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Putting the spotlight on the first 1000 days, to improve children’s futures #LongRead

The first 1000 days is the name of a global movement that recognises the importance of the period between conception and a child’s 2nd birthday as a unique window of opportunity to shape healthier futures.

The right nutrition and care during this 1,000 day window can have a profound effect on a child’s ability to grow, learn, and achieve their potential.

Professor Kerry Arabena, Chair for Indigenous Health and Director of the Onemda VicHealth Koori Health Unit, and colleagues in the Indigenous Health Equity Unit in The University of Melbourne’s School for Population and Global Health are driving First 1000 Days work in Victoria and Australia more widely.

A recent symposium at the University of Melbourne examined what is needed to ensure the best start for Aboriginal and Torres Strait Islander children during this period, and heard of several promising initiatives from across the country.

Participants heard the The Abecedarian Approach is grounded in the three interlinked domains of learning games, conversational reading, and enriched care-giving, unified through the overarching concept of language priority.

To reduce the worrying rate of removal of children from families, the symposium heard that the best results come from coordinated interventions that properly engage parents and vulnerable children with interrelated issues — such as maternal mental health, parental incarceration, racism and familial stress — and also engage with the child protection and welfare systems.

The symposium also heard of the importance of better engagement with fathers and their greater involvement in the early stages of parenting.

Many thanks to Professor Kerry Arabena for providing this report of the symposium.

 ****

Kerry Arabena writes:

More than 100 participants from over 30 different institutions were present at the recent ‘First 1000 Days Scientific Symposium’ led by the Indigenous Health Equity Unit in The University of Melbourne’s School for Population and Global Health.

The Symposium focused attention on the fundamentals of human development at a time in a child’s life when changes in service integration and family engagement can deliver on the promise of childhood equity.

It promoted multi-agency strategies that engage families to focus on the early period of child development, the first 1000 days from conception to age 2 years.

It considered how to develop and apply high quality evidence to the issue of childhood vulnerability in Aboriginal and Torres Strait Islander populations that is grounded both in the neuroscience of early brain development and in the complex effects of social and community environments on children’s development.

Mr Andrew Jackomos provided an overview of his work in Victoria as the Aboriginal Children’s Commissioner.  He highlighted a strengths based approach, emphasising the successes of the majority of Indigenous peoples, and the critical role of kin and culture for those that are vulnerable in the population. Amongst the latter, issues surrounding the removal of Indigenous children were key.

Vulnerability amongst children was multifactorial in origin, and predisposed the child to exposure to neglect and abuse in both the family context and in the state care intended to protect them. Despite good government intentions, poor outcomes have continued to escalate, with increased rates of out-of-home care increasingly in non-indigenous communities.

Research into the factors impacting on reasons for and the impact of out-of-home care has examined causal factors, service provision, the experiences of the child, and monitoring and facilitation of the timing of return to the family.

Major drivers to out-of-home care or poorer outcomes subsequent to care include lack of role models, increased rates of autism amongst children, inter-generational trauma, placement in non-indigenous contexts and lack of understanding of cultural connections and community input, the influence of substance abuse and incarceration, and, critically, male domestic violence.

Active community involvement and linkages between service systems including justice, health and education were highlighted as key for future progress and enhanced outcomes.

Participants also heard that coordinated interventions that properly engage parents and vulnerable children with interrelated issues — such as maternal mental health, parental incarceration, racism and familial stress — and also engage with the child protection and welfare systems, have the best chance of being effective.

Effective programs in Central Australia
Two regional approaches that promote multi agency strategies that engage families and focus on the early period of child development from conception to age 2 years include preventative programs from the Central Australia Aboriginal Congress geared towards increasing attendance and engagement – the Nurse Family Partnership Program, and the Congress Preschool Readiness Program- and the ‘Baby One Program’ from Apunipima Cape York Health Council from north Queensland.

Led from community controlled health agencies and supported by universities, these initiatives support service specific enhancements at the local and regional levels to ensure supports are equitably available for vulnerable families.

The Congress Preschool Readiness Program – a 7 week initiative for children 31/2 years of age which utilises the Abecederian Approach-aims to increase school preparedness and participation amongst indigenous children through assisting with preschool choice, enrollment and in the provision of practical support.

The program has demonstrated remarkable gains with rapid improvements in developmental outcomes amongst the majority of the children who participated, with participation in the full 7 weeks yielding developmental advances equivalent to 6 months duration, as measured using Bayley scores.

Critically, however, those children who were the most disadvantaged failed to demonstrate gains, indicating that intervention occurring at this stage of child development may already be too late for these children.

The Nurse Family Partnership Program, by contrast, is a parent focused intervention geared towards improving pregnancy outcomes, child health and development, and enhanced parental self sufficiency, by means of the establishment of a therapeutic relationship emphasising continuity of care between a nurse and the child’s mother from 28 weeks gestation to 2 years of age.

These programs emphasise the benefit of pre-distribution- targeting the child at the earliest stages of development- in conjunction with more traditional concepts of redistribution and remediation, to maximize potential.

Learning from Cape York programs
Similarly, the Baby Baskets program from Cape York, was developed to promote better maternal and child health outcomes for women in the Cape York communities in Queensland.

It was developed by the Apunipima Cape York Health Council, and as such reflects self-governance and local ownership. Baskets, with items supporting antenatal and postnatal care for the mother, infant and wider family, promoted engagement with health care workers and information exchange, trends which were borne out in subsequent evaluations.

The success of this program precipitated the genesis of the Baby One Program, which encourages holistic, family based antenatal and postnatal care driven by indigenous health workers and the local community.

It focuses on enhancing engagement between families and health workers and providers, the empowerment and education of health workers, and facilitating information exchange on health education and promotion, during the first 1000 days, and into subsequent pregnancies. This is enabled through home-based visits commencing during pregnancy with continuity of care through engagement with the same health worker throughout.

Health workers also benefit from participation in the program, through ongoing professional development and education on best practice models of care, which permit empowerment and capacity building.

Significantly, the program has identified the need for better engagement with fathers and their greater involvement in the early stages of parenting.  This is being addressed through current efforts to source funding to engage male health workers.

Internationally, the First 1000 Days is focused on reducing undernutrition around the globe. Combining evidence based medical care and social support, it includes actions that target:
• adolescents — through healthy behaviour modification, delaying pregnancy and parenting education;
• women of reproductive age — with preconception care, good nutrition, healthy lifestyle education and strategies to reduce gestational diabetes;
• neonates — through promoting breastfeeding, good nutrition, and family support and preservation; and infants and children — with good nutrition, family support and appropriate learning and stimulation.

Early benefits last a lifetime
The Symposium also demonstrated the importance of the First 1000 Days across the lifetime. Taking an ecological approach to early childhood, adolescence and ageing, participants heard from leaders in the field about the ways in which the first 1000 days can catalyse equity across a person’s lifetime.

Professor Joseph Sparling from the University of Melbourne discussed the critical role of development and intervention within the first 3 years, in terms of impact on the life course, as highlighted by James Heckman.

He emphasised that early interventions with proven efficacy demonstrate benefits right across the lifespan, including educational outcomes in middle age.

Improved cognitive outcomes in vulnerable children have been demonstrated in those exposed to the Abecedarian Approach across the first four years of life compared with their control peers.  The Abecedarian Approach is grounded on the 3 interlinked domains of learning games, conversational reading, and enriched care-giving, unified through the overarching concept of language priority.

After very promising outcomes following interventions using the Abecedarian Approach in Canada and the USA, Sparling is currently conducting the Northern Territory Research Project involving a quasi-experimental intervention arm of exposure to the Abecedarian Approach through parent-child playgroups, compared against a control, with the primary outcome being level of school readiness.

Early findings indicate the importance of dosage, as language development scores were enhanced by increased exposure to reading conversational sessions.

On the importance of adolescence
Dr Peter Azzopardi, an adolescent health researcher at South Australian Health and Medical Research Institute (SAHMRI) and Murdoch Children’s Research Institute (MCRI), discussed the unique properties of adolescence from a developmental viewpoint, and its interconnectedness with the first 1000 days.

It provides a window of vulnerability in which limbic areas of the brain regulating emotion and reward develop prior to prefrontal functions of planning and logic.  It is the period that coincides with risk raking behavior, the initial stages of family formation and increased roles and responsibilities concerning employment and citizenship.  Developments in the first 1000 days and throughout childhood influence, and are consolidated in, adolescence.

The residual negative effects of intra-uterine growth retardation (IUGR) on cognitive outcomes in adolescence can be mitigated by a supportive environment in infancy and childhood.  Similarly, whilst opportunities exist for ‘catch-up growth’ after IUGR in the first 1000 days, rapid growth and weight gain in later childhood and adolescence following initial under-nutrition is associated with increased risks of chronic disease in adulthood.  The different disease profiles of Indigenous Australians adds further complexities to the interpretation of current research.

Adolescence may also form the foundations for the prenatal and antenatal health for the subsequent generation.  Adolescent pregnancy, more common amongst indigenous Australians compared with the general population, carries increased risk of low birth weight infants, prematurity and increased neonatal mortality.  These effects are exacerbated if birth spacing is less than 2 years – a common scenario for adolescent mothers.

Data is, however, largely lacking regarding the impacts particular to Indigenous Australians.  Particular areas of focus for healthy adolescent development, using an ecological model to support research, programs and service provision, includes cultural well-being and development, enabling environments which support aspirations, the provision of basic needs, support around issues of justice, key health areas, sexual health and parenting supports.

Early pathways to dementia?
Professor Tony Broe (AO) from the Neurosciences Australia Institute focused on a lifecycle approach to brain growth, ageing, and cognition, in which it is recognized that brain growth and neuroplasticity peak in childhood and adolescence.

The Koori Growing Old Study focuses on urban and regional Koori communities from New South Wales.  Elevated rates of dementia were noted amongst Koori participants, compared with national averages, and were consistent across urban and rural sites.  Dementia was also noted to have earlier onset generally amongst the Koori participants.  Reasons for these results are likely to be complex and multifactorial.

To begin disentangling influences, successful parenting was explored through the proxy measure of the Childhood Trauma Questionnaire.  Preliminary findings indicate that childhood trauma and poor parenting are correlated with increased risk of dementia in later life.

Direct impacts upon brain growth such as brain structure and function and indirect mechanisms including co-morbid mental health issues and substance use, are likely to contribute, and argue for interventions directed across the range of risk factors.

All three presenters showed the importance of the First 1000 Days as an enabling environment to support family and community responses to enhance growth and development across a person’s lifetime.

We can support the inherent strengths and resilience in communities by bringing together disparate programs — home nursing, child protection and fathering support — with evidence-based very early learning programs. This will allow a coordinated effort in responding to the full impact of social determinants, improve access to comprehensive services and link those in need with local, Indigenous-led services.

This Symposium saw the development of a Scientific Committee to ensure the quality and integrity of work carried out under the First 1000 Days banner in Australia.

Evidence generated through the Scientific Committee will inform the next Symposium aiming to strengthen families through Community Governance and the final Symposium will focus on Policy and Implementation.

Through these Symposiums and the resultant Committees, the Indigenous Health Equity Unit supports the translation of evidence into practice, policy and implementation efforts across Australia. The Delegates Forum will set the agenda for future work.

• The symposium was chaired by Professor John Mathews, and facilitated by Professor Kerry Arabena (pictured below with colleagues.


 

 

 

 

 

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