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Evidence-Based Interventions in Infancy
Hiram E. Fitzgerald, Ph.D.Michigan State University
fitzger9@msu.edu
Updates on Interventions in Infant Mental Health
WAIMH Regional Congress
Acre, Israel
September, 2009
• Systems Perspectives and altering the Risk-Resilience Life Course Continuum
• What are we trying to prevent?
• What are we trying to promote?
• When should we act?
• What do we gain from prevention?
• Community based prevention
– Early Head Start– Wiba Anung (Early Star)– Systems Change
Systems Perspectives and Altering the Risk-Resilience Life Course Continuum
Traditional Approach to Change: Linear Modeling, Linear Thinking
INTERVENTION OUTCOME
Foster-Fishman, P. (2007). Campus to campus partnerships. Michigan State University.
Intervention
Outcome
When in reality, things are not linear…
Foster-Fishman, P. (2007). Campus to campus
partnerships. Michigan State University.
Transactional Linkages in a Primary Family System: Model for Assessing the Risk-Resilience Continuum
Exogenous Influences
Boundaries
Transitions
Stories
Codes Rituals
Roles
Father Mother
Source: Loukas, A., Twitchell, G. R., Piejak, L. A., Fitzgerald, H. E., & Zucker, R. A. (1998). The family as a unity of interacting personalities. In L. L’Abate (Ed.), Family psychopathology: The relational roots of dysfunctional behavior (pp. 35-59). New York: Guilford.
Sibling 2Sibling 1
Individual
Family
Agency
Service System
Community
Imp
act
Individual
Family
Agency
Service System
Community
Imp
actSystems Levels Model for Transformational Change
Outcome Levels
Outcome Levels
Feedforward
Inter-relation
ship
s
Individual
Family
Agency
Service System
Community
Time
Outcome Levels
© University-Community Partnerships Check Points Training University Outreach and EngagementMichigan State University, 2001.
What are we trying to Prevent?
Risks that Threaten the Risk-Resilience Continuum
Sources of Risk Factors
Child Variables
Genetic load, Congenital Influences, Perinatal Effects
Parent Variables
Parenting Skills, Psychopathology
Parent History and Functioning
Psychopathology, Child Rearing History
Family Functioning
Marital Conflict. Family Cohesion, Family Disorganization. Stress
Community and Societal Functioning
Employment, Social Support Networks, Neighborhood Violence Exposure
PRIMARY SYSTEM: Child Variables
• Biological diathesis (genetic, congenital, perinatal)
• Difficult temperament during infancy and early childhood
• Externalizing behavior, aggression, behavioral undercontrol, oppositional defiant disorder
• Attention problems, ADHD
• Sensation seeking personality
• Relationship difficulties
• Negative emotionality, depression
• Shyness, social withdrawal, social phobias
• Low sense of self esteem
• Alcohol and other expectancies: Internalized schemas
• Poor value orientation
PRIMARY SYSTEM: Family variables
• Disorganized parenting
• Relationship difficulties
• Severe physical punishment as primary discipline technique
• Family history of alcohol/drug use
• Parental drug use
• Neutral or favorable parental attitude toward drug/alcohol use
• Parents with antisocial personality disorder, depression or other forms of psychopathology
• Marital conflict
• Poor moral values
ADJUNCTIVE SYSTEMS: School Context Variables
• Early and persistent antisocial behavior
• Lack of parent support for educational achievement
• Lack of high quality supplemental child care and early childhood education
• Lack of preparation for school success (birth to five)
• Lack of individual commitment to school
• Academic failure beginning in late elementary school
• Peer group selection in transitional school settings
• Lack of involvement in positive extracurricular activities: civic engagement
ADJUNCTIVE SYSTEMS: Social & Community Context Variables
• Easy access to drugs/alcohol
• High drug use environments
• High stress environments (violence, poverty, unemployment)
• Poor community moral values/behavior
• Poor community cohesion (sense of neighborhood)
What are We Trying to Promote?
Factors that Enhance Resilience for the Primary System
Factors Highly Related to Early Developmental Success: Birth to Five
1. Ongoing nurturing relationships with the same adults
2. Physical protection, safety, and regulation of daily routine
3. Experiences responsive to individual differences in such characteristics as temperament
4. Developmentally appropriate practices related to perceptual-motor, cognitive, social stimulation, and language exposure
5. Limit-setting (discipline), structure (rules and routines), and expectations (for positive outcomes)
6. Stable, supportive communities (violence free) and culture (a sense of rootedness and connectedness)
SYSTEMS APPROACH TO PROTECTIVE FACTORSChild Variables
• Positive parent-child relationships (birth to five)
• Adaptive temperament
• Effective socialization skills: Self control & empathy
• Positive preparation for school success (pre-kindergarten)
• Positive peer relationships
• Positive self esteem
• Involvement in religious and pro-social activities: moral (behavioral) values
• Positive expectancies future oriented
PRIMARY SYSTEM: Family Variables
• Positive family relationships and sense of unity (family cohesion)
• Family rules and expectancies (family organization)
• Parental monitoring with clear rules of conduct
• Involvement of parents in the lives of their children
• Family codes, stories, and sense of rootedness
• Positive marital relationships
• Monitored access to alcohol/drugs
ADJUNCTIVE SYSTEMS: School Context Variables
• Academic success
• Positive teacher attitudes
• Reinforcement of life skills and drug/alcohol refusal skills
• Strong student bonds to school
• Students have an identity and sense of achievement
• Positive peer groups
ADJUNCTIVE SYSTEMS: Social & Community Context Variables
• Opportunities for bonding with and engaging with family, school, and community
• Anti-drug/anti underage drinking community norms
• Community norms on alcohol that deglamorize its use, restrict advertising
• Awareness of laws and consequences
• Low prevalence of neighborhood crime and violence
• Community sense of shared concern for all children
When Should We Act?
(from an Infant Mental Health Relationship Perspective:
neurobiological, social-emotional, cognitive structures)
It’s Not All Timing, but Time does Matter
Organizational Periods During Prenatal Development: Vulnerability to Environmental Teratogens
Adapted from: iK. L. Moore (1977). The developing human: Clinically oriented embryology. (2nd edition, p. 136). Philadelphia: W. B. Saunders.
Frontal Cortex and HPA Axis
Executive Function, Behavior Regulation, Emotion Regulation
Adaptive Processes & Functions
STRESS
Neural & Neuro-endocrine Systems
Extra-familial systems
Behavioral & Psychological Systems
Allostasis: Stress Regulatory System (Sterling & Eyer, 1988).
Postnatal Organizational Periods
Developmental Process
Maximum Period of Organization
System
Motor development Prenatal to age 4 Exploration
Emotion regulation Birth to age 2-3 Self control
Visual processing Birth to age 2-3 Orienting in space
Emotional attachment
Birth to age 2 Emotional and social systems
Language acquisition
Birth to age 4 CommunicationCognition/thought
Second language 1 year to age 4 Communication
Math/logical thinking 1 year to age 4 Cognitive processing
Music and rhythm 3 years to age 5 Creative expression
What Do We Gain from Prevention?
A higher yield on great finishes and a solid return on investment
$4.11
$6.89
$5.06$3.72
Perry Pre-School Project
Elmira PEIP Chicago Parent-Child Centers
AbecedarianProject
Established Returns on Investment from Research-Based Early Childhood Programs for Every Dollar
Invested
Heckman, J. 2004
Evidence Based Preventive-Intervention Programs for Families Birth to Five
• Service-Based Approaches• Ready, Set, Grow: Passport. • Starting Early Starting Smart (SESS). • Comprehensive Child Development Program (CCDP). • Houston Parent-Child Development Center (PCDC). • Information-Based Approaches• Parents as Teachers (PAT). • Healthy Families America (HFA). • Harlem Study. • Infant Health and Development Program (IHDP). • Behavior and/or Relationship-Based Approaches• Interactive Guidance (IG). • Carolina Abecedarian Project• Steps Toward Effective Enjoyable Parenting (STEEP) • The UCLA Family Project (UCLA FP). • Nurse Family Partnership (NFP).
To determine whether the intervention was more effective than no service, or another service, in accomplishing the desired outcomes
To inform practice by providing feedback information to staff and to other interested persons concerning
the characteristics of participants who were most successful in accomplishing outcomes
the context or conditions under which the intervention was most effective in accomplishing outcomes
the characteristics of the intervention process that were most successful in accomplishing outcomes
Evaluations that provide information about the characteristics of participants, the context, and the process that relate to why or how outcomes were or were not achieved are most useful to practitioners and policy makers.
WHY EVIDENCE BASED PRACTICES?
Best Practice Brief No, 16, B. Tableman (Ed). University Outreach & Engagement, © Michigan State University Board of Trustees
Case study of the process and results of intervention with an individual child and parent(s). This approach is informative about techniques and dynamics of change, but is not necessarily representative of all persons receiving services. Case studies generally reflect success stories.
Summary of standardized observational assessments, structured reporting from parents and providers, and/or community data for the group of children and parents served. Summaries present what happened to those receiving service. There is no way of knowing whether the results would have occurred in any case without intervention.
Quasi-experiment comparing outcome information about the group receiving services to that for a group presumed to be comparable. The actual comparability of the two groups can be questioned. Sometimes involve population based samples.
Randomized design. Assigning persons randomly to a service group or to a control group. Any differences in outcome between the two groups can be attributed to the
intervention.
RESEARCH METHODS AND EARLY INTERVENTIONS:Information about the effectiveness of early interventions come four types of sources
Best Practice Brief No, 16, B. Tableman (Ed). University Outreach & Engagement, © Michigan State University Board of Trustees 2000.
LINKING TARGETS TO INTERVENTIONS
Intervention Target Intervention
behavior of the mother vis-à-vis the infant providing information, modeling, reinforcing the mother’s positive interaction and effective caregiving
mother’s perceptions and expectations: (mental representation or internal working model) of the infant, of appropriate parenting, of herself— reflecting her experiences as a child, her current issues, and her beliefs and attitudes
helping her to become aware of how her own nurturing experiences and current and past relationship issues are impacting her interaction with her infant
behavior of the infant showing, and interpreting for, the mother what the baby can do or is communicating; using videotape, an assessment tool, speaking for the baby, etc.
infant’s perceptions and expectations reflecting his/her experience with caregiving
changing the parent’s responsiveness to and interaction with the infant
context—the mother’s personal relationships, environment, and other conditions affecting the mother and infant
reducing the stresses in relation to basic needs and relationships; increasing social supports
behavior of the father involving the father in the intervention with the mother
father’s perceptions and expectations identifying the father’s special role in relation to support of the mother and education of the infant
Requirements for Replicating Programs
• Programs must exist that have been evaluated and demonstrated to be effective– New programs, diverse sites
• Program description must be sufficiently described for others to replicate it– Journal page restrictions, lack of detailed manuals
• Local providers must be willing to replicate faithfully– Fidelity of implementation
• Replicating research-documented programs assumes new results will be comparable to the original demonstration project– But place and people matter
Adapted from McCall, R. B. (2009). Evidence-based programming in the context of practice and
policy. SRCD Social Policy Reports.
Community-based Prevention Programs
Example 1: Early Head Start
The National Evaluation United States
The Early Head Start Research and Evaluation Project
Began in 1995
3001 children and families followed from enrollment in program to child age 3
Experimental Design Impact Study
Early Head Start Control Group
Brattleboro, VT
New York,
NY
Pittsburgh, PA
Sumter, SC
Jackson, MI
Russellville, AR
Kansas City, MO
Marshalltown, IA
Kansas City, KS
Logan, UT
Denver, CO (2 programs)
Kent, WA
Sunnyside, WA
Alexandria, VA
Venice, CA
McKenzie, TN
Early Head Start Research Sites
Types of Programs
Program options based on needs of families and community:
• HOME BASED: included weekly home visits and a minimum of 2 group socialization experiences per month (7 programs)
• CENTER BASED: also included a minimum of 2 home visits per year (4 programs)
• MIXED: combination of both home-based and center-based approaches (6 programs)
Many Measures Used in the Project
Implementation data, including ratings
Family service use data 7, 16, and 28 months after enrollment (both program and control)
Child and family data collected when children were 14, 24, and 36 months old. Follow up studies at 60 months and five years of age.
Videotaped observations of parent-child interactionVideotaped observations of parent-child interaction Interviewer observationsInterviewer observations Parent interviewParent interview Child assessmentsChild assessments
Highlight Findings from the
National Study
EHS Was Broadly Effective Across a Wide Array of Outcomes
The cognitive, language, and physical development of program children was better at ages 2 and 3 than for control children
Program parents demonstrated more behaviors that supported children’s learning and well-being than control parents
Greater warmth and emotional supportivenessLess detachmentMore parent-child playMore stimulating home environmentsMore support for language and learningMore daily readingLess spanking by both mothers and fathers
Program parents demonstrated greater involvement in self-sufficiency activities than control parents
Less likely to have subsequent birthsMore likely to be involved in educational or job training activities
Early Head Start in Jackson, Michigan: a
Home Visiting Approach
Early Parenting Impacts Child Cognitive Development
• Parent supportiveness, home language and literacy environments, daily reading, emotional responsiveness, and knowledge of child development at 24 months were all related to more optimal cognitive development
Dosage: Time in Program
• The average amount of time in the program was 21 months (SD = 12 months)
• Home visitation that families received ranged from one to 46 months
Dosage: Number of Completed Home Visits• The average number of visits was 71 completed (SD = 50)
• Families ranged from one to 282 completed visits
Dosage Results
The number of home visits was related to:– More support of literacy
and language in the home environment
– More cognitive growth fostering behaviors
– More parent supportive behaviors of child during play
– Lower levels of parenting stress
– More support seeking from service providers
Program Effects
• Parents in the program group
– were more likely to seek support from outside the family (formal services providers and by spiritual means)
– were less detached in their play interactions with their children
– were less supportive in their interactions while teaching their children
– were more likely to attain education and employment services
• Children in the program
– were more likely to receive child development services
Example 2: Head Start. Wiba Anung (Early Star)
Michigan
•
• Population (2008) 10,003,422
• Square km 154,890
• Sq. km Inland Water 64,000
• Length (km) 790
• Widest Point (km) 384
• From Pokagon to Lac Veux-Desert tribes: 10 hour drive
Total Demographic Characteristics: Wiba Anung
• 9 Sites
– Head Start• 19 classrooms• 23 teachers• 17 assistant teachers
– Early Head Start• 19 classrooms• 36 teachers• 15 assistant teachers
• Child Demographics (N=558)
– Ethno-racial• 85% American Indian• 9% Caucasian• 2% Hispanic• 1% Pacific Islander• Less than 1% Black• 2% Multi-racial, non-native
– Age• 38% 0 to 3 years• 23% 3 to 4 years• 30% 4 to 5 years• 9% 5 and older
Note. ECEd = Early Childhood Education
Teacher Preparation
Tribal Elders
Parents
Cultural Curriculum
Child Functioning
ECEd/Child Development
Tribal Culture
MSU-BCMM Articulation
Model for Enhancing System Promoting Resilience Factors for Children, Parents, and Teachers in Tribal Head Start Programs
Culturally Appropriate Curriculum and Identity:
• Every individual is rooted in culture
• Local culture is most relevant
• Learn local culture from local residents
• Cultural inclusion in evidence-based curriculum is developmentally appropriate practice
• Instilling cultural identity within acculturation demands
• Dual language contexts
• Culturally competent staff
• Multicultural experiences prepares for life in multicultural society
• Self reflection is essential for staff
• Systemic approach to program delivery is essential
Adapted from the Administration for Children and Families Head Start Performance Standards, 1992
School Readiness Results:The percentage of students who meet expected norms on each of the subtestsNorms developed from a sample of 958 Head Start studentsnorms based on age of the child in monthsIncludes data for all students who completed both Fall and Spring assessments (n=109)
77%83%
75%82%
45%55%
29%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Colors and Shapes Picture Descriptionand SpatialRecognition
Numbers andCounting
Letters and Writing
% of children meeting expected norms - Fall 2008% of children meeting expected norms - Spring 2009
Student Improvement: Presents the percentage of students who did not meet expected norms on the subtest during the fall, but who did meet expected norms on the subtest in the spring Includes data for only students who did not meet the expected norms for the subtest
52%
69%
37% 38%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Colors & Shapes (n=25) Picture Description &Spatial Recognition (n=26)
Numbers & Counting(n=59)
Letters & Writing (n=76)
% of children who moved from not meeting expected norms to meeting expected norms
*Note that the sample size for each subtest indicates the number of students who did not meet expected norms in the fall
Student Declines: Presents the percentage of students who did meet expected norms on the subtest during the fall, but who did not meet expected norms on the subtest in the spring Includes data for only students who did meet the expected norms for the subtest
7%15%
25% 25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Colors & Shapes (n=83) Picture Description &Spatial Recognition (n=82)
Numbers & Counting(n=49)
Letters & Writing (n=32)
% of children who moved from meeting expected norms to not meeting expected norms
*Note that the sample size for each subtest indicates the number of students who did meet expected norms in the fall
• Home Environment (Aggregate & Local Site)– Mean Scores and Normative Expectations for:
• Inappropriate Expectations of Children• Lack of Empathy• Family Environment
– Mean Scores for:
• Family Involvement (able to compare to previous HS sample)• Emotional Coaching• Family Support Scale• Alcohol and Tobacco Use (able to compare to national sample)• Social Problem Solving• Collective Self-Esteem Scale• Ethnic Identity Measure
• Classroom Environment (Aggregate & Local Site)– Mean Scores for:
• CLASS (able to compare to national preschool sample)• Teacher-Child Relationship Scale (should be able to compare to a national
preschool or HS sample)• Teacher Experience of Stress
• Child Outcomes (Aggregate & Local Site)– Mean Scores and Normative Expectations for:
• Academic Outcomes• Behavioral Competence
– Reported by teachers– Reported by parents
FEEDBACK: OUTCOMES 10 SITE HEAD START PROGRAMS
A Community Based Systems Change Approach
A Science of Community Change
• Traditional and valued scientific paradigms are often not likely to be applicable
• Community change initiatives place a strong emphasis on community involvement, community choice, and community building
• A uniform intervention is not likely to be appropriate when so many facets of a community’s system require change
• Actual change in communities in specific services and in community systems is more likely governed by political, ideological, or fiscal priorities than by research findings
Adapted from McCall, R. B. (2009). Evidence-based programming in the context of practice and policy. SRCD Social Policy Reports. P. 11
THE INDICATOR PROJECTis an attempt to help us know, together, how we are doing.
Intellectualand Social
DevelopmentEconomy
Health Safety
EnvironmentCommunity
Life
SafetySafety
Child Abuse and NeglectChild Abuse and Neglect
Domestic ViolenceDomestic Violence
Unintentional Injury DeathsUnintentional Injury Deaths
Violent CrimeViolent Crime
Neighborhood SafetyNeighborhood Safety
5 Indicators
Domestic ViolenceDomestic Violence
Domestic violence is underreported. Many victims do not notify authorities.
Rate of Reported Victims of Domestic Violenceper 100,000 Population, Capital Area,1996-2005 The rate in 2005 is at its
highest level in the past 10 years, but is less than the Michigan rate.
662Capital Area:
677Michigan:
Community Collaborative
Higher Education
Business & EntrepreneurialCommunity
State and RegionalGovernment
BTW
Creating Systemic Community Partnerships
University Outreach and Engagement, Michigan State University 2009
Movement Toward a Systemic and Developmental Approach
Singular, Non-Developmental Approach
Singular but Developmental Approach
Systemic and Developmental Approach
Focus on single individual representative from the community agency in the partnership
Involve multiple individuals from a single level of influence (all managers or all case workers) in the partnership
Involve multiple individuals from multiple levels of influence in the partnership
Focus on single community agency
Focus on single community agency while involving in periphery other community agencies
Focus on multiple community agencies as equal partners
Focus on single community sector/university department
Focus on single community sector/university department while involving in periphery influencing sectors/departments
Focus on multiple community sectors/university departments as primary in partnership
Focus on primary outcome only Focus on primary outcome while including other variables in model as “extraneous”
Focus on primary and other variables to more fully understand the complexity of promoting the primary outcome
Prenatal
Assessing Proximal and Distal Causal Forces
Proximal Influences
Proximal Influences
Proximal Influences
Partner SelectionsWorkplaceSociety
PeersSchoolCommunity
ParentsFamily (Kin)Neighborhood
Distal
Influ
ence
s
Late Adolescence Stage (18-25)
Early Adolescence Stage (10-14)
Early Childhood Stage (0-5)
Risk Resilience
Birth to Work Framework: Transforming Community Based Initiatives into Community Based Research Networks to Link Program
Outcomes to Systems Level Change
Exposure to multiple, inter-related, and cumulative risk factors imposes heavy developmental burdens during early childhood and induces, facilitates, and/or maintains development of dysfunctional behavior patterns.
From Neurons to NeighborhoodsNational Research Council, Institute of Medicine, 2000
Factors Highly Related to Negative Early Organizational Processes
Funding Sources
Early Head Start: DHHS: Administration for Children, Youth, and Families, National Institute of Child Health and Human Development, and the Ford Foundation, Michigan State University Office of University Outreach and Engagement
Wiba Anung: University of Colorado American Indian/Alaska Native Head Start Research Center (DHHS: Administration for Children, Youth, and Families); Michigan State University Office of University Outreach and Engagement, Michigan State University Native American Institute.
© 2007 Michigan State University Board of Trustees
Contact Information
Hiram E. Fitzgerald, Ph.D.
Associate Provost for University Outreach and Engagement
University Distinguished Professor, Psychology
and Editor, Infant Mental Health Journal (2010-2012)
Michigan State University
Kellogg Center, Garden Level
East Lansing, MI 48824-1022
Email: fitzger9@msu.edu
Web site: outreach.msu.edu
Phone: 517 353 8977
Fax: 517 432-9541
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