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Emotional Stimulation for acutely and severely malnourished children in SNNPR

By Dr. Alessandro Conticini and Mrs. Valérie Quéré

Dr. Alessandro Conticini joined Play Therapy Africa as Co-Director after having headed the Child Protection, Adolescent Development and HIV Programme at UNICEF Ethiopia, and previously senior researcher for the Macroeconomics and Health Commission in WHO Head Quarter. His work includes directing research, programme formulation and evidence-based policy development for vulnerable children in developing countries.

Mrs. Valérie Quéré is a human rights lawyer and child psychotherapist, with a master degree in international human rights and a number of certifications as a PSS therapist. Mrs. Quéré has been working in the area of justice and gender based violence in several countries. Valérie directs training programmes for law enforcement agents, social workers and child psychotherapists.

PTA would like to thank the Pulitzer Foundation, Ceil, Michael and Christina, for their tireless and enthusiastic support. Our gratitude also to UNICEF for their facilitation and aid.

Research has shown that the survival rate of malnourished children during food crises critically depends not just on the availability of appropriate therapeutic food, but also on the emotional and physical stimulations available for both the child and the caregiver (usually the mother). Studies have shown that the combined use of emergency nutrition support and emotional stimulation techniques provides for lower malnutrition rates, a higher rate of child survival, and quicker recovery from malnutrition1. Hunger and food insecurity cause serious mental or cognitive disabilities, especially in young children due to chronic nutritional deficits, lack of social/emotional stimulation, parent-child emotional detachment, withdrawal and neglect. At the same time, parent-child emotional deficiencies cause reduced food intake and significantly diminish the overall survival rate of children2.

In many emergencies, hunger and food insecurity cause severe stress and damage the psychosocial well-being of the affected population. Conversely, the psychosocial effects of an emergency can impair food security and nutritional status. The latter is particularly relevant for children and their caretakers.

During the 2008/2009 and 2009/2010 food crisis in Ethiopia, with support from the Pulitzer Foundation and collaboration with UNICEF, Play Therapy Africa (PTA) took a leadership role in the management of 49 outreach therapeutic sites (that include but go beyond OTP sites) and one hospital in the Southern Nations (SNNPR). This role involved the introduction of an approach whereby emotional stimulation and good parenting skills were promoted, in addition to emergency therapeutic food distribution for severe acute malnourished (SAM) children.


The intervention sites were selected by the Regional Bureau of Health on the basis of the expected severity of food shortage in the monitored districts. The project and its initial methodology were presented to members of all NGOs working with malnourished children in SNNPR. These professionals had an opportunity to express their views and concerns regarding the intervention during a joint review meeting held in Awassa town. Federal and Regional authorities (DPPA and DPPB) were also present and explained the project and its proposed methodology to allow for consistency with mainstream government led programmes. The University of Awassa reviewed the intervention in order to grant ethical approval.

One Health Extension Worker (HEW) and one youth/community volunteer were selected by the Bureau of Health and the Bureau of Youth respectively in each intervention site. PTA then provided a series of practical training that allowed for basic techniques of emotional stimulation and good parenting skills to be acquired by trained professionals. Professionals from NGOs working on the sites were also trained. The training was practical and experiential, meaning that the participants were constantly relating the newly acquired techniques to the ways they themselves had been raised, and the ways they were raising their own children. This allowed for the trained professionals to use the approach in their own domestic life before adopting it as a modus operandum in their work place.

At the end of the training, professionals were requested gradually to introduce the techniques as an additional experimental component of the existing protocol for the management of SAM children. Clinical supervisors were also deployed by PTA to ensure the quality of services provided. Mothers that had one or more children enrolled in Therapeutic Feeding Units (TFU), or Outpatient Therapeutic Programmes (OTP), also received coaching to strengthen the emotional bond with their child and to stimulate him/her physically and emotionally. The intervention was based on coaching, not teaching, so that HEW and Youth had to organise weekly practice groups among mothers and their children, or organise door to door visits for enrolled mothers to practice with them. The coaching would last for a three months period. In the selected hospital, the coaching took place daily with inpatient children. Mothers were then requested to practice the new skills daily with their children.

In 20 sites, professionals were trained to measure systematically the physical and emotional outcomes of the intervention. The same measurements were conducted for a control group in three sites where SAM was managed but this psycho-social intervention was not being implemented. A total of 555 children under 5 years were followed for the purpose of the study, 49.9% were girls. Nearly one-third (32%) of admitted children were between 12 to 23 months of age, while the remaining where equally distributed in the age range of 0-12 months, 24-35months, 36-47 months, and 48-60 months.


The programme has resulted in the following documented achievements:

Increased Speed of Recovery

Overall, 31.2% of children who received a combination of therapeutic food and emotional stimulation were discharged from TFU and OTP at the end of the fourth treatment week. A cumulative total of 40.7% were discharged at the end of the fifth treatment week. In contrast, no child was discharged before the end of the sixth week in the control group of children who only received therapeutic food.

Children who were provided with a combination of emotional stimulation and therapeutic feeding tended to gain weight at a faster rate than children who were only provided with therapeutic feeding. This has direct implications in terms of the costs of SAM management.

Prevention of emotional, development and intellectual loss/damage

Malnourished children in the intervention group demonstrated equivalent cognitive, emotional and development capacities as children coming from the same socio-economic environment who had not been severely malnourished. In contrast, malnourished children in control groups demonstrated a severe loss of cognitive, emotional and development potential. These data were collected using internationally recognized assessment tools such as the ASQ3, as well as qualitative emotional development observations.

Increased resilience from being exposed to future severe and acute malnutrition

Initial qualitative data indicate that treated children and caregivers may be less likely to relapse into acute and severe forms of malnutrition caused by non-food availability factors. However, this initial finding will need additional investigation before firm conclusions can be drawn.

Cross-fertilisation effect

Mothers who learnt and practiced emotional stimulation with their malnourished child started to apply the same techniques with the other children in the household and gradually sensitized and explained the purpose and benefits of the intervention to their husbands and relatives.

Increased empowerment of women and gender balance in community and family decision making

An initial qualitative assessment4 has suggested that the effects of emotional stimulation through filial play coaching have positively impacted not just the level of maternal and child depression, but also provided for women's empowerment within the family and communities for positive decision making. Most of the mothers who participated in the emotional stimulation intervention reported that they felt much closer to their children, and were much more likely than control-group mothers to say that their children had become more independent and playful since recovering from SAM. Many mothers also attributed other changes in family life to the programme, including increases in paternal involvement in child care, the cessation of harsh punishment by one or both parents, and reductions in domestic violence. None of the control mothers whose children received food alone through the OTP programme reported such changes.

Interviewed mothers also reported a progressive positive involvement of neighbours by imitation. Not all women reported equally powerful effects. Factors such as severe illness in the child or parent and extreme poverty tended to mitigate the effects of emotional coaching. However, even many of the very poor mothers attributed remarkable changes in outlook and family communication to the emotional stimulation intervention. This suggests another way of looking at the link between women's empowerment and child survival, which has been traditionally explained by women's agency in health seeking. We suggest the reverse may also be true; programmes to improve care-giving may directly contribute to women's empowerment, and contribute to the promotion of a virtuous cycle to help rescue malnourished children in vulnerable communities.

While further investigation is needed, the preliminary results suggest that a combination of emergency therapeutic food relief for children coupled with emotional stimulation has a leveraging effect, not just on the short term survival and physical and emotional outcomes for children, but also on the prevention of long term consequences5. It also suggests that the introduction of emotional stimulation techniques through a coaching approach leads to a gradual shift in the ways children are cared for within the community, increasing the probability of a less violent and more nurturing environment. Mothers were found to continue practising emotional stimulation and good parenting skills principles well beyond the official ending of the programme, suggesting some form of sustainability. Finally, the increased speed of recovery by emotionally stimulated children, and the reported low proportion of relapse among them seem to suggest that the proposed intervention could contribute to reducing the overall intervention costs of severe acute malnutrition.

For more information, contact: Alessandro Conticini, email:

The full report, Emotional Stimulation in the Context of Emergency Food Interventions Final Report Addis Ababa - August 2009, is available at: and search Resources

Show footnotes

1Supplementing nutrition in the early years: the role of early childhood stimulation to maximize nutritional inputs. Child and Youth Development 2009. The World Bank, Volume 3, N.1.

2Sally Grantham-McGregor et al. Developmental potential in the first 5 years for children in developing countries. The Lancet 2007. Volume 369, Issue 9555, Pages 60 - 70.

3Ages and Stages Questionnaire (ASQ).

4H. Epstein and A. Conticini. "Each child comes with his own luck"? A psychosocial intervention for malnourished children strengthens parental and spousal bonds in Ethiopia. Manuscript submitted for review, 2010.

5See also S. Grantham-McGregor et al. Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study. Lancet 1991;338(8758):1-5.

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Dr. Alessandro Conticini and Mrs. Valérie Quéré (). Emotional Stimulation for acutely and severely malnourished children in SNNPR. Field Exchange 40, February 2011. p84.



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