Early Childhood Care and Development (ECCD) programs across the world majorly focus on nutrition and early stimulation along with other health interventions such as immunization, hygiene, educational and support measures for caregivers to ensure consistent care and support for children. Even though ECCD programs work with multiple departments, they have limited colla-boration with child mental health and child protection systems [27].

While there are child protection programs around the world, those working specifically in the context of early childhood, are relatively limited. For those that do work in the area of early childhood, there are very few that integrate ECCD issues with child protection. Examples of integrated programming include UNICEF’s programme guidance for early childhood development [28] and Plan International’s development of program models and tools to integrate child protection into ECCD, as reflected in their exploratory studies in Uganda, Bolivia and Timor-Leste [29]. Save the Children, has also attempted, in few of their programs, to integrate child protection into ECCD but while they focus on orphans and vulnerable children, they do not have a mental health component [30].

There are examples of child violence prevention programs, which have been successfully implemented both in developed and developing countries [29,31-35], through parents, nurses or community health worker in the primary health care system. These have focused, and legitimately so, mostly on positive parenting, monitoring for prevention child maltreatment (through home visits by community health care workers), mother–child therapy interventions, provision of primary health care services and safe spaces for children to grow and play. However, these programs have worked largely in family settings–an approach that India could draw upon but that would not be entirely applicable to its context, because the socio-economic situation of many vulnerable children often does not allow for family members to be present for the child. Therein lies the importance, in the Indian context, of the role of the ECCD workers and the need to integrate child protection into the government preschool system.

The key objectives of ECCD and child protection programs are to ensure age-appropriate development, early stimulation and primary prevention. The World Health Organization’s Nurturing care framework also recommends providing for the children’s physical and emotional needs, protection from harm along with learning and development opportunities as its central tenet [36]. Given that ECCD programs qualify as a universal intervention, their coverage tends to be wide, and ECCD workers and educators are ideally placed to implement protection strategies to assist children at risk of abuse and neglect [37]. Thus, ECCD programs may serve as effective vehicles to protect children from adversities.

Furthermore, as erstwhile described, exacerbated by poverty and other vulnerabilities, mental health needs of children from adverse circumstances are high – placing children at increased risk of continued child protection problems. Thus, it is imperative for integrated ECCD and child protection programs to include child mental health interventions. Effectively addressing emotional and behavioral problems that are consequences of protection issues, would be critical to the successful implementation of early childhood care and protection services and programs [9].

We, herein, address the question of how to integrate child protection and mental health interventions into existing ECCD programs by describing the experience of a pilot project in the Indian context. It provides the rationale, methodology and content of service delivery for integrating child protection and mental health interventions into the existing ECCD program, the Integrated Child Development Scheme (ICDS), highlighting emerging concerns and challenges and drawing from the interventions to show how some of these were addressed. We also discuss how child care service providers, particularly pediatricians, can play a pivotal role in this endeavor.

Prior to this pilot project a large community-based child and adolescent mental health service project, had been implemented by us. The community-based project had executed a resource mapping and needs assessment for community child and adolescent mental health services [4], prior to the start of its activities. With the objective of promoting early stimulation and optimum development in children, activities such as implementation of early stimulation, training and capacity of Anganwadi workers on early stimulation (child protection was not a prominent focus of the program at the time) were conducted. The observations and experiences of our work are available elsewhere (www.nimhans childproject.in).

Subsequently this experience was used to develop a pilot project that focused exclusively on ECCD inter-ventions, to include child mental health and protection interventions. In order to obtain a more specific under-standing of how ICDS staff view child protection issues, an additional assessment was done prior to this project, and the findings incorporated into the design and content of the interventions.

The potential of the integrated child development scheme: The ICDS provides a huge opportunity to incorporate protection components into ECCD because of its universal coverage agenda, particularly in socio-economically deprived communities where some of the most vulnerable children reside. Also, the anganwadi worker, the key worker in the ICDS scheme, conducts non-formal education and early stimulation activities for a given group of children, on a daily basis, over a relatively long time period (such as a year). This provides a perfect platform, not only for early screening and referral for developmental delays, emotional and beha-vioral and protection issues, but also to engage children in personal safety awareness programs.

Protection programs, policies and laws relevant to young children: As a signatory to the UNCRC, the Indian Government established a statutory body, the National Commission for Protection of Child Rights (NCPCR), in 2007, and more importantly, the Ministry of Women and Child Development, launched the Integrated Child Protection Scheme (ICPS) in 2009. The ICPS translates into programs, the vision of a secure environment for all children, as envisaged in the Juvenile Justice (Care and Protection of Children) Act, 2015, which in turn is based on principles of ‘protection of child rights’ and ‘best interest of the child’. It aims at building a protective environment for children in difficult circumstances, as well as other vulnerable children, by bringing together various child protection schemes under one roof and integrating additional interventions for protecting children and preventing harm [39].

India has enacted another key law with regard to child protection – The Protection of Child Sexual Offences (POCSO) Act 2012 which aims to effectively address sexual abuse and sexual exploitation of children. The act defines various forms of sexual abuse, focuses on mandatory reporting issues, stringent punishment graded as per the gravity of the offence, and requisite child-friendly court processes [40].

Despite the existing range of ECCD programs and services, there are gaps and challenges, at knowledge, skill and policy levels, leading to inadequate realization of child protection laws and policies. Some of the challenges observed during the course of our child mental health and protection work in recent years include: limited understanding of child protection and psycho-social issues within child protection system, lack of focus on protection services for young children, inadequate knowledge and skills to identify and address protection concerns, especially in young children and paucity of systematic and standardized materials and protocols for child protection response.

ICDS staff knowledge and skills in child development and protection issues: Based on the needs assessment exercise conducted with anganwadi workers within the ICDS, for a deeper understanding on the staff’s perspectives on young child protection, various issues emerged (which also reflect the general lacunae in the child protection system in the country). Anganwadi workers have not been trained in the use of systematic assessments in child protection, nor in assessment of child mental health and development issues.

Young children in anganwadis: The children in the Anganwadis are drawn from vulnerable homes and communities. Their families were characterized by low socio-economic status, residence in urban slums, sub-stance abuse in caregivers, domestic violence, violence and conflict (extending through neighbor-hoods). The primary caregivers were frequently day laborers, so they were absent for most of the day i.e. as such children’s interactions with primary caregivers were limited to a couple of hours a day. Consequently, they spent the maximum number of hours at the anganwadi, with the anganwadi worker serving as a key caregiver.

Conceptual framework: Based on the available literature, a comprehensive framework for integration would entail the following: i) early stimulation and development, including provision for learning opportunities; ii) providing alternative opportunities for developing healthy attachment, particularly for children who are from compromised or dysfunctional families; iii) creating awareness in children regarding personal safety and abuse issues to enable early reporting of abuse experiences; and iv) equipping ECCD workers with knowledge, skills and methods to identify protection risks in young children. Including emotional and behavioural issues, and to address them, depending upon the severity.

The aim of the intervention was to integrate mental health and protection services for young children between the ages of 0 to 6 years into the existing the ICDS program.

As shown in Fig.1, we used a multi-pronged approach to provide com-munity-based mental health and protection services for promotive, preventive and curative care through direct service delivery for children, and training and capacity-building of anganwadi workers.

Fig. 1 Conceptual framework for integration of child protection and mental health with early childhood care and development.

The interventions were implemented in anganwadis in which the ICDS is implemented, in vulnerable urban communities the Bangalore. Anganwadis from the five (urban slums) near our center were selected. From amongst these, anganwadis were selected, which had greater number of children, and more than one center in the same location were selected – in order to ensure that a greater number of children would be reached through a single visit.

In all, during the 7 months, the interventions were carried out in 31 Anganwadi centers (Table I). Based on the context of intervention and the conceptual framework, two types of interventions were implemented to integrate child mental health and protection into the ICDS program, through i) direct services for children and ii) capacity building initiatives for ICDS staff.

Direct services for children: This was carried out in two distinct steps viz., individual assessment of development, mental health and protection issues in anganwadi children, and group activities for children in anganwadis.

An assessment proforma comprising of questions on child development, emotional and behavioral issues and protection concerns was developed (available at: https://www.nimhanschildproject.in/anganwadis-phcs/). It was based on existing clinical assessment proformas at the department of child and adolescent psychiatry in a tertiary care facility. The proforma has also drawn from the community-based programs previously executed by the authors, particularly in young child institutions, where children orphan and abandoned children, with serious child protection issues, reside. This assessment was not primarily aimed at arriving at a diagnosis, but mainly geared to help child care service providers to identify and understand children’s problems and vulnerabilities, with a view to helping them to access appropriate inter-ventions. Due to the variation in developmental abilities and needs, the proforma was adapted to three sub-groups of children under the age of 6 years: 0 to 1 year, 1 to 3 years and 3 to 6 years.

The assessments were conducted in the anganwadi. An average of 20 minutes was spent engaging with the child and about 15 minutes with the anganwadi worker, for completion of an individual child’s assessment. To ensure that the assessments were accurate i.e., that they truly reflected children’s developmental abilities, allowing them to respond freely, ice-breakers and group activities were used to build rapport with children Developmental checklists were filled out by observing the child and asking him/her to perform simple tasks and activities that would allow for assessment of develop-mental skills and abilities. Information about the child’s family context and related protection issues was gathered by interviewing anganwadi workers and helpers.

Following each assessment, for mild to moderate developmental, mental health and protection issues, the anganwadi worker was provided with first level inputs including what the Anganwadi worker may do to help the child, and how she could counsel the parents. For complex issues (such as developmental disabilities) requiring specialized assistance, the anganwadi worker was assisted to refer the child to the dept. of child and adolescent psychiatry of a tertiary care facility and/or to the concerned child welfare committee.

Group activities were conducted with the anganwadi children along with anganwadi workers (also as part of their capacity building through demonstration and on-the-job training). These group sessions with children, focused on domains of development, mental health and protection, and comprised of the following: Activities for promotion of early stimulation and optimum develop-ment in the five key areas of child development (physical, social, speech and language, cognitive and emotional development). including fine motor activities to develop pre-writing skills; Activities for socio-emotional develop-ment, with a focus on helping children recognize and manage emotions, and develop empathy; and, Activities for child sexual abuse prevention and personal safety.

Capacity building of anganwadi workers: This was done using capacity building workshops and on-the-job training.

One of the key objectives of the intervention was to build the knowledge and skills of the anganwadi workers in the areas of child development, mental health and protection. The specific training objectives included enabling anganwadi workers to: Understand the context of child abuse and neglect, including physical, emotional and sexual abuse; Identify and provide first level and emergency responses and necessary referrals in the context of child abuse and neglect; Administer the assessment proforma to child developmental, protection and mental health needs and issues in individual children; Use personal safety and sexual abuse prevention module with preschoolers; and, identify and manage (including refer) emotional and behavioral problems, develop-mental and protection issues among young children.

The training content is detailed in Box I. It was delivered using creative participatory and experiential methods, such as role play, case discussions, simulation games, demonstrations, brain-storming, pile sorting/ listing – so that the learning was made fun and interesting, but also to enable workers to learn necessary methodologies for use with young children.

Over a 7-month period, training and capacity building activities were conducted through 4 one-day workshops, which were held once in two months, at the tertiary care facility that the project was based out of. Other times, weekly sessions were held on an on-going basis, for clusters of anganwadis (4 to 12 Anganwadi workers) located near each other. This enabled Anganwadi workers to avoid travelling long distances to attend training; and it allowed them to complete their morning tasks com-fortably in order to free up their time for the afternoon session. The training team ensured that a friendly, light-hearted learning environment was created in the Anganwadi and in workshops.

Alongside the training, daily field visits were used by the team, to provide on-the-job support to the anganwadi workers. This included demonstrations on conducting activities for early stimulation and development, and for personal safety and abuse prevention, administration of the assessment proforma and management of common emotional and behavioral problems in young children. Additionally, revision and recap of some of the training workshops/sessions were also done in one-on-one sessions with anganwadi teachers, to help them link theory and practice issues in the field.

Development of activities and materials for use with children: In order to provide Anganwadi workers with standardized methods in their direct work with children, several materials have been developed for intervention purposes. Some of these materials were also translated into the local language. The materials include the following: activity book for socio-emotional develop-ment in pre-school children; child sexual abuse and personal safety module - activity-based awareness and learning for preschoolers and children with developmental disabilities; early stimulation and development activity books and flip charts (for use with parents, teachers and caregivers); Stories for preschoolers on themes of loss and grief, separation anxiety and attachment, etc. (material available at: https://www. nimhanschildproject. in/interventions/pre-school-0-to-6-years/).

Given the contextual challenges of the anganwadi workers, the team developed and adopted several types of strategies, throughout its implementation processes, so as to provide for a more enabling learning and work culture and environment for the workers (Box II).

Process outcomes of interventions: Since our interventions were not part of a research study, no measures were used to examine the effectiveness of the interventions we provided. However, based on observations and feedback received from anganwadi workers, some critical qualitative process outcomes, mainly in terms of anganwadi workers’ attitudes and learning were found. The anganwadi workers over come their initial reluctance, appreciated learning relevant skills and interventions, and became more aware of the child protections risks and interventions.

As evidenced by the gaps in literature, there is little data on young child protection and mental health issues in developing contexts, including in India. It is critical therefore for research and intervention studies to be undertaken in non-clinical, community settings to better understand health, protection and developmental issues in some of the most vulnerable children in our country i.e. those who are least likely to access protection and mental health services. Whether for action research or programmatic interventions, the existing ECCD program, namely the ICDS, with its coverage and reach, provides the best chance that a low resource country such as India has, to protect its most vulnerable children.

While a great many systemic measures and changes are required to enable the ICDS to gear itself to integrated programming that straddles child development, pro-tection and mental health, child health experts, who are already available within the secondary and tertiary levels of healthcare, can initiate transformations through the approaches they bring to child services. Pediatricians usually see children and families regularly and over a long period, thus having the advantage of trust and a personal relationship that allows them to gain a deeper knowledge of the child’s background, including family systems and dynamics. The relationship pediatricians have with the children and parents is devoid of the stigma usually associated with mental health and child protection professionals, thus causing parents and caregivers to be more open and receptive to their suggestions and inputs [41]. Consequently, they are well-placed to pick up on child protection concerns and provide recommendations and/or referrals to child protection systems [42]. Pediatricians can also lead the way in child protection in India, including to provide capacity building support to the ICDS.

The training courses conducted by job training centers who provide capacity building programs to anganwadi workers require major re-examination and over-hauls, so that they develop integrated conceptual frameworks and interventions that cater to the critical domains of early childhood development, protection and mental health, and use pedagogies that are appropriate to those who work with young children–the use of creative and participatory methodologies in training programs are more likely to be translated into practice at field level, in direct work with children.

It is true that anganwadi workers experience a great many challenges and thus work under extraordinarily difficult conditions. It is understandable that high workloads, and lack of health insurance, to serve as demotivating factors for them. This is why methodology is as critical as the content – more so perhaps in this context. The challenge is not so much about the potential opportunities these programs and systems provide for the integration of protection services for young children, rather how best to plan an intervention through which the capacities of the service providers could be developed by navigating through their many challenges.

We have begun work with state departments on sharing the models and methods described in this paper. In conclusion, experiences from our pilot project suggest that an empathic approach, that acknowledges the anganwadi workers challenges and limitations, and takes them into consideration in program design, would be the way forward. The use of less conventional approaches that are built into local traditions and cultures, creating community-based forums that workers are keen to be a part of, is a key strategy for making space and time for their capacity building and for their work with children. We have begun work with state departments on sharing the models and methods described in this paper. In addition to the commitment of the ICDS scheme and its functionaries, further work, research and experiences across the country will determine the scalability of these methods.

Funding: United Nation Children’s Fund (UNICEF), India; Competing interests: None stated.

1. The United Nations. Convention on the Rights of the Child. Treaty Series 1989; 1577, 3. Accessed Apr 2, 2020. Available from: https://www.ohchr.org/documents/professionalinter est/crc.pdf %0A%0A

2. Statistical Report on Children of India. Ministry of Women & Child Development. Governement of India. Children in India 2018 -A Statistical Appraisal. Accessed Apr 26, 2020. Available from: http://mospi.nic.in/sites/default/files/publi cation_reports/Children%20in%20India%202018%20%E2 %80%93%20A%20Statistical%20 Appraisal_26oct18.pdf

3. Seth R. Protection of children from abuse and neglect in India. JMAJ. 2013;56;5.

4. National Crime Records Bureau. Crime in India. Ministry of Home Affairs. Government of India. Accessed Apr 25, 2020. Available from: https://ncrb.gov.in/crime-in-india-table-addtional-table-and-chapter-contents?field_date_ value%5 Bvalue%5D%5Byear%5D=2017&field_select_ table_title_ of_ crim_value= 6&items_per_page=All

5. Ministry of Women and Child Development. PIB: Cases Filed Under POCSO. 2019. Accessed Apr 25, 2020. Available from: https://pib.gov.in/newsite/pmreleases.aspx?mincode= 64

6. Ministry of Women and Child Development G. PIB: Ministry of Women & Child Development -Year End Review 2018. 2019. Accessed April 25, 2020. Available from: https://pib.gov.in/newsite/pmreleases.aspx?mincode=64

7. Koot, H.M., Van Den Oord, E.J.C.G., Verhulst, F.C.　et al.　Behavioral and Emotional Problems in Young Preschoolers: Cross-Cultural Testing of the Validity of the Child Behavior Checklist/2-3.　J Abnorm Child Psychol. 1997;25:183-96.

8. World Health Organization. Child abuse and neglect. Accessed April 5, 2020. Available from: http://www. who.int/violence_injury_prevention

9. Osofsky JD, Lieberman AF. A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children. Am Psychol. 2011; 66:120-8.

10. Margolin G, Gordis EB. Children’s Exposure to Violence in the Family and Community. Curr Dir Psychol Sci. 2004; 13:152-5.

11. Runyan D, May-Chahal C, Ikeda R, Hassan F, Ramiro L. Child abuse and neglect by parents and other caregivers. World Rep Violence Heal. 2002;57-86.

12. Prado EL, Dewey KG. Nutrition and brain development in early life. Nutr Rev. 2014;72:267-84.

13. Baker-Henningham H, Lopez-Boo F. Early childhood stimulation interventions in developing countries: A comprehensive literature review. IZA Discussion Paper No. 5282. 2010. Accessed February 25, 2020. Available from:https://papers.ssrn.com/sol3/papers.cfm?abstract_ id= 1700451

14. Saarela JM. Time Does Not Heal All Wounds: Mortality Following the Death of a Parent. J Marriage Fam. 2011; 73:236-49.

15. Wade M, Zeanah CH, Fox NA, Tibu F, Ciolan LE, Nelson CA. Stress sensitization among severely neglected children and protection by social enrichment. Nat Commu. 2019; 10:57-71.

16. Mills R, Alati R, O’Callaghan M, et al. Child abuse and neglect and cognitive function at 14 years of age: Findings from a birth cohort. Pediatrics. 2011;127:4-10.

17. Teicher MH, Samson JA, Anderson CM, Ohashi K. The effects of childhood maltreatment on brain structure, function and connectivity. Nature Rev Neurosc. 2016;17: 652-66.

18. Smith M, Mcisaac J-L. Adverse Childhood Experiences: Early Childhood Educators Awareness and Perceived Support [Internet]. Mount Saint Vincent University; 2019. Accessed August 16, 2020. Available from: http://ec.msvu. ca/xmlui/handle/10587/2090

19. Jimenez ME, Wade R Jr, Lin Y, Morrow LM, Reichman NE. Adverse experiences in early childhood and kindergarten outcomes. Pediatrics. 2016;137:e20151839.

20. Kolla NJ, Malcolm C, Attard S, Arenovich T, Blackwood N, Hodgins S. Childhood maltreatment and aggressive behavior in violent offenders with psychopathy. Can J Psychiatry. 2013;58:487-94.

21. Putnam FW. The Impact of Trauma on Child Development. Juv Fam Court J. 2006;57:1-11.

22. Young JC, Widom CS. Long-term effects of child abuse and neglect on emotion processing in adulthood. Child Abuse Negl. 2014;38:1369-81.

23. Storr CL, Nicholas Ialongo SS, Anthony JC, Breslau N. Childhood antecedents of exposure to traumatic events and posttraumatic stress disorder. Am J Psychiatry. 2007;164: 119-25.

24. Sege RD, Siegel BS. Effective discipline to raise healthy children. Pediatrics.2018;142:e20183112.　

25. Tierney AL, Nelson CA. Brain Development and the Role of Experience in the Early Years. Zero Three. 2009;30:9-13.

26. Flaherty EG, Thompson R, Litrownik AJ, et al. Effect of early childhood adversity on child health. Arch Pediatr Adolesc Med. 2006;160:1232-8.

27. Lannen P, Ziswiler M. Potential and perils of the early years: The need to integrate violence prevention and early child development (ECD+). Aggression Violent Beh. 2014;19: 625-8.

28. United Nation Children’s Fund (UNICEF). Programme guidance for early childhood development. 2017 Accessed April 05, 2020. Available from: https://www.unicef.org/early childhood/files/FINAL_ECD_Programme_Guidance._ September._2017.pdf

29. Enhancing child protection through early childhood care and development | Plan International. Accessed April 12, 2020. Available from: https://plan-international.org/publications/enhancing-child-protection-through-early-childhood-care-and-development

30. Save the Children. Early Childhood Care and Development (ECCD) Various Modalities of Delivering Early Cognitive Stimulation Programs for 0-6 year olds. 2016. Accessed March 24, 2020. Available from: https://resourcecentre.save thechildren.net/node/10016/pdf/alt._eccd_models_ final_0. pdf

31. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population-based prevention of child maltreatment: The U.S. triple P system population trial. Prev Sci. 2009;10:1-12.

32. MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet. 2009;373:250-66.

33. Mikton C. Two challenges to importing evidence-based child maltreatment prevention programs developed in high-income countries to low- and middle-income countries: Generali-zability and affordability. 2012. Accessed August 15, 2020. Available from: https://uwe-repository.worktribe.com/output /954731/two-challengesto-importing-evidence-based-child-maltreatment-prevention-programs-developed-in-high-income-countries-to-low-and-middle-income-countries-generalizability-and-affordability

34. Skeen S, Tomlinson M. A public health approach to preventing child abuse in low- and middle-income countries: A call for action. Int J Psychol. 2013;48:108-16.

35. Puffer ES, Green EP, Chase RM, et al. Parents make the difference: a randomized-controlled trial of a parenting intervention in Liberia. Glob Ment Heal. 2015;2:e15.

36. Jeong J, Franchett E, Yousafzai AK. World Health Organization Recommendations on Caregiving Inter-ventions to Support Early Child Development in the First Three Years of Life: Report of the Systematic Review of Evidence. 2018. Accessed August 25, 2020. Available from: https://www.who. int/maternal_child_adolescent/guidelines/SR_Caregivin_ interventions_ECD_Jeong_Final_05Mar2020_rev.pdf? ua=1

37. Fenton A. Using a Strengths Approach to Early Childhood Teacher Preparation in Child Protection using Work-Integrated Education. Asia-Pacific J Coop Educ. 2013; 14: 3:157-69.

38. Kapil U. Integrated Child Development Services (ICDS) scheme/ : A program for holistic development of children in India. Indian J Pediatr. 2002;69:597-601.

39. Child Related Legislation | Ministry of Women & Child Development | Government of India. Juvenile Justice (Care and Protection Of Children) Act, 2015 [Internet]. Accessed September 14, 2020. Available from: https://wcd.nic.in/acts/ juvenile-justice-care-and-protection-children-act-2015

40. Protection of The Protection of Children from Sexual Offences Act, 2012 [Internet]. Ministry of Women & Child Development, Government of India. Accessed April 2, 2020. Available from: https://wcd.nic.in/act/2315

41. Dubowitz H. Pediatrician’s role in preventing child maltreatment. Pediatr Clin North Am. 1990;37:989-1002.