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Can targeted and intensive home visiting programmes improve child development? Evidence from a 5-year RCT
Dr. Orla Doyle15th WAIMH Congress, 2016, Prague 30th May 2016
+Background
Steep socioeconomic gradient in children’s development
Early intervention programmes can be an effective means of reducing inequalities
Home visiting programmes (HVPs) provide support and education to parents from pregnancy/birth onwards Systematic reviews report some short & long terms effects, but modest
effect sizes (e.g. Sweet & Applebaum, 2004; Miller et al. 2011)
Aim of this study: Use a randomized controlled trial, which experimentally modified the environment of disadvantaged families, to investigate the effectiveness of home visiting in an Irish
context
+‘Preparing for Life’ Programme
Preparing for Life: one of first and longest running experimental early childhood interventions in Ireland
Community-led initiative: operated by Northside Partnership in highly disadvantaged area of Dublin
Evidence of need: Children scored below the norm on cognitive & socioemotional skills on school entry
Aim: Improve levels of school readiness by assisting parents in developing skills to prepare their children for school
+ ‘Preparing for Life’ Programme
Random Assignment
PFLTREATMENT
N = 115
Non-PFLCONTROLN = 118
PFL Participants233
1. Public health information
2. Access to a support worker
3. €100 worth of child developmental materials annually
4. Home visiting programme
5. Triple P Positive Parenting Programme
1. Public health information
2. Access to a support worker
3. €100 worth of child developmental materials annually
+ Evaluation Design Eligibility Criteria:
Pregnant women residing in PFL catchment area btw Jan 2008-August 2010
Recruitment: Maternity hospital (~20 weeks) & within the local community Population-based recruitment rate: 52%
Randomisation: Unconditional probability randomisation strategy 115 allocated to Treatment and 118 allocated to Control No statistical differences on 107/116 BL measures (92%)
Assessments: Interviews: 7 home-based assessments (BL, 6, 12, 18, 24, 36, 48 months) Direct assessments: Cognitive skills & executive functioning at 48 months
Methods: IPW-adjusted permutation tests with 100,000 replications controlling for gender
+ RESULTS: HEALTH
6 months 12 months 18 months 24 months 36 months 48 months0
10
20
30
40
50
60
70
80
90
100
12% 14% 14%
40%
15%20%
Impact of PFL on Parent Reported Child Health
% Statistically Significant Effects*
Assessment Point
% S
igni
fican
t
*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.
+Example 1: Body Mass Index at Age 4*
Overweight/Obese at Age 4 Age 40%
5%
10%
15%
20%
25%
30%
35%
40%
45%
23%
41%
Treatment Control
% o
f chi
ldre
n w
ith o
vwew
ight
/obe
se
*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.
+ RESULTS: SOCIAL
6 months 12 months 18 months 24 months 36 months 48 months0
10
20
30
40
50
60
70
80
90
100
0% 0%
13%
31%35%
44%
Impact of PFL on Parent Reported Socio-Emotional Skills
% Statistically Significant Effects*
Assessment Point
% S
igni
fican
t
*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.
+Example 1: Behavioural Problems*
24 months 36 months 48 months0
2
4
6
8
10
12
14
16
18
0%1%
2%
9%8%
17%
TreatmentControl
CBCL
% b
ehav
iour
al p
robl
ems u
sing
Child
Beh
avio
r Ch
eckl
ist (C
BCL)
*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.
+RESULTS: COGNITION
6 months 12 months 18 months 24 months 36 months 48 months0
10
20
30
40
50
60
70
80
90
100
0% 0%
9%
63%
83%
50%
Impact of PFL on Parent Reported Cognit -ive Skills
% Statistically Significant Effects*
Assessment Point
% S
igni
fican
t
*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.
+Direct Cognitive Assessments at Age 4
British Ability Scale II (BAS II; Elliot, Smith, & McCullock, 1997)
Verbal Ability
Pictorial Reasoning
Ability
Spatial Ability
General Conceptual
AbilityEarly Number Concepts
Naming Vocabulary
Verbal Comprehension
Picture Similarities
Pattern Construction
Copying
+ BAS GCA & Upper Level Clusters: Standard Scores*
N(nTREAT/ nCONTROL)
MTREAT (SD)
MCONTROL (SD)
IPW weighted p values with
controls Effect size
(Cohen’s D)P1 P2
General Conceptual Ability
128
(69/59)
97.7(14.4)
88.0(12.6) 0.000 0.001 0.72
Spatial Ability 129(69/60)
96.0(17.0)
86.0 (15.3) 0.000 0.001 0.62
Pictorial Reasoning 132(71/61)
99.2 (12.9)
93.2 (10.9) 0.002 0.002 0.51
Verbal Ability 134(71/63)
98.6(13.1)
90.3(12.4) 0.002 0.002 0.65
*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.
+ Executive Functioning Scores
Effortful control: Day/night task (Kochanska, Aksan, Penney, & Doobay, 2007)
Delay of gratification: Modified version of Mischel’s original delay of gratification task (Mischel, Shoda, & Rodriguez, 1989)
N(nTREAT/ nCONTROL)
MTREAT (SD)
MCONTROL (SD)
IPW weighted p values with
controls Effect Size
P1 P2
Effortful Control 117(63/54)
22.0(6.4)
19.2(5.9) 0.023 0.037 0.45
(D)Ability to Delay Gratification
129(68/61) 75% 72% 0.345 0.345 1.13
(OR)
+ How does PFL compare to other home visiting programmes (HVPs)?
Meta-analyses of HVPsPFL
Sweet & Appelbaum
(2004)
Miller et al., (2011)
Filene et al., (2013)
Physical Health ~ ~ 0.11Overweight BMI
0.46
Socioemotional Skills 0.10 ~ ~
CBCL Total Problems
0.36
Cognitive Skills 0.18 0.30 0.25BAS GCA Score
0.72
Abecedarian (HVP & ECCE): ES 0.62 cognitive skills @ age 5Nurse Family Partnership HVP: ES 0.18 cognitive skills @ age 6
+Conclusions
Home visiting programmes can improve the cognitive & socioemotional skills and health of disadvantaged children
Potential mechanisms PFL children lived in higher quality home environments PFL parents less likely to have permissive parenting style Better screentime practices
Results robust to small sample size, differential attrition, multiple hypothesis testing, differential misreporting & contamination
PFL Phase II currently being rolled out
For more information please see: http://geary.ucd.ie/preparingforlife/
+ Thanks to our Funders