+

Can targeted and intensive home visiting programmes improve child development? Evidence from a 5-year RCT

Dr. Orla Doyle15th WAIMH Congress, 2016, Prague 30th May 2016

+Background

Steep socioeconomic gradient in children’s development

Early intervention programmes can be an effective means of reducing inequalities

Home visiting programmes (HVPs) provide support and education to parents from pregnancy/birth onwards Systematic reviews report some short & long terms effects, but modest

effect sizes (e.g. Sweet & Applebaum, 2004; Miller et al. 2011)

Aim of this study: Use a randomized controlled trial, which experimentally modified the environment of disadvantaged families, to investigate the effectiveness of home visiting in an Irish

context

+‘Preparing for Life’ Programme

Preparing for Life: one of first and longest running experimental early childhood interventions in Ireland

Community-led initiative: operated by Northside Partnership in highly disadvantaged area of Dublin

Evidence of need: Children scored below the norm on cognitive & socioemotional skills on school entry

Aim: Improve levels of school readiness by assisting parents in developing skills to prepare their children for school

+ ‘Preparing for Life’ Programme

Random Assignment

PFLTREATMENT

N = 115

Non-PFLCONTROLN = 118

PFL Participants233

1. Public health information

2. Access to a support worker

3. €100 worth of child developmental materials annually

4. Home visiting programme

5. Triple P Positive Parenting Programme

1. Public health information

2. Access to a support worker

3. €100 worth of child developmental materials annually

+ Evaluation Design Eligibility Criteria:

Pregnant women residing in PFL catchment area btw Jan 2008-August 2010

Recruitment: Maternity hospital (~20 weeks) & within the local community Population-based recruitment rate: 52%

Randomisation: Unconditional probability randomisation strategy 115 allocated to Treatment and 118 allocated to Control No statistical differences on 107/116 BL measures (92%)

Assessments: Interviews: 7 home-based assessments (BL, 6, 12, 18, 24, 36, 48 months) Direct assessments: Cognitive skills & executive functioning at 48 months

Methods: IPW-adjusted permutation tests with 100,000 replications controlling for gender

+ RESULTS: HEALTH

6 months 12 months 18 months 24 months 36 months 48 months0

10

20

30

40

50

60

70

80

90

100

12% 14% 14%

40%

15%20%

Impact of PFL on Parent Reported Child Health

% Statistically Significant Effects*

Assessment Point

% S

igni

fican

t

*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.

+Example 1: Body Mass Index at Age 4*

Overweight/Obese at Age 4 Age 40%

5%

10%

15%

20%

25%

30%

35%

40%

45%

23%

41%

Treatment Control

% o

f chi

ldre

n w

ith o

vwew

ight

/obe

se

*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.

+ RESULTS: SOCIAL

6 months 12 months 18 months 24 months 36 months 48 months0

10

20

30

40

50

60

70

80

90

100

0% 0%

13%

31%35%

44%

Impact of PFL on Parent Reported Socio-Emotional Skills

% Statistically Significant Effects*

Assessment Point

% S

igni

fican

t

*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.

+Example 1: Behavioural Problems*

24 months 36 months 48 months0

2

4

6

8

10

12

14

16

18

0%1%

2%

9%8%

17%

TreatmentControl

CBCL

% b

ehav

iour

al p

robl

ems u

sing

Child

Beh

avio

r Ch

eckl

ist (C

BCL)

*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.

+RESULTS: COGNITION

6 months 12 months 18 months 24 months 36 months 48 months0

10

20

30

40

50

60

70

80

90

100

0% 0%

9%

63%

83%

50%

Impact of PFL on Parent Reported Cognit -ive Skills

% Statistically Significant Effects*

Assessment Point

% S

igni

fican

t

*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.

+Direct Cognitive Assessments at Age 4

British Ability Scale II (BAS II; Elliot, Smith, & McCullock, 1997)

Verbal Ability

Pictorial Reasoning

Ability

Spatial Ability

General Conceptual

AbilityEarly Number Concepts

Naming Vocabulary

Verbal Comprehension

Picture Similarities

Pattern Construction

Copying

+ BAS GCA & Upper Level Clusters: Standard Scores*

N(nTREAT/ nCONTROL)

MTREAT (SD)

MCONTROL (SD)

IPW weighted p values with

controls Effect size

(Cohen’s D)P1 P2

General Conceptual Ability

128

(69/59)

97.7(14.4)

88.0(12.6) 0.000 0.001 0.72

Spatial Ability 129(69/60)

96.0(17.0)

86.0 (15.3) 0.000 0.001 0.62

Pictorial Reasoning 132(71/61)

99.2 (12.9)

93.2 (10.9) 0.002 0.002 0.51

Verbal Ability 134(71/63)

98.6(13.1)

90.3(12.4) 0.002 0.002 0.65

*IPW-adjusted permutation tests with 100,000 replications controlling for gender. One tailed (right-sided) test.

+ Executive Functioning Scores

Effortful control: Day/night task (Kochanska, Aksan, Penney, & Doobay, 2007)

Delay of gratification: Modified version of Mischel’s original delay of gratification task (Mischel, Shoda, & Rodriguez, 1989)

N(nTREAT/ nCONTROL)

MTREAT (SD)

MCONTROL (SD)

IPW weighted p values with

controls Effect Size

P1 P2

Effortful Control 117(63/54)

22.0(6.4)

19.2(5.9) 0.023 0.037 0.45

(D)Ability to Delay Gratification

129(68/61) 75% 72% 0.345 0.345 1.13

(OR)

+ How does PFL compare to other home visiting programmes (HVPs)?

Meta-analyses of HVPsPFL

Sweet & Appelbaum

(2004)

Miller et al., (2011)

Filene et al., (2013)

Physical Health ~ ~ 0.11Overweight BMI

0.46

Socioemotional Skills 0.10 ~ ~

CBCL Total Problems

0.36

Cognitive Skills 0.18 0.30 0.25BAS GCA Score

0.72

Abecedarian (HVP & ECCE): ES 0.62 cognitive skills @ age 5Nurse Family Partnership HVP: ES 0.18 cognitive skills @ age 6

+Conclusions

Home visiting programmes can improve the cognitive & socioemotional skills and health of disadvantaged children

Potential mechanisms PFL children lived in higher quality home environments PFL parents less likely to have permissive parenting style Better screentime practices

Results robust to small sample size, differential attrition, multiple hypothesis testing, differential misreporting & contamination

PFL Phase II currently being rolled out

For more information please see: http://geary.ucd.ie/preparingforlife/

+ Thanks to our Funders