The Legacy for Children™ Randomized Control Trial: Effects on Cognition Through Third Grade for Young Children Experiencing Poverty.

OBJECTIVE: In an effort to promote the health and developmental outcomes of children born into poverty, the Centers for Disease Control and Prevention (CDC) conceptualized and designed the Legacy for Children™ (Legacy) public health prevention model. This article examines the impact of Legacy on children's cognitive and language development (intelligence quotient [IQ], achievement, language skills, and early reading skills) using both standardized assessments and parent-reported indictors through third grade. METHODS: Data were collected from 2001 to 2014 from 541 mother-child dyads who were recruited into the 2 concurrent randomized controlled trials of Legacy in Miami and Los Angels. Cognitive and/or language outcomes of children were assessed annually from age 2 to 5 years as well as during a follow-up visit in the third grade. RESULTS: Children experiencing Legacy at the Los Angeles site had significantly higher IQ and achievement scores at 2 and 6 years postintervention, equivalent to approximately one-third of an SD (4 IQ points). IQ results persisted over time, and the difference between intervention and comparison groups on achievement scores widened. There were no significant differences in cognitive outcomes in the Miami sample. There were no significant differences in language outcomes for either site. CONCLUSION: Legacy shows evidence of effectiveness as an intervention to prevent cognitive delays among children living in poverty. The mixed findings across sites may not only reflect the impact of heterogeneous risk profiles noted by other intervention research programs but also warrant additional study.

Behavioral and socioemotional outcomes through age 5 years of the legacy for children public health approach to improving developmental outcomes among children born into poverty.

OBJECTIVES: We evaluated Legacy for Children, a public health strategy to improve child health and development among low-income families. METHODS: Mothers were recruited prenatally or at the birth of a child to participate in Legacy parenting groups for 3 to 5 years. A set of 2 randomized trials in Miami, Florida, and Los Angeles, California, between 2001 and 2009 assessed 574 mother-child pairs when the children were 6, 12, 24, 36, 48, and 60 months old. Intent-to-treat analyses from 12 to 60 months compared groups on child behavioral and socioemotional outcomes. RESULTS: Children of mothers in the intervention group were at lower risk for behavioral concerns at 24 months and socioemotional problems at 48 months in Miami, and lower risk for hyperactive behavior at 60 months in Los Angeles. Longitudinal analyses indicated that children of intervention mothers in Miami were at lower risk for behavior problems from 24 to 60 months of age. CONCLUSIONS: Randomized controlled trials documented effectiveness of the Legacy model over time while allowing for implementation adaptations by 2 different sites. Broadly disseminable, parent-focused prevention models such as Legacy have potential for public health impact. These investments in prevention might reduce the need for later intervention strategies.

Legacy for ChildrenTM: a pair of randomized controlled trials of a public health model to improve developmental outcomes among children in poverty.

BACKGROUND: One in five Americans under age 18 lives in a family below the Federal poverty threshold. These more than 15 million children are at increased risk of a wide variety of adverse long-term health and developmental outcomes. The early years of life are critical to short- and long-term health and well-being. The Legacy for ChildrenTM model was developed in response to this need and marries the perspectives of epidemiology and public health to developmental psychology theory in order to better address the needs of children at environmental risk for poor developmental outcomes. METHODS/DESIGN: The Legacy for ChildrenTM group-based parenting intervention model was evaluated as a pair of randomized controlled trials among low-income families in Miami and Los Angeles. The study was designed to allow for site-stratified analysis in order to evaluate each model implementation separately. Evaluation domains include comprehensive assessments of family, maternal, and child characteristics, process outcomes, and prospective programmatic cost. Data collection began prenatally or at birth and continues into school-age. DISCUSSION: The societal costs of poor developmental outcomes are substantial. A concerted effort from multiple sectors and disciplines, including public health, is necessary to address these societal concerns. Legacy uses a public health model to engage parents and promote overall child well-being in families in poverty through rigorous evaluation methodologies and evidence-based intervention strategies. This study collects rich and modular information on maternal and child outcomes, process, and cost that will enable a detailed understanding of how Legacy works, how it can be refined and improved, and how it can be translated and disseminated. Taken together, these results will inform public policy and help to address issues of health disparities among at-risk populations. TRIAL REGISTRATION: NCT00164697.

Tracking childhood exposure to lead and developmental disabilities: examining the relationship in a population-based sample.

Elevated levels of lead detected in the blood are associated with harmful effects on children's learning and behavior. The goal of the current Environmental Public Health Tracking Project was to examine the relationship between selected developmental disabilities and childhood blood lead levels in a population-based sample. Using extant datasets from the Florida Department of Health, Childhood Lead Poisoning Prevention Program, and the Florida Department of Education, we were able to isolate a linked dataset of children who were tested for lead poisoning and attended public schools. Special education categories served as a proxy for developmental disabilities; the prevalence of these disabilities in the sample of children with blood lead levels was compared with that in children who attended the same schools but were not tested for lead poisoning. Results indicated that children screened for lead poisoning were more likely to be receiving services for behavior problems, mental retardation, learning disabilities, or a speech-language impairment than other children attending the same schools. Implications for using administrative datasets to examine this relationship are discussed.

Public health approach to the study of mental retardation.

We applied a public health approach to the study of mental retardation by providing a basic descriptive epidemiological analysis using a large statewide linked birth and public school record database (N = 327,831). Sociodemographic factors played a key role across all levels of mental retardation. Birthweight less than 1000 g was associated with the highest individual-level risk, but the impact varied considerably, depending on maternal educational level. Low maternal education was associated with the largest effects at the population level for mild and moderate/severe mental retardation. Focusing exclusively on specific biomedical causes is of little use in developing public health plans; a broader biosocial perspective reflecting the interactive complexity of the risk factors comprising the various etiological patterns is needed.

Tracking preschool children with developmental delay: third grade outcomes.

Educational outcomes were evaluated for 2,046 preschool children identified with developmental delay. Results indicated that at third grade, 26% were in regular education and the remaining 74% were receiving special education services. The most common disability classifications at outcome were specific learning disabilities and educable mentally handicaps. Regular education, but not special education, children had higher retention rates than did the general population. The presence of one or more secondary exceptionalities in preschool was more common for special education than regular education children. Regular education and special education children did not differ on other factors studied. This study highlights the importance of developmental delay as an exceptionality category and advances our understanding of the long-term implications of such delay.

Using developmental epidemiology to choose the target population for an intervention program in a high-risk neighborhood.

Used epidemiologic techniques to evaluate the appropriate recruitment strategy for an intervention in a high-risk inner-city neighborhood. Risk factor epidemiology can play a major role in the design of community interventions by assisting in the estimation of the potential effects of different recruitment strategies. The long-term goal of this intervention program for infants and young children was to improve outcomes in elementary school. Our results indicated that that among mothers in the catchment area, the relative risks associated with levels of maternal education for high prevalence disabilities were smaller than in the whole school district. These data suggest that recruiting any mother in the catchment neighborhood would result in more individuals who could benefit from the intervention receiving services and in a larger reduction in cases of developmental problems associated with the risk factor. That is, the study sample was defined by residence in a neighborhood rather than by individual risk factors to maximize the impact on the number of cases that could be prevented.

Commentary: individual risk prediction, individual risk, and population risk.

Provides a background to efforts aimed at impacting developmental outcomes across society and discusses challenges and consequences resulting from such efforts. Child and adolescent clinical psychology studies health and behavior with a focus on individuals. This may or may not present an accurate picture of factors relating to the overall levels of health and behavior in a population. In contrast, epidemiology typically studies health and behavior with a focus on populations. Differences between the clinical and epidemiological approaches are most apparent when promoting policy aimed at preventing future disorders or reoccurrence of disorders in at-risk individuals. Awareness of these issues may help clinical psychologists in efforts to inform or shape public policy.

Identification of early risk factors for language impairment.

The current study is a population-based investigation of birth risk factors for school-identified specific language impairment (SLI). The sample consisted of 244,619 students (5,862 SLI) born in Florida between 1989 and 1990 who were in the Florida public school system at ages 6-7. Epidemiological measures of effect were used to investigate both individual- and population-level risk for SLI. Very low birth weight (VLBW), low 5-min Apgar score, late or no prenatal care, high birth order, and low maternal education were associated with highest individual-level risk. Low maternal education and having an unmarried mother was associated with the highest population-level risk. The results not only suggest who needs to be screened for a future developmental disability, but identify a group of children who are at-risk for an SLI placement in school. Early intervention services for these children may be the most effective approach to reducing the incidence of school-identified SLI.

Early risk factors for mental retardation: role of maternal age and maternal education.

The predictive value of maternal age and education in relation to rates of administratively defined mental retardation in a 3-year birth cohort (N = 267,277) was studied. Low maternal education placed individuals at increased risk for both educable mentally handicapped (EMH) and trainable mentally handicapped (TMH) placements. Older maternal age was associated with increased risk of mental retardation, but for individuals with EMH, this age effect was only seen in the lowest education group. In terms of population-level risk, it was younger mothers with 12 years of education or less whose births were associated with the greatest proportion of mental retardation. From a public policy viewpoint, children born to mothers with low levels of education are an important group to target for prevention/early intervention efforts.