Support the Caregivers Intervention (SCI) for Strengthening Ethiopian Families
Experts around the world agree that the early years are critical for emotional health, social understanding, and learning. In Ethiopia, where family, community, and tradition are so deeply rooted, these early moments are even more important.
By Sahilu Baye Alemu
Introduction: Why Caregivers Matter
Good morning, and thank you for joining. As you read, I invite you to think about a moment with a young child, a newborn curled in a blanket, a toddler reaching out for your hand, a little one exploring the world with wide eyes. These simple moments shape a child’s future. Experts around the world agree that the early years are critical for emotional health, social understanding, and learning. In Ethiopia, where family, community, and tradition are so deeply rooted, these early moments are even more important.
Our children are raised by more than just parents, they are cared for by grandmothers, siblings, neighbors, and elders. But at the heart of a child’s development is the caregiver, the person who provides the emotional grounding every day. Over the years, I’ve met caregivers from all walks of life. I’ve seen mothers in rural villages giving all they have, teachers in busy classrooms in Addis Ababa working under great pressure, and caregivers in orphanages balancing the needs of many children. Some caregivers show immense patience, but many also carry heavy stress, emotional exhaustion, and lack of support.
When caregivers struggle, children struggle. But when caregivers feel supported and understood, children thrive. The Support the Caregivers Intervention (SCI) was created to help meet this need. It equips caregivers with practical, culturally relevant tools to connect emotionally with young children, especially those with special needs. These children often require more sensitivity, consistency, and calm guidance. Today, I’d like to share how SCI helps strengthen Ethiopian families and contributes to early childhood development.
What the SCI Program Offers
SCI provides caregivers with four key skills to support children emotionally and socially. These skills are based on international child development research but are shaped by Ethiopian values of family loyalty, community responsibility, and interdependence. The four central skills SCI focuses on are:
Attachment and the Secure Base
Insightfulness
Reflective Functioning and Reflective Dialogue
Emotional Regulation and Empathy
These skills help caregivers create a strong, stable emotional foundation for children, particularly those facing poverty, illness, disability, trauma, or loss. For children living in difficult circumstances, the most important protective factor is a caregiver who is emotionally stable, responsive, and present.
1. Attachment and the Secure Base
Attachment is the deep emotional bond between a child and their caregiver. From the moment they’re born, babies seek comfort and security from their caregivers. When caregivers respond with warmth, consistency, and understanding, children develop a secure attachment. This secure base allows them to feel safe enough to explore the world and develop confidence. In SCI, caregivers learn about different attachment styles: secure, insecure, and disorganized. They also learn practical ways to respond to their child’s emotional needs. For example, when a toddler cries because their mother leaves for work, it’s not misbehavior but fear. Recognizing this and responding with calm and reassurance helps create security.Caregivers also need emotional support to be effective. Many face heavy responsibilities, long workdays, and personal stress. Through SCI, caregivers learn coping strategies to help them manage their emotions, which strengthens their ability to provide the emotional stability children need.
2. Insightfulness: Understanding the Child’s Inner World
Insightfulness is the ability to see a child’s behavior from their point of view. It means understanding what a child might be feeling, beyond just what they are doing. For example, a child refusing to eat may be anxious, or a child who hits may be frustrated but doesn’t yet know how to express it. SCI teaches caregivers to view behavior as communication. They ask themselves, what might this child be feeling? What message is this behavior sending? What support does this child need from me? By practicing insightfulness, caregivers stop reacting in frustration and begin responding with understanding. This helps children feel heard and valued, which builds trust and emotional confidence.
3. Reflective Functioning and Reflective Dialogue
Reflective functioning is the ability to understand both a child’s emotions and one’s own. Many caregivers discover that their reactions to a child’s behavior are shaped by their own past. For example, a caregiver may feel frustrated with a crying child because they were raised in a household where emotions were ignored. SCI helps caregivers pause before reacting, allowing them to make thoughtful, intentional choices. Instead of responding automatically, caregivers learn to reflect on their feelings and the child’s needs before acting. Reflective dialogue is a simple but powerful tool to help children understand and express their emotions. Even with very young children or those with special needs, caregivers can use phrases like, 'I see you’re worried' or 'That sound scared you' to name the child’s feelings. This helps children make sense of their emotions and builds emotional resilience. It’s especially important for children with special needs, who may struggle to express themselves verbally.
4. Emotional Regulation and Empathy
Caregiving is demanding, and many caregivers work in loud, stressful environments with limited resources. Emotional regulation is the ability to remain calm and patient, even when emotions run high. SCI teaches caregivers simple strategies, such as slow breathing, taking a pause before responding, and grounding techniques to help them stay present and focused. When caregivers regulate their own emotions, they are better able to empathize with their child. Empathy is the ability to understand and share a child’s feelings. It tells the child that their emotions matter and that they are seen and understood, even if they can’t express themselves clearly. For children with special needs, this empathy is critical, as it creates a sense of connection despite any communication barriers.
SCI and Children with Special Needs
Children with special needs often face stigma, isolation, and limited access to services. SCI helps caregivers see beyond the diagnosis and understand the child as a unique individual with their own emotional world. Caregivers learn to observe body language, manage sensory overload, and establish routines that help the child feel safe and supported.
Celebrating small steps is also an important part of the process. When caregivers feel supported, they can better celebrate their child’s progress, no matter how small, which encourages growth and builds confidence for both the caregiver and the child.
Conclusion: Moving Forward Together
At the heart of early childhood development is the relationship between the caregiver and the child. By supporting caregivers, we help strengthen families and communities. SCI offers a research-based, culturally grounded approach that equips caregivers with the tools they need to nurture their children, especially those with special needs.
When caregivers thrive, children thrive. Families grow stronger, and communities become more resilient. So, what can you do next?
For caregivers: Reflect on how you can apply these skills in your daily life. Try focusing on one skill at a time, such as being more mindful of your child’s emotional cues or taking a moment to pause before reacting.
For professionals: Encourage caregivers to take part in the SCI program and provide support in helping them practice these skills.
For everyone: Consider how you can help strengthen the community of caregivers around you, whether by offering emotional support, sharing resources, or simply being present.
Together, we can build a stronger, more supportive future for Ethiopia’s youngest generation. Thank you for being part of this journey.
By Sahilu Baye Alemu, Child Development Specialist and Founding Director of Enrichment Center Ethiopia (ECE)
Adopting the term 'a unique multifaceted condition' instead of 'multiple disabilities' or 'complex disabilities'
When we think of multiple disabilities we immediately want to provide multiple practitioners. When ‘complex disabilities’ is used to describe a baby or infant, it seems to justify offering a very complicated support system. Even the word ‘disability’ is inappropriate for very young children because it feels like a very negative medical prognosis.
By Peter Limbrick
While there has been a wealth of creative, scientific thinking and revolutionary advances in molecular biology, genetics, and medical technology since the middle of the last century, there has been no corresponding progress in how we support a baby or pre-school child who has two or more challenges to development, learning and quality of life. It feels as though we are stuck in the age of the steam engine and telegraph as though quantum theory, space travel and the internet are all still waiting to happen.
So what can happen to an infant who has these multiple challenges? The traditional and still current approach in countries with high economies is to add a new practitioner for each condition or need that is discovered. For a child with neurological impairment from birth there could, at the extreme, be a neonatologist, paediatrician, special nurse, health visitor and physiotherapist at the head of the procession, closely followed by speech and language therapist, teacher for visually impaired children, teacher for hearing impaired children, play therapist, psychologist and so on. The list and the sequence will be different for each child but the dangers are the same. The family can be overloaded by multiples of appointments, clinics, assessments and reviews. Then there are travel and childcare costs to get to appointments. There will inevitably be duplications, contradictions and gaps in this dangerous mêlée – all adding to parents’ stress, confusion and anxiety.
The child can be overwhelmed by the requirement to relate to so many people – far more people than we would impose on a typically developing child and she or he might have to suffer a daily and weekly routine crammed with discipline-specific programmes. Pre-school practitioners suffer too with increasing demands on their time as they try to meet parents’ aspirations for regular sessions of this or that in this crazy world of multiples.
How did this come about? We learned in the last century that individual practitioners, whether from education or health, can help children and adults who have an individual diagnosis or challenge. We now blindly assume that the answer for young children who have multiple diagnoses is simply to multiply the practitioners. This scatter-gun approach has happened by default and, in my view, is not tenable within the resources available in most countries. Nor should we perpetuate it when we give some thought to what is fair to children. Some infants, perhaps because of prematurity, have not yet bonded with their parent. Other infants have cognition and communication difficulties. Others are just plain nervous and fearful. For these babies and young children it is illogical to impose ever more practitioners just on the basis that each one has expertise in this or that impairment while we should be thinking instead about the collective impact on the child. For some reason children who have plural challenges manage to creep under our child-centred radar and fail to evoke our empathy, sensitivity or professionalism. Could this be because we remain stuck in an overly medical approach from the last century seeing the diagnoses under the microscope but not the child under our nose?
Ludwig von Bertalanffy* tells us that General Systems Theory is founded on the understanding that there are models, principles and laws shared by different fields of human endeavour, for example, physics, chemistry, biology, economics and sociology. Speaking of the various entities that we encounter in any of these fields (e.g. atoms, molecules, bacteria, humans, factories, supermarkets) he says, ‘…the entities concerned can be considered in certain respects, as systems, i.e. complexes of elements standing in interaction.’ (p 33) He goes on to say:
The meaning of the somewhat mystical expression, ‘the whole is more than the sum of the parts’ is simply that constitutive characteristics are not explainable from the characteristics of isolated parts. The characteristics of the complex, therefore, compared to those of the elements, appear as ‘new’ or ‘emergent’.
(p 55)
I take this to mean that if you add four wheels, an internal combustion engine and a steering wheel together you get a means of getting to work. If you add boiler, thermostat and radiators together you get heat all around the house. If you add cerebral palsy, blindness and learning difficulty together you get a unique multifaceted condition that is very much more than the sum of its parts. Just as we cannot understand cars or central heating unless we learn how the bits fit together and relate to each other, so we cannot help a child who has a multifaceted condition by focusing on the separate impairments as though they were not standing in interaction. This is the trap we keep falling into with children who have plural challenges and difficulties in their development, learning and quality of life - examining and treating separate bits without ever getting to know the whole child.
A systems perspective suggests that a child’s various conditions and impairments will stand in interaction with each other and that the resulting, emergent multifaceted condition will be greater than the sum of its parts. The condition resulting from any complex of single challenges will have new or emergent characteristics that the separate elements do not have. Also, no two multifaceted conditions can ever be the same. Each is unique.
Let us imagine a young child whose diagnosis includes autism and blindness. As a developing infant he has to endure, celebrate, learn and accommodate to all the things other autistic children are also dealing with but he has to do it without the advantage of sight. At the same time, he is striving to meet all social, psychological and educational challenges of blindness but with the additional challenges of being autistic. I would suggest the interaction between the two conditions significantly affects the neurological processes and outcomes in his development and learning.
Going further, when a child’s diagnosis includes autism, blindness and cerebral palsy her developing brain has the task of establishing neural patterns and pathways for posture, mobility, co-ordination and dexterity without the advantages of sight and within the constraints of autistic perceptions and social interactions. Following systems theory, the three challenges inevitably merge together into a new complex which is much more than the sum of its parts.
The challenge we have as parents, practitioners and academics is to respond to children’s multifaceted conditions with 21st century thinking about multifaceted support systems. Parents are better equipped to meet this challenge because seeing the whole child comes naturally. But if we want practitioners to join all their discipline-specific interventions together then there has to be some sort of science that tells them how to do it – hopefully with effective training, resources and support. In my experience these skills do not come naturally to practitioners who have by training moved their focus from the whole child to this or that specialism. If we do not commit ourselves to a scientific approach with a systems perspective for the development, learning and quality of life of children who each have a unique multifaceted condition we will remain fumbling in the dark with last century’s trial and error strategies. I hope this website will help.
* Bertalanffy, L. (1968) General Systems Theory. New York: George Braziller
If you would like to comment on this essay for the News Bulletin or Essay Page on this website, please send an e-mail to peter.limbrick@mailfence.com
Knowing that neuroplasticity is pivotal for neurodevelopment, why should pediatricians eagerly look for a diagnosis?
Advances in developmental science force us to reconsider the models of disease and wellness. Not only pediatricians but parents, educators, policy makers, and citizens as well, must focus more on nurture and early relationships.
An essay by Lidia Giúdici, MD and Alejandro Maccarrone, MD
This essay is written as a response to the essay Adopting the term 'a unique multifaceted condition' instead of 'multiple disabilities' or 'complex disabilities'.* After the statement in the essay, ‘When we think of multiple disabilities we immediately want to provide multiple practitioners’ we could add ‘and then prompt one (or several) diagnoses.’ The essay also stated, ‘Even the word disability is inappropriate for very young children because it feels like a very negative medical prognosis.’ In our view, diagnostic labels can be inappropriate.
As practitioners, therapists, and family/caregivers, we have experienced and shared mounting evidence that, in early years, timely interventions and nurturing wellness promote lifelong physical and mental health, despite initial prognoses. Indeed, prognostic statements should be avoided.
If we know that neuroplasticity is pivotal for neurodevelopment, why should pediatricians eagerly look for a diagnosis? Perhaps not necessary. By examining or recalling many individual stories, we can easily find that the first diagnosis made at very early years changed (or disappeared) over time.
There are several contributors to this eagerness to make a diagnosis and they do not exclusively belong to pediatricians. We can outline the most frequent determinants:
Lack of pediatric preparedness for caring for developmentally-challenged babies and toddlers. Pediatricians need training in the management of developmental issues and knowledge about interdisciplinary practice. The lack of training prompts a need for making a diagnosis involving referrals to sub-specialities in order to ‘achieve the label’.
Teachers in mainstream pre-schools lack training to approach children with, or at risk for, neurodevelopmental challenges or delays. The lack of this training leads to an unnecessary pressure when a child doesn´t behave in a ‘normal way’.
Parents can be anxious if their child is not ‘normal’. They want a label to explain what has happened with him/her.
A diagnosis is needed to achieve the provision of adequate and timely intervention/s. Nowadays, many stakeholders, especially in low and middle income countries, won´t provide services without a disability certificate which must display a diagnosis. Public Health policy needs to change.
This eagerness to diagnose worsens if the child appears to have more than one developmental challenge. We don´t mean that we should not seek for a diagnosis; however, we should know that a diagnosis in these early years places a burden on family life if it is inaccurate and if it does not reflect the real and future status of the child’s development. Why is this so true?
Infants and children are ‘under construction’; we know that experiences in childhood are determinant for future growth and development. Pediatricians must have training so they can appreciate the intertwining influences (eg, genetic, nutritional, environmental, social) that affect the developmental process. Pediatricians must also recognize that developmental outcomes rely on the family, neighborhood, and cultural context in which the child is developing. Basic sciences of development validate this focus on the contextual determinants of child health. Reports from life-course research support this approach as well.
These advances in developmental science force us to reconsider the models of disease and wellness. Not only pediatricians but parents, educators, policy makers and citizens must focus more on nurture and early relationships from the very beginning - instead of trying to repair, diagnose, and prescribe treatments for problems that could have been prevented or minimized. Developmental science gives us knowledge that we must apply in policy and practice to improve current health, educational, social, and economic outcomes across the life span.
In this context, we must consider the effect of prolonged or toxic stress response on brain development and function, and we must educate in the concept of safe, stable, and nurturing relationships to avoid childhood adversity and promote mental health. Thus, education is of founding importance for community, policy-makers and professionals.
Finally, the ecobiodevelopmental (EBD) model of disease and wellness compels us to start ‘thinking developmentally’. Only by working together, are we going to achieve better outcomes. Then, hopefully, not too many diagnoses will be needed.
Lidia B. Giúdici
Pediatra- Neonatóloga
Directora de la Carrera de Especialización en Desarrollo Infantil- Facultad de Medicina-UBA- Argentina
Directora Académica de ALSEPNEO- Asociación Latinoamericana de Seguimiento Pediátrico y Neonatal www.alsepneo.com
Alejandro Maccarrone
Pediatrician- Neonatologist
Adjunct Professor of Pediatrics at the Faculty of Medicine, UNR
2nd Chief in Neonatal Intensive Care Unit- Hospital del Centenario- Rosario- Santa Fe- Argentina
Academic Secretary in ALSEPNEO www.alsepneo.com
If you would like to comment on this essay for the News Bulletin or Essay Page on this website, please send an e-mail to peter.limbrick@mailfence.com
Contrasting a therapy approach with an educational approach to the early skill of moving on the floor
Building the case for moving early child and family support out of hospitals into education settings
By Peter Limbrick
The two sessions I describe below are constructed from my experience over many years. There are three subheadings:
A therapy approach to the early skill of moving on the floor
An education approach to the early skill of moving on the floor
Discussion
A therapy approach to the early skill of moving on the floor
For this, we are a fly on the wall observing a single session in a hospital’s paediatric physiotherapy department, centre or clinic. A baby boy or infant is supine on a therapy mat with a physiotherapist kneeling at his side and the parent nearby but not too close.
The therapist knows the child well. He has significant motor issues with a neurological cause. She had carried out an assessment schedule before attending a multidisciplinary assessment meeting to compare notes with other practitioners and agree a plan for the child’s future treatment. This plan had included regular physiotherapy sessions in the hospital with some home visits if possible.
The therapist is working on the new skill of rolling from supine. Her work to date has shown that the child is developmentally ready for this and she has told the parent what the new task is. She will help the child roll from back to side and observe how he responds. From this she will know how to proceed. She manages the child with kindness.
One approach she uses is to turn the child’s head to one side and hold it with one hand. She uses the other to press at a particular point on the child’s torso. The child’s knees come up and he rolls to the side. In another approach she initiates rolling by bringing one leg up and over the other held straight. She began the session with some relaxation exercises and was careful to practise rolling to both sides from supine.
The parent is pleased to see some progress. The child has not been entirely happy with the explorations and has shed a few tears. At some point, in this session or a later one, the therapist will suggest how this new rolling skill could be practised at home.
[PLEASE NOTE: In very vague terms I have described work that requires deep knowledge of motor development, of infant reflexes and of dangers to be avoided. I hope no one uses my crude outline as a guide to action. I am not a physiotherapist.]
An education approach to the early skill of moving on the floor
We are a fly on the wall now in part of a community children’s centre, kindergarten or nursery. The child we are focusing on has the same motor issues as the child with the physiotherapist above. A teacher is observing the baby or infant who is lying on his back not doing anything in particular. She kneels at his side, talks to him very gently and holds a toy above him. It is a toy she knows he has responded to before so she talks to him about it and jiggles it so it makes its noise. She might even have a familiar song to go with this toy.
Seeing that she has got his attention, she slowly puts the toy on the mat to his side. The child shows he is excited now and seems to be trying to turn his head to see where the toy has gone. Still talking or singing to him, she helps him roll with gentle pressure at his shoulder or hip. Once on his side he looks at the toy and she helps him touch it with the hand that is uppermost. There is much praise and excitement. She returns him to his back and then plays the same game going to the other side.
Quite soon, they both decide the game is over and she changes the activity to something less demanding. When she gets an opportunity she will show the child’s parent what they were doing because rolling to the side is something new which he might do again at home (if he is not already doing so). The teacher makes a note of the child’s response intending to discuss it with colleagues. She wonders if she was helping him in the right way.
Discussion
Now that I have used two imagined scenes placed at opposite ends of a spectrum, many readers will jump to the same conclusion as me that it would be ideal for the two practitioners (paediatric physiotherapist and teacher) to join their knowledge, skills and experience in a joint effort of collective competence – and including the parent who knows so much more about the child. Staying with the ideal, this should happen in an education setting to avoid as much as possible the busy, neurotic and morbid mind sets and atmospheres in general hospitals. The physiotherapist’s support would probably be intermittent rather than being with the child as regularly as the teacher is.
To reinforce my argument for moving early child and family support out of hospitals into education settings, I will compare and contrast the two approaches. The child in the hospital session will be Child A and the child in the education setting will be Child B. There is no reason why they cannot be the same child. For simplicity, practitioners are female and children are male.
Both practitioners are motivated to help the child using their care and skills. Both will try to share all or some of these skills with the parent so they are better equipped to bring up their child.
Child B is helped in the education setting that is part of his normal life. Child A has had a journey to hospital that has disrupted normal feeding/ sleeping/ playing routines. Child and/ or parent might be nervous and apprehensive in the hospital environment and consequently unable to make the most of the session – or even react against it.
The therapist with Child A might feel that a few tears are inevitable and will sensitively continue the work. The teacher with Child B might want to avoid tears as much as possible and will take comforting a crying child as a priority. It is possible that Child A’s tears come in part from the strangeness of the environment and/ or is picking up the parent’s feelings.
Child A was a patient fitted into a planned treatment slot of fixed duration. There is pressure here for the therapist to make the best of the time available. Child B is in a familiar environment with familiar child-centred routines and is relaxed. He is more or less available for un-forced interactions with staff members depending on many factors including tiredness, mood...
Both practitioners know the child’s development and learning so far and can judge readiness for new learning. It is possible the therapist had set a rolling-to-the-side target before the session or even at the end of the previous session. The teacher had no such target in mind. She initiated the rolling game spontaneously when the child looked at the toy and some instinct made her move the toy to the side.
Therapist and Child A might perceive the rolling activity as an exercise, while teacher and Child B saw it as a game (but, for the teacher, of developmental significance).
The teacher was aware of Child B’s pleasure/ displeasure, attention, interest, motivation, vision, hearing, preference for a particular toy and, perhaps, of an emerging skill of touching the toy with his hands when in an appropriate position in which he could see both toy and hands. All of this came into the game. At the most basic and clinical level, the therapist might have focused only on Child A’s motor activity. (I have seen this basic clinical approach but I assume it is rare. On the other hand, any parent who tries to learn from videos on the internet will probably see this clinical approach to rolling.)
Both of these activities could have been in the child’s home with practitioners doing home visits.
I hope this comparison helps justify my ambition for early child and family support to move out of hospitals into education settings and for a child’s on-going development and learning to be considered an education issue rather than a health issue. I acknowledge I have described two opposite ends of a spectrum without describing what happens in the middle where perhaps, therapy becomes less clinical and, regrettably, teachers are less whole-child in their knowledge and skills.
If you would like to comment on this essay for the News Bulletin or Essay Page on this website, please send an e-mail to peter.limbrick@mailfence.com