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