US Government Action Plan for Children in Adversity_Neil Boothby_4.26.13


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  • The estimate of 200 million children is an estimate based on “proxy” indicators, namely stunting and poverty, simply because no other indicators for child development in developing countries existed at that time. UNICEF has been working with countries to close this knowledge gap – and to develop a composite picture of the status of child development in the early years. Early childhood development indicators were introduced into MICS 3. DHS also collects similar indicators, but to date, these have not been routinely analyzed.
  • 8 out of 9 children in Sub-Saharan Africa live past their 5th birthday.Levels & Trends in Child Mortality: Report 2012. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation.
  • National Scientific Council on the Developing Child (2007). The Timing and Quality of Early Experiences Combine to Shape Brain Architecture: Working Paper #5. Jack P. Shonkoff, M.D., presentation at the U.S. Government Evidence Summit on Protecting Children Outside of Family Care. December 12, 2011. Washington, DC.
  • Although not the only time to provide developmental support, return on investment for human capital growth is greatest in children’s early years. Dr. James Heckman, a Nobel Laureate in Economics, has shown that rates of return on investments made during the early childhood years average between 7 and 10 percent, greater than investments made at any other time in the life cycle. President Obama noted this evidence in his 2013 State of the Union address, making a clear connection between strategic investments in young people and the progress of our nation.Carneiro, P.M. and Heckman, J.J. (2003). Human Capital Policy. NBER Working Paper Series, vol. w9495. The Heckman Equation.   In his 2013 State of the Union address, President Obama stated, “Study after study shows that the sooner a child begins learning, the better he or she does down the road…Every dollar we invest in high-quality early childhood education can save more than seven dollars later on -- by boosting graduation rates, reducing teen pregnancy, even reducing violent crime.” 
  • Secure attachment with a permanent primary caregiver Environment rich with stimulation, they are more likely to survive, thrive, and grow up to be productive adults. Early childhood health and developmental protections, which link the young child’s cognitive, social/emotional, language, and motor development with stable and supportive caregiving, help break cycles of poverty and inequality, particularly among the most vulnerable children. National Scientific Council on the Developing Child. (2004). Young children develop in an environment of relationships: Working Paper Number 1. Retrieved from  Walker, S. et al. (2011) Inequality in early childhood: Risk and protective factors for early childhood development. The Lancet, 378 (9799). Engle, P. et al. (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 378 (9799).
  • Evidence, like these results from a randomized control trial with stunted children in Jamaica, shows that early childhood interventions that address stimulation in conjunction with nutrition and health services reap higher returns than either alone.
  • Information about children outside of family care is scarce. Because these children are omitted from many surveys and studies (most of which are household-based), they have fallen off the statistical map. It is difficult to know how many children are living in such precarious situations, except for scattered estimates from some specific countries. Local, national and international governmental and non-governmental partners do not have comprehensive and effective systems and strategies for assessing national prevalence or identifying and enumerating children outside of family care in most low and middle income countries. Inadequate birth registration systems further exacerbate the problem. It is costly, methodologically complex and sometimes politically sensitive to survey children living outside households, in institutions, on the street or involved in illicit activities. Consequently, most such children are statistically invisible and further marginalized for want of “evidence” about them, remaining consistently at risk and underserved by policies and services.Clay, et al. (2012). A call for coordinated and evidence-based action to protect children outside of family care. The Lancet. Published online December 12.
  • The Bucharest Early Intervention ProjectGreenberg, A. and Williamson, J. “Families Not Orphanages”. The Better Care Network
  • An estimated 80 percent of children in institutions have living parents.
  • DOMESTIC VIOLENCE = Child Disciplinary Practices at Home (Domestic Violence)This report analyses findings on child discipline from 35 MICS and DHS surveys conducted in low- and middle-income countries in 2005 and 2006. Questions on child discipline were addressed to the mother (or primary caregiver) of one randomly selected child aged 2–14 years in each household. 25 – 30% children experience severe forms of physical punishment in 13 countries. The most severe forms of physical punishment (hitting the child on the head, ears or face or hitting the child hard and repeatedly). SEXUAL VIOLENCE - WHO estimates that 150 million girls and 73 million boys under 18 experienced forced sexual intercourse or other forms of sexual violence during 2002FGM - According to a UNICEFestimate, between 100 and 140 million girls and women in the world have undergone some form of female genital mutilation/cutting. 2005EXPLOITATION – Study in 2000 suggest that 5.7 million were in forced or bonded labour, 1.8 million in prostitution and pornography,TRAFFICKING - 1.2 million were victims of trafficking.DOMESTIC VIOLENCE: Between 133 and 275 million children worldwide are estimated to witness domestic violence annually
  • The Bucharest Early Intervention ProjectGreenberg, A. and Williamson, J. “Families Not Orphanages”. The Better Care Network
  • WHO, Preventing Violence: The Evidence. Series of briefings on violence prevention, 2011
  • US Government Action Plan for Children in Adversity_Neil Boothby_4.26.13

    1. 1. CORE Group Spring MeetingApril 2013US Government Action Plan for Children inAdversityNew Science for Old ProblemsNeil BoothbyUSG Special AdviserandSenior Coordinator for the USAID AdministratorChildren in Adversity1
    2. 2. A diverse portfolio of assistance2PL 109-95
    3. 3. A legislative requirementPublic Law 109-95: The Assistance for Orphans and Other Vulnerable Children inDeveloping Countries Act of 2005Requirements:International assistance to highly vulnerable children is comprehensive, coordinated,and effective, and built on evidence-based practices.• Special Advisor (appointed or delegated by the Secretary of State)• Interagency strategy to determine strategic priorities• Whole-of-government M&E system• Annual reports to Congress• USAID is the lead agency (Senior Coordinator to the USAID Administrator)• $2.85 billion per annum3
    4. 4. From evidence to actionResults of the U.S. GovernmentEvidence Summit on Children Outsideof Family Care (December 2011):• 150 experts participated• 3,500 articles were reviewed• Senior interagency leaders committedto developing a strategy, published inLancet• 60 authors contributed to 7 paperspublished in Child Abuse and Neglect:The International Journal• One year later (December 2012), theU.S. Government Action Plan onChildren in Adversity was launched atthe White House4
    5. 5. U.S. Government Action PlanThe first-ever strategic guidance for U.S. government assistance to children overseas5
    6. 6. Children in Adversity: who are they?25%live inextremepoverty1.9 billion childrenin LMICAdversity: Serious deprivation or dangerPoor health and nutritionLow educationattainmentOutside of family careExposure to violence, exploitation, abuseUnited Nations Population Division World Population Prospects 2010UNICEF State of the World’s Children 20126
    7. 7. Critical Pathways and Investments7compromised
    8. 8. Action Plan ObjectivePromoteEvidence-BaseIntegrationStrengthenSystemsPut FamilyCare FirstProtect Childrenfrom Violence,Exploitation,Abuse, andNeglectBuild StrongBeginningsPRIORITYSUPPORTING8
    9. 9. White House LaunchDecember 19, 2012"And every child — no matter where they live, no matter thecircumstances into which they are born — should have theopportunity to survive and thrive… And so while we know that ourfuture prosperity and our security are intimately tied into theresults we deliver for children today, we also know that we havewithin our power today to ensure that all children survive and gethealthy food, all children grow up in a family, and all children aresafe from the violence and terror that sometimes erupts in ourworld.”USAID Administrator Rajiv Shah, December 19, 20129
    10. 10. “It is easier to build strong children than to repair broken men.”Frederick Douglass10
    11. 11. U.S. Government CommitmentGoal:The U.S. Government will help ensure that children underfive not only survive, but also thrive by supportingcomprehensive programs that promote sound developmentof children through the integration of health, nutrition, andfamily support.Outcomes: Increase the percentage of children achieving age-appropriate growth and developmental milestones. The number of USG-funded programs that integratehealth, nutrition, developmental protections, andcaregiving support is increased.11
    12. 12. The global burden• 6.9 million children under the age of 5 worldwide die eachyear.• More than 25 times that number -- over 200 millionchildren -- survive, but do not reach their developmentalpotential.• As a result, their countries have an estimated 20 percentloss in adult productivity.Grantham McGregor, S. et al., (2007). Developmental potential in the first 5 years for children indeveloping countries. Lancet, 369:60-70WHO and UNICEF. Care for Development.12
    13. 13. 109891Expected to diebefore their5th birthday.Expected to livepast their5th birthday.Approximately 1/3 are notexpected to reach theirdevelopmental potentialGrantham-McGregor et al. Lancet. 2007January 6; 369(9555): 60–70In Sub-Saharan Africa,for every 1000 children born in 2011…13
    14. 14. The importance of early intervention14
    15. 15. Adversity impairs development15
    16. 16. The economics:breaking the poverty cycleRates of return on investments made during the early childhood years averagebetween 7 and 10 percent, greater than investments made at any other time inthe life cycle. 16
    17. 17. What works?HealthcareStandard health screenings for pregnant womenSkilled attendants at deliveryChildhood immunizationsWell-child visitsNutritionBreastfeeding promotionSalt iodizationIron fortificationEarly LearningParenting programs (during pregnancy, after delivery and throughout early childhood)Childcare for working parents (of high quality)Free preprimary school (preferably at least two years with developmentally appropriate curriculum andclassrooms, and quality assurance mechanisms)Social ProtectionServices for orphans and vulnerable childrenPolicies to protect rights of children with special needs and promote their participation and access to ECDservicesFinancial transfer mechanisms or income supports to reach the most vulnerable families (could include cashtransfers, social welfare, etc.)Child ProtectionMandated birth registrationJob protection and breastfeeding breaks for new mothersSpecific provisions in judicial system for young childrenGuaranteed paid parental leave of least six monthsDomestic violence laws and enforcementTracking of child abuse (especially for young children)Training for law enforcement officers in regards to the particular needs of young children17Source: World Bank. Strategic Evaluation Impact Fund.
    18. 18. Two birds, one stone18
    19. 19. Sustained results0%1%2%3%4%5%6%7%height weight%increaseofmeancomparedtocontrolgroupSupplementationMaternal tutoringBothSource: Van der Gaag, J. School Performance and Physical Growth of Underprivileged Children: Results of theBogotá Project at Seven Years. (1983). World Bank, Washington D.C.19
    20. 20. What does success look like?• The percentage of children achieving age-appropriategrowth and developmental milestones is increased. National surveillance through DHS and MICS (data iscollected but as yet not analyzed) Project-level indicators (WHO, UNICEF, World Bank, andNGOs have models. USAID has as yet not adopted any).• The number of USAID-funded programs that integratehealth, nutrition, developmental protections, and caregivingsupport is increased. Reported through annual reports to Congress requiredby PL 109-95.20
    21. 21. “Any proposed programs should respect the primacy of the family.”James J. Heckman, Nobel Laureate in Economics21
    22. 22. U.S. Government CommitmentGoal:U.S. Government assistance will support and enable families tocare for their children, prevent unnecessary family-childseparation, and promote appropriate, protective andpermanent family care.Outcomes: Increase the percentage of children living withinappropriate, permanent, and protective family care. Reduce the number of children living in institutions. The percentage of families providing adequate nutrition,education opportunities, care, and protection for theirchildren is increased.22
    23. 23. The global burdenThe most vulnerable children in the world – children outside offamily care – have fallen off the statistical map.Global estimates:• 17.8 million children have lostboth parents• 2-8 million children may be livingin institutional care• 1.1 million children are traffickedfor forced labor• 1.8 million children are victims ofsex trafficking or pornography• 300,000 children are associatedwith armed forces or groupsAll children count, but not all children are counted.23
    24. 24. Children are at high risk ofgrowing up without a biologicalparent, usually their fatherPercentage of children under 5 living with theirbiological mother but w/o their biological fatherPercentage of children under 5 living with theirbiological father but without their biologicalmother, andPercentage of children under 5 living without bothbiological parents (x-axis)Source: UNICEF. Inequities in Early Childhood Development: What the data say - Evidencefrom the Multiple Indicator Cluster Surveys. February 2012. Figure 5, Page 9.Note: This analysis included 40 countries.24
    25. 25. The importance of family• Optimal support for child health, nutrition, and developmentcomes through protective and permanent caregiving in afamily environment. Children outside of family care often experience higherprevalence of abuse, neglect, lack of stimulation, poorhealth, and inadequate nutrition with negative long-term outcomes.• Most children (approx. 80%) are institutionalized as a result ofextreme poverty rather than parental death or abandonment.25
    26. 26. The effects of caregiving• Institutionalization can lead to serious developmental, cognitive,emotional delays and challenges. Children placed in appropriate family care by age 2 recovernormative growth and development by age 8. Children removed from institutions after age 2 do not reachnormative ranges.EEG level: Institutionalized children EEG level: Never-institutionalized children• Placing children in protective family care results in better childoutcomes and is significantly less expensive than institutional care.26
    27. 27. What works?• Household economic strengthening plus support forcaregivers Employment, savings and loans programs, cash transfers Positive parenting: reducing harsh discipline, substance abuse HIV prevention and treatment Child care• Genuinely free and equally accessible primary education• Family tracing and reunification in emergencies• Family reunification, foster- and kinship-care27
    28. 28. What does success look like?• The percentage of children living within appropriate, permanent,and protective family care is increased. National surveillance through a new measurement tool(currently under development, to be piloted in 2 countries)• The percentage of children living in institutions is reduced. National surveillance focusing on 6 priority countries• The percentage of families providing adequate nutrition, educationopportunities, care, and protection for their children is increased. Project-level indicators monitored within targeted sub-populations.28
    29. 29. “Safety and security don’t just happen;they are the result of collective consensus and public investment. We owe our children, the mostvulnerable citizens in our society, a life free of violence and fear.”Nelson Mandela29
    30. 30. U.S. Government CommitmentGoal:The U.S. Government will facilitate the efforts of nationalgovernments and partners to prevent, respond to, andprotect children from violence, exploitation, abuse, andneglect.Outcomes: Reduce the percentage of children who experienceviolence, abuse, exploitation, and neglect. Increase the percentage of children who receive care andprotection.30Obj 3 - Protect Children
    31. 31. The global burden• Between 133 million and 275 million children areestimated to witness domestic violence annually.• 25-30% of children experience severe forms ofpunishment.• 150 million girls and 73 million boys under 18 experiencedforced sexual intercourse or other forms of sexual violencein one year.• 36 percent of girls and 29 percent of boys globally havebeen sexually abused.• 115 million children are engaged in hazardous work; 5.5million are in forced labor.• 1.8 million children are victims of sex trafficking orpornography.• An estimated 300,000 children are associated with armedforces or groups. 31
    32. 32. The lasting effects of adversityCDC. Adverse Childhood Experiences.32
    33. 33. Health impacts:violence against childrenHealth-risk behaviors• Sexual promiscuity• Sexual perpetration• Alcohol abuse• Illicit/injected drug use• SmokingMental health and well-being• Depression, post-traumaticstress disorder (PTSD)• Aggression• Anxiety• Somatic complaints• Attempted suicide• Social ostracism• Anxiety• Academic achievement• Re-victimization• Unwanted pregnancyDisease and injury• STDs, including HIV• Gynecological problems• Heart disease• Diabetes• Stroke• Cancer• Suicide33
    34. 34. Association between childhood sexualviolence and selected health conditions,females 13–24 years old, Swaziland, 20073.73.53.0 2.92.3 2.32.0**Adjusted for age, community setting, SES, and orphan statusSource: Jim Mercy, CDC34
    35. 35. What works?• Developing nurturing relationships between children and caregivers• Strengthening the economic status of households• Reducing access to and use of alcohol, illegal drugs, and weapons• Promoting gender equality to prevent violence against girls and women(addressing violence against women and children together)• Changing cultural norms and social attitudes that promote violence;integrating violence prevention into sector programs• Support programs for survivors and initiatives to reverse under-reporting of violence, exploitation, abuse, and neglect35
    36. 36. What does success look like?• The percentage of children who experienceviolence, exploitation, abuse, and neglect is reduced. National surveillance through the Violence AgainstChildren Surveys.• The percentage of children who receive appropriate care andprotection after experiencing violence, exploitation, abuse, orneglect is increased. Project-level indicators monitored within targeted sub-populations.36
    37. 37. OutcomeReduce % children not meetinggrowth and developmentalmilestonesReduce % children living outsideof family care (COFC)Reduce % children whoexperience violence orexploitationExisting DataStunting and Poverty (DHS) [usedas ‘proxy’ indicators]COFC living *in* HHs(DHS, MICS)CDC VACSDOL/ILO Child Labor SurveysMissingCognitive Delays, DevelopmentalMilestonesCOFC living *outside* of HHsUSG Funding for VACSFilling the GapMeasurement Experts GroupMeasurement Experts GroupMethods Development/GrandChallengePromoting VACS and CLS inPriority CountriesMeasurement Challenges3 outcomes6 countries5 years37Results-based Approach
    38. 38. Build Strong BeginningsProtect ChildrenPut Family Care FirstOutcomes for Rwanda3840% reduction in the number of children under the age of five with cognitive delays– Integrate cognitive & social stimulation into existing child health and nutrition programs– Coordinate with faith-based actors in their application of caregiving programs75% reduction in the number of children living outside of family care– Prevent child-family separation through provision of nutrition, care, education and protect– Close all orphanages in all provinces. De-institutionalize 3,400 child from orphanages to family care– Strengthen national surveillance system for children living outside of family care50% reduction in violence against children in target populations– Incorporate anti-violence counseling for children into current projects reaching 60,000 children & families– Support national childhood violence surveillance systemsElimination of exploitive child labor from tea industry– Remove 4,000 children from tea industry supply chain through transition into service work & schools– Implement an integrated child labor monitoring system