Understanding and Supporting Childhood Stimulation

Photo Credit: Free from Stock Snap user Cristian Newman

The First Peoples Child & Family Review (vol11/no1/2016) has recently published a report of a study, conducted as a joint project between the Ingram School of Nursing of McGill University and the Kitiganik Health Centre, on Odeminiwin:  Understanding and Supporting Childhood Stimulation in an Algonquin Community.  The study is based on research undertaken in the Algonquin community of Rapid Lake in rural Québec.

The aim of the study was “to explore parenting practices and cultural traditions regarding childhood stimulation in this community as well as primary caregivers’ perceptions of the use of the ASQ”.  The ASQ is the Ages and Stages Questionnaire carried out by the maternal-child nurse in the community as a regular screening for developmental delay in children aged 0-66 months.

The authors note, “Stimulating relationships are fundamental to healthy development in infancy and early childhood (Shonkoff & Phillips, 2000)…. Where stimulation is not sufficient in early childhood, development may be delayed resulting in long-term health effects.  Regular assessments using screening tools to identify developmental delays through infancy and childhood, as well as early interventions such as stimulation activities to correct these delays are the ‘gold standard’ across Canada (Williams & Clinton, 2011).  Despite this standard, there is a lack of understanding regarding how different cultural groups perceive the implementation of these evaluation tools and activities within their communities.”

The study points out that Aboriginal communities in Canada have both protective factors against, and risk factors for, childhood developmental delay.  “Cultural continuity is one protective factor important to Aboriginal conceptions of health, contributing to wellbeing, self-identity and self-esteem.”  Community programs that support young families, and facilitate the transmission of traditional language, values, beliefs and customs, are cited as a valuable means of promoting cultural continuity.

However, risk factors are also higher than average in Aboriginal communities.  “A national survey by Health Canada of First Nations communities between 2008 and 2010 reported the three top challenges to community wellness were identified as alcohol and drug abuse (82.6% of respondents), housing (70.7%) and employment (65.9%) (Health Canada, 2011).”

Of all the available standardized tools in common use, ASQ has been identified by the First Nations and Inuit Health Branch of Health Canada as a culturally-appropriate tool for use in First Nations communities since it “can be readily adapted to…many different populations, including First Nations” (Dionne, McKinnon & Squires, 2010; Dion-Stout & Jodoin, 2006).  The authors of the study point out that, despite these recommendations, there is lack of clarity on what adaptations would be required to make ASQ “culturally appropriate” or whether adapting the tool would impact the validity of its results (Dionne et al, 2014).

The authors note the important contributions of Aboriginal Head Start (AHS) in promoting child health and development.  However, “a recent study involving children of Aboriginal heritage suggests that preschool age is not early enough for the introduction of developmental activities” (Benzies et al, 2011) and the authors note, “The use of development assessment tools can fill an important gap prior to the enrollment of a child in Aboriginal Head Start, where more formalized services are lacking”.

The community selected for the study, Rapid Lake, is a semi-isolated community in rural Québec.  The authors point out, “Due to the physical isolation of this community and lack of employment opportunities, the rate of unemployment is estimated at 80-90%, dependent on the season.  Most community members receive monthly social assistance and live in low quality housing in crowded conditions (Lang et al, 2010).  Conflict has impacted this community both internally, through leadership crises, and externally with disputes between the provincial and federal governments over political and financial matters.  The effects of colonization and assimilation are still evident in this community today, including the legacy of the reservation system, the Indian Act of 1876, and residential schools (Lepage, 2009; Royal Commission on Aboriginal Peoples, 1996).”

The authors also note, however, that “despite this colonial history, the Rapid Lake community remains resilient through the preservation of their culture.  Many Rapid Lake families continue to live a traditional lifestyle practicing cultural activities such as beading, sewing, hunting, fishing and trapping.  Community members are also active in efforts to maintain control over their land and local governance, and many speak Algonquin and teach this to their children as a primary language (Sherman et al, 2011).”

The study was prompted by one of the advanced practice nurses in the community who is the maternal-child nurse, with specific training in obstetrics and pediatrics, and who follows the care of women throughout pregnancy, delivery and the school-aged years of their child’s life.  She felt a resistance from caregivers, who often reported losing activity sheets given to them or simply not completing the suggested activities at home.  She wanted to better understand how community members felt about the ASQ.

The three objectives of the study were:

1. To gain an understanding of parenting practices and cultural traditions regarding childhood stimulation in the community.
2. To gain an understanding of how the use of ASQ and activities were perceived by primary caregivers in the community.
3. To work with caregivers to develop a locally adapted child stimulation activity.

The project was divided into four phases of data collection:

• Key informant interviews
• A focus group
• A pilot activity
• A community presentation of the results

In order to be eligible for participation in the project, participants had to be self-identified community members, 18 years or older, able to communicate in English, French or Algonquin (via an interpreter) and willing to provide written or verbal consent.

The five broad themes that emerged from the study analysis were:

1. Historical trauma: “Something is broken”. When asked about traditional parenting practices, both Aboriginal and non-Aboriginal participants struggled to provide examples.  Other community participants supported this statement, explaining that they were not sure why they did not know examples of parenting traditions.  The health care workers observe many parents are not confident in parenting.  When asked about the greatest challenge parents face in the community, one mother, having stated, “Drugs and alcohol”, explained, “If the mother stops, the husband doesn’t stop; if the husband stops, the mother doesn’t stop…they both go on the same road…to ‘misery land’…and the kid doesn’t have nothing after.”  The authors note, “Parenting within the frame of historical trauma and the realities of addiction, poverty and violence means that many parents don’t have the physical or emotional reserves beyond their family’s basic needs to devote to parenting”.  A community member stated, “Raising a child is hard when you feel good.  Imagine when you feel bad.”  The study finding was that childhood stimulation through play and activities is therefore not a priority under these circumstances.
2. Stimulation through participation. The study found, “While many parents struggle with these challenges, childhood development is still a concept primary caregivers are aware of and assess as their children grow.”  However, “in contrast, childhood stimulation is not as familiar”. A grandmother explained that, in the Algonquin tradition, stimulation would take place passively where children participate in household routines with their families, mimic caregivers and play alone or with siblings and other children, particularly through outdoor play, learning how to fish, skate and play seasonal sports.  The study finding, therefore, was that parent-child activities explicitly targeting stimulation were not a common practice in the community.
3. “The land takes care of the kids”. The study notes, “Spending time in the bush is an important part of life for many community members.  Participants explained that time spent on their traditional land allows them to take part in cultural traditions such as hunting, trapping and fishing.  Traditional parenting practices are more evident in the bush, they said, and parents are more involved in the stimulation of their young children there.”  Being in the bush imposes regular routines for children, including going to bed early, waking up early, and playing in the yard between mealtimes, and there is increased tactile, visual and language stimulation between parent and child as children participate with their parents in hunting.  “Community members explained that time spent in the bush is also important for adults, as the bush is a much healthier environment than their community, supporting a healthier and more active lifestyle.”
4. ASQ:a tool or a test? The ASQ was described as a negative intervention by many primary caregivers, as the assessment and scoring process made them feel judged.  The study notes, “As a result, the activity sheet that accompanies the ASQ is seen as a treatment and only when something is wrong do parents seek help to promote development….An educational professional described that it was difficult to broach the topic of developmental delay without offending parents as many associate it with drug and alcohol use during pregnancy.  Thus the judgment felt during scoring and the social stigma make it difficult to discuss the topic of childhood development.”
5. Fostering community support. When asked what they thought a useful stimulation activity could look like, a group activity, such as a playgroup, was the most common suggestion, to make learning more fun and interesting, and to offer peer support in the learning process.  “In addition to a group activity, participants agreed on the need for a reformatted activity sheet by reducing the writing to only five or six words per activity, including only simple activities parents would be comfortable doing at home, and adding pictures and colours.  All participants agreed that some of the activities already included were a good fit, such as stacking household items, scribbling, and container games such as placing socks in a basket, and that some were already doing these activities at home.  One mother explained that it was important to continue to use the activity sheet because it acts as an ‘extra push’ to ‘involve parents more in their kids’ lives.”

The outcome of the study was a community decision to establish an Odeminiwin, meaning playgroup in Algonquin, focusing on the youngest children in the community, to promote stimulation from an early age.  The playgroup was established using the Aboriginal Infant Development Policy and Procedure Manual written by the British Columbia Infant Development Program, along with participant input.  Daycare and AHS workers and several mothers and elders were invited to help organize and provide suggestions in order to promote community ownership over the playgroup.

The Odeminiwin focused on activities for children below 12 months old; families with children in this demographic were invited to attend and to bring any siblings or family members, in recognition of the role the extended family plays in stimulation.  It included games selected by participants from the ASQ activity sheet.  Food was provided at the end of the activity to promote discussion amongst the adults while the children continued to play.  A more colourful, reformatted ASQ activity sheet with less writing, and including only five activities (one from each area of development) was given to participants.