A public health research-to-practice model for improving child health and development in low-income families: CDC’s Legacy for Children™
The public health and economic impacts of childhood poverty are well documented. In 2009, approximately 15 million, or more than one in every six, children in the United States lived in a family subsiding below the federal poverty threshold (DeNavas-Walt, Proctor & Smith, 2010). These children are at significantly higher risk for a range of adverse health and developmental outcomes, including poor physical health, school performance and social-emotional and behavioral outcomes (e.g., Brooks-Gunn & Duncan, 1997; Currie, 2005; Swanson, 2004). These consequences often do not end in childhood, but translate into increased personal and societal impacts into adolescence and adulthood (e.g., Duncan, Ziol-Guest & Kalil, 2010). Holzer and colleagues (2007) estimated that childhood poverty costs the United States $500 billion per year.
Effective, evidence-based strategies to prevent the negative consequences of poverty are needed to lessen the short- and long-term impact on individuals and the costs to society. Research has shown that helping children in poverty reach their full potential calls for broad-based efforts to create supportive and nurturing parenting environments. To produce the best return on investment, such strategies to promote human development are better targeted earlier, rather than later, in childhood (Cunha & Heckman, 2009). Thus, efforts to facilitate positive parenting early in childhood have notable potential.
As the impacts of childhood poverty are complex and entrenched, preventing the negative impacts of childhood poverty will require involvement from multiple sectors and disciplines. In 1994, the Centers for Disease Control and Prevention (CDC) engaged experts and partners to explore a public health approach to improving child health and developmental outcomes among low-income families. The approach identified through this process was a primary prevention program for low-income parents of infants and young children. To maximize the likelihood of program uptake and sustainability, it was recommended that the program be implemented in community settings with groups of parents. Legacy for ChildrenTM (Legacy) was thus designed as a public health initiative to optimize child health and development by increasing positive parenting practices among low-income mothers. As discussed below, results and lessons learned from Legacy’s rigorous evaluation methods and strategic partner involvement can inform practitioners and policymakers about how to better address health disparities in at-risk populations.
The Legacy intervention is being evaluated via a set of two randomized controlled trials (ClinicalTrials.gov registry # NCT00164697). Research and intervention methods are briefly described here; full details are available from the authors. Two sites participated in the trials: the University of California - Los Angeles and the University of Miami. Eligibility criteria were similar for both sites: mothers had to be at least 18 years of age, be comfortable speaking English, intend to raise their child to speak primarily English and have income below 200 percent of the poverty level (operationalized by receipt of MediCal/Medicaid, food stamps or Temporary Assistance for Needy Families eligibility). Each site also had geographic inclusion criteria based on proximity to the program location. Los Angeles participants were recruited at prenatal clinics during the 28th week of pregnancy. Miami mothers were recruited in the hospital within 72 hours of delivery, had to have received prenatal care, and had to plan to remain in the catchment area for at least 1 year. Study participants who consented were randomized to groups at a rate of 3 (intervention) to 2 (comparison) to maximize statistical power.
Each site was allowed to develop its own curriculum tailored to population- and culture-specific strengths and needs, based on five overarching intervention goals: 1) Support parental responsibility, parental investment, and parental devotion of time and energy; 2) Support responsive, sensitive parent-child relationships; 3) Support mothers’ effectiveness in guiding their children’s behavioral and emotional regulation; 4) Support mothers’ facilitation of their children’s verbal and cognitive development; and 5) Promote mothers’ sense of community. The Legacy intervention began prenatally (Los Angeles) or at birth (Miami), lasted until 3 or 5 years of age, respectively, and consisted of weekly group meetings supplemented by occasional one-on-one visits and group outings in the community.
Evaluation methods were chosen to maximize participants’ representation in the final dataset. Extensive efforts were made to minimize attrition, including free transportation to assessment locations, regular contact between assessments, and compensation for each data collection session attended. Multi-method assessments (i.e., self-report surveys, standardized cognitive tests, and ratings of videotaped interactions) were conducted at baseline and when the children were 6, 12, 24, 36, 48 and 60 months old. Although the main outcomes of interest were children’s socioemotional, behavioral and cognitive development, assessments also included a variety of hypothesized mediators of those impacts, such as mothers’ positive parenting practices, self-efficacy, role commitment, role satisfaction, and sense of community. Additionally, prospective process and economic evaluations were conducted.
Results from the first 5 years suggest positive impacts. Children of Legacy mothers had fewer behavioral concerns at 24 months and fewer socioemotional problems at 48 months in Miami, and lower levels of hyperactive behavior at 60 months in Los Angeles. Longitudinal analyses indicated that children of intervention mothers in Miami were at lower risk of behavior problems from 24 to 60 months of age (Kaminski et al., 2012; Kaminski et al., 2010). Analyses of observed mother-child interactions and child cognitive outcomes suggest site-specific advantages favoring intervention families in these areas as well.
In 2010, we began assessing more distal outcomes when the children were in third and fourth grades. The multimethod, multireporter design includes child-, parent- and teacher-reported data; school records; standardized cognitive tests; ratings of videotaped mother-child interactions; and in-home and neighborhood observations. We are also collecting saliva from mothers and children, for DNA extraction. With participant DNA, we will be able to investigate the genetic contribution to the impact of Legacy and conduct genetically informed longitudinal analyses of non-intervention influences on child development. This data collection wave will continue through 2013.
Translation into practice
The next phase in this research-to-practice cycle involves a measured approach to more widespread dissemination. CDC and the Administration for Children and Families (ACF) are partnering on these efforts. CDC and ACF are currently examining the feasibility of implementing Legacy in Early Head Start (EHS) settings given the match between Legacy and Early Head Start populations and the potential for Legacy implementation to support Head Start Performance Standards and the Head Start Parent, Family, Community Engagement Framework. A pilot study is being conducted with five EHS sites in four southeastern states. Initial results indicate that Legacy can be successfully implemented in EHS programs, resulting in regular weekly attendance by a majority of participating families. Additionally, all five sites will continue with the Legacy program for a second year of implementation. As a next step in moving from research to practice, we plan to conduct a broader demonstration of Legacy’s effectiveness in Early Head Start or another mainstream service delivery system in order to test Legacy’s impact on child health and development on a larger scale. By so doing, we hope to determine how parent-focused prevention models such as Legacy can be broadly disseminated in ways that address the needs of children at environmental risk for poor developmental outcomes while impacting the societal and personal costs of those outcomes.
Note: The findings and conclusions in this report are those of the authors, and do not necessarily reflect the official position of the Centers for Disease Control and Prevention.
Jennifer Kaminski, PhD, is a Health Scientist on the Child Development Studies Team at the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities. There she conducts and consults on prevention research activities related to typical and atypical child development, including the longitudinal follow-up of the randomized trial of Legacy for Children™. She currently serves as secretary for APA Division 37, Society for Child and Family Policy and Practice.
Ruth Perou, PhD, is the team leader of the Child Development Studies Team at the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities. Dr. Perou is the project director of and principal investigator for Legacy for ChildrenTM, CDC's national program to promote optimal child development outcomes in low income families. She is also working on implementing CDC's public health research agendas on Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome and related comorbidities. She is the co-chair of the Infant and Child Health Committee of the Maternal and Child Health Section of the American Public Health Association. She is the CDC representative on the American Academy of Pediatrics Bright Futures Implementation Committee. She is the CDC liaison to the Carter Center Mental Health Task Force.
Lara Robinson, PhD MPH, is a behavioral scientist with the Centers for Disease Control and Prevention’s (CDC) Child Development Studies Team within the National Center on Birth Defects and Developmental Disabilities. She leads the Legacy for Children™ Early Head Start Feasibility Project. From 2006 to 2008 she completed Postdoctoral Integrative Research Training in Child Mental Health at the Pennsylvania State University. Clinically, she has worked in Early Intervention and as a mental health consultant for child care centers.
Brooks-Gunn, J., & Duncan, G. J. (1997). The effects of poverty on children (PDF, 283KB). Future of Children, 7(2), 55-71.
Cunha F. & Heckman J. J. (2009). The economics and psychology of inequality and human development (PDF, 1.10MB). Journal of the European Economics Association, 7, 320-364.
Currie, J. (2005). Health disparities and gaps in school readiness (PDF, 107KB). Future of Children, 15, 117-138.
DeNavas-Walt C., Proctor B. D., & Smith J. C. (2010). U.S. Census Bureau current population reports (p60-238) income, poverty, and health insurance coverage in the United States: 2009. Washington, DC: U.S. Government Printing Office.
Duncan, G. J., Ziol-Guest, K. M., & Kalil, A. (2010). Early-childhood poverty and adult attainment, behavior, and health. Child Development, 81, 306-325. doi: 10.1111/j.1467-8624.2009.01396.x
Holzer, H., Schanzenbach, D. W., Duncan, G. J., & Ludwig, J. (2008). The economics costs of childhood poverty in the United States. Journal of Children and Poverty, 14, 41-61.
Kaminski, J. W., Perou, R. P., Visser, S. N., Danielson, M. L., & The Legacy for Children™ Study Group. (August, 2011). Legacy for Children™: A randomized controlled trial of a public health parenting program. Paper presented at the American Psychological Annual Convention, Washington, DC.
Kaminski, J. W., Perou, R. P., Visser, S. N., Scott, K., G., Beckwith, L., Howard, J., Smith, D. C., & Danielson, M. L. (2012). Behavioral and socioemotional outcomes through age 5 of the Legacy for Children™ public health approach to improving developmental outcomes among children born into poverty. Manuscript submitted for publication.
Swanson, C. B. (2004). Who graduates? Who doesn’t? A statistical portrait of public high school graduation, Class of 2001. The Urban Institute Education Policy Center.