Play in Childhood Has Long-Term Benefits for Stunted Children

KINGSTON, Jamaica, July 31 -- For growth-retarded children, an excess of play, talk, and toys can help avoid psychosocial hurdles in adolescence, according to a 16-year follow-up study.

Growth retardation, which affects 30% of children younger than five globally, is associated with poor development and behavioral problems in late adolescence, reported Susan Walker, Ph.D., of the University of the West Indies here and colleagues, in an online report in the August BMJ.

In an original study in 1986-1987, the researchers identified 129 stunted children (ages nine months to 24 months) living in poor neighborhoods here. The children were assigned to one of four groups: control (no intervention), supplementation with 1 kg milk-based formula each week, play stimulation, or both for two years,

Stimulation focused on enhancing interactions between mother and child, she said. The mothers were taught play techniques by trained community health workers and were encouraged to talk to their child and use positive reinforcement rather than physical punishment. Home-made toys and simple picture books were left with the families, and mothers were encouraged to play with their children and to incorporate play activities into daily routines.

In the investigators' 16-year follow-up, primary analysis indicated that participants (now ages 17 to 18) who received stimulation in childhood had significantly improved overall scores compared with those who did not receive the intervention (P=0.049).

However, small benefits from milk-based supplementation seen at seven years disappeared by 11 years and finally had no significant effect (P=0.17). Hunger, the investigators added, was not a significant factor.

Participants given stimulation therapy reported less anxiety (mean difference -2.81, 95% confidence interval - 5.02 to - 0.61), less depression (mean difference - 0.43, CI, - 0.78 to - 0.07), and higher self-esteem (mean difference 1.55, CI, 0.08 to 3.02). Parents reported fewer attention problems (mean difference - 3.34, CI - 6.48 to - 0.19).

However, using a more stringent level of significance (P<0.01), because of the multiple comparisons, only the reported difference in anxiety was statistically significant, the investigators said.

Nevertheless, Dr. Walker noted that although the scores for anxiety, depression, and self-esteem were not large at an individual level, at a population level, these changes could have an important role in reducing emotional disorders.

Stimulation did not affect contact with the police, sexual behavior, or use of alcohol, cigarettes, and marijuana.

However, it did improve antisocial behavior. Compared with the no-stimulation participants, the stimulation teenagers were less likely to have been suspended from school (stimulation 31.3%; no stimulation 47.3%; P=0.01) or to have been expelled although the latter did not reach statistical significance (stimulation 2.1%; no stimulation 10.9%; P=0.08).

Much attention has been paid to poor cognition and school achievement in undernourished children, the researchers said, but changes in their psychosocial functioning may be just as important to their quality of life.

"Stimulation in early childhood produced sustained improvements in the psychosocial functioning of stunted children. The next challenge is to develop interventions that can meet the needs of the enormous number of stunted children," they said.