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Why Early Intervention? Exploring the Evidence

THE EARLY INTERVENTION FOUNDATIONOctober, 2014

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EconomicsThe drivers and consequences of early

environments

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1. Wide and persistent gaps in children’s wellbeing and development emerge very early in life.

2. These factors have important consequences for future and intergenerational outcomes.

3. These factors are not set in stone immediately, and can be influenced by timely intervention.

4. Programmes which successfully improve these factors deliver substantial individual and social benefits over time.

Evidence from economic and social research, established over many years, supports the following principles:

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1. Wide and persistent gaps in children’s wellbeing and development emerge very early in life

Source: Goodman and Gregg (2010)

• 80% of the FSM attainment gap at age 16 is present by age 7 (Save the Children, 2013)

• Half of all lifetime cases of mental illness begin by age 14 (Kessler et al., 2005)

• Babies from a poorer background or from certain ethnic minority groups have, on average, lower birth weight (Dearden et al., 2006; Goodman and Gregg, 2010)

• Children in poorer families have a worse home learning environment (Dearden et al., 2011)

• Less cognitive stimulation and emotional support in disadvantaged families (Moon, 2012)

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2. These factors have important consequences for future and intergenerational outcomes

• Poor speech and language at age 5 predicts with worse literacy, employment and mental health outcomes at age 34 (Law et al., 2009)

• Children with lowest reading ability at age 7 have 20% lower wages at age 33 (Currie and Thomas, 1999)

• Social skills at age 11 predict degree status, physical health, likelihood of depression and other mental health problems, and likelihood of criminal activity by age 42 (Carneiro et al., 2007)

• The most important predictor of life satisfaction in adulthood is emotional health in childhood, followed by the child’s conduct (Layard et al., 2013)

• Childhood psychological problems result in 15% lower wages and 8% less chance of relationship stability in adulthood (Goodman et al., 2011)

• A person’s risk of obesity at age 33 is 40-50% higher if their mother smoked while she was pregnant (Power and Jefferis, 2002)

• Up to half of the rich-poor gap in children’s cognitive ability can be accounted for by differences in their parents’ cognitive ability. This link remains even after taking into account parental education, family background and the child’s home learning environment. (Crawford et al., 2011)

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3. These factors are not set in stone immediately, and can be influenced by timely intervention

• IQ scores become relatively stable by age 10 (Cunha et al., 2006) • Early childhood programmes for poor

children can increase verbal ability and reasoning skills through early elementary school (Garces et al., 2002; Belfield et al., 2006; Ludwig and Miller, 2007)

• Social skills are more malleable than cognitive skills after the age of 7 (Carneiro et al., 2007)

• A number of socio-emotional learning programmes have been shown to improve children’s social skills, psychological/emotional adjustment, and problem behaviours (Gutman and Schoon, 2013)

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4. Programmes which successfully improve these factors deliver substantial individual and social benefits over time

• Meta-analyses of the long-run effects of early childhood education arrive at an estimated social return of $3.60 for every $1 invested (Lee et al., 2012)

• Chicago Child-Parent Centers delivered substantial benefits by the time participants were 26, mainly through increased earnings and reduced criminal justice and child welfare costs. The benefit-cost ratio was highest for the preschool group at 10.8, compared with 4.0 for the school-age group. (Reynolds et al., 2011)

• HighScope Perry Preschool Program delivered a long-run social rate of return of 7-10% by the time participants were age 40, mainly through improved employment and earnings, reduced crime and reduced welfare dependence.

• This is a conservative estimate that does not include health benefits; it is still higher than the typical historical rate of return on equity. (Heckman et al., 2010)

• Carolina Abecedarian Project intervened with disadvantaged children aged 0-8 and resulted in substantial benefits by the time participants were in adulthood.

• These included higher maternal earnings (Barnett and Masse, 2007), higher educational attainment, reduced crime and use of welfare benefits (Moon, 2014) and improved physical health (Campbell et al., 2014).

• Jamaican Study involved home visiting, nutritional supplements and psychosocial stimulation for growth-stunted toddlers for 2 years. It resulted in 25% higher earnings 20 years later, enabling participants to catch up with non-stunted individuals. (Gertler et al., 2014)

• Follow-up studies of Family Nurse Partnership suggest returns of $3-5 per $1 invested, mainly through reduced child welfare costs. (Department of Health, 2011)

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PsychologyOptimising child development and reducing

developmental risks

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1. The environments children grow up in shape their development (Bronfenbrenner, 1979; Sameroff, 2010)

2. Early Intervention can support children’s development by reducing the risks and increasing the protective factors in their environments (Belsky, 1993; O’Connell, 2009)

3. The attachment relationship is one environment that informs children’s expectations about themselves and others (Bowlby, 1988)

4. Children’s behaviour is shaped by its consequences (Bandura, 1977; Patterson et al., 1989)

Research in psychology can tell us how to optimise a child’s development.

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1. Child development is shaped by the environments they grow up in

A child’s development is shaped by bidirectional processes occurring within the nested environments of the family, community and society (Bronfenbrenner, 1979; Sameroff, 2010)

Children’s well being and developmental outcomes are consistently linked to the quality of these systems and the connections between them (Belsky, 1993; Benson and Buehler, 2012)

SocietyCommunityFamilyThe Child

An ecological model of child development

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2. Risk and protective factors exist on each ecological level

Interventions that aim to reduce the risks and increase the protective factors on multiple ecological levels consistently improve child outcomes (Olds, et al. 1997; Heggenler, Schoenwald and Bourdoin, 1998)

Studies repeatedly suggest that child maltreatment is best predicted by a variety of risk and protective factors that exist on all four levels (Rutter, 2000).

For example, the ALSPAC study team (Sidebotham and Heron, 2006) observed that child maltreatment is best predicted by the following four factors:

Individual: Low child birth weightFamily: Parental mental health problemsCommunity: Poor social networksSociety: Low socio-economic status

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3. The attachment relationship creates the context in which children develop expectations about themselves and others

• Parents are in the best position to support their child’s attachment security if they were securely attached as a child (Main et al., 1985)

• Attachment security is not always protective. Negative life events may decrease attachment security over time (Sroufe et al., 2011)

• Interventions that aim to improve parents’ sensitivity and their attachment security have significantly improved outcomes for children with a disorganised attachment (Cicchetti et al. 2006; Lieberman et al. 2006).

Infant behaviours (clinging, crying, smiling and sucking) illicit a response from caregivers

Parents who respond sensitively and predictably to these cues foster a sense of attachment security in their children

A secure attachment fosters positive expectations of the world and a sense of mastery

It also provides the context in which children learn how to successfully regulate their own emotions and behaviour

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4. Children’s behaviour is shaped by its consequences

Children often behave in aggressive and non-compliant ways

Negative and aggressive child behaviours may increase through inadvertent reinforcement from parents, peers and teachers

Parents learn how to provide appropriate consequences for negative child behaviours, as well as strategies for improving positive child behaviour

Children’s behaviour improves; children learn over time how to better regulate their own behaviour

• Adult behaviours that inadvertently encourage negative child behaviours may ‘train’ delinquency and conduct problems over time (Patterson et al. 1989; Dishion et al., 1999).

• Conduct problems also place children at risk for mental health problems and school failure as they mature (Scott et al. 2001).

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NeuroscienceAn emerging science relevant to Early

Intervention

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1. Early adversity is associated with increased risk of long term poor outcomes and changes in neurobiological structure and function.

2. Epigenetic changes can follow early adversity (preliminary evidence).

3. Brain development is crucial not just in childhood but also in adolescence.

4. There are gaps in the neuroscientific literature.

We can learn from neuroscience about Early Intervention that:

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The neuroscience evidence for Early Intervention is largely indirect. However there is substantial evidence that:

Brain development is crucial not just in childhood but also in adolescence• Puberty represents a period of synaptic reorganisation and so

the brain might be more sensitive to experiential input.

• Increase in white matter and decrease in grey matter density in the prefrontal cortex and the parietal cortex has now been demonstrated by several studies.

• Changes at the level of the brain and cognition seem to map onto behaviours commonly associated with adolescence, such as risk-taking.

• Development of executive function, social cognition and perspective taking is shown to be ongoing during adolescence.

(Blakemore & Choudhury, 2006)

Early adversity is associated with increased risk of long term poor outcomes and changes in neurobiological structure and function • There is a heightened reactivity to threat in child victims of

family violence.• When shown pictures of angry faces as opposed to calm faces,

there is an increased activity in the brain areas that process emotion compared to non-victims. (Mcrory et al., 2011)

• There is a general association between child adversities and regional brain grey matter volume.

• Reducing exposure to adverse social environments during early life may optimize brain development and reduce subsequent mental health risks in adult life. (Walsh et al., 2013)

Epigenetic changes follow early adversity (preliminary evidence)• Genetics and the environment are inextricably intertwined. • Across the globe, several studies have found correlations

between many environmental variables – large and small – with how a foetus, infant, or child develops, such as:

socioeconomic status (Leatherman et al. 1995) neighbourhood wealth (Drewnowski et al. 2007) homelessness and availability of shelter (Smith & Richards 2008) maternal nutrition during pregnancy (Barker 1998) maternal smoking during pregnancy (von Kries et al 2002) psychological stress (Gohlke et al 2004)(Clarkin, P. 2014)

There are gaps in the neuroscientific literature• Longitudinal studies that look at the malleability of

neurobiological changes and epigenetic modulation and the association between these early changes and future mental health problems have not been conducted.

• To date, the evidence only indicates that early adversity shapes neuro-cognitive development in ways that are consistent with a potential for increased vulnerability for a range of future poor outcomes.

• Longitudinal studies are required to empirically demonstrate the mechanisms of this association and address issues regarding reversibility.

Widening the debate: EIF recently launched our #ScienceSeries of seminars and lectures to examine the role and importance of science in informing Early Intervention policy and practice.

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ProgrammesDemonstrating the impact of Early Intervention on

the ground

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Early Interventions & the Programmes Library

• In addition to the evidence supporting the theories which underpin early intervention as a broad approach, there is a substantial body of evidence demonstrating that particular early interventions are very effective at improving outcomes for young people and families.

• Information on these interventions or programmes – how they’re delivered, the ideas behind them, how they’re implemented and how effective they are – is housed in the EIF Guidebook Programmes Library.

To help connect commissioners to the programmes they will find most useful, we have classified interventions according to nine outcome categories that represent a range of ways in which early intervention programmes can provide real value to children, young people and their families.

• Two of these (the family & the home, and positive early child development) indicate the broader context of impact, and the remaining seven address specific outcome areas, such as substance misuse and crime.

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Family Nurse Partnership (FNP)

• Family Nurse Partnership (FNP) is a home visiting programme for young mothers expecting their first child.

• Mothers enrol in the programme early in their pregnancy and receive visits from a family nurse on a weekly basis just before and after the birth of their child and then fortnightly until their child’s second birthday.

• During these visits, mothers learn about their young child’s health and development and receive support for their own wellbeing.

• FNP has established evidence of providing long-term benefits for young mothers and their children, including reduced arrests & crime convictions, reduced preventable cause mortality and reduced rates of depression and anxiety in children (Eckenrode et al., 2010; Olds et al., 2014; Kitzman et al., 2010)

Examples of well-established and effective early interventions include…

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• The Incredible Years (IY) Preschool Basic Programme is for parents with serious concerns about the behaviour of a child between the ages of three and six.

• Parents attend 18 to 20 weekly group sessions where they learn strategies for interacting positively with their child and discouraging unwanted behaviour.

• This programme has established evidence of improving parenting skills and child behaviour from multiple randomised controlled trials (Webster-Stratton, C., 1984; Hutchings et al., 2007; Scott et al., 2001).

Examples of well-established and effective early interventions include…

Incredible Years (BASIC Preschool Programme)

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Multisystemic Therapy (MST)

• Multisystemic Therapy (MST) is for families of young people between the ages of 12 to 17 who have exhibited serious antisocial and delinquent behaviour.

• MST therapists provide the young person and their parents with individual and family therapy over a four to six month period with the aim of doing ‘whatever it takes’ to improve the family’s functioning and the young person’s behaviour.

• MST has established short and long term evidence of improving child and family outcomes from multiple RCTs, including reducing antisocial behaviour and reoffending rates, improving family functioning, and the reducing need for out-of-home care (Butler et al., 2011; Ogden et al., 2006; Sawyer et al., 2011)

Examples of well-established and effective early interventions include…

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References – EconomicsAn Anatomy of Economic Inequality in the UK (2010): http://sticerd.lse.ac.uk/case/_new/publications/NEP.aspBarnett and Masse, 2007: http://nieer.org/sites/nieer/files/BenefitCostAbecedarian.pdfBelfield et al., 2006: http://jhr.uwpress.org/content/XLI/1/162.abstract?sid=d2c84bdb-98a3-496d-815f-0ac6ff1d5d52Campbell et al., 2014: http://www.sciencemag.org/content/343/6178/1478Carneiro et al., 2007: http://cee.lse.ac.uk/ceedps/ceedp92.pdfCrawford et al., 2011: http://www.eucconet.com/wp-content/uploads/Claire-Crawford.pdfCunha et al., 2006: http://jenni.uchicago.edu/papers/Cunha_Heckman_etal_2006_HEE_v1_ch12.pdfCurrie and Thomas, 1999: http://www.nber.org/papers/w6943Dearden et al., 2006: http://onlinelibrary.wiley.com/doi/10.1111/j.1475-5890.2006.00026.x/abstractDearden et al (2011): http://www.llcsjournal.org/index.php/llcs/article/view/140Department of Health, 2011, FNP Evidence Summary LeafletGarces et al., 2002: https://www.aeaweb.org/articles.php?doi=10.1257/00028280260344560Gertler et al., 2014: http://www.sciencemag.org/content/344/6187/998Goodman et al., 2011: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076863/Goodman and Gregg, 2010: http://www.jrf.org.uk/sites/files/jrf/poorer-children-education-full.pdfGutman and Schoon, 2013: https://educationendowmentfoundation.org.uk/uploads/pdf/Non-cognitive_skills_literature_review_2.pdfHeckman et al., 2010: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145373/Kessler et al., 2005: http://www.ncbi.nlm.nih.gov/pubmed/15939837Law et al (2009): http://www.ncbi.nlm.nih.gov/pubmed/19951922Lee et al., 2012: http://www.emeraldinsight.com/doi/abs/10.1108/17466661211213670Ludwig and Miller, 2007: http://qje.oxfordjournals.org/content/122/1/159.shortMoon (2012): http://www.seriworld.org/16/qt_PdfDown.html?mncd=0305&pub=20120317&seq=262Moon, 2014: https://heckman.uchicago.edu/sites/heckman2013.uchicago.edu/files/uploads/Research_Cards/CB_Analysis_ABC.pdfPower and Jefferis, 2002: http://www.ncbi.nlm.nih.gov/pubmed/11980805Reynolds et al., 2011: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817956/Save the Children, 2013: http://www.savethechildren.org.uk/sites/default/files/docs/Too_Young_to_Fail_0.pdf

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References – Psychology

Cicchetti, D., Rogosch, F.A., and Toth, S.L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions, Development and Psychopathology, 18, 623 – 649.

Dishion, T.J., McCord, J., and Poulin, F. (1999). When interventions harm: Peer groups and problem behaviour, American Psychologist, 63, 538 – 548.

Leiberman, A.F., Ghosh Ippen, C., and van Horn, P. (2006). Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial, Journal of the American Academy of Child and Adolescent Psychiatry, 45, 913 – 918. Main, M., Kaplan, N. and Cassidy, J. (1985). Security in infancy, childhood and adulthood: A move to the level of representation, Monographs of the Society for Research in Child Development, 50, 66 – 104.

Patterson, G.R., Debaryshe, B.D., and Ramsey, E. (1989). A developmental perspective in antisocial behaviour, American Psychologist, 44, 329 – 335.

Scott, S., Knapp, M., Henderson, J., and Maughan, B. (2001). Financial cost of social exclusion: Follow-up study of antisocial children into adulthood, British Medical Journal, 323, 191 – 194.

Sroufe, L. A., Coffino, B., & Carlson, E. (2010). Conceptualizing the role of early experience. Lessons from the Minnesota longitudinal study. Developmental Review, 30, 36-51.

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References – Neuroscience

Blakemore SJ1, Choudhury S. (2006) Development of the adolescent brain: implications for executive function and social cognition. J Child Psychol Psychiatry. 2006 Mar-Apr;47(3-4):296-312.  Clarklin, P. (2014) Developmental Plasticity and the “Hard-Wired” Problem, http://kevishere.com/2014/06/10/developmental-plasticity-and-the-hard-wired-problem  Drewnowski A, Rehm CD, Solet D. 2007. Disparities in obesity rates: Analysis by ZIP code area. Social Science & Medicine 65 (12): 2458-63.  Gohlke BC, Frazer FL, Stanhope R. 2004. Growth hormone secretion and long-term growth data in children with psychosocial short stature treated by different changes in environment. J Pediatr Endocrinol Metab 17:637–643. Leatherman TL, Carey JW, Thomas RB. 1995. Socioeconomic change and patterns of growth in the Andes. Am J Phys Anthropol. 97(3):307-21. McCrory, E., De Brito, S.A., Sebastian, C.L., Mechelli, A., Bird, G., Kelly, P.A., and Viding, E.. "Heightened neural reactivity to threat in child victims of family violence." Current Biology, Vol. 21 No. 23, Dec. 6, 2011.  Smith C, Richards R. 2008. Dietary intake, overweight status, and perceptions of food insecurity among homeless Minnesotan youth. Am J Hum Biol. 20(5):550-63.  von Kries R, Toschke AM, Koletzko B, Slikker W Jr. 2002. Maternal smoking during pregnancy and childhood obesity. Am J Epidemiol 156(10):954-61. Walsh, N. D., Dalgleish, T., Lombardo, M. V., Dunn, V. J., Van Harmelen, A.-L., Ban, M., & Goodyer, I. M. (2014). General and specific effects of early-life psychosocial adversities on adolescent grey matter volume. NeuroImage : Clinical, 4, 308–318.

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References – Programmes

Butler, S., Baruch, G., Hickey, N., & Fonagy, P. (2011). A randomized controlled trial of multisystemic therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 1 220 – 1235.

Eckenrode, J., Campa, M., Luckey, D., Henderson, C., Cole, R., Kitzman, H., Anson, E., Sidora-Arcoleo, K., Powers, J., & Olds, D. (2010). Long-term Effects of Prenatal and Infancy Nurse Home Visitation on the Life course of Youths: 19-Year Follow-up of a Randomized Trial. Archives of Pediatric and Adolescent Medicine, 164, 9 – 15

Hutchings, J., Bywater, T., Daley, D., Gardner, F., Whitaker, C., Jones, K., Eames, C., and Edwards, R.T., (2007). Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial. British Medical Journal, 334, 678.

Kitzman, H., Olds, D.L., Cole, R., Hanks, C., Anson, E.A., Arcoleo, K.J., Luckey, D., Knudtson, M.D., Henderson Jr, C.R., & Holmberg, J. (2010). Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Children, Archives of Pediatrics and Adolescent Medicine, 164, 412 – 418

Ogden, T.H., Kristine Amlund (2006). Multisystemic Treatment of Serious Behaviour Problems in Youth: Sustainability of Effectiveness Two Years after Intake. Child and Adolescent Mental Health, 11, 142 – 149.

Olds, D.L., Kitzman, H., Knudtson, M.D., Anson, E., Smith, J.A., and Cole R. (2014). Effect of Home Visiting by Nurses on Maternal and Child Mortality Results of a 2-Decade Follow-up of a Randomized Clinical Trial. JAMA Pediatrics, 168(9), 800-806 Sawyer, A.M. and Borduin, C.M. (2011). Effects of Multi-systemic Therapy through midlife: A 9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 79, 643 – 652

Scott S, Spender Q, Doolan M, Jacobs B and Aspland H. (2001) Multicentre controlled trial of parenting groups for child antisocial behaviour in clinical practice. British Medical Journal, 323, 194 – 197.

Webster-Stratton, C. (1984). Randomised trial of two parent-training programmes for families with conduct-disordered children. Journal of Consulting and Clinical Psychology, 52, 666 – 678..