EARLY CHILDHOOD PROGRAMS

A multitude of studies document that preschool programs which are supportive of and helpful to parents, which foster mother-infant attachment, and which enable children to learn pre-academic and social skills can increase the children’s success in elementary and high school (Karoly, et al., 1998). Some of these programs are as follows:

• Kempe Prevention Research Center for Family and Child Health
• The Infant Health and Development Program (IHDP)
  
• Dare To Be You (DTBY)
  

I. Kempe Prevention Research Center for Family and Child Health
Dr. David Olds and Colleagues, University of Colorado Health Sciences Center

In the early 1960s, Dr. David Olds and his colleagues began an extensive, well-designed, randomized study of a comprehensive program of in-home visits by nurses to "high risk" young women beginning during their first pregnancy and continuing through the second year of their child’s life. This first project was conducted with low income, unmarried, white women in the semi-rural community of Elmira, NY, and has been replicated with a low income African American population in Memphis, TN, and Denver, CO. As of October, 1998, the status of these trials was as follows:

ELMIRA Nurse Home Visitation N=400	MEMPHIS Nurse Home Visitation N=1138	DENVER Lay vs Nurse Home Visits N=735
Pregnancy – 4 year analysis complete	Pregnancy – 4 year analysis complete	Sample delivered by Dec., 1995
15 year analysis complete	5 year follow-up data gathered	2 year data gathered
19 year follow-up underway	Post-kindergarten follow-up under way	4 year follow-up underway (Hill, 1998)

In the Elmira study, families received a mean of nine home visits during pregnancy and 23 from the child’s birth through his second birthday. During the home visits, nurses promoted three aspects of maternal functioning: health- related behaviors during pregnancy and the early years of motherhood, care provided to their children, and maternal personal life-course development, such as family planning, education, and employment. The young women and other family members were taught how to give effective physical and emotional care to their children, and how to deal successfully with the challenges of education, finding work, and planning future pregnancies.
(Olds, et al., 1997a)

Compared to the control group, pregnant women in the home visitation group:

• reduced their smoking
  
• improved their diet
  
• had fewer kidney infections
  
• increased their social support
  
• increased their use of formal services
  
• had 75% fewer preterm deliveries
  
• gave birth to infants with higher birth weights
  (Hill, 1998)
  

At the end of the fist two years, the treatment group showed an 80% reduction in child maltreatment and a 56% reduction in emergency room visits. At the end of four years, the treatment group, compared to the control group, showed a 43% reduction of subsequent pregnancies and an 84% increase in employment (Hill, 1998). When this group was again studied fifteen years after the initiation of the project, the results were as follows:

Moreover, the Elmira 15 year follow-up child outcomes show a significant impact on some of the most serious forms of adolescent behavior:

• reductions in adolescent cigarette and alcohol use.
  
• reductions in adolescent run-away.
  
• reductions in adolescent arrests and convictions/probation violations.
  (Hill, 1998)

A recent replication of this program in Memphis, TN with a sample of 1139 primarily African-American women at less than 29 weeks’ gestation, with no previous live births, and with at least two sociodemographic risk factors (unmarried, less than 12 years education, unemployed). The goal was to determine whether home-visitation services provide a way to improve maternal and child outcomes, including whether any reduction occurred in risks posed by limited intellectual functioning, mental health, and mastery on the part of caregivers (mothers’ ability to anticipate and deal with their children’s needs). As in the Elmira study, the women were randomly assigned to the intervention group or the control group. Nurses made an average of seven (range=0-18) home visits during pregnancy and 26 (range 0-71) visits from birth to the children’s second birthday. Results at the two year follow-up are as follows:

In addition, women in the intervention group were more likely to use other community services, more likely to be working, attempted breast feeding more frequently, and held fewer beliefs about child-raring associated with child abuse and neglect (i.e., lack of empathy, belief in physical punishment, unrealistic expectations for infants). They reported higher levels of perceived mastery, and their homes were "more conducive to children’s development. " The mothers were taught how to recruit other family members and friends to help with the pregnancy, birth, and early care of the child. They came to trust the nurses who helped them set small, achievable goals that increased their confidence in their own self-management skills and their sense of self- efficacy (Kitzman, et al., 1997, 650).

It must be emphasized that this program involves carefully structured protocols and educational materials designed for different levels of intellectual functioning. The researchers stress that the results of their studies may be applied only to other home-visitation programs that are based on their model. However, while most other such programs have failed, theirs at least provides substantive data regarding the efficacy of their approach.

II. The Infant Health and Development Program (IHDP)

The Infant Health and Development Program (IHDP) was a multifaceted intervention designed for low birth weight and their families in eight cities: Little Rock, Bronx, Boston, Miami, Philadelphia, Dallas, Seattle, and New Haven. It was a randomized, clinical trial involving 985 infants and their families which tested the efficacy of a program consisting of high-quality pediatric follow-up and in-home family education and support services for the first three years of life, and an educational day care center (at least 4 hours per day, 5 days per week) from ages 1 to 3. Several studies have shown the positive impact of IHDP on children’s health and development, compared to children who received only pediatric follow-up, through the first three years of life (Brooks-Gunn, Klebanov, Liaw, & Spiker, 1993; IHDP, 1990; Ramey et al., 1992).

One study from this program (Bradley, et al. (1994) focused on a subsample from the larger IHDP -- specifically, 410 children with the risk factors of prematurity (< 37 weeks gestational age), low birth weight (< 2,500 g), and poverty. They investigated whether resilience in early childhood was greater for those subjects who received the IHDP intervention than for the control group who received only pediatric follow-up. They defined resilience in terms of a multi-dimensional outcome: freedom from major developmental problem in cognitive competence, behavioral competence, health status, and growth status. They also examined relative protection, that is, whether an accumulation of protective caregiving experiences in the home increase the likelihood that children would show early resilience. Moving beyond simply delineating protective mechanisms, they focus "on specific aspects of caregiving and the caregiving context that may serve as protective mechanisms because the family environment most directly impinges on children through such aspects of caregiving" (p.426). These are low density in the home, a safe area in which to play, responsivity of the parent, acceptance of the child, variety of experiences for the child, and the availability of enriching learning materials.

Key findings from this study were that, by the age of three, 39% of the IHDP children were functioning in the normal range for cognitive, social/ adaptive, health, and growth parameters, compared to only 11% of the control group. Moreover, the resilient IHDP children were receiving more responsive, accepting, stimulating, organized care in their own homes, and these homes were safer and less crowded. Children having three or more protective factors and participating in the IHDP intervention more often showed early signs of resilience.

III. Dare To Be You (DTBY)
Jan Miller-Heyl, Davis MacPhee, and Janet J. Fritz, Colorado State University

The authors emphasize that DTBY is not affiliated with Drug Abuse Resistance Education (D.A.R.E.), the program offered through local law enforcement agencies. DTBY is funded by the Center for Substance Abuse Prevention.

Historically, DTBY has focused on children ages 5 to 18, their parents, and/or community professionals who work with them. Based on developmental theories of self-efficacy and family interaction theory, the program’s "core assumption is that improved perceptions of parental self-efficacy result in family system interactions that foster resiliency in youth, in part because a strong sense of parental competence promotes consistent and supportive child-rearing practices" (Miller-Heyl, et al., 1998, 258). DTBY’s major objective is to facilitate the development of youths’ resiliency to substance use, but by virtue of how it does what it does, the beneficial effects are seen in many arenas. An evaluation of the original program found that "preadolescents increased significantly in resiliency factors such as internal locus of control, resistance to peer pressure, and decision making skills," plus they were less likely to use alcohol and tobacco (Fritz, Miller-Heyl, Kreutzer, and MacPhee, (1995).

Noting that "adolescent problems usually originate much earlier in development, often in families who are struggling to meet basic physical and emotional needs," the researchers agreed with other scholars in insisting that "early family intervention is essential if incipient problems are to be prevented (Gallagher, 1990)," and that "prevention programs are most effective when they target multiple contexts -- not just the child or parents but the community as well (Ramey, MacPhee, and Yeates, 1982). " They then adapted the DTBY program for families of preschoolers, ages 2 to 5 years old. This adaptation consists several components, key among which are the following:

1. Children’s Program -- Separate curricula were developed for the 2 to 3 year olds and the 4 to 5 year olds. Concepts being taught to parents (such as " thumbs up, thumbs down") were incorporated into developmentally appropriate games and experiences which provided a common vocabulary to set and enforce norms. The researchers used the school-age DTBY curriculum for older siblings, and infant care was also available.

2. Parents’ Program -- The researchers wrote a manual of activities for parents, with adaptations for different learning styles and cultures. The activities were designed to develop self-efficacy, self-esteem, internal locus of control, decision-making skills, effective reasoning, effective child-rearing strategies, communication skills, stress management techniques, an understanding of developmental norms for children, and peer support. Parents also received $200 for completing the entire course and the evaluation materials, and a family meal was served at each session.

3. Staff and Community Training -- DTBY concepts were incorporated into the regular in-service training for day care or Head Start workers, plus a 15-hour training series was provided for community preschool teachers and other care givers. The community commitment to this program was evident in that several local agencies co-sponsored 15 to 18 hours of community team training for 18-35 volunteers at each site.

The program was tested at four sites, which varied in population density (urban, town, rural) and ethnic composition (Ute Mountain Ute, Hispanic, and Anglo. Prevalence of risk factors in participating families included: 33.5% were school dropouts, 50.8% had less than $15,000 annual income, 41.1% had a family history of substance abuse, 39.4% were single parents or stepparents, and 22.6% lived in a "community at risk," that is, a community with a documented rate of substance abuse above 90% of the population.

Over a five year period, successive cohorts of families were randomly assigned to an experimental (n-496) or control (n=301) group. Families received a minimum of 24 hours of training with follow-up support. Key findings are as follows:

1. The intervention group increased in self-efficacy and self-esteem , relative to no change in the control group, and these changes were still present at the two-year follow-up, Increases in parental self-efficacy, which the researchers see as the key mechanism of change, correlated with greater use of democratic child-rearing practices, appropriate limit-setting and decreased reliance upon physical punishment. Interestingly, participants who felt the least competent as parents initially benefited most from the intervention, and even parents whose self-efficacy scores decreased still learned effective child-rearing practices.

2. Harsh punishment decreased, while effective discipline and limit setting increased through the year 2 follow-up, while scores for the control parents remained more stable over time. The magnitude of treatment impact grew larger with succeeding cohorts, and these changes in child rearing were evident regardless of family social class or social support.

3. Parents in the intervention group showed decreases on the Lack of Ability to Parent scores and in their tendency to blame their children, but no intervention/control differences emerged until the 2-year follow-up. Targeted children’s developmental levels were enhanced, and oppositional behavior declined.

4. The researchers had hoped that the parents’ social network would increase as parents formed friendships with other participants. However only Support Satisfaction showed a significant change between the pretest and the 1 year follow-up, with the intervention group increasing more than the control group. They concluded that "structural changes in these parents’ social systems occur gradually, if at all" (Miller-Heyl et al., 1998, 278).

5. Regarding locus of control, the belief that Chance controls outcomes declined significantly for the treatment group between pretest and postest and for both groups between pretest and subsequent follow-ups. The belief that Powerful Others control outcomes also declined but not as consistently as did the belief in chance or fate. The researchers concluded that, overall, "the DTBY workshops had a minimal impact on locus of control" (Miller- Heyl et al., 1998,

6. Parents in both the intervention and control groups reported increases in stress levels over time, stating they were overburdened with child- rearing responsibilities and money problems. It is especially noteworthy that intervention parents showed trends toward increased education and income at the one-year follow-up, but these effects had disappeared a year later. The authors speculate that the lack of impact on socioeconomic status may well explain the persistent levels of stress.

The High/Scope Educational Research Foundation’s Perry Preschool Project (PPP)

The following review was provided by Benard and is reprinted here with her permission.

The High/Scope Educational Research Foundation’s Perry Preschool Project (PPP) is one of a handful of long term follow-up evaluations of an actual prevention intervention. It began in Ypsilanti, Michigan in 1962 as a longitudinal study of children from poor African-American families who attended a preschool program at ages 3 and 4 that focused on their cognitive, language, social, and behavioral development. The High/Scope model emphasized active child-initiated learning, problem-solving, decision-making, planning, and a high degree of interaction between adults and children and among the children themselves. In addition, teachers conducted weekly home visits and encouraged parents to be involved as volunteers in the classroom (Berruta-Clement, et al, 1984).

As Berruta-Clement and colleagues reported in 1984, children who participated in the program showed the following outcomes at age 19 compared to a control group:

• Increases in cognitive gains
  
• Improved scholastic achievement during school years
  
• Decreases in crime/delinquency
  
• Decreases in teen pregnancy
  
• Increases in post-secondary enrollment
  
• Increases in high school graduation rate
  
• Increases in employment rate
  
• Benefits exceeded costs sevenfold
  

Furthermore, in a follow-up study of this population at age 27, Wickart and Schweinhart (1993) found that project participants have made the transition to adulthood far more successfully than adults from similar backgrounds. They have committed far fewer crimes, have higher earnings, and possess a greater commitment to marriage.

A related High/Scope study (Schweinhart and Weikart, 1986) compared 15-year-olds who participated in the High/Scope model with those from a traditional nursery school approach and a direct instruction, academic focused approach. The study revealed that students from the High/Scope and nursery school groups reported engaging in:

• One-half as many acts of personal violence
  
• One-fifth as many acts of property violence
  
• One-half as many serious offenses
  
• One-half as many acts of drug abuse
  
• More sports and after-school activities.
  

In addition, their families reported regarding them more favorably.

A follow-up (Schweinhart and Weikart, 1997a,b) to age 23 of this preschool comparison study found that children in the High/Scope program which gives children multiple decision making over their class activities, or a play- oriented nursery school, committed fewer crimes had better success on the job, and maintained healthier relationships than those who received direct instruction in which teachers led the activities, workbooks were the only classroom materials, and the acquisition of academic skills was the prime objective. This new research confirms many experts’ beliefs that the best preschools offer a child-directed curriculum in which teachers let children’s interests guide the learning. According to a spokesperson for the National Association for the Education of Young Children, "If we don’t work at helping kids learn self-control, it gets difficult later on."

[Note: PPP has been credited with reducing the cost of delinquency and crime by approximately $2,400 per child (Barnett and Escobar, 1990).]