TMW Center for Early Learning + Public Health Community-Wide Demonstration Project
Phase: NA
Conditions: Language Development
Sponsor: University of Chicago

Version Date : 3/23/2020 
TMW Center for Early Learning & Public Health Community-Wide Demonstration Project 
 
Protocol Title: TMW Center for Early Learning & Public Health Community Wide 
Demonstration Project 
PI: Dana Suskind, M.D. 
Funding: Internally funded, department funds 
Sponsor: University of Chicago PI 
Type of Research: Behavioral intervention 
Intervention: Experimental curricula to change parental knowledge and beliefs 
Protocol Version Date: 3/23/2020 
 

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TMW Center for Early Learning + Public Health 
Community-Wide Demonstration Project 
Protocol Narrative 
 
 
 
1. Introduction 
 
The TMW Center for Early Learning + Public Health has developed and individually tested a series 
of digital interventions aimed at impacting parent and caregiver knowledge, beliefs, and behavior 
to foster a child’s foundational language, cognitive, and social-emotional development.  The 
interventions include 3Ts-Newborn, 3Ts-Well Baby, 3Ts-Home Visiting, and 3Ts-Let’s Talk!, all of 
which comprise the TMW interventions. The 3Ts interventions were named for the three easy to 
use strategies that are shared with parents/caregivers to support their child’s development: Tune 
In, Talk More, and Take Turns. To date, the TMW Center has tested each of these interventions in 
randomized controlled trials, with an ultimate aim of implementing each as part of a 
comprehensive, multiple touchpoint intervention approach from birth through age three years 
(see Figure 1 below).  To this end, the TMW Center is launching a community-wide demonstration 
project in partnership with the Children’s Services Council of Palm Beach County, Florida, in which 
the TMW interventions will be delivered at scale through partners who work with families across 
health, education, and social service systems.  The goal of this partnership is to reach 60% of all 
families with children age birth through three with at least one TMW intervention over the five-
year partnership, with a significant percentage of families receiving more than one intervention.  
The TMW Center will evaluate the efficacy of the multiple intervention approach in impacting 
parent knowledge, beliefs, and behavior and child developmental outcomes, and develop an 
implementation model that can be used in other communities.  
 
 
Importance of Language Acquisition on Cognitive Development 
 
A child’s early language exposure is a primary component of language development and in 
ultimate educational and intellectual achievement (Bruner, 1981; Chapman, 2000; Gallaway & 
Richards, 1994; Hart & Risley, 1995; Huttenlocher, Haight, Bryk, Selzer, & Lyons, 1991; Rowe, 
2008).  Betty Hart and Todd Risley (1992) conducted a landmark study that demonstrated the 
tremendous impact of a child’s early language milieu on future learning, revealing a significant 
correlation between the number of words to which a child is exposed between the ages of 0-4 
years and his/her ultimate IQ and academic success (Hart & Risley, 1992; 1995).  Their findings 
were both significant and alarming, demonstrating the critical and time-sensitive role that early 
language exposure plays in a child’s life.  Their follow-up with the same children at 9-10 years of 
age confirmed that preschool and elementary school interventions came too late to alter these 
trajectories; the reverberations of early linguistic deprivation were likely to follow these children 
throughout their lives. 
 
Children born into poverty experience an overwhelming inequality in their early language 
experience.  Hart and Risley’s study revealed a steep socioeconomic gradient in early exposure to 
language.  At the end of their third year of life, children from families of high-socioeconomic status 
(SES) heard approximately forty-five million words while children from low-SES backgrounds 

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heard only approximately thirteen million.  The tragedy for these children is not unalterable.  It is 
neither genetics nor a lack of potential that lies at the heart of this inequality.  Rather, it is 
inadequate parental knowledge of child language development.  Rowe (2008) demonstrated that 
the relationship between SES and parental communication ability is mediated by parental 
knowledge.  Other studies have corroborated this, showing that the effect of SES on a child’s 
vocabulary was primarily dictated by maternal speech (Hoff, 2003).  Encouragingly, studies have 
also demonstrated that a well-planned parent-directed language intervention may increase low-
SES parents’ use of facilitative language with their children (Oneil-Pirozzi, 2009; Suskind et al., 
2013).  The TMW Center for Early Learning + Public Health – formerly the Thirty Million Words 
Initiative – was founded, in part, to develop and implement such interventions, via the suite of 
TMW Curricula. 
 
 
Advancing the science of scaling 
 
Several of the TMW interventions have already been implemented and evaluated individually at 
small scale through randomized controlled trials and have demonstrated efficacy in raising 
parents’ knowledge of child development and improving the quality of parent-child interactions 
(Leung et al. 2018, Suskind et al. 2018, Suskind et al. 2016). Yet little is known about the way 
findings from small-scale, controlled experiments are affected when the interventions are scaled 
up, calling into question the applicability of experimental findings to broad-scale interventions, 
with crucial implications for policymakers and researchers. As discussed in a series of papers from 
Al-Ubaydli et al. (2017), neither the population nor the situation of experimental studies are 
usually representative of the larger population and situation they would be generalized to (for 
example, the intervention is delivered in a different way, or adherence is usually lower at scale). 
Therefore, the effects found in experimental studies can substantially differ from the effects that 
one would observe at large scale. This community-wide implementation will allow the TMW 
Center to document the challenges involved in the scaling process and give us a unique 
opportunity to evaluate the effects of the interventions in a non-experimental and more realistic 
setting.   
 
In 2018, the TMW Center conducted a request for partnership process and identified the 
Children’s Services Council of Palm Beach County, Florida (CSC) as its partner in developing and 
implementing this community-wide implementation approach.  The TMW Center and CSC are 
committed to a five-year partnership through 2023, during which the TMW interventions will be 
offered to families receiving care or participating in programming in Palm Beach County hospitals, 
pediatric clinics, and community agencies.  The CSC is a governmental agency in Palm Beach 
County charged with allocating a local property tax revenue stream that is dedicated to supporting 
services for children from birth to age 18 outside of K-12 education, with a focus on prevention 
and early intervention services.  In this vein, the CSC funds social service agencies across Palm 
Beach County that deliver services to pregnant women, children, and families. The TMW Center 
will train CSC partner agencies that already work in hospitals and CSC-affiliated pediatric clinics 
to distribute TMW interventions with local Palm Beach families.  See below for detailed 
descriptions of the relationships between TMW Center, CSC, CSC-funded agencies, and 
participating hospitals and clinics. 
 
Program implementation 

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Beginning in early 2020, the interventions will be delivered in one hospital (St. Mary’s Medical 
Center) and three to five pediatric clinics (Soma Medical Center, P.A. #3, Soma Medical Center, P.A. 
#4, Military, and others still to be named).  Once the implementation model is developed further, 
TMW Center and CSC partners will then extend programming to other CSC partner hospitals, 
clinics, and community agencies in the county. Three interventions will be offered to 
parents/caregivers across the birth through age three range:  
1. 3Ts-Newborn, a video shared with parents/caregivers during a universal screening in 
hospital mother-baby units;  
2. 3Ts-Well Baby, four videos shared during well child immunization visits at 1-, 2-, 4-, 
and 6-months in pediatrician offices; and  
3. 3Ts-Let’s Talk!, a series of eight group classes involving education, feedback, and goal 
setting for parents/caregivers of children age one through three, delivered in a 
community-based organization.  
 
The TMW Center and its partners will offer the interventions to parents/caregivers of children 
within the eligible age range in the partner birthing hospitals, pediatric clinics, and community 
agencies of Palm Beach County.  The interventions will be offered to all parents/caregivers who:  
 
can engage in English or Spanish content,  
 
have a child in the specified age range for each intervention, and  
 
are receiving services or engaging in programming in partnering institutions. 
Further selection criteria for each intervention are described in the “TMW Interventions 
Description” section below.  The institutions CSC will engage to participate in this study are all 
within a target set of zip codes that has been determined by CSC.  
 
 
 
 
TMW Tech Platform 
To facilitate the delivery of the digital interventions to parents/caregivers, support providers in 
offering the interventions to families, and collect data for the program evaluation, TMW Center 
has built the TMW Tech Platform.  This Tech Platform will collect informed consent, play the video 
interventions, facilitate the collection of survey data, and provide a dashboard for The TMW 
Center to monitor parents/caregivers’ progress through the intervention. Participants will 
Figure 1 : TMW Interventions 

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complete surveys during the interventions in partner sites and will be texted or emailed links to 
complete surveys in the later time points not connected to specific interventions, as specified in 
the Study Timeline on page 7 below. There is a parent-facing component that participants can 
access using a phone, tablet, or computer.  The TMW Tech Platform will also send text messages 
or nudges to encourage further participation throughout the interventions and to reinforce 
content so as to help parents/caregivers build habits (York et al. (2018) and Doss et al. (2018)). 
These text messages will be content nudges to remind participants of ways they can use the 
strategies learned throughout the interventions in their day to day life. For example, “remember 
to use the 3Ts to build your baby’s brain while you drive to school!” 
 
Through the parent-facing component, participants will be given access to additional videos and 
educational resources that they can continue to view after completing the educational 
interventions. These online educational components are optional and parents/caregivers can 
view as many or as few as they wish throughout the course of the study. Samples of screens that 
the parent/caregivers will see while logged into the app are included in Appendix D  
 
2. Protocol 
 
General idea 
 
To evaluate the impact of the interventions, we need to compare the outcomes of families who 
receive them (treated families) to the outcomes of families who do not (comparison families), 
making sure those two types of families are on average comparable initially. The sample of treated 
families will consist of all the families who enroll in the TMW interventions in the hospitals and 
clinics of the treated community (the target zip codes for intervention delivery). To define the 
sample of comparison families, the TMW Center and CSC will work to find a comparison hospital 
with similar socioeconomic characteristics and child developmental outcomes as the treated 
community. Then within this comparison group, we will define a sample of comparison families 
who have similar individual characteristics as the treated families (based on data shared by CSC 
and baseline data we will collect). Once the samples of treated and comparison families are 
defined, we will follow them over time to compare the evolution of their outcomes. Comparison 
group data collection will begin in 2021. The enrollment and data collection plan will be 
established in conjunction with the CSC and elaborated in this protocol prior to enrolling any 
participants. 
 
We will collect survey data from all participants who enroll in a TMW program.  In doing so, we 
will collect data at a population level that will allow for deeper machine learning analysis and for 
eventual optimization of the metrics that need to be collected at a population level to monitor 
program effects.   
 
The ideal progression through the TMW interventions is the following: parents/caregivers enroll 
in the program on the mother-baby unit, on a continuous basis, in all the hospitals where the 3Ts-
Newborn intervention will be in place. Before watching the 3Ts-Newborn video, we will gain 
informed consent and then collect demographic information and a survey eliciting participants’ 
beliefs and expectations of child development. We will then engage with families in partnering 
pediatric clinics, starting at their first well-child checkup, where they will receive the 3Ts-Well 
Baby intervention.  In later years of the partnership (beginning in 2021), parents/caregivers can 

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participate in the 3Ts-Let’s Talk! intervention through a local participating social service agency. 
Throughout this participation, parents/caregivers’ beliefs and behaviors as well as children’s 
development will be regularly assessed through surveys administered by the TMW Tech Platform 
before and after each program.  
 
The TMW Tech Platform is designed modularly, so that parents/caregivers are not required to 
have participated in a previous intervention to participate in a subsequent intervention.  For 
instance, a parent could participate in 3Ts-Newborn, but not 3Ts-Well Baby, and then could 
participate in 3Ts-Let’s Talk! at a later time, or they could participate solely in 3Ts-Well Baby.  Prior 
to engaging with TMW interventions for the first time – regardless of which intervention is 
selected – participants will complete the informed consent module on the TMW Tech Platform. 
 
In the comparison group, we will ask participants to fill out the same series of surveys, at the same 
age points (birth, 6, 9, 12, 24 and 36 months). This large-scale continuous data collection in both 
the treated and comparison groups is crucial to evaluate the impact of the interventions, and will 
also be a valuable source of real time information for clinics on the population’s needs. 
Comparison group families will also complete an informed consent module before filling out any 
surveys.  Further detail regarding recruitment and enrollment of this comparison group of 
families will be amended to this protocol prior to beginning that phase of the study. 
 
 
TMW Intervention Descriptions 
Please see below for further information about each of the TMW interventions. 
 
3Ts-Newborn 
This intervention is completed with parents/caregivers of newborns while they are still on the 
maternity ward. Participants will complete the 3Ts-Newborn educational intervention after 
finishing Florida’s Universal Infant Risk Screen, conducted by the HomeSafe agency. After 
completing the eConsent module and providing basic demographic data (parent name, child date 
of birth, and parent date of birth), participants will complete the 20-item version of the SPEAK 
survey using the tablet. After this, they will watch the 10-minute education intervention video, 
also on the tablet. Finally, parents/caregivers will complete a post-intervention 10-item version 
of the SPEAK survey using the tablet. 
 
3Ts-Well Baby 
The 3Ts-Well Baby Intervention will take place in pediatricians’ offices during regularly schedule 
immunization appointments. All participants at participating locations will be offered the 
opportunity to complete a video module at their child’s appointment from the ages of 1 to 6 
months. This intervention will take place in the clinic entirely on a tablet. If a participant did not 
complete the 3Ts-Newborn intervention, they will complete the eConsent module, provide basic 
demographic information (parent name, child name, child date of birth, parent date of birth), 
and the 10-item SPEAK survey prior to viewing the first educational module. Participants who 
return for multiple well-child appointments while the child is younger than 7 months may 
complete up to a total of 4 educational video modules, one per visit. All participants who 
complete Module 4 will also complete a post-intervention 10-item SPEAK survey, using the 
tablet. 
 

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3Ts Let’s Talk! 
Beginning in 2021, the 3Ts-Let’s Talk! intervention will be offered to parents/caregivers who 
engage in community programming in Palm Beach County. Participants need not have 
completed previous interventions to be part of this intervention, and if this is their first 
interaction with TMW, will complete the eConsent module, provide basic demographic 
information (parent name, child name, child date of birth, parent date of birth), and complete the 
10-item SPEAK. 3Ts Let’s Talk! will take place at partnering community organizations and 
participants will review educational modules with other parents/caregivers in a group setting. 
 
 
 
 
Measures 
 
The study timeline below presents the measures we plan to collect, at which ages, for the three 
dimensions of interest: parent behaviors, parent beliefs, and child development (see the Appendix 
A.1. for the list of acronyms). We have prioritized scales that have been validated, have evolutive 
versions allowing them to be used longitudinally, have a Spanish version, are relatively short, and 
predict longer run outcomes.  We outline below the full set of measures that we will collect from 
families who participate in every TMW intervention starting at birth.  For families who participate 
in fewer than the full set of interventions, we will collect data starting from their first intervention 
(e.g. the first 3Ts-Well Baby session) through the remainder of their participation. In addition, 
basic demographic information (parent name, child name, child date of birth, parent date of birth)  
will be collected by all participants only once at the start of their first intervention, regardless of 
child’s age. Participants can choose to opt out from the interventions at any time, or to not 
participate in a particular assessment time point. All measures will be completed by the 
participant through the TMW Tech Platform. 

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2Y + 2 weeks 
Baby 
Speak 10 
PACOTIS 
1Y – 2 weeks 1Y + 2 weeks 2Y – 2 week 
3Y – 2 weeks 
5Y 
Baby 
Speak 10 
StimQ 
(reading) 
0-5 SPEAK 
10 
StimQ 
(reading) 
MCDI I-SF 
PACOTIS 
 
MCDI II-SF 
PACOTIS 
 
0-5 SPEAK 
10 
StimQ 
(reading) 
3Y + 2 weeks 
MCDI II_SF 
PACOTIS 
 
CSC data sharing 
Kindergarten readiness 
3Ts-Newborn 
3Ts-Well Baby (1-6 months) 
3Ts-Let’s Talk ! (variable start, 0-3 years) 
0M 
1M 
6M 
9M 
Consent 
SPEAK 20 
Demographics 
Consent 
Demographics 
Baby Speak 10 
*not done if 
they 
participated in 
3Ts-newborn* 
Baby Speak 10 
PACOTIS 
 
*done at 
conclusion of 3Ts 
– Well Baby video 
#4* 
Completed remotely via personal device on TMW 
app 
In Hospitals 
In Pediatric Clinics 
In Community Organizations 
In clinic via 
the TMW-
Web 
Platform 
In clinic via 
the TMW-
web 
platform 
 
In clinic via 
the TMW-
web 
platform 
Data Sharing 
Study Timeline 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Baseline 
These measures will be collected at the parent’s first interaction with the TMW study, regardless 
of time point. Following the eConsent, participants will be asked to provide contact information 
and basic demographic information, including their name, their date of birth, and their child’s date 
of birth. Then participants will be asked to fill out one survey, the Survey of Parental Expectations 
and Knowledge about Language Learning (SPEAK) that assess their knowledge and beliefs. The 
version of the SPEAK to be used will depend on the child’s age and at which intervention they are 
completing the baseline measures. If done at the 3Ts-Newborn intervention, participants will 
complete SPEAK-20. If done at the start of the 3Ts-Well Baby intervention, participants will 
complete the Baby SPEAK-10.  Consent and surveys will be collected digitally through the secure 
online platform. 
 
6 months 
At age 6 months participants will be asked to fill out the Baby SPEAK-10 and PACOTIS surveys, 
either onsite at their pediatric visit via the tablet provided by CSC partners or at home by logging 
into the TMW Tech Platform.  Participants in the treatment community will have access the 
surveys upon completion of the fourth 3Ts-Well Baby intervention Video, while participants in the 
comparison group will receive a notification from the TMW Tech Platform that it is time to 
complete the surveys. These surveys will take approximately 10 minutes to complete. 
 
9 months 
At age nine months, all participants will be asked to fill out two surveys, the Baby SPEAK-10 and 
the PACOTIS. The PACOTIS is a self-report measure of the respondent’s perceived impact on their 
child’s development. All participants will receive a notification from the TMW Tech Platform that 
it is time to complete the surveys. These surveys, which are completed through the TMW Tech 
Platform, will take approximately 10 minutes to complete. 
 
12 months 
Two weeks before the child turns 12 months, participants will receive a notification from the TMW 
Tech Platform that it is time to complete their next surveys. They will be asked to complete the 
Baby SPEAK-10 and the StimQ-Reading Subscale. The StimQ is a parent report measuring parental 
verbal responsivity and involvement in their child’s development. 
 
Two weeks after the child turns 12 months, participants will receive another notification from the 
TMW Tech Platform asking them to complete a second set of surveys, consisting of the MacArthur-
Bates Communicative Development Inventories: Short Form Level 1 (MCDI I-SF) and the PACOTIS. 
The MCDI I-SF is a parent report assessing children’s vocabulary comprehension and production, 
appropriate for children 8-18 months. These surveys, which are completed through the TMW 
Tech Platform, will take approximately 10 minutes to complete. 
 
 
 
 
 
 

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24 months 
Two weeks before the child turns 24 months, participants will receive a notification from the TMW 
Tech Platform that it is time to complete their next surveys. They will be asked to complete the 
SPEAK-10 and the StimQ-Reading Subscale. These surveys, which are completed through the 
TMW Tech Platform, will take approximately 10 minutes to complete. 
 
Two weeks after the child turns 24 months, participants will receive another notification from the 
TMW Tech Platform asking them to complete a second set of surveys, consisting of the MacArthur-
Bates Communicative Development Inventories: Short Form Level 2 (MCDI II-SF) and the 
PACOTIS. The MCDI II-SF is an extension of the MCDI-I-SF and is appropriate for ages 16-30 
months. These surveys, which are completed through the TMW Tech Platform, will take 
approximately 10 minutes to complete. 
 
36 months 
Two weeks before the child turns 36 months, participants will receive a notification from the TMW 
Tech Platform that it is time to complete their next surveys. They will be asked to complete the 
SPEAK-10 and the StimQ-Reading Subscale. These surveys, which are completed through the 
TMW Tech Platform, will take approximately 10 minutes to complete. 
 
Two weeks after the child turns 36 months, participants will receive another notification from the 
TMW Tech Platform asking them to complete a final set of surveys, consisting of the MacArthur-
Bates Communicative Development Inventories: Short Form Level 2 (MCDI II-SF) and the 
PACOTIS. Spanish speaking participants will not complete the MCDI II-SF at 36 months, because 
the Spanish version does not go beyond 30 months, while an extension to 37 months has recently 
been developed in English. These surveys, which are completed through the TMW Tech Platform, 
will take approximately 10 minutes to complete. 
 
 
Project stakeholders and exact location of research 
This partnership consists of many stakeholders who are involved in varying capacities with the 
delivery of the TMW interventions.  The following chart lays out the stakeholders and their roles 
with the project. 
 
Stakeholder 
Role 
TMW Center  
Research center at the University of Chicago.  Intervention 
creation, training, technical assistance, evaluation.  Project 
owner for the research evaluation. 
Children’s Services Council of 
Palm Beach County (CSC) 
Governmental, countywide agency in Palm Beach County, FL.  
Convener of implementing parties in Palm Beach County, 
partner 
in development 
of 
a 
replicable 
intervention 
implementation model.  The CSC funds various services for 
children and families across Palm Beach County, including 
services provided by HomeSafe (detailed below).  No CSC staff 
will have direct interaction with participants.   
 
TMW Center and CSC have a signed MOU in place that provides 
for the five-year partnership.  The two parties will exchange 
identifiable and anonymous-level data per the terms of a data 
sharing agreement amended to their MOU. 

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HomeSafe 
Social service agency that serves as the entry agency for CSC’s 
System of Care.  HomeSafe delivers a universal Infant Risk 
Screening in all birthing hospitals across Palm Beach County.  
HomeSafe’s Hospital Liaisons will offer the 3Ts-Newborn 
intervention to parents/caregivers in conjunction with their 
delivery of the Infant Risk Screening at St. Mary’s Medical 
Center. 
 
The CSC funds HomeSafe and has a contractual agreement in 
place to provide for HomeSafe’s participation in the 3Ts-
Newborn intervention.  TMW Center is establishing a reliance 
agreement with HomeSafe to recognize University of Chicago’s 
IRB as the single site of record for the study. 
St. Mary’s Medical Center 
Largest birthing hospital in Palm Beach County.  HomeSafe 
Hospital Liaisons will offer 3Ts-Newborn postpartum to 
parents/caregivers in the St. Mary’s mother-baby unit.  No St. 
Mary’s medical staff will be involved in the delivery of the 3Ts-
Newborn intervention.  TMW Center has secured permission 
from St. Mary’s Medical Center to deliver 3Ts-Newborn in their 
hospital to their patients. 
Soma Medical Center 
Group of adult and pediatric primary care medical clinics in 
Palm Beach County.  Soma Medical staff will offer 3Ts-Well 
Baby to parents/caregivers of children receiving care in Soma 
clinics.  As detailed below in Section 4, Soma’s front desk staff 
will offer the 3Ts-Well Baby intervention to parents/caregivers 
at the start of their clinic visit.  Soma medical assistants (MAs) 
will assist parents/caregivers in accessing the videos and 
surveys and close out intervention sessions on the tablets. 
 
 
Please see Appendix B for the partnership structure and contractual agreements that support this 
work. 
Over the course of the five-year partnership, more hospitals and clinics will begin to offer TMW 
interventions in the context of their care.  The TMW Center and CSC will work to identify 
appropriate partner agencies to offer 3Ts-Let’s Talk, anticipated to begin in 2021.  The TMW 
Center will work with each stakeholder to establish a reliance on the University of Chicago’s IRB 
prior to that stakeholder offering the intervention to any parents/caregivers.  The TMW Center 
and CSC have a signed MOU in place for the partnership that will be updated annually. 
 
All survey collection for the 9, 12, 24, and 36 month time points will be completed via the TMW 
Tech Platform that a participant can access via their personal smartphone, tablet, or computer. 
 
3. Statistical methodology 
 
Assessing the impact of a program at large scale raises several statistical challenges.  To identify 
the causal effect of a program, one needs to compare the outcomes of families who receive the 
interventions to the outcomes of families who did not receive them, making sure the two types of 
families are on average initially comparable. At small scale, such comparability is obtained 
through randomization of families into treatment or control group pre-intervention and 
comparison of average outcomes post-intervention. When the treated unit is an entire community, 
Figure 2 : Project stakeholders 

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applying such an experimental method would require obtaining a sample of communities, and 
implementing the program in a randomly selected subset of them. This poses a substantial 
logistical and financial challenge. In practice, interventions will be implemented in only one 
community, so we will need to rely on non-experimental techniques such as difference-in-
differences, matching, and synthetic control. Those methods, although they rely on different types 
of data and assumptions, all aim at recovering the (counterfactual) situation of the community 
receiving the interventions, had it not received any intervention.  
 
The synthetic control approach consists of using all available comparison groups and weighting 
their outcome (e.g. school readiness score) such that the weighted sum of control outcomes is as 
close as possible to the outcome of the treated community before intervention. The impact of the 
intervention is measured as the difference between the outcome of the treated group after 
intervention and the weighted sum of control outcomes after intervention (i.e. the "synthetic" 
control), computed with the weights that have been determined before intervention (Abadie & 
Gardeazabal (2003), Abadie et al. (2010)). Given that this approach requires outcome data for 
several untreated groups, during several years before intervention, we will only be able to use it 
for measures that hospitals, pediatric clinics or schools of PBC already collect (e.g. pediatricians’ 
screeners or school readiness measures). 
 
The difference-in-differences approach consists of choosing one comparison group and 
comparing the evolution of the outcome of the treated group before and after intervention to the 
evolution of the outcome of the comparison group between the same dates. The impact of the 
intervention is measured as the difference between these two trends (being themselves 
differences over time, hence the name), assuming outcomes evolve the same way in the 
comparison group as in the treated group, had it not received any intervention (Card (1990)). For 
this assumption to be plausible, the choice of the comparison group, as well as the choice of the 
sample of families to be surveyed inside this group to measure average outcome, is crucial.  To 
help determining the comparison group and control families, we will combine difference-in-
differences with matching methods.  
 
Matching consists of using pre-intervention characteristics of the treated and control units 
(communities, families) and finding for each treated unit the control unit that has the same 
characteristics. If we observe a large number of characteristics, it becomes impossible to match 
treated and control units on all these characteristics, so we instead compute for each unit a score 
that summarizes these characteristics in one dimension, and match treated and control units 
based on this score (propensity-score matching). Those methods guarantee that treated and 
control units have similar observed characteristics and are thus more likely to evolve the same 
way.  
 
Difference-in-differences method requires data from only one comparison group (as opposed to 
synthetic control), so it will be suitable for the measures we need to collect on our own (Table 1). 
Statistical tests will be used to assess the level of significance of the impacts. We will also use 
machine learning techniques to investigate the heterogeneous impacts of the interventions. 
 
 
4. Recruitment and exclusion criteria 
 

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Staff of the partner agencies and clinics (outlined in Figure 2, above) will be trained to offer the 
TMW interventions to parents/caregivers in the course of their regular work in hospitals and 
clinics. These staff will be trained by the TMW Center to initiate a parent’s interaction with the 
TMW Tech Platform, and will offer potential participants a tablet (iPad or other) on which they 
can view an informational video and complete the eConsent module if they choose.  The 
informational video will be created by the TMW Center to introduce potential participants to the 
TMW interventions, present the opportunity to participate in the study, and outline potential risks 
and benefits of participation.   
 
Parents/caregivers on the postpartum mother-baby unit will be systematically and continuously 
approached in their rooms at the end of the newborn’s hearing screening or infant risk screening 
(both of which are conducted universally in all Florida hospitals) and offered to enroll in the TMW 
interventions and engage with 3Ts-Newborn. All parents/caregivers with a live birth who speak 
English or Spanish will be offered participation at this time point, with the exception of 
parents/caregivers whose newborn is very ill and in the NICU and parents/caregivers with open 
cases with the Department of Children and Families in which the child may be removed from 
custody.  These participants may participate in the TMW interventions at later time points and 
will not be excluded from later participation.  Underage parents/caregivers age 16 and older are 
considered emancipated by Florida law upon the birth of their child and will be offered the 
intervention. 
 
Parents/caregivers will be offered the opportunity to receive the 3Ts-Well Baby interventions 
during the first six months of Well Child pediatric visits. Front desk staff at partner pediatric clinics 
will be trained by the TMW Center to briefly describe the study and ask any parent with a child 
within the target age range (0-6 months) if they would like to learn more about participating. If 
the parent expresses interest, the front desk staff will look them up in the TMW Tech Platform, 
using their name and birthdate as an identifier, to determine if they have already participated in 
any 3Ts programming (3Ts-Newborn or earlier 3Ts-Well Baby modules). If the participant has 
already consented as part of a previous intervention, they will be given the iPad to watch the next 
3Ts-Well Baby educational video. If they are new to the system, the front desk staff will set them 
up with a new account and have the participant view the informed consent module before 
beginning the intervention.  No identifying information about the parent or child will be saved in 
the TMW Tech Platform until the parent has given informed consent. 
 
Per discussions with our partner pediatric clinics, front desk staff are the ideal staff to introduce 
the study to eligible families and set them up to use the tablet because they have more time to give 
parents/caregivers one-on-one attention than other medical staff. Because of this, our partner 
pediatric clinics have advocated strongly for the front desk staff to address parents/caregivers 
about participation. These front desk staff are trained on how to support parents/caregivers and 
share resources with them, and will be thoroughly trained by TMW staff on how to present the 
intervention.  Parents/caregivers will take the tablet with them throughout the clinic visit to 
engage in the survey and video components during downtime.  Medical Assistants (MAs) will 
support participants’ use of the tablet as needed during the visit, and will close out sessions on the 
tablet once a participant has finished. 
 
Beginning in 2021, parents/caregivers will also be offered the opportunity to receive 3Ts-Let’s 
Talk! upon engaging with a partner agency that is offering the 3Ts-Let’s Talk! parent classes.  All 

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engagement for this participation will be conducted via the TMW Tech Platform.  At all times, if 
the parent has not previously enrolled in the TMW interventions, he/she will first receive the 
informed consent module and provide basic demographics information (parent name, child name, 
and parent and child DOBs) before receiving any other content. 
 
Exclusion criteria are as follows: 1) parents/caregivers under the age of 18 who are not 
emancipated minors (In Florida, all minors 16 and older who give birth are automatically 
considered to be emancipated minors, and therefore will be eligible for this study), 2) 
parents/caregivers who do not have legal custody of their child, 3) parents/caregivers who do not 
speak enough English or Spanish to receive their educational information in that language.  As 
mentioned earlier, parents/caregivers whose infant is very ill will not be approached at the 3Ts-
Newborn time point, but will have opportunity to participate in subsequent TMW programs. 
 
 
5. Consent 
 
Because we will be offering the intervention universally through programming in hospitals, 
clinics, and community agencies across Palm Beach County, it is critical that the consent process 
be consistent in order to ensure that participants are fully informed of the nature of the study and 
their rights.  We will therefore deliver the consent through the TMW Tech Platform, which allows 
us to standardize this process and ensure each potential participant receives the same 
information, and to ensure that all signed consents are documented and stored in a secure 
manner.   
 
Prior to enrollment, all participants will engage in the TMW Tech Platform’s informed consent 
module. This module will be shown at the first time point the participant engages with. For 
example, if a participant does not engage with the 3Ts-Newborn intervention, they will view the 
informed consent module prior to beginning the 3Ts-Well Baby intervention. This consent module 
will grant consent to participate in any number of subsequent TMW interventions so that 
participants do not have to be re-consented at each time point. In this module, participants will 
watch a short informational video that introduces the TMW interventions, explains the study, 
outlines risks and benefits, and clarifies the optionality of participation.  Embedded throughout 
this video are quiz questions that check for understanding of the content of the video and reinforce 
the important points of participating.  The participant will then be offered the opportunity to 
enroll and will read and digitally sign the consent form.  Only once this consent is complete will 
the participant be able to engage with the TMW interventions.  Upon signing, a digital copy of the 
consent will be made available to the participant by a link sent to their email or phone number 
(via SMS text).   
 
After answering each comprehension check question, the correct information about the study will 
be reinforced to the participant.  Please see Appendix C for the workflow of this eConsent process. 
 
The TMW Center team will work with the IRB to finalize the script of this consent video, the 
comprehension check questions, and the workflow of the eConsent process prior to creating the 
eConsent video and building out the module on the Tech Platform.  Spanish speaking participants 
will receive the informed consent module in Spanish. After receiving IRB feedback and approval 
on the English consent script and document, the materials will be translated into Spanish. 

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Participants have the contact information of the TMW Center’s Technical Assistance coordinator 
who is local to Palm Beach County.  The Coordinator can answer any questions that they have 
about the study both before enrolling and during their participation in the study. 
 
As part of the eConsent module, participants will complete a separate HIPAA authorization form, 
through a digital signature on the TMW Tech Platform, to allow their data to be shared between 
the TMW Center, CSC, and the Florida Department of Health. 
 
6. Confidentiality and Data Sharing 
 
The TMW Tech Platform will collect and store all assessment and participation data from enrolled 
participants.  The TMW Tech Platform is currently being designed and built, in alignment with the 
security and authentication specifications of the University of Chicago Information Security Office 
(ISO).  The TMW Tech Platform is hosted on the servers of the University of Chicago Center for 
Research Informatics’ (CRI) Kenwood Data Center.  CRI will provide the Tech Platform’s ongoing 
support and maintenance.  We will secure a full Authorization to Operate for the Tech Platform 
from the ISO prior to beginning this evaluation.  
 
Data will be collected exclusively in electronic form via the TMW Tech Platform.  Only trained and 
authorized research personnel will have access to the data.  Data will be carefully monitored on 
an ongoing basis to ensure the privacy and confidentiality of participant data.  Participant records 
will be assigned anonymous alphanumeric unique identifiers in order to minimize the risk of data 
being associated with a participant’s identity.  Access to the database and the ability to modify the 
system will be restricted to trained research personnel with specific reason to access it.   
 
Per the terms of a data sharing agreement executed by University of Chicago’s University Research 
Administration (URA), identifiable data for enrolled participants that includes program 
participation, assessment scores, and kindergarten readiness data will be shared with and 
received from the Children’s Services Council of Palm Beach County.  The TMW Center and CSC 
will link participants’ unique identifiers from the TMW Tech Platform and CSC’s data collection 
system in order to verify the records to share.  All data will be transmitted through a secure file 
transfer protocol (or similar) and will be maintained according to the data sharing agreement. 
Participants will grant permission for this during the informed consent process. The TMW Center 
will share the following information with CSC: Data about which 3Ts interventions a participant 
completed, enrollment and opt-out rates, results from surveys administered throughout the study 
(as listed in the Measures section of this document). In order to match records, the TMW Center 
will disclose the parent name, parent date of birth, child name, and child date of birth. The CSC 
will share the following information with the TMW Center: Data about what CSC and community 
programming a participant completes and any parent or child assessments collected as part of 
those programs, and kindergarten readiness scores which the CSC collects in the course of their 
work with families. Neither the TMW Center nor CSC will share this information with anyone else. 
 
The TMW Center will also receive identifiable demographic information for enrolled participants 
from Florida’s Department of Health’s vital statistics through a data sharing agreement.  These 
data will include the participant’s zip code, household income, education level, birth metrics, 

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insurance status, and other household and demographic information.  Participants will grant 
permission for this during the informed consent process and through a stand-alone HIPAA 
authorization form. The TMW Center will not share this information with anyone else. 
 
7. Financial considerations 
Participants will not be compensated for their participation.  There is no financial cost to 
participants. 
 
8. Risks and benefits 
 
Given the educational nature of this research, minimal risks are anticipated. Participation involves 
receiving educational materials and answering survey questions. Sharing this information poses 
a risk of a potential loss of confidentiality.  As described above, these risks will be mitigated by a 
comprehensive data privacy and security strategy with the TMW Tech Platform and thorough 
training for research personnel to ensure data are handled appropriately.  
 
For parents/caregivers, potential benefits include increased knowledge of the importance of early 
childhood language and cognitive development and skills to support that development. For the 
hospitals and clinics, benefits include evidence-based educational materials for their patients and 
valuable information on their patients’ and community’s needs.  
 
9. Conflict of interest 
 
There is no COI with regard to the conduct of this project. 
 
10. Publication plan 
 
Dr. Suskind, Prof. List, and their research teams will publish the primary findings of the project in 
academic journals and field-specific publications.  Results will be analyzed for a first manuscript 
during or after the second year of the study and additional manuscripts will follow. 
 
 
 
 
 
 
 
 
 
 
 

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References 
 
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Country. American Economic Review, 93(1), 113-132 
 
Abadie, A., Diamond, A., & Hainmueller, J. (2010). Synthetic control methods for comparative case 
studies: Estimating the effect of California’s tobacco control program. Journal of the American 
statistical Association, 105(490), 493-505 
 
Al-Ubaydli, O., List J.A., LoRe, D., Suskind, D. (2017). Scaling for Economists: Lessons from the non-
adherence problem in the medical literature. Journal of Economic Perspectives, 31(4), 125-144 
 
Al-Ubaydli, O., List J.A., Suskind, D. (2017). What can we learn from experiments? Understanding 
the threats to the scalability of experimental results. American Economic Review. Papers & 
Proceedings, 107(5), 282-286 
 
Bruner, J. S. (1981). The social context of language acquisition. Language & Communication, 1, 
155–178 
 
Card, D. (1990). The impact of the Mariel boatlift on the Miami labor market. ILR Review, 43(2), 
245-257 
 
Chapman, R. (2000). Children’s language learning: An interactionist perspective. Journal of Child 
Psychology and Psychiatry, 41, 33–54 
 
Doss, C., Fahle, E. M., Loeb, S., & York, B. N. (2018). More than Just a Nudge: Supporting 
Kindergarten Parents with Differentiated and Personalized Text-Messages. Journal of Human 
Resources 
 
Gallaway, C. & Richards, B. J. (1994). Input and interaction in language acquisition. Cambridge, 
England: Cambridge University Press 
 
Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experience of young 
American children.  Baltimore, MD: Brookes 
 
Hart, B., & Risley, T. R. (1992). American parenting of language learning children: Persisting 
differences in family child interaction observed in natural home environments. Developmental 
Pyschology, 28, 1096–1105 
 
Hoff, E. (2003), The specificity of environmental influence: Socioeconomic status affects early 
vocabulary development via maternal speech, Child Development, September/October 2003, 
74(5), 1368-1678 
 
Huttenlocher, J., Haight, W., Bryk, A., Selzer, M., & Lyons, T. (1991). Early vocabulary growth: 
Relation to language input and gender. Development Psychology, 27, 236–248 
 

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Leung, C. Y.Y., Hernandez, M., Suskind, D.L., Enriching home language environment among families 
from low-SES backgrounds: A randomized controlled trial of a home visiting curriculum, Early 
Childhood Research Quarterly, 2018 
 
O'Neil-Pirozzi, T. M. (2009). Feasibility and benefit of parent participation in a program 
emphasizing preschool child language development while homeless. American Journal of Speech-
Language Pathology, 18(3), 252-263 
 
Rowe, R. L. (2008). Child-directed speech: relation to socioeconomic status, knowledge of child 
development and child vocabulary skill. Journal of Child Language, 35, 185–205 
 
Suskind, D. L., Y., C. Y., Webber, R. J., Hundertmark, A. C., Leffel, K. R., Fuenmayor Rivas, I. E., & 
Grobman, W. A. (2018). Educating Parents About Infant Language Development: A Randomized 
Controlled Trial. Clinical Pediatrics, 57(8), 945–953 
 
Suskind, D., Leffel, K., Graf, E., Hernandez, M., Gunderson, E., Sapolich, S., Suskind, E., Leininger, L. 
Goldin-Meadow, S., Levine, S. C. (2016). A parent-directed language intervention for children of 
low socioeconomic status: A randomized controlled pilot study. Journal of Child Language, 43(2), 
366-406 
 
Suskind, D., Leffel, K. R., Hernandez, M. W., Sapolich, S. G., Suskind, E., Kirkham, E., & Meehan, P. 
(2013) An exploratory study of “Quantitative Linguistic Feedback”: Effect of LENA Feedback on 
Adult Language Production. Communication Disorders Quarterly. 34(4) 199-209 
 
York, B. N., Loeb, S., & Doss, C. (2018). One step at a time: The effects of an early literacy text 
messaging program for parents of preschoolers. Journal of Human Resources 
 
 
 
 
 

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Appendix A. List of acronyms 
 
A.1. Measures: 
 
MCDI-SF 
MacArthur-Bates Communicative Development Inventories–Short Form 
[parent report assessing children's developing abilities in early language, including 
vocabulary comprehension, production, gestures, and grammar] 
PACOTIS  
Parental Cognition and Conduct Toward the Infant Scale 
[parent report assessing perceived self-efficacy and parental impact] 
SPEAK  
Survey of Parents’/Providers’ Expectations And Knowledge 
[parent report developed by TMW Center to assess knowledge and expectations of 
early development and parenting practices] 
StimQ  
[parent report measuring parental verbal responsivity and involvement in 
developmental advance] 
 
 
A.2. Interventions: 
 
NB 
 
3Ts-Newborn  
[a video shared with parents during the Universal Newborn Screening in maternity 
wards] 
 
WB 
 
3Ts-Well Baby 
[four videos shared during immunization visits at 1 week, 2, 4 and 6 months in 
pediatrician offices] 
 
LT! 
 
3Ts-Let’s Talk! 
[a series of group classes for parents/caregivers of 1 to 3 years old children delivered 
in a community-based organization] 
 
A.3.Stakeholders 
 
CSC 
 
Children’s Services Council 
[Governmental countywide agency in Palm Beach County, FL. A primary 
implementation partner] 
 
 
 
 

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Appendix B: TMW Center Partners and Agreements 
 
 
 
 

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Appendix C. e-Consent Workflow and script 
 
 

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e-Consent Script 
 
Video with parent-child B-roll and voiceover: What is the purpose of the 3Ts Program study?  
 
 
In the first years of life, your child’s brain is like a sponge that soaks in all that is going on around her. 
Each word you say, each hug you share, each tear you dry. Your interaction when your child is young 
affects the rest of his life. How he will learn to talk, read, get along with others, and manage his feelings. 
As a parent, your role is crucial – every moment you interact with your child builds his brain.  
 
 
The TMW Center at the University of Chicago and the Children’s Services Council of Palm Beach 
County want to partner with you in your child’s first years. We’ve made the 3Ts program to support you 
and teach you ways to help your child learn and grow.  
 
You can find the 3Ts program in your hospital, doctor’s office, community centers, and online.  
 
This is an educational research study to learn how well the 3Ts program supports young children’s 
development.  
 
In the 3Ts program, you will fill out surveys. We will ask about your child, your household, and your 
ideas about child development. This will help us learn how well 3Ts program works.  We will use the 
results to make the program better for you, your child, and other families. 
 
Let’s make sure we’re being clear. 
 
Question: What is the purpose of this study?  
a. To give medical advice and care 
b. To test an educational program  
 

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Let’s Review: The 3Ts program is educational. It was designed to teach parents and caregivers about 
their young children’s cognitive development. There is no medical care involved. 
 
 
What is involved in the study?  
 
This study takes place in the hospital, clinics, and community agencies. You will watch educational 
videos on a tablet.  
 
You will fill out surveys about your child, your household, and your ideas about your child’s 
development.  If you complete all parts of the study, you will take surveys nine times over four years. 
 
Question: What will I be asked to do in the study?  
a. Have blood tests and extra medical visits 
b. Watch videos and fill out surveys  
 
Let’s Review: You will watch videos and take surveys. No medical tests are part of this study. 
 
 
What if I don’t want to participate in this study? 
 
This study is optional.  You do not have to join. You may quit at any time. If you choose not to 
participate, it will not affect your or your child’s care with your doctors, clinics, or any local agencies.    
 
Question: Is this study voluntary? 
a. Yes. You have the right to choose if you want to participate. You may quit at any time.  
b. No. You are required to participate in this study.  
 
Let’s Review: This study is optional. You do not have to join. You can quit at any time.  
 

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What is required for this study? Are there risks? 
This is an educational program. There is no cost to you or your insurance.  
 
There could be a loss of privacy when you share your data with us.  Our team takes great care to keep 
your information safe.  
 
There may be a benefit of learning how to enhance your child’s development. We hope the results from 
this study will help other families. 
 
What about my information? 
 
We will ask your name, your date of birth, and your child’s date of birth. We will also ask for your phone 
number or email. This information is called personally identifiable since it can identify you or your child. 
 
 We will keep all information private and safe. Only trained staff will see your records.  We will never 
disclose your or your child’s identity. 
 
We will share data with the Children’s Services Council of Palm Beach County.  We will receive your 
Healthy Start Prenatal and Infant Risk screening data. This was collected by the Children’s Services 
Council along with your child’s birth certificate. 
 
We will receive data from the Florida Department of Health. This information is gathered with your 
child’s birth certificate.  All information we collect through this study will be kept private. 
 
Question: Will my information be kept confidential?  
a. Yes, my information will kept private and safe. Only the trained staff will see my records. 
b. No, my information will be shared with anyone who asks for it.  
 
Let’s Review: All of your data will be kept private and safe. Only members of the research team can 
view it.  
 

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If you have questions, call the research team at 773-834-8629 or email the3Ts@bsd.uchicago.edu. 
 
Want to participate?  Please review the consent form below and sign.  You will be sent a copy of this 
consent form via email or text. 
 
[Consent form displayed on screen to scroll through/review] 
 
The research project has been explained to me.  I have not been given a guarantee of benefits from 
participating. I will be sent a signed copy of this consent form. 
 
I agree to participate in this study.  My participation is voluntary and I do not have to sign this form if I 
do not want to participate. 
 
I certify that I have legal custody of my child. I agree to let my child to participate in this study. 
 
Signature: ______________________________ [will sign via finger on iPad] 
[iPad will capture date and time of signature] 
 
Name: ___________________ [enter on iPad] 
Date of birth: __________ [enter on iPad] 
Child’s date of birth: _______ [enter on iPad] 
 
Where should we send you a copy of this form? 
Text: [Enter phone number] 
Email: [Enter email] 
 
 

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Your phone number and/or email will be used to send you a copy of this consent form. We will also use it 
to offer you additional 3Ts video resources and let you know when it is time to complete your surveys. 
We will not share this information with anyone. 
 
 
 
 
 
 
Appendix D. Visual examples of online parent content. 
 
Introduction to a survey – participants will be directed to the parent-facing component of the secure 
TMW Tech Platform to complete surveys in the later time points not connected to specific 
interventions. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Example of Video Content – participants can watch videos to learn more about the topics shown in 
the 3Ts Interventions. 
 
 
Example of educational resources: In addition to videos, parents can view text and image based 
reminders of how to use the 3Ts