Tailoring Early Interventions to Maximize Child Benefits and Feasible Service Delivery Sharon Landes

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Tailoring Early Interventions to Maximize Child
Benefits and Feasible Service Delivery Sharon
Landesman Ramey, Ph.D.Craig T. Ramey,
Ph.D.Directors, Georgetown UniversityCenter on
Health and EducationIntervention and treatment
for Alcohol-Affected Individuals The Next
ChallengeAtlanta October 22 -23 2007
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Scientific Foundations for the new Education
Science

• Research on neuroplasticity (animal models)
• Studies of extreme deprivation (orphanages,
• maternal deprivation, isolation)
• Demonstration projects
• Naturalistic and longitudinal studies
• Randomized controlled trials (RCTs) to test
• the efficacy of a planned intervention to
• alter the life course

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Applied Biosocial Contextual Development
(ABCD) A Framework for Understanding Human
Development
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Randomized Controlled Trials (RCTs)we have
conducted include

• The Abecedarian Project (ABC)
• Project CARE
• Infant Health and Development Program (8 sites)
• Romanian Orphanage Studies
• Intensive Pediatric CI Therapy (cerebral palsy)
• National Transition Demonstration Study (31
  sites)
• Testing pre-K curricula and coaching models
• System and statewide scale-up studies
• 
  Ramey Ramey

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PRINCIPLES OF EFFECTIVE EARLY INTERVENTION

• Timing (onset, duration, offset)
• Intensity (per day/wk/mth/yr(s))
• Direct learning experiences
• Breadth of services/supports
• Individual differences
• Environmental maintenance

Ramey Ramey (1998), American Psychologist
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1. Principle of Timing

• When the intervention begins and ends
  significantly influences magnitude of effects
• Neurodevelopmental theory and research are
  central to understanding important features of
  CNS that rapidly developing at certain ages
• Development at earlier stages sets conditions for
  later stages (cumulative toll hypotheses)
• Principle is highly similar to that in teratology

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Evidence supporting the principle of timing

• Derives from cross-study comparisons,
  meta-analyses of gt 25 interventions
• Usually larger and more lasting effects occur
  when intervention begins earlier and lasts longer
• Limitation Inherent confounds in research
  related to this principle, since most RCTs that
  produced the largest gains began earlier,
  continued longer, and probably were more fully
  implemented

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• Synaptogenesis by brain region graph illustrates
• plausible biological basis for Principle of Timing

Adapted from Huttenlocher in Ramey Ramey Right
from Birth (1999)
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2. Principle of Dosage (Intensity)

• Interventions which are more intensive (as
  indexed by hours per day, days per week, etc.)
  produce larger changes
• Exact specification of optimal doses has been
  very difficult, largely due to cost and pragmatic
  issues in intervetion reserach
• Some evidence consistent with threshold
  hypothesis (mostly at lower limits)
• Highly similar to dose-response curve principle
  in teratology

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Mothers Speech and Infant VocabularyNaturalisti
c evidence consistent with RCT support for
Principle of Dosage
Huttenlocher et al, Developmental Psychology,
(1991)
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3. Principle of Direct Learning Experiences

• Interventions that directly alter the childs
  experiences (i.e., transactions with others and
  environment) have significantly greater effects
  than do those that indirectly change the childs
  life (e.g., parenting programs, coordination of
  service delivery supports)
• Note majority of early interventions have
  focused on indirect effects based on hope that
  these would lead to sustainable environmental
  supports (to date, this hypothesis has not been
  confirmed)

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4. Principle of Breadth of Services/Supports

• Early interventions that are multi-component and
  address child needs in health, cognition,
  social-emotional development generally produce
  larger and longer lasting effects
• Limitations
• Research evidence has many confounds, since
  broader programs also tend to be more intensive
  and include direct learning experiences
• most intervention programs tested in RCTs
  focused on children with multiple needs and risk
  conditions (due to natural co-occurrence)

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5. Principle of Individual Differences

• Some children benefit more (or less) than do
  other children
• This principle has been affirmed primarily by
• Findings that children with greater needs for
  environmental supports tend to benefit more
• Findings that children with more substantial CNS
  insult may not benefit as much from generic
  (i.e., not spectrum-specific intervention)
  intervention
• Similar to teratology principle of differential
  genetic susceptibility or Gene X Environment
  Interaction Effect

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6. Principle of Environmental Maintenance

• Benefits of early intervention are sustained
  longer when children continue to receive strong,
  appropriate environmental supports after
  intervention ends
• Limitation Almost impossible to separate effects
  of subsequent depriving or harmful environments
  (which could reverse benefits of early
  intervention) from the need for true
  maintenance
• Influenced by the fact that special needs
  children display different issues that result
  in problems that depend on their age and
  setting (e.g., problems of teens differ from
  those of preschoolers)

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Examples affirming these principles from some of
our longitudinal RCTs

• Interventions for children from highly
  impoverished, often chaotic environments
  (Abecedarian Project and Project CARE Romanian
  Orphanage studies)
• Targeted interventions for
• Low birthweight, premature infants (IHDP)
• Children with moderate to severe neuromotor
  impairments (Project ACQUIRE)

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ABC Project (Craig Ramey, PI) 1972 2007
(ongoing)

• The Abecedarian (ABC) Project was a randomized
  controlled trial (RCT) that tested the efficacy
  of intensive, theory-informed early childhood
  education for extremely low resource (high-risk)
  children
• 99 of living original participants still in
  longitudinal follow-up study at age 30 yrs
• Inter-generational data being collected as well

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Key Research Questions 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 and/or
• from k through 2nd grade?

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The Abecedarian Design Early Intervention
Program

• Control Group_
• Adequate nutrition
• Supportive social services
• Low-cost or free primary
• health care

• Treatment Group _
• Adequate nutrition
• Supportive social services
• Free primary health care
• Preschool treatment
• Intensive (full day, 5 days/week,
• 50 weeks/year, 5 years)
• Learningames Curriculum
• Cognitive / Fine Motor
• Social / Self
• Motor
• Language
• Individualized pace

Campbell Ramey, 1995 American Educational
Research Journal
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Z Scores and Mean Standardized Scores for
High-Risk Preschool Treatment and
ControlChildren in the Abecedarian Project at
Nine Preschool Measurement Occasions
Ramey et al, 2000 Applied Developmental Science
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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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ABC Project Influences on IQ by Child Age
Adapted from Martin, Ramey, Ramey, American
Journal of Public Health, 1996
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Brief Summary of Abecedarian K-2 Transition
Program

• Individualized focus on academic and learning
  activities in school and at home
• Emphasis on reading, mathematics, and writing
• Master Home/School Resource Teachers (12 children
  and families per teacher)
• Development of an individualized and documented
  supplemental curriculum for each child
• Explicit attention and action relevant to family
  circumstances, as needed
• Summer camps with academically relevant
  experiences
• Ramey Ramey, 1999

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Abecedarian Project Woodcock-Johnson Age-referenc
ed Reading Standard Scores at age 8
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The Abecedarian (ABC) Project Longitudinal Effect
Sizes for Reading by Treatment Group
Campbell, Ramey, Pugello, Sparling,
Miller-Johnson (2001) Applied Developmental
Science
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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)

• 18 Months to 21 Years Old

• Intelligence (IQ)
• Reading and math skills
• Academic locus-of-control
• Social Competence
• Years in school,
• including college
• Full-time employment

• Grade Repetition
• Special Education
• placement
• Teen Pregnancies
• Smoking and drug
• use

Plus benefits to mothers of these children
(education, employment)
Ramey et al, 2000
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Project CARE

• RCT designed to replicate Abecedarian Project
  (ABC)
• Added a new treatment group to test the
  efficacy of
• an intensive 5-year home visiting program using
  the
• ABC intervention (to test indirect vs direct
  effects)
• Affirmed same findings in early childhood
  through
• to young adulthood from educational
  intervention, but
• no benefits of home visiting on child outcomes

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The Infant Health and Development Program (IHDP)

• Intervention replicated Abecedarian Project
• New target group premature, low birthweight
  children
• gestation and lt 2500 gm at birth
• Conducted at 8 sites (N985 children families)
• Intervention modified for specific biological
  risk factors
• Educational intervention lasted only until 3 yrs
  old (CA)
• Follow-up reported through age 18 yrs
• IHDP, JAMA,
  1990

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Infant Health Development Program Outcomes
(plt.01) at 12, 24, 36 months
Ramey 1999, adapted from Gross, Spiker, Haynes,
1997, Helping Low Birth Weight, Premature Babies
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Examples of findings affirmingPrinciple of
Individual Differences

• In ABC, children with lowest IQ mothers (lt70)
  showed markedly larger benefits than those whose
  mothers had IQs gt90
• In IHDP, intervention more efficacious in
  preventing mental retardation (IQlt70) for
  premature, low birthweight children with less
  educated mothers or lower IQ mothers
• In IHDP, very low birthweight infants did not
  benefit as much

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Stanford-Binet IQ Scores at 36 Months Heavier LBW
Group (2001-2500gm)
Infant Health and Development, JAMA, 1990
Ramey, AAAS, 1996
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Stanford-Binet IQ Scores at 36 Months Lighter LBW
Group (lt2000gm)
Infant Health and Development, JAMA, 1990
Ramey, AAAS, 1996
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Mother-child IQ discrepancy scoresat 48 months
(ABC Project)
Low IQ mothers
Control
X31
Intervention
IQ Points
Normal IQ mothers
Low IQ mothers
X9
Normal IQ mothers
X7.1
X- 4
Control
Intervention
Ramey Ramey, 1999
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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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The case for targeted interventions for
particular types of children, families, schools,
regions

• Knowledge about specific child or community
  conditions are higher relevant to
  treatment/intervention content and implementation
• Targeted interventions can be combined with
  general best practices for children and schools
• Opportunity to study brain-behavior interactions
  over time as well as need for understanding
  systems change
• Strong advocacy and clinical support

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An example of a highly intensive, targeted
intervention that challenges conventional
practices
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Intensive Pediatric Therapy for Children with
Cerebral Palsy

• Based on fundamental principles of learning
  theory, clinical rehab reports of adults with
  stroke, and animal experiments
• First-ever RCT to test a highly intensive form of
  therapy targeted for children with hemiparesis
• Results demonstrated large and sustained
  benefits, plus spillover effects (unanticipated)
  to other domains of development
• DeLuca, Echols, Ramey,
  Child Neurology, 2006

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Key features of Pediatric CI Therapy

• Highly intensive (6 hours per day, 21 consecutive
  days)
• Direct and active engagement of child as learner
• Responsive to childs interests, initial
  competence
• Based on learning theory principles
• Designed to promote generalization
• Constraint leads child to focus on impaired
  limb,
• overcome developmental disregard, eliminate
• competing responses, create new CNS pathways
• 
  DeLuca, Echols, Ramey (2007)

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PMAL Frequency Rating of Upper Extremity Use
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PMAL Quality Rating of Upper Extremity Movement
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Spillover Effects from Intensive Pediatric CI
Therapy

• Increased positive social-emotional
  responsiveness
• Reduced behavioral problems
• Improved communication skills
• Decreased sensory aversion to touch
• Improved gross motor and mobility skills
• Increased self-confidence and independence
• DeLuca,
  Echols, Ramey, 2007

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Individual Differences Principle in Pediatric CI
Trial
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Challenges for the Science of Implementation

• Need to understand how to promote changes in
  practice consistent with sound evidence
• Tremendous skepticism and backlash about whether
  this is another passing fad
• Lack of public accountability and information
  systems to judge progress and identify urgent
  problems

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Innovation in Real Time Science

• Need for timely and ongoing feedback to all
  participants, funders, and the public
• Should we treat provision of high quality
  education with the same urgency as a public
  health problem that children are being harmed
  if a solid education is not given?
• Longitudinal tracking, surveillance, and
  practical guidance to families and educational
  systems

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For copies of this PowerPoint presentation,please
download from our website http//che.georgetown.
eduor contactDr. Sharon Landesman Ramey
[phone]email sr222_at_georgetown.edu