Early Head Start and

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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
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10 Hallmarks of Children WhoSucceed in School

• Eager to learn
• Ask lots of questions
• Work hard and know effort matters
• Have good social-emotional skills
• Can assess their own skills well
• Parents are role models for learning

• 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
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Good health is the foundation for learning,
development and school success.
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The developmental domains of health, cognition,
social and emotional development are closely
linked by neurobiological connections and
personal experiences.
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WHO Definition of Health

• A state of complete physical, mental
• and social well-being and not merely the
• absence of disease or infirmity.

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Health Promotion and Disease Prevention

• Promotion of mental health
• mentoring in cognitive, social
• and emotional basics
• responsive language experiences
• stable and caring adults
• good role models

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Health Promotion and Disease Prevention

• Promotion of social well-being
• Safe environments
• Enjoyable play and learning activities
• Supportive, informative and frequent
• interactions with parents and
• other adults

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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

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Seven Essential Transactions ForCaregivers with
Young Children

• 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
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Sources of Available Support for Early
Intervention Funding

• 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)

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Psychosocial Developmental Priming Mechanisms

• 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

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Potential Levels of Early Intervention

• Developmental of Biomedical affordances
• Prenatal and perinatal services
• Childrens direct learning opportunities
• Development of family skills
• Development of professionals knowledge and
  skills
• Development of community and cultural norms
  concerning inclusion

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Statement of the problem

• For a variety of reasons, the early years are
  believed to be the most efficacious period to
  intervene in the lives of poor children.
• 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.

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Stages for the Development of a Scientific
Knowledge-Base

1. Proof of concept studies
2. Efficacy studies
3. Effectiveness studies
4. Efficiency studies

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Hierarchy of Criteria for Evidence-based
Practices

• 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

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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?

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• 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.

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ABC Eligibility

• Recruitment in community agencies serving poor
  women
• High Risk Index
• Other criteria
• Healthy newborn child
• Living within commuting distance of FPG
• Likely to remain in area

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Who was invited to take part?

• 120 families invited to enroll
• 8 refused random assignment
• 2 infants reassigned at insistence of authorities
• 1 ineligible due to biological condition
  (seizure disorder with moderate MR)

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Participants

• 4 cohorts of children born between 1972 and 1977
• Half randomly assigned to preschool education
  program, half were controls
• Original Sample N Males Females
• Treated 57 29 28
• Control 54 23 31
• Total 111 52 59

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Study Design
EE
E
EC
29 Males 28 Females
R
23 Males 31 Females
CE
N111
C
CC
Follow-up Assessments
Preschool Treatment Ages 0-5
Preschool Treatment Ages 0-5
School-age Treatment Ages 5-8
Age 12
Age 15
Age 21
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Educational Intervention

• Very intense
• 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
• 1 3 infants
• 1 45 toddlers
• 1 7 preschoolers

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Preschool Curriculum

• Eclectic in nature
• Stressed contingently responsive early
  environment for infants
• Learningames for the First Three Years
  (Sparling Lewis, 1979, recently reissued)
• Natural part of infants or toddlers day
• Learningames for Threes and Fours A Guide to
  Adult and Child Play (Sparling Lewis, 1984)

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Key Abecedarian (ABC) Program Components

• Health and Mental Health
• Nutrition
• Family Support
• Parent Involvement
• Early Childhood Education

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Preschool Results

• Tests of cognitive development constituted major
  outcome during early years
• Infants equivalent at outset (3 month Bayley MDI
  scores)
• Cognitive measures
• Bayley Scales of Infant Development
• 318 months
• Stanford-Binet Intelligence Scale (Form LM, 1972
  norms)
• 24 years
• Wechsler Preschool Primary Scale of
  Intelligence
• 5 years

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Preschool Test Scores
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Percent of Abecedarian Sample in Normal IQ Range
(gt84) by Age (longitudinal analysis)
Martin, Ramey, Ramey, 1990 American Journal of
Public Health
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Brief Summary of Abecedarian ResultsDuring
Preschool Period

• Positive Effects on
• IQ Performance
• Learning cognitive performance
• Social responsiveness
• Language development
• Decreased Effects
• Incidence of intellectual disability

• Resilience to biological risk conditions
• Maternal education
• Maternal employment
• Ramey Ramey, 1999

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School-Age Program
EE
E
EC
R
CE
C
CC
Follow-up Assessments
Preschool Treatment Ages 0-5
Preschool Treatment Ages 0-5
School-age Treatment Ages 5-8
Age 12
Age 15
Age 21
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School-Age Program

• Home-School Resource teacher (first three years
  of school)
• Consultation with classroom teacher
• Individualized curriculum items based on needs
• Encouragement of parental involvement with home
  activities
• Liaison between home school
• Family support as needed

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School-Age Results

• Reading Scores
• Strong preschool effect on reading scores at age
  8 (plt.01)
• Significant trend for EEgtECgtCEgtCC (plt.05)
• No effect for school-aged treatment alone

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School-Age Results

• Trend for preschool effect on mathematics scores
  (plt.10)
• Linear trend in mathematics scores not
  significant
• No effect for school-age treatment alone

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Long-Term Effects
EE
E
EC
R
CE
C
CC
Follow-up Assessments
Preschool Treatment Ages 0-5
Preschool Treatment Ages 0-5
School-age Treatment Ages 5-8
Age 12
Age 15
Age 21
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Long-Term Effects

• Intellectual measures in the follow-up
• 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

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Long-Term Effects on intellectual development

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Long-Term Effects, continued

• 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.

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Can we identify mediators of long-term treatment
effects on cognitive development?

• 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.

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Long-Term Effects, continued

• Adding child and family characteristics to the
  prediction model
• 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

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Long-Term Effects, continued

• 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

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Long-Term Effects, continued

• There is also a main effect for the HOME score
• 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 mothers marital status.

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Long-Term Effects, continued

• Does a modest effect on IQ test performance
  matter?
• The evidence indicates that the significant
  long-term effect of treatment on academic
  performance was mediated by its effect on early
  cognitive performance.

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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

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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

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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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Long-Term Effects, continued

• Teenaged parenthood was less likely for those
  having preschool treatment.

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What was the early intervention worth?

• Cost-benefit study was carried out at the
  National Institute of Early Education Research
  (NIEER) at Rutgers University
• Leonard Masse and Steven Barnett

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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 -
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Ratio of Costs to Benefits

• NIEER researchers estimated that the Abecedarian
  program will save society, on average, 4 for
  every dollar spent.

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Why would it save money?

• 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).

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Why would it save money? (continued)

• 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).

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NIEER Conclusions

• 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.

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Abecedarian Project
Ramey Ramey, 1999 MR/DD Research Review
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Key Findings from Abecedarian Project(Abecedaria
n one who learnsthe 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
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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

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Adapted from Wasik, Ramey, Bryant, Sparling.
Child Development, 1990
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Abecedarian (ABC) Preschool Findings Replicated
in theFirst 3 Years of Life in Randomized
Controlled Trials (RCTs)

• Arkansas
• Connecticut
• Florida
• Massachusetts
• New York

North Carolina Pennsylvania Texas Washington
Ramey Ramey, 2000 in Securing the Future
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Infant Health and Development Program

• Designed to test the efficacy of ABC intervention
• for children who were lt 37 weeks
• gestation and lt 2500 gm at birth
• Conducted at 8 sites
• Intervention modified for biological risk factors
• Intervention lasted only until 36 mos. CA

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Infant Health and Development Program (2001-2500
grams)
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Childrens IQ at 36 months Maternal Education
X Treatment Group
Infant Health and Development Program
Ramey Ramey (1998), Preventive Medicine
(n232)
(n162)
(n166)
(n104)
(n134)
(n63)
(n76)
(n48)
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Outcomes Affected Positively (plt.01) by the
Infant Health Development Program
12 Months 24 Months 36 Months
Cognitive Development NS
Adaptive and Prosocial Behavior - -
Behavior Problems -
Vocabulary -
Receptive Language -
Reasoning - -
Home Environment NS -
Maternal Interactive Behavior - -
Maternal Problem Solving - -
Ramey 1999, adapted from Gross, Spiker, Haynes,
1997, Helping Low Birth Weight, Premature Babies
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Recommendations

• 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

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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

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Health and human development are mutually
enhancing. Head Start can and is promoting both.