Friday, January 24, 2020

Earlier Childhood Intervention: Before Pre-K

Discussions of early childhood interventions often work backward from kindergarten--with a focus on providing preschool programs. Whatever the merits of such programs (and I've described some weaknesses of the evidence supporting them here and here), they arrive too late for many at-risk children. For example, some evidence suggest that the cognitive gap for black children as a group opens up somewhere between ages 1 and 2--that is, well before a pre-K program starts. 

The Spring 2019 issue of Future of Children is devoted to a seven-paper symposium, plus and introduction, on the theme of "Universal Approaches to Promoting Healthy Development." The overall theme is to explore programs that start with home visits for parents of new babies. The idea is that such home visits can help link new parents to other community and health care resources, in a way that helps improve child development (and reduces child mistreatment).

It's easy to hypothesize about reasons why universal visit for new parents might work really well, or on the other side might be unwanted or too costly or impractical. Thus, the issue focuses on actual programs of this type and evidence on how they have worked. Here are a few examples, as summarized in the introductory essay by Deborah Daro, Kenneth A. Dodge, and Ron Haskins.

One example involves a program called Family Connects, which is described in this issue in a paper called “Universal Reach at Birth: Family Connects,” by Kenneth A. Dodge and W. Benjamin Goodman. As summarized by Daro, Dodge, and Haskins:
In this article, Dodge and Goodman report the results of three studies using the Family Connects model that illustrate its feasibility and show the strengths it could bring to broader implementation. The first trial encompassed nearly 5,000 children born in two hospitals in Durham, NC, between July 1, 2009, and December 31, 2010. Half the babies and their families were randomly assigned to an experimental group, the other half to a control group. ...
The Family Connects program consists of three pillars: home visiting, community services, and data and monitoring. During the home visiting portion, a discussion took place between a parent, usually the mother, and a program nurse. The interview was conducted in the family home during the first few weeks of the child’s life and lasted from 90 to 120 minutes. The visiting nurse assessed family risk in 12 domains, and then the mother and nurse developed a plan to promote the child’s development and wellbeing. Where necessary, and when agreed to by the mother, the nurse arranged visits to community agencies. Birth records were used to record family needs and services received. 
The results of the intervention are encouraging. First, while 94 percent of the families had at least one need that merited intervention, most were minor or moderate. Only 1 percent of the families required immediate intervention because of serious need; about half had serious to moderate needs that could be resolved by home visits, brief counseling, or other nonemergency services; and 44 percent had serious needs that required connection with community resources, such as treatment for substance abuse or depression, or intensive home visiting programs and other social services. Because Family Connects reaches the full population of birthing families in a community, it can reinforce targeted home-visiting programs by becoming a primary source of referral to them. In Durham, for example, Family Connects is the single most frequent source of referrals to Early Head Start and to Healthy Families Durham ...  One important finding was that a month after the nurse’s involvement ended, 79 percent of families said they’d followed through to make a community connection. Even more impressive, 99 percent of the families involved with Family Connects said they would recommend the program to other new mothers. 
A longer-term follow-up was conducted when the children were six months old. In this study, when compared with control group mothers, those in the experimental group reported 16 percent more community connections; reported more positive parenting behaviors and higher-quality father-infant relationships; were nearly 30 percent less likely to show signs of clinical anxiety; and reported 35 percent fewer serious injuries or illnesses among their infants that required hospitalization. Throughout their first year of life, infants of experimental families had many fewer emergency medical episodes than did control babies. In addition to these positive findings, the Dodge team examined records of Child Protective Services over the children’s first five years. Their review showed that children in the program group received 39 percent fewer protective services investigations than children in the control group.

In another article, Christina Altmayer and Barbara Andrade DuBransky discuss the "Welcome Baby " program in an essay called “Strengthening Home Visiting: Partnership and Innovation in Los Angeles County.” Again, as summarized by Daro, Dodge, and Haskins:
The authors discuss how a universal offer of assistance establishes a foundation on which public and private agencies can plan meaningful systemic reform—and spark incentives for greater investments in services directed to vulnerable families. The vision builds on Welcome Baby, the county’s universal home visiting program funded by First 5 LA, which provides as many as nine contacts to pregnant women and new parents until a child’s ninth month. Three contacts occur before birth, one at bedside in the birthing hospital, and five afterward in the home. Piloted in one hospital in 2009, the program is now available to new parents delivering in 14 hospitals throughout the county. These facilities deliver more than a third of all births in the county, and almost 60 percent of births occurring in the county’s highest-risk communities. As of June 2018, the program had reached more than 59,000 families. ...
One evaluation of the pilot program compared Welcome Baby participants to new parents in the same communities who didn’t access the program; it found favorable impacts on parental capacity, child development, and service utilization up to three years following program enrollment. A randomized trial of the program is currently being conducted to provide a more rigorous account of its effects. 
Other examples include the First Born program. "a targeted universal home visiting program that serves all first-time parents in several New Mexico communities," and discussion of the options opened up by the he Family First Prevention and Service Act, approved by Congress as part of the Bipartisan Budget Act of 2018.

The basic instinct behind these programs is similar to that behind pre-K programs like Head Start: that is, addressing child development issues earlier could potentially be more effective and less expensive than trying to address them later. However, it pushes that insight into looking at the period before and after birth, rather than waiting until pre-K arrives at ages 3 or 4. Indeed, some scholars in the field have even suggested that there could be a positive social payoff from redistributing some spending from standard pre-K programs to programs that affected parents and their even younger children.