1. Early Head Start and Developmental Disabilities Craig T. Ramey, Ph.D. Georgetown Distinguished Professor of Health Studies Director, Georgetown Center on Health and Education EHS Disabilities Summit Washington, D.C. February 5, 2004

2. 10 Hallmarks of Children Who Succeed in School Eager to learn Eager to learn Ask lots of questions Ask lots of questions Work hard and know effort matters Work hard and know effort matters Have good social- emotional skills Have good social- emotional skills Can assess their own skills well Can assess their own skills well Parents are role models for learning Parents are role models for learning Parents promote learning at home Parents promote learning at home Family routines support doing well in school Family routines support doing well in school Parents set and maintain limits Parents set and maintain limits Schools have high student expectations, support teacher development, and communicate frequently with parents Schools have high student expectations, support teacher development, and communicate frequently with parents Ramey & Ramey, Going to School, 1999

3. Good health is the foundation for learning, development and school success.

4. The developmental domains of health, cognition, social and emotional development are closely linked by neurobiological connections and personal experiences.

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

6. Health Promotion and Disease Prevention Promotion of mental health Promotion of mental health mentoring in cognitive, social mentoring in cognitive, social and emotional basics and emotional basics responsive language experiences responsive language experiences stable and caring adults stable and caring adults good role models good role models

7. Health Promotion and Disease Prevention Promotion of social well-being Promotion of social well-being Safe environments Safe environments Enjoyable play and learning activities Enjoyable play and learning activities Supportive, informative and frequent Supportive, informative and frequent interactions with parents and interactions with parents and other adults other adults

8. Some Facts about Developmental Disabilities Majority of children with intellectual, social Majority of children with intellectual, social and emotional disabilities are born healthy and emotional disabilities are born healthy Biological risk conditions(e.g., LBW, prematurity) Biological risk conditions(e.g., LBW, prematurity) result in different outcomes, depending on cognitive, result in different outcomes, depending on cognitive, social and emotional support social and emotional support About 11% of children are in special education About 11% of children are in special education Ethnic and regional differences in developmental Ethnic and regional differences in developmental disabilities are poorly understood disabilities are poorly understood

10. Seven Essential Transactions For Caregivers with Young Children 1. Encourage exploration 2. Mentor in basic skills 3. Celebrate developmental advances 4. Rehearse and extend new skills 5. Protect from inappropriate disapproval, teasing, and punishment 6. Communicate richly and responsively 7. Guide and limit behavior Ramey & Ramey, 1999 Right from Birth

11. Sources of Available Support for Early Intervention Funding Elementary and Secondary Education Act: Elementary and Secondary Education Act: Title I: Disadvantaged Children Title V: Innovative Block Grant Early Head Start Early Head Start Head Start Head Start Child Care Development Fund (CCDF) Child Care Development Fund (CCDF) Temporary Assistance for Needy Families (TANF) Temporary Assistance for Needy Families (TANF) Early Reading First Early Reading First Social Services Block Grant Social Services Block Grant Even Start Even Start Early Intervention (0-2 yrs; 3-5 yrs) Early Intervention (0-2 yrs; 3-5 yrs)

12. Psychosocial Developmental Priming Mechanisms Encouragement to explore the environment Encouragement to explore the environment Mentoring in basic cognitive and social skills Mentoring in basic cognitive and social skills Celebrating new skills Celebrating new skills Rehearsing and expanding new skills Rehearsing and expanding new skills Protection from inappropriate punishment or ridicule for developmental advances Protection from inappropriate punishment or ridicule for developmental advances Stimulation in language and symbolic communication Stimulation in language and symbolic communication

13. Potential Levels of Early Intervention Developmental of Biomedical affordances Developmental of Biomedical affordances Prenatal and perinatal services Prenatal and perinatal services Children’s direct learning opportunities Children’s direct learning opportunities Development of family skills Development of family skills Development of professionals’ knowledge and skills Development of professionals’ knowledge and skills Development of community and cultural norms concerning inclusion Development of community and cultural norms concerning inclusion

14. Statement of the problem For a variety of reasons, the early years are believed to be the most efficacious period to intervene in the lives of poor children. For a variety of reasons, the early years are believed to be the most efficacious period to intervene in the lives of poor children. Development appears to be more malleable in the early years. Development appears to be more malleable in the early years. Children who arrive at kindergarten lacking basic readiness skills tend to fall further behind in later years. Children who arrive at kindergarten lacking basic readiness skills tend to fall further behind in later years. Massive attempts to prepare poor children for school success, such as Head Start, were initially disappointing. Massive attempts to prepare poor children for school success, such as Head Start, were initially disappointing. Research was needed to learn whether intensive early intervention that began in the infancy period could make more lasting difference for poor children. Research was needed to learn whether intensive early intervention that began in the infancy period could make more lasting difference for poor children.

15. Stages for the Development of a Scientific Knowledge-Base 1. Proof of concept studies 2. Efficacy studies 3. Effectiveness studies 4. Efficiency studies

16. Hierarchy of Criteria for Evidence-based Practices Multi-site randomized controlled trial Multi-site randomized controlled trial Single site randomized controlled trial Single site randomized controlled trial Single site randomized trial (not controlled) Single site randomized trial (not controlled) Case/control study Case/control study Observational study Observational study Opinions of best practices Opinions of best practices

17. Key Research Question for Abecedarian (ABC) Project Can the cumulative developmental toll experienced by high-risk children be prevented or reduced significantly by providing systematic, high-quality, early childhood education from birth through kindergarten entry?

18. The Abecedarian (ABC) Project is a randomized controlled trial (RCT) that tests the efficacy of early childhood education for high-risk children and their families.

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

20. Who was invited to take part? 120 families invited to enroll 120 families invited to enroll 8 refused random assignment 8 refused random assignment 2 infants reassigned at insistence of authorities 2 infants reassigned at insistence of authorities 1 ineligible due to biological condition (seizure disorder with moderate MR) 1 ineligible due to biological condition (seizure disorder with moderate MR)

21. Participants 4 cohorts of children born between 1972 and 1977 4 cohorts of children born between 1972 and 1977 Half randomly assigned to preschool education program, half were controls Half randomly assigned to preschool education program, half were controls Original SampleNMalesFemales Original SampleNMalesFemales Treated 572928 Treated 572928 Control 542331 Control 542331 Total1115259 Total1115259

22. EC EE CC CE 29 Males 28 Females 23 Males 31 Females Study Design R E C Age 12Age 15Age 21 Preschool Treatment Ages 0-5 Follow-up Assessments School-age Treatment Ages 5-8 N=111

23. Educational Intervention Very intense Very intense Full day childcare program Full day childcare program 5 days/week 5 days/week Year round Year round Began in infancy (mean entry age: 4.4 months, range: 6 weeks to 6 months) Began in infancy (mean entry age: 4.4 months, range: 6 weeks to 6 months) 5 years, until kindergarten entry 5 years, until kindergarten entry University-based setting University-based setting Medical care on site Medical care on site Stable staff Stable staff Low adult : child ratios Low adult : child ratios 1 : 3 infants 1 : 3 infants 1 : 4–5 toddlers 1 : 4–5 toddlers 1 : 7 preschoolers 1 : 7 preschoolers

24. Preschool Curriculum Eclectic in nature Eclectic in nature Stressed contingently responsive early environment for infants Stressed contingently responsive early environment for infants Learningames for the First Three Years (Sparling & Lewis, 1979, recently reissued) Learningames for the First Three Years (Sparling & Lewis, 1979, recently reissued) Natural part of infant’s or toddler’s day Natural part of infant’s or toddler’s day Learningames for Threes and Fours: A Guide to Adult and Child Play (Sparling & Lewis, 1984) Learningames for Threes and Fours: A Guide to Adult and Child Play (Sparling & Lewis, 1984)

25. Key Abecedarian (ABC) Program Components Health and Mental Health Health and Mental Health Nutrition Nutrition Family Support Family Support Parent Involvement Parent Involvement Early Childhood Education Early Childhood Education

26. Preschool Results Tests of cognitive development constituted major outcome during early years Tests of cognitive development constituted major outcome during early years Infants equivalent at outset (3 month Bayley MDI scores) Infants equivalent at outset (3 month Bayley MDI scores) Cognitive measures Cognitive measures Bayley Scales of Infant Development Bayley Scales of Infant Development 3–18 months 3–18 months Stanford-Binet Intelligence Scale (Form LM, 1972 norms) Stanford-Binet Intelligence Scale (Form LM, 1972 norms) 2–4 years 2–4 years Wechsler Preschool & Primary Scale of Intelligence Wechsler Preschool & Primary Scale of Intelligence 5 years 5 years

27. Preschool Test Scores

28. Percent of Abecedarian Sample in Normal IQ Range (>84) by Age (longitudinal analysis) Martin, Ramey, & Ramey, 1990 American Journal of Public Health

29. Positive Effects on: IQ Performance IQ Performance Learning & cognitive performance Learning & cognitive performance Social responsiveness Social responsiveness Language development Language development Decreased Effects: Incidence of intellectual disability Incidence of intellectual disability Brief Summary of Abecedarian Results During Preschool Period Resilience to biological risk conditions Resilience to biological risk conditions Maternal education Maternal education Maternal employment Maternal employment Ramey & Ramey, 1999 Ramey & Ramey, 1999

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

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

32. School-Age Results Reading Scores: Reading Scores: Strong preschool effect on reading scores at age 8 (p<.01) Strong preschool effect on reading scores at age 8 (p<.01) Significant trend for EE>EC>CE>CC (p EC>CE>CC (p<.05) No effect for school-aged treatment alone No effect for school-aged treatment alone

34. Trend for preschool effect on mathematics scores (p<.10) Trend for preschool effect on mathematics scores (p<.10) Linear trend in mathematics scores not significant Linear trend in mathematics scores not significant No effect for school-age treatment alone No effect for school-age treatment alone School-Age Results

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

37. Long-Term Effects Intellectual measures in the follow-up Intellectual measures in the follow-up Age-appropriate Wechsler scales administered Age-appropriate Wechsler scales administered Full Scale IQ used in plots Full Scale IQ used in plots Examiners unaware of earlier treatment/control status Examiners unaware of earlier treatment/control status Because school-age treatment had no effect, reverted to two-group model Because school-age treatment had no effect, reverted to two-group model

38. Long-Term Effects on intellectual development

39. Long-Term Effects, continued Treated children earned higher scores across time Treated children earned higher scores across time Treatment/control group difference was greater during the early, treatment years Treatment/control group difference was greater during the early, treatment years Slopes differ in treatment/post-treatment phases Slopes differ in treatment/post-treatment phases Treated children differed from control children in rates of change during treatment years but not during post-treatment years Treated children differed from control children in rates of change during treatment years but not during post-treatment years Both groups showed upward trends during the early years and declines in post-treatment years Both groups showed upward trends during the early years and declines in post-treatment years Up to young adulthood, the group with early treatment maintained an advantage over controls. Up to young adulthood, the group with early treatment maintained an advantage over controls.

40. Can we identify mediators of long- term treatment effects on cognitive development? Can we identify mediators of long- term treatment effects on cognitive development? Early task orientation mediated effects of early treatment on test scores but effect size did not show much change when this factor was entered into the model. Early task orientation mediated effects of early treatment on test scores but effect size did not show much change when this factor was entered into the model. Early verbal development accounted for much of the treatment effect on test performance, and in later years, wholly accounts for it. Early verbal development accounted for much of the treatment effect on test performance, and in later years, wholly accounts for it.

41. Long-Term Effects, continued Adding child and family characteristics to the prediction model Adding child and family characteristics to the prediction model No significant effect for child gender No significant effect for child gender No significant treatment x gender interaction No significant treatment x gender interaction Gender x time 2 interaction reflects complex pattern of change in intellectual test performance of males and females over time Gender x time 2 interaction reflects complex pattern of change in intellectual test performance of males and females over time

42. Long-Term Effects, continued Females change more rapidly in early childhood Females change more rapidly in early childhood Females decline more sharply than males in early adolescence Females decline more sharply than males in early adolescence Males decline more sharply than females in later adolescence Males decline more sharply than females in later adolescence

43. Long-Term Effects, continued There is also a main effect for the HOME score There is also a main effect for the HOME score Main effect is moderated by a HOME x age interaction Main effect is moderated by a HOME x age interaction Effect of HOME is stronger in the early years Effect of HOME is stronger in the early years Parental attitudes in early life did not have a significant effect on intellectual test performance. Parental attitudes in early life did not have a significant effect on intellectual test performance. No significant effects of mother’s marital status. No significant effects of mother’s marital status.

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

45. Long-Term Effects, continued Does a modest effect on IQ performance really matter? Early treatment was associated with significantly higher scores on reading from age 8 to age 21 Early treatment was associated with significantly higher scores on reading from age 8 to age 21

46. Long-Term Effects, continued Does a modest effect on IQ matter? Early treatment was associated with significantly higher scores on math from age 8 to age 21 Early treatment was associated with significantly higher scores on math from age 8 to age 21

47. Long-Term Effects, continued Real-life benefits in young adulthood Treated group attained more years of education Treated group attained more years of education Treatment associated with increased likelihood of attending a 4-year college or university Treatment associated with increased likelihood of attending a 4-year college or university

48. Long-Term Effects, continued Teenaged parenthood was less likely for those having preschool treatment. Teenaged parenthood was less likely for those having preschool treatment.

49. What was the early intervention worth? Cost-benefit study was carried out at the National Institute of Early Education Research (NIEER) at Rutgers University Cost-benefit study was carried out at the National Institute of Early Education Research (NIEER) at Rutgers University Leonard Masse and Steven Barnett Leonard Masse and Steven Barnett

50. Cost of Abecedarian Program Compared with Others (1999 Dollars) ABC CH Schools Child Care Head Start Annual Cost per Child $11,152$13,401$7,070$5,616 Annual Teacher Salary $31,460 $24,050- $31,350 (+) $15,308 -

51. Ratio of Costs to Benefits NIEER researchers estimated that the Abecedarian program will save society, on average, $4 for every dollar spent. NIEER researchers estimated that the Abecedarian program will save society, on average, $4 for every dollar spent.

52. Why would it save money? Individuals who had early childhood education are projected to earn, on average, roughly $143,000 more over their lifetimes than preschool controls. Individuals who had early childhood education are projected to earn, on average, roughly $143,000 more over their lifetimes than preschool controls. Mothers of children who had the free preschool program are expected to earn about $133,000 more over their lifetimes (preliminary figures). Mothers of children who had the free preschool program are expected to earn about $133,000 more over their lifetimes (preliminary figures).

53. Why would it save money? (continued) School districts can expect to save about $11,000 per child because of reductions in the need for special or remedial education services. School districts can expect to save about $11,000 per child because of reductions in the need for special or remedial education services. There appeared to be a reduction in smoking among those with early childhood education, leading to better health and longer lives (saving approximately $164,000 per person). There appeared to be a reduction in smoking among those with early childhood education, leading to better health and longer lives (saving approximately $164,000 per person).

54. NIEER Conclusions The Abecedarian program effected significant savings to society. The Abecedarian program effected significant savings to society. The estimate may be conservative because of the community where the children grew up – relatively affluent and low crime. The estimate may be conservative because of the community where the children grew up – relatively affluent and low crime. Benefits of a similar analysis for the Perry Preschool study estimate $7 saved for each dollar spent. This was due largely to a significant reduction in criminal involvement among treated individuals. Benefits of a similar analysis for the Perry Preschool study estimate $7 saved for each dollar spent. This was due largely to a significant reduction in criminal involvement among treated individuals.

55. Abecedarian Project Ramey & Ramey, 1999 MR/DD Research Review

56. Key Findings from Abecedarian Project (“Abecedarian” …one who learns the basics such as the alphabet) 5 to 21 Years Old Intelligence (IQ) Reading and math skills Academic locus-of-control Social Competence Years in school, including college Full-time employment Maternal education Maternal employment Grade Repetition Special Education placement Teen Pregnancies Smoking and drug use Ramey et al, 2000

57. Project CARE A RCT designed to be a replication of Abecedarian Project (ABC) with a 2 nd treatment group to test the potential efficacy of an intensive home visiting program with the same ABC educational curriculum for 5 years

58. Adapted from Wasik, Ramey, Bryant, & Sparling. Child Development, 1990

59. Abecedarian (ABC) Preschool Findings Replicated in the First 3 Years of Life in Randomized Controlled Trials (RCT’s) ArkansasConnecticutFloridaMassachusetts New York Ramey & Ramey, 2000 in Securing the Future North Carolina Pennsylvania Texas Washington

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

61. Infant Health and Development Program (2001-2500 grams)

62. Children’s IQ at 36 months: Maternal Education X Treatment Group (n=232)(n=162)(n=166)(n=104)(n=134)(n=63)(n=76)(n=48) Infant Health and Development Program Ramey & Ramey (1998), Preventive Medicine

63. Outcomes Affected Positively (*p<.01) by the Infant Health & Development Program 12 Months 24 Months 36 Months Cognitive Development NS++ Adaptive and Prosocial Behavior --+ Behavior Problems -++ Vocabulary-++ Receptive Language -++ Reasoning--+ Home Environment NS-+ Maternal Interactive Behavior --+ Maternal Problem Solving --+ Ramey 1999, adapted from Gross, Spiker, & Haynes, 1997, Helping Low Birth Weight, Premature Babies

64. Recommendations Recognize the WHO concept of health and Recognize the WHO concept of health and its implications for Head Start programs its implications for Head Start programs Promote the WHO concept of health to Promote the WHO concept of health to communities, programs, families and communities, programs, families and children children Emphasize health promotion and disability Emphasize health promotion and disability prevention prevention

65. Recommendations Design and implement a strong accountability system that continuously monitors program quality and documents child and program progress and outcomes To inform quality improvements To inform quality improvements To strengthen training and technical assistance To strengthen training and technical assistance

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