Evidence-Based Interventions in Infancy Hiram E. Fitzgerald, Ph. D. Michigan State University fitzger 9@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 INTERVENTI ON OUTCOME Foster-Fishman, P. (2007). Campus to campus partnerships. Michigan State University.
When in reality, things are not linear… Intervention Outcome 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 Boundaries Stories Exogenous Influences Mother Father Codes Rituals Sibling 2 Sibling 1 Roles Transitions 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.
Systems Levels Model for Transformational Change Time Outcome Levels Individual Outcome Levels Family Agency Family Outcome Levels Service System Agency Service System Family Community Agency Service System Impact Inter-relationships Individual Community © University-Community Partnerships Check Points Training Michigan State University, 2001. University Outreach and Engagement Feedforward Impact Individual
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 FACTORS Child 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: i. K. L. Moore (1977). The developing human: Clinically oriented embryology. (2 nd edition, p. 136). Philadelphia: W. B. Saunders.
Frontal Cortex and HPA Axis Executive Function, Behavior Regulation, Emotion Regulation
Allostasis: Stress Regulatory System (Sterling & Eyer, 1988). Neural & Neuroendocrine Systems Adaptive Processes & Functions Extra-familial systems STRESS Behavioral & Psychological Systems
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 Communication Cognition/thought Second language 1 year to age 4 Communication Math/logical thinking 1 year to age 4 Cognitive processing Music and rhythm Creative expression 3 years to age 5
What Do We Gain from Prevention?
A higher yield on great finishes and a solid return on investment 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).
WHY EVIDENCE BASED PRACTICES? 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. Best Practice Brief No, 16, B. Tableman (Ed). University Outreach & Engagement, © Michigan State University Board of Trustees
RESEARCH METHODS AND EARLY INTERVENTIONS: Information about the effectiveness of early interventions come four types of sources 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. 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 Mc. Call, 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 u u u 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
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 centerbased approaches (6 programs)
Many Measures Used in the Project u u u 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 interaction § Interviewer observations § Parent interview § Child assessments
Highlight Findings from the National Study
EHS Was Broadly Effective Across a Wide Array of Outcomes u u 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 supportiveness Less detachment More parent-child play More stimulating home environments More support for language and learning More daily reading Less spanking by both mothers and fathers u Program parents demonstrated greater involvement in self-sufficiency activities than control parents Less likely to have subsequent births More 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) • • Square km Sq. km Inland Water Length (km) Widest Point (km) 10, 003, 422 154, 890 64, 000 790 384 • 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
Model for Enhancing System Promoting Resilience Factors for Children, Parents, and Teachers in Tribal Head Start Programs Tribal Elders ECEd/Child Development Tribal Culture Teacher Preparation MSU-BCMM Articulation Note. ECEd = Early Childhood Education Cultural Curriculum Parents Child Functioning
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 subtests Norms developed from a sample of 958 Head Start students norms based on age of the child in months Includes data for all students who completed both Fall and Spring assessments (n=109)
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 *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 *Note that the sample size for each subtest indicates the number of students who did meet expected norms in the fall
FEEDBACK: OUTCOMES 10 SITE HEAD START PROGRAMS • 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
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 Mc. Call, R. B. (2009). Evidence-based programming in the context of practice and policy. SRCD Social Policy Reports. P. 11
THE INDICATOR PROJECT is an attempt to help us know, together, how we are doing. Intellectual and Social Development Economy Health Safety Environment Community Life
Safety 5 Indicators Child Abuse and Neglect Domestic Violence Unintentional Injury Deaths Violent Crime Neighborhood Safety
Domestic Violence Rate of Reported Victims of Domestic Violence per 100, 000 Population, Capital Area, 1996 -2005 Domestic violence is underreported. Many victims do notify authorities. The rate in 2005 is at its highest level in the past 10 years, but is less than the Michigan rate. Capital Area: 662 Michigan: 677
Community Collaborative Higher Education BTW Business & Entrepreneurial Community State and Regional Government
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 while involving in periphery other community agencies Focus on multiple community agencies as equal partners 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
Birth to Work Framework: Transforming Community Based Initiatives into Community Based Research Networks to Link Program Outcomes to Systems Level Change Assessing Proximal and Distal Causal Forces Late Adolescence Stage (18 -25) Proximal Influences Partner Selections Workplace Society Early Adolescence Stage (10 -14) Proximal Influences al I st Proximal Influences Di Early Childhood Stage (0 -5) nf lu en ce s Peers School Community Parents Family (Kin) Neighborhood Prenatal Risk Resilience
Factors Highly Related to Negative Early Organizational Processes 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 Neighborhoods National Research Council, Institute of Medicine, 2000
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.
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: fitzger 9@msu. edu Web site: outreach. msu. edu Phone: 517 353 8977 Fax: 517 432 -9541 © 2007 Michigan State University Board of Trustees
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