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Responsive parenting: Interventions and outcomes

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In addition to food, sanitation and access to health facilities children require adequate care at home for survival and optimal development. Responsiveness, a mother's/caregiver's prompt, contingent and appropriate interaction with the child, is a vital parenting tool with wide-ranging benefits for the child, from better cognitive and psychosocial development to protection from disease and mortality. We examined two facets of responsive parenting -- its role in child health and development and the effectiveness of interventions to enhance it -- by conducting a systematic review of literature from both developed and developing countries. Our results revealed that interventions are effective in enhancing maternal responsiveness, resulting in better child health and development, especially for the neediest populations. Since these interventions were feasible even in poor settings, they have great potential in helping us achieve the Millennium Development Goals. We suggest that responsiveness interventions be integrated into child survival strategies.
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991
Bulletin of the World Health Organization | December 2006, 84 (12)
Abstract In addition to food, sanitation and access to health facilities children require adequate care at home for survival and
optimal development. Responsiveness, a mother’s/caregiver’s prompt, contingent and appropriate interaction with the child, is a
vital parenting tool with wide-ranging benefits for the child, from better cognitive and psychosocial development to protection
from disease and mortality. We examined two facets of responsive parenting its role in child health and development and the
effectiveness of interventions to enhance it — by conducting a systematic review of literature from both developed and developing
countries. Our results revealed that interventions are effective in enhancing maternal responsiveness, resulting in better child health
and development, especially for the neediest populations. Since these interventions were feasible even in poor settings, they have
great potential in helping us achieve the Millennium Development Goals. We suggest that responsiveness interventions be integrated
into child survival strategies.
Bulletin of the World Health Organization 2006;84:992-999.
Voir page 997 le résumé en français. En la página 998 figura un resumen en español.
Introduction
With only a decade left to achieve the
Millennium Development Goals, the
status of the world’s children remains
grim. Every year, 10.6 million children
die before reaching their fifth birthday;
of these four million die within 28 days
of birth. e vast majority of these
deaths occur in the developing world
due to poor health and development,
and an estimated six million deaths can
be averted with universal coverage of
available health interventions.
1
While children need food, sanita--
tion and access to health services to
survive and develop optimally, a warm
and affectionate relationship with an
adult caregiver who is responsive to the
child’s needs is equally important.
2
Such
a relationship strongly influences the
child’s health and development, ensuring
survival as well as physical, neurophysi-
-
ological and psychological health.
2–4
One of the key features of healthy
caregiving behaviour is responsiveness.
It means parenting that is prompt, con--
tingent on the child’s behaviour and
appropriate to a child’s needs and de-
-
velopmental state.
5
Responsiveness can
be of various types, depending on which
Responsive parenting: interventions and outcomes
Neir Eshel,
a
Bernadette Daelmans,
b
Meena Cabral de Mello,
b
& Jose Martines
b
.998
Public Health Reviews
a
Department of Molecular Biology, Princeton University, New Jersey, USA.
b
Department of Child and Adolescent Health and Development, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. Correspondence to Dr
Cabral de Mello (email: cabraldemellom@who.int).
Ref. No. 06-030163
(
Submitted: 17 January 2006 – Final revised version received: 30 June 2006 – Accepted: 24 July 2006
)
child behaviour the caregiver most
often the mother — is responding to: a
sign of illness, a verbal overture, a facial
expression or an exploratory initiative.
In each case, however, the mother’s ac--
tions are child-initiated and directed.
Responsiveness is most often con--
ceptualized as a three-step process.
4,6
(1) Observation: e caregiver (usually
the mother) observes the child’s cues,
such as movements and vocalizations.
(2) Interpretation: e caregiver accu--
rately interprets these signals, e.g. real--
izing that an irritable infant is tired and
needs rest, or is showing signs of illness.
(3) Action: e caregiver acts swiftly,
consistently and efficiently to meet the
child’s needs.
To measure responsive behaviour,
researchers observe the child and mother
in their natural environment and note
what proportion of the child’s cues
bring about a prompt, contingent and
appropriate response.
5
A commonly used
inventory is the Home Observation for
Measurement of the Environment, in
which the interviewer observes the child
at home.
7
We aimed to review the benefits of
responsive parenting on physical, mental
and social wellbeing of children, as well
as the efficacy of interventions directed
at enhancing maternal responsiveness.
Methods
We conducted a systematic review of the
literature for the role of responsive par--
enting in child health and development
and the effectiveness of interventions
used to enhance it. English-language
articles were searched in the following
databases: Medline (PubMed), WHO--
LIS (the WHO Library database),
Cochrane Review, the World Bank, the
Latin American and Caribbean Center on
Health Sciences Information (LILACS),
and KoreaMed (Table 1). More than 200
papers (reviews and experimental stud--
ies) and book chapters were consulted,
with an emphasis on recent articles that
focused on responsiveness. We made a
concerted effort to include articles from
developing countries, but relaxed the
selection criteria as most of the studies
on responsiveness were from developed
countries.
We chose 50 articles that were rep--
resentative examples of articles in each
section (correlative studies and interven--
tions), with priority given to randomized
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Bulletin of the World Health Organization | December 2006, 84 (12)
Public Health Reviews
Responsive parenting: interventions and outcomes
Neir Eshel et al.
controlled trials. e studies we reviewed
had sufficient detail to classify them as
interventions or correlational studies and
were focused on responsive care. e
selected articles were subdivided by loca--
tion (developed or developing country)
and domain of responsiveness (correla--
tive study of outcomes or experimental
intervention). If the study was correla--
tive, it was further divided by type of
outcome: psychosocial or physical. If it
was an intervention study, it was divided
into home visiting or comprehensive.
To aid in analysis, all cited intervention
studies were summarized in a tabular
format that included authors, publish--
ing year, study site, intervention type,
outcome measures and outcome.
Results
Maternal responsiveness
improves child health and
development
A large corpus of research has linked
maternal responsiveness to improved
child health and development, in both
the immediate and long term, since the
first path-breaking works.
8,9
Developed countries
Our analysis showed that in developed
countries, maternal responsiveness was
most often associated with language,
cognitive and psychosocial development.
For example, responsiveness contributed
uniquely to language acquisition, even
after considering the mothers expressive--
ness and other confounds.
10
Maternal
responsiveness in early childhood was
associated with social competence and
fewer behavioural problems at three
years;
11
increased intelligence quotient
(IQ) and cognitive growth at four-
and-a-half years;
12
school achievement
at seven years;
7
as well as higher IQ
and self-esteem, and fewer behavioural
and emotional problems at age 12.
13
Many of these studies focused on low-
birth-weight infants
14
or other at-risk
populations,
15
and found that maternal
responsiveness had a protective effect on
health and development.
Conversely, a lack of maternal
responsiveness was often associated
with behavioural problems and delayed
cognitive development.
4
In a sample
of high-risk Chicago youth, a lack of
maternal responsiveness during infancy
predicted disruptive behaviour at 10
years.
16
In this study, 26% of children
whose mothers scored in the lowest
quartile of responsiveness during in--
fancy developed a disruptive behaviour
disorder compared to 16% of children
of moderately responsive mothers, and
no children of highly responsive moth--
ers. Similarly, a sample of 100 children
from low-income families in the United
States of America (USA) revealed that
maternal unresponsiveness during in--
fancy predicted aggressive and disruptive
behaviour at age three.
17
A transactional
model was used to explain this, i.e. an
unresponsive parent provokes more in--
tense demands from the infant, creating
burdens for the parent and beginning
an aversive cycle that ultimately leads
to behavioural problems in the child.
is model may be particularly relevant
for malnourished infants, who are often
listless or unresponsive. Such behaviour
can frustrate the mother or lead her to
direct her time elsewhere, only amplify--
ing the problem.
4
It is important to note that in these
studies, maternal responsiveness often
exerted its effects via infant attachment,
the affective bond between the infant
and caregiver.
8
In general, responsive
caregiving resulted in secure attachment
(i.e. a warm and trusting relationship),
which led to social competence and
fewer behaviour problems.
18
Unpredict--
able or rejecting caregiving, however, led
to insecure attachment (i.e. an avoidant,
anxious or disoriented relationship),
which was associated with later prob--
lems.
19
We opine that responsiveness
largely influences child development,
with or without attachment.
Developing countries
While research from developing coun--
tries has not been as extensive as in
developed countries we found that the
effects of maternal responsiveness on
child development were relevant here
too. In rural Ethiopia, mothers’ verbal
responsiveness predicted concurrent
vocabulary development in their chil--
dren.
20
Similarly, in rural India, stimula--
tion by the mother was associated with
greater behavioural development and
intelligence in 196 malnourished three-
year-old children.
21
A study of a low-income Chilean
population revealed three types of ma--
ternal sensitivity(defined as the ability
to accurately perceive and promptly and
appropriately respond to the infant’s
signals) that correlated with nutrition,
attachment and mastery behaviour
(e.g. enthusiasm and persistence) of
children:
22
(1) mothers who overcame
hurdles to provide care that promoted
physical, cognitive and psychological
health; (2) mothers who provided physi--
cal and nutritional care, but neglected
the emotional response; and (3) mothers
who failed on all accounts. e first type
of mothers had more attached infants,
who were better nourished and more
competent than those of the less “sensi--
tive” (i.e., unresponsive) mothers.
Other health outcomes
Responsive caregiving leads to enhanced
survival and growth, as well as protects
from disease.
4
One of many health out--
comes associated with maternal respon--
siveness, besides cognitive and psychoso--
cial effects, was the protective effect of
responsiveness on the development of
low-birth-weight infants.
14
We found that in many developing
countries nutrition and maternal respon--
siveness were inextricably linked. In a
study from West Bengal, India, mothers
of the most undernourished boys (7–18
months old) had the lowest maternal re--
sponsiveness scores.
23
In Chile, mothers
of malnourished infants had low levels
of nonverbal responsiveness,
24
and in an
East African village, malnutrition was
described as a disorder of mother–child
attachment.
25
Conversely, studies of positive de--
viants”, or children who demonstrated
above-average health and development
despite impoverished environments,
showed that responsive childcare was
a crucial factor for their success.
26
For
example, a study of 260 children in
rural India demonstrated a significant
association between maternal respon--
siveness and positive deviance with
regard to motor, mental and overall
development.
27
Similarly, a study of 220
children in Mexico revealed that a less
restrictive mother–infant interaction
helped explain adequate nourishment
despite adverse conditions.
28
Interventions enhance maternal
responsiveness
While it is established that responsive
parenting benefits the child’s cognitive
and psychosocial development and pro--
tects from disease and mortality, two
questions remain (1) can this skill
be promoted; and (2) if so, then how?
Our review of childcare interventions
revealed that the skill can be promoted
and that current interventions are effec--
tive in enhancing responsiveness. We
993
Bulletin of the World Health Organization | December 2006, 84 (12)
Public Health Reviews
Responsive parenting: interventions and outcomes
Neir Eshel et al.
Table 1. Search strategy and number of articles identified for maternal responsiveness
Database Search terms Number of articles
deemed relevant
MedLine (PubMed) (Responsive OR Responsiveness OR Sensitivity) AND (“Parenting”[MeSH]
OR “Maternal Behavior”[MeSH] OR “Mother–Child Relations”[MeSH])
AND (“Child Development”[MeSH] OR “Longitudinal studies”[MeSH] OR
“Intervention Studies”[MeSH])
215
WHOLIS (WHO Library database) Words or phase: Child development OR attachment OR parenting AND
intervention
2
Cochrane Review Parenting OR mother–infant OR child development 3
World Bank Parenting OR maternal OR child development 7
LILACS (Latin American and Caribbean
Health Services)
Parenting OR child development 4
KoreaMed Parenting OR mother–infant OR attachment AND intervention 16
reviewed intervention strategies in the
context of responsiveness and present
combined results from both the devel--
oped and developing world (which has
not been attempted before) (Table 2)
to help provide a background for the
expansion of maternal responsiveness
enhancing interventions.
e World Health Organizations
manual for improving motherchild
interaction mentions that All adults
have the capacity to lovingly care for
their children, but a number of reasons
stop some from doing so: poverty, stress,
illness, or just lack of awareness of the
need for such care”.
29
e interventions
we reviewed attempted to tackle the lack
of awareness factor by using a number
of strategies, such as home visits, clinic
care, adult education, community proj-
-
ects, family therapy and mass media
education.
Developed countries
e most common interventions in--
cluded home visits and a combination
of home visits and clinic care. Home-
visiting programmes aimed to support
families in promoting a positive home
environment with the belief that infant
development occurs best at home. Ben--
efits of home visits, as opposed to other
strategies, included greater capacity for
follow-up care and the possibility to ex--
tend coverage to hard-to-reach families.
Within home-visiting programmes,
we found a great diversity in techniques
and outcomes. One of the more suc--
cessful trials
30
targeted 100 infants (six
months old) who were selected shortly
after birth for being irritable, and there--
fore at risk for developing insecure
attachment. e individually tailored
interventions three two-hour sessions
over three months — aimed to improve
maternal responsiveness. e study as--
sessed mother–infant interaction and
infant exploration before and after the
intervention, as well as attachment secu--
rity three months after the intervention.
e authors found that immediately
post-intervention, mothers were more
responsive and infants more sociable and
engaged in exploration. ree months
later, 62% of intervention infants were
classified as secure, compared to 28% of
control infants. e effect of interven--
tion on maternal responsiveness and
child cooperation persisted until the
third year.
31
We believe that this is strong
evidence for a causal relation between re--
sponsiveness and attachment, which was
not proved in the correlational studies
reviewed above.
10–28
e most emulated home-visit in--
tervention was conducted in semi-rural
upstate New York,
32
which tracked 400
mothers deemed needy (because they
were teenaged, unmarried, or from a
low socioeconomic background), and
provided them with weekly nurse-run
home visits from pregnancy through to
when their child was two years old. e
intervention focused on positive health-
related behaviours, competent childcare
and maternal development (e.g., family
planning, education). e randomly as--
signed control group received standard
clinic-based care. Immediately following
the intervention, intervention families
had decreased abuse and neglect and in--
creased more appropriate mother–infant
interaction.
32
At 3–4 years, intervention
children had 45% fewer behavioural
problems and lived in less hazardous
environments than control children.
33
When these children were 15 years old,
the intervention group had decreased
criminal and antisocial behaviour:
there were approximately 50% fewer
runaways and arrests, and less drug use
in the intervention group relative to the
controls.
34
We conclude that home visita--
tion programmes have the potential for
long-term benefits.
Most home-visiting interventions
benefit children and their families. e
analysis of 34 home-visit studies target--
ing at-risk infants showed consistently
improved home environments and par--
enting skills.
35
Similarly, a review of six
large home-visiting programmes in the
USA found a positive effect on parent--
ing attitudes and practices, particularly
for the neediest populations.
36
However,
the latter review cautioned that the
programmes struggled to enrol and re--
tain families and that the benefits were
modest, particularly for child health
and development. us, not all reports
in this field may have had obvious posi--
tive results.
To maximize the impact on families
developed countries generally combined
home visiting and clinic care to create a
comprehensive intervention. However,
given the amount of resources required
for such interventions, they have gener--
ally focused on at-risk populations, such
as low-birth-weight infants.
In a longitudinal study in Vermont,
seven in-hospital and four home teach--
ing sessions were held for mothers on
how to adapt to their low-birth-weight
infants, including how to act respon--
sively.
37
Nine years later, these children
showed better academic performance
and behaviour than low-birth-weight in--
fants who were randomly assigned not to
receive the intervention. At the follow-up,
intervention infants did not differ from
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Bulletin of the World Health Organization | December 2006, 84 (12)
Public Health Reviews
Responsive parenting: interventions and outcomes
Neir Eshel et al.
Table 2. Review of interventions enhancing maternal responsiveness in developed and developing countries
Study Study site Interventions Outcome measures Findings
Achenbach et al.,
1999
37
USA Three months of home and
hospital sessions to teach mothers
about caring for low-birth-weight
infants
Children’s cognitive develop-
-
ment, school performance and
behaviour
Better academic performance
and behaviour; prevention of
low-birth-weight associated
cognitive lags
Cooper et al.,
2002
42
South Africa Six months of home visits by
trained non-professionals to
encourage responsiveness
Maternal mood, mother–infant
relationship and infant growth
At six months, three times the
maternal sensitivity, six times
the maternal positive affect
and 20% greater infant growth
Gardner et al.,
2003
40
Jamaica Two months of home visits to
improve maternal–child interaction
Child cognition and behaviour Children were more
cooperative, happy, and better
at problem-solving
Grantham-McGregor
et al., 1991
44
;
Walker et al., 2000
45
and 2005
46
Jamaica Two years of food
supplementation, psychosocial
stimulation, both, or control
medical care
After intervention, child
cognition, perceptual/motor
skills and memory. At 11–12
years of age, child growth and
IQ
a
. At 17–18 years, cognitive
skills and school achievement.
Both interventions provided
small global benefits. At 11–12
years, stimulation led to half
standard deviation higher IQ.
At 17–18 years, stimulated
children had higher IQs and
were less likely to drop out of
school
Heinicke et al.,
1999
6
USA Two years of relationship-based
weekly home visits or clinic-based
paediatric follow-up
Mother–infant interaction;
mother’s perceived support;
infant behaviour and security;
maternal responsivenesss
Mothers were 20% more
responsive and infants were
three times more securely
attached
Olds et al., 1986
32
,
1994
33
and 1998
34
USA Nurse visits from pregnancy
through age two years, or control
care in clinic
At age two years, child
abuse and neglect, home
environment, and emergency
room visits. From two to
four years, child health and
development, maltreatment,
and living conditions. At
age 15 years, self-reports
of criminal and antisocial
behavior
At age two years, less abuse
and neglect, more appropriate
interactions, and fewer
emergency room visits. From
two to four years, 45% fewer
behavioral problems and less
hazardous environment. At
15 years, less drug use, more
than 50% fewer runaways and
arrests, and fewer sex partners
Super et al., 198
48
Colombia Three years of home visits for
psychosocial stimulation
Maternal responsiveness Increased responsiveness after
intervention
Super et al., 1990
49
Colombia Three years of food
supplementation, psychosocial
stimulation, both, or control
medical care
Physical growth At three years, intervention
group grew 2.6 cm and 642 g
more than control group. At
six years, growth was 1.7 cm
and 448 g increased. Overall,
children were 30% less stunted
van den Boom
1994
30
and 1995
31
Netherlands Three months of home visits to
enhance sensitive responsiveness
At nine, 12, and 36 months,
maternal responsiveness
and attentiveness, infant
sociability and exploration, and
attachment
At nine and 12 months,
positive results on all scales.
At age three, maternal
responsiveness and child
cooperation continued to be
improved
Waber et al., 1981
47
Colombia Three years of nutritional
supplementation and/or maternal
education
Child’s cognitive development Food supplementation led to
enhanced development
Walker et al., 2004
41
Jamaica Weekly home visits, at 0–8 weeks
and 7–24 months, focusing on
psychosocial interventions for low-
birth-weight infants
Overall child development Intervention eliminated
developmental delays and led
to better home environment
Wendland-Carro
et al., 1999
43
Brazil Shortly after delivery, video and
discussion about mother–infant
interaction (intervention) or
information on basic caregiving
(control)
Maternal sensitive
responsiveness and physical
contact
At one month, more vocal
exchanges and physical
contact; greater overall
responsiveness
a
IQ = Intelligence quotient.
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Public Health Reviews
Responsive parenting: interventions and outcomes
Neir Eshel et al.
normal-birth-weight children, whereas
control low-birth-weight infants per--
formed significantly worse. is study
showed that a short-term, early interven--
tion can prevent developmental delays
often associated with low-birth-weight.
In general, interventions that combine
clinic care and home visiting have been
found to reduce (by 0.5–0.75 standard
deviations) the decrease in intellectual
performance usually suffered by at-risk
infants.
38
Developing countries
It was difficult to find randomized con--
trolled trials on responsiveness in devel--
oping countries. However, the evidence
base is expanding with a growing agree--
ment that parenting interventions are
feasible for improving child health and
development.
39
In the studies we re--
viewed, interventions used home visits
and home visits in combination with
nutritional supplementation.
Home visits to provide support and
improve parenting was a well-established
intervention in several developing coun--
tries, especially Bolivia, Honduras, India,
Indonesia, Jamaica, Democratic Peoples
Republic of Korea, Mexico, Peru, South
Africa and Sri Lanka.
39
Unfortunately,
while there is a lack of published studies
tracking outcomes, a few well-designed
studies have provided good results.
A two-stage intervention carried out
on a cohort of 234 low-birth-weight
infants in Kingston, Jamaica showed
positive results.
40
e first stage (from
0 to 8 weeks) focused on improving
maternal responsiveness (e.g. mothers
were encouraged to talk to their babies
and respond to their cues) and had a
beneficial effect on child behaviour and
problem solving at seven months.
40
e
second stage (from 7 to 24 months)
attempted to enhance maternal–child
interactions, including demonstrations
of play techniques. After both stages,
children had improved home environ--
ments and development, eliminating the
delays expected among low-birth-weight
infants.
41
e costs of supplies and train--
ing were low enough for the intervention
to be feasible in the relatively resource-
poor Jamaican community.
In an indigent community in South
Africa, 32 control mother–infant dyads
were compared with 32 dyads who un-
-
derwent home visits by paraprofessionals
for the first six months of infant life.
42
e visits focused on encouraging ma--
ternal responsiveness. e study found
a large improvement in mother–infant
interaction and in the height and weight
of infants. We believe that although the
study was nonrandomized, it showed
that increasing maternal responsive--
ness/sensitivity affects physical growth
of infants.
e effects of these interventions
cannot be explained merely by the in--
creased attention to the mothers in the
intervention group. In Brazil, mothers
were provided with one of two interven--
tions shortly after delivery: a short video-
tape and discussion meant to enhance
mother–infant interaction, or a control
intervention focused on basic caregiving
skills.
43
Both the interventions were care--
fully controlled to give the same amount
of attention to all mothers. Follow-up at
one month showed that the intervention
group was more responsive to and engaged
in more physical contact with their infants
an important result for a very low-cost
intervention. us we hypothesize that the
specificity of the intervention i.e., its
focus on responsiveness is an important
factor in its success.
To maximize outcomes and address
immediate community needs, many
interventions combined responsiveness
training with nutritional supplementa--
tion. A sample of stunted children (9–24
months old) from Jamaica received nu--
tritional supplementation, psychosocial
stimulation, both types of interventions,
or neither type, in two years of weekly
home visits.
44
Children who received
either type of intervention showed
improved mental and motor develop--
ment, while those who received both
interventions resembled non-stunted
children. ese benefits persisted until
the age of 12, when children who had
received the combined interventions had
half a standard deviation greater IQs
than those who had not.
45
At age 17,
children who had received stimulation
demonstrated greater cognitive func--
tion and were less likely to drop out of
school than stunted children who had
not received any intervention.
46
A comparable study was completed
in Bogota, Colombia, in the 1980s, in
which 280 children at risk for malnu--
trition were provided with either food
supplementation, home visits, both, or
routine medical follow-up.
47,48
e twice-
weekly home visits included educating
mothers about parenting. Immediately
after applying the intervention(s), sup--
plementation increased the cognitive
ability of children,
47
stimulation (home
visits) increased maternal responsive-
-
ness,
48
while the combined intervention
showed no added benefit. At six years,
children who received the combined
intervention were significantly taller
than the other groups, and the most
malnourished children were most likely
to benefit.
49
We hypothesize that though these
studies did not focus exclusively on re-
-
sponsiveness, they provide strong evidence
that parenting education can benefit chil--
dren beyond that from mere nutritional
supplementation, and that care practices
are crucial for optimal physical growth and
psychosocial development.
Discussion
To our knowledge, this is the first such
review that integrates maternal respon--
siveness studies from both developed
and developing countries and defines
responsiveness, discusses its effects on
child health and development as well
as the success of interventions meant
to enhance it. We conclude that: (1) re--
sponsiveness is a basic, but vital, parent--
ing tool, denoting prompt, contingent
and appropriate interactions between
the mother and child; (2) responsive
parenting has wide-ranging benefits for
the child, from psychosocial develop--
ment to improved health and physical
growth; and (3) interventions in both
developed and developing countries
have been modestly effective in enhanc--
ing maternal responsiveness, leading to
better child health and development,
especially for at-risk children.
One of the limitations of our review
was that articles were restricted to the
English language, limiting research from
developing countries. Our preliminary
search of non-English databases, how--
ever, revealed few relevant articles. More
research needs to be done in developing
countries before a polylingual analysis
is warranted. Some of the studies we
reviewed included interventions not
directly related to responsiveness (e.g.
nutritional supplementation). Although
most studies included responsiveness-
only conditions
44
or an attentional
placebo,
43
the occasional lack of proper
controls made it difficult to analyse the
singular effect of responsiveness training.
In the studies we reviewed the influ--
ence of responsiveness on child health
outcomes was not always clear”.
4
It is
possible that children destined for bet--
ter outcomes induced better maternal
responsiveness, while children destined for
996
Bulletin of the World Health Organization | December 2006, 84 (12)
Public Health Reviews
Responsive parenting: interventions and outcomes
Neir Eshel et al.
Résumé
Sensibiliser davantage les parents ou les personnes qui s’occupent d’enfants aux besoins des enfants
qu’ils élèvent : interventions et résultats
Outre une alimentation adaptée, une bonne hygiène et un accès
à des établissements de santé, les enfants ont besoin, pour que
leurs chances de survie et leur développement soient optimaux,
de recevoir des soins appropriés dans leur foyer. La réactivité,
c’est-à-dire la capacité à réagir rapidement et de manière adaptée
aux interactions avec l’enfant, est une composante essentielle
de la sensibilité aux besoins infantiles, qui apporte une grande
variété de bénéfices, allant d’un meilleur développement cognitif
et psychosocial à un renforcement de la protection contre les
maladies et la mort. A travers une revue sysmatique de la
littérature provenant de pays développés et en développement,
nous avons examiné deux aspects de la sensibilité des parents
aux besoins de l’enfant : son rôle dans l’état de santé et le
développement de l’enfant et l’efficacité des interventions visant
à la renforcer. Les sultats de cette étude indiquent que ces
interventions parviennent à augmenter la réactivité maternelle,
d’où une amélioration de l’état de santé et du développement
des enfants, notamment parmi les populations dont les besoins
sont les plus criants. Ces interventions étant praticables même
dans les pays pauvres, elles présentent un important potentiel de
contribution à la réalisation des Objectifs du Millénaire pour le
développement. Nous proposons d’intégrer les interventions de
sensibilisation aux besoins infantiles dans les stratégies en faveur
de la survie des enfants.
stunted development rejected attempts
at responsiveness. In other words, respon--
siveness may be a symptom rather than
a cause. Similarly, it was possible that
inherited personality traits confounded
the results of the various studies, in that
responsive mothers were more likely
to give birth to well adjusted children.
Evidence from the interventions we
reviewed, however, contradicted these
claims. In controlled trials, those moth--
ers who were randomly assigned to
responsiveness training had children
with better health and development.
is suggests that responsiveness is a
causative factor in enhancing a child’s
wellbeing.
We believe that as more research is
completed, it will become increasingly
practical and efficacious to advocate re--
sponsiveness in developing countries.
One important advance would be to
develop a package of resources to pro--
vide guidance on promoting responsive
parenting through public health venues.
Such a package would include training
materials for health workers and fami--
lies, planning guidelines and materials
to monitor and assess the programmes,
among other resources. With collabora--
tion from country-based groups, this
package would be invaluable in optimiz--
ing child heath policies.
Conclusions
We conclude that there is a strong link
between childcare, development and
health, with more responsive caregiv-
-
ing associated with better outcomes.
For more than three decades, experts
in developed and developing countries
have designed interventions to increase
responsiveness of mothers to their in-
-
fants, hoping that these would improve
health and development of children.
ese interventions have shown consis--
tent, if modest benefits, both in boost--
ing responsiveness and in promoting
health and development.
35
In developed
countries, the interventions seemed most
effective when targeted at needy popula--
tions and focused on specific behavioural
change.
50
In developing countries, they
have been successfully integrated into
routine care or other types of interven--
tions. Moreover, experiences in these
settings have shown that not only are
responsiveness-focused interventions
feasible, but that their benefits extend to
other areas, including physical growth.
Since the research sample was small,
however, more support must be provided
to expand current research efforts, such
as in Jamaica
46
and South Africa.
42
We
argue that while more research needs to
be done to maximize success, current
interventions are capable of boosting
responsiveness and promoting child
health and development.
To achieve a two-third reduction
in child mortality, as expressed in Mil--
lennium Development Goal 4, children
would need to receive adequate care at
home in addition to health facilities. We
believe that with sufficient knowledge
and support, mothers could become
more responsive to their infants, begin--
ning a positive cycle of rewarding inter--
actions that ultimately leads to improved
outcomes for the child, and thus for
society. We suggest that responsiveness
interventions be integrated into child
survival strategies to increase our chances
to meet the Millennium Development
Goal. O
Acknowledgements
We thank Professor Gretel Pelto for pro--
viding insightful comments during the
preparation of this manuscript.
Competing interests: none declared.
997
Bulletin of the World Health Organization | December 2006, 84 (12)
Public Health Reviews
Responsive parenting: interventions and outcomes
Neir Eshel et al.
Resumen
Ejercicio responsivo de la parentalidad: intervenciones y resultados
Además de alimentos, una buena higiene y acceso a los centros
de salud, los niños han de disfrutar de una atención adecuada en
el hogar si se desea garantizar su supervivencia y un desarrollo
óptimo. La capacidad de respuesta, esto es, una reacción rápida,
flexible y solícita de la madre o el cuidador a las necesidades del
niño, constituye un medio de parentalidad vital que redunda en
beneficio del niño por varios motivos, desde un mejor desarrollo
cognitivo y psicosocial hasta la protección frente a enfermedades y
a la muerte. Realizamos una revisión sistemática de publicaciones
de países tanto desarrollados como en desarrollo para examinar
dos aspectos de la parentalidad responsiva: su función en la
salud y el desarrollo del niño, y la eficacia de las intervenciones
tendentes a mejorarla. Nuestros resultados muestran que las
intervenciones mejoran eficazmente la responsividad materna,
en beneficio de la salud y el desarrollo del niño, especialmente en
las poblaciones más necesitadas. Dado que esas intervenciones
fueron viables incluso en entornos pobres, podrían ser de gran
ayuda para alcanzar los Objetivos de Desarrollo del Milenio.
Proponemos por tanto que las intervenciones de aumento de la
capacidad de respuesta se integren en las estrategias de mejora
de la supervivencia infantil.

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... Caregiver responsiveness supports healthy development during infancy (Eshel et al., 2006). During responsive caregiver-infant interactions, caregivers recognize and contingently respond to infants' cues in predictable, developmentally appropriate ways that support behavioral regulation, socioemotional and cognitive growth, and autonomy. ...
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Introduction Parents' sensitivity and responsiveness to their infants may be affected by the widespread availability and use of mobile devices. The present study examined the impact of maternal digital media use on maternal attention and the quality of mother-infant interaction during breastfeeding. Methods Mothers and infants ( n = 25 dyads) participated in a within-subject experiment. Mothers breastfed their infants under one experimental and one control condition, counterbalanced across two laboratory visits. During the Digital Media condition, mothers watched a television show on a tablet. During the Control condition, mothers listened to classical music at ambient levels. Video records were later coded to assess maternal attention to the infant, tablet, or elsewhere and evaluate the quality of mother-infant interaction. Results There were more disruptions in maternal attention to the infant during the Digital Media ( M = 3.7, S.E . = 0.2 per minute) vs. Control condition ( M = 1.7, S.E . = 0.2 per minute, p < 0.001). The proportion of the meal duration mothers spent focused on their infant was significantly lower during the Digital Media ( M = 52.5%, S.E . = 3.9) vs. Control condition ( M = 83.9%, S.E . = 4.0%, p < 0.001). Lower maternal attention to the infant was associated with lower maternal sensitivity to cues ( p = 0.03) and cognitive growth fostering ( p = 0.002), as well as lower infant clarity of cues ( p = 0.001). Lower maternal attention was also associated with less socioemotional growth fostering ( p < 0.001) and lower infant responsiveness to the mother ( p < 0.001) regardless of whether digital media was present or absent, but during the Digital Media condition, mothers engaged in more socioemotional growth fostering ( p = 0.004) and infants were more responsive to mothers ( p = 0.03). Discussion The presence of digital media during infant feeding led to more interruptions to mothers' attention to their infants and the time mothers spent focused on digital media displaced time spent focused on their infants. The degree to which mothers were attentive to their infants vs. digital media was a more important predictor of most aspects of interaction quality than the mere presence of digital media.
... Children living in supportive family environments may be better equipped to handle life's challenges (Butler et al., 2022; Thompson et al., 2007); having supportive parents when facing di cult situations can help children cope with stress throughout their lives and be more resilient (Frosch et al., 2021). In 2006, the World Health Organization conducted a study in various countries, including India, Colombia, the United States, Chile, Mexico, Jamaica, Brazil, South Africa and the Netherlands (Eshel et al., 2006). The study found that maternal responsiveness is linked with positive child development; children who receive responsive care at age 12 tend to have higher IQs and self-esteem and fewer behavioural and emotional problems. ...
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... Certains facteurs peuvent impacter ce développement chez les jeunes, tels que des facteurs génétiques, individuels, environnementaux ou bien éducatifs (Fiorilli et al., 2019 ;Morin et al., 2017 ;Patterson et al., 2018 ;Roskam et al., 2007 ;Rothenberg et al., 2021 (Jeon et Neppl, 2019 ;Lee, 2023 ;Neppl et al., 2015 (Eshel et al., 2006 ;Whittle et al., 2013 (Batanova et Loukas, 2013 ;Bullock et al., 2018 ;Zhao et al., 2023). Parmi Les recherches montrent que des pratiques hostiles impactent davantage l'émergence de comportements externalisés qu'internalisés chez les jeunes (Han et Kim, 2022 ;Khoury et al., 2021 ;Yoo et Ahn, 2023). ...
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... In the South Asian context, evidence comes from rural Pakistan (Obradović et al., 2016;Rasheed & Yousafzai, 2015) and rural Bangladesh (Aboud & Akhter, 2011), is focused on children 0-2 years of age, and assesses responsive interactions observationally. Responsive caregiving has also been found to be associated with several other child outcomes, such as increased mouthfuls of food eaten (Aboud & Akhter, 2011), improved breastfeeding duration (Ventura, 2017), and reduced emergency room visits (Eshel et al., 2006). As a result, responsive caregiving was integrated into the Nurturing Care Framework, a global policy roadmap developed by the World Health Organization, the United Nations Children's Fund, and the World Bank in 2018, and is widely considered a key input that countries should invest in to facilitate healthy early child development (ECD) (WHO, UNICEF & the World Bank, 2018). ...
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This systematic review aimed to examine whether parental insightfulness is associated with parental sensitivity, parent and child mental health, and attachment in autistic children. Eligible articles used a quantitative research design and included participants who were parents or caregivers of a child diagnosed with autism and who completed a measure of parental insightfulness. Eight papers (six studies) met inclusion criteria. Parental insightfulness was associated with higher parental sensitivity and attachment security. No studies investigated associations between parental insightfulness and parent mental health. Although research is limited, parental insightfulness appears to be associated with parental sensitivity and child attachment in families of autistic children. More research is required to confirm whether these relationships exist cross-culturally, and with different caregivers.
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Short-term Effects of Early InterventionA Developmental Framework for Early InterventionThe Early Intervention SystemLong-term Effectiveness of Early InterventionSummary and Conclusions