judith carta, ph.d. juniper gardens children’s project university of kansas presentation prepared...

When More Means Less: Cumulative Risks and their Impact on Children’s and Families’ Outcomes

Judith Carta, Ph.D.Juniper Gardens Children’s ProjectUniversity of Kansas

Presentation prepared for the Australian Centre for Child ProtectionUniversity of South AustraliaMarch 17, 2011

Except on one specific issue

Australia and the US have much in common and a wealth of knowledge and wisdom to share

It’s been a topic of recent discussion among our heads of state.

Juniper Gardens Children’s Project

A collaboration between university and community focused on prevention of risks associated with poverty

JGCP began in the mid-1960s when residents of NE Kansas City, KS, a low-income community, joined with University of Kansas Faculty to address concerns about child development.

JGCP’s New Home as of June, 2010

The Children’s Campus of Kansas City Multiple agencies worked

together on capital campaign to build a center of evidence-based practice

Model Infant-Toddler and Preschool Classrooms

One-stop shopping for services for families

Evaluation and referral to other family services

Focus on translation of research to practice

+Some of the things we’ve learned about the effects of poverty on children and how to PREVENT adverse outcomes.

Today’s Focus

1. Poverty exacts a toll on children in numerous ways.

More likely to live in a single-parent family

Family experiences food insecurity

Exposed to more environmental risks, toxins

In homes with parental substance abuse, maternal depression, lower levels of parent education

In low quality child care

Substandard housing

Unsafe neighborhoods

Parents much less likely to be employed

Less access to quality health care

Example of common risks for children in poverty

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Substandard housing



Conditions for Poor Children Are Less Supportive

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Model of Caregiving Risks within Home EnvironmentsAffected by Substance Abuse

Caregiving Risks

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SociodemographicRisks

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Ecological-Transactional Model of Caregiving Risks

2. The consequences of poverty-related risks show up in numerous areas of development.

Born at lower birth weight Less successful in school1

More likely to show behavior problems (disobedience, impulsiveness) and, when older, commit crimes1

Higher risk of becoming a teen parent2

Experience more accidents and injuries2

Be poor as an adult2

Obesity2

Chronic health problems (asthma, anemia)2

Receive lower quality child care2

Consequences for Children in Poverty Are Really Different

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_____________

1Duncan, Zio-Guest, & Kalil (2010) 2Moore et al. (2009).

Early Childhood Longitudinal Study – Birth Cohort (ECLS-B)

Nationally-representative sample of approximately 11,000 children born in 2001

Data collected at 9 months, 24 months, 48 months, and in Kindergarten

Current analyses focus on 9 and 24 months• Analyses of the 9-month sample were limited to children

aged 8-11 months (N = 7,400)• Analyses of the 24-month sample were limited to

children aged 22-25 months (N = 7,200)

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3. The influence of risks shows up early and grow over time.

Birth

Early Infancy

Late Infancy

Early Toddler

Late Toddler

Early Preschool

Late Preschool

Responsive Parenting

Talking and Readingto Child

Evidence-Based Interventions in Language, Literacy, Social

Competence

Age 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs

Re

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High Quality Child Care

Caregiving Risks(e.g., ignoring)

Caregiver Characteristics Risks (e.g. depression)

Environmental Risks(poor nutrition, toxins)

Normative developmental trajectory related to school readiness:--Social-Emotional, Physical, Cognitive, Language Skills

Fig. 3. Risk factors influence developmental trajectories related to school readiness and the gap grows over time

4. Risks associated with poverty often accumulate and have a multiplicative effect on children’s outcomes.

Relationship Between Cumulative Environmental Risk and Developmental Outcome for High Exposure Group

Relationship Between Cumulative Environmental Risk and Developmental Outcome for High Exposure Group

0 1 2 3 4 5 6

Number of Environmental Risk Factors

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In our study of the effects of prenatal drug exposure, preschool children prenatally exposed to drugs and alcohol WHO HAD GREATER NUMBERS OF RISKS had Developmental Quotients that were further from the norm of 100.

Why is it that we see this multiplier effect of risk?

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From Lisbeth Schorr:

–An example of how the presence of risk factors and absence of protective factors can influence a child’s outcomes over time

– From Within Our Reach: Breaking the Cycle of Disadvantage






Substandard housing




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The News is Not All Bad.

5. Responsive parenting can mediate the effects of poverty.

We know the qualities of parent interactions that promote children’s

development.

Consistent Warm Nurturing Stable Predictable Contingent

Enhancing Parent-Child Interaction is Critical

But where do you begin?

Parent Behavior Can Be affected by:

Immaturity and inexperience

Low educational attainment

Depression or other mental health problems

Family violence Substance abuse Economic stress Illness

In a Context of Multiple Risks

• Where Risks Affect Parenting,• Parenting Affects Child

Behaviors and• Child Behaviors Affect

Outcomes,

Where do you begin to intervene?

The Prevention Riddle

•What’s the best way to cut through the onion?






Substandard housing




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Do you begin with the outer layers and work inward…(distal risks)?

Or address the center first (parent and child behaviors)?

We know that we cannot ignore the outer edge

Parents who are dealing with survival and safety will have difficulty responding to parent training.

Programs must be able to respond to families’ needs in a comprehensive, intensive and flexible way.

Shonkoff & Phillips, From Neurons to Networks, 2000

We must also focus on center

Relying simply on enhancing family support will probably not improve child outcomes.

Children can’t wait for distal risks to be ameliorated.

Programs that focus on enhancing specific parent-child interactions have greatest impact on child outcomes.

6. Our most promising interventions appear to be those that are comprehensive as well as focused and intensive.

How Intervention Programs Can Alter the Developmental Trajectories of Infants and Toddlers in Low-Income Families:

The Example of Early Head Start

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Early Head Start Is an Intensive and Comprehensive

Two-Generation Program

Self-Sufficiency and Healthy Families

Parenting

Child Development

Positive parenting, stimulation of learning and language, positive home environment Enhanced at all 3 ages

Negative parenting Reduction in spanking of 2- and 3-year-olds Mothers less detached when children were 2 and 3

Improved parent mental health all 3 ages Less parenting distress, conflict at age 2 Reduced maternal depression when kids were age 5

Parental self-sufficiency Increased school and training when children were 2 and 3 No impacts on income

Impacts on Parenting and Home Environment, by Child’s Age

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Social-emotional development Reduced aggression at 2, 3, and 5

Positive approaches to learning Enhanced at ages 3 and 5

Cognitive and “academic” skills Positive at ages 2 and 3 No impacts at age 5

Language development Vocabulary, English speakers at 2 and 3 Vocabulary, Spanish speakers at age 5

Some positive health effects at each age

Impacts on Children’s Development, by Age

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7. Highest risk families may be least likely to show effects of

our intervention.

No impacts for families in highest risk group when children were 2 and 3 years old

Effects more likely among moderate-risk families when children were 2 and 3 years old.

EHS Impacts by Risk Levels

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In general, higher risk families received less intervention More likely to drop out before their children reached

age 3 More likely to miss home visiting appointments Less likely to be fully engaged and involved during

home visits

Possible reasons for lower impacts for higher risk families

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A dilemma: Families who need interventions most may be least likely to get them.

8. Technology may help us engage the most difficult to engage families.

Question: Could cell phones help?

Keep families engaged in a parenting intervention

Keep them from dropping out

Give parents ideas on how to use the parenting intervention throughout their daily activities

Strengthen relationship with home visiting/parenting coach

Purpose of Cell phone parenting project is to see if adding cell phones to a parenting intervention will:

Improve our ability to keep families from dropping out of the intervention.

Keep families more actively engaged in the intervention.

Help families learn to apply parenting skills throughout their daily activities with high fidelity, thus increasing the “dosage” of the intervention.

Overview of Design of Cell Phone Project

Randomized clinical trial testing the effectiveness of Cell Phone Enhanced Parenting

3 groups: Planned Activities Training (PAT) (like PPP) Cell Phone Enhanced Planned Activities

Training (CPAT) Wait-List Control Group

Planned Activities Training (from Project SafeCare©)

A research-based intervention that teaches parents to plan and structure activities to prevent challenging child behaviors.

Family coaches deliver training in homes in 5-7 sessions.

Coaches teach parents positive interaction skills and help parents teach child expectations, routines, simple rules.

Parents learn to engage the child in planning and preparing in advance for daily routines and play.

Cell Phone Enhanced ParentingParents in CPAT group: Given a cell phone and an allotment of

minutes provided by AT&T Receive twice daily text messages and

weekly phone calls from their coach CPAT mothers can use the phone to call/

text their coach and can also use it for other reasons but cannot go over their allotted minutes.

Text Messages: Questions A text message question is sent daily asking

about use of one aspect of PAT, their interactions with their child, or their child’s behavior “On a scale of 1-10 (10 is best), how did a

mealtime go today?” “Did you have fun with your child today?” “What is one cute thing your child did today?” “How did you catch your child being good

today?”

Messages designed so responses can be brief

CPAT: Other Ways Cell Phones Enhance PAT

One text message each day to remind parent to use a specific PAT strategy.

Cell phones are used to confirm home visits.

Text give parents up-to-date information about free fun community activities.

Sending Text Messages

Family Coaches send text messages and receive parents’ responses in different ways On the Family Coaches’ project cell phone Using Notepager Pro software – can be

scheduled in advance and sent to a group Using an email program

Options save time and allow family coach to schedule messages in advance

CPAT mothers demonstrated greater pre-post improvement than Control Group mothers on most observed parenting behaviors on the KIPS (Keys to Interactive Parenting Scale) (Comfort & Gordon, 2005)

Cohort One Data Showing Lower Attrition Rate for CPAT Group

Implications for practice

Reduced attrition and improved engagement of high-risk families may be worth cost of cell phones/minutes.

Cell phones increase ability to stay connected with highly mobile families.

Being able to stay in touch throughout the week can help us to strengthen relationships with hard-to-reach families.

Conclusions: It’s Time that More Risk Means More:

1. High quality comprehensive support services based on evidence-based practice.

2. Focus on providing parents with skills they need for supporting their children’s development.

3. Intensity that matches what families actually need.

4. Coordination and collaboration among agencies that provide these needed services to families.

Thank you and come visit us in Kansas!

[email protected]

You know how to get there!

Three-level Prevention/Intervention Services

Treatment:

Provide intensive interventions for a few children and families.

Early Intervention:

Intervene early for some children and families.

Universal Prevention:

Focus on evidence-based instruction and supportive learning environment

Some

Few

All

Adapted from Osher, Dwyer, Jackson (2004)

Recommended practices for improving social-emotional learning (Meta-analysis of 57 programs by Durlack, in press)• Sequenced: Does the program apply a planned set of activities to develop skills sequentially in a step-by-step fashion?• Active: Does the program use active forms of learning such as role-plays and behavioral rehearsal with feedback?• Focused: Does the program devote sufficient time exclusively to developing social and emotional skills?• Explicit: Does the program target specifi c social and emotional skills?

Durlack, Journal of Community Psychology, in press)

judith carta, ph.d. juniper gardens children’s project university of kansas presentation prepared...

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