13

Promoting Healthy Development Through Intervention

The care and protection of young children are shared responsibilities. At their most intimate level, they require the investment and attention of a limited number of adults. In their broadest context, they depend on an environment that supports the childrearing function of families. In the final analysis, healthy child development is dependent on a combination of individual responsibility, informal social supports, and formalized structures that evolve within a society.

From the time of the nation's founding over 200 years ago, mainstream culture in the United States has viewed the rearing of children largely as a matter of individual self-reliance and family privacy. Consequently, the threshold for government involvement is high and the level of public investment is limited in comparison to that of other industrialized societies. Three prominent examples of this distinctive national characteristic are the absence of universal health care, the relatively limited availability of publicly funded early childhood care and education, and the resistance to paid, jobprotected leave for working parents after the birth or adoption of a child (Kamerman, 2000; Kamerman and Kahn, 1995).

Within this social and political context, all families with young children in the United States have needs that extend beyond the boundaries of total self-sufficiency. These range from the universal to the particularistic—from primary health care for all and nonparental child care for a majority, to specialized services for a variety of vulnerable subgroups. Over the past four decades, a wide range of public policies and programs have been designed to address these specialized needs in order to promote healthy



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From Neurons to Neighborhoods: The Science of Early Childhood Development 13 Promoting Healthy Development Through Intervention The care and protection of young children are shared responsibilities. At their most intimate level, they require the investment and attention of a limited number of adults. In their broadest context, they depend on an environment that supports the childrearing function of families. In the final analysis, healthy child development is dependent on a combination of individual responsibility, informal social supports, and formalized structures that evolve within a society. From the time of the nation's founding over 200 years ago, mainstream culture in the United States has viewed the rearing of children largely as a matter of individual self-reliance and family privacy. Consequently, the threshold for government involvement is high and the level of public investment is limited in comparison to that of other industrialized societies. Three prominent examples of this distinctive national characteristic are the absence of universal health care, the relatively limited availability of publicly funded early childhood care and education, and the resistance to paid, jobprotected leave for working parents after the birth or adoption of a child (Kamerman, 2000; Kamerman and Kahn, 1995). Within this social and political context, all families with young children in the United States have needs that extend beyond the boundaries of total self-sufficiency. These range from the universal to the particularistic—from primary health care for all and nonparental child care for a majority, to specialized services for a variety of vulnerable subgroups. Over the past four decades, a wide range of public policies and programs have been designed to address these specialized needs in order to promote healthy

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From Neurons to Neighborhoods: The Science of Early Childhood Development development in the preschool years (Shonkoff et al., 2000; Zigler et al., 1996). These highly diverse initiatives have been included under the broad umbrella of what is called “early intervention.” CONCEPTS OF INTERVENTION AND THEORIES OF CHANGE Disentangling the Concept Early childhood intervention is more a concept than a specific program (Guralnick, 1998; Shonkoff and Meisels, 2000). Much of its diversity is related to differences in target groups—from the broad-based agendas of health promotion and disease prevention, early child care, and preschool education to the highly specialized challenges presented by developmental disabilities, economic hardship, family violence, and serious mental health problems, including child psychopathology, maternal depression, and parental substance abuse. Within this context, the diversity among and within subgroups is as great as that across the general population. Generalizations about children with developmental disabilities are particularly problematic. As a distinct population, they represent a markedly heterogeneous group of individuals with a wide variety of impairments that differ in both their defining features and level of severity. These impairments may include various combinations of delayed or atypical skills in cognition, communication, motor performance, emotional reactivity, and social relatedness, among others. Specific disorders range from commonly recognized conditions (e.g., Down syndrome, cerebral palsy, spina bifida, and autism) to relatively rare and less known disorders (e.g., Rett syndrome, trisomy 13, and metachromatic leukodystrophy), with a large proportion of children whose conditions elude both a definitive diagnosis and a known cause (Guralnick, 1997; Shonkoff and Marshall, 2000). Children with developmental problems that are presumed to be secondary to the influences of an adverse caregiving environment (e.g., poverty, family violence, parental mental illness) comprise a similarly heterogeneous population. In both circumstances (i.e., whether the vulnerability originates primarily in the biology of the child or the stresses in the environment), the cultural values of the family create a distinctive childrearing context that can present yet another set of challenges to the delivery of professional services in a highly pluralistic society (García Coll and Magnuson, 2000; Lewis, 2000). Nevertheless, all children deemed eligible for early intervention programs share a common characteristic—concern about their development or behavior, regardless of the cause, and a belief that formalized services can increase the probability of a more positive outcome. Another major source of diversity among early childhood interventions

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From Neurons to Neighborhoods: The Science of Early Childhood Development is the marked heterogeneity of service formats. These include multiple variations and combinations of center-based and home-based models, guided by different blends of child-focused and family-focused philosophies. Significant differences in staffing configurations contribute additional variability, ranging from the highly professionalized services delivered by educators, developmental therapists, social workers, and nurses with advanced degrees to the highly personalized supports provided by community workers with limited formal education or training. Widely differing views on the definition of “early” provide yet another element of variability, ranging from preschool programs targeting 4-year-olds to prenatal services focused on expectant mothers. The breadth and the depth of these differences illustrate the diversity of the field of early childhood intervention (Guralnick, 1997; Shonkoff and Meisels, 2000; Zeanah, 2000). The extent of this heterogeneity underscores the challenges confronting policy development, service coordination, and evaluation research. Closely related to the diversity of early childhood programs is the extent to which interventions are defined differently depending on the disciplinary lens through which they are viewed. Early intervention is a collection of service systems whose roots extend deeply into a variety of professional domains, including health, education, and social services (Meisels and Shonkoff, 2000). It is a field whose knowledge base has been shaped by a diversity of theoretical frameworks and scientific traditions, from the instruction-oriented approach of education (Bailey, 1997; Bruder, 1997; Wolery, 2000) to the psychodynamic approach of mental health services (Emde and Robinson, 2000; Greenspan, 1990; Lieberman et al., 2000; Osofsky and Fitzgerald, 2000), and from the conceptual models of developmental therapies (Harris, 1997; McLean and Cripe, 1997; Warren et al., 1993) to the randomized control trials of clinical medicine (Infant Health and Development Program, 1990; Palmer et al., 1988). At its best, early intervention embodies a rich and dynamic example of multidisciplinary collaboration. Less constructively, it can reflect narrow parochial interests that invest more energy in the protection of professional turf than in serving the best interests of children and families. As its knowledge base has matured, the field of early childhood intervention has evolved from its original focus on children to a growing appreciation of the extent to which family, community, and broader societal factors affect child health and development. A natural outgrowth of this evolution is a recognition that individual programs are always delivered within a multilayered context, and that their effects are always moderated by the influences of more pervasive social, economic, and political forces. Thus, successful policies for children who live in adverse circumstances may have less to do with the impact of specific services and be more a matter of changing the larger environment in which the children are reared. This

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From Neurons to Neighborhoods: The Science of Early Childhood Development growing awareness is likely to lead to further expansion of the concept of early childhood intervention to include such wide-ranging policy concerns as housing, employment practices, community policing, and taxation, among many others (Garbarino and Ganzel, 2000; Sameroff and Fiese, 2000). Theories of Change All successful interventions are guided by a theoretical model that specifies the relation between their stated goals and the strategies employed to achieve them (Weiss, 1995). Sometimes these frameworks are articulated explicitly; other times, they are implicit but not clearly formulated. After more than a quarter century of remarkable growth and continuing maturation, the basic sciences of child development and neurobiology have converged with the learned experiences of a broad array of intervention policies and programs to generate sufficient knowledge to build an intellectually rigorous, common theory of change for the field. The essential characteristics of this framework are drawn from the core concepts outlined in Chapter 1 and buttressed by the wealth of information contained in this report. They stand on the shoulders of decades of creative theoretical formulations about the process of human development. Most prominent among these are the transactional model first formulated by Sameroff and Chandler (1975) and later adapted to the challenges of early intervention by Sameroff and Fiese (1990, 2000); the ecological model articulated by Bronfenbrenner (1979) and subsequently expanded to a bioecological model by Bronfenbrenner and Ceci (1994); the concepts of vulnerability and resilience applied to a wide variety of biological and environmental conditions by Werner and Smith (1982), Garmezy and Rutter (1983), and Rutter (2000); the process model of parenting developed by Belsky (1984); the social support model for families of children with disabilities popularized by Dunst (1985); the developmental contextual perspective proposed by Lerner (1991); the biosocial model adopted for an intervention targeting low-birthweight, premature infants by Ramey and colleagues (1992); the principles of developmental psychopathology formulated by Cicchetti and Cohen (1995); the social context model constructed by the MacArthur Foundation Research Network on Psychopathology and Development (Boyce et al., 1998); and the developmental framework for early intervention for both biologically and environmentally vulnerable children presented by Guralnick (1998). Taken together, the substance of these models converges to a remarkable degree and applies equally well across the diverse mixture of policies and programs that characterize early childhood intervention in the United States today. This shared theory of change has several central features:

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From Neurons to Neighborhoods: The Science of Early Childhood Development All strategies of intervention, regardless of the target group or the desired outcomes, can be derived from normative theories of child development. That is to say, the general principles of development apply to all children, independent of their biological variability or the range of environments in which they live. All domains of development unfold under the interactive influences of genetic predisposition and individual experience. The trajectories of experience-expectant skills (e.g., motor development) are relatively less susceptible to intervention effects and those of experience-dependent skills (e.g., literacy) are affected more significantly, but no area of human competence is completely predetermined by intrinsic factors. Young children's relationships with their primary caregivers have a major impact on their cognitive, linguistic, emotional, social, and moral development. These relationships are most growth-promoting when they are warm, nurturing, individualized, responsive in a contingent and reciprocal manner, and characterized by a high level of “goodness of fit.” A young child's environment is both physical and social. Its impact on development is mediated through the nature and quality of the experiences that it offers and the daily transactions that transpire among people inside and outside the home. The ability of caregivers to attend to the individualized needs of young children is influenced by both their internal resources (e.g., emotional health, social competence, intelligence, educational attainment, personal family history) and the external circumstances of their lives (e.g., family environment, social networks, employment status, economic security, experience with discrimination). The cumulative burden of multiple risk factors and sources of stress compromises the capacity of a caregiver to promote sound health and development. The buffering function of protective factors and sources of support enhances it. Early intervention programs are designed to affect children directly (through the provision of structured experiences) and indirectly (through their impact on the caregiving environment). Child-focused interventions involve developmentally guided educational opportunities or specifically prescribed therapies or both. Caregiver-focused interventions include varying combinations of information, instruction, emotional support, and assistance in securing needed resources and related services. The determination of appropriate child and family outcomes, and their assessment, require an appreciation of the importance of individual differences among children, an understanding of the extent to which the caregiving environment is changeable, and a realistic appraisal of the match between the resources of the service program and the goals of the intervention.

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From Neurons to Neighborhoods: The Science of Early Childhood Development The success of an intervention is determined by the soundness of the strategy, its acceptability to the intended recipients, and the quality of its implementation. EMPIRICAL FINDINGS, PROFESSIONAL EXPERIENCE, AND CURRENT PRACTICE A comprehensive review and synthesis of the full corpus of early intervention research was beyond the resource capacity of the committee. The literature analyzed for this report was therefore culled largely from an extensive number of published reviews (Barnett, 1995; Benasich et al., 1992; Berlin et al., 1998; Brooks-Gunn et al., 2000; Casto and Mastropieri, 1986; Currie, 2000; Farran, 1990, 2000; Gomby et al., 1995, 1999; Guralnick, 1997, 1998; Halpern, 2000; Karoly et al., 1998; Lazar et al., 1982; Shonkoff and Hauser-Cram, 1987; St. Pierre et al., 1995b; Yoshikawa, 1995) and supplemented by original publications for a selected number of flagship studies. In contrast to its rich and widely endorsed conceptual foundation, the empirical knowledge base on the efficacy of early childhood intervention is relatively uneven. The diversity of target populations and service models that have been studied, and the methodological deficiencies of much of the available literature, contribute to this lack of consistency in the existing database. Most important in this regard is the extent to which a large proportion of studies that address questions of causality have suffered from inappropriate research designs, inadequate analytic approaches, or both, as described in Chapter 4. Notwithstanding these limitations, more than three decades of developmental research and program evaluation have generated the following core of replicated findings, whose convergence strengthens their presumed validity: In the absence of formal intervention, social class differences in scores on standardized developmental measures that favor children in better educated, higher-income families begin to emerge between 18 and 24 months of age and increase over time (Golden and Birns, 1976; McCall, 1979). In the absence of formal intervention, there is a general decline in performance on standardized developmental measures for children with established cognitive disabilities, documented most clearly in toddlers and preschoolers with Down syndrome, across the first five years of life (Guralnick, 1998; Guralnick and Bricker, 1987). Well-designed and successfully implemented interventions can enhance the short-term performance of children living in poverty, with reported effect sizes ranging up to 1.0 standard deviation in the preschool

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From Neurons to Neighborhoods: The Science of Early Childhood Development years (Farran, 1990, 2000; Guralnick, 1998; Karoly et al., 1998; Ramey and Campbell, 1984; Schweinhart et al., 1993). Well-designed and successfully implemented interventions can promote significant short-term gains on standardized cognitive and social measures for young children with documented developmental delays or disabilities, with reported effect sizes ranging from 0.5 to 0.75 standard deviation (Casto and Mastropieri, 1986; Farran, 1990, 2000; Guralnick, 1998; Shonkoff and Hauser-Cram, 1987). Short-term impacts on the cognitive development of young children living in high-risk environments are greater when the intervention is goaldirected and child-focused in comparison to generic family support programs (Farran, 2000; Guralnick, 1998). Measured, short-term impacts on the cognitive and social development of young children with developmental disabilities are greater when the intervention is more structured and focused on the child-caregiver relationship, although the effects are highly variable in view of the marked diversity of child impairments and their severity (Farran, 2000; Guralnick, 1988, 1998; Shonkoff and Hauser-Cram, 1987). Short-term IQ gains associated with high-quality preschool interventions for children living in poverty typically fade out during middle childhood, after the intervention has been completed; however, long-term benefits in higher academic achievement, lower rates of grade retention, and decreased referral for special education services have been replicated (Barnett, 1995; Karoly et al., 1998; Lazar et al., 1982), with reported long-term effect sizes ranging from 0.1 to 0.4 standard deviation (Ramey and Campbell, 1984; Schweinhart et al., 1993). Extended longitudinal investigations into the adolescent and adult years are relatively uncommon but provide documentation of differences between the intervention and control groups for economically disadvantaged children in high school graduation, income, welfare dependence, and criminal behavior (Karoly et al., 1998; Schweinhart et al., 1993; Yoshikawa, 1995). Long-term follow-up data on children with disabilities are scarce, although follow-up studies of children with autism demonstrate persistent benefits of intensive preschool interventions that are followed by continuing specialized services during middle childhood (McEachin et al., 1993; Lovaas, 1987). Analyses of the economic costs and benefits of early childhood interventions for low-income children have demonstrated medium- and long-term benefits to families as well as savings in public expenditures for special education, welfare assistance, and criminal justice (Barnett, 2000; Barnett and Escobar, 1990; Karoly et al., 1998).

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From Neurons to Neighborhoods: The Science of Early Childhood Development Successful child-focused intervention programs for economically disadvantaged groups are designed to provide children with cognitively stimulating environments that they are presumed to be less likely to experience at home. Such programs typically offer rich, school-based learning curricula, often in combination with a wide variety of developmentally enhancing activities in a classroom setting. Several recent comprehensive reviews of such interventions have attempted to discern patterns of impact across programs (Bryant and Maxwell, 1997; Farran, 1990, 2000; Yoshikawa, 1994, 1995). Unfortunately, despite a plethora of investigations, most conclude that it is difficult to draw clear conclusions about the effectiveness of any of a variety of specific intervention approaches. The limitations of this literature are due largely to basic problems in research design (e.g., lack of random assignment, lack of comparable comparison groups) that make the findings of individual studies less reliable and difficult to compare with each other. A more fundamental barrier to comparisons across studies, however, is the considerable variability among intervention programs on a number of important dimensions, such as the age of the children at time of entry, the characteristics of the target population, the nature of the program components, the intensity and duration of service delivery, issues regarding comparison or control conditions, and the nature of the staff and their training. Consequently, it is not possible to be certain that differences in outcomes, when they are found, are due to any one (or a combination) of these factors. Generally speaking, programs that have demonstrated the largest and longest-lasting cognitive gains have been administered to children with multiple risks and have offered the most intensive and longest-lasting services. For example, the largest initial IQ gains were documented in the Milwaukee Project, which targeted low-income, black mothers with intellectual limitations and offered full-day infant and preschool child care for the first five years of life, as well as parent education and job training (Garber, 1988). The association between the intensity or duration of service and child outcomes, however, has not been a consistent finding in other studies. In contrast to the extensive attention paid to cognitive performance, relatively few evaluations of child-focused interventions for low-income children have provided short-term outcome data on social adjustment. Those studies that have reported such information generally have not found much evidence of either reduced problems or increased positive behavior. Nevertheless, some researchers have argued that the subsequent documentation of differences in progress through school and into adulthood (as illustrated by differential rates of welfare dependence and criminal behavior) reflect a social rather than a cognitive impact (Barnett, 1995; Yoshikawa, 1995). In addition to the broad array of child-focused programs that have

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From Neurons to Neighborhoods: The Science of Early Childhood Development undergone extensive evaluation, many interventions for low-income children have focused primarily on parents and parenting, employing various combinations of home visits, group supports, and informational sessions (Brooks-Gunn et al., 2000; Seitz and Provence, 1990). Some of these programs have combined parent-focused components with center-based child care. Despite the considerable diversity of designs, most services are based on the common assumption that parents play a central role in their children's development and that interventions for low-income children are most efficient when they target parents' behavior directly. Such services typically provide some form of social support, both instrumental and emotional, as well as instruction about children 's development. The expectation is that reliable support will reduce parental stress and consequently enhance parental mental health and caregiving capacity, whereas instructional materials on children 's development will improve parenting behavior by addressing parents ' presumed lack of information about what is appropriate and developmentally enhancing for their children (Seitz and Provence, 1990). A recent review by Olds and colleagues (1999) suggests that interventions for socioeconomically disadvantaged families that are largely parent-focused work best when the parents perceive that they or their children need help. Generally speaking, programs that offer both a parent and a child component appear to be the most successful in promoting long-term developmental gains for children from low-income families. Most of the documented benefits have clustered in the realm of social development, perhaps because of early program impacts on risk factors for antisocial behavior. A review by Yoshikawa (1995) of the effects of early childhood intervention programs found that all four of the programs that showed a long-term impact on chronic delinquency had influenced multiple family risk factors in early childhood, including parent-child interaction. Nevertheless, these findings are suggestive, not conclusive, and comparable information on a broader range of interventions is necessary before meaningful conclusions can be drawn about which program components, and in which combination, are successful in promoting positive long-term social outcomes. In recent years, a growing number of interventions have focused on family literacy as a key strategy for improving the home learning environment for young children. Some programs (e.g., Even Start) offer intergenerational literacy activities that include child and adult instruction, as well as parenting education (St. Pierre and Swartz, 1995). Others (e.g., the Home Instruction Program for Preschool Youngsters, or HIPPY) emphasize instruction for parents on how to create a stimulating environment for their children, as well as offering model activities and complementary materials such as books (Baker et al., 1999). To date, evaluation results for both types of programs have been modest and inconsistent. In the future, much

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From Neurons to Neighborhoods: The Science of Early Childhood Development more rigorous evaluations with randomized assignment will be needed to assess their effectiveness. In contrast to the marked heterogeneity of program models for children living in socioeconomically disadvantaged circumstances, early intervention services for young children with developmental disabilities operate within a more circumscribed arena, guided by a federal entitlement to services for all children with a diagnosed impairment or a documented developmental delay (with the additional option for states to serve infants at risk for subsequent developmental problems). This entitlement was first established in 1986 under Part H of Public Law 99-457 and reauthorized in 1997 under Part C of the Individuals With Disabilities Education Act (Public Law 105-17). Although the mandate for individualized family service plans provides room for considerable variability, virtually all programs for children with special health or developmental needs employ a family-centered model that combines individual child therapies and educational experiences with an array of parent services, such as support groups, individual counseling, and instrumental assistance in securing materials and related services specific to the child 's disability. Finally, unlike interventions for low-income children, programs for children with special needs are required to provide access to a designated array of professional services in natural environments, including those offered by educators, physical and occupational therapists, and speech and language pathologists (Harbin et al., 2000). Beyond both the prescriptions of the law and the evolving conceptual and empirical foundations of the field, much of the knowledge base that shapes the current practice of early childhood intervention is based on professional experience. Central to this perspective is a firm belief in the benefits of family-centered services, the importance of cultural competence, and the impact of relationships on relationships. In this context, a broad spectrum of policies and programs are implemented by a wide variety of service providers, guided by a clear conviction that the impact of their efforts is determined by the extent to which their relationships with families affect the relationships between parents and their children, which, in turn, have a significant impact on child health and development (Barnard, 1998; Berlin et al., 1998; Gilkerson and Stott, 2000; McDonough, 2000). ASSESSING DEVELOPMENTAL OUTCOMES AND MEDIATORS Assessing Child Abilities The evaluation of development in young children is a complex task. The growing cultural diversity of the early childhood population in the United States intensifies that complexity. Superimposed on this formidable

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From Neurons to Neighborhoods: The Science of Early Childhood Development challenge, the high-stakes assessment of competence in children who are adapting to a wide variety of biological vulnerabilities and environmental stressors remains one of the thorniest issues facing the early intervention field. Thus, for more than three decades, researchers and service providers have struggled with both the identification of significant child outcomes and their valid and reliable measurement (Brooks-Gunn and Weinraub, 1983; Cicchetti and Wagner, 1990; Gilliam and Mayes, 2000; Honzik, 1983; Meisels, 1994, 1996; Zigler and Trickett, 1978). Traditional Emphasis on IQ and Early Skill Acquisition From its earliest beginnings, the field of early childhood intervention has focused considerable attention on the promotion of intelligence. Although there is still widespread interest in this objective, there is also a great deal of concern about the way in which this elusive construct is conceptualized and measured. Debate on this issue has been lively in both academic and policy circles. It centers on both the general challenges inherent in developmental assessment during the early childhood period and the specific value and limitations of an IQ test as an appropriate measure of program effects (McCall et al., 1972; Meisels and Atkins-Burnett, 2000). Perhaps the most important limitation of an IQ score in the context of evaluating the performance of children in an early intervention program is the fact that it is standardized for age and therefore is not useful as a measure of growth or developmental change (see Chapter 4). Nevertheless, its popularity as a measure of intervention impact has been remarkably robust. Moreover, although the evaluation literature is vast and diverse in its focus, highly variable in its methodological rigor, and often inconsistent in its findings, there is a clear pattern regarding short-term impacts on standardized test performance. Specifically, a wide variety of services, both for children living in poverty and for those with biological vulnerabilities, have demonstrated significant gains in IQ during the first five years, followed by a subsequent fade-out of effects during middle childhood (Campbell and Ramey, 1994; Lally et al., 1988; McCarton et al., 1997; Schweinhart et al., 1993; Walker and Johnson, 1988). The magnitude of these initial treatment-control differences has been moderately high, ranging from effect sizes of 0.5 to 0.75 standard deviation (Casto and Mastropieri, 1986; Farran, 1990, 2000; Guralnick, 1998; Shonkoff and Hauser-Cram, 1987). The most striking exception to the fade-out phenomenon has been demonstrated in an intensive intervention program for children with autism, which produced sustained treatment-control differences in IQ scores well into the middle childhood years, while the children continued to receive special services as needed (McEachin et al., 1993; Lovaas, 1987).

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From Neurons to Neighborhoods: The Science of Early Childhood Development beliefs and practices related to leaving young children unsupervised, or different patterns of discipline in association with disagreement about the criteria for defining maltreatment, can result in highly sensitive challenges for a child welfare system (Korbin, 1994; Rose and Meezan, 1996). Families from different cultures also have different beliefs and understanding about developmental disabilities and mental health problems, which may influence their reactions to diagnoses, adaptation to the challenges of caring for a child with special needs, and preferences among service delivery options (Bernheimer et al., 1990; Coates and Vietze, 1996; Lynch and Hanson, 1998; Seligman and Darling, 1997). Recognizing the critical importance of cultural differences, as described in Chapter 3, each of the diverse service streams that constitute the early childhood intervention landscape endorses the central importance of cultural competence as a cornerstone of state-of-the-art practice. Consequently, an increasing number and variety of resources to provide guidance in this area have proliferated in recent years. Most of the available material, however, is conceptual rather than empirical (Johnson-Powell, 1997; Lewis, 2000; Lynch and Hanson, 1998), Thus, despite widespread consensus about its importance, the underlying science of cultural competence remains to be developed. Identifying and Responding to the Special Needs of Distinctive Subgroups Notwithstanding the common knowledge base that transcends the compartmentalized world of early childhood intervention, specific population subgroups confront unique challenges that require specialized expertise. For children, the presence of a biologically based disability, such as cerebral palsy or a sensory loss, requires an intervention strategy that incorporates knowledge about both normative child development and adaptation to a specific physical impairment. For mothers, the diagnosis of depression or a substance abuse problem adds an enormous burden to the normative stresses of parenting, and necessitates services that go beyond the provision of simple advice and support. And for families that confront severe economic hardship and ongoing domestic violence, the needs of their young children extend beyond the addition of educational enrichment activities. The overarching challenge for both policy makers and service providers is to integrate specialized services (when they are required) in a comprehensive framework that addresses the generic needs of all children and families, while recognizing the importance of individual differences and the necessity of cultural competence in an increasingly pluralistic society. Another dimension of special needs requiring sensitive attention is the extent to which early childhood interventions might be beneficial for some but have unintended negative consequences for others. From the perspec-

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From Neurons to Neighborhoods: The Science of Early Childhood Development tive of the family, programs that focus explicitly on parent training may send a message of presumed incompetence, which might undermine a mother's or father's self-confidence and contribute inadvertently to less effective performance. Similarly, parenting interventions that respond to cultural differences in a dismissive or pejorative manner are likely to precipitate significant conflict or be rejected as unacceptable. Related to these concerns, some observers have cautioned that the provision of formally organized support services may sometimes interfere with the natural development of the informal social networks needed by all families (Affleck et al., 1989). Indeed, one study found that professionally directed support groups may actually serve as additional stressors for some mothers (Krauss et al., 1993). Some services may also have the unintended consequence of limiting child opportunities. For example, inappropriate interventions may cause some parents to interact with their child in an unnatural, therapeutic manner rather than through a natural and comfortable parent-child relationship. From the perspective of the child, a tightly structured intervention that is delivered in a highly prescriptive style may interfere with the normal adaptive and self-righting mechanisms that are inherent in the developmental process. In a comparable fashion, isolation from normative settings for a child with a disability results in a distorted social world that provides limited opportunities for healthy adaptation. Inevitable tensions between the generic and idiosyncratic characteristics and needs of children and families create a complex agenda for the early childhood field. All children, with or without biological or environmental vulnerabilities, do best when they are reared in a nurturing environment that responds to their individuality and invests in their well-being. All families, regardless of their material resources, depend on informal social supports and varying levels of professional service. Thus, despite the challenges of special needs, the general principles of development apply to all children and families across the broad array of early childhood service systems. Influencing and Assessing the Impacts of Postintervention Environments The demands of policy makers for evidence of long-term impacts as a result of investments in early childhood programs have put service providers and program evaluators in a difficult bind. Central to this dilemma is the widely endorsed assertion that effective early intervention services do not serve as inoculations that confer a lifetime of immunity against the adverse effects of later experiences. Indeed, no intervention prior to school entry can ever be powerful enough to fully buffer a vulnerable child from

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From Neurons to Neighborhoods: The Science of Early Childhood Development the negative effects of attending a demoralizing school or living in a dangerous neighborhood. The extensive documentation of IQ fade-out, particularly for children who live in impoverished environments and receive a mediocre public education, was described earlier. Nevertheless, the few studies that have followed early childhood program graduates through the school years and into adult life have demonstrated variable patterns of so-called sleeper effects in such areas as high school graduation, welfare dependence, income, and criminal behavior (Lally et al., 1988; Schweinhart et al., 1993). The need for more longitudinal data to further elucidate this phenomenon is clear, but follow-up studies must pay greater attention to the continuing influence of the child 's environment throughout the life span. The key challenge facing early childhood intervention professionals is the need to establish the standard of proof that must be met in order to endorse a program as effective. The immediate and short-term benefits for both families and taxpayers are real, and their value should not be diminished. Moreover, the medium-term benefits of reduced grade retention and special education referrals can be quite large economically and could justify the initial costs of early intervention, even in the absence of longer-term impacts. Strengthening the Service Infrastructure Services to promote the health and well-being of all young children, as well as early intervention efforts for those who are developmentally vulnerable, cover a diverse and highly fragmented array of policies, programs, and funding sources. This fragmentation has been the object of considerable criticism for decades. The extensive knowledge base presented in this report provides a powerful tool to guide the design of a more rational and efficient infrastructure for early childhood services that incorporates the multiple streams that have evolved independently over the years. Beyond the general challenges of excessive service fragmentation and redundancy, the limited availability of mental health assistance for children under age 6 represents a massive gap in the current early childhood infrastructure (Knitzer, 2000). This shortcoming is particularly problematic in view of the high prevalence of emotional and behavioral problems in young children and the inextricable interrelation among cognitive, social, and emotional development, as elaborated in Chapter 5 and Chapter 6. Two striking examples illustrate the magnitude of this problem. First, the federal mandate to provide family-centered services for infants and toddlers with developmental disabilities or delays, under the provisions of Part C of the Individuals with Disabilities Education Act, focuses primarily on cognitive, language, and motor impairments and does not accord a

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From Neurons to Neighborhoods: The Science of Early Childhood Development comparable entitlement to services for children whose difficulties lie in the domains of emotional and social development. In a similar fashion, multiple federal programs address the problem of child maltreatment, and all states require mandatory reporting of suspected child abuse or neglect, yet large numbers of maltreated young children are managed in child welfare systems that have limited professional expertise in normative child development, developmental disabilities, and early childhood mental health. Both the failure to incorporate state-of-the-art mental health expertise into policies and programs designed to address the needs of children with disabilities and the absence of sophisticated developmental services for young children who have been maltreated are dramatic examples of the significant gap between current knowledge and practice. Assessing Costs and Making Choices Among Early Childhood Investments The early era of early childhood intervention in the United States focused relatively little attention on the question of cost. Whether the target population was dealing with the stresses of poverty or the challenges of developmental disability, public funds were appropriated on the basis of assumed need and the return on investment was rarely quantified. Beginning in the 1980s and continuing to the present, all health and human services have been faced with increasing demands for cost-effectiveness and demonstrated cost-benefit. This shift has been embedded in a changing political climate characterized by reductions in taxes and appropriations for government social programs, devolution of authority from the federal to state and local levels, and an increasing reliance on market solutions to address health and human services needs. In this context, early childhood intervention programs face a less forgiving environment that demands evidence of both measurable impacts and more efficient service delivery. Although much of the impetus for greater accountability has been stereotyped as a lack of commitment to the well-being of vulnerable children, it is important to note that the rigorous assessment of costs and benefits is the best way to ensure that finite resources are used in the best interests of children and families. It is essential, however, to also recognize that the distribution of benefits matters. For example, savings to a school budget do not necessarily accrue to families and children in need. Thus, although public financial gains are generally desirable, a policy that resulted in the same net benefits, but proportionally more for the children and relatively less for the general taxpayer, might be preferred. The costs of early childhood services vary considerably. Averages per child range (in 1994 dollars) from Missouri Parents As Teachers (less than $1,000 per year) to the Avance Family Support and Education program

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From Neurons to Neighborhoods: The Science of Early Childhood Development ($1,600 per year for 1 or 2 years), Even Start Family Literacy Programs ($2,660 for 1 year), Child and Family Resource Programs ($3,220 per year for 5 years), Head Start Family Service Centers ($3,500 per year for 3 years), Head Start ($4,000 per year for 1 or 2 years), New Chance ($8,300 per year for 1.5 years), the Comprehensive Child Development Program ($8,600 per year for 5 years), and the Infant Health and Development Program ($10,000 per year for three years) (St. Pierre et al., 1995b). With such a wide discrepancy in costs, both annually and as a function of the number of years of program enrollment, the demand for evidence of intervention impacts is compelling and the need for more data on cost-effectiveness is clear. In their efforts to develop model early childhood programs that can have significant and long-lasting impacts, interventionists have periodically designed and evaluated elaborate service models with costs per child that have exceeded $8,000 to $10,000 per year. Yet legislators and service providers typically have budgets that are too small to offer such programs to more than a small fraction of the children who could profit from them. Early intervention researchers generally ask “What works?” and “How does it work?” Budget-constrained policy makers and practitioners typically seek the most cost-effective programs that serve the largest possible number of needy children. How significant an impact must an intervention have to be worthwhile? Is a cheaper-by-half, scaled-back version of a proven program likely to provide at least half the benefits? If several interventions show documented benefits but a decision maker cannot fund them all, how should he or she choose among the alternatives? Is the $4.66 billion the United States spent on Head Start programs in 1999 too much or too little? These are some of the difficult policy questions that arise. Cost-effectiveness and cost-benefit frameworks (Gramlich, 1990; Levin, 1983) are useful though imperfect means of addressing all of these issues. Each begins with a systematic accounting of the full costs of an intervention program. Dollar expenditures on staff salaries and benefits generally make up the bulk of such costs. However, a complete cost accounting must include subtler expenditures, such as the value of the time volunteers spend helping out with the program and the cost of the needed classrooms or other facilities. Thus, volunteer time is not free, since it could have been used productively for some other purpose; facilities are not free, because scaling up a program to provide services for tens of thousands of children often requires major expenditures to rent or build facilities. The benefits of early childhood programs are often difficult to quantify with a monetary value. Their accurate assessment requires a precise comparison of developmental outcomes for children who received program services and otherwise similar children who did not. As described in Chap-

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From Neurons to Neighborhoods: The Science of Early Childhood Development ter 4, randomized experimental designs often provide the strongest basis for estimating program impacts. But the measurement of child development is not always straightforward, and the assignment of a dollar value to a given outcome is a complex challenge. The most commonly measured dependent variable in the intervention literature is IQ. This report argues that important domains of child development and well-being also include emotional health and social behavior, and a full cost-benefit perspective underscores the importance of a broad conception of child outcomes. For example, IQ gains may benefit society by increasing the productivity of the nation's workforce. However, as shown by data from the High/Scope Perry Preschool Program, the societal value of improvements in children's mental health and reductions in criminal activity can easily exceed the value of IQ-based productivity gains. Reactions to the assignment of dollar values to impacts on children 's development often range from skepticism to moral indignation. Advocates often ask how one can assign a dollar value to the lives that are saved by child care safety regulations, or to a boost in self-esteem for a child who avoids the stigma of assignment to a special education program. In contrast to the questions asked of cost-benefit analyses, some investigators conduct cost-effectiveness studies to avoid the problem of benefit valuation by simply comparing the relative costs of programs designed to meet similar goals (Barnett, 2000). In view of their systematic attempt to account for the dollar value of all important program benefits, cost-benefit studies are more complex and ambitious than cost-effectiveness approaches. Program benefits, such as reduced use of special education services or decreased grade repetition, can be assigned specific dollar values based on what school systems spend to provide special and regular education services. However, these valuations of school-related benefits are likely to be conservative, in the sense that they omit the value to children and their families of avoiding stigmatizing education classifications and tracks. Quantifying the benefits of early childhood intervention programs for such long-term outcomes as criminal behavior and adult career success is exceedingly more difficult, since it requires the maintenance of contact with intervention and control group participants over a very long period of time. When the complete accounting of such benefits is not possible, a cost-benefit analysis evaluates all possible costs and benefits and then makes prudent judgments about whether the missing data would be likely to push the computed difference between benefits and costs in a positive or negative direction. Table 13-1 summarizes results from a cost-benefit analysis of the High/Scope Perry Preschool Program (Schweinhart et al., 1993). Random assignment of children to intervention and control groups, the systematic follow-

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From Neurons to Neighborhoods: The Science of Early Childhood Development TABLE 13-1 Costs and Benefits of the High/Scope Perry Preschool Program Total cost per child $12,356 Total benefits per child $70,786 K-12 expenditures saved 6,872 Higher adult earnings 14,498 Crime saving 49,044 Other 372 NOTE: Adapted from Schweinhart et al. (1993:Table 43). Data are in 1992 dollars and discounted at 3 percent. up of both groups through age 27, and a careful accounting of both costs and benefits make this program a good example to illustrate the cost-benefit approach. On the minus side, the study sample was small (117 children in all were interviewed at age 27) and located in a single Midwestern city, which suggests a need for replication before much is made of the specific benefit estimates emerging from the study. Since program impacts on IQ test scores were no longer found by the time the children reached age 8, this study illustrates the potential value of an early childhood intervention that produces long-term impacts in important social domains despite the apparent transient nature of its short-term cognitive effects. Details on procedures for the cost and benefit accounting method are provided by Schweinhart and his colleagues (1993). Despite the value of the economic analyses that have been conducted on the Perry Preschool Program, several features of the intervention make it difficult to generalize from the findings. One remarkable factor is its high cost ($12,356 per child in 1992 dollars and $14,683 in 1998 dollars for a 1to 2-year program), which is much higher than that of the typical Head Start program ($5,021 per child in 1998). This reflects its greater intensity of services compared with most early education programs, which makes it all but impossible to generalize to less intensive interventions. A second, and perhaps even more remarkable factor, is the size and nature of the reported benefits. At age 27, the full complement of measured benefits totaled $70,786, far in excess of the $12,356 costs of the program. Thus, despite the IQ fade-out by third grade, the answer to the question of whether the resources expended on the program were socially profitable is a resounding “yes.” Specifically, although the IQ impacts were short-lived, children who participated in the intervention spent significantly less time in special education programs and were less likely to repeat a grade, differences that saved their schools some $6,872 when averaged across all children served. As large as these savings may seem, they are still not consid-

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From Neurons to Neighborhoods: The Science of Early Childhood Development ered sufficient by some policy makers to outweigh program costs. Twice as large (some $14,498 per child) as the education benefits, however, were the higher earnings enjoyed by program participants in their young adult years. Beyond the savings linked to education costs and employment earnings, the greatest impact in the Perry Preschool benefit-cost calculus was the computed value of the favorable differences in crime victim and incarceration costs for program participants relative to the control group. In fact, the costs to the criminal justice system and the costs of crime victimization are so large that the striking intervention-control differences in rates of criminal activity translated into a $49,044 program benefit per individual served. Relatively few of the total benefits were reaped by the children enrolled in the Perry Preschool program. In fact, of the $70,786 total benefits, only $8,815 accrued to the participating children, mostly in the form of higher earnings in their early adult years. The $49,044 crime-related benefits constitute savings to taxpayers and potential crime victims, as did a nearly $7,000 savings from lower enrollment in special education programs. Thus, while a complete cost/benefit accounting considers all sources of benefits, it is important to identify to what extent the participants themselves are receiving the benefits. The long-term analyses of the High/Scope Perry Preschool Program clearly demonstrate that a very intensive early intervention program can produce benefits far in excess of its costs. Despite the value of such a study, however, it does not begin to address a larger set of questions that are crucial for policy makers and practitioners. For example, do less expensive, less intensive programs also produce more benefits than costs? If resources are limited, is it better to offer high-quality programs to fewer children or more affordable programs to a larger number? Neither a single study nor a collection of evaluations of other high-cost, intensive studies can begin to answer these important questions. The only way to address this complex and critically important issue is to evaluate a range of high- and low-intensity programs. Such evaluations may well suggest that there are smaller but still positive benefits for smaller programs. Welfare-to-work experiments in the 1980s resulted in precisely that conclusion (Gueron and Pauly, 1991). Very expensive (e.g., $10,000 per participant), intensive programs produced more benefits than costs, but so too did less expensive (e.g., $1,000 per participant) training-based programs, as well as extremely modest investments (e.g., $100 per participant) in job-search programs. Thus, cost-benefit information from a wide range of potential programs can help policy makers analyze trade-offs between intensity and coverage in the context of highly constrained budgets. Regrettably, the number of early intervention services for which cost and benefit data are available is exceedingly small and confined largely to

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From Neurons to Neighborhoods: The Science of Early Childhood Development highly intensive programs. Consequently, it is difficult to provide economically guided answers to pressing questions about the optimal level of social investment that should be made in a wide range of early childhood efforts, such as Head Start, nutrition programs, and parenting education. Similarly, it is not possible to set safety and group size standards for child care settings based on reliable knowledge of their costs and benefits. The answers to these and many other important policy questions await further study. CONCLUSIONS Early childhood interventions are provided under the auspices of a wide variety of policies and programs. These include high-prevalence services, such as child care and early childhood education, as well as targeted interventions for a range of vulnerabilities, including economic hardship, childhood disabilities, parental substance abuse, and child maltreatment, among others. State-of-the-art early childhood programs are guided by a rich knowledge base that reflects a mixture of developmental theory, empirical research, and professional experience. A critical examination of this knowledge reveals considerable agreement on theoretical concepts, both replicable patterns and inconsistencies in the empirical data, and substantial gaps in potentially important areas of investigation. The research literature on the efficacy and effectiveness of early intervention programs encompasses thousands of peer-reviewed papers, monographs, edited volumes, and project reports. Despite continuing debate about the nature of the underlying science and its methodological rigor, there is considerable agreement across all service streams about desired child outcomes, and about important family-based and community-based factors that influence child health and development. Generally speaking, well-designed early interventions that are child-focused produce immediate gains on standardized developmental measures, most commonly IQ scores. These findings have been replicated in multiple studies of children living in a variety of adverse circumstances and those with a wide range of diagnosed disabilities, although the largest benefits are typically found in model demonstration projects that generally incur high costs per child. For children at risk because of low socioeconomic status, the shortterm benefits of higher IQ scores typically fade out during the middle childhood years, but persistent intervention-control group differences have been documented, favoring those who received early services, in later academic achievement, retention in grade, and referral for special education. Long-term follow-up data on low-income children are more limited but provide some evidence of intervention-control differences in high school graduation, employment, dependence on public assistance, and involve-

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From Neurons to Neighborhoods: The Science of Early Childhood Development ment in the criminal justice system. Comparable longitudinal data on children with disabilities are not available. Complementary but distinct from child-focused interventions, a variety of early childhood services are delivered through family-focused models, many of which are home-based. Research on model programs reveals that well-designed services with explicitly defined goals can be effective in changing parenting practices and influencing parent-child interactions. For families of children with cognitive, language, or sensory impairments, enhanced parental competencies linked to greater understanding of the child's special needs are important mediators of improved child outcomes. The measurable effects of parent-focused interventions on standardized child development scores in economically disadvantaged families, however, are less conclusive, and there is little empirical documentation that nonspecific, general family support models for high-risk families, which typically are less expensive to deliver, have significant impacts on either parent behavior or assessed child performance. In the final analysis, there is considerable evidence to support the notion that model programs that deliver carefully designed interventions with well-defined goals can affect both parenting behavior and the developmental trajectories of children whose life course is threatened by socioeconomic disadvantage, family disruption, or diagnosed disability. Programs that combine child-focused educational activities with explicit attention to parent-child interaction patterns and relationship building appear to have the greatest impacts. In contrast, services that are supported by more modest budgets and based on generic support, often without a clear delineation of intervention strategies matched directly to measurable objectives, appear to be less effective for families facing significant risk. The general question of whether early childhood programs can make a difference has been asked and answered in the affirmative innumerable times. This generic query is no longer worthy of further investigation. The central research priority for the early childhood field is to address more important sets of questions about how different types of interventions influence specific outcomes for children and families who face differential opportunities and vulnerabilities. To this end, program evaluators must assess the distinctive needs that must be met, the soundness of the intervention strategy, its acceptability to the intended recipients, the quality of its implementation, and the extent to which less intensive, broader-based programs can be developed that are both beneficial and cost-effective. Programs with only transitory impacts on children's IQ scores may still be socially profitable investments. The measurement of specific program effects on children must go beyond traditional cognitive evaluations (such as IQ) and include greater focus on a broad range of functional capacities, particularly in the social and emotional domains. Middle- and long-term

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From Neurons to Neighborhoods: The Science of Early Childhood Development follow-up studies also must pay greater attention to the assessment of subsequent and continuing environmental influences on development after the intervention has been completed. Although sometimes hard to quantify, program benefits and costs provide vital information for budget-constrained policy makers and practitioners. Nevertheless, there currently are few systematic data on the costs and benefits of intensive early childhood interventions, and almost none on the less intensive, real-world services that are more likely to be implemented on a large scale. Practitioners and policy makers need careful evaluations of a broad portfolio of intervention programs, including both modest and intensive models, as programs with the largest impacts on children are not always the most practical to implement. Although not all decisions about allocating resources for early childhood programs need be based solely on considerations of financial costs and benefits, the need for better economic data is clear. The current agenda for early childhood policy and service delivery in the United States is embedded in four objectives: Full access to programs whose effectiveness has been demonstrated must be ensured for all eligible children and families. A culture of ongoing experimentation must be established to promote the design, implementation, and evaluation of alternative approaches for those circumstances in which existing interventions are found to have minimal impact. A strong commitment to rigorous quality control must be established and sustained, in order to ensure that all available resources are used in the most effective and efficient manner. It is essential that all early childhood policies and programs be designed and implemented within a culturally competent context and in a manner that respects the importance of individual differences among children and families. A fundamental challenge facing the nation is to find an appropriate balance between long-term investment in human capital development and the moral responsibility to ensure that the quality of life for young children does not fall below a minimum level of decency. Stated simply, certain services are deemed worthy of support because they generate significant long-term dividends. Other programs are essential not because they result in later financial benefits but because they reflect society's commitment to those who are most vulnerable and who cannot help themselves.