Meeting/Event

Intervening Early: Progress and Opportunities in Child Service Settings

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Meeting Summary

Overview

Several studies of prevention programs for young children have shown long-term effects on conduct problems, substance use, juvenile delinquency and arrests, and economic self-sufficiency. Early childhood is an opportune time for fostering children's social, emotional, and cognitive development to prevent negative developmental trajectories. But it can be challenging to develop new interventions or adapt existing programs for very young children and families in real-world settings. The purpose of this meeting was to review existing prevention programs for children ages 0-5 years and their families that are designed to improve child, parent, and family outcomes in a variety of domains (e.g., parenting, education, family functioning, substance use, mental health), with a particular focus on programs delivered within child service settings. In addition, the speakers discussed opportunities for advancing the science of prevention for young children through the translation of basic research—particularly on self-regulatory processes—into novel interventions, and research on the translation of evidence-based interventions into practice.

The National Institute on Drug Abuse (NIDA), in collaboration with the National Institute of Mental Health (NIMH), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institutes of Health Office of Behavioral and Social Sciences Research (OBSSR), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration for Children and Families (ACF) Office of Planning, Research and Evaluation (OPRE) organized the meeting.

Intervening Early: Promoting a Translational Perspective
Elizabeth Robertson, Ph.D.

Characteristics of Infants, Young Children, and Their Families in Child Service Settings

Summary

This session was chaired by Aria Crump (NIDA). Speaker Lauren Supplee (ACF) presented on the structure of Head Start and Early Head Start and the demographics of children and families who participate in those programs; and Margaret Burchinal (University of North Carolina) presented data on children and families who use diverse child care settings, including home-based or parental care versus center-based care. Highlights of the discussion, moderated by Brenda Jones Harden (University of Maryland), focused on the extensive data sets available on demographics, risk status, and family factors for Head Start, Early Head Start, and child care utilization. Consequently, these can provide potential contexts for Type II prevention intervention research.

Head Start and Early Head Start: Structure, Demographics of Children and Families, and Outcomes
Lauren Supplee, Ph.D.

Head Start and Early Head Start are presented as potential contexts for prevention and intervention research. The organizational structure of both programs, demographics of the population served, and the outcomes of program participation for both children and families are described. The organizational structure includes information on the policy councils, parent involvement, special populations such as American Indian and Alaska Native children, program operations such as full-day versus part-day, and the program's performance standards. An overview of participant demographics includes both child and family characteristics such as age, income, and family risk factors (e.g., substance use and criminal activity). Finally, information about child outcomes in cognitive, social-emotional, and mental health; nutrition and immunizations; and family services is presented, based on research conducted by the Office of Planning, Research and Evaluation.

Child Care: Children and Families in Diverse Settings
Margaret Burchinal, Ph.D.

Most children in the United States experience child care before they enter kindergarten. The type, amount, and quality of those child care experiences vary widely. Data from three large extant data sets were examined: (1) the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (SECCYD), (2) the National Household Educational Survey (NHES), and (3) the Pre-Kindergarten Evaluation conducted by the National Center for Early Development and Learning (NCEDL). The SECCYD and NHES included information about child care for children from birth through entry to kindergarten, whereas the SECCYD and NCEDL included information about the quality of child care. Analyses described the proportion of children in each type of care; amount of care; and quality of care as a function of gender, ethnicity, family income, maternal education, and marital/partner status. Results indicated that use of exclusive parental care declined as children approached school age, whereas use of center care increased. Income was positively related to use of more child care, higher quality child care (even in publicly funded programs), and less reliance of exclusive parental care. African-American children tended to experience lower quality care, and income was less related to child care type, quantity, and quality when compared with other children.

Intervention Studies Within Child Service Settings

Summary

This session was chaired by Amy Goldstein (NIMH). Craig Ramey (Georgetown University) presented some basic principles derived from first-generation prevention research programs, including Abecedarian, Perry Preschool, and Chicago Child Parent Centers; David Olds (University of Colorado) discussed the research trials designed to test and refine the Nurse-Family Partnership, a home visiting nurse program for disadvantaged first-time mothers; Thomas Dishion (University of Oregon) spoke about an ecological approach to intervention in early childhood, The Early Steps Project, which embeds the Family Check-Up intervention into the Women, Infants, and Children (WIC) service setting; and Philip Fisher (Oregon Social Learning Center) presented an early intervention for foster children and looked at children's attachment, stress neurobiology, and long-term placement outcomes. Highlights from the discussion, which was moderated by Harolyn Belcher (Kennedy Krieger Institute), focused on effective interventions that can reach young families through existing service systems, like WIC, Head Start, or foster care, and on how the most vulnerable children and families are often the most motivated and responsive to the interventions

Principles to Help Guide Next Generation Interventions: Some Examples from Randomized Controlled Trials Concerning School Readiness
Craig T. Ramey, Ph.D.

Principles that support effective early childhood interventions (timing, intensity, direct learning experiences, breadth of services and supports, individual differences, and environmental maintenance) are presented within the context of a comprehensive, multilevel, contextual (biological, social, environmental) developmental model. To illustrate the principles, research findings from the Abecedarian Preschool Program (from 18 months to 21 years); Project CARE, a replication of the Abecedarian program; and the Infant Health and Development Program are presented. For example, findings from the Abecedarian Preschool Program are used to illustrate that the timing of an intervention—when it begins and ends—can influence outcomes. The principles are relevant to developing the next generation of early childhood interventions and the implementation of evidence-based early childhood interventions in service settings.

Using Randomized Controlled Trials to Test and Refine the Nurse-Family Partnership
David L. Olds, Ph.D.

The Nurse-Family Partnership (NFP) is a program of prenatal and infancy home visiting by nurses for socially disadvantaged mothers bearing first children. The nurses have three major goals: (1) to improve the outcomes of pregnancy by helping women improve their prenatal health; (2) to improve the child's subsequent health and development by helping parents provide more competent care of the child in the first 2 years of life; and (3) to help parents become more economically self-sufficient by helping women plan subsequent pregnancies and helping them make appropriate choices about finishing their education and finding work. To evaluate NFP, scientifically controlled trials were conducted first with a sample of White women living in semi-rural Elmira, New York; then with a large sample of Black women living in Memphis, Tennessee; and more recently with a sample that included a large number of Hispanic women in Denver, Colorado. The Denver trial also examined NFP impact when delivered by paraprofessional visitors. Results showed that the program has produced consistent and enduring impacts on each of the domains targeted by the program. Results of each trial were used to focus subsequent trials and to identify areas of program vulnerability so that program improvements can be made. As the program is replicated in new communities throughout the United States, careful attention is given to faithful reproduction of essential program elements. The program is adapted and tested before it is applied to new populations, societies, or cultures.

An Ecological Approach to Intervention in Early Childhood: The Promise of Embedding the Family Check-Up into Service Delivery Settings such as Women, Infants, and Children (WIC)
Thomas J. Dishion, Ph.D.

In this presentation, an overview of an ecological approach to family intervention and treatment (ecoFIT) as applied to the Women, Infants, and Children service setting in early childhood is provided. Also, the Early Steps Project, a randomized trial of the ecoFIT model, is described, and outcome data are presented. The Early Steps Project involved 731 families distributed across rural, suburban, and metropolitan settings. When the children were ages 2 and 3 years, the families were offered a family check-up in addition to linked interventions tailored and adapted to the families' needs. Assessments were conducted at ages 2, 3, and 4 years. The findings from the first 3 years of the project revealed that the intervention improved child behavior problems, especially for the most problematic children; improved direct observation measures of parents' positive behavior support; and reduced maternal depression. Improvements in child behavior problems were mediated by improvements in positive parenting. The effects were observed after approximately 3 hours of contact per year. These findings suggest the effectiveness of brief family-centered interventions delivered in a public health setting to prevent the early emergence of mental health problems in young children.

Early Intervention for Foster Children: Effects on Children's Attachment, Stress Neurobiology, and Long-Term Placement Outcomes
Philip Fisher, Ph.D.

Children in foster care are often perceived as globally at risk for poor outcomes, yet the specific nature of the risks they face and the extent to which outcomes may vary for individual foster children are poorly understood. Key findings of an ongoing research program focusing on foster preschoolers are described: (1) although many children are adrift in the foster care system, others readily achieve permanent placements, although the likelihood of permanency decreases as the number of placements increases; (2) variations in foster children's maltreatment experiences and placement histories are associated with specific deficits in certain neurobiological systems (the hypothalamic-pituitary-adrenal system and the prefrontal cortex), which are, in turn, associated with poor psychosocial outcomes; and (3) early intervention for foster preschoolers works. In the context of a randomized trial to evaluate an intervention, evidence was obtained to support the assertion that early intervention in this population is efficacious in improving and/or stabilizing functioning in neurobiological systems affected by early stress; impacting the elements of caregivers' behavior towards children most critical to the healthy development of these neurobiological systems; increasing foster children's secure attachment-related behaviors; and increasing the likelihood of permanent placements. The intervention that has produced these results (Multidimensional Treatment Foster Care for Preschoolers) is described, and implications of these data for future research and policy are considered.

New Explanatory Paradigms: Self-Regulatory Processes and Implications for Prevention

Summary

This session was chaired by LeShawndra Price (NIMH). Thomas Boyce (University of British Columbia) presented on the neurobiology of stress and health, showing how children of low socioeconomic status (SES) may develop dental caries from the combination of bacterial exposure due to poor dental hygiene and socially partitioned stress and adversity. Dante Cicchetti (University of Minnesota) presented on stress and resilient functioning - specifically, the role that regulation of adrenal steroid hormones, electroencephalography hemispheric asymmetry, gene-environment interactions, personality functioning, and emotion regulation play in the diverse pathways to competent adaptation in maltreated children. Mark Greenberg (Pennsylvania State University) presented a developmental model that incorporates cognition, emotion, and behavior; and an intervention - the PATHS curriculum - that fosters social and emotional learning using this model. Finally, William Pelham (University at Buffalo, The State University of New York) presented on early intervention for attention-deficit hyperactivity disorder. A highlight of the discussion, moderated by Daniel Shaw (University of Pittsburgh), was that at least one of the following factors affects most children seen in settings designed to provide assistance to the most vulnerable families in the United States: SES, vulnerability to trauma, cortisol/dehydroepiandrosterone, protective effects in the context of maltreatment, inhibitory control, and social and emotional learning. The issue is to tailor these factors into effective interventions.

Stress Neurobiology, Risk and Resilience
W. Thomas Boyce, Ph.D.

Childhood morbidities are non-randomly distributed in the population such that a subset of the population accounts for more than half of biomedical and psychiatric morbidities and health care utilization. Factors that may account for this distribution of health problems—specifically, the interactive effects of biological stress reactivity and social context on child outcomes—are presented. In particular, low socioeconomic status, adverse life events, and family instability are presented as factors that may influence the social partitioning of differences in childhood physical and mental health disorders, through interactions with neurobiological vulnerability. Current research on childhood dental caries is presented to further illustrate how the interplay between stress, biological risk, and social context may affect health outcomes. Individual differences in children's susceptibility to contextual effects may be an important consideration for designing early childhood interventions that will impact public health.

Stressful Challenges and Resilient Functioning: Illustrations from a Multi-Level Perspective on Child Maltreatment
Dante Cicchetti, Ph.D.

Resilient functioning is the attainment of unexpected competence despite the experience of significant adversity, and is among the most intriguing and adaptive phenomena of human development. Although growing attention has been paid to discovering the processes through which individuals at high risk do not develop maladaptively, the empirical study of resilience has focused predominantly on detecting the psychosocial determinants of the phenomenon. For the field of resilience to grow, efforts to understand underlying processes will be facilitated by more interdisciplinary research that is designed within a developmental psychopathology framework. This type of research would entail a consideration of psychological, biological, and environmental-contextual processes from which pathways to resilience might eventuate (known as equifinality), as well as those that result in diverse outcomes among individuals who have achieved resilient functioning (known as multifinality). Examples are provided of a multi-level perspective on resilience in child maltreatment, which is one of the most severe and stressful challenges children can confront. These include research on the role that the regulation of adrenal steroid hormones, EEG hemispheric asymmetry, gene-environment (GxE) interactions, personality functioning, and emotion regulation play in the diverse pathways to competent adaptation in maltreated children. The possible relation between the mechanisms of neural plasticity and resilience is discussed. This presentation emphasizes the importance of adopting a multiple-levels-of-analysis perspective for designing and evaluating interventions aimed at fostering resilient outcomes in persons facing significant stress and adversity.

Emotion Regulation, Inhibitory Control, and Social Competence
Mark Greenberg, Ph.D.

A developmental model that attempts to integrate processes across cognition, emotion, and language during the preschool and early school-age periods is presented. The model focuses on how optimal development in each of these domains contributes to effective social and emotional competence and how both individual characteristics and environmental difficulties may impact development. Of critical importance to the development of early social and emotional competence are responsive and sensitive adults who care for and model effective social interactions. In addition, a young child's developing ability to use language to express emotional states, and the development of inhibitory control (the ability to stop and calm down and to delay impulsive actions) are key developmental skills that predict social and emotional functioning. The curriculum Promoting Alternative Thinking Strategies, which is based on this theoretical model, is presented, with specific illustrations of how lessons and daily generalization activities and skills, beginning in the preschool years, can effectively build the skills of emotion regulation and inhibitory control. Use of these skills is linked to decreases in both externalizing and internalizing behavior problems in preschool and school-age children. Data are presented to illustrate that improvements in prefrontal abilities mediate improvements in behavior in randomized trials. Finally, the need for a closer integration of research on developmental neuroscience and prevention science is presented.

Early Intervention for ADHD: Targets, Settings, Methods, and Mechanisms
William Pelham, Ph.D.

This presentation describes what is known about treatment for ADHD in childhood, particularly for young children. Issues of target behavior in assessment and outcome measurement (DSM symptoms versus impairment) and settings in which treatment must be provided are discussed. Four recently completed or ongoing treatment studies, including one focusing exclusively on early intervention (psychosocial treatment as prevention for medication) with ADHD children in kindergarten and first grade are described. Suggestions for improving understanding of putative underlying mechanisms of psychopathology by including measures of these constructs in intervention studies are presented along with constraints.

Moving Interventions Into Sustaining Systems

Summary

This session was chaired by Dara Blachman (OBSSR). Karen Bierman (Pennsylvania State University), and Cathy Kipp and Lynda Sheffer (Head Start of York County) presented on implementing research-based interventions in Head Start classrooms; Mary Dozier (University of Delaware) and Carole Shauffer (Youth Law Center) spoke about implementing and integrating specialized mental health services into child welfare settings with a focus on infants; Richard Spoth (Iowa State University) discussed moving interventions into sustaining systems using partnerships between the university, the cooperative extension service, and the public school system; and Marion Forgatch (Oregon Social Learning Center) talked about implementing evidence-based practice on a nationwide scale in Norway. Highlights of the discussion, moderated by Janice Cooper (Columbia University), included the need for high levels of fidelity to the core intervention when "scaling up," while still recognizing the need for adapting to community needs. To achieve this goal, multiple factors must be considered: race, ethnicity, language proficiency, policy as well as the family/caregiver, and the need for support by family and the community.

Implementing and Integrating Research-Based Supports into Existing Head Start Classrooms
Karen Bierman, Ph.D., Cathy Kipp, and Lynda Sheffer

Whereas efficacy trials can identify efficacious intervention strategies, effectiveness research that bridges the gap to service delivery in real-world systems is critical for improving practice. The Head Start research project called REDI (Research-based, Developmentally Informed) uses developmental theory and prior efficacy trials to identify research-based instructional strategies that target social-emotional skills and language-emergent literacy skills. In a randomized, controlled effectiveness trial, Head Start teachers in three counties integrated the REDI curricula and coaching strategies into their traditional curricula (High Scope or Creative Curriculum). A well-specified curriculum and mentored professional development helped teachers to implement the intervention. During the first 3 years of the current funding, the research design followed 2 cohorts of 4-year-old children (N = 356: 19 percent Hispanic, 26 percent African-American; 54 percent girls) in 44 Head Start classrooms; classrooms were randomly assigned to intervention or "usual practice" comparison groups. Multimethod assessments revealed significant differences favoring children in the enriched intervention classrooms on measures of vocabulary, emergent literacy, emotional understanding, social problem solving, social behavior, and learning engagement. During the final 2 years of the current funding, the project is focusing on identifying and coping with the challenges of supporting long-term sustainability for the REDI practices within the partnering Head Start programs. The REDI program is described, outcome findings are reviewed, and "lessons learned" are discussed in terms of the importance of researcher-practitioner collaborations that extend from program design through sustainable program accommodation and ownership.

Implementing and Integrating Specialized Mental Health Services into Child Welfare Settings
Mary Dozier, Ph.D., and Carole Shauffer, M.Ed., J.D.

The child welfare system is an important arena for evidence-based practice. There have been relatively few evidence-based interventions developed specifically for children in this system. Administrators and staff at all levels have heard the call to use evidence-based practice but are often confused about how to begin.

In this presentation, a model of intervention for the youngest children in the child welfare system is described. Over the last 15 years, key challenges confronting infants and toddlers in the system have been identified, and intervention components that target these issues have been developed. The intervention has been shown to be effective in helping children develop more secure attachments to caregivers and better ability to regulate behavior and physiology.

Issues involved in implementing and disseminating the intervention are discussed. Essential to effective implementation is educating child welfare officials about the specific developmental challenges facing infants and toddlers. All decisionmakers, both formal and informal, should be educated to ensure that the intervention is embedded in the culture of the agency.

Moving Interventions into Sustaining Systems: Study of the PROSPER Community-University Partnership Model
Richard Spoth, Ph.D.

During the past 3 decades, the field of prevention science has confronted two major challenges: the development of evidence-based interventions (EBIs) and effective strategies for scaling up EBIs to achieve public health impact. The Promoting School-Community-University Partnerships to Enhance Resilience (PROSPER) Project builds on a program of translational research that addresses the second of these challenges by using a network of partnerships that link the Land Grant University Extension System and public school system for intervention delivery.

A summary of key challenges and opportunities encountered as the field moves toward sustaining intervention systems for scaling up EBIs is presented, and a community-university partnership approach to address those challenges and opportunities is described. Next, the PROSPER project background, starting with a description of the project's partnership model and design—a sequential cohort, randomized, controlled study of 28 school districts in Iowa and Pennsylvania—is presented. Early findings are summarized, including results on EBI recruitment from general populations, quality of EBI implementation, proximal family and youth competency outcomes, and local sustainability of interventions. Substance use outcomes at a follow-up assessment conducted 1½ years past baseline are also presented.

Finally, an overview of future directions for testing and evaluating the sustainability of community implementation teams and EBIs is presented. A design for an expanded network of partnerships is outlined along with anticipated barriers to surmount in this planned work.

Implementing Evidence-Based Practice on a Large Scale
Marion Forgatch, Ph.D.

The transplant of an efficacious intervention from a controlled environment to a community is a delicate operation. This operation requires sensitive instruments capable of assessing competent adherence to methods that predict changes in mechanisms and outcomes. Data were presented on the transfer of Parent Management Training–the Oregon Model (PMTO), an evidence-based method from the United States to Norway in a nationwide implementation. Measures were created using direct observations from two separate settings. Fidelity of Implementation (FIMP), a measure used to evaluate competent adherence to PMTO principles and procedures, is based on data from DVD recordings of intervention sessions. PMTO parenting practices were measured by observation of video recordings of family interaction tasks. Several studies have shown that intervention-induced changes in parenting practices produce benefits to youth outcomes, including delinquency, externalizing, internalizing, and academic functioning. This study examined fidelity in relation to change over training, drift across successive generations of professionals trained in Norway, and as a measure with predictive validity to parenting practices. Fidelity decayed from Generation 1 (G1) to G2 but returned to G1 levels by G3. Norwegian findings from a treatment population replicate U.S. findings with a prevention sample. Structural equation modeling was used in both studies to show that therapists' FIMP scores (measured during intervention) predict improvements in maternal and paternal parenting, which were measured before and following intervention.

Issues and Strategies for Assessing Benefits, Costs, and Cost Effectiveness of Preventive Interventions in Child Service Settings

Summary

This session was chaired by Jeffrey Evans (NICHD). Although there are programs for young children (e.g., the Nurse-Family Partnership [home visiting] and Incredible Years Series) that have demonstrated economic benefits, there is still a need for further economic analysis of early interventions. This panel addressed some of the issues involved in developing economic data for interventions in early childhood. Greg Duncan (Northwestern University) discussed the use of intervention effect sizes for guiding policies for early intervention (i.e., large apparent effect sizes may cost too much to be worth the investment, while inexpensive programs with modest effects may be cost-effective when viewed from a population-base perspective) among other economic considerations; Michael Foster (University of North Carolina) recommended a culture of open inquiry where data are accessible to researchers to assess the findings from effectiveness studies using state-of-the-art methodology; and Steve Aos (Washington State Institute for Public Policy) encouraged researchers to collaborate with policy experts to help translate findings into usable material for consideration by policy decisionmakers at the State level. Highlights of the discussion, moderated by Alka Indurkhya (Harvard University), included the need to have convincing evaluation designs and appropriate perspectives of economic analysis, as well as a focus on monetary and non-monetary benefits, not just effect sizes. There was also a discussion about incentives for sustainability and the need for support for replication research.

Penny Wise and Effect Size Foolish 
Greg Duncan, Ph.D.

The pros and cons of relying on effect sizes of early interventions to guide policy are described, and an alternative approach to presenting policy-relevant results based on the costs and benefits of early intervention is described. Methods for estimating costs and benefits are suggested, and specific examples from early intervention findings are used to illustrate these points. Estimates of costs and benefits should capture a wide array of issues that may be salient to policymakers, such as costs to participants in addition to taxpayer costs, or benefits of impacting multiple related outcomes along with the target outcome. In sum, policy should be guided by good evaluation designs, consideration of benefits relative to costs (not just effect sizes), and a wide-ranging look at policy options.

A Culture of Open Inquiry: Producing Credible Evidence on Program Effects
E. Michael Foster, Ph.D.

The translation of research-based interventions into real-world settings will require higher standards of intervention evidence. The need to establish a culture of open inquiry for intervention findings is addressed, including better data sharing that will allow for outside analysis of robustness and representativeness of findings. In addition, improved methodology, analytic plans, and reporting are important, as is research that is conducted by a mix of investigators to match the expertise required to test interventions.

Statistics for the State House: Outcomes of Prevention Programs that Matter for Policy-Level Decisions
Steve Aos, M.S.

What research-based information motivates State-level policymakers to take action? Perspectives on the types of information from program evaluations that have proven useful (as well as those that have not) to state legislators and executive staff are considered. The outcomes identified as most salient are those that use some measure of costs and benefits, and those that focus on "big picture" outcomes of interest to legislators. The production of some of these big-picture outcomes places significant additional research demands on program evaluation. Approaches that have been tried in Washington State are used as examples.

Summary and Next Steps

Attendees included researchers from across the country and employees from various Federal agencies that support research about young children and families. Meeting goals included identifying critical research gaps that need to be addressed to (1) foster novel program development or improvement of early childhood interventions and (2) increase the uptake and implementation of effective preventive interventions for young children and their families within child service settings.

Below are some examples of future research directions:

  • Encourage the establishment or use of existing appropriate large-scale representative populations of children aged 0-5 and their families, and make those data available for analysis across disciplines;
  • Continue to design small efficacy and effectiveness trials to provide understanding of varied intervention designs, mechanisms of change, the core elements of an intervention, and efficient training before taking an intervention to scale;
  • Expand prevention intervention research to identify core components to ensure fidelity to critical processes that affect outcomes;
  • Encourage collaborative partnerships between researchers and community practitioners to design effective research paradigms that can later be transferred to child service settings;
  • Encourage research that embeds interventions within service systems, incorporates economic analyses, and examines organizational and management factors that may influence implementation, fidelity, and outcomes of early intervention;
  • Improve research design and methodologies to increase power and discern benefits of interventions;
  • Improve biological and cognitive measurement to expand research on understanding the neurobiological developmental processes and implications for preventive interventions in early childhood;
  • Encourage the translation of basic research to design novel prevention programs within the context of child service settings; and
  • Encourage research on mapping the social and developmental environments of children to understand how early intervention affects the child's developmental trajectory.