# Presentation: 493422

## Transition to Early Childhood

- Marie C. McCormick
- Harvard School of Public Health
- February, 2005

## Pathways for Environmental Effects on Neurodevelopment

- Parental Processes

**Notes:**
The development of intervention strategies in early childhood to foster cognitive and social/emotional development rests on an extensive and still emerging theoretical framework on how the child’s environment, especially poverty, influences his/her development.  Among these pathways is the direct effect of the family and its approach to parenting.  A substantial literature has developed describing a variety of parental processes and their effect on the child.

## Pathways for Environmental Effects on Neurodevelopment

- Parental Processes
- Parental physical and emotional health
- Provision of stimulating experiences in the home
- Parental sensitivity
- Parental harshness

**Notes:**
Specifically, parental processes are thought to include parental physical and emotional health, their ability to provide stimulating experiences in the home, their sensitivity to the child’s developmental stage and needs, and their harshness or disciplinary strategies.

## Model for Effect of Socioeconomic Factors 

- Mat. Ed

- Earnings

- Financial Strain

- Depressive Sx

- Social Support

- Parenting

- Outcomes

**Notes:**
These factors can be arrayed in  models like this.  Parental resources, like education and social support, may ameliorate the effects of external stressors.  In their absence, financial resources may be inadequate, causing strain, which in turn, can lead to depressive symptoms in the absence of buffering social support.  The parents’ distress limits their ability to provide the appropriate developmental experiences for the child and to respond to their needs, thus affecting development.  Of importance is the substantial empiric evidence supporting this causal pathway, providing information to design and evaluate appropriate interventions.

## Pathways for Environmental Effects on Neurodevelopment

- Parental Processes
- Neighborhood Processes

**Notes:**
More recent work has focused on neighborhood processes.  Such processes might have both  direct and indirect influences on child development.  For preschool children, the effects are likely to be indirect, since the parents are the major influence on development.  While relatively recent, this emerging literature suggests that neighborhood has an independent effect on child health and development beyond the home environment. 

## Neighborhood Processes

- Resources for Parents
- Relationships
- Norms or Collective Efficacy

**Notes:**
The mechanisms by which neighborhood may affect development include resources for parents.   Such resources would include the availability and quality of schools or day care, recreational activities, and other services.  Besides these institutional resources, the neighborhood also serves as a source of social interaction for parents which may be either a source of support, or a source of distress, depending on the characteristics of those living in the area.  Finally, the neighborhood may serve to reinforce norms of behavior or monitor the quality of the neighborhood in terms of cleanliness and access to services.  

## Pathways for Environmental Effects on Neurodevelopment

- Parental Processes
- Neighborhood Processes
- Child Care Processes

**Notes:**
Also of more recent interest is the increasingly important area of child care outside the home.  It is very clear that poor quality child care is deletorius, while higher quality care may offset less effective parenting processes.  However, much of this literature lacks control for selection bias, i.e. the characteristics of the families that choose certain types of child care, and more definitive studies are needed.
      Based on the information on parenting processes that influence early child development, earlier investigators completed controlled studies of early educational interventions for healthy, disadvantaged children, and demonstrated their highly positive effect on cognitive development.  There were also studies on therapeutic interventions for children with established organic bases for developmental difficulties.  However, before IHDP, the efficacy of early childhood interventions in a population heterogeneous for socio-economic class and neurologic status had not been established.

## The Infant Health and Development Program

- An Example of Child Care Processes

**Notes:**
 It would prove difficult to change many aspects of parental characteristics, since they may be fixed by the time of the birth of the child.  Likewise, changing neighborhoods is not easy.  However, changing child care can be done, but must be done well.  To illustrate, I will provide an overview of one study examining the effects of early childhood education.  The Infant Health and Development Program is a multi-site randomized trial and follow-up of an early childhood educational program.  

## IHDP

- Intervention

- Follow-up

- Mediating Variables

- Child
- Outcomes

- Secondary
- Effects

- Intervening Variables

- Child
- Outcomes

- Secondary
- Effects

- P
- H
- A
- S
- E
- 1

- P
- H
- A
- S
- E
- 2-4

**Notes:**
The outline of the research design is presented on this slide.  To get  a study population heterogeneous for socioeconomic and neurologic status, we selected preterm, low birth weight infants as the tareget.  To be eligible, children had to be less than 38 weeks and less than 2500 grams at birth.  The sample was further stratified, so that two-thirds of the subjects were <2000 grams.  In Phase I, the trial period, the sample was randomly assigned to the educational intervention, and to high-risk follow up for the the first three years of their lives.  The primary outcomes reflected the health and developmental status of the child at the end of that period.  However, since the intervention included two years of free center-based care, we were interested in assessing the effects of having such a resource, and these were considered secondary effects.  A substantial number of mediating variables were collected including those thought to be directly influenced by the intervention such as the home environment, and those not directly targeted by the intervention but possibly influencing the results such as maternal mental health. I will not have time to discuss these intervening variables, but would be happy to answer questions. Phases 2 and 3 included follow-up assessments primarily at 5 and 8 years of age; Phase 4 is being planned.

## Study Enrollment

- Screened for Enrollment :        4551

- Protocol Exclusions       -3249

- Eligible for Recruitment:          1302

- Refused  Consent             -274

- Randomized:                               1028

- Withdrawn:                             -43

- Primary  Analysis Group:          985

**Notes:**
Of the 4551 children screened to be enrolled, only about 1300 were found to be eligible. Refusals for consent and withdrawals after group assignment was known were few.  The primary analysis group consists of 985 infants.  Twins and other eligible children living in the same household were also included in the study.  For study purposes, one child was randomly selected for group assignment, and the other’s status yoked to the study  child.  Thus, the overall study sample consisted of slightly over 1,000 children, although the primary analyses reflect only the primary  analysis group.  

## Reasons for Exclusion(n=3249)

**Notes:**
 Most of those excluded were on the basis that they did not live within the catchment zone of the educational center, the 45 minute drive thought to be the maximum for preschool children.  The notation here about gestational age over 37 weeks reflects the fact that the instrument  used to assess gestational age, tended to underestimate the duration of gestation by about two weeks.

## IHDP

- 985LBW,PT Infants

- Intervention
- n=382

- Follow-up
- n=623

- Mediating
- Variables

- Child
- Outcomes

- Secondary
- Effects

**Notes:**
The study population, thus consisted of 382 children assigned to the intervention and 623 assigned to the comparison arm.

## IHDP

- _IHDP_

- _Intervention_
- FU Services
- Home Visits
- Child Dev. Ctr.
- Parent Supp.Grp.

- _Follow-up_
- FU Services

- _Mediating Variables_

- _Child Outcome_

- _Secondary Effects_

**Notes:**
Children in both groups received high-risk follow-up services at 4-6 month intervals throughout.  The intervention group received an educational program delivered through a package of home visits, center-based services and parent support groups.

## Content of IHDP

- Follow-up Services
- 	(Every 3-6 Months)
- 	Frequent Health and Developmental
- 	Surveillance
- 	Referral for Health and Social Services
- Home Visits
- 	(Every week until 12 mons.then every other week)
- 	Partners for Learning Curriculum
- 	Parent Problem Solving
- 	Social Support

- Child Developmental Centers
- 	(5 days/week, 8 hours/day, 12-36 months)
- 	Partners for Learning
- Parent Support Groups
- 	Parent Education
- 	Social Support

## IHDP

- INT

- FU

- MED VARS

- _Child Outcomes_
- Cognitive Development
- (IQ)

- SE

**Notes:**
 For the major assessment points at 3,5 and 8 years of age, every attempt was made to obtain as a complete assessment as possible, including roving assessors at 3 and 8 years of age.  Cognitive assessments were completed on 93%, 82% and 89% at the three major data points.  Cognitive assessments were the Stanford Binet at age three, and the age-appropriate Weschler instruments at later ages.  School achievement was assessed using the Woodcock-Johnson instruments.

## Cognitive Outcomes of IHDP at Age 8-Total

- (SB=Stanford Binet, WPPSI=Weschler Preschool)

- p<0.05

**Notes:**
Highly significant results at age three with diminution in the overall sample by age 5and 8.

## Cognitive Outcomes of IHDP at Age BWT=2001-2500

- (SB=Stanford Binet, WPPSI=Weschler Preschool)

- *

- *

- *

- *p<0.05

**Notes:**
However, these results reflect largely the group under 2000 grams, as smaller but significant differences in IQ persisted in the heavier birth weight group.

## School Achievement Scores at Age 8 in IHDP

- p<0.05

- T=Total,H=Bwt 2001-2500,L=BWT<=2000,rd=reading,
- ma=math

**Notes:**
What also emerged in this group  was a differences in school achievement, significant for mathematics favoring the intervention group.  The differences for the total sample were not significant, nor were the comparisons for the smaller group.  

## IHDP

- INT

- FU

- MED VARS

- _Child Outcomes_
- Behavior

- SE

**Notes:**
 For the major assessment points at 3,5 and 8 years of age, every attempt was made to obtain as a complete assessment as possible, including roving assessors at 3 and 8 years of age.  Cognitive assessments were completed on 93%, 82% and 89% at the three major data points.  Cognitive assessments were the Stanford Binet at age three, and the age-appropriate Weschler instruments at later ages.  School achievement was assessed using the Woodcock-Johnson instruments.

## Behavioral Outcomes of IHDP-Total

- Parental Report on the Achenbach

- *

- *p<0.05

**Notes:**
A small but clinically important reduction in reported behavior problems was seen  following the intervention, but no differences at later ages.

## IHDP

- INT

- FU

- MED VARS

- _Child Outcomes_
- Health Status

- SE

**Notes:**
Because we were exposing LBW, preterm children to congregate child care at one year of age, we wished to document any potential negative side effects in terms of health.

## MEAN REPORTED MORBIDITY INDEXIHDP Intervention and Follow-up Groups, 36 months

- <=2000g

- 2001-2500g

- Mean
- (S.D.)
- Reported
- Morbidity
- Index

- N.S.

- p<0.001

**Notes:**
Indeed, the parents of those in the intervention groups reported more episodes of  illness than those in the follow-up group, only 18% of whom were in some sort of day care by the end of the study.

## OTHER HEALTH STATUS MEASURESIHDP Intervention and Follow-up Groups, 36 months

- Measure

- Reported Serious Morbidity Index			NS
- Stein Functional Status Scale				NS
- Growth						NS
-     Length						NS
-     Body Mass Index					NS
- General Health Ratings Scale				NS

**Notes:**
However, there was no difference in terms of serious episodes of illness (lasting >30 days, or requiring hospitalization or ER use), the effect of health problems on activities of daily living (Stein scaled) or health, or in parental ratings of child health.  Thus, we concluded that we had obtained substantial early benefits in cognitive and behavioral development at the price of a small number of short, not severe episodes of illness.

## IHDP

- INT

- FU

- MED VARS

- _Child Outcomes_

- _Secondary Effects_
- Health Services
- Use

**Notes:**
This was confirmed when we examined health care use.  This secondary effect was of potential concern as the literature documents substantial increases in health care use for the families of children in center based care. 

## MEAN NUMBER OF DOCTOR VISITSIHDP Intervention and Follow-up Groups, 36 Months

- Mean
- (SD)
- of
- Doctors
- Visits

- <=2000g

- 2001-2500g

- p=0.04

**Notes:**
A small, statistically significant increase in doctors visits was seen for the intervention group.  No other type of health care use was increased.  Most of this increase was seen in the second year of life, when the children entered into the centers.

## IHDP

- INT

- FU

- MED VARS

- _Child Outcomes_

- _Secondary Effects_
- Maternal Outcomes

**Notes:**
We also were interested in whether women would take advantage of the free day care to return to work or continue education.

## CHILD AGE AT MATERNAL ENTRY INTO WORKFORCEIHDP Intervention and Follow-up Groups

- % Employed

-                             Child Age (mons.)

**Notes:**
Intervention mothers were more likely to return to work earlier, but by three the overwhelming majority of mothers were working at least part-time.  These results were very different from earlier studies of disadvantaged children, suggesting a very different economic environment for families.  

## OTHER MATERNAL OUTCOMESIHDP Intervention and Follow-up Groups

- Subsequent Child-bearing		NS
- Further Educational Attainment	NS

**Notes:**
No differences in subsequent child-bearing or educational attainment were seen.

Where does IHDP fit in the intervention literature?

##  Early Intervention

- Modalities
- Home visiting
- Center-based
- Activities
- Education/Developmental stimulation
- Therapeutic (PT, OT, etc.)
- Parenting skills to prevent abuse

**Notes:**
I will not address the issues of child-focused intervention as being a relatively special field that is not my area of expertise.  When we come to parent-focused interventions, we can examine the effects of such programs by mode of intervention, the type of activities, and by target audience

##  Early Intervention

- Target Populations
- Socially disadvantaged infants
- Infants with identified neurodevelopmental disabilities
- Low birth, premature infants.

## Early Intervention for Disabled

- 53 Studies
- Criteria for Enrollment
- <36 months of age
- Principal problem was not poverty
- Child in home/foster care

- Shonkoff, 1987

## Summary of Meta-analysis

| Category of Disability | #Studies | Effect (SD) |
| --- | --- | --- |
| All | 46 | 0.62 |
| MR | 29 | 0.42 |
| Dev. Delay | 20 | 0.70 |
| Mixed | 24 | 0.94 |

- Shonkoff, 1987

## Perry Preschool Study: Economic effects at age 27

*Perry Preschool Study*: Economic effects at age 27

- _Source_: http://www.highscope.org

- 7%

- 29%

- 36%

- 13%

- 41%

- 20%

## Perry Preschool Study: Mean number of arrests by age 27

- 0.7

- 1.2

- 0.5

- 2.3 arrests

- 1.5

- 2.5

- 0.6

- 4.6 arrests

## Abecedarian Project: Reading scores at 8, 12, 15, and 21 years by preschool group

- _Note_: Standardized reading scores as measured by the Woodcock-Johnson.
- _Source_: Campbell, Ramey, Pungello, Sparling, & Miller-Johnson, in press.

## Abecedarian Project: Mathematics scores at 8, 12, 15, and 21 years by preschool group

- _Note_: Standardized mathematics scores as measured by the Woodcock-Johnson.
- _Source_: Campbell, Ramey, Pungello, Sparling, & Miller-Johnson, in press.

## Conclusion

- Post-natal environment is a powerful predictor of child outcomes, for all children
- Evidence is increasing that early childhood interventions can improve outcomes for children at risk for a variety of reasons
- Intensive programs may have lasting effects