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 RiskResilience 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.
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
Individual
Agency
Family
Service System
Outcome Levels
Agency
Inter-relationships
Individual
Service System
Family
Community
Community
Agency
Service System
Feedforward
Community
© University-Community Partnerships Check Points Training
Michigan State University, 2001.
University Outreach and Engagement
What are we trying to Prevent?
Risks that Threaten the RiskResilience 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
•
•
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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: iK. 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
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
Established Returns on Investment from ResearchBased Early Childhood Programs for Every Dollar
Invested
$6.89
$5.06
$4.11
Perry PreSchool Project
$3.72
Elmira PEIP
Chicago ParentChild Centers
Abecedarian
Project
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 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
Early Head Start Research Sites
Kent, WA
Sunnyside,
WA
Brattleboro,
VT
Jackson,
Marshalltown, MI
Pittsburgh,
IA
New
PA
York,
Logan,
NY
UT
Kansas City,
Denver, CO
Alexandria,
MO
(2 programs) Kansas
VA
City, KS
McKenzie,
Venice,
TN
Sumter, SC
Russellville,
CA
AR
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

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


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

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
10,003,422
154,890
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
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)
100%
90%
80%
83%
77%
75%
82%
55%
70%
60%
49%
45%
50%
40%
29%
30%
20%
10%
0%
Colors and Shapes Picture Description
and Spatial
Recognition
Numbers and
Counting
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
100%
90%
69%
80%
70%
60%
52%
37%
50%
38%
40%
30%
20%
10%
0%
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
100%
90%
80%
70%
60%
50%
25%
40%
30%
20%
7%
25%
15%
10%
0%
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
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 McCall, 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 not 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
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
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
Peers
School
Community
Early
Childhood
Stage (0-5)
Proximal Influences
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: fitzger9@msu.edu
Web site: outreach.msu.edu
Phone: 517 353 8977
Fax: 517 432-9541
© 2007 Michigan State University Board of Trustees