long-lasting
impacts on brain architecture and function” (Shonkoff et al., 2012).
The effects of early adversity on long-term health have been shown through the
Adverse Childhood Experiences (ACE) Study, one of the largest investigations ever
conducted to assess associations between childhood adversity and later-life health and
well-being (CDC and Kaiser Permanente, 1998). The study is a collaboration between
the Centers for Disease Control and Prevention and Kaiser Permanente's Health
Appraisal Clinic in San Diego. The ACE Study’s findings suggest that certain
experiences are major risk factors for the leading causes of illness and death as well as
poor quality of life (see Figure 3). Though the study has focused on the United States, it
is critical to understanding how some of the worst health and social problems can arise
as a consequence of adverse childhood experiences. Realizing these connections is
likely to improve efforts toward prevention and recovery, including doubling up efforts to
strengthen children’s protective factors. Children who manage, and even do well, in the
face of serious hardship typically have developed an array of adaptive capabilities
embedded in neurobiological function, behavioral skills, relationships, and cultural or
community connections. Resilience is the result of a combination of protective factors,
11
which can be enhanced through strategic investments, including building the capabilities
of caregivers and strengthening the communities that together form the environment of
relationships essential to children’s lifelong learning, health, and behavior (Center on
the Study of the Developing Child at Harvard University, 2015; National Scientific
Council on the Developing Child, 2015).
FIGURE 3: Adverse childhood experiences influence health and well-being throughout
the lifespan
SOURCE: CDC and Kaiser Permanente (1998).
Nutrition
Good nutrition is fundamental to child health and well-being, beginning with a mother’s
nutritional status before and during pregnancy (UNICEF, 2013). Proper nutrition is a key
element in combating child mortality and morbidity: approximately 45 percent of all
deaths of children under the age of 5 in low-income countries are attributable to
undernutrition (WHO, 2016). Beyond its role in ensuring survival, the association
between nutrition in early life and long-term health has been of interest for decades
(Bhutta, 2013). The biological and epidemiological linkages between various types of
undernutrition (stunting, wasting, and micronutrient deficiencies) and impaired cognitive
development in the early years is well established (Black and Dewey, 2014). Nutrition
plays a key role in healthy child development, particularly in the early years as
neurodevelopmental building blocks are being formed and nutritional needs are high
(Ramkrishnan et al., 2011). The effect of poor nutrition on young children, particularly
between ages 0–8, and most acutely during the 1,000-day period from conception to
age 2 years, can be devastating and enduring, having serious implications for health,
12
behavioral and cognitive development, future reproductive health, and future workforce
productivity.
Poor nutrition can lead to stunting, a condition that is defined as height for age
below the fifth percentile on a reference growth curve. Stunting is used as a measure of
nutritional status and serves as an important indicator for chronic undernutrition. Factors
contributing to stunting include poor maternal health and nutrition before, during, and
after pregnancy, as well as inadequate infant feeding practices, particularly during the
1,000 days from conception through a child’s second birthday (WHO, 1997). Stunting
early in life seriously affects brain functioning and can cause permanent cognitive
impairment. As a result, it has been associated with consequences that threaten equity
throughout the life cycle, including diminished health, poor school performance and
early termination, and reduced work capacity and future earning potential (Hoddinot et
al., 2013). Malnutrition adds staggering health costs for already financially burdened
countries.
Early stunting has been used as an indicator, along with poverty, to estimate the
number of children who are at risk for not reaching their developmental potential.
Currently, nearly one in four children under age 5 worldwide is stunted. This massive
burden poses serious threats to individual and community capacity for health, stability,
and productivity. The vast majority of the 159 million children under age 5 who are
stunted live in Asia and Africa (UNICEF, 2015). The good news is that global stunting
prevalence has declined from nearly 40 percent in 1990 to 24 percent in 2014.
Nearly 20 years of research has demonstrated that nutrition programs that are
combined with health, water and sanitation, and child development interventions—
emphasizing stimulating and responsive parenting—achieve greater immediate and
long-term effects (Black and Dewey, 2014). A groundbreaking randomized controlled
trial in Jamaica revealed that stunted children who received targeted nutrition
interventions alongside support for parents had better outcomes than children receiving
only nutrition interventions. A 20-year follow-up shows that the stunted Jamaican
toddlers who received 2 years of psychosocial stimulation had higher IQs and
experienced reduced anxiety and depression and less violence. Strikingly, their future
earnings were 50 percent greater than the nonstimulated stunted group. In fact, their
earnings were comparable to a nonstunted sample, indicating that the stimulation
intervention enabled them to catch up to their well-nourished peers (GranthamMcGregor et al., 1997 and 2007; Gertler et al., 2014).
In 2014, more than 80 leading researchers from multiple disciplines consolidated
the existing evidence to advance knowledge concerning an integrated approach to
improving both nutrition and early childhood development. The resulting collection of 20
articles provides a portrayal of the current state of the science linking brain
development, psychology, nutrition, and growth, reviewing the impact and lessons
learned from integrated interventions to improve outcomes across these domains (Black
and Dewey, 2014). It is essential that current policies and programs take this learning
into consideration and that funding is used to support evidence-based programming
rather than unintegrated program siloes that sever children’s needs into separate and
uncoordinated services.
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Early Childhood Care and Education
Young children’s growth and development are profoundly shaped by nurturing care and
opportunities for play, learning, education, and interaction with responsive adults—
whether these occur at home, in out-of-home caregiving environments, such as child
care centers, or in formal or informal child-centered spaces and educational settings in
the community (Britto et al., 2013; Ginsburg, 2007). These early interactions lay the
groundwork for developmental potential, including physical, cognitive, social, and
emotional growth. Skills required for schooling, employment, and family life build
cumulatively on these dimensions of developmental potential. Indeed, nurturing early
childhood care and education are fundamental to quality basic education and serve as a
foundation for equity (Irwin et al., 2007).
Significant disparities in early learning experiences for low-income children can
set the stage for achievement gaps that persist through years of school and lead to a
lifetime of missed opportunities, inequities, and even health challenges. Increasing
access to quality early childhood care and education is considered an effective
“equalizer” (Irwin et al., 2007). Research from developing countries shows that early
childhood development programs lead to higher levels of primary school enrollment and
educational performance, which in turn positively affect employment opportunities later
in life. On the contrary, children who start school late and lack the necessary skills to be
able to learn constructively are more likely to fall behind or drop out completely, often
perpetuating intergenerational cycles of poverty (Engle et al., 2011). Studies show that
the returns on investments in early childhood care and education are highest among
poorer children, for whom these programs may serve as a stepping stone out of poverty
or exclusion (Heckman, 2006).
Despite the proven benefits of early childhood care and education programs,
access and attendance remain very low in many developing countries, particularly for
children from marginalized populations, including children with disabilities. Attendance
in early learning programs among children ages 3 and 4 is less than 50 percent in the
majority of countries with available data (UNICEF, 2016). Low attendance is related to
limited access—a direct result of the lack of prioritization placed on early childhood
programs—and associated minimal funding.
Inadequate attention to the foundational early childhood period has affected
global efforts to achieve basic targets in education. Fortunately, the previous lack of
focus on early childhood development has been addressed in the post-2015 global
development agenda. Target 4.2 of the United Nations’ Sustainable Development
Goals, announced in September 2015, states that, by 2030, “all girls and boys have
access to quality early childhood development, care and pre-primary education so that
they are ready for primary education” (United Nations, 2015). The challenges involved
in achieving universal access to early childhood development programs are enormous,
particularly given ingrained patterns of underinvestment in this area.
The economic science is clear and compelling: investments in learning and
development during the early years result in greater cost savings than investments
made later in the life cycle (Heckman, 2008). According to the World Bank, high-income
countries spend an estimated 1.6 percent of their gross domestic product (GDP) on
family services and preschool for children aged 0–6 years and 0.43 percent of GDP on
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preschools alone. By comparison, low-income countries tend to spend far less than 0.1
percent on preschools (Engle et al., 2011). Yet, even in resource-rich countries,
developmental vulnerability increases as socioeconomic status decreases (Irwin et al.,
2007). Increasing preschool enrollment rates to 25 percent could yield an estimated
$10.6 billion through higher educational achievement, and a 50 percent increase could
generate $33.7 billion (Engle et al., 2011). Such investments in preprimary
environments yield even greater dividends when coupled with community-based health
and nutrition programs and parenting support. Unless governments—including bilateral
agencies—allocate increased resources to quality early childhood care and education
programs, and, in particular, target children in the lowest economic quintile, economic
disparities will continue and widen.
Protection from Violence and Neglect
Over the last few decades, knowledge has accumulated about how normative child
development can be significantly derailed by exposure to violence and neglect,
particularly when such exposure is repeated or chronic (Center on the Developing Child
at Harvard University, 2016). Science shows that early exposure to maltreatment can
disrupt healthy development and have lifelong consequences (Cicchetti and Toth, 2016;
Pollak, 2015). Research also shows that violence against women and children often cooccur and share common risk factors (Patel, 2011). Women who experience violence
from their partners are more prone to depression and less likely to earn a living or
provide consistent and nurturing care for their children (National Resource Center on
Domestic Violence, 2002). Fortunately, effective strategies to prevent violence against
women and children are becoming more fully understood and utilized (WHO, 2010;
Bernard van Leer Foundation, 2011; KNOW Violence, undated).
Child maltreatment includes experiencing violent discipline, witnessing intimate
partner violence, and being neglected by caregivers (Hillis et al., 2015). Caregivers’
failure to provide sufficient and adequate nutrition, clothing, shelter, sleep, or medical
care and to ensure that the child’s surroundings and activities are responsive, nurturing,
and safe all constitute forms of neglect toward a child, leading to more severe
deprivations over time. Research has demonstrated that healthy child development can
be derailed not only as the result of physical or sexual abuse but also by the lack of
sufficient quality experiences, nurturing, and opportunities to learn, particularly in the
early years (Cicchetti, 2013). Despite neglect being, by far, the most prevalent form of
child maltreatment, it receives far less public attention than physical or sexual abuse
(Center on the Developing Child at Harvard University, 2012).
When caregiver or other adult responses to children are violent, erratic,
inappropriate, or simply absent, developing brain circuits can be disrupted, affecting
how children learn, solve problems, and relate to others (Center on the Developing
Child at Harvard University, 2012). Such experiences, particularly in the sensitive period
of early childhood, can lead to lasting physical, mental, and emotional harm with longterm effects. Affected children are more likely to suffer from attachment disorders,
regressive or aggressive behavior, depression, and anxiety. Child maltreatment and
other adverse experiences can affect immediate and long-term health, cognitive
function, and socioemotional well-being (Margolin and Elana, 2004; National Scientific
15
Council on the Developing Child, 2010a). Violence and neglect often cycle through
generations, negatively affecting individual and collective opportunities for productivity
and health over many years.
A first step in preventing violence and neglect is better understanding their
magnitude, nature, and consequences. The CDC’s Violence against Children Surveys
measure physical, emotional, and sexual violence against girls and boys. The surveys’
data have been released in eight countries, with data collection ongoing in several more
(CDC, undated). In early 2016, the CDC released a groundbreaking report estimating
the global burden of violence against children throughout the world. The study combines
data from 38 reports spanning nearly 100 countries to calculate the number of children
affected by violence in the past year. Conservative estimates of the data show that a
minimum of 50 percent of children in Asia, Africa, and North America experienced
serious forms of violence and that more than half of all children in the world—1 billion
children ages 2–17 years—are victims of violence, subjected to regular physical
punishment by their caregivers (Hillis et al., 2015). An estimated 275 million children
witness domestic violence every year. Often, intimate partner violence tends to co-occur
with the direct victimization of children (UNICEF, 2014b). Further exposure is detailed in
a statistical analysis of violence against children released by UNICEF in 2014, shedding
light on the prevalence of different forms of violence against children, with global figures
and data from 190 countries (UNICEF, 2014b). Where relevant, data are disaggregated
by age and sex to provide insights into risk and protective factors.
The prevalence of violence experienced by children ages 0–8 is difficult to
assess because much of the violence occurs within the privacy of individual homes,
child care centers, and residential institutions, and thus is often hidden from public view.
Caregivers committing violence against children are unlikely to self-report or seek help,
particularly where violent discipline is a cultural norm or a social taboo. In lower-income
countries, social services are minimal and underresourced, often ill-equipped to assess
or effectively respond to violence against children. In addition, existing data-collection
mechanisms lack age-appropriate diagnostic tools for children under 15 years of age
(Bernard van Leer Foundation, 2012). Nevertheless, data show that the first year is the
most dangerous period in a child’s life with respect to the risk to survival not only from
neonatal causes but also from violence, abuse, and neglect (Da Silva e Paula et al.,
2013).
The economic costs associated with neglect of and violence against children can
be broadly divided into two categories: direct and indirect. The direct costs are more
immediate and easier to measure, including (1) health care costs associated with
treatment of physical injuries and psychological and behavioral problems; (2) social
welfare costs incurred for monitoring, preventing, and responding to neglect of and
violence against children; and (3) criminal justice costs associated with ensuring that
perpetrators are punished and that victims are protected. Indirect costs may be less
obvious, but loom much larger. These include significant losses in future productivity
arising from the negative and often irreversible impact that childhood neglect and
violence have on child development and well-being. Adults who experienced violence
and/or neglect in childhood have lower levels of education, more limited opportunities
for employment, lower earnings, and fewer assets. The adverse experiences in early
childhood significantly reduce human capital formation, with serious repercussions for
16
individuals, families, and societies as a whole (Santos Pais, 2015; Berens and Nelson,
2015).
Studies of costs associated with violence against children reference the
proportion of gross national income/gross domestic product potentially lost due to
expenditure on response, prevention, and productivity losses. Estimates vary depending
on the types of violence studied and how comprehensively the direct and indirect costs
are assessed. Even when these assumptions are taken into consideration, the lowest
estimates at national, regional, or global levels indicate that costs range between 2 and
10 percent of GDP, representing a significant cost to national and global economies
(Fearon and Hoeffler, 2014). One study estimates that the global economic impacts and
costs resulting from the consequences of physical, psychological, and sexual violence
against children can be as high as $7 trillion. This massive cost is higher than the
investment required to prevent much of that violence (Pereznieto et al., 2014).
We can take steps to protect the world’s children from violence and neglect. Data
show that the following strategies are effective in preventing both: teaching positive
parenting skills; economically empowering households; reducing violence and neglect
through protective policies; improving health, child protection, and support services;
changing the social norms that support violence; and teaching children social,
emotional, and life skills. These strategies are based on CDC’s core package THRIVES
(Hillis, 2015) and similar guidance from UNICEF and WHO (UNICEF, 2014a) and are in
support of the United Nations’ 2030 Sustainable Development Goal to “end all forms of
violence against children” (Hillis et al., 2016).
Violence prevention and response interventions have typically focused on
school-aged children through programs in schools and communities. More can be done
to empower actors across multiple sectors who provide services targeting young
children and their families to play a key role in preventing maltreatment and neglect in
children’s early and most formative years. Nevertheless, although the evidence clearly
shows that “prevention pays,” current levels of spending on preventive and responsive
actions in relation to violence against and neglect of children remain very low
(Pereznieto et al., 2014).
FAMILIES ON THE FRONT LINES: SUPPORTING CAREGIVERS
To truly eradicate poverty and foster equity and to seriously put children at the heart of
the global development agenda, we must recognize and support the critical role that
families—which are, by nature, broadly defined—play in promoting children’s health,
development, education, and protection. Services delivered to children—whether
primary health and nutrition care, early childhood care and development, education, or
protection—do not work in a vacuum. They are most effective when they consider the
vital role of family in children’s lives and well-being. Without the consistent, nurturing
and protective care of parents and caregivers, children’s well-being suffers across
domains.
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Empowering Women, Supporting Children
Women’s and children’s rights have been bifurcated by advocates and policy makers for
decades, but in many ways they are indivisible in the real lives of many women and
children. This is not to suggest that the promotion of women’s empowerment and
children’s rights are entirely interchangeable. Whether seen as separate or
complementary causes, it is important that children are not left out of the equation as
workplace and economic productivity or women’s empowerment and well-being are
promoted.
The link between a mother’s education, health, nutrition, psychosocial wellness,
safety, and socioeconomic status and her children’s well-being is inextricable. Maternal,
newborn, and child health programs are therefore often co-located. Yet, beyond the
health sector, a gap begins to emerge between that which is done to promote women’s
empowerment and that which is done to support children.
For instance, quality and affordable child care is a critical part of advancing
women’s full participation in economic, political, and civic life, yet it is often missing from
policy discourse and program implementation. As any working parent can attest, quality
child care is a critical link between efforts to promote employment opportunities and
holistic child well-being, particularly for poor working families (Heymann, 2006).
Pursuing fundamentally separate agendas for women and children can be a disservice
to both.
Indeed, labor policies that either facilitate or hinder working adults’ ability to
balance work and caregiving responsibilities have a particularly large impact on women
and children. Paid maternity—or, more preferably—parental leave is a key first step,
though caregiving does not end at infancy. Finding affordable and quality child care that
meets the needs of children and working parents remains difficult worldwide, particularly
in low-income countries. Huge gaps in access persist, quality is often substandard, and
laws and policies to regulate care are often nonexistent or unenforced (Clinton
Foundation and Gates Foundation, 2015).
As a result, the number of young children who are left without adult care while
their parents work long hours outside of the home continues to grow. This situation
negatively affects the health, development, and safety of these children, impacting their
future potential as well as the ability of working parents to be fully productive. According
to results from UNICEF’s Multiple Indicator Cluster Surveys, more than 17 percent of
children under age 5 are left home alone or in the care of another child under the age of
10 (UNICEF, 2012). Poor families are more likely to leave a child in inadequate care
than wealthier families, and children from the poorest families are two times less likely
to attend an organized early childhood care and education program than the richest
families (UNICEF, 2012).
The Safety Net
Improving workplace policies and child care opportunities is important but insufficient,
especially for the poorest families who work as part of the informal economy where
workplace policies are essentially irrelevant. When vulnerable parents and families are
unable to cope on their own, broader systems of support are often necessary. Social
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protection systems are central to reducing poverty and can have a direct and positive
impact on poor families by improving access to better health, more schooling, economic
assistance, and skills building. Effective and well-functioning social service and child
welfare systems are vital to a nation’s social and economic progress and are as
important to global development programs as are strong health systems. Yet, in most
low-income countries, these systems are understaffed and underresourced. The human
resource constraint is critical. With proper investments and training, social service
workers are able to help ensure that effective prevention and support services are
available to the most vulnerable populations. Social service providers work to register
births, connect families with essential services, prevent family-child separation, support
alternative care, reunite families, provide critical psychosocial support, and link
vulnerable families and parents with social protection schemes and economic
strengthening activities (Global Social Service Workforce Alliance, 2015).
Globally, researchers, policy makers, and program implementers have
increasingly recognized that family strengthening for the poorest families is key to
effective responses to ensure healthy and holistic child development and protection.
Economic assistance is a core aspect of a family-strengthening approach. Household
economic-strengthening interventions target the family as the beneficiary and include
interventions that focus on increasing access to household savings, credit, income
generation, and employment opportunities. For example, conditional cash-transfer
programs provide money to poor families to target poverty and increase family capital
contingent on caretakers engaging in certain target behaviors, such as sending children
to school, taking them for health clinic visits, and ensuring vitamin supplements and
nutritious food. There is promising evidence regarding the benefits of conditional cashtransfer programs for families with young children (Elder et al., 2014). A review of nearly
50 published or publicly available randomized controlled trial research studies on
household economic-strengthening interventions confirmed mostly positive effects on
children’s outcomes, including improved nutrition status and increased enrollment in
education (Chaffin and Mortensen Ellis, 2015). The review also illustrated how
conditional cash transfers can have secondary and longer-term positive impacts on
children beyond those stipulated in the conditions of the cash transfer, including
reduced sexual activity in adolescence and lower levels of psychological distress. Still,
implementation of cash transfer programs—whether conditional or unconditional—
varies considerably, and mixed results from some programs require further
consideration (Chaffin and Mortensen Ellis, 2015). Research has helped to identify a
combination of interventions that effectively lift vulnerable households out of poverty and
improve caregiving environments, resulting in positive and measurable outcomes for
children across domains.
The Ultimate Breakdown: Children Living Outside of Family Care
When vulnerable parents and families do not have the resources to meet basic needs,
the risk of child neglect and separation from the birth family increases. Extreme poverty
and inadequate access to basic services have led to millions of children living outside of
family care—in institutions, on the street, trafficked, or separated from their families as a
result of conflict, disaster, forced labor, or disability (Maholmes et al., 2012). These
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children have largely fallen off the world’s statistical maps (Clay et al., 2011). For
instance, there is currently no global data on the numbers of children living in
institutions. Estimates range from 2 to 8 million, but the actual number of orphanages or
residential institutions and the number of children living in them are unknown. Many
institutions are unregistered, and underreporting is widespread. No international
monitoring frameworks exist, and many countries do not routinely collect or monitor data
on institutionalized children (Berens and Nelson, 2015).
The fact is, we measure what we care about, and we care about what we
measure. Given the inextricable links among data, advocacy, and strategic action—not
to mention the extraordinarily negative effects of spending early childhood without the
nurturing and protective care of a permanent caregiver—this kind of invisibility has reallife repercussions for the world’s most vulnerable children.
Strengthening families must be a global priority if we are serious about promoting
children’s well-being from survival to thrival. With inadequate investments in families, it
will be impossible to reduce child morbidity and mortality, improve educational
outcomes, and protect children from violence, exploitation, and abuse. Yet, despite the
critical role families play in children’s lives, they receive short shrift in global
development policies and programs. The one passing reference to “families” in the
United Nation’s new sustainable development goals is a case in point (United Nations,
2015). It has been said that family is like oxygen—taken for granted until it is gone.
Children do not fare well without at least one stable and committed relationship with a
supportive parent, caregiver, or other adult. We cannot truly support children without
investing in these relationships (Richter and Naicker, 2013).
PROTECTING THE FUTURE THROUGH STRATEGIC INVESTMENT
As global scientific and development communities continue to learn more about what
works to promote children’s optimal health, development, and protection, there is
growing recognition of the need to finance successful programs beyond the pilot stage
and take them to scale at the national level. A funding gap to support comprehensive
early childhood programs has existed for some time. Given the strong evidence base
and “proof of concept,” it is time to close it (IOM/NRC, 2015).
Improving investments in coordinated programs for children ages 0–8 requires
harmonization across funding streams and sectoral siloes. Child development is
multidimensional and therefore requires multisectoral investments. As a promising
example, the World Bank has been increasing support for integrated early childhood
programs in recent years. Between 2001 and 2013, it invested $3.3 billion in early
childhood programs through health, education, and social protection programs targeting
pregnant women, young children, and their families. The World Bank has also invested
substantially in research and impact evaluations concerning programs for children ages
0–8, focusing on early childhood nutrition, health, and development and expanding the
evidence base on effective, quality, and scalable interventions (World Bank, 2014;
Denboba et al., 2014). In April 2016, the World Bank and UNICEF jointly launched a
global alliance on early childhood development (Kim, 2016). Prioritization of early
childhood development is also occurring on the U.S. domestic front, with U.S. tax
20
dollars allocated to early childhood programs through the Departments of Education and
Health and Human Services (U.S. Office of Management and Budget, 2016).
Nevertheless, similar levels of attention and prioritization have yet to be seen in
the realm of U.S. government foreign assistance programs. Indeed, U.S. international
assistance to children is substantial and channeled through offices in multiple U.S.
government departments and agencies—the Departments of Agriculture, Defense,
Health and Human Services, Labor, and State; the U.S. Agency for International
Development (USAID); and the Peace Corps (U.S. Government, 2014). Yet, to date,
limited funds have been set aside for early childhood development per se.
Public Law 109-95, titled the Assistance for Orphans and Other Vulnerable
Children in Developing Countries Act of 2005, was signed into law to promote a
comprehensive, coordinated, and effective response on the part of the U.S. government
to the world’s most vulnerable children (U.S. Congress, 2005). It calls for an interagency
strategy and a whole-of-government monitoring and evaluation system. The act also
establishes a special advisor, currently based at the USAID, but the position comes with
no oversight or funding authority.
In 2012, in accordance with Public Law 109-95, the U.S. government released
the Action Plan on Children in Adversity, the first whole-of-government strategic
guidance for U.S. international assistance programs (U.S. Government, 2012). The plan
is grounded in evidence that shows that a promising future belongs to those nations that
invest wisely in their children, while failure to do so undermines social and economic
progress. It states that child development is a cornerstone for all development and
therefore central to U. S. development and diplomatic efforts. The action plan seeks to
achieve three principal objectives: (1) Build strong beginnings; (2) Put family care first;
and (3) Protect children from violence, exploitation, abuse, and neglect. Multiple offices
within 11 U.S. government departments and agencies agreed to specific actions to
implement the plan.
No dedicated funding was appropriated to implement the plan until fiscal year
2015. Since then, appropriations’ report language has suggested that approximately
$10 million per year be directed toward its implementation. Annual reports to Congress
suggest that multiple U.S. government offices contribute broadly to the plan’s
objectives, though details related to inputs and outcomes are slim. One of the action
plan’s strengths is its focus on measurable results, specifically achieving significant
reductions in the number of children not meeting age-appropriate growth and
developmental milestones; children living outside of family care; and children who
experience violence or exploitation. Despite these laudable goals, it would appear that
few U.S. government programs are tracking these outcomes (U.S. Government, 2014).
U.S. government appropriations continue to provide robust support for important
global health, nutrition, and education programs (Kaiser Family Foundation, undated),
though none of the corresponding funding directives includes language to support
investments specifically in early childhood development. The one exception is the
President’s Emergency Plan for AIDS Relief (PEPFAR), which has a 10 percent setaside for Orphans and Vulnerable Children’s (OVC) Programming, which has
historically promoted integrated programs for children affected by HIV and AIDS. In
2016, House report language recommended that PEPFAR integrate the action plan’s
“Strong Beginnings” objective into programs for the prevention of mother-to-child
21
transmission of HIV. In addition, Senate report language directed that up to $20 million
of OVC program funds be used for children living outside of family care (U.S. Congress,
2015b).
The lack of explicit reference to the importance of integrated and coordinated
cross-sectoral investments in early childhood development in funding directives and
strategies for the U.S. government’s foreign assistance portfolio has meant that such
activities are not prioritized or do not occur at all. Despite significant investments in
maternal, newborn, and child health and nutrition programs and the synergies that exist
between such investments and child development outcomes, the USAID’s Bureau for
Global Health, which is home to maternal and child health and nutrition programs,
currently does not track funding, programming, or outcomes related to early childhood
development (U.S. Government, 2014). Nor has early childhood development been
included in the USAID’s education strategy (USAID, 2011). In a more hopeful vein, the
USAID’s nutrition strategy recognizes the important linkages between appropriate
nutrition and the holistic growth, health, and development of young children (USAID,
2014). A similar lack of prioritization exists within other U.S. government international
assistance programs. For example, the Centers for Disease Control and Prevention,
which does significant work to prevent child morbidity and mortality, has received no
appropriations to continue its important work conducting Violence against Children
Surveys or to implement its corresponding program, THRIVES. The Eunice Kennedy
Shriver National Institute of Child Health and Human Development supports important
research related to child health and development, but there is currently no established
feedback loop to ensure that science is informing U.S. government international
programs and policies. Of note, the Department of State has no office, ambassador, or
other high-level appointee to represent global children’s issues.9
As a result, those attempting to deliver integrated programs for young children at
the country level are left to stitch together a patchwork quilt of funding from separate
and uncoordinated donor sources. This has serious implications for programmers who
are committed to providing comprehensive services to the most vulnerable households
and families. It also creates complications for those attempting to measure and assess
the overall impact of U.S. government international assistance to young children.
A CONCLUDING CALL TO ACTION
With its significant investments in international development, the technical expertise and
research capabilities embedded within key agencies, and diplomatic outreach, the U.S.
government is well positioned to lead and mobilize around a sensible and strategic
global agenda for young children. Child development is, after all, one of the world’s
greatest challenges in scope, scale, and impact. The persistent lack of attention to child
development in policies and programs threatens the socioeconomic fabric of nations.
The failure to invest in the developmental potential of children locks families,
communities, and nations into poverty and threatens global security. Evidence from
across disciplines—from neuroscience to biological and developmental science to
economic science—has clearly demonstrated that investing in young children’s holistic
9
The State Department’s Special Advisor for Children’s Issues oversees intercountry abduction and adoption only.
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well-being is a proven pathway out of poverty and into promise. It is past time to take
that road.
Authors
G. Huebner: Consultant, CPC Learning Network, Columbia University, Senior
Associate, Maestral International, Member, National Academy of Medicine Forum on
Investing in Young Children Globally
N. Boothby: Allan Rosenfield Professor of Forced Migration and Health, Mailman School
of Public Health, Columbia University
J. L. Aber: Willner Family Professor in Psychology and Public Policy at the Steinhardt
School of Culture, Education and Human Development, and University Professor, New
York University
G. L. Darmstadt: Associate Dean for Maternal and Child Health, Professor of Neonatal
and Developmental Pediatrics in the Department of Pediatrics, Stanford University
School of Medicine
A. Diaz: Jean C. and James W. Crystal Professor, Departments of Pediatrics and
Preventive Medicine, Icahn School of Medicine at Mount Sinai, Director, Mount Sinai
Adolescent Health Center
A. S. Masten: Regents Professor, Irving B. Harris Professor of Child Development,
Distinguished McKnight University Professor, Institute of Child Development, University
of Minnesota, Twin Cities
H. Yoshikawa: Courtney Sale Ross Professor of Globalization and Education,
Steinhardt School of Culture, Education and Human Development, and University
Professor, New York University
I. Redlener: Clinical Professor, Health Policy and Management and Pediatrics, The
Earth Institute, Columbia University
A. Emmel: Manager of Global Health Advocacy Initiatives, American Academy of
Pediatrics
M. Pitt: Assistant Professor of Pediatrics, Director of Global Health Education, University
of Minnesota, Co-Leader of the Association of Pediatric Program Directors Global
Health Pediatric Education Group
L. Arnold: Associate Professor of Pediatrics and of Emergency Medicine, Yale School of
Medicine, Chair, Section on International Child Health, American Academy of Pediatrics
23
B. Barber: New America Fellow, Director, Center for the Study of Youth and Political
Conflict, University of Tennessee
B. Berman: Clinical Professor of Pediatrics, University of California San Francisco,
Benioff Children's Hospital Oakland
R. Blum: William H. Gates Sr. Chair, Department of Population, Family and
Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University
M. Canavera: Associate Director, CPC Learning Network, Mailman School of Public
Health, Columbia University
J. Eckerle: Assistant Professor in the Division of Global Pediatrics, Director of the
Adoption Medicine Clinic, Medical Director for Utilization Review, UMMC, Faculty in the
Center for Neurobehavioral Development, University of Minnesota
N. A. Fox: Distinguished University Professor, Interim Chair, Department of Human
Development and Quantitative Methodology, University of Maryland
J. L. Gibbons: Professor Emerita of Psychology, Saint Louis University
S. W. Hargarten: Associate Dean, Global Health, Professor and Chair of Emergency
Medicine Medical College of Wisconsin, Member, National Academy of Medicine
C. Landers: Assistant Professor of Population and Family Health, Mailman School of
Public Health, Columbia University
C. A. Nelson III: Professor of Pediatrics and Neuroscience, Harvard Medical School,
Professor of Education, Harvard University, Richard David Scott Chair in Pediatric
Developmental Medicine Research, Boston Children's Hospital Laboratories of
Cognitive Neuroscience
S. D. Pollak: Letters and Sciences Distinguished Professor of Psychology and
Pediatrics, University of Wisconsin - Madison
V. Rauh: Professor, Population and Family Health at the Columbia University Medical
Center, Director, Child, Adolescent and Family Health Certificate
M. Samson: Senior Lecturer in Economics, Williams College
F. Ssewamala: Professor of Social Work and International Affairs; Director, Columbia
University International Center for Child Health and Asset Development
N. St Clair: Associate Professor of Pediatrics, Medical College of Wisconsin Director,
Department of Pediatrics Global Child Health Training Program
24
L. Stark: Associate Professor, Program on Forced Migration and Health, Director, CPC
Learning Network, Columbia University
R. Waldman: Professor of Global Health, George Washington University
M. Wessells: Professor of Clinical Family and Population Health, Mailman School of
Public Health, Columbia University
S. L. Wilson: Associate Professor of Pediatrics, Medical College of Wisconsin,
International Adoption Clinic, Child Development Center
C. H. Zeanah: Mary Peters Sellars Polchow Chair, Vice Chair, Child and Adolescent
Psychiatry, Professor of Psychiatry and Pediatrics, Tulane University
REFERENCES
Berens, A. E., and C.A. Nelson. 2015. The science of early adversity: Is there a role for
large institutions in the care of vulnerable children? Lancet, January 29 (online).
http://dx.doi.org/10.1016/S0140-6736(14)61131-4.
Bernard van Leer Foundation. 2011. Hidden violence: Protecting young children at
home. The Hague: Bernard van Leer Foundation.
http://resourcecentre.savethechildren.se/sites/default/files/documents/4665.pdf
Bernard van Leer Foundation. 2012. Stopping it before it starts: Strategies to address
violence in young children’s lives. The Hague: Bernard van Leer Foundation.
Bhutta, Z. 2013. Early nutrition and adult outcomes: Pieces of the puzzle. Lancet
382(9891):486–487.
Black, M., and K. Dewey, eds. 2014. Every child’s potential: Integrating nutrition and
early childhood development interventions. Annals of the New York Academy of
Sciences 1308: 1-255.
Boothby, N., R. L. Balster, P. Goldman, M. G. Wessells, C. H. Zeanah, G. Huebner, J.
Garbarino. 2012. Coordinated and evidence-based policy and practice for
protecting children outside of family care. Child Abuse and Neglect: The
International Journal, 36(10): 743-751.
Britto, P. R., P.L. Engle, and C.M. Super, eds. 2013. Handbook of early childhood
development research and its impact on global policy. Oxford: Oxford University
Press.
Carneiro, P. M., and J.J. Heckman. 2003. Human capital policy. IZA Discussion Paper
No. 821.
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=434544.
CDC (U.S. Centers for Disease Control and Prevention). Undated. Violence against
children surveys.
http://www.cdc.gov/violenceprevention/vacs/.
CDC and Kaiser Permanente. 1998. The adverse childhood experiences study.
http://www.cdc.gov/violenceprevention/acestudy/index.html.
25
Center on the Developing Child at Harvard University. 2012. The science of neglect:
The persistent absence of responsive care disrupts the developing brain.
Working Paper No. 12. www.developingchild.harvard.edu.
Center on the Developing Child at Harvard University. 2014. A decade of science
informing policy: The story of the National Scientific Council on the Developing
Child. www.developingchild.harvard.edu.
Center on the Developing Child at Harvard University. 2015. The science of resilience
(In Brief).
www.developingchild.harvard.edu
Center on the Developing Child at Harvard University. 2016. Neglect (Deep Dives).
www.developingchild.harvard.edu
Center on the Developing Child at Harvard University. Undated. Brain architecture.
http://developingchild.harvard.edu/science/key-concepts/brain-architecture/
Chaffin, J., and C. Mortenson Ellis. 2015. Outcomes for children from household
economic strengthening interventions: A research synthesis. Child Protection in
Crisis Learning Network and Women’s Refugee Commission for Save the
Children UK. http://www.cpcnetwork.org/resource/outcomes-for-children-fromhousehold-economic-strengthening-interventions/
Chan, M. 2013. Linking child survival and child development for health, equity, and
sustainable development. Lancet 381:1514–1515.
Cicchetti, D. 2013. Annual research review: Resilient functioning in maltreated
children—past, present, and future perspectives. Journal of Child Psychology
and Psychiatry 54:402–422.
Cincchetti, D., and S. L. Toth. 2016. Child maltreatment and developmental
psychopathology: A multilevel perspective. In Developmental psychopathology,
3rd ed., Vol 3, edited by D. Cincchetti. Hoboken, NJ: Wiley. Pp. 513–563.
Clay, R., L. C. deBaca, K. M. De Cock, E. Goosby, A. Guttmacher, S. Jacobs, A.
Pablos-Mendez, S. Polaski, G. Sheldon, D. Steinberg. 2011. A call for
coordinated and evidence-based action to protect children outside of family care.
Lancet, December 12 (online). DOI: 10.1016/S0140-6736(11)61821-7.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)618217/abstract.
Clinton Foundation and Bill and Melinda Gates Foundation. 2015. No ceilings: The full
participation report. http://noceilings.org/report/report.pdf.
Da Silva e Paula, C., C. Landers, T. Kilbane. 2013. Preventing violence against young
children. In Handbook of early childhood development research and its impact on
global policy, edited by P. R. Britto, P. L. Engle, and C. M. Super. Oxford: Oxford
University Press.
Denboba, A. D., L. K. Elder, J. Lombardi, L. B. Rawlings, R. K. Sayre, Q. T. Wodon.
2014. Stepping up early childhood development: Investing in young children for
high returns. The World Bank Group and Children’s Investment Fund.
http://documents.worldbank.org/curated/en/2014/10/20479606/stepping-up-earlychildhood-development-investing-young-children-high-returns.
26
Elder, J. P., W. Peguegnat, S. Ahmed, G. Bachman, M. Bullock, W. A. Carlo, V.
Chandra-Mouli, N. A. Fox, S. Harkness, G. Huebner, J. Lombardi, V. M. Murry,
A. Moran, M. Norton, J. Mulik, W. Parks, H. H. Raikes, J. Smyser, C. Sugg, M.
Sweat, N. Ulkuer. 2014. Caregiver behavior change for child survival and
development in low- and middle-income countries: An examination of the
evidence. Journal of Health Communication 19 (supp. 1): 25–66.
DOI: 10.1080/10810730.2014.940477
Eloundou-Enyegue, P. 2014. Comment, Institute of Medicine Forum on Investing in
Young Children Globally: The Cost of Inaction for Young Children Globally,
Washington, DC.
http://www.nationalacademies.org/hmd/Activities/Children/InvestingYoungChildre
nGlobally/2014-APR-17/Day%201/Panel%202/9-Eloundou-Enyegue-Video.aspx.
Engle, P. L., L. C. H. Fernald, H. Alderman, J. Behrman, C. O’Gara, A. Yousafzai, M.
Cabral de Mello, M. Hidrobo, N. Ulkuer, I. Ertem, S. Iltus. 2011. Strategies for
reducing inequalities and improving developmental outcomes for young children
in low-income and middle-income countries. Lancet 378 (9799): 1339 –1353.
Engle, P. L., M. E. Young, G. Tamburlini. 2013. The role of the health sector in early
childhood development. In Handbook of early childhood development research
and its impact on global policy, edited by P. R. Britto, P. L. Engle, and C. M.
Super. Oxford: Oxford University Press.
Evans, G. W., D. Li, and S. Sepanski Whipple. 2013. Cumulative risk and child
development. Psychological Bulletin 139(6)1342–1396.
Fearon, J., and A. Hoeffler. 2014. Conflict and violence assessment paper: Benefits and
costs of the conflict and violence targets for the post-2015 development agenda.
Copenhagen, Denmark: Copenhagen Consensus Center.
Gertler, P., J. Heckman, R. Pinto, A. Zanolini, C. Vermeersch, S. Walker, S. M. Chang,
S. Grantham-McGregor. 2014. Labor market returns to an early childhood
stimulation intervention in Jamaica. Science 344:998–1001.
Ginsburg, K. R. 2007. The importance of play in promoting healthy child development
and maintaining strong parent-child bonds. Pediatrics 119(1): 182-191.
Global Social Service Workforce Alliance. 2015. The state of the social service
workforce 2015 report: A multi-country review.
http://www.socialserviceworkforce.org/system/files/resource/files/State%20of%20
the%20Social%20Service%20Workforce%202015%20Report%20%20A%20Multi-Country%20Review.pdf.
Grantham-McGregor, S., S. P. Walker, S. M. Chang, C. A. Powell. 1997. Effects of early
childhood development supplementation with and without stimulation on later
development in stunted Jamaican children. American Journal of Clinical Nutrition
66(2): 247-253.
Grantham-McGregor, S., Y. B. Cheung, S. Cueto, P. Glewwe, L. Richter, B. Strupp.
2007 Developmental potential in the first 5 years for children in developing
countries. Lancet 369(9555):60–70.
Heckman, J. J. 2006. Skill formation and the economics of investing in disadvantaged
children. Science 312(5782):1900–1902.
27
Heckman, J. J. 2007. The economics, technology, and neuroscience of human
capability formation. Proceedings of the National Academy of Sciences of the
United States of America 104(33):13250–13255.
Heckman, J. J. 2008. Schools, skills and synapses. Economic Inquiry 46(3):289–324.
Heckman, J. J. Undated. Invest in early childhood development: Reduce deficits,
strengthen the economy.
http://heckmanequation.org/content/resource/invest-early-childhooddevelopment-reduce-deficits-strengthen-economy.
Heymann, J. 2006. Forgotten families: Ending the growing crisis confronting children
and working parents in the global economy. Oxford: Oxford University Press.
Hillis, S. D., J. A. Mercy, J. Saul, J. Gleckel, N. Abad, H. Kress. 2015. THRIVES: A
global technical package to prevent violence against children. Atlanta: Centers
for Disease Control and Prevention.
Hillis, S., J. Mercy, A. Amobi, H. Kress. 2016. Global prevalence of past-year violence
against children: A systematic review of minimum estimates. Pediatrics 137(3):1–
13.
Hoddinot, J., et al. 2013. Adult consequences of growth failure in early childhood.
American Journal of Clinical Nutrition 98:1170–1178.
IHME (Institute for Health Metrics and Evaluation). 2014. Financing global health 2014:
Shifts in funding as the MDG era closes. University of Washington, Seattle.
http://www.healthdata.org/sites/default/files/files/policy_report/2015/FGH2014/IH
ME_PolicyReport_FGH_2014_0.pdf.
IOM (Institute of Medicine). 2000. From neurons to neighborhoods: The science of early
childhood development. Washington, DC: The National Academies Press.
IOM/NRC (Institute of Medicine and National Research Council). 2014. The cost of
inaction for young children globally: Workshop summary. Washington, DC: The
National Academies Press.
http://www.nationalacademies.org/hmd/Reports/2014/The-Cost-of-Inaction-forYoung-Children-Globally.aspx.
IOM/NRC. 2015. Financing investments in young children globally. Washington, DC:
The National Academies Press.
http://www.nap.edu/catalog/18993/financing-investments-in-young-childrenglobally-summary-of-a-joint.
Irwin, L. G., A. Siddiqi, C. Hertzman. 2007. Early childhood development: A powerful
equalizer.
http://www.who.int/social_determinants/resources/ecd_kn_report_07_2007.pdf.
Jensen, S. K. G., R. R. Bouhouch, J. L. Walson, B. Daelmans, R. Bahl, G. L. Darmstadt,
T. Dua. 2015. Enhancing the child survival agenda to promote, protect, and
support early childhood development. Seminars in Perinatology 39(5):373–386.
Kaiser Family Foundation. Undated. Budget tracker: Fiscal year snapshot.
http://kff.org/interactive/budget-tracker/snapshot/2017/.
Kim, J.Y. 2016. Remarks by the World Bank group president Jim Yong Kim at the early
childhood development event. April 14.
http://www.worldbank.org/en/news/speech/2016/04/14/remarks-world-bankgroup-president-jim-yong-kim-early-chilhood-development.
28
KNOW Violence in Childhood. Undated. The initiative.
http://www.knowviolenceinchildhood.org/about/initiative.
Lawn, J. E., h. Blencowe, S. Oza, D. You, A. C. Lee, P. Waiswa, M. Lalli, Z. Bhutta, A.
J. Barros, P. Christian, C. Mathers, S. N. Cousens. 2014. Every newborn:
Progress, priorities, and potential beyond survival. Lancet 384(9938): 189-205.
Lombardi, J., J. F. Harding, M. C. Connors, A. H. Friedman-Krauss. 2016. Coming of
age: A review of federal early childhood policy 2000–2015. Build Initiative.
http://www.buildinitiative.org/Portals/0/Uploads/Documents/RisingtotheChallenge
Prologue.pdf.
Maholmes, V., J. D. Fluke, R. D. Rinehart, G. Huebner. 2012. Protecting children
outside of family care in low and middle income countries: What does the
evidence say? Child Abuse and Neglect: The International Journal 36(10):685–
688.
Margolin, G., and B.G. Elana. 2004. Children's exposure to violence in the family and
community. Current Directions in Psychological Science 13(4):152–155.
Masten, A. S. 2014. Global perspectives on resilience in children and youth. Child
Development 85(1):6–20.
National Resource Center on Domestic Violence. 2002. Children exposed to intimate
partner violence. http://vawnet.org/assoc_files_vawnet/nrc_children.pdf
National Scientific Council on the Developing Child. 2004. Young children develop in an
environment of relationships. Working Paper No. 1.
www.developingchild.harvard.edu.
National Scientific Council on the Developing Child. 2005/2014. Excessive stress
disrupts the architecture of the developing brain. Working Paper No. 3.
www.developingchild.harvard.edu.
National Scientific Council on the Developing Child. 2007. The timing and quality of
early experiences combine to shape brain architecture. Working Paper No. 5.
www.developingchild.harvard.edu.
National Scientific Council on the Developing Child. 2010a. Persistent fear and anxiety
can affect young children's learning and development: Working Paper No. 9.
www.developingchild.harvard.edu.
National Scientific Council on the Developing Child. 2010b. Early experiences can alter
gene expression and affect long-term development. Working Paper No. 10.
www.developingchild.harvard.edu.
National Scientific Council on the Developing Child. 2015. Supportive relationships and
active skill-building strengthen the foundations of resilience. Working Paper No.
13.
www.developingchild.harvard.edu.
Patel, D. 2011. Preventing violence against women and children. Washington, DC: The
National Academies Press.
Pereznieto, P., A. Montes, L. Langston, S. Routier. 2014. The costs and economic
impact of violence against children. Overseas Development Institute and the
Child Fund Alliance.
http://childfundalliance.org/wp-content/uploads/2014/10/ODI-Policy-Brief.-Thecost-and-economic-impact-of-violence-against-children.pdf.
29
Pollak, S. D. 2015. Multi-level developmental approaches to understanding the effects
of child maltreatment. Development and Psychopathology 27:1387–1397.
Ramkrishnan, U., T. Goldbenberg, L. H. Allen. 2011. Do multiple micronutrient
interventions improve child health, growth, and development? Journal of Nutrition
141(11):2066–2075.
Richter, L., and S. Naicker. 2013. A review of published literature on supporting and
strengthening child-caregiver relationships (parenting). Cape Town, South Africa:
Human Sciences Research Council.
Santos Pais, M. 2015. Viewpoint: The economic costs of violence against children.
http://srsg.violenceagainstchildren.org/viewpoint/2015-0713_1307#sthash.DZRwCegz.dpuf
Shonkoff, J. P., L. Richter, J. van der Gaag, Z. A. Bhutta. 2012. An integrated scientific
framework for child survival and early childhood development. Pediatrics
129(2):e460–e472.
Singer, P. 2014. Linking children’s developmental potential to a nation’s development
potential In The cost of inaction for young children globally: Workshop summary.
Washington, DC: The National Academies Press.
UNICEF (United Nations Children’s Emergency Fund). 2012. Inequalities in early
childhood development.
https://olc.worldbank.org/sites/default/files/Inequities_in_Early_Childhood_Develo
pment_What_the_data_say_UNICEF_2012.pdf.
UNICEF. 2013. Improving child nutrition: The achievable imperative for global progress.
http://www.childinfo.org/files/NutritionReport_April2013_Final.pdf.
UNICEF. 2014a. Ending violence against children: Six strategies for action.
http://www.unicef.org/publications/index_74866.html.
UNICEF. 2014b. Hidden in plain sight: A statistical analysis of violence against children.
http://files.unicef.org/publications/files/Hidden_in_plain_sight_statistical_analysis
_EN_3_Sept_2014.pdf.
UNICEF. 2015. Levels and trends in child malnutrition. UNICEF – WHO- World Bank
Group joint estimates. Key findings of the 2015 edition.
http://www.unicef.org/media/files/JME_2015_edition_Sept_2015.pdf
UNICEF. 2016. UNICEF data: Monitoring the situation of children and women.
http://data.unicef.org/ecd/early-childhood-education.html#sthash.SrnCaVKr.dpuf
UNICEF and WHO (World Health Organization). 2012. Care for child development.
http://www.unicef.org/earlychildhood/index_68195.html.
United Nations. 2015. Transforming our world: The 2030 agenda for sustainable
development. New York: United Nations General Assembly.
http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E.
USAID (United States Agency for International Development). 2011. Education:
Opportunity through learning. http://pdf.usaid.gov/pdf_docs/Pdacq946.pdf.
USAID. 2014. Multi-sectoral nutrition strategy, 2014–2025.
https://www.usaid.gov/sites/default/files/documents/1867/USAID_Nutrition_Strate
gy_5-09_508.pdf.
30
U.S. Congress. 2005. Assistance for Orphans and Other Vulnerable Children in
Developing Countries Act of 2005. Public Law 109-95, 109th Cong. (November
8).
https://www.congress.gov/109/plaws/publ95/PLAW-109publ95.pdf.
U.S. Congress. 2015a. State, Foreign Operations, and Related Programs
Appropriations Bill, 2016: House report.
http://appropriations.house.gov/uploadedfiles/hrpt-114-hr-fy2016-stateforop.pdf.
U.S. Congress. 2015b. State, Foreign Operations, and Related Programs
Appropriations Bill, 2016: Senate report.
https://www.congress.gov/114/crpt/srpt79/CRPT-114srpt79.pdf.
U.S. Department of State. 2015. Enduring leadership in a dynamic world: Quadrennial
diplomacy and development review.
http://www.state.gov/documents/organization/241429.pdf.
U.S. Government. 2012. The U.S. government action plan on children in adversity: A
framework for international assistance: 2012–2017.
https://www.usaid.gov/sites/default/files/documents/1860/United%20States%20A
ction%20Plan%20on%20Children%20in%20Adversity.pdf.
U.S. Government. 2014. Annual report to Congress: The U.S. government action plan
on children in adversity.
http://www.childreninadversity.gov/docs/default-source/annual-reports/pl10995_hvc_final.pdf?sfvrsn=4.
U.S. Office of Management and Budget. 2016. Budget of the U.S. government: Fiscal
year 2015.
https://www.whitehouse.gov/sites/default/files/omb/budget/fy2017/assets/budget.
pdf.
Wachs, T. D. and A. Rahman. 2013. The nature and impact of risk and protective
influences on children’s development in low-income countries. In Handbook of
early childhood development research and its impact on global policy, edited by
P. R. Britto, P. L. Engle, and C. M. Super. Oxford: Oxford University Press.
WHO (World Health Organization). 1997. Global database on child growth and
malnutrition. Geneva, Switzerland: World Health Organization.
WHO. 2010. Violence prevention: The evidence. Series of briefings on violence
prevention. Geneva, Switzerland: World Health Organization.
http://www.who.int/violence_injury_prevention/violence/4th_milestones_meeting/
evidence_briefings_all.pdf.
WHO. 2016. Fact sheet: Children: reducing mortality.
http://www.who.int/mediacentre/factsheets/fs178/en/.
World Bank. 2014. Invest early: Early childhood development as a driver for results.
http://www.worldbank.org/en/results/2014/06/02/invest-early-early-childhooddevelopment-a-driver-for-results.
31
Suggest Citation:
G. Huebner, N. Boothby, J. L. Aber, G. L. Darmstadt, A. Diaz, A. S. Masten, H.
Yoshikawa, I. Redlener, A. Emmel, M. Pitt, L. Arnold, B. Barber, B. Berman, R.
Blum, M. Canavera, J. Eckerle, N. A. Fox, J. L. Gibbons, S. W. Hargarten, C.
Landers, C. A. Nelson III, S. D. Pollak, V. Rauh, M. Samson, F. Ssewamala, N.
St Clair, L. Stark, R. Waldman, M. Wessells, S. L. Wilson, and C. H. Zeanah.
2016. Beyond Survival: The Case for Investing in Young Children Globally.
Discussion Paper, National Academy of Medicine, Washington, DC.
https://nam.edu/wp-content/uploads/2016/09/Beyond-Survival-The-Case-for-Investingin-Young-Children-Globally.pdf.
Disclaimer: The views expressed in this Perspective are those of the authors and not necessarily of the
authors’ organizations or of the National Academy of Medicine (NAM). The Perspective is intended to help
inform and stimulate discussion. It has not been subjected to the review procedures of, nor is it a report of,
the NAM or the National Academies of Sciences, Engineering, and Medicine. Copyright by the National
Academy of Sciences. All rights reserved.
32