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Between 2001 and 2005, researchers from the Harvard School of Public Health and their colleagues at Teachers College Columbia University conducted a follow-up study of adolescents who, as babies, had participated in the Infant Health and Development Program (IHDP), an early intervention program for low-birthweight, premature infants funded by the Robert Wood Johnson Foundation (RWJF).
The program, which began in 1982, is the first and as of 2006 only multisite, randomized study of the effectiveness of a comprehensive early intervention program for low-birthweight, premature infants. It offered home visits, center-based education and family support.
This grant enabled researchers to contact 636 (64.6 percent) of the original 985 children in the study to determine whether the children (now age 18) still experienced any benefits from their participation in the early intervention services.
Earlier assessments of the IHDP found that, at age 3, children who received early intervention services had significantly higher IQs and fewer behavior problems than those who had not received the services. By age 8, the advantages persisted, although at a more modest level and only among the heavier low-birthweight children.
RWJF provided $3,509,052 to support this unsolicited project. Previous RWJF grants supported the Infant Health and Development Program (close to $25.6 million) and its replication program ($1.5 million).
In a 2000 Institute of Medicine report, From Neurons to Neighborhoods: the Science of Early Child Development, a committee of child development experts concluded that early childhood intervention programs can improve cognitive and behavioral outcomes for vulnerable children by providing them with formalized education and health and social services in their preschool years.
The committee cited thousands of studies demonstrating immediate gains in IQ scores and other positive outcomes among low-income children and children with disabilities.
Only a few early childhood intervention programs have followed the children enrolled into their adolescent and adult years to determine how long these benefits persist.
While such findings are promising, these projects served a small group of healthy, low-income children from a single site. The researchers could not draw conclusions about the likely impact of early intervention on other, more diverse populations.
In contrast to these projects, the Infant Health and Development Program, initiated in 1982 by researchers at Harvard School of Public Health and Teachers College Columbia University, and funded by RWJF, served a large group of low-birthweight, premature infants who were recruited from eight sites across the country and were diverse with respect to health, social and economic status.
An examination of these children in adolescence would add an important component to the growing body of evidence about the long-term impact of early intervention programs.
In 1982, researchers at the Harvard School of Public Health joined with faculty from Teachers College Columbia University in designing and conducting the Infant Health and Development Program (IHDP). This program was the first and, as of 2006, only multisite, randomized study of the effectiveness of a comprehensive early intervention for preterm, low-birthweight babies.
Some 985 preterm, low-birthweight babies participated in the study. To ensure that the children were diverse with regard to health and socioeconomic status, the researchers:
All participating infants received high-risk follow-up pediatric care with frequent clinical assessments and annual developmental testing. The researchers randomly assigned the children to either the intervention or follow-up only group.
Between 1985 and 1988, the 377 children in the intervention group also received:
Home visits on a weekly basis for the first year and biweekly until age 3. The home visitors, who were at least college graduates, were specially trained and guided by intervention-specific materials.
The 608 children randomly assigned to the follow-up only group received the same intensive pediatric services as children in the intervention group but did not receive the additional early education services.
To evaluate the impact of the IHDP, researchers assessed children's cognitive and behavioral functioning at the conclusion of the intervention (age 3) and then again at ages 5 and 8. (See Appendix 1 for details on methodology for early project phases.)
Funding of Early Phases
In addition to support from RWJF, the early phases of the project received support from the Pew Charitable Trusts; National Institute of Child Health & Human Development of the National Institutes of Health; and the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services.
Findings at 36 Months and at 5 and 8 Years
The research team produced numerous articles on the early phases of the project (see Appendix 2 for a list of representative articles). The following key findings appear in a 1998 article by McCormick et al. "The Infant Health and Development Program: Interim Summary," in Developmental and Behavioral Pediatrics.
The Web site of the Promising Practices Network includes Key Evaluation Findings from the IHDP. The network, operated by RAND Corporation, profiles programs that its staff has screened for quality and evidence of positive effects.
RWJF also funded over the long term the work of David Olds, Ph.D., to provide nurses to home visit young women both before and after the birth of their babies. See the Grant Results on the Nurse-Family Partnership program. Also, see the special report on Olds' work, The Story of David Olds and the Nurse Home Visiting Program.
In addition, although RWJF has never focused on children's health issues per se, a lot of its funding has benefited children. Programs include:
Between 2001 and 2005, the IHDP research team conducted a follow-up study to determine whether adolescents who had received intervention services as infants still experienced benefits at age 18. The research team investigated the following questions:
In 1995, when the children in the IHDP turned 10, RWJF provided a grant (ID# 028127) to test the feasibility of tracking the children in their adolescent years.
Staffs at the eight study sites were able to contact between 61 and 74 percent of the 878 eligible participants (i.e., those who had not died or withdrawn from the study by age 8).
Since staff had achieved these contacts with limited resources, researchers concluded that, with further recruitment efforts, they could recontact a high percentage of participants for their adolescent follow-up study.
When the researchers began the follow-up study in 2001, they reconnected with the research teams at the eight study sites. These teams helped the researchers locate the families who had participated in the early intervention program.
Researchers were able to locate and reassess 636 (64.6 percent) of the 985 original participants at age 18. This represented 72 percent of the eligible participants but was lower than the anticipated response rate. (See Limitations.)
Researchers obtained information from adolescents and their caregivers related to academic achievement, behavior, cognitive abilities and physical health.
To provide continuity, researchers used the same instruments they had used in the earlier assessments to the extent possible (some instruments were not applicable to adolescents).
For the follow-up study, researchers added questions from the Youth Risk Behavior Surveillance System, a biannual survey of high school students conducted by the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention. Questions addressed risk behaviors and related problems, including suicidal ideation/attempts, smoking, alcohol and marijuana use, and risky sexual activity. Researchers also questioned both the youth and their caregivers about general behavior problems and about youth involvement with the justice system.
At age 18, the youth were able to respond directly to questions about their academic progress and risk behaviors. Questioning youth directly on sensitive topics, however, raised issues of safety related to a participant's report of risk behaviors and problems. Researchers developed a backup safety plan to deal with this issue. (See Lessons Learned.)
See Appendix 3 for list of assessment instruments.
To communicate findings from the 18-year follow-up study, the research team:
See the Bibliography for details on publications related to the follow-up study findings. During the project period, the researchers also reported findings related to earlier phases of the project in published articles and abstracts. These are also cited in the Bibliography.
Researchers reported findings on the follow-up study in an article in Pediatrics, "Early intervention in Low Birth Weight Premature Infants: Results at 18 Years of Age for the Infant Health and Development Program." (This article is available online.) Key findings as reported in the article:
In a presentation at the May 2006 Pediatric Academic Societies Meeting, "Self-Perception of Education Performance and Future Expectations in Very Low Birth Weight Infants at 18 Years of Age" (abstract available online), researchers reported additional findings.
In an unpublished article ("Long-Term Maternal Effects of Early Childhood Intervention: Findings from the Infant Health and Development Program"), researchers reported on the impact of IHDP on mothers.
With regard to effects on siblings, researchers noted, in a report to RWJF:
Researchers noted limitations to the findings in their article in Pediatrics, "Early Intervention in Low Birth Weight Premature Infants: Results at 18 Years of Age for the Infant Health and Development Program."
In their article in Pediatrics, researchers concluded that:
According to the researchers (in their article in Pediatrics), the modest but persistent benefits experienced by adolescents who had participated in the project intervention as infants "provides substantial reinforcement to the emerging literature on longer-term effects of early intervention."
In contrast to previous studies, which involved largely poor, healthy children, the IHDP sample of premature, low-birthweight babies from diverse cities around the country is more heterogeneous with regard to health and socioeconomic status. "[T]his phase of the IHDP provides important support for the efficacy of early educational interventions in the longer-term outcomes of children," researchers wrote. "[T]he results provide support for extending such educational opportunities to a broader spectrum of children than included in previous studies."
As of 2006, researchers are continuing a longitudinal analysis of the study data, examining long-term patterns of cognitive functioning and behavior over the 18-year period, rather than only at a single point in time. They are also seeking funding for a follow-up study of IHDP youth as they enter adulthood.
Subsequently, the results have been presented to several professional groups:
Follow-up Study of Adolescents Who Participated in the Infant Health and Development Program
Harvard University School of Public Health (Boston, MA)
Marie C. McCormick, M.D., Sc.D.
The Infant Health and Development Program: Methodology and Intervention Components of Early Phases
A description of the Infant Health and Development Program appears on the Web site of the Promising Practices Network. The network, operated by RAND Corporation, profiles programs that its staff has screened for quality and evidence of positive effects. The following is a summary of the project methodology.
Site Selection and Sample
Researchers recruited the sample of low-birthweight preterm infants from eight geographically and economically diverse sites around the country. RWJF selected the sites through a national solicitation in 1984. The major criteria for participation were as follows:
The eight sites were:
Infants eligible for the study:
A total of 4,551 infants were screened for eligibility. The primary analysis group consisted of 985 infants who met the eligibility criteria and whose families gave consent to participate. Infants were enrolled between October 1984 and August 1985 in two birthweight subgroups (or strata):
Within each subgroup, researchers randomly assigned infants to either the intervention group (N=377) or follow-up-only group (N=608).
Infants assigned to the intervention group received an educational program adapted for low-birthweight infants from the Carolina Abecedarian Project, an early intervention for socially disadvantaged normal birthweight children.
The intervention had three components:
Infants in both the intervention and follow-up-only groups received periodic medical, developmental and social service assessments with referral for community services as needed. At the end of the intervention period (age 36 months), the children received whatever community educational programs were available at the site.
The assessment completion rates were 92 percent at age 36 months, 82 percent at age 5 years and 89 percent at age 8 years.
The Infant Health and Development Program: A Selection of Articles on the Early Phases of the Program
Blair C, Ramey CT and Hardin JM. "Early Intervention for Low Birthweight, Premature Infants: Participation and Intellectual Development," American Journal on Mental Retardation, 99(5): 542554, 1995.
Bradley RH, Whiteside L, Mundfrom DJ, Casey PH, Kelleher KJ and Pope SK. "Contribution of Early Intervention and Early Caregiving Experiences to Resilience in Low-Birthweight, Premature Children Living in Poverty," Journal of Clinical Child Psychology, 23: 425434, 1994.
Bradley RH, Burchinal MR and Casey PH, "Early Intervention: The Moderating Role of the Home Environment," Applied Developmental Science, 5(1): 28, 2001.
Brooks-Gunn Jeanne, McCarton CM, Casey PH, McCormick MC, Bauer CR, Bernbaum JC, Tyson J, Swanson M, Bennett FC, Scott DT, Tonascia J and Meinert CL. "Early Intervention in Low-Birth-Weight Premature Infants: Results Through Age 5 Years from the Infant Health and Development Program," Journal of the American Medical Association, 272(16): 12571262, 1994.
Brooks-Gunn Jeanne, Liaw F-r and Klebanov PK. "Effects of Early Intervention on Cognitive Function of Low Birth Weight Preterm Infants," Journal of Pediatrics, 120(3): 350359, 1992.
Brooks-Gunn J, Klebanov PK, Liaw F-r and Spiker D. "Enhancing the Development of Low-Birthweight, Premature Infants: Changes in Cognition and Behavior over the First Three Years," Child Development, 64: 736753, 1993.
Fewell RR and Scott KG. "Cost Analysis Decisions for IHDP," in Helping Low Birth Weight, Premature Babies: The Infant Health and Development Program (Ruth T. Gross, Donna Spiker, and Christine W. Haynes (eds). Palo Alto, Calif.: Stanford University Press, 1997.
"Enhancing the Outcomes of Low-Birth-Weight, Premature Infants: A Multisite, Randomized Trial. Infant Health and Development Program," Journal of the American Medical Association, 263(22): 30353042, 1990.
Hollomon HA and Scott KG. "Influences of Birthweight on Educational Outcomes at Age Nine: The Miami Site of the Infant Health and Development Program," Journal of Developmental & Behavioral Pediatrics, 19(6): 404410, 1998.
Liaw F-r and Brooks-Gunn J. "Cumulative Familial Risks and Low-Birthweight Children's Cognitive and Behavioral Development," Journal of Clinical Child Psychology, 23(4): 360372, 1994.
McCarton CM, Brooks-Gunn J, Wallace IF, Bauer CR, Bennett FC, Bernbaum JC, Broyles S, Casey PH, McCormick MC, Scott DT, Tyson J, Tonascia J and Meinert CL. "Results at Age 8 Years of Early Intervention for Low-Birth-Weight Premature Infants," Journal of the American Medical Association, 277(2): 126132, 1997.
McCormick MC, McCarton C, Tonascia J and Brooks-Gunn J. "Early Educational Intervention for Very Low Birth Weight Infants: Results from the Infant Health and Development Program," Journal of Pediatrics, 123(4): 527533, 1993.
McCormick MC, McCarton C, Brooks-Gunn J, Belt P and Gross RT. The Infant Health and Development Program: Interim Summary," Developmental and Behavioral Pediatrics, 19(5): 359370, 1998.
Ramey CT, Bryant DM, Waski BH, Sparling JJ, Fendt KH and LaVange LM. "Infant Health and Development Program for Low Birth Weight, Premature Infants: Program Elements, Family Participation, and Child Intelligence," Pediatrics, 89: 454465, 1992.
Spiker D, Ferguson J and Brooks-Gunn J. "Enhancing Maternal Interactive Behavior and Child Social Competence in Low Birth Weight, Premature Infants," Child Development, 64: 754768, 1993.
The Infant Health and Development Program: Assessment Instruments for Follow-Up Study at Age 18
The researchers used the following instruments to measure cognitive, behavioral and health outcomes of 18-year-olds in the follow-up survey.
Institutional Review Board (IRB). A committee at academic institutions and medical facilities that monitors research studies to assure, both in advance and by periodic review, that appropriate steps are taken to protect the rights and welfare of human subjects.
Low-birthweight (LBW). The World Health Organization (WHO) defines low-birthweight as weight at birth of less than 2,500 grams (5.5 pounds). This is based on epidemiological observations that infants weighing less than 2,500 grams are approximately 20 times more likely to die than heavier babies.
Source: Child Trends DataBank
Source: www.who.int/reproductive health/publications/low_birthweight/low_birthweight_estimates.pdf
Randomized controlled trial. In a randomized controlled trial, the impact of a program is determined by randomly assigning individuals to an intervention group or control group. Random assignment refers to the assignment of individuals in the pool of all potential participants to either the experimental (treatment) group or the control group in such a manner that their assignment to a group is determined entirely by chance.
Suicidal ideation. The strict definition is wanting to take one's own life or thinking about suicide without actually making plans to commit suicide, but the term is often used to refer to having the intent to commit suicide, including planning how it will be done.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Gray RF, Indurkhya A and McCormick MC. "Prevalence, Stability and Predictors of Clinically Significant Behavior Problems in Low Birth Weight Children at 3, 5, and 8 Years." Pediatrics, 114(3): 736743, 2004. Available online.
Gray R and McCormick MC. "Early Childhood Intervention Programs in the US: Recent Advances and Future Recommendations." Journal of Primary Prevention, 26: 259275, 2005. Abstract available online. Full text requires subscription or fee.
Martin A, Brooks-Gunn J and Klebanov P. "Long-Term Maternal Effects of Early Childhood Intervention: Findings from the Infant Health and Development Program (IHDP)." Journal of Applied Developmental Psychology, 29(2): 101–117, 2008.
McCormick MC, Brooks-Gunn J, Buka SL, Goldman J, Yu J, Salganik M, Scott DT, Bennett FC, Kay LL, Bernbaum JC, Bauer CR, Martin C, Woods ER and Casey PH. "Early Intervention in Low Birth Weight Premature Infants: Results at 18 Years of Age for the Infant Health and Development Program." Pediatrics, 117(3): 771780, 2006. Available online.
Roberts G, Bellinger D and McCormick MC. "A Cumulative Risk Factor Model for Early Identification of Academic Difficulties in Premature and Low Birth Weight Infants." Maternal and Child Health Journal, 11: 161172, 2007. Abstract available online. Full text requires subscription or fee.
Yu J, Buka SL, McCormick MC, Fitzmaurice GM and Indurkhya A. "Behavioral Problems and the Effects of Early Intervention on Eight-Year-Old Children with Learning Disabilities and the Effects of Early Intervention." Maternal and Child Health Journal, 10: 329338, 2006. Abstract available online. Full text requires subscription or fee.
Ron Gray, Alka Indurkhya and Marie C. McCormick, "Prenatal and Perinatal Risk Factors for Subsequent Behavior Problems in Preterm Low Birth Weight Children up to Age Eight Years," at the Pediatric Academic Societies' Annual Meeting, May 36, 2003, Seattle. Abstract available online.
Ron Gray, Alka Indurkhya and Marie C. McCormick, "Prevalence, Stability and Time Trends of Clinically Significant Behavior Problems in Children Born Prematurely," at the Pediatric Academic Societies' Annual Meeting, May 36, 2003, Seattle. Abstract available online.
Ron Gray, Alka Indurkhya and Marie C. McCormick. "Comparing the Child Health Questionnaire Behavior and Mental Health Scales with the Child Behavior Checklist in the Assessment of Outcomes for Preterm Low Birth Weight Children," at the AcademyHealth Annual Research Meeting, June 2729, 2003, Nashville, Tenn. Abstract available online.
Gehan Roberts, David Bellinger and Marie McCormick, "Identifying Early Predictors for School Age Academic Difficulties in Former Low-Birth-Weight Infants," at the Pediatric Academic Societies' Annual Meeting, May 1, 2004, San Francisco. Abstract available online.
Jennifer Yu, Stephen Buka, Marie McCormick, Garrett Fitzmaurice and Alka Indurkhya, "Do Early Intervention Programs Alleviate Behavioral Problems in Children with Learning Disabilities?" poster presentation at the Annual AcademyHealth Conference, June 26, 2005, Boston. Proceedings available online (go to page 30 for abstract).
CR Martin, Z Zheng, SL Buka and MC McCormick, "Social Development and Physical Health Outcomes in Very Low Birth Weight (VLBW, <1500g) Infants at 18 Years of Age," at the Pediatric Academic Societies Annual Meeting, May 1, 2006, San Francisco. Abstract available online.
CR Martin, Z Zheng, Stephen L Buka and MC McCormick, "Self-Perception of Education Performance and Future Expectations in Very Low Birth Weight Infants at 18 years of Age," at the Pediatric Academic Societies Meeting, May 1, 2006, San Francisco. Abstract available online.
Report prepared by: Jayme Hannay
Reviewed by: Mary B. Geisz
Reviewed by: Molly McKaughan
Program Officer: Laura C. Leviton
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