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Centre of Excellence for Early Childhood Development

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What Do We Know About Center-Based Programs for

Infants and Toddlers?

Effective Programs for Early Child Development: Linking Research to Policy and Practice

Banff, Canada, March 16 – 19, 2003Donna Spiker, Ph.D.


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Selected Programs for Infants & Toddlers

• Abecedarian Project• Project CARE• Chicago Child-Parent Center• Syracuse Family Development

Research Program • Infant Health and Development

Program

Source: Karoly et al. (1998), Investing in our children.


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Rationale for IHDP Study

• Neonatal intensive care was saving more and more LBW infants

• LBW infants at risk for delays• When LBW is combined with social risk,

greater chance for delays• Previous intervention research with high

risk samples suggested benefits


4

Areas of Risk for LBW Infants


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Medical Complications

• Lower Respiratory-Tract Conditions• Neurologic Problems• Ophthalmologic Problems• Sensori-Neural Hearing Loss• Serious Congenital Anomalies• Illnesses Resulting in Rehospitalization

in First Year of Life


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DQ and IQ Test Scores

• LBW < NBW From 3-78 Months• Differences at all ages related to degree

of LBW• Differences more pronounced from 30-78

months by social class

Source: McBurney & Eaves. In: Dunn, HG (Ed.). (1986). The sequelae of low birthweight: The Vancouver study.


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School-Related Deficits• Cognitive Abilities:

• Spatial Relations• Quantitative Concepts• Visual Matching

• Academic Achievement:• Math

• Visual-Motor Integration:• Form-Copying

SOURCE: Klein, N, Hack, M, Gallagher, J., Fanaroff, AA. (1985) Pediatrics.


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Behavior ProblemsIdentified By Teachers

• Difficulty Attending to Tasks• Difficulty Working Independently• Difficulty Following Directions• Socially Withdrawn• Passive Behavior

SOURCE: Klein NK. (1988). Journal of Special Education


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Early Intervention Programs for LBW Infants

• Nursery• Home-Based• Combined Nursery and Home-Based

Some Reported Short-term Benefits• Weight Gain at Faster Rate• Reduced Apnea• Enhanced Mother-Child Interaction• Higher Bayley MDI Scores at 6 Months,

1 and 2 Years


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Preschool Program For NBW, At Risk Children

• Head Start• Perry Preschool Program• Syracuse Family Program• Abecedarian Project• Project CARE

Some Long-term Benefits:• Higher Academic Achievement• Lower Grade Retention• Lower School Drop-out• Reduced Juvenile Delinquency• Increased Employment


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Rationale for the IHDP

• LBW at risk for health and developmental dysfunction.

• Early intervention studies for NBW at risk children demonstrate positive, long-term effects.


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However…at the time…..

• Results from these single site studies are not generalizable;

• Biologic constraints of LBW infants might limit their response to intervention;

• The effect of exposure to infections in group care is unknown in LBW infants.


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A National, Multisite, Randomized Clinical Trial

Purpose: To evaluate a comprehensive intervention designed to improve the health and development of LBW, premature infants.

Program Components:» Early Child Development Services» Family Support Services» Pediatric Follow-up Services

SOURCE: IHDP. (1990). Journal of the American Medical Association. Gross, Spiker & Haynes. (1997). Helping premature, low birth weight babies.


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Organization of the IHDP

THE ROBERT WOOD JOHNSON FOUNDATON

NATIONAL ADVISORY COMMITTEE

NATIONAL STUDY OFFICE

OFFICE FOR PROGRAM DEVELOPMENT

RESEARCH STEERING COMMITTEE

8 PARTICIPATING UNIVERSITIES


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Participating Sites

• University of Arkansas for Medical Sciences (ARK)• Albert Einstein College of Medicine (EIN)• Harvard University of Medical School (HAR)• University of Miami School of Medicine (MIA)• University of Pennsylvania School of Medicine (PEN)• University of Texas Health Sciences Center (TEX)• University of Washington School of Medicine (WAS)• Yale University School of Medicine (YAL)


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Target Sample Size Per Site

Intervention Group (1/3 of total sample)

Follow-up Group(2/3 of total sample)

Total

LighterBirth Weight Group(2/3 of total sample)

30

15

60

30

90

45HeavierBirth Weight Group(1/3 of total sample)

45 90 135Total

Lighter Birth Weight Group = <2000 grams

Heavier Birth Weight Group = 2001-2500 grams


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IHDP Study Enrollment

Screened for EligibilityProtocol exclusions

Eligible for RecruitmentRefused consent

RandomizedWithdrawn

Primary Analysis Group

4511-3249

1302- 274

1028- 43

985


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Reasons for ExclusionExcluded Infants = 3249

Infant death:7%

Resided outside of catchment area:

47%

Other exclusions:20%

Infant medical or maternal exclusion:

7%

Gestational age >37 weeks:

19%


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Birth Weight by Site(n = 985)

22 25 2736

1832 25

3841 41 29

38

3441 35

40 34 32 35 4434 36 40

23

0102030405060708090

100110

ARK EIN HAR MIA PEN TEX WAS YAL

Birth Weight (g):

Perc

ent

< or = 1500 1501 - 2000 2001 - 2500


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Maternal Race/Ethnicity by Site(n = 985)

53 4533

7895

71

1738

40

7

131446

15

60

9 15

8159

1

1

2

3

4

0102030405060708090

100110


Perc

ent

Black Hispanic White, other


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Maternal Education By Site(n = 985)

3852

16

6444

58

27 21

3318

27

23

33

35

2829

29 30

57

1323

7

45 50

0102030405060708090

100110


Perc

ent

<12th grade High school graduate Some college


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Maternal Age By Site(n = 985)

7 11 618 16 20

7

18 117

16 1325

7 9

6457

56

5757

48

5861

1121

319 14 7

31 23

40102030405060708090

100110


Age in Years:

Perc

ent

< 18 18 & 19 20 - 30 > 30


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Maternal Age Breakdown (N = 985)

AGE(YRS) N %13-17 103 10.518 54 5.519 71 7.220-30 568 57.731-35 145 14.736-40 37 3.8> 40 7 0.7


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The IHDP Intervention

• Adapted from two longitudinal studies of early intervention with NBW, socially at risk children:

– The Abecedarian Project– Project CARE


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8085

9095

100105

110115

3 6 12 18 24 36 48 60

AGE IN MONTHS

MD

I OR

IQ S

CO

RE Educational Child Care

Control

Bayley MDI Stanford-Binet Wechsler

The Abecedarian Project:Mean Developmental

and IQ Scores

Source: Ramey, C.T., Campbell, F.A., (1987) in: The Malleability of Children


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Subsequent Abecedarian Project Results

• Positive effects through age 21:– IQ scores– Academic test scores

• Long-term effects greater when intervention started earlier

• Source: Ramey & Campbell, 1994; Ramey et al, 1999; Campbell et al, 2001.


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IHDP ProgramDescription


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Intervention Components

• HOME VISITS (Discharge-36 months)• Partners for Learning Educational Program• Parent Problem-Solving• Social Support

CHILD DEVELOPENT CENTERS (12-36 months)• Partners for Learning Educational Program

PARENT GROUPS (12-36 months)• Parent Education• Social Support


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Program ServicesFollow-Up Group

Health Surveillance

Development Assessments

Referral for Medical and Family Services

(years)

0 to 3

0 to 3

0 to 3

Intervention Group

Health Surveillance

Development Assessments

Referral for Medical and Family Services

0 to 3

1 to 3

1 to 3

Home Visits

Child Development Centers

Parent Groups


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Time and Location of Assessments

Year 3

30 Monthsclinic

36 Monthsclinic and home

Year 2

18 Monthsclinic

24 Monthsclinic

Year 1

40 weeksclinic

4 Monthsclinic

8 Monthsclinic

12 monthsclinic and home

Note: all ages are corrected for prematurity


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Major Research Questions

• Do the Intervention and Follow-up Groups differ in:

• Cognitive Development?• Behavior Competence?• Health Status?


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Cognitive Development

Stanford-Binet Intelligence Scale, Form L-M, 3rd ed.*

*Assessor uninformed of treatment group status


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Behavioral Competence

The Achenbach Child Behavior Checklist for Ages 2-3*

* Assessor uninformed of treatment group status


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Health Status• Morbidity

– Morbidity Index +– Serious Morbidity Index +

• Functional Status– Stein Functional Status Scale– Growth: Length *– Growth: Body Mass Index *

• Maternal Perception of Health– Rand General Health Ratings Index

+ Summed across all assessments 0-36 months * Assessor uniformed of treatment group status


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Other Outcome Measures

ChildNeuro-developmental Status

Receptive Language

Visual-Motor Integration

Temperament

Prosocial Behavior

MotherGeneral Health

Mental Health

IQ

Knowledge of Infant Development

Problem Solving

Health/Social Services

Education

Employment

EnvironmentHousehold Composition

Life Events

Social Support

Marital QualityQuality of Home Environment

Mother/Child Interaction

Child Care Arrangements


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IHDP STUDY RESULTS


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Retention of Study Sample

All Study Subjects

By Treatment Group:

Intervention

Follow-up

By Birth Weight Group:

Lighter

Heavier

Initial N

985

377

608

362

623

36-Month N

913

350

563

330

583

% Retained

92.7

92.8

92.6

91.2

93.6


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Mean IQ Scores at 36 Months

Intervention Mean

(SD)

98.0(18.5)

91.0(19.0)

Follow-Up Mean

(SD)

84.8(19.0)

84.4(20.5)

Difference

13.2

6.6

Effect Size

(p-value)

0.83(p<0.001)

0.41(p<0.001)

Heavier

Lighter


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Percentage of Children With IQ Scores <70, <85, <100, by Treatment Group

6354

79

11

33

21

0102030405060708090

100

<70 <85 <70

36-MONTH STANFORD-BINET IQ SCORE

PER

CEN

TAG

E O

F C

HIL

DR

EN InterventionFollow-Up


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Percentage of Children With IQ Scores <70 & <85,

by Birth Weight Group

7.9 4.8

63.3

18.8

46.6

18.2

54.7

26.8

47.6

31.425.6

28.7

0102030405060708090

100

<70 <85 <70 <85 <70 <85

36-MONTH STANFORD-BINET IQ SCORE

PER

CEN

TAG

E O

F C

HIL

DR

EN InterventionFollow-Up

<1500 g 1501-2000 g 2001-2500 g


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Mean IQ Scores at 36 Months:By Birth Weight Group, Race & Maternal

Education

85.7 89.5

103.6

76.186.7

76.1

94.986.3

87.299.0

87.3

76.2

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Black-Fu White-Fu Black-Int White-IntMothers with High School Education or Less

Mea

n IQ

Sco

res

at 3

6 M

onth

s HeavierLighterTotal

Source: Brooks-Gunn, Gross, Kraemer, Spiker, Shapiro. (1992). Pediatrics.


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Mean IQ Scores at 36 Months: By Birth Weight Group, Race & Maternal

Education

105.0 99.8

117.1

84.9

107.0

84.9

105.7

89.5

108.4 109.9

91.784.9

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

Black-Fu White-Fu Black-Int White-IntMothers with Some College or More Education

Mea

n IQ

Sco

res

at 3

6 M

onth

s HeavierLighterTotal

Source: Brooks-Gunn, Gross, Kraemer, Spiker, Shapiro. (1992). Pediatrics.


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Child Behavior Checklist Scores at 36 Months

• Mean CBCL score: INT < FU• Effect size = -.18• P = .006• FU group = 1.8 times more likely to

have CBCL scores in clinical range– 18.8% of FU group– 13.9% of INT group


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Cumulative Morbidity Index at 36 Months

• Mean morbidity index score was higher for INT group, for Lighter group only:

– Effect size = .29 – P < .001

• No significant group differences in serious morbidity index scores


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Other Health Status Measures at 36 Months

Non-significant treatment effects for:• Stein Functional Status Scale• Growth:

– Length – Body Mass Index

• Rand General Health Status Index


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36 Month Other Outcomes


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36 Month HOME Inventory Total Scores

HeavierLighter

INT

39.338.2

FU

37.236.8

P >

.01

.05

Effect Size

.34

.19

.

Source: Bradley et al. (1994). Journal of Educational Psychology.


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36 Month Home Inventory Subscale Scores (contd)

Learning MaterialsHeavierLighter

Learning StimulationHeavierLighter

INT

6.46.0

3.93.6

FU

5.45.4

3.53.6

P >

.001.01

.01

.

Effect Size

.43

.27

.39--


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INT3.05.93.2

FU2.75.63.1

P >.001.01.05

Effect Size.24.22.14

ModelingVarietyAcceptance

Subscales not significant: Language Stimulation, Physical Environment, Responsivity

36 Month Home Inventory Subscale Scores (contd)


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Mother-Child Interaction at30 Months

Problem solving interactions: INT > FU for:• Mother’s quality of assistance• Child’s:

– Task persistence– Time on-task– Enthusiasm– Overall rating of social competence

Source: Spiker, Ferguson, Brooks-Gunn. (1993). Child Development.


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Other Maternal Outcomes at36 Months

• INT mothers were more likely to:Be employed (80% vs 72%)Return to work earlier

• No treatment group differences for:Education (months in school)Subsequent fertilityReceipt of public assistance

Source: Brooks-Gunn, McCormick, Shapiro, Benasich, Black. (1994). American Journal of Public Health.


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Participation In IHDP Intervention

COMPONENT Mean S.D. Range

• Home visits 66.7 21.6 0-100• Parent groups 3.7 3.3 0-12• Days at center 267.3 150.0 0-468

Source: Ramey, Bryant, Wasik, Sparling, Fendt, LaVange. (1992). Pediatrics.


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36 Month IQ Scores By Participation in Intervention

Source: Ramey, Bryant, Wasik, Sparling, Fendt, LaVange. (1992). Pediatrics.

16.9 13.03.5

35.5

19.6

11.96.91.90.0

10.0

20.0

30.0

40.0

50.0

60.0

Follow-upGroup (561)

Low IntParticipation

(97)

Medium IntParticipation

(124)

High IntParticipation

(126)

Perc

enta

ge o

f Sam

ple

IQ < or = 85

IQ < or = 70


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Summary of 36 Month IHDP Results

For Intervention Group Children:

Cognitive Development. Higher IQ scores.Behavioral Competence. Lower maternal report of behavior problemsHealth Status. Higher maternal report of minor illnesses for Lighter group only.


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Summary of 36 Month IHDP Results (cont’d)

For intervention Group Children:

Small, but significant, improvements in:Mother-child interactionChild social competence and task persistenceQuality of home environment


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Summary of 36 Month IHDP Results (cont’d)

Positive INT effects greatest for:Heavier weight infants

Most disadvantaged infants (lower maternal education, lower family income)

Those with higher levels of participation in the intervention

Positive effects at 7 of 8 sites shows replicability across diverse communities


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Implications of the IHDP Study:Birth to Age 3

Largest multi-site RCT to evaluate an intervention with LBW infants and toddlers.Site diversity allows generalization of results.Definitive evidence of efficacy of early intervention for LBW premature infants.Greatest effects with those at social risk.Group care feasible for biologically vulnerable infants.Relevance to eligibility issues for early intervention.


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IHDP Phase II Follow-up

Follow-up of Study Cohort To Determine Long-Term Significance

At Age 5 and Age 8 years


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Age 5 WPPSI IQ Scores: Heavier Group

INT

93.998.095.4

FU

89.795.491.7

Difference

4.22.63.7

p <

.02NS.03

VerbalPerf

FULL


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Age 5 WPPSI IQ Scores: Lighter Group

VerbalPerf

FULL

INT

88.892.689.8

FU

89.594.791.3

Difference

-0.7-2.1-1.5

p <

NSNSNS


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Age 5 PPVT-R Scores

INT

84.580.9

FU

78.580.3

Difference

6.00.6

p <

.006NS

HeavyLight


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Age 5 Child Behavior Checklist Scores

INT

29.233.131.9

FU

33.332.833.0

Difference

-4.10.4

-1.1

p <

.06NSNS

HeavyLight

TOTAL


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Age 5 Health Measures

No significant treatment differences for:

• Morbidity Index• Hospitalizations


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What can we say about key components of high-quality center-based programs for

infants and toddlers?


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Key Program Characteristics

• Small group size• High teacher-child ratio• High health & safety standards• Appropriate facilities and play materials• Well-trained teachers• Transportation to center (if needed)


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Key Program Characteristics (contd)

• Consultation with health providers and social workers

• Attention to parent-center communication and alliance via:– Parent groups – Home visits– Parent-teacher communication (notes,

visits to center)


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Key Program Characteristics (contd)

• Developmentally-appropriate curriculum:– Play-based– Has affective and cognitive focus

• Ongoing monitoring and training to assure implementation of educational curriculum


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Essential Features of Curriculum• Encourage exploration• Mentor in basic skills• Celebrate developmental advances• Guided rehearsal & extension of new

skills• Protect from inappropriate disapproval,

teasing, or punishment• Provide a rich & responsive language

environmentSource: Ramey & Ramey. (1992). Mental Retardation.


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Policy Issues to Consider

• How to scale up and maintain high quality

• How to hire, train, and retain highly qualified teachers

• How to achieve optimal parent participation


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Policy Issues to Consider (contd)

• How to serve diverse populations (e.g., diverse cultures, children with disabilities and other special needs)

• How to coordinate center-based programs with other health and social services families need

• How to fund programs


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Policy Issues to Consider (contd)

• How to provide continuous high quality programs after age 3 to maximize long-term benefits.

• How to increase public awareness of:– the need for high quality early care,– the need for ongoing high quality education

to sustain early benefits.


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For more information:–See reference list provided

–Contact Donna Spiker at:[email protected]

SRI International333 Ravenswood Avenue – BN190

Menlo Park, CA 94025

mailto:[email protected]


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References

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