Early Intervention: The Integration of Science and Practice Michael J. Guralnick, PhD Director, Center on Human Development and Disability Professor of Psychology and Pediatrics University of Washington Seattle, WA, USA

Challenge for Early Intervention Expectation is that systematic, comprehensive, experientially-based Early Interventions will: enhance the development of children already exhibiting delays (known or unknown etiology); alter trajectory; prevent secondary complications prevent delays from occurring for children at risk

Current Status: Services and Supports High Resource Countries 100 Expected and Accepted 75 Percent Receiving Services 50 25 1975 1986 2016

Current Status: Services and Supports Policy Initiatives : Service Systems Sectors Education, Child Care, Health, Social Services, Mental Health Early Intervention Systems Are In Place

Current Status: Services and Supports Low and Middle Resource Countries 23% at risk for or with an established disability (Walker, 2011) Long-term Strategic Plans Building Infrastructure Professional Training Combating Negative Attitudes Primary Prevention Programs

Why Focus on the Early Childhood Period? Pragmatic/Humanitarian Meeting family needs in most stressful period Support and strengthen families Family-centered supports and services have become the central feature of early intervention programs Linkage developmental perspective

Why Focus on the Early Childhood Period? Plasticity Unique window of opportunity to alter developmental trajectory Early Intervention System Neurobiological and behavioral mechanisms Responsiveness to environmental input Developmental cascade

Why Focus on the Early Childhood Period? Investment: Long-term Benefits Financial perspective Quality of life

Who Are These Vulnerable Children? Biological Risk (preterm) (genetic risk) Environmental Risk Developmental Delay Autism Spectrum Disorder

What Happens in the Absence of Early Intervention? Environmental Risk Developmental Level 5 4 3 2 1 Chronological Age (years) Biological Risk Developmental Level 5 4 3 2 1 Chronological Age (years) Developmental Level 5 4 3 2 1 Chronological Age (years) Developmental Delay Autism Spectrum Disorder Developmental Level 5 4 3 2 1 Chronological Age (years) (Guralnick, 2005, 2012, 2013, 2016)

Why Do Declines in Development Occur Over Time? Emerging Genetic Influences Toxic Burden Artifact of More Complex Test Items Less Than Optimal Environmental Experiences Allow Biological or Historical Constraints to Exert Unusual Level of Influence on: Family Patterns of Interaction

Level of Child Development Family Patterns of Interaction Developmental Resources Organizational Processes Cognition Language Motor Social-emotional Sensory-perceptual Executive function Metacognition Social cognition Motivation Emotion regulation Constraints Constraints Social and Cognitive Competence Stressors Non-Optimal Environment Family Patterns of Interaction

What are the Important Family Patterns of Interaction (Environmental Influences)? Relationships: Parent-Child Transactions Discourse framework Instructional partnership Socioemotional connectedness Development Over Time Discourse framework Instructional Partnership Socioemotional connectedness Expansions, modeling, contingent responding Scaffolding; zone of proximal development Secure attachment

Relationship Formation Instructional partnership Discourse framework Socioemotional connectedness Sensitive - Responsiveness Positive Affect Engagement

Child Social and Cognitive Competence Family Patterns of Interaction Stressors Stressors Family Patterns of Interaction Parent-Child Transactions Discourse framework Instructional Partnership Socioemotional connectedness Expansions, modeling, contingent responding Scaffolding; zone of proximal development Secure attachment

Child Social and Cognitive Competence Family Patterns of Interaction Stressors Stressors Family Patterns of Interaction Environmental Risk Family Resources Personal Characteristics of Parents Material Resources Mental and physical health Intellectual ability Attitudes and cognitive readiness Coping style Perceived confidence and competence Financial resources Social support

Effects on Family Patterns of Interaction Discourse framework Instructional partnership Socioemotional connectedness Quality of Parent-Child Transactions Intensity and Number of Stressors

Sources of Parent-Child Transaction Difficulties Genetic Etiologies Down Syndrome Expressive language Morphosyntactic weakness Task motivation

Genetic Etiologies Williams Syndrome Developmental Influence Over Time Eye Movement Planning Problems Visual Exploration Spatial-Cognitive Abilities Visual Attention Relationships Joint Attention Developmental Influence Over Time Language and Cognitive Development (Karmiloff-Smith, 2009)

Genetic Etiologies Fragile X Syndrome Emotion regulation Gaze aversion Working memory Social anxiety Motivation

Child Social and Cognitive Competence Family Patterns of Interaction Stressors Stressors adjust moderate Family Patterns of Interaction Parent-Child Transactions Discourse framework Instructional partnership Socioemotional connectedness Family Orchestrated Child Experiences Parent’s social network Peer network Stimulating environment Child care Community activities Preschool program Focus on special interests and needs Health and Safety Provided by Family Protection from violence Preventative health Environmental hazards Family Resources

Child Social and Cognitive Competence Stressors Stressors adjust moderate Family Patterns of Interaction Parent-Child Transactions Family Orchestrated Child Experiences Health and Safety Provided by Family Discourse framework Discourse framework Parent’s social network Protection from violence Peer network Stimulating environment Instructional partnership Instructional partnership Preventative health Child care Environmental hazards Socioemotional connectedness Socioemotional connectedness Community activities Preschool program Focus on special interests and needs Family Resources

Child Social and Cognitive Competence Stressors Stressors adjust moderate Family Patterns of Interaction Parent-Child Transactions Family Orchestrated Child Experiences Health and Safety Provided by Family Discourse framework Parent’s social network Parent’s social network Protection from violence Peer network Peer network Stimulating environment Stimulating environment Instructional partnership Preventative health Child care Child care Environmental hazards Socioemotional connectedness Community activities Community activities Preschool program Preschool program Focus on special interests and needs Focus on special interests and needs Family Resources

Child Social and Cognitive Competence Stressors Stressors adjust moderate adjust moderate Family Patterns of Interaction Parent-Child Transactions Family Orchestrated Child Experiences Health and Safety Provided by Family Discourse framework Parent’s social network Protection from violence Protection from violence Peer network Stimulating environment Instructional partnership Preventative health Preventative health Child care Environmental hazards Environmental hazards Socioemotional connectedness Community activities Preschool program Focus on special interests and needs Family Resources

Developmental Science Similar Declines to be Expected Due to Stressors for All Four Vulnerable Groups (Environmental Risk, Biological Risk, Developmental Delay, Autism Spectrum Disorder) Developmental Mechanisms of Influence Apply to All Groups Association Studies (likely causal influences) Unique Adjustments by Group, Subgroup, and Individual Child and Family Unit Overall Goal of Early Intervention is Clear: Optimize Family Patterns of Interaction

Evaluate Risk and Protective Factors at all Three Levels Intervention Process Evaluate Risk and Protective Factors at all Three Levels Engage in Problem-Solving Process with Family and Intervention Team to Optimize Family Patterns of Interaction Continuity over Time Comprehensiveness Relationships Consider in Intervention Phase

Family Patterns of Interaction Health and Safety Provided by Family Protection from violence Preventative health Environmental hazards Parent-Child Transactions Discourse framework Instructional partnership Socioemotional connectedness Family Orchestrated Child Experiences Parent’s social network Peer network Stimulating environment Child care Community activities Preschool program Focus on special interests and needs

Heterogeneous Group of Children with Developmental Delays Intervention group 80 60 General Development Quotient 40 Control group 20 home visiting structured curriculum 30 40 50 60 Intervention Follow-up Months Chronological Age (years) (Thomaidis et al., 2000)

Preterm Children Intervention group Cognitive Development Index 110 Intervention group 105 100 95 Cognitive Development Index 90 Control group 85 80 12 24 36 Age in Months (Infant Health & Development Program)

Early Learning Composite Chronological Age (years) Autism (toddlers) Intervention group 80 70 Early Learning Composite (Mullen) 60 Control group 50 40 2 (baseline) 3 4 Chronological Age (years) (Dawson, et al., 2010)

Autism (toddlers) Intervention group Control group 80 Intervention group 70 Vineland Adaptive Behavior Composite (Standard Score) 60 Control group 50 40 2 (baseline) 3 4 Chronological Age (years) (Dawson, et al., 2010)

Chronological Age (years) Down Syndrome 1.00 Intervention groups (all) 0.80 0.60 Developmental Rate 0.40 Woods et al. (1984) Scharav & Shlomo (1986) Schnell (1984) Berry et al. (1984) 0.20 1 2 3 4 5 Chronological Age (years)

Chronological Age (months) Developing Countries .2 Iron-Deficient Anemia .1 Parent-Child Intervention -.1 Positive Social-Emotional Behavior -.2 -.3 Surveillance Only -.4 6 12 18 Chronological Age (months) (Lozoff, et al., 2010)

Family Orchestrated Child Experiences: Preschool Pre-Academic: Universal Preschool Program: Inclusion Typically Developing Children 15 Intervention 10 Children with Mild and Moderate Delay Early Literacy (raw scores) 5 No Intervention 4 5 Chronological Age (years) (Phillips & Meloy, 2012)

Family Orchestrated Child Experiences: Preschool Quality of Peer Relationships 50 .4 40 .3 30 Responsive to Peer (Proportion) Total Positive Interactions .2 20 .1 10 Inclusive Specialized Intervention Control (Guralnick, 1981,1988) (Guralnick, et al., 2006)

Autism: Infant Intervention 120 Intervention 100 80 Developmental Quotient (Mullen) Visual Reception 60 40 Declined Treatment 20 Parent-Child Training (Pilot Study) Sensitive responsiveness Low intensity (12 sessions plus boosters) Prevent cascade of events 9 12 15 18 24 36 Chronological Age (months) 100 Intervention 80 Developmental Quotient (Mullen) Language 60 40 Declined Treatment 20 9 12 15 18 24 36 Chronological Age (months) (Rogers, et al., 2014)

Related Benefits Reduce emotional distress Enhance parental coping Build support networks Promote parenting confidence and competence Fewer special services required Greater productivity Enhanced community integration Family Outcomes

How Successful Has This Focus on the Early Childhood Period Been? Pragmatic/Humanitarian – Strengthen Families Plasticity – Enhance Child Development Investment: Long-term Benefits – Financial and Quality of Life Expected and Accepted

Challenges for Research and Future Advances Variability in Outcome Efficacy Studies Moderating Factors Sensitivity to environmental input (genetic) Subgroups genetic etiology common biological pathways historical factors similar behavioral profiles Understanding Factors Influencing Longer-Term Outcomes

Challenges and Future Directions for Community Practices Scaling-Up to Early Intervention Community-Based Systems Lower levels of effectiveness in outcomes Fading out of effects over time Reasons for Practice Concerns Heterogeneous set of intervention strategies—many not evidence-based Policies not applied in an effective or systematic fashion Limited Resources

Reason for Progress and the Future of Early Intervention Integration of Science and Practice Developmental Science Intervention Science Early Intervention Practice

Family Patterns of Interaction Early Intervention System Social Services Mental Health Child Care Health Education System of Supports