Transcript Document

Early Head Start and
Developmental Disabilities
Craig T. Ramey, Ph.D.
Georgetown Distinguished Professor of Health Studies
Director, Georgetown Center on Health and Education
EHS Disabilities Summit
Washington, D.C.
February 5, 2004
10 Hallmarks of Children Who
Succeed in School
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Eager to learn
Ask lots of questions
Work hard and know
effort matters
Have good socialemotional skills
Can assess their own
skills well
Parents are role models
for learning
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Parents promote
learning at home
Family routines support
doing well in school
Parents set and
maintain limits
Schools have high
student expectations,
support teacher
development, and
communicate frequently
with parents
Ramey & Ramey, Going to School, 1999
Good health is the foundation
for learning, development and
school success.
The developmental domains
of health, cognition, social and
emotional development are
closely linked by
neurobiological connections
and personal experiences.
WHO Definition of Health
A state of complete physical, mental
and social well-being and not merely the
absence of disease or infirmity.
Health Promotion and Disease Prevention
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Promotion of mental health
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mentoring in cognitive, social
and emotional basics
responsive language experiences
stable and caring adults
good role models
Health Promotion and Disease Prevention
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Promotion of social well-being
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Safe environments
Enjoyable play and learning activities
Supportive, informative and frequent
interactions with parents and
other adults
Some Facts about Developmental Disabilities
Majority
of children with intellectual, social
and emotional disabilities are born healthy
Biological risk conditions(e.g., LBW, prematurity)
result in different outcomes, depending on cognitive,
social and emotional support
About
11% of children are in special education
Ethnic and regional differences in developmental
disabilities are poorly understood
Seven Essential Transactions For
Caregivers with Young Children
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Encourage exploration
Mentor in basic skills
Celebrate developmental advances
Rehearse and extend new skills
Protect from inappropriate disapproval,
teasing, and punishment
Communicate richly and responsively
Guide and limit behavior
Ramey & Ramey, 1999
Right from Birth
Sources of Available Support for
Early Intervention Funding
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Elementary and Secondary Education Act:
Title I: Disadvantaged Children
Title V: Innovative Block Grant
Early Head Start
Head Start
Child Care Development Fund (CCDF)
Temporary Assistance for Needy Families (TANF)
Early Reading First
Social Services Block Grant
Even Start
Early Intervention (0-2 yrs; 3-5 yrs)
Psychosocial Developmental
Priming Mechanisms
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Encouragement to explore the environment
Mentoring in basic cognitive and social skills
Celebrating new skills
Rehearsing and expanding new skills
Protection from inappropriate punishment or
ridicule for developmental advances
Stimulation in language and symbolic
communication
Potential Levels of Early Intervention
Developmental of Biomedical affordances
Prenatal and perinatal services
Children’s direct learning opportunities
Development of family skills
Development of professionals’ knowledge
and skills
Development of community and cultural
norms concerning inclusion
Statement of the problem
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For a variety of reasons, the early years are
believed to be the most efficacious period to
intervene in the lives of poor children.
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Development appears to be more malleable in the
early years.
Children who arrive at kindergarten lacking basic
readiness skills tend to fall further behind in later
years.
Massive attempts to prepare poor children for
school success, such as Head Start, were initially
disappointing.
Research was needed to learn whether intensive
early intervention that began in the infancy period
could make more lasting difference for poor
children.
Stages for the Development of a
Scientific Knowledge-Base
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Proof of concept studies
Efficacy studies
Effectiveness studies
Efficiency studies
Hierarchy of Criteria for
Evidence-based Practices
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Multi-site randomized controlled trial
Single site randomized controlled trial
Single site randomized trial (not controlled)
Case/control study
Observational study
Opinions of best practices
Key Research Question for
Abecedarian (ABC) Project
Can the cumulative developmental toll
experienced by high-risk children
be prevented or reduced significantly
by providing systematic, high-quality,
early childhood education from
birth through kindergarten entry?
The Abecedarian (ABC) Project is a
randomized controlled trial (RCT)
that tests the efficacy of early
childhood education for high-risk
children and their families.
ABC Eligibility
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Recruitment in community agencies
serving poor women
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High Risk Index
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Other criteria
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Healthy newborn child
Living within commuting distance of FPG
Likely to remain in area
Who was invited to take part?
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120 families invited to enroll
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8 refused random assignment
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2 infants reassigned at insistence of authorities
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1 ineligible due to biological condition
(seizure disorder with moderate MR)
Participants
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4 cohorts of children born between 1972 and
1977
Half randomly assigned to preschool education
program, half were controls
Original Sample
 Treated
 Control
 Total
N
57
54
111
Males
29
23
52
Females
28
31
59
Study Design
EE
E
29 Males
28 Females
EC
R
N=111
23 Males
31 Females
CE
C
CC
Follow-up Assessments
Preschool
Treatment
Ages 0-5
School-age
Treatment
Ages 5-8
Age 12
Age 15
Age 21
Educational Intervention
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Very intense
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Full day childcare program
5 days/week
Year round
Began in infancy (mean entry age: 4.4 months, range: 6 weeks to 6
months)
5 years, until kindergarten entry
University-based setting
Medical care on site
Stable staff
Low adult : child ratios
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1 : 3 infants
1 : 4–5 toddlers
1 : 7 preschoolers
Preschool
Curriculum
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Eclectic in nature
Stressed
contingently
responsive early
environment
for infants
Learningames for
the First Three
Years (Sparling & Lewis, 1979, recently reissued)
Natural part of infant’s or toddler’s day
Learningames for Threes and Fours: A Guide to Adult and Child
Play
(Sparling & Lewis, 1984)
Key Abecedarian (ABC) Program Components
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Health and Mental Health
Nutrition
Family Support
Parent Involvement
Early Childhood Education
Preschool Results
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Tests of cognitive development constituted major outcome during
early years
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Infants equivalent at outset (3 month Bayley MDI scores)
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Cognitive measures
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Bayley Scales of Infant Development
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Stanford-Binet Intelligence Scale (Form LM, 1972 norms)
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3–18 months
2–4 years
Wechsler Preschool & Primary Scale of Intelligence
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5 years
Preschool Test Scores
Mean Standardized Score
120
110
100
90
80
Treated
Control
70
60
0.25
0.5
1.5
2
3
Age at Testing (years)
4
5
Percent of Abecedarian Sample in Normal IQ
Range (>84) by Age (longitudinal analysis)
Martin, Ramey, & Ramey, 1990
American Journal of Public Health
Brief Summary of Abecedarian Results
During Preschool Period
Positive Effects on:
 IQ Performance
 Learning & cognitive
performance
 Social responsiveness
 Language development
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Resilience to biological risk
conditions
Maternal education
Maternal employment
Decreased Effects:
 Incidence of intellectual
disability
Ramey & Ramey, 1999
School-Age Program
EE
E
EC
R
CE
C
CC
Follow-up Assessments
Preschool
Treatment
Ages 0-5
School-age
Treatment
Ages 5-8
Age 12
Age 15
Age 21
School-Age Program
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Home-School Resource teacher
(first three years of school)
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Consultation with classroom teacher
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Individualized curriculum items based on needs
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Encouragement of parental involvement with home activities
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Liaison between home & school
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Family support as needed
School-Age Results
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Reading Scores:
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Strong preschool effect on reading scores at age 8
(p<.01)
Significant trend for EE>EC>CE>CC (p<.05)
No effect for school-aged treatment alone
Four-Group Reading Scores at Age 8
96
Standard Score
94
92
90
88
86
84
82
EE
EC
CE
Treatment Group
CC
School-Age Results
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Trend for preschool effect on
mathematics scores (p<.10)
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Linear trend in mathematics scores not
significant
No effect for school-age treatment alone
Four-Group Math Scores at Age 8
98
Standard Score
96
94
92
90
88
86
EE
EC
CE
Treatment Group
CC
Long-Term Effects
EE
E
EC
R
CE
C
CC
Follow-up Assessments
Preschool
Treatment
Ages 0-5
School-age
Treatment
Ages 5-8
Age 12
Age 15
Age 21
Long-Term Effects
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Intellectual measures in the follow-up
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Age-appropriate Wechsler scales
administered
Full Scale IQ used in plots
Examiners unaware of earlier
treatment/control status
Because school-age treatment had no
effect, reverted to two-group model
Long-Term Effects on intellectual
development
Adjusted IQ Trajectory, Ages 2 to 21 Years
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105
IQ Scores
95
85
Treated
Control
75
2
3
4
5
6.5
8
12
Age (Years)
15
21
Long-Term Effects, continued
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Treated children earned higher scores across time
Treatment/control group difference was greater
during the early, treatment years
Slopes differ in treatment/post-treatment phases
Treated children differed from control children in
rates of change during treatment years but not
during post-treatment years
Both groups showed upward trends during the early
years and declines in post-treatment years
Up to young adulthood, the group with early
treatment maintained an advantage over controls.
Can we identify mediators of longterm treatment effects on cognitive
development?
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Early task orientation mediated effects of
early treatment on test scores but effect
size did not show much change when this
factor was entered into the model.
Early verbal development accounted for
much of the treatment effect on test
performance, and in later years, wholly
accounts for it.
Long-Term Effects, continued
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Adding child and family characteristics
to the prediction model
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No significant effect for child gender
No significant treatment x gender interaction
Gender x time2 interaction reflects complex
pattern of change in intellectual test performance
of males and females over time
Long-Term Effects, continued
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Females change more rapidly in early childhood
Females decline more sharply than males in early
adolescence
Males decline more sharply than females in later
adolescence
Age x Gender Interaction in Control Group
105
IQ Score
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95
85
Female
Male
75
0
5
10
15
Age (years)
20
25
Long-Term Effects, continued
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There is also a main effect for the HOME
score
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Main effect is moderated by a HOME x age interaction
Effect of HOME is stronger in the early years
Parental attitudes in early life did not have a
significant effect on intellectual test
performance.
No significant effects of mother’s marital
status.
Long-Term Effects, continued
Does a modest effect on IQ test performance
matter?
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The evidence indicates that the significant longterm effect of treatment on academic performance
was mediated by its effect on early cognitive
performance.
Long-Term Effects, continued
Does a modest effect on IQ performance really
matter?
Early treatment was associated with significantly
higher scores on reading from age 8 to age 21
Predicted Reading Scores, Ages 8 to 21, by Treatment
Group
100
95
IQ Score
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90
85
Control
Treatment
80
8
12
Age (Years)
15
21
Long-Term Effects, continued
Does a modest effect on IQ matter?
Early treatment was associated with significantly
higher scores on math from age 8 to age 21
Predicted Math Scores, Ages 8 to 21, by Treatment Group
100
95
IQ Score
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90
85
Control
Treatment
80
8
12
Age (Years)
15
21
Long-Term Effects, continued
Real-life benefits in young adulthood
Treated group attained more years of education
 Treatment associated with increased likelihood of
attending a 4-year college or university
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Students Ever Attending a Four-Year College or University,
in percentage, by treatment group
40
Percentage of Group
35
30
25
20
15
10
5
0
Control
Treated
Group
Long-Term Effects, continued
Teenaged parenthood was less likely for those having
preschool treatment.
Age at Birth of First Child
20
19.5
19
Age in Years
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18.5
18
17.5
17
16.5
Control
Treated
Group
What was the early intervention worth?
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Cost-benefit study was carried out at the
National Institute of Early Education
Research (NIEER) at Rutgers University
Leonard Masse and Steven Barnett
Cost of Abecedarian Program Compared with
Others (1999 Dollars)
ABC
CH
Schools
Child
Care
Head
Start
Annual Cost
per Child
$11,152
$13,401
$7,070
$5,616
Annual
Teacher
Salary
$31,460
$24,050$31,350
(+)
$15,308
-
Ratio of Costs to Benefits
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NIEER researchers estimated that the
Abecedarian program will save society, on
average, $4 for every dollar spent.
Why would it save money?
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Individuals who had early childhood
education are projected to earn, on
average, roughly $143,000 more over
their lifetimes than preschool controls.
Mothers of children who had the free
preschool program are expected to earn
about $133,000 more over their lifetimes
(preliminary figures).
Why would it save money? (continued)
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School districts can expect to save about
$11,000 per child because of reductions in the
need for special or remedial education services.
There appeared to be a reduction in smoking
among those with early childhood education,
leading to better health and longer lives (saving
approximately $164,000 per person).
NIEER Conclusions
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The Abecedarian program effected significant
savings to society.
The estimate may be conservative because of
the community where the children grew up –
relatively affluent and low crime.
Benefits of a similar analysis for the Perry
Preschool study estimate $7 saved for each
dollar spent. This was due largely to a
significant reduction in criminal involvement
among treated individuals.
Abecedarian Project
Ramey & Ramey, 1999 MR/DD Research Review
Key Findings from Abecedarian Project
(“Abecedarian” …one who learns
the basics such as the alphabet)
5 to 21 Years Old
• Intelligence (IQ)
• Reading and math skills
• Academic locus-of-control
• Social Competence
• Years in school,
including college
• Full-time employment
• Maternal education
• Maternal employment
• Grade Repetition
• Special Education
placement
• Teen Pregnancies
• Smoking and drug
use
Ramey et al, 2000
Project CARE
A RCT designed to be a replication of
Abecedarian Project (ABC)
with a 2nd treatment group
to test the potential efficacy of an intensive
home visiting program with the same
ABC educational curriculum for 5 years
Adapted from Wasik, Ramey, Bryant, & Sparling. Child Development, 1990
Abecedarian (ABC) Preschool Findings Replicated in the
First 3 Years of Life in Randomized Controlled Trials (RCT’s)
Arkansas
Connecticut
Florida
Massachusetts
New York
North Carolina
Pennsylvania
Texas
Washington
Ramey & Ramey, 2000
in Securing the Future
Infant Health and Development Program
Designed
to test the efficacy of ABC intervention
for children who were < 37 weeks
gestation and < 2500 gm at birth
Conducted at 8 sites
Intervention modified for biological risk factors
Intervention lasted only until 36 mos. CA
Infant Health and Development
Program (2001-2500 grams)
Infant Health and Development Program
Children’s IQ at 36 months:
Maternal Education X Treatment Group
110
105
Control
Intervention
100
95
90
85
Ramey & Ramey (1998)
Preventive Medicine
80
75
70
Some High
School
High School
Graduate
Some College
College
Graduate
(n=232)(n=162)
(n=166)(n=104)
(n=134)(n=63)
(n=76)(n=48)
Outcomes Affected Positively (*p<.01)
by the Infant Health & Development Program
12 Months
Cognitive Development
Adaptive and Prosocial Behavior
Behavior Problems
Vocabulary
Receptive Language
Reasoning
Home Environment
Maternal Interactive Behavior
Maternal Problem Solving
NS
-
NS
-
24 Months
+
+
+
+
-
36 Months
+
+
+
+
+
+
+
+
+
Ramey 1999, adapted from Gross, Spiker, & Haynes, 1997, Helping Low Birth Weight, Premature Babies
Recommendations
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Recognize the WHO concept of health and
its implications for Head Start programs
Promote the WHO concept of health to
communities, programs, families and
children
Emphasize health promotion and disability
prevention
Recommendations
Design and implement a strong accountability
system that continuously monitors program
quality and documents child and program
progress and outcomes
To
inform quality improvements
To strengthen training and technical assistance
Health and human
development are mutually
enhancing. Head Start can
and is promoting both.