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A comparative evaluation of an infant stimulation program for public health utilizatio Arlett, Christine 1977

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a COMPARATIVE EVALUATION OF AN INFANT STIMULATION PROGRAM FOB PUBLIC HEALTH UTILIZATION CHRISTINE ARLETT B.Sc, University of Leicester, 1972 M.A., University of B r i t i s h Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept th i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June, 1977 by xn Christine Arlett, 1977 In presenting th is thes is in p a r t i a l fu l f i lment of the requirements for an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make it f ree ly ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th is thes is for scho la r ly purposes may be granted by the Head of my Department or by his representat ives . It is understood that copying or pub l i ca t ion of th is thes is fo r f i n a n c i a l gain sha l l not be allowed without my wri t ten permission. Department of ffaCHO^Y The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 D a t e A w ^ f ^79?-ABSTRACT An i n f a n t s t i m u l a t i o n p r o g r a m d e v e l o p e d f o r m o t h e r s f r o m low i n c o m e a r e a s w i t h c h i l d r e n u n d e r t h e age o f t h r e e y e a r s i s d e s c r i b e d . The p r o g r a m was d e v e l o p e d f o r u s e i n a p u b l i c h e a l t h s e t t i n g and i n v o l v e d c l o s e c o l l a b o r a t i o n w i t h p e r s o n n e l f r o m a number o f community s e r v i c e a g e n c i e s . The p r o g r a m , w h i c h h a d a d u r a t i o n o f e i g h t weeks, i n v o l v e d a c o m b i n a t i o n o f g r o u p m e e t i n g s a n d home v i s i t s . Outcome was a s s e s s e d i n t e r m s o f d e v e l o p m e n t a l q u o t i e n t s and e s t i m a t e s o f t h e q u a l i t y o f t h e home e n v i r o n m e n t . T h r e e additional)^ p r o g r a m s c o n s i s t e d o f a w a i t i n g l i s t c o n t r o l and p r o g r a m s i n w h i c h e a c h o f t h e two i n t e r v e n t i o n c o m p o n e n t s , home v i s i t s and g r o u p m e e t i n g s , were o f f e r e d s e p a r a t e l y . A s s e s s m e n t s were c a r r i e d o u t p r i o r t o t h e p r o g r a m s , i m m e d i a t e l y f o l l o w i n g them and f o u r months l a t e r . P r e -a s s e s s m e n t s e s t a b l i s h e d t h e e q u i v a l e n c e o f t h e f o u r g r o u p s on b o t h t h e d e p e n d e n t m e a s u r e s and s o c i o e c o n o m i c i n d i c e s , a l t h o u g h t h e g r o u p s w ere f o u n d t o d i f f e r on t h e measure o f m a t e r n a l i n t e l l i g e n c e o b t a i n e d . F o l l o w i n g i n t e r v e n t i o n , t h e s c o r e s o b t a i n e d on b o t h d e p e n d e n t m e a s u r e s f o r t h e home v i s i t s p l u s g r o u p m e e t i n g s p r o g r a m were f o u n d t o be s i g n i f i c a n t l y g r e a t e r t h a n t h o s e o b t a i n e d b y t h e w a i t i n g l i s t c o n t r o l c l i e n t s . The e f f e c t o f t h e home v i s i t s o n l y p r o g r a m was i n d e t e r m i n a t e a s t h e s c o r e s d i d n o t d i f f e r s i g n i f i c a n t l y f r o m e i t h e r t h e c o n t r o l g r o u p o r t h e home v i s i t s p l u s g r o u p m e e t i n g s p r o g r a m . C l i e n t s i n t h e g r o u p m e e t i n g s o n l y p r o g r a m d i d n o t d i f f e r s i g n i f i c a n t l y f r o m c o n t r o l g r o u p c l i e n t s on e i t h e r m e a s u r e . S i m i l a r r e s u l t s were o b t a i n e d a t f o l l o w up a s s e s s m e n t s , w i t h no e v i d e n c e o f any d e c l i n e i n s c o r e s f o l l o w i n g t h e end o f i n t e r v e n t i o n . Whereas the correlations observed between maternal i n t e l l i g e n c e and children's developmental quotients remained much the same over the three assessment periods, the correlations between the home environments and the children's developmental quotients increased, both concurrently and pre d i c t i v e l y , following intervention. These findings were interpreted as providing support for the hypothesis that the changes i n the home environments r e s u l t i n g from the programs were indeed important ones in terms of the children's development. There was some evidence to suggest that the socioeconomic indices of age, education and income of mother were p o s i t i v e l y related to outcome, while, in addition, maternal i n t e l l i g e n c e was related to the maintenance of treatment e f f e c t at follow up. The co r r e l a t i o n of socioeconomic status with outcome was consistent with the results of other infant stimulation programs but was not considered to r e f l e c t on the effectiveness of the program as a l l of the c l i e n t s in the study were of low socioeconomic status. The implications of these r e s u l t s are discussed both i n terms of the further development and implementation of the program described and in the context of research in the area of infant stimulation. iv T a b l e o f C o n t e n t s Abs t r a c t i i L i s t o f T a b l e s v L i s t o f F i g u r e s v i a c k n o w l e d g e m e n t s v i i L i t e r a t u r e R e v i e w 1 The E a r l y D e v e l o p m e n t P r o g r a m 27 Method 33 R e s u l t s 46 D i s c u s s i o n 70 R e f e r e n c e s . . . . . . . . . . 7 9 A p p e n d i x A: E v a l u a t i o n Q u e s t i o n n a i r e 86 A p p e n d i x B: Home V i s i t s ..................................... 88 A p p e n d i x C: G r o u p M e e t i n g s 92 V L I S T OF TABLES T a b l e I Summary o f t h e e x p e r i m e n t a l d e s i g n 35 T a b l e I I C h a r a c t e r i s t i c s o f t h e c l i e n t p o p u l a t i o n 38 T a b l e I I I c o r r e l a t i o n s between d e s c r i p t i v e and d e p e n d e n t v a r i a b l e s 48 T a b l e I V P r o c e s s m e a s u r e s ..................................50 T a b l e V Means and s t a n d a r d d e v i a t i o n s o f B a y l e y DQs and HOME s c o r e s a t p r e - and p o s t ^ a s s e s s m e n t s ..........52 T a b l e V I Summary o f one-way a n o v a s on p o s t - a s s e s s m e n t d a t a ...........52 T a b l e V I I Homogeneous s u b s e t s o f p o s t - a s s e s s m e n t d a t a d e t e r m i n e d b y Tu k e y t e s t a t a 5% s i g n i f i c a n c e l e v e l 53 T a b l e V I I I A s s i g n m e n t o f t r e a t m e n t p r o g r a m s t o a 2 x 2 m a t r i x ............................................55 T a b l e I X Summary o f 2 x 2 a n o v a s on p r e - and p o s t -a s s e s s m e n t d a t a ...56 T a b l e X C o r r e l a t i o n s o f p r e - and p o s t - a s s e s s m e n t d e p e n d e n t measures w i t h d e s c r i p t i v e m e a s u r e s ......58 T a b l e X I Means and s t a n d a r d d e v i a t i o n s o f B a y l e y DQs and HOME s c o r e s a t p r e - , p o s t - and f o l l o w up a s s e s s m e n t s 61 T a b l e X I I Summary o f one-way a n o v a s on f o l l o w up d a t a 63 T a b l e X I I I Homogeneous s u b s e t s o f f o l l o w up d a t a d e t e r m i n e d by T u k e y t e s t a t a 5% s i g n i f i c a n c e l e v e l 63 T a b l e X I V Summary o f 2 x 2 a n o v a s on f o l l o w up a s s e s s m e n t d a t a 6 4 T a b l e XV c o r r e l a t i o n s o f p r e - , p o s t - and f o l l o w up a s s e s s m e n t d a t a w i t h d e s c r i p t i v e m e a s u r e s .........68 v i LIST OF FIGURES figure 1 Mean Bayley DQs as a function of time of assessment and intervention strategy ..............66 Figure 2 Mean HOME scores as a function of time of assessment and intervention strategy ..............67 ACKNOWLEDGEMENTS My thanks to a l l those at the Richmond Health Department without whose help t h i s study could not have been r e a l i z e d . In pa r t i c u l a r , my thanks to Margi Bates, Marg Fletcher and T r i c i a Hilburn for t h e i r w i l l i n g p a r t i c i p a t i o n i n the programs. My thanks also to the student nurses and th e i r i n s t r u c t o r s , Eve Norman and Maggie Smith, for their cooperation. My thanks to the members of my committee for t h e i r help with a l l the stages of t h i s d i s s e r t a t i o n . In pa r t i c u l a r , I am deeply indebted to Helen Best who i n i t i a l l y aroused my intere s t in the area of infant stimulation and whose support during the implementation of t h i s study was invaluable. F i n a l l y , thank you, Ross and Jessica, for your help and your tolerance. 1 LITEEATOEE gEVIEW Differences in the rate of development of young children have been attributed to a variety of factors. T r a d i t i o n a l l y , discussion of these factors has centred around the r e l a t i v e importance of environmental and hereditary influences. On the whole, the research, that i s available suggests that the h e r i t a b i l i t y of i n t e l l i g e n c e i s high (Jensen, 1973). However, this research has largely focused on data obtained from children over the age of seven, that i s , after the age at which IQ scores have been found to s t a b i l i z e . Infant IQ scores have not been found to be s i g n i f i c a n t l y correlated with l a t e r IQ scores, although they have been shown to be both v a l i d and r e l i a b l e i ndicators of infant functioning fBayley, 197 0). At the same time, there i s growing evidence to suggest that the environment i s an important influence on the development of infants. This evidence has originated from two sources. F i r s t l y , i t has come from observational studies in which a number of environmental variables have been examined in r e l a t i o n to children's performance on developmental tasks. Secondly, intervention programs have demonstrated that changes i n the environment can lead to changes i n developmental status. The Early Development Program, which forms the subject of the present study, i s one such program. The remainder of t h i s chapter w i l l therefore be concerned with a b r i e f discussion of some of the influences on i n t e l l e c t u a l a b i l i t y reported in the l i t e r a t u r e , followed by an examination of the diff e r e n t types of intervention programs which have been developed. F i n a l l y , some of the issues raised by t h i s l i t e r a t u r e w i l l be discussed. 2 flereditarj Influences Numerous studies have demonstrated that hereditary factors are important predictors of the nature and l e v e l of i n t e l l e c t u a l a b i l i t y in children over the age of seven (Herrnstein, 1973). The strongest evidence comes from the study of i d e n t i c a l twins who have been reared apart. In a review of the available data, Jensen (1970) found that the IQ scores of i d e n t i c a l twins reared apart correlated more highly than did those of either ordinary s i b l i n g s or f r a t e r n a l twins reared together. Such findings point to the conclusion that the h e r i t a b i l i t y of i n t e l l i g e n c e i s Mgh. However, i t must be stressed that this conclusion i s based on only four studies, a l l of which involved small numbers of subjects. Further, the results of one of these studies have recently been c a l l e d into guestion. Research studies investigating hereditary predictors of infants* developmental progress are r e l a t i v e l y scarce. Wilson (Wilson, 1974; Wilson S Harpring, 1972) has reported the correlations of Bayley Scale scores obtained in a longitudinal study of twins reared together. The correlations for monozygotic infant twins were found to approach the r e l i a i i i l i t y of the test i t s e l f and most were s i g n i f i c a n t l y higher than the correlations for dizygotic twins. = These findings are consistent with a conclusion of high h e r i t a b i l i t y of i n t e l l i g e n c e i n infancy. On the other hand, easier (1976) examined the correlations between adopted infants' developmental guotients and the IQ scores of their natural mothers. Although the correlations were s t a t i s t i c a l l y s i g n i f i c a n t , none of the values were very high and the correlations were lower than those generally reported 3 between the IQ scores of older children and t h e i r parents, easier discusses three factors which may have contributed to these generally modest correlations. The f i r s t was the homogeneity of the maternal sample with respect to education and s o c i a l background. The second factor was related to the nature of the Gesell scale such that easier guestions whether genetically determined att r i b u t e s were adeguately assessed. The third factor was the influence of environmental variables. This was supported by the finding that the correlations obtained when the infants were residing in an i n s t i t u t i o n were higher than subseguent ones when t h e i r environments d i f f e r e d . This study i s therefore consistent with the hypothesis that hereditary variables are important in determining the i n t e l l e c t u a l performance of infants but that they can only be considered i n the context of environmental variables. Socioeconomic Influences Socioeconomic background has also received considerable attention as a predictor of i n t e l l e c t u a l a b i l i t y . On the whole, the correlations reported are low for infants but become increasingly s i g n i f i c a n t as the children become older (Bayley, 1970). Thus, for example, Bayley (1965) reported no s i g n i f i c a n t differences between lower and middle class infants during the f i r s t f i f t e e n months of l i f e , whereas by three to four years s o c i a l class was found to be s i g n i f i c a n t l y and p o s i t i v e l y correlated with IQ. Similar r e s u l t s were reported by Wilson (1974). Use of assessment procedures with less weighting on motor development during the f i r s t year of l i f e , has pointed to 4 s o c i a l c l a s s d i f f e r e n c e s i n performance as e a r l y as seven months of age ( l a c h s , D z g y r i s 5 Hunt, 1971). I t would t h e r e f o r e seem t h a t the i n t e l l e c t u a l development of lower c l a s s c h i l d r e n f a l l s behind that of middle c l a s s c h i l d r e n at some point b e f o r e the age of t h r e e , perhaps as e a r l y as t h a t of seven months. There i s some problem of i n t e r p r e t a t i o n of the impact of socioeconomic v a r i a b l e s , as they may be c o n s i d e r e d to r e f l e c t both h e r e d i t a r y and environmental i n f l u e n c e s . In p r a c t i c e , attempts have been made t o r e s o l v e t h i s problem through s t u d i e s of adopted or f o s t e r i n f a n t s . Thus, f o r example, the c o r r e l a t i o n s between i n f a n t s ' DQs and t h e i r n a t u r a l mothers* socioeconomic c l a s s have been found t o be g r e a t e r than those between the i n f a n t s ' DQs and the socioeconomic c l a s s of t h e i r adoptive mothers (Beckwith, 1971). S i m i l a r r e s u l t s have been reported with r e s p e c t to e d u c a t i o n a l l e v e l o f the n a t u r a l and adoptive mothers (Honzik, 1957). These r e s u l t s seem to support a h e r e d i t a r y i n t e r p r e t a t i o n of the c o r r e l a t i o n s of socioeconomic s t a t u s with the development of i n f a n t s . However the c o r r e l a t i o n between mental development and socioeconomic s t a t u s i s i n t e r p r e t e d , e i t h e r as r e f l e c t i n g h e r e d i t a r y or environmental i n f l u e n c e s , i t seems c l e a r t h a t socioeconomic s t a t u s i s an important p r e d i c t o r o f the mental development of young c h i l d r e n . S i i y i £ P E l s n t a l I n f l u e n c e s The importance of the environment as an i n f l u e n c e on e a r l y c h i l d development was f i r s t demonstrated i n a number of s t u d i e s of i n f a n t s l i v i n g i n extremely impoverished environments, such as i n s t i t u t i o n s (e.g. ainsworth, 1962; G o l d f a r b , 1955; S p i t z , 5 1945; Yarrow, 1964). In p a r t i c u l a r , a number of studies demonstrated that changes i n the environment could act to prevent the developmental lags found in these i n f a n t s . Thus, for example, a longterm study carried out by Skeels (1966) demonstrated dramatic increases i n IQ i n retarded infants who were cared for by older retarded g i r l s on a one-to-one basis. Saltz (1969) contrasted a group of infants i n a foster grandparents program with a group cared f o r by volunteers. S i g n i f i c a n t differences i n cognitive development and adjustment were found favouring the group cared for by the foster grandparents. Saltz attributed these differences to the greater involvement of the grandparents with the infants as compared to the volunteers. A study by Casler (1965a,b) suggested that i t i s s p e c i f i c a l l y the amount of perceptual stimulation rather than the more global variable of parenting that i s of importance. In this study, infants given s p e c i f i c t a c t i l e and auditory stimulation showed l e s s of a decline in rate of development than those given s o l e l y auditory stimulation. A subsequent study using a larger sample (Casler, 1970) found no s i g n i f i c a n t differences as a r e s u l t of increased t a c t i l e stimulation with or without increased auditory stimulation, although a s i g n i f i c a n t negative c o r r e l a t i o n was found between the age at which treatment was started and the o v e r a l l developmental quotient. The lack of s i g n i f i c a n t differences may have resulted from the high l e v e l s of stimulation already offered i n the i n s t i t u t i o n involved. More recently, the impact of less extreme variati o n s i n environmental experiences has come under study. A recent review 6 of studies of non- i n s t i t u t i o n a l i z e d infants (Barnard and Douglas, 1974) c i t e s evidence to suggest that a large number of environmental variables may influence the nature and rate of infant development. These variables may be c l a s s i f i e d according to their animate versus their inanimate nature and their influence may be considered both q u a l i t a t i v e l y and quantitatively. Several studies have demonstrated that the amount and nature of the inanimate stimulation available to infants has a dire c t influence on their development. Yarrow, Rubenstein, Pedersen and Jankowski (1972) using a sample of 41 f i v e to six month old infants examined three aspects of the inanimate stimulation available to the infants i n t h e i r homes: responsiveness, complexity and variety. S i g n i f i c a n t correlations were obtained between these variables and cognitive-motivational and fine motor development variables in the infants. On a more s p e c i f i c l e v e l , both White (1967) and Greenberg (1971) have demonstrated that the amount of visual stimulation available to infants in the f i r s t three months of l i f e i s an important determinant of the rate of perceptual-motor development i n these infants. The nature and l e v e l of animate stimulation also influences the development of infants during the f i r s t three years of l i f e . Yarrow et a l (1972) examined a number of s o c i a l stimulation variables i n addition to the inanimate ones discussed above. They found that l e v e l (amount weighted by i n t e n s i t y ) , variety (the d i f f e r e n t types of behaviour e l i c i t e d and the d i f f e r e n t physical settings where interaction occurred), and contingency 7 of caretaker response to infant's d i s t r e s s were a l l s i g n i f i c a n t l y correlated with the infant's o v e r a l l developmental progress. In contrast, the demonstrativeness of the caretaker and the contingency of caretaker response to positive infant vocalizations did not correlate highly with the infant development indices. h variable which may be considered as i n d i r e c t l y influencing the nature of the s o c i a l environment of infants i s the achievement-orientation of the parents. High parental achievement-orientation has been repeatedly found to be correlated with high scores by infants on developmental tests (Freeberg and Payne, 1967). One way in which parental achievement-orientation may influence children's s o c i a l environment i s through the nature of the teaching s t y l e adopted by the parents. Mothers' teaching s t y l e s have been shown to be related to t h e i r educational l e v e l (Streissguth and Bee, 1972) in that mothers with college education used less s p e c i f i c instruction and less negative feedback than did mothers with high school education or less. Although these studies would seem to suggest that the more environmental stimulation available to infants, the better their performance on developmental tests, there i s some evidence to indicate that very large amounts of stimulation are detrimental to infa n t s ' developmental progress. Wachs, Uzgyris and Hunt (1972) have reported that infants with the poorest cognitive development came from 'over-stimulating' homes, p a r t i c u l a r l y i n terms of noise l e v e l and a c t i v i t y . They further suggest that overstimulation may be g u a l i t a t i v e as well as guantitative such 8 that stimulation which i s too discrepant from the i n f a n t s 1 l e v e l s of functioning would also be detrimental. However, there i s as yet l i t t l e evidence to support this l a t t e r hypothesis. Thus there i s evidence from a number of sources to support the hypothesis that environmental variables , i n terms of both the nature and the amount of stimulation offered to the i n f a n t , influence the developmental progress of i n f a n t s . Thus, by the l a t e s i x t i e s , s u f f i c i e n t evidence had been accumulated to support the conclusion that both hereditary and environmental variables have an influence on the mental development of i n f a n t s . In addition, early studies had demonstrated that the developmental delays r e s u l t i n g from extremely impoverished environments could be reversed through increased stimulation of the infants. As a r e s u l t , a number of research programs were developed i n a variety of settings to investigate the p o s s i b i l i t y of f a c i l i t a t i n g infant development through early intervention i n the infants* environments. In p a r t i c u l a r , these interventions have been aimed at preventing the r e l a t i v e decline in i n t e l l e c t u a l a b i l i t y observed i n children from low socioeconomic backgrounds. Generally speaking, three strategies have been developed: e n r o l l i n g the children i n daycare programs to provide them with extra stimulation, tutoring the children within the home sett i n g , and teaching the mothers to provide more stimulating environments for their children. Examples of programs employing the three types of intervention strategies with children under the age of three years w i l l now be discussed i n some d e t a i l . The purpose of such a review i s to determine whether i t i s possible to effect change 9 in the developmental status of young children through enrichment programs and i f i t i s possible, to determine which strategies are most e f f e c t i v e for which populations, and how t h e i r effectiveness r e l a t e s to the i r cost. Daycare Intervention Programs Perhaps the best known of the daycare programs i s the one developed at the Syracuse University Children's Centre by Caldwell and her coworkers (Caldwell & Richmond, 1968; Caldwell & Smith, 1970) . The contents of the program have been continually revised since i t s inception in 1964, although the educational aims have remained constant. The educational program focuses on the development of personal-social attributes; motor, perceptual and cognitive functioning; and the acquis i t i o n of c u l t u r a l l y relevant knowledge. A high adult;child r a t i o i s maintained, with any given infant being the r e s p o n s i b i l i t y of a single caretaker. Careful attention i s paid to selecting appropriate lev e l s of stimulation for each infant and avoiding unnecessary r e s t r i c t i o n s on early exploratory behaviour. The nature of the subject population has varied considerably over the years. I n i t i a l l y , children from a l l s o c i a l c l a s s l e v e l s were accepted, but subsequently only lower class children were accepted into the program. Results of the program are complex, due to the variations in content and subject population over time. In. general, however, gains have been demonstrated on measures of cognitive development as a function of p a r t i c i p a t i o n in the program. For instance, the mean developmental test scores for a l l the 10 children who entered the program before three years of age and who were in the program for at le a s t six months increased 14 points from the time of entry to the time of leaving. In contrast the scores for a control group dropped 7 points. Cross-sectional analysis at dif f e r e n t age leve l s suggested that the main e f f e c t of the program with lower class children was to prevent the decline i n scores observed in the control group. On the other hand, the gains for middle class children over the program were found to be twice as large as those for lower class children. A major factor in th i s finding seems to be the stimulation l e v e l of the home as assessed by Caldwell's Inventory of Home Stimulation (Caldwell, Heider and Kaplan, 1966). This inventory consists of 45 binary items rated on the basis of observational and interview information covering a number of environmental variables such as the mother's responsivity and the provision of appropriate play materials, within a given s o c i a l c l a s s , children from more stimulating homes gained more from the daycare program than children from less stimulating homes. These findings emphasize the importance of the home environment and have led workers at the S.O.C.C. to s h i f t the focus of the program towards a home intervention program similar to those discussed below. An example of a s p e c i f i c study carried out at the S.O.C.C. i s the Piagetian sensori-motor t r a i n i n g program reported by Honig and B r i l l (1970). 32 black infants from low income families were divided into an experimental and a control group. The experimental infants attended the S.U.C.C. over the period of 6 months to 12 months of age on a half-day basis, f i v e days a 11 week. The in s t r u c t o r s were given extensive t r a i n i n g i n Piaget's theory of sensori-motor development and the types of tasks and materials which could be used i n stimulating such development. No s i g n i f i c a n t differences were observed between the experimental and the control groups on o v e r a l l developmental test scores. The experimental group performed s i g n i f i c a n t l y better than the control group on scales designed to te s t s p e c i f i c Piagetian concepts such as object permanence and means-end re l a t i o n s h i p s . This would seem to suggest that s p e c i f i c i t y of t r a i n i n g and stimulation of infants may result i n s p e c i f i c i t y of the developmental impact of the program. It i s unfortunate that more information regarding the r e l a t i v e effectiveness of d i f f e r e n t programs carried out at the S.O.C.C. i s not r e a d i l y available. Such a s e t t i n g , where st a f f and source population remain f a i r l y constant, but program content i s variable should be able to provide a great deal of useful information f o r subsequent program development elsewhere, at present, however, the information available i s scattered and fragmented such that few conclusions can be drawn. The r e s u l t s do suggest that the o v e r a l l program i s e f f e c t i v e i n preventing the decline in developmental status found i n control subjects, and that the effectiveness of the program may be li m i t e d by i t s lack of impact on the children's home environments. An example of a broad based program providing f u l l health and daycare services i s the Frank Porter Graham Child Development Centre at the University of North Carolina {Bobinson, 1968, 1973). The children come from a mixture of socioeconomic backgrounds and range i n age from a few weeks to 12 f i v e years. S p e c i f i c intervention programs are provided for groups of children, the content of these programs appearing to vary considerably from time to time. Data i s available which demonstrates a r e l i a b l e d i f f e r e n t i a l i n Bayley Mental Scale performance of 5 to 15 points favouring a sample of 31 children enrolled i n the program i n comparison to a control group receiving only the health care benefits. Thus p a r t i c i p a t i o n i n t h i s daycare program would appear to have had a b e n e f i c i a l influence on the children's mental development. Fowler (1972) describes his Demonstration Infant Daycare and Education Program i n Toronto as oriented towards fostering the development of autonomy, problem solving, and s o c i a l and i n t e l l e c t u a l a b i l i t y i n infants ranging from 3 to 30 months of age. Both guided learning sessions and free play periods are provided in groups of three to four infants to one adult. A curriculum i s developed for each c h i l d i n d i v i d u a l l y on the basis of his/her performance on standardized tests. Data i s available concerning cumulative samples of children who participated i n the program for a minimum of three months. Consistent with Caldwell's findings, the t h i r t y middle class children showed greater gains in scores on the Bayley Mental Scales (mean increase=19.17) than the nine lower class children {mean increase= 16.11), with only the former being s t a t i s t i c a l l y s i g n i f i c a n t . A control group of eighteen middle c l a s s , home-reared children showed i n s i g n i f i c a n t gains (mean increase=6.61), which were s i g n i f i c a n t l y lower than the gains for the middle class children enrolled in the daycare. Unfortunately, the experimental group had s i g n i f i c a n t l y higher scores than the 13 control group at the st a r t of the program so that these findings cannot be considered conclusive. On a more r e s t r i c t e d basis. Palmer (1972) developed a program i n which 120 two year old male children were brought into a centre for one hour sessions twice a week for eight months. Children receiving s p e c i f i c concept training were compared with children in play or no treatment conditions on their a b i l i t y to discriminate dimensional concepts. Following completion of the program, as well as i n a one year follow up, the concept training and play groups outperformed the no-treatment group. Few differences were found between the concept tra i n i n g and play groups and although the former did better on most tasks i n the f i r s t post-test, the l a t t e r did better on follow-up. This suggests that the one-to-one rela t i o n s h i p i s a more important variable than what i s taught. The r e s u l t s of these four daycare programs therefore suggest that daily exposure to a c a r e f u l l y designed daycare environment with a high adult:cbild r a t i o w i l l produce cognitive gains in children under the age of three. S p e c i f i c i t y of program content does not seem to be important i n r e l a t i o n to o v e r a l l developmental test performance. Middle class children appear to benefit more from daycare programs than do lower class children. This finding has been interpreted as underscoring the importance of the home environment for the cognitive development of infants {Starr, 1971). The necessary r e s t r i c t i o n of daycare programs i n terms of lack of impact on the home environment has led some investigators to explore the p o s s i b i l i t y of developing programs which take place within the home setting. 14 Home Tutoring; Programs Such a home intervention program i s that developed by Gordon (1973) for lower class mothers i n r u r a l areas of F l o r i d a . The intervention strategy i n i t i a l l y involved weekly v i s i t s by indigenous paraprofessionals who used a structured curriculum with an emphasis on Piagetian sensori-motor training and language development. after one year i n the program, the experimental group performance on the Bayley and G r i f f i t h s Scales was s i g n i f i c a n t l y better than a control group's. Subsequent r e s u l t s show that t r a i n i n g during the f i r s t year of l i f e was unrelated to performance at age two unless additional training was provided during the second year. As Gordon points out, a number of l i m i t a t i o n s of t h i s program may have decreased i t s effectiveness. F i r s t l y , the curriculum was very narrow and structured with no emphasis on cu r i o s i t y and exploration i n the use of materials - the stress appearing rather to l i e on the speed of progress through the material. The a c t i v i t i e s chosen were both middle class in nature and lacking i n c u l t u r a l relevance and the tasks were considered as tests rather than as play. Secondly, the focus was e n t i r e l y on the c h i l d with no attempt being made to a l t e r h is or her environment. This may account for the lack of further progress in the children in the one year program. A t h i r d l i m i t a t i o n and a major problem for the study - was the necessary curtailment of the program due to the mothers frequently not being at home for the weekly v i s i t s . As a resu l t of these findinqs, several modifications were made i n the program. In p a r t i c u l a r , small qroup learning 15 sessions were i n s t i t u t e d for the children enrolled i n the program, who at this stage were aged from two to three years. The attendance at the children's groups was high and the mother's attendance at the home v i s i t s was higher than i t had been in the past. Painter (1969), working with Karnes at the University of I l l i n o i s , c arried out a home t u t o r i a l program f o r twenty infants aged from eight to twenty months. Tutors with professional backgrounds worked with each infant for one hour a day, f i v e days a week but the mothers were not involved i n any way. At the end of one year, the experimental group scored s i g n i f i c a n t l y higher on the C a t t e l l Infant Scale than a control group matched for sex, age and race. The Washington D. C. Infant Education Research Project developed by Schaefer and Aronson (1972) i s another home tutoring program which did not involve the mothers. College students with special t r a i n i n g acted as tutors, interacting with the children i n da i l y one hour sessions over the period of f i f t e e n to t h i r t y - s i x months, with a primary emphasis on cognitive and verbal stimulation. The lower cl a s s , black children in this program scored s i g n i f i c a n t l y higher on the Bayley, Binet, and Peabody than a control group - primarily due to the decline in scores in the l a t t e r group. Additional information suggests that the mother-child r e l a t i o n s h i p was s i g n i f i c a n t l y related to the t u t o r - c h i l d r e l a t i o n s h i p and to improvement in the c h i l d . Follow up data collected one year after termination of the program revealed a s i g n i f i c a n t drop i n the i n t e l l i g e n c e scores of the children i n the experimental 1 6 g r o u p o v e r t h i s p e r i o d . T h i s d e c l i n e i n s c o r e s p a r a l l e l s t h a t f o u n d by G o r d o n (1973) and s u g g e s t s t h a t home t u t o r i n g w i t h o u t m a t e r n a l i n v o l v e m e n t may n o t be e f f e c t i v e on a l o n g t e r m b a s i s . The C a r l e t o n U n i v e r s i t y C h i l d D e v e l o p m e n t P r o j e c t , d e v e l o p e d by Ryan ( 1 9 7 4 , 1976) h a s y i e l d e d t h e o n l y n e g a t i v e r e s u l t s i n t h i s a r e a . T h i s p r o g r a m i n v o l v e d f i f t y - o n e c h i l d r e n a g ed f r o m one t o t w e n t y - f o u r months f r o m f o r t y - t w o f a m i l i e s r e s i d i n g i n a l o w i n c o m e h o u s i n g p r o j e c t . A c o n t r o l g r o u p c o n s i s t e d o f e l e v e n c h i l d r e n a ged f r o m one t o e i g h t e e n months f r o m e l e v e n f a m i l i e s l i v i n g i n a s i m i l a r b u t s e p a r a t e h o u s i n g d i s t r i c t . The c h i l d r e n were a d m i n i s t e r e d t h e G r i f f i t h s S c a l e s o f M e n t a l D e v e l o p m e n t a t s i x month i n t e r v a l s c o r r e s p o n d i n g t o t h e i r y e a r a n d h a l f - y e a r b i r t h d a t e s . The f o r m a t p r i m a r i l y i n v o l v e d w e e k l y home v i s i t s by v o l u n t e e r s s u p p l e m e n t e d by g e n e r a l m e e t i n g s o f p a r e n t s , t u t o r s and p r o j e c t s t a f f w h i c h w e r e , h o w e v e r , v e r y p o o r l y a t t e n d e d . No d i f f e r e n c e s were f o u n d b e tween t h e c o n t r o l and e x p e r i m e n t a l g r o u p s ' p e r f o r m a n c e s on t h e G r i f f i t h s , w i t h b o t h g r o u p s s h o w i n g a d e c l i n i n g t r e n d i n DQs o v e r t i m e . Ryan a t t r i b u t e s t h i s l a c k o f s u c c e s s i n p a r t t o t h e l a c k o f i m p a c t o f t h e home t u t o r i n g p r o g r a m on t h e c h i l d r e n ' s home e n v i r o n m e n t s . The r e s u l t s o f t h e s e f o u r home t u t o r i n g p r o g r a m s t h e r e f o r e s u g g e s t t h a t i n t e n s i v e t u t o r i n g b y s p e c i a l l y t r a i n e d home v i s i t o r s may have a f a v o u r a b l e s h o r t - t e r m i m p a c t on c h i l d r e n ' s d e v e l o p m e n t a l p r o g r e s s . G a i n s o b t a i n e d t h r o u g h home t u t o r i n g , h o w e v e r , a p p e a r t o d e c l i n e f o l l o w i n g t e r m i n a t i o n o f t h e p r o g r a m . I n a d d i t i o n , t h e i n t e n s i t y and s t r u c t u r e o f home t u t o r i n g p r o g r a m s may be r e l a t e d t o t h e i r e f f e c t i v e n e s s . 17 Mother-oriented Programs A number of programs have been developed which have focused on improving the mothers' teaching s k i l l s rather than on d i r e c t tutoring of the children. For instance, the Ypsilanti-Carnegie Infant Education Project developed by i e i k a r t and Lambie (1969) involved a trained teacher working i n each home over a period of twenty months. Children were phased into the program at 3, 7 and 11 months of age. The emphasis of the program was on providing i n d i v i d u a l i z e d programming for the children, developing the mother's teaching s t y l e , helping the mother to learn how to int e r a c t with her c h i l d and, to a lesser extent, d i r e c t tutoring. A contrast program was provided by a paraprofessional who provided more direct stimulation to the c h i l d and a more general service to the family. In addition, a no intervention control group was included. After a period of four months, there were no s i g n i f i c a n t differences between these three programs on Bayley Scale scores. Karnes, Teska, Hodgins and Badger (1970) have reported on a program for twenty low income mothers of children aged thirteen to twenty-seven months aimed at t r a i n i n g the mothers to teach their children through the use of educational toys. The format involved weekly two hour group sessions over a f i f t e e n month period in which both c h i l d - and mother-centred a c t i v i t i e s were discussed, and monthly home v i s i t s . The mothers were paid to attend the weekly meetings and transportation was provided. At t h i r t y - s i x months the children i n the program showed higher IQs as measured by the Stanford-Binet and the I.T.P.A. than an untreated group. Two possible explanations for the r e l a t i v e 18 effectiveness of t h i s program i n contrast to Weikart and Lambie's are the longer duration of intervention and the use of group meetings of the mothers as the primary intervention strategy. Some researchers have developed programs which focus e n t i r e l y on language development. Thus Irwin J1960) described a program i n which twenty-four mothers were lent books and told to read to their children f o r f i f t e e n minutes each day for the time their children were aged thirteen to t h i r t y months. The children's spontaneous vocalizations were recorded during home v i s i t s and scored for phoneme frequency. A control group consisted of ten children who received no intervention. No s i g n i f i c a n t difference i n mean phoneme frequency was found between the two groups fo r the f i r s t four months of the program, but after this period the experimental group scored s i g n i f i c a n t l y and consistently higher. These findings suggest that r e l a t i v e l y simple intervention strategies can produce change on s p e c i f i c measures, although their impact may not be immediately apparent. Levenstein (Levenstein, 1970; Madden, Levenstein & Levenstein, 1976) has also developed a verbally oriented program for twenty to forty-three month old children. The intervention strategy adopted was semi-weekly home v i s i t s by 'Toy Demonstrators* who acted as models for the mothers, the goal of the program being to stimulate verbally oriented play in the mother-child dyads. I n i t i a l l y , the program employed trained s o c i a l workers and had a duration of seven months. Subseguently, the duration was extended to ten months each year for two years 19 and unpaid volunteers with college education and paid mother graduates from the previous program were employed as the Toy Demonstrators. Data were also collected for three t e s t - r e t e s t comparison groups. Scores on the C a t t e l l Infant Scales and the Stanford-Binet showed s i g n i f i c a n t increases for the children i n the experimental groups as compared to those i n the control groups. These gains were maintained into the t h i r d grade of school. The r e s u l t s pointed to a l i n e a r r e l a t i o n s h i p between amount of intervention (two years, one year or no years i n the program) and follow up IQ scores. Education of the home v i s i t o r s was not found to be related to treatment outcome. A number of studies have focused on the parent-child r e l a t i o n s h i p as a mediating factor i n f a c i l i t a t i n g infant development. Unfortunately, these studies are largely characterized by a lack of objective assessment procedures. For example, Bromwich (1976) describes a program developed f o r use in the UCLA Infant Studies Project whose focus i s not on teaching the mother to teach s k i l l s to her infant, but on enhancing the quality of the mother-infant i n t e r a c t i o n . Assessment i s in terms of progression through a sequence of six leve l s of maternal behaviours ranging from enjoyment i n interacting with her infant to independent generation of a wide range of develop mentally appropriate a c t i v i t i e s . No data has yet been reported as to the effectiveness of this program. Heinicke (1976), also at U.C.L.A., describes a study contrasting two psychoanalytic s o c i a l work approaches, open-ended and problem oriented, offered to parents i n conjunction with a preschool program. Shen compared with children in a 20 separate preschool whose parents did not receive s o c i a l work intervention, children whose parents did receive treatment, p a r t i c u l a r l y of the open-ended type, showed improved scores on the Stanford Binet and personal adjustment ratings. Scheinfeld, Bowles, Tuck and Gold (1970) also set t h e i r goal as an al t e r a t i o n of the nature of the parent-child rel a t i o n s h i p . In p a r t i c u l a r , the desired changes were a s h i f t in the parents' perception of themselves from that of c o n t r o l l i n g agents to that of teachers. This was to be effected in part through the suggestion of concrete a c t i v i t i e s by a home v i s i t o r , a favourable outcome was obtained i n terms of the v i s i t o r s ' assessments of change and open-ended interviews recorded before and after the program, but measures of the developmental progress of the infants were not obtained. This means that the hypothesis that the p o s i t i v e changes i n the parent-child relationship would f a c i l i t a t e the c h i l d ' s development remains untested. The rationale underlying the development of programs focussing on changes i n the mothers' behaviour was that gains re s u l t i n g from such programs would show greater maintenance than gains r e s u l t i n g from programs focussing on d i r e c t tutoring of the children. There i s no evidence i n the above studies to support or to refute t h i s hypothesis. However, mother-oriented programs do seem to produce results comparable to those obtained in home tutoring programs. One advantage of mother-oriented programs i s that they seem to meet with greater cooperation on the part of the c l i e n t s . This i s based on the observation that the reports of home tutoring programs frequently refer to 21 motivational problems such as non-attendance at home v i s i t s , whereas such problems do not seem to be as prevalent i n the reports of mother-oriented programs. General Issues These studies of early intervention programs, taken as a whole, c l e a r l y support the position that such programs can have an impact on the i n t e l l e c t u a l development and emotional adjustment of young children, k few general issues do, however, need to be discussed i n more d e t a i l . The f i r s t of these i s whether there i s any p o s s i b i l i t y that the intervention w i l l be d i r e c t l y or i n d i r e c t l y hazardous to the c h i l d . G o l l i n (1968) has pointed to a number of conditions that have been shown experimentally to impede the performance of young children on cognitive tasks. The f i r s t of these i s the establishment of a f a i l u r e set. Thus, for example, H i l l (1965) reported that performances of 4 year old children on a simple object discrimination task were ea s i l y shaken by previous adverse conditions. He also reported that the e f f e c t s of adverse experience upon subsequent learning varied with age, producing greater disruption in younger subjects. The second condition discussed by G o l l i n as impeding learning in young children i s overtraining. The e f f e c t s of overtraining have been primarily studied i n reversal s h i f t discrimination tasks. The evidence suggests that whereas overtraining f a c i l i t a t e s reversal i n children aged four years and up, i t i s disruptive for the younger children. The t h i r d condition which may impede learning in young children i s the presence of i n t e r f e r i n g , i r r e l e v a n t 22 s t i m u l i i n the learning task. G o l l i n c i t e s evidence to suggest that such stimuli are more disruptive for younger children than for older ones. This suggests that careful attention must be paid to gearing the learning a c t i v i t i e s to each i n d i v i d u a l child's capacities and i n t e r e s t s . In practice, such eventualities do not seem to have been a problem i n that most programs have demonstrated superior performance by the target children. One study, however, has reported a decline i n IQ following intervention (Ryan, 1974), corresponding to the decline observed i n control group children. The author attributes the negative r e s u l t s to lack of control over more fundamental s o c i a l and economic influences in the children's environments and lack of appropriate evaluation procedures. However, th i s study does not appear to d i f f e r widely from others reporting positive r e s u l t s with respect to these two variables, such that the source of the d i s p a r i t y in outcomes remains unclear. This underscores the need for comparative research where either the same program i s applied to d i f f e r i n g populations, or programs d i f f e r i n g with respect to well-defined variables are applied to comparable populations. The majority of the programs reviewed above have not involved either of the above strategies, nor have they reported s u f f i c i e n t detailed information to allow for meaningful comparisons between programs. A second issue concerns the long term s t a b i l i t y of the changes r e s u l t i n g from increased stimulation early in l i f e . The data which i s available i s scarce and c o n f l i c t i n g . Skeels (1966) followed thirteen infants who were moved from a minimally 23 stimulating orphanage to a home for retarded children where they were given much stimulation and from which they were a l l eventually placed in homes. As young adults, a l l were s e l f -supporting, eleven were married of whom nine had children and the median number of educational grades completed was twelve. In contrast, of a control group who had remained i n the orphanage, f i v e were i n s t i t u t i o n a l i z e d , only two married, of whom one was divorced, and the median number of grades completed was three. I t i s apparent, however, that as the difference i n the quality of the environments of these two groups was maintained throughout their childhood, the eff e c t s cannot be attributed e n t i r e l y to the early intervention phase. Rheingold (1956) studied the effects of 'extensive mothering' over the period of six to eight months of age on i n s t i t u t i o n a l i z e d c h i l d r e n . At termination, the main difference between the experimental and the control groups was i n terms of s o c i a l responsiveness, with no s i g n i f i c a n t differences i n developmental rate. One year l a t e r , the only differences observed between the two groups were that the experimental group was more vocal during the testing s i t u a t i o n . Of the early intervention programs discussed above, three (Madden et a l , 1976; Palmer, 1972; Schaefer & Aronson, 1972) have reported a trend towards declining I . Q . scores after the termination of the program, although the differences between the experimental and the control group scores at follow up remained s i g n i f i c a n t . Gordon (1969), on the other hand, found that improvements were not maintained one year following the end of the program. Discrepancies i n degree of maintenance are 24 presumably a function of the nature of the program and the quality of the environment which the c h i l d experiences following the termination of the program. On the whole, programs have not paid much attention to the problem of incorporating strategies aimed at improving maintenance. One would predict, for instance, that programs attempting to a l t e r parent's behaviour might show more maintenance than those concentrating on tutoring the children d i r e c t l y . However, as discussed above, there i s no firm evidence to support t h i s prediction. k f i n a l issue which needs to be raised i s whether or not differences in program design r e l a t e to effectiveness. Unfortunately very few studies have incorporated comparative research strategies, nor i s s u f f i c i e n t demographic data available concerning the populations served to allow f o r meaningful comparisons. For instance, no attempt has been made to compare a tutoring program outside the home with one taking place within the home, so t h e i r r e l a t i v e effectiveness cannot be determined. Three questions i n particular r e l a t i n g to proqram design require further discussion. The f i r s t question, concerning the effectiveness of maternal mediation as opposed to direct tutoring, has frequently been raised in the l i t e r a t u r e . Karnes et a l (1970) have reported succesful outcomes r e s u l t i n g from parent t r a i n i n g , stressing the personal gains to the mother of increased feelings of competency and control. Gordon (1969), on the other hand, reports an i n a b i l i t y to motivate the mothers i n his study such that the exercises were not continued in the absence of the tutor. This difference may be accounted for by the wide differences between 25 these two programs i n approach and content, as well as i n the professional status of the s t a f f . There i s no data available at th i s point which can be used to determine whether maternal mediation i s more or less e f f e c t i v e or economical than dir e c t tutoring. The second question relates to the r e l a t i v e effectiveness of professionals as opposed to paraprofessionals as intervention agents. Successful outcomes have been reported using both trained and untrained paraprofessionals as well as using professionals. Weikart and Lambie (1969) attempted to contrast professional and paraprofessional intervention but confounded the type of intervention with the intervention agent such that no conclusions could be reached concerning the agent e f f e c t alone. However, Levenstein (Madden et a l , 1976) has recently reported that unpaid volunteers with college education and paid former mother-participants (none of whom had more than high school education) were as e f f e c t i v e i n carrying out a home v i s i t i n g program as were s o c i a l workers with master's degrees. F i n a l l y , the t h i r d question concerns whether provision of a curriculum r e s u l t s i n better outcome. Gordon (1969) reports no s i g n i f i c a n t differences between groups taught with a s t r i c t curriculum and those taught without one. On the whole, the evidence suggests that intervention programs with a highly focussed content w i l l show l i t t l e generalization of impact, such that they do not result i n improvements in o v e r a l l developmental performance (e.g. Honig S B r i l l , 1970; Palmer, 1972). In conclusion, i t would seem that i t i s possible to f a c i l i t a t e the development of children under three through 26 environmental enrichment programs. The fact that successful programs have been developed i n a variety of settings i n North America suggests that these findings are not s p e c i f i c to one target population. On the other hand, t h i s same fact makes i t d i f f i c u l t to a r r i v e at any conclusive picture of optimal intervention strategies from a detailed comparison of the diffe r e n t programs. 27 THE EARLY DEVELOPMENT PROGRAM I n t h i s c h a p t e r t h e r a t i o n a l e and n a t u r e o f t h e E a r l y D e v e l o p m e n t P r o g r a m w i l l be d i s c u s s e d . The p r o g r a m s d i s c u s s e d i n t h e p r e c e e d i n g c h a p t e r c l e a r l y f a l l b e y o n d t h e s c o p e o f most community a g e n c i e s i n t h a t t h e y r e q u i r e i n t e n s i v e i n v o l v e m e n t o f h i g h l y q u a l i f i e d p r o f e s s i o n a l s , a h i g h s t a f f : c h i l d r a t i o , and a l o n g d u r a t i o n o f i n t e r v e n t i o n w i t h e a c h s p e c i f i c c h i l d . S i g n i f i c a n t l y , none o f t h e s e p r o g r a m s h a s i n v o l v e d e x i s t i n g a g e n c y p e r s o n n e l a s s t a f f , t h e m a j o r i t y r e l y i n g i n s t e a d on s p e c i a l l y t r a i n e d p a r a p r o f e s s i o n a l s f u n d e d by r e s e a r c h g r a n t s . I n c o n t r a s t , one o f t h e o b j e c t i v e s d u r i n g t h e d e v e l o p m e n t o f t h e E a r l y D e v e l o p m e n t P r o g r a m was t h a t t h e f o r m a t s h o u l d be s u c h t h a t t h e p r o g r a m c o u l d f e a s i b l y be i n c o r p o r a t e d i n t o an e x i s t i n g c o m m u n i t y s e r v i c e a g e n c y . P u b l i c h e a l t h s e r v i c e s a r e g e a r e d t o w a r d s p r e v e n t i v e h e a l t h p r o g r a m s a n d t h e p u b l i c h e a l t h n u r s e r o l e c l e a r l y e n c o m p a s s e s t h e a r e a o f p a r e n t s k i l l t r a i n i n g . F u r t h e r , p u b l i c h e a l t h n u r s e s by means o f new b aby v i s i t s a nd w e l l baby c l i n i c s , r e g u l a r l y come i n t o c o n t a c t w i t h h i g h r i s k p o p u l a t i o n s . An e a r l y i n t e r v e n t i o n p r o g r a m was t h e r e f o r e c o n s i d e r e d t o f a l l i n t o t h e e x i s t i n g p u b l i c h e a l t h f r a m e w o r k and t h e p r e s e n t p r o g r a m was d e v e l o p e d o v e r t h e c o u r s e o f two p i l o t s t u d i e s f o r i m p l e m e n t a t i o n i n a p u b l i c h e a l t h s e t t i n g . The g o a l o f t h e p r o g r a m was t o i m p r o v e t h e c h i l d r e n ' s e n v i r o n m e n t s so a s t o f a c i l i t a t e t h e c h i l d r e n ' s m e n t a l d e v e l o p m e n t . T h i s i m p r o v e m e n t i n t h e c h i l d r e n ' s e n v i r o n m e n t s was t o be a c c o m p l i s h e d t h r o u g h c h a n g e s i n t h e m o t h e r s ' b e h a v i o u r t o w a r d s t h e i r c h i l d r e n 1 . I n p a r t i c u l a r , i n t e r v e n t i o n was a i m e d 28 at: i) increasing the mothers* knowledge concerning early c h i l d development; i i ) teaching the mothers how to use this knowledge in their daily interactions with th e i r i n fants; i i i ) motivating the mothers to spend more time in educational a c t i v i t i e s with their children; iv) helping the mothers to improve the guality of the i r relationship with th e i r children so as to increase t h e i r effectiveness as the children's teachers. The underlying philosophy of the program was that i n order to provide an optimal learning environment for her c h i l d , a mother must f i r s t be sensitive to the child ' s educational needs and second be motivated to organize the c h i l d ' s environment so that i t w i l l meet these needs. S e n s i t i v i t y to the child * s needs was considered to be an observational s k i l l that could be taught and which would be enhanced by knowledge of c h i l d development. The program was therefore developed to provide mothers with both training in observational s k i l l s and information about di f f e r e n t aspects of early c h i l d development. The motivation required to organize the environment around the child ' s needs was considered in large part to r e f l e c t the importance attributed by the mother to her role i n promoting her c h i l d ' s development. One aspect of the program was therefore to present the mothers with evidence that t h e i r role was important, both through the information 1. The word 'mother' i s used throughout as referr i n g to the child' s primary caretaker. 29 given to them and through th e i r i nteractions with the program s t a f f . The motivation required to respond to the c h i l d ' s needs was also considered to r e f l e c t the degree to which the mother was able to cope with her own needs. The program therefore also offered an opportunity to discuss these needs and their importance with respect to the children's needs. Socioeconomic c r i t e r i a of low family income and low l e v e l s of maternal education were used i n the selection of c l i e n t s for the program 2. These c r i t e r i a were arrived at on the basis of the l i t e r a t u r e which suggests that children from low socioeconomic backgrounds do progressively less well on developmental tests over the f i r s t three years of l i f e as compared with middle class children. The age range of children accepted into the program was 3 months to 2 years. The program's effectiveness has been assessed in terms of the following measures. a) An estimate of the quality of the c h i l d ' s environment. The measure selected to provide t h i s estimate was the Inventory of Home Stimulation (Caldwell, Heider S Kaplan, 1966), henceforth referred to as HOflE. This inventory consists of 45 binary items rated on the basis of observational and interview information. The items cover the following areas: emotional and verbal responsivity of the mother; avoidance of r e s t r i c t i o n and punishment; organization of environment; provision of %. It must be pointed out that one p i l o t study involved a middle class population. Consistent with other research studies, these middle class children were also found to benefit from the program. 30 appropriate play materials; maternal involvement with the c h i l d , and oppportunities for variety i n daily routine. The HOME was selected for use in th i s study because of the strong evidence li n k i n g HOME scores in infancy with l a t e r performance on developmental t e s t s (Elardo, Bradley & Caldwell, 1975). b) An estimate of the c h i l d ' s developmental status. The Bayley Scales of Mental Development (Bayley, 1969) was selected to provide an index of the children's mental development. This scale consists of a variety of tasks arranged in chronological order. A basal age i s determined for each c h i l d and a mental age derived by adding points for each additional item passed. This mental age i s then converted into a developmental quotient on the basis of Bayley's (1969) standardization sample of 1,262 children. The Bayley Scales i s , at present, the most widely used of the infant development tests available (Barnard & Douqlas, 1974). It was selected f or use in thi s study because of i t s a b i l i t y to cover the age range required and i t s recent and careful standardization.. c) Process measures of attendance at group meetings and home v i s i t s . Poor attendance has been found to be a problem in other programs (e.g. Gordon, 1973; Ryan, 1974). Program effectiveness and the motivation of c l i e n t s to participate in the program may th e o r e t i c a l l y be considered independently. However, i n prac t i c e , attendance needs to be considered as one index of program success. 31 d) E v a l u a t i o n s o f t h e p r o g r a m by t h e m o t h e r s . The m o t h e r s were a s k e d t o c o m p l e t e an e v a l u a t i o n q u e s t i o n n a i r e a t t h e end o f t h e p r o g r a m (see A p p e n d i x A ) . T h i s q u e s t i o n n a i r e was c o n c e r n e d w i t h t h e m o t h e r s ' p e r c e p t i o n s o f t h e n a t u r e o f t h e program and o f t h e e x t e n t t o w h i c h t h e p r o g r a m met t h e i r o b j e c t i v e s . The f e e d b a c k f r o m t h i s q u e s t i o n n a i r e was u s e d p r i m a r i l y i n p l a n n i n g s u b s e q u e n t p r o g r a m s . The f o r m a t s e l e c t e d f o r t h e p r o g r a m i n v o l v e d a c o m b i n a t i o n o f g r o u p m e e t i n g s and i n d i v i d u a l home v i s i t s o v e r a p e r i o d o f e i g h t w e eks. The g r o u p m e e t i n g s w ere h e l d w e e k l y w i t h i n t h e n e i g h b o r h o o d i n w h i c h t h e c l i e n t s l i v e d and b a b y s i t t i n g was p r o v i d e d n e a r b y . The f i r s t p o r t i o n o f e a c h g r o u p m e e t i n g i s used t o d i s c u s s , w i t h r e f e r e n c e t o t h e s p e c i f i c c h i l d r e n i n t h e p r o g r a m , v a r i o u s a s p e c t s o f c h i l d d e v e l o p m e n t s o a s t o i n c r e a s e t h e m o t h e r s ' a w a r e n e s s o f and i n t e r e s t i n t h e i r own c h i l d ' s d e v e l o p m e n t . D u r i n g t h e s e c o n d h a l f o f t h e m e e t i n g s , m o t h e r s were e n c o u r a g e d t o b r i n g up any c o n c e r n s t h a t t h e y had r e g a r d i n g t h e i r c h i l d r e n f o r g e n e r a l d i s c u s s i o n . T h i s p o r t i o n was a i m e d a t i m p r o v i n g t h e m o t h e r - c h i l d r e l a t i o n s h i p s i n t h a t t h e q u a l i t y o f t h i s r e l a t i o n s h i p h a s a d i r e c t b e a r i n g on t h e s u c c e s s o f t h e t u t o r i n g p r o g r a m ( H e i n i c k e , 1976; S c h a e f e r & A r o n s o n , 1972) The home v i s i t s were c a r r i e d o u t w e e k l y and l a s t e d f o r a b o u t f o r t y - f i v e m i n u t e s . The i n d i v i d u a l home c o n t a c t s s e r v e d b o t h t o p r o v i d e t r a i n i n g i n o b s e r v a t i o n a l s k i l l s t h r o u g h d i r e c t i n s t r u c t i o n , m o d e l l i n g , a n d homework a s s i g n m e n t s and t o t r a n s l a t e t h e m a t e r i a l d i s c u s s e d i n t h e p r e c e d i n g w o r k s h o p i n t o a c t i v i t i e s w h i c h e a c h m o t h e r c o u l d do w i t h h e r c h i l d . I n t h e e a r l y v i s i t s , a c t i v i t i e s were s u g g e s t e d by t h e home v i s i t o r b u t 32 the mother was encouraged to participate increasingly i n the planning as the program porgressed. Mothers were asked to carry out the a c t i v i t i e s daily and to write a b r i e f description of what had happened. These records were read through and discussed during each subsequent v i s i t . Mothers were shown how to make some of the toys required for the a c t i v i t i e s , while other toys were lent out to them. 33 METHOD Objectives of the present study The present study was designed to provide a controlled evaluation of The Early Development Program described i n Chapter 2. In addition, the study was designed to evaluate the r e l a t i v e influence of the two intervention components, namely the home v i s i t s and the group meetings. It was predicted that a program involving both group meetings and home v i s i t s would be more e f f e c t i v e than programs involving these components in i s o l a t i o n . This prediction was based on the reasoning that these two components would work together to produce changes i n the mothers' behaviour. Thus home v i s i t s would provide mothers with the "how-to" for change through modelling, direct i n s t r u c t i o n and homework assignments. The group meetings, on the other hand, would provide the mothers with the background information on early c h i l d development which would serve as a framework fo r the a c t i v i t i e s generated by the home v i s i t s . In addition, the group meetings would provide the mothers with an opportunity to discuss the issues involved in providing an optimal learning environment for t h e i r children with other mothers i n the same si t u a t i o n . Furthermore, the combination of group meetings and home v i s i t s should r e s u l t in increased attendance rates as a re s u l t of the increased involvement of the mothers in the program. An estimate of maternal i n t e l l i g e n c e and indices of socioeconomic status were also obtained. The l i t e r a t u r e reviewed i n Chapter 1 points to these variables as important predictors 34 of the development of young children. I t was therefore considered important that they be assessed across the treatment groups. In addition, t h i s data allowed an examination of the re l a t i v e c o rrelations of an index of the guality of the home environment, an estimate of maternal i n t e l l i g e n c e , and the socioeconomic variables of maternal education and family income with infants* developmental quotients. Information on a l l these variables has rarely been available f or the same sample of infants. Design Three contrasting intervention programs were offered simultaneously i n three d i s t i n c t areas, while c l i e n t s in a fourth area served as a waiting l i s t control group. The three programs were: (i) a program where the mothers only received home v i s i t s ; ( i i ) a program where the mothers only attended group meetings; and ( i i i ) a combined treatment program where the mothers both received home v i s i t s and attended group meetings. The home v i s i t i n g component was the same for programs (i) and < i i i ) , as was the group meetings component for programs <ii) and | i i i ) . A summary of the design, including the numbers of c l i e n t s in each intervention program, i s given i n Table I. Clients 35 TABLE I Summary of the experimental design j r i INTERVENTION J STRATEGY J U i ) j Home v i s i t s J only j. I ( i i ) J Group meetings j only r PKE-ASSESSMENT1 Bayley,HOME Raven 2 weeks September N= 13 INTERVENTION PERIOD 8 weeks Weekly home v i s i t s POST-ASSESSMENT Bayley HOME 2 weeks December N=11 F O L L Q B OP ASSESSMENT Bayley HOME 2 weeks A p r i l | N=10 N=11 Weekly group meetings N= 9 I ( i i i ) j Home v i s i t s j plus |group meetings f  N=12 Weekly home v i s i t s plus weekly group meetings N=12 I (iv) | Waiting l i s t | control i N=12 No contact M=11 N= 8 f N=12 j 1. Clie n t s who dropped out prior to the post-assessment period were not included in the analyses of the pre-assessraent data. 36 Four areas of Richmond with high concentrations of low income families were selected as target areas for the study. Each area was randomly assigned to one of the treatment conditions. The community health nurses and s o c i a l welfare workers involved i n and around these areas were informed of the nature of the intervention planned and were asked f o r r e f e r r a l s to the programs. The nurses and s o c i a l workers were given two basic c r i t e r i a for r e f e r r a l to the program, notably low income and/or education of the mothers, and at least one c h i l d f a l l i n g i n the desired age range of three months to two years at the start of the program. In addition, they were provided with the following l i s t of possible reasons f o r r e f e r r a l to serve as a guideline in their selection of c l i e n t s for the program: a) concern over the guality of the c h i l d ' s learning environment; b) concern over the mother-child relationship; c) mother considered to be in need of information concerning c h i l d development and/or child-rearing techniques; d) mother and/or c h i l d isolated from the surrounding community. Referral was made only i f the mother expressed some int e r e s t i n the program when contacted by the community health nurse or s o c i a l worker. After, receiving a r e f e r r a l , the experimenter contacted the prospective c l i e n t , described the program in more d e t a i l and asked her for a firm commitment to p a r t i c i p a t e i n both the eight-week program and the pre-, post- and follow-up 37 assessments- If more than one c h i l d in the family f e l l i n t o the required age group, the younger one was selected as the target for intervention. Assignment of families to treatment condition was based e n t i r e l y on the area i n which they l i v e d . At the s t a r t of the programs, the number of c l i e n t s in each group was: home v i s i t s only, 13; group meetings only, 11; home v i s i t s plus group meetings, 12; waiting l i s t c ontrol, 12. Five c l i e n t s f a i l e d to complete the program, i . e . were not available for post-assessment. Two of these were from the groups only program, two from the home v i s i t s only program and one was i n the c o ntrol group. Data from these c l i e n t s were not included i n the pre-assessment analyses. In addition, one further c l i e n t from the groups only program and one from the home v i s i t s only program were not available for follow up as they had moved out of B.C. The following descriptive information was obtained from each family: age and sex of a l l children, ages of parents, education of parents, occupations of parents, and annual family income. In addition, the mothers were asked to complete sets C, D and E of the Standard Progressive Matrices (Raven, 1958), henceforth referred to as Raven, to provide an estimate of maternal i n t e l l i g e n c e . The means and standard deveiations obtained on these measures for the o v e r a l l sample and each intervention group separately are given in Table I I . Dependent Variables (i) Outcome measures 38 TABLE II Chara c t e r i s t i c s of the c l i e n t population Variable Overall sample N=4 3 Home v i s i t s only N=11 Group meetings only N= 9 Home JWaiting v i s i t s J l i s t plus | control group | meetings j N=12 | N=11 + 14.00 | 16.45 -I I r a t i o Age of children at pre-assessment (months) Bayley DQs at pre-assessment 14. 81 15. 91 12. 56 4- 0.51 SD 7. 84 8. 12 8.22 101.40 101.27 95.00 7.37 J 8.31 -4-104.83 1103.00 1.08 SD 12. 93 13.52 15.54 10.46 | 12.30 4 4 34.75 | 34.36 HOME scores at pre-assessment 34. 47 35.64 32.78 SD 4. 36 -4~ 4.01 5.87 4 3.60 | 4.20 0.72 Age of mother (years) 25. 72 24.82 24. 44 27.92 J 25.27 SD 4 . 3 3 3. 92 4~ 1.54 6.02 3.37 | 3.69 Education of mother (years) Annual family income ($100) M — 4 ~ SD -i—4-M 11. 21 11.27 11.00 0. 97 4~ 0. 90 11.67 j 10.81 1.74 1.00 0.89 | 0.98 11,100 11,500 10,700 11,500 |10,600 SD 3772 3643 3937 j. 3896 j 4081 I 0.16 4-Mother 1s Raven score (max=36) 24.37 19. 89 20. 11 28.92 | 26.55 I SD| 6.78 6.75 7.77 - 4 6 . 6 6 * ] 3.70 | 4.41 1 4 J *£<0.01 39 The rationale for the se l e c t i o n of the following variables as appropriate evaluation measures for the program was discussed i n Chapter 2 and w i l l only be summarized here. a) Developmental quotients The Bayley Scales of Mental Development was selected as a measure of the children's developmental quotients because of i t s a b i l i t y to cover v i r t u a l l y the entire ranqe of ages involved, i t s recent, extensive standardization and i t s high r e l i a b i l i t y {Bayley, 1969). The s p l i t - h a l f r e l i a b i l i t y c o e f f i c i e n t s obtained for the 14 age groupings of the standardization sample ranged from 0.81 to 0.93, with a median value of 0.88. Additional information i s avail a b l e concerning tester-observer agreement. A percentage of agreement was computed for each item administered to 90 infants 8 months of age. The mean of the percentages of agreement was 89.4 and the standard deviation was 0.71 (Bayley, 1969). In the few cases where the children did reach c e i l i n g on the Bayley the Stanford-Binet was administered in i t s stead. b) Quality of the home environment The HOME was selected as an index of the quality of the ch i l d ' s environment on the basis of i t s standardized format, the a v a i l a b i l i t y normative data, and the high i n t e r - r a t e r r e l i a b i l i t y c o e f f i c i e n t s reported (Elardo et a l , 1975). c) Mothers* evaluations An evaluation questionnaire (see Appendix A) was administered to each mother followinq the end of the proqram. 40 This questionnaire was designed to provide information concerning the mothers' perceptions of the nature of the program, their goals in enr o l l i n g i n the program, and the extent to which the program met these goals. The mothers were also asked to rate the components of the intervention strategy offered to them {presentation and discussion i n the group meetings; a c t i v i t i e s suggested and personal contact i n the home v i s i t s ) on 7 point scales for both enjoyment and usefulness. F i n a l l y , the mothers were asked to indicate which format {home v i s i t s only, group meetings only or home v i s i t s plus group meetings) they thought that they would have preferred. Three indices of s a t i s f a c t i o n with the program were derived: (i) the average rating for each mother of the extent to which her goals were met by the program; ( i i ) the ratings of enjoyment and usefulness of the separate components of the home v i s i t s and the group meetings; and ( i i i ) the percentage of mothers in each group who selected the program they were offered as the preferred format. i i i ) Process measures The following process measures were obtained: a) Group attendance This was the t o t a l number of groups attended by each mother. 41 b) Home v i s i t attendance This was the t o t a l number of v i s i t s completed for each mother. c) Home v i s i t o r ' s rating of the mother's involvement i n the program This was based on the following six seven-point rating scales, completed by the home v i s i t o r at the end of the program: interested i n a c t i v i t i e s - uninterested in a c t i v i t i e s ; c a r r i e s out a c t i v i t i e s - does not carry out a c t i v i t i e s ; open to suggestions - r e s i s t s new ideas; friendly - h o s t i l e ; relaxed -tense; open - defensive. Procedure (i) assessments The assessments were carried out by five assessors who were blind as to the assignment of c l i e n t s to groups and to the study's hypotheses. Two assessors were involved i n the pre-assessments and three were involved in the post-assessments with no assessor being involved in both assessment periods. Within each assessment period, each assessor was assigned an equal number of assessments in each treatment condition. Each assessment was carried out i n one continuous session i n the c l i e n t ' s home. The order of administration was f i r s t the HOME, then the Bayley Scales. The Raven was administered at the end of the pre-assessment session. The assessments were carr i e d out i n the two weeks prior to the s t a r t of the proqrams, the two weeks 42 following the programs and in a two week period four months after the end of the programs. The use of d i f f e r e n t assessors at pre- and post- assessment was considered to reduce the p o s s i b i l i t y of bias towards the study's hypotheses. On the other hand, i t accentuated the importance of the establishment of acceptable i n t e r - r a t e r r e l i a b i l i t i e s on the outcome measures. The following procedure was used to ensure high i n t e r - r a t e r r e l i a b i l i t y . The assessors observed the author carry out at least one complete assessment, for which the procedures and scoring were discussed i n d e t a i l . Following t r a i n i n g , the assessors were i n turn observed by the author. At t h i s time, a tester-observer r e l i a b i l i t y c o e f f i c i e n t was obtained by computing the percentage of items for which the tester and the observer were i n agreement. The minimum acceptable c o e f f i c i e n t was set at 0.90, and t h i s was achieved i n a l l cases 1. The t r a i n i n g provided varied with the previous experience of the assessors. As concerns the Bayley Scales, three of the assessors had had extensive experience such that further training was not undertaken. The remaining two assessors together carried out a number of practice assessments. Each of 1. An exception to t h i s procedure was necessitated by the sudden withdrawal, for personal reasons, of one of the assessors i n the midst of the pre-assessments. Therefore, another assessor had to be found at short notice to complete some of the remaining assessments. Fortunately, someone with extensive professional experience i n infant testing was available, but the urgency forced t r a i n i n g to be r e s t r i c t e d to a discussion of the procedures and scoring c r i t e r i a and no tester-observer r e l i a b i l i t y was computed. This was not f e l t to constitute a major problem for the study in view of the small number of assessments involved, t h e i r equal d i s t r i b u t i o n across groups, the ease with which high r e l i a b i l i t i e s had been obtained f o r the other assessors and the person's professional background. i* 3 these assessors tested at least one baby in each 6 month age range of the Bayley Scales while being observed by the other. This follows the tr a i n i n g procedure outlined by Bayley (1969), although i t f a l l s somewhat short of the i d e a l number of tr a i n i n g assessments l i s t e d for the younger age le v e l s . A l l of the assessors were required to complete, i n pairs, a minimum of three HOMEs, with each assessment being followed by a discussion of the interview s t y l e and scoring c r i t e r i a . The pre-assessments were not scored u n t i l the end of the program, but the information they provided was used informally in planning the home v i s i t s . A l l the mothers were contacted by phone i n the period between the post- and follow up assessments and given feedback on their children's performance on the pre-and post- tests, along with some suggestions regarding appropriate a c t i v i t i e s at that point. A sim i l a r phone c a l l was made to a l l the mothers following the follow up assessments. {ii) Home V i s i t s The home v i s i t s were made by t h i r d year student nurses as part of a course on 'normal' families. Each student nurse was randomly assigned one family from each of the two treatment conditions receiving home v i s i t s . The home v i s i t o r s met with the experimenter in small groups of three to f i v e f o r one hour each week of the program. During these meetings the preceeding week's home v i s i t s were discussed and the student nurses were given a summary of the mothers' group meetings for that week. Following this the content of the coming week's v i s i t s were planned. Each home v i s i t lasted for a minimum of half an hour and a maximum of one hour. Each family was v i s i t e d once a week, at a time when the target c h i l d was expected to be awake. I f f o r any reason a v i s i t had to be cancelled, the student nurse attempted to reschedule i t . The student nurses were asked to make notes on their v i s i t s to be used i n the planning of subsequent v i s i t s . In addition, they kept a separate record of instances where the mother did not cooperate with their v i s i t as evidenced both by non-attendance and by the mother's behaviour during the v i s i t such as her leaving the T.V. on and entertaining v i s i t o r s . At the end of the program, the student nurses were asked to complete a rating scale designed to provide an overall rating of the cooperativeness of the mothers. Details of the contents of the home v i s i t s are given i n Appendix B. ( i i i ) Group Meetings The group meetings were held i n the recreation centres of the two areas involved. In the groups only condition t h i s proved to be a very pleasant room - carpeted, bright and a t t r a c t i v e l y furnished. In contrast, the room in which the groups in the combined condition were held was large, dark and e s s e n t i a l l y unfurnished. In both cases the babies were looked after in a nearby room by the same two babysitters in f a i r l y s i m i l a r conditions. A l l the group meetings in each condition were attended by the community health nurse for that area. The same group leader was involved in both conditions. Each meeting lasted for one and a half hours and consisted of a presentation and discussion of some aspect of early c h i l d 45 development. For example, one meeting was devoted to language development, while another focused on the development of motor s k i l l s . The focus of the meetings was both on s p e c i f i c d e t a i l s of a factual nature and on the issues which the aspect of development under discussion raised for parents. The atmosphere of the group meetings was informal, with the amount of di d a c t i c presentation of material being kept to a minimum. Thus the group leader organized each meeting around a discussion by the mothers of their own experiences with respect to the week's topic. In addition, a number of audio-visual aids were employed to make the sessions more varied and in t e r e s t i n g . P a r t i c u l a r l y successful was the use of s l i d e s taken of the children actually i n the program to i l l u s t r a t e stages of motor development. A l l participants received a telephone reminder for the f i r s t two meetings. Following t h i s , only those who had missed the previous meeting were reminded of the next one. A maximum of three consecutive reminders were made to any one c l i e n t . Details of the in d i v i d u a l meetings are given i n Appendix C. 46 RESULTS Two options were available for the analysis of the data. The f i r s t involved the use of change scores as the basis for analysis, the second the independent analysis of the scores at each time period. In view of the increased error variance re s u l t i n g from the use of change scores (Cronbach S Furby, 1970), the second option was adopted in t h i s study. Due to the lack of random assignment of c l i e n t s to groups, i t was necessary to f i r s t establish that no s i g n i f i c a n t differences existed between the groups on the dependent measures at the pre-assessment period. Characteristics of the c l i e n t population The means and standard deviations for the descriptive variables of age of c h i l d at pre-assessment, Bayley score at pre-assessment, HOME score at pre-assessment, family income, age of mother, education of mother, and mother's Raven score are given in Table II (see page 38), both for the o v e r a l l sample and for each treatment group separately. One way analyses of variance were carried out on a l l of these descriptive variables in order to determine the i n i t i a l eguivalence of the four treatment groups. The F r a t i o s obtained in these analyses are also given i n Table I I . The F r a t i o s obtained for the variables of age of c h i l d at pre-assessment, Bayley score at pre-assessment, HOME score at pre-assessment, family income, age of mother and education of mother were a l l ^ i n s i g n i f i c a n t at the 5% l e v e l . The groups did d i f f e r s i g n i f i c a n t l y on the mothers'' Raven scores (F (1 ,39) = 6.66, 47 £<0.01), with those mothers i n the home v i s i t s only and group meetings only programs having lower scores than those i n the home v i s i t s plus group meetings and waiting l i s t control programs. This s i g n i f i c a n t difference i n Raven scores w i l l necessarily l i m i t the conclusions that can be drawn from comparisons of the home v i s i t s plus group meetings program with the home v i s i t s only and group meetings only programs. The matrix of in t e r - c o r r e l a t i o n s between these descriptive measures i s given i n Table I I I . The number of co r r e l a t i o n c o e f f i c i e n t s computed i s high enough that some may be expected to be s i g n i f i c a n t by chance. The interpretation of these c o e f f i c i e n t s i s therefore highly tentative. Of part i c u l a r i n t e r e s t are the co r r e l a t i o n s between the two dependent measures, the Bayley and HOME scores, and the estimate of maternal i n t e l l i g e n c e provided by the mothers' Raven scores. The Bayley scores at pre-assessment are not related to the pre-assessment HOME scores (r=-0.03, NS), nor are they s i g n i f i c a n t l y related to the mothers* Raven scores (r=0.26, p_<0. 10) . The re l a t i v e values of these correlations indicate that, at the start of the study, the estimate of maternal i n t e l l i g e n c e i s a better predictor of the c h i l d * s performance l e v e l than i s the estimate of the qua l i t y of the ch i l d ' s environment. The cor r e l a t i o n between the Raven scores and the HOME scores i s i n s i g n i f i c a n t {r=-0.05, NS), suggesting that the qual i t y of the home environment provided by mothers i s not related to their i n t e l l i g e n c e . It i s d i f f i c u l t to compare the correlation obtained between the Bayley and the HOME scores with those reported by Caldwell 48 TABLE III Correlations between descriptive and dependent variables Age of ch i l d Age of ch i l d Age of mother 0. 14 Income 0.03 Education of mother 0. 15 Rav en score of mot her •0. 04 Bayley DQ <pre-as s mt) I 1 HOME score (pre-assmt) +-0.00 0.51**1 Age of mother 0.14 0.29 0.22 -0. 03 -0.05 0.10 -4-Income 0.03 0. 29 0.21 -0. 07 0.09 0.16 Education of mother 0.15 0. 22 0.21 0. 34* 0. 13 0.17 Raven score of mother -0. 04 -0. 03 -0.07 0.34* 4- 4-0.26 -0. 05 Bayley DQ <pre-assmt) 0.00 -0. 05 0.09 0. 13 0. 26 -0. 03 HOME score (pre-assmt) 0.51** 0. 10 0. 16 0. 17 -0. 05 -0.03 *p<0.05 **p_<0.0 1 49 {Elardo et a l , 1975; Bradley S Caldwell 1976a,b) as the ages of the children in t h i s study vary, whereas Caldwell reports data for cross-sectional age groups. However, Caldwell does not report s i g n i f i c a n t correlations between HOME scores and Bayley scores u n t i l the children are 3 years of age. The low correlations found between these two variables at pre-assessment are therefore considered to be consistent with Caldwell's data. HOME scores were found to be s i g n i f i c a n t l y related to the age of the c h i l d {r=0.51,£<0.01). Although t h i s does not pose a problem for the interpretation of the results of t h i s study, as the treatment groups were matched for age of c h i l d , i t does point to a l i m i t a t i o n of the HOME Inventory for use i n uncontrolled studies. Comparison of process measures across treatment groups The means and standard deviations obtained for the three process measures are provided i n Table IV. a) Group meeting attendance. The mean number of groups attended by each mother was found to be s i g n i f i c a n t l y higher i n the home v i s i t s plus group meetings program than i n the group meetings only program {t(19) = 2.01, p_<0.05). b) Home v i s i t attendance. No s i g n i f i c a n t differences in home v i s i t attendance were found between the home v i s i t s plus group meetings and home v i s i t s only programs (t (21) =0. 54, NS) . c) Home v i s i t cooperation. There was a tendency f o r the mothers i n the home v i s i t s plus group meetings program to be rated by the home v i s i t o r s as more cooperative in the v i s i t s than those i n the home v i s i t s only program (t (21) =0.96, p_<0.20). 50 TABLE IV Process measures Intervention strategy Group meetings attendance Home v i s i t attendance Home v i s i t cooperation {excluding dropouts) Home v i s i t cooperation (including dropouts) Home v i s i t s only I SD 6.91 0.70 9. 27 6. 03 6. 23 9.25 Group meeting only H SD 4.22 1.85 Home v i s i t s plus group meetings SD 5.83 1.80 6.67 1.30 1 1. 67 5. 85 11.67 5. 85 51 This difference became s i g n i f i c a n t when the two drop outs i n the home v i s i t s only program were included in the data (there were no drop outs i n the home v i s i t s plus group meetings program {t(23)=2.03, £<0.05). Analysis of the dependent measures at £ost-assessment The means and standard deviations obtained on the two dependent measures at post-assessment are provided i n Table V. Comparable data from the pre-assessments are also included i n thi s table. These data were analysed by means of two one-way analyses of variance. The re s u l t s of these analyses are summarized i n Table VI. Highly s i g n i f i c a n t differences were found between the groups on both measures (Bayley: F(3,39)=5.82, £<0,01; HOME: F(3,39)=6.80, jD_<0.01). Post hoc comparisons, using a Tukey test, were carried out to determine the effectiveness of each treatment group separately. The homogeneous subsets obtained at a 555 signi f i c a n c e l e v e l are given i n Table VII. These comparisons indicate that the home v i s i t s plus group meetings program was ef f e c t i v e i n producing s i g n i f i c a n t change on both dependent measures. The home v i s i t s only program can be seen to have resulted i n an intermediate amount of change, such that the scores do not d i f f e r s i g n i f i c a n t l y either from the home v i s i t s plus group meetings program or from the control group. The group meetings only program was not e f f e c t i v e i n producing change on either the HOME or the Bayley as compared to the control group. The four intervention programs may be conceptualized i n terms of a 2 x 2 matrix of home v i s i t s (offered or not offered) 52 TABLE V Means and standard deviations of Bayley DQs and HOME scores at pre- and post-assessments MEASURE BAYLEY DQS HOME SCORES Home v i s i t s only Pre-assessment Post-assessment 101.27 SD I i SD 13.52 1 0 8 . 0 0 1 1 6 . 8 5 I .) ! 9 4 . 8 9 1 1 2 . 6 1 Pr e-assessment — — 4 SD — h 35.64J 4.01 Post-assessment I I SD 3 7 . 5 5 ! 2.58; I t 3 3 . 1 1 1 3 . 6 6 I i 1 Group meetings only 9 5 . 0 0 1 5 . 54 3 2 . 7 7 J 5 . 8 7 I Home v i s i t s plus group meetings 104.83 1 0 . 46 118.25|11.06 j. I 34.7513.60 I I 38.33)3.58 1 1 Waiting l i s t control 1 0 3 . 0 0 1.2. 30 I 101.00)13.21 I 34.36|4.20 I a 34.55J 2.21 I TABLE VI Summary of one-way anovas on post-assessment data 1 i I 1 VARIABLE 1 i SOURCE T ~ 1 df | 1 1 SUM OF SQUARES T 1 i i MEAN SQUARE T I 1 I I RATIO J i r 1 i i 1 Bayley | DQs | Groups S (Groups) 1 3 ] i 39 | 3 2 2 6 . 31 7 2 0 1 . 0 9 i i i i 1 0 7 5 . 44 1 8 4 . 6 4 i 1 1 1 5 . 8 2 * f 1 1 j 1 1 i i _ HOME | Scores j Groups S (Groups) 1 3 | 1 39 J 1 8 9 . 7 8 3 6 3 . 0 1 j i . 1 . 6 3 . 26 9. 31 1 1 1 6 . 8 0 * I 1 i *£<0.01 53 TABLE VII Homogeneous subsets of post-assessment data determined by Tukey test at a 5% s i g n i f i c a n c e l e v e l BAYLEY DQs • •% Subset 1 Group meetings Waiting l i s t Home v i s i t s | only control only | M 94.89 101.00 108.00 I Subset 2 Home v i s i t s Home v i s i t s only plus group meetings I 108.00 118.25 HOME SCORES Subset 1 Group meetings Waiting l i s t only control a 33. 11 34.54 Subset 2 Waiting l i s t Home v i s i t s control only M 34.54 37.55 Subset 3 Home v i s i t s Home v i s i t s only plus group meetings M 37. 55 38.33 „ i 54 by group meetings {offered or not offered), as i l l u s t r a t e d i n Table V I I I . In order to test the hypothesis of an inter a c t i o n between the home v i s i t s and group meetings components of the intervention strategy, a 2 x 2 analysis of variance was carried out for the two le v e l s of home v i s i t s and group meetings for each dependent measure. Rs for the one-way analyses, i n i t i a l analysis of the pre-test data were necessary due to the lack of random assignment of c l i e n t s to groups. The resu l t s of the pre-and post- assessment analyses for both dependent measures are summarized in Table I X . No s i g n i f i c a n t effects were found at pre-assessment. a t post-assessment, a s i g n i f i c a n t main eff e c t of home v i s i t s was found for both measures (Bayley: F (1, 39) = 12. 81, p_<0.01; HOME: F (1, 39} = 18.98, p_<0.01), while the main effect of group meetings was non-significant in both cases (Bayley: F (1,39)=0.21 , NS; HOME: F (1, 39) =0. 07, NS) . a s i g n i f i c a n t i nteraction e f f e c t was found with respect to the Bayley DQs (F {1, 39) =3. 85, p_<0.05) supporting the r e s u l t s of the one-way analysis in pointing to an int e r a c t i o n between home v i s i t s and group meetings. The interaction e f f e c t for the HOME scores was non-significant (F{1,39) =1.41, NS) . Taken together with the findings of a s i g n i f i c a n t main e f f e c t for the home v i s i t s component, the lack of s i g n i f i c a n t interaction points to the home v i s i t s component as the primary source of variance i n the data. This conclusion i s somewhat at odds with the findings of the one-way analysis in which the group receiving home v i s i t s only were not found to be s i g n i f i c a n t l y d i f f e r e n t from the control group. Thus the effectiveness of the home v i s i t s only program remains unresolved. 55 TABLE VIII Assignment of treatment programs to a 2 x 2 matrix GEOOP MEETINGS HOME VISITS Offered Not Offered Offered Home V i s i t s Plus Group Meetings Group Meetings Only Not Offered Home V i s i t s Only Con t r o l 56 TABLE IX Summary of 2 x 2 anovas on pre-and post -assessment data J ' " | MEASURE ( • • • • ' • " j \ SOURCE \ SUM OF J SQUARES} i f i i | MEAN | J SQUARE | 1 i RATIO J i J Bayley DQs i Pre-assmt iHome v i s i t s | 158.50| 1 158.50} i 0.95 1 |Group meetings | 34. 36 | 1 I 34.361 0.21 | |Home v i s i t s x | | group meetings| 355. 20| 1 | 355.201 2.14 J jResidual | 6477.801 39 | 166.101 i Post-assmt 1 Home v i s i t s j 2364.74) 1 12364.741 12.81** I JGroup meetings | 76.401 1 J 76.40J 0.41 1 |Home v i s i t s x | J group meetings| 711.44 | 1 | 711.44) 3.85* \ 1 Residual | 7201.081 39 i 184.64 1 JHOME scores J Pre-assmt JHome v i s i t s j 27. 61 j 1 1 27.611 1.43 J |Group meetings | 1Home v i s i t s x | J group meetings] 15. 66 J 1. 30| 1 1 15.66) | 1.30J 0.81 \ 0.07 | JResidual | 754.89| 39 | 19.36} i Post-assmt |Home v i s i t s | 176.63| 1 I 176.63 18.98**I jGroup meetings | 0. 62 j 1 1 0.621 0.07 J I Home v i s i t s x | | group meetingsl 13. 131 1 J 13.131 1.41 J i , , |Residual | 363.01| J . _ - J . . . . . . JL_ 39 1 9.311 . i J . i *£<0.05 **£<0.01 57 Correlations for the scores on the dependent measures obtained at post-assessment with the descriptive variables col l e c t e d at pre-assessment are provided in Table X. , The data obtained for these measures at pre-assessment are also included in t h i s table for comparison purposes. Performance on the Bayley at post-assessment i s highly correlated with performance at pre-assessment <r=0.66 ,p_<0 .0 1) , with mother's education (r=0.33, p_<0.05) , with mother's Raven score (r=0.39,p_<0.01) and with HOME score at post-assessment <r=0.35,p_<0.05) . This l a s t c o r r e l a t i o n i s to be contrasted with the low cor r e l a t i o n observed between these two variables at pre-assessment {r=-0.03, NS). The higher c o r r e l a t i o n at post-assessment could r e f l e c t the increase i n age of the children, as Caldwell reports increasing correlations between HOME and Bayley scores with age. However, i t seems unlikely that the eight weeks at issue are long enough to produce such changes in themselves. It i s possible that there e x i s t s a threshold below which the quality of the environment does not influence infa n t s ' development. The program could serve to raise the guality of the environments past that threshold thus resulting i n the higher c o r r e l a t i o n observed. In addition, the increase i n c o r r r e l a t i o n could r e f l e c t a t h i r d variable, such as compliance with treatment, which influences both the Bayley and the HOME scores. It should be noted that, whatever the explanation may be, t h i s increase i n corr e l a t i o n between the Bayley and the HOME scores re s u l t s in the HOME scores being as predictive of the Bayley scores as are the Raven scores. HOME scores at post-assessment are s i g n i f i c a n t l y correlated TABLE X Correlations of pre- and post-assessment dependent measures with descriptive measures PRE- 1 POST-ASSESSMENT BAYLEY DQ ASSESSMENT BAYLEY DQ PRE-ASSESSMENT HOME SCORE POST- -ASSESSMENT HOME SCORE AGE OF CHILD 0.00 -0.04 0.51** 0.36* AGE OF MOTHER -0.05 0.09 0. 10 0. 32* FAMILY INCOME 0. 09 0.19 0. 16 0. 36* EDUCATION OF MOTHER 0. 13 0. 33* 0. 17 0. 34* MOTHER'S RAVEN SCORE 0. 26 0. 39* -0. 06 0.07 PRE-ASSESSMENT BAYLEY DQ 0.66** -0.03 0.09 POST-ASSESSMENT BAYLEY DQ 0.66** 0.02 PRE-ASSESSMENT HOME SCORE -0. 03 0.02 0.35* 0.61** POST-ASSESSMENT HOME SCORE 0.09 0.35* 0.61** *P<0.05 **P<0.01 with age of c h i l d (r=0.36,£<0.05) , aqo of mother (r=0. 33 ,£<0. 05) , family income (r=0. 3 6, 2<0. 05) , and mother's education (r=0. 34,e<0. 05) , although not with mother's Raven score (r=0.07, NS). This cluster of s i g n i f i c a n t c o r r e l a t i o n s raises the question that the effectiveness of intervention i n producing change on the HOME inventory may have been influenced ay socio-economic variables. Thus treatment would seem to have been most e f f e c t i v e with older mothers with a higher income l e v e l and higher education, even within the r e s t r i c t e d ranqe concerned. This i s consistent with the results published by Caldwell. The low corr e l a t i o n of post-assessment HOME scores with the estimate of maternal i n t e l l i g e n c e suggests that other aspects of high educational attainment are responsible for the high correlation obtained for education, such as compliance with homework assignments or achievement-orientation. Mothers^ evaluations A large number of c l i e n t s did not return the evaluation questionnaire, despite repeated reminders. The percentages of completed questionnaires received for each intervention proqram were: home v i s i t s only, 6 4 % ; group meetings only, U4£; home v i s i t s plus qroup meetings, 83%. It was f e l t that these numbers were too small for meaningful s t a t i s t i c a l analysis. However, two observations stand out as worth discussion. The f i r s t i s that i f the return of the questionnaire i s considered as an index of compliance, i t corroborates the evidence from the process measures in that highest return was from the home v i s i t s plus group meetings program and lowest return was from the qroup 6 0 meetings only program. The second observation concerns the response received to the question of which format for the program the mothers would have preferred. A l l of the mothers in the home v i s i t s plus group meetings program who completed the questionnaire chose t h i s format, whereas none of the respondents in the group meetings only program selected group meetings only as their preferred format. The responses received from the mothers i n the home v i s i t s only program were mixed, with 5 selecting home v i s i t s only and 2 selecting home v i s i t s plus group meetings. These findings suggest that mothers perceive group meetings only as the l e a s t s a t i s f a c t o r y format for such a program, amd that those mothers i n the home v i s i t s plus group meetings program were the most s a t i s f i e d with the format offered to them. Analysis of dependent measures at follow-up No follow-up data was available for the control group, as they had been offered an intervention program during the follow-up period. A paired samples t-test of the pre- and post-assessment scores for the control group showed no change on either dependent measure, indicating that there was no test-retest e f f e c t . Post-assessment scores were therefore used for the control group in the analysis of the follow-up data. The means and standard deviations obtained on the two dependent measures at follow-up are provided in Table XI. Comparable data from the pre- and post- assessments are also included i n t h i s table. These data were analysed by means of two one-way analyses of variance. The results of these analyses are summarized i n 61 TABLE XI Means and s t a n d a r d d e v i a t i o n s o f B a y l e y DQs and HOME s c o r e s a t p r e - , p o s t - and f o l l o w up a s s e s s m e n t s * • ' — j MEASURE j HOME | V I S I T S | ONLY r - • | GROUP |MEETINGS | ONLY • T — - — r JHOME V I S I T S I I PLUS GROUP j | MEETINGS | WAITING L I S T CONTROL 1 j BAYLEY DQS 1 ! I ! j P r e - a s s e s s m e n t i fi 1 SD i 101.27 i 13.52 I 95.00 j 15.54 I 104.83 | | 10.46 J 103.00 12. 30 1 P o s t - a s s e s s m e n t j M 1 SD |108.00 I 16.85 | 94.89 | 12.61 j 118.25 | | 11.06 | 101.00 13. 21 1 F o l l o w up j M 1 SD |112.40 | 17.36 1 93.50 | 14.45 | 122.25 I | 15.40 I j HOME SCORES I i 1 1 j P r e - a s s e s s m e n t 1 I 1 SD \ 35.64 I 4.01 | 32.78 | 5.87 | 34.75 | j 3.60 1 34. 36 4.20 i P o s t - a s s e s s m e n t i M 1 SD | 37.55 j 2.58 | 33.11 | 3.66 1 38.33 | | 3.58 | 34.55 2. 21 1 F o l l o w up 1 I i SD j 38.40 I 3.27 | 34.00 I 3.59 I 39.33 | 1 3.34 1 ( 1 1 J . 1 I 1. F o l l o w up d a t a were n o t a v a i l a b l e f o r t h i s g r o u p . 62 Table XII. Highly s i g n i f i c a n t differences were found between the groups on both measures (Bayley: F(3,37)= 7.00, g<0.01; HOME: F(3,37) =7.63, p<0.01) . Post hoc comparisons, using a Tukey test and a 5% l e v e l of sig n i f i c a n c e , were carried out on this data. The resultant homogeneous subsets are given i n Table XIII. The resu l t s indicate that the pattern found at post-assessment i s maintained at this follow-up point. The scores i n the home v i s i t s plus group meetings program were s i g n i f i c a n t l y d i f f e r e n t from the control group on both measures. The effects of the home v i s i t s only program remain indeterminate as f a r as the Bayley DQs are concerned, as the scores did not d i f f e r s i g n i f i c a n t l y either from those i n the control group or from those i n the home v i s i t s plus group meetings program. The home v i s i t s only program did d i f f e r s i g n i f i c a n t l y from the control group with respect to the HOME scores at t h i s point. Scores obtained from the group meetings only program did not d i f f e r s i g n i f i c a n t l y from the control group's. The follow up data were also subjected to a 2 x 2 analysis of variance. The re s u l t s are summarized in Table XI?. As at post-assessment, a s i g n i f i c a n t main eff e c t of home v i s i t s was found for both measures (Bayley: F (1 ,37) =16. 90, p<0.01; HOME: F (1,37) =21.60, D.<0.01), while the main eff e c t of group meetings was non-significant (Bayley: F(1,37)=0.16, NS; HOME: F (1,37) =0.07, NS). The in t e r a c t i o n term was non-significant for both measures (Bayley: F{1,37)=3.27, E<0.10; HOME: F (1 ,37) =0.56 , NS). Taken together with the resu l t s of the one-way analyses, these findings suggest that the home v i s i t s only program was 63 TABLE XII Summary of one-way anovas on follow up data | VARIABLE i i SOURCE ! If ~x~ \ \ i SUM OF SQUARES - r -l i i MEAN SQUARE T 1 1 I \ RATIO J i Bayley 1 DQs T Groups S(Groups) 1 3 | 37 i 1 1 \ i 4839-56 8528.69 l 1 i • 1613.19 230.51 1 1 7.00* | i HOME j Scores i ._ . i Groups S (Groups) 1 1 3 | 37 r 1 i .3 221.23 357.79 T 1 1 73.74 9.67 T _ J _ -7.6 3* | . . . i * e < o . o i TABLE XIII Homogeneous subsets of follow up data determined by Tukey test at a 5% si g n i f i c a n c e l e v e l i 1 BAYLEY DQs Subset 1 Group meetings Waiting l i s t Home v i s i t s \ only control only J M 93.50 101.00 112.40 | Subset 2 Home v i s i t s Home v i s i t s only plus group meetings a 112.40 122.25 HOME SCORES Subset 1 Group meetings Waiting l i s t only control M 34.00 34.55 Subset 2 Home v i s i t s Home v i s i t s only plus group meetings I 38.40 3 9 . 3 3 . j 64 TABLE XIV Summary of 2 x 2 anovas on f o l l o w up assessment data j MEASURE • i" • | SOURCE r ••• r |SUM OF | ISQUARES | i f J MEAN J 1 SQUARE J p RATIO "S J i Bayley DQs | Follow up j assmt |Home v i s i t s 13894.26| i 13894.261 16.9 0** 1 ! 1 Group meetings | 35. 76| 1 1 35.76 | 0. 16 i J Home v i s i t s x | group meetings | 753. 991 1 1 753.99J 3.27* ! 1 R e s i d u a l 18528.69| 37 1 230.51J • i i i _ i _ _ „ , , _ i • i l l J HOME s c o r e s | Follow up J assmt |Home v i s i t s | 208. 881 1 | 208.88| 21.60** 1 JGroup meetings 1 0.651 1 1 0.651 0.07 ! J Home v i s i t s x j group meetings 1 5.48J 1 1 5.481 0.5 6 ! J R e s i d u a l J 357.791 37? 9.67J « ... _ . , — _ . i ... , _ i i i i ,i i J *p<0. 10 **p<0.01 65 e f f e c t i v e i n producing change in the home environments at the follow up point, although i t s effectiveness i n terms of the Bayley DQs remains indeterminate. The r e l a t i v e effectiveness of the three intervention programs i s i l l u s t r a t e d i n Figures 1 and 2. I t i s important to note that there i s no evidence of any decline i n scores following the end of the program.. The matrix of i n t e r - c o r r e l a t i o n s between the pre-, post-, and follow-up assessment data and the descriptive measures i s provided in Table XV. The correlations, on the whole, follow the trends observed at post-assessment, such that these trends may be interpreted with . somewhat greater confidence. The Bayley scores at follow up are s i g n i f i c a n t l y related to the HOME scores at follow up (r=0.55, g<0.01) and at post-assessment (r=0.39, £<0.05) but not to those at pre-assessment <r=0.16, NS). The finding that post-assessment HOME scores are s i g n i f i c a n t l y related to follow up Bayley scores, while pre-assessment HOME scores are not, provides some support for the hypothesis that the changes i n the environment produced by the program are important ones i n terms of the children's subsequent development. The corr e l a t i o n s of the Bayley scores with the Haven scores remained much the same{r=0.36, g<0.05) as at pre-and post-assessment. The HOME scores continued to be correlated with the children's aqe, althouqh less so than before (r=0.30, p_<0.10). This suqqests that the hiqher correlations i n i t i a l l y obtained may have been influenced by the younqest babies for whom some of the items on the inventory were inappropriate. HOME scores at 66 TABLE XV Correlations of pre-, post- and follow up assessment data with descriptive measures •i 1 HOME score (follow up assmt) N=3 0 Age of ch i l d Bayley DQ (pre-assmt) N=43 0.00 Bayley DQ (post-assmt) N=4 3 -0.04 Bayley DQ (follow up assmt) M=30 -0.05 HOME score (pre-assmt) N=43 0. 51** HOME score (post-assmt) N=43 0.36* 0.30 Age of mother -0.05 0.09 0.00 0. 10 0.32* 0.06 Income 0.09 0. 19 0.31 0. 16 0. 36* 0.30 Education of mother 0.13 0.33* 0.32 0. 17 0.34* 0.43* Raven score of mother 0.26 0.39** 0.36* -0.06 0.07 0.32 Bayley DQ (pre-assmt) 0.66** 0.51** -0.03 0. 09 0.07 -+-Bayley DQ {post-as smt) 0.66** 0.73** 0.02 0.35* 0.41* Bayley DQ {follow up assmt) 0.51** 0.73** 0. 16 0.39** 0.5 5** HOME score (pre-assmt) -0.03 0.02 0. 16 0.61** 0.52** HOME score (post-as smt) 0.09 0.35* 0. 39* 0.61** 0.67** HOME score (follow up assmt) 0.07 0. 41** 0.55** 0.52** 0.67** *p_<0.05 **p<0.01 67 12 5 + FIGURE 1 Mean Bayley DQs as a function of time of assessment and intervention strategy 120 + 115 4-110 + 105 + 100 + Home v i s i t s plus group meetings Home v i s i t s only >x Waiting l i s t control 95 + -x Group meetings only 90 + Pre-assmt Post-assmt Follow up assmt FIGURE 2 Mean HOME scores as a function of assessment and intervention of time strategy 69 follow up were correlated with the socioeconomic indices of income (r=0.30, p<0.10) and education of the mother (r=0.43, j><0.05). In addition, however, they are correlated with Raven scores (r=0.32, jKO.10). This may suggest that i n t e l l i g e n c e plays a part i n determining the maintenance of treatment change. 70 DISCUSSION The r e s u l t s c l e a r l y demonstrate that the program involving both home v i s i t s and group meetings resulted i n highly s i g n i f i c a n t changes i n the children's developmental quotients and home environments over the eight week period. Further, the results demonstrate that these changes were maintained four months after the end of the program, with no evidence of any declining trend over t h i s period. In comparison with the infant stimulation programs discussed i n Chapter I, the home v i s i t s plus group meetings program stands out i n terms of i t s effectiveness, p a r t i c u l a r l y in view of the b r i e f duration of the program. Support was found for the hypothesis that the combination of group meetings and home v i s i t s i s an important factor i n the success of this type of program. Group meetings alone produced no changes i n the measures used, which i s hardly surprising i n view of the poor attendance of the majority of the group members. The eff e c t s of home v i s i t s alone remains indeterminate, as the res u l t s of t h i s group did not d i f f e r s i g n i f i c a n t l y from either the control group or the home v i s i t s plus group meetings program i n a l l but one of the analyses. Although there i s evidence to support an i n t e r a c t i v e e f f e c t of home v i s i t s and group meetings, t h i s conclusion must be gua l i f i e d by the differences in Raven scores found between the mothers i n the home v i s i t s only and the home v i s i t s plus group meetings programs. Further research i s needed to c l a r i f y the effectiveness of the home v i s i t s only program. The group meetings served to give the mothers information about c h i l d development, along with an opportunity to discuss 71 th e i r concerns with other mothers. The results therefore indicate that a general discussion of c h i l d development and of child-rearing issues does not per se r e s u l t in changes i n the children's developmental quotients or the mothers' organization of the children's environments - in other words, does not r e s u l t i n any positive and l a s t i n g changes in the mothers* behaviour towards th e i r children i n t h i s regard. However, t h i s conclusion must be q u a l i f i e d by the poor attendance of the c l i e n t s i n t h i s program. Thus i t may be that a sim i l a r program which incorporated more e f f e c t i v e strategies for maintaining high attendance would achieve positive r e s u l t s . On the other hand, the low attendance and r e l a t i v e l y high drop out rate i n the groups only program may r e f l e c t the mothers' perceptions of the meetings as e s s e n t i a l l y peripheral to their day-to-day l i v e s such that low attendance i s inevitable with t h i s format. The home v i s i t s , on the other hand, served to give the mothers concrete, i n d i v i d u a l i z e d a c t i v i t i e s , along with an opportunity to discuss their children's development on a one-to-one basis with someone who modelled positive caretaker behaviours for them. The results of the home v i s i t s only program therefore indicate that the suggestion of s p e c i f i c a c t i v i t i e s to mothers along with an opportunity to discuss t h e i r children's development on a one-to-one basis may re s u l t i n some positive behaviour change i n the mothers as re f l e c t e d in the gains i n the children's developmental guotients and HOME scores. These res u l t s are consistent with the generally positive outcomes reported by other mother-oriented programs involving only home v i s i t s {Heinicke, 1976; Levenstein, 1970). 72 However, the r e s u l t s of this study suggest that these changes can be enhanced by the addition of the group meetings. This i s f e l t to r e s u l t from two factors. F i r s t l y , the combination of learning experiences provided by the home v i s i t s and the group meetings may r e s u l t i n greater learning. Thus the information provided in the meetings can be used by the c l i e n t s as a broad conceptual framework for the more s p e c i f i c information and a c t i v i t i e s offered i n the home v i s i t s . Such a framework may help the c l i e n t s to absorb new information and generate a c t i v i t i e s for themselves. In addition, the opprortunity to discuss similar concepts and examples i n two separate settings should enhance the learning process through overlearning. Secondly, the group meetings may affect the home v i s i t s by serving to produce and/or maintain a more f a c i l i t a t i v e mother-child r e l a t i o n s h i p through the group's discussion of both the mother's expectations and experiences and alte r n a t i v e courses of action in problem s i t u a t i o n s . Positive changes in the mother-child relationship may i n themselves enhance the effectiveness of the mother i n her role as teacher i n the a c t i v i t i e s suggested. As far as the process measures are concerned, the re s u l t s supported the hypothesis that the home v i s i t s serve to maintain high attendance at the group meetings. The home v i s i t s may have had t h i s e f f e c t because they made the program more central to the c l i e n t s ' everyday l i v e s or because of the extra contact and commitment involved. A further study looking at the eff e c t of varying the contents of the home v i s i t s would be necessary to resolve t h i s issue. 73 On the other hand, addition of the group meetings did not aff e c t home v i s i t attendance. This stemmed from the high home v i s i t attendance i n both programs which may be considered to have resulted from three factors. F i r s t l y , non-attendance at group meetings was a passive act whereas a c l i e n t would have had to take positive action to miss a home v i s i t . Secondly, because of the one-to-one nature of the home v i s i t s , mothers were more l i k e l y to perceive non-attendance at the v i s i t as a personal affront to the v i s i t o r than non-attendance at a group meeting to the group leader. Thirdly, the student nurses carrying out the home v i s i t s were motivated by course requirements to complete as many as possible. Examination of the drop outs i n the three groups lends support to these arguments. Both drop outs from the groups only program occurred in the f i r s t h a l f of the program, whereas the two drop outs in the home v i s i t s only program did not occur u n t i l the second hal f , although the v i s i t o r s i n both cases f e l t that the mothers would have l i k e d to have dropped out e a r l i e r . Addition of the group meetings did seem to a f f e c t the cooperation and involvement of the mothers in the home v i s i t s as rated by the home v i s i t o r s . The eff e c t was s l i g h t when only those mothers who completed the program were considered, but i t became s i g n i f i c a n t when the two mothers who dropped out near the end of the home v i s i t s only program were included. Combined with the lack of drop outs from the combined program, th i s suggests that the addition of group meetings to home v i s i t s may mave increased the cooperativeness of the mothers even to the extent of preventing some from dropping out of the program. 74 Two other programs have involved a combination of home v i s i t s and group meetings. Karnes et a l (1970) report successful outcomes from a combination of weekly group meetings with monthly home v i s i t s , the contents of the group meetings and home v i s i t s being s i m i l a r to those described in the present study. Her results therefore provide support for the conclusions reached here. Ryan (1974, 1976), on the other hand, found no s i g n i f i c a n t improvement as a re s u l t of weekly home v i s i t s plus monthly group meetings. However, the content of both the group meetings and the home v i s i t s d i f fered from those described here as the group meetings were devoted to s o c i a l a c t i v i t i e s and the home v i s i t s were intended as tutoring sessions 'with the children. Both the group meetings and the home v i s i t s were c a r r i e d out by volunteers. These differences i n content and personnel make i t d i f f i c u l t to draw meaningful comparisons between Ryan's res u l t s and those of the present study. In addition to these two programs, Gordon (1973) has reported that addition of group learning sessions f o r the children s i g n i f i c a n t l y enhanced the effectiveness of his home tutoring program and the attendance at the home v i s i t s . The children i n the present study may be considered to have been involved i n group learning sessions while th e i r mothers attended t h e i r group meetings. Thus group meetings f o r the children may be an additional variable enhancing the effectiveness of the home v i s i t s i n the present study. Further research c l a r i f y i n g the r o l e of the children's groups would therefore seem to be indicated. The results suggest, therefore, that the combination of group meetings and home v i s i t s i s superior to either component 75 separately i n terms of the process measures and to the group meetings component with regard to the outcome measures used. An int e r e s t i n g area for further research would be to determine how much of each component i s necessary to the success of the program. Thus, f o r instance, Karnes et a l (1970) report a a successful outcome, i n terms of both attendance and Binet I.Q. scores, using a combination of weekly groups and monthly home v i s i t s , over a period of f i f t e e n months. Consistent with other programs in this area, there was some evidence to suggest that the effectiveness of the program was influenced by the socioeconomic variables of income and education. This tendency does not invalidate the finding that the home v i s i t s plus group meetings program was e f f e c t i v e with a low income population. However, further research i s needed to investigate the r o l e of socioeconomic variables and other possible predictors of success such as the number of children in the family, the number of adults looking after the c h i l d and the presence of the father i n the home. As far as the program i t s e l f i s concerned, further research i s needed to investigate a number of modifications in the program. For instance, i t seems l i k e l y that involvement of the father i n the program would enhance i t s effectiveness. Further, the age range of 3 months to 2 years was set somewhat a r b i t r a r i l y and the e f f e c t s of a more r e s t r i c t e d range, such as under one year or one to two years needs to be investigated. Following the changes occuring as a re s u l t of the program, the quality of the home environment was predictive of the infant's mental development four months l a t e r . This i s 76 consistent with : Caldwell's findings and provides further evidence for the importance of environmental variables i n early c h i l d development. The low but s i g n i f i c a n t correlations observed between maternal i n t e l l i g e n c e and infants' developmental guotients are consistent with the l i t e r a t u r e in t h i s area (Casler, 1976). A new and s i g n i f i c a n t finding was that, with respect to the measures used, maternal i n t e l l i g e n c e was not related to the quality of the c h i l d ' s environment. The g e n e r a l i z a b i l i t y of t h i s finding may be guestionned due to the r e s t r i c t e d range of scores in the present sample. However, i t does c a l l into question the interpretation of the environment as primarily a mediatinq hereditary variable. Further research, preferably using samples of children homoqeneous in aqe and not involved i n a stimulation proqram, i s needed to validate these findings. The implications these r e s u l t s have for public health are clear: i f the goal i s infant stimulation, simply presenting the mothers with information regarding c h i l d development i n a group se t t i n g , the l e a s t expensive alternative, i s not s u f f i c i e n t to re s u l t i n p o s i t i v e changes in the children's development. Weekly home v i s i t s where concrete a c t i v i t i e s are suggested may r e s u l t in some positive changes but these can be greatly enhanced by the addition of group meetings, at r e l a t i v e l y l i t t l e extra cost. One of the objectives of this study was to determine whether an e f f e c t i v e infant stimulation program could be developed which could f e a s i b l y be undertaken by a public health agency. The issues involved i n the successful implementation of the program i n such a setting have yet to be investigated. 77 Although the success of the program indicates that extensive training of the home v i s i t o r s i s not ess e n t i a l , the tr a i n i n g and ch a r a c t e r i s t i c s of the group leader and home v i s i t o r supervisor may well be c r i t i c a l for the effectiveness of the program. Further research i s therefore reguired to determine appropriate s t a f f s e l ection and training procedures. However, two aspects of the program make i t p a r t i c u l a r l y a t t r a c t i v e for implementation in a public health s e t t i n g . F i r s t l y , the short duration of the program i s noteworthy, both i n terms of i t s limited manpower demands and i n terms of broadening the a c c e s s i b i l i t y to such a program. Secondly, the successful use of student nurses to carry out the home v i s i t s i s p a r t i c u l a r l y s i g n i f i c a n t . Thus, while use of the group leader to do the home v i s i t s i s a preferrable arrangement i n terms of continuity and personalization of the contents of the program, the increase i n cost were t h i s necessary to the success of the program would render the program inpracticably expensive. As i t i s , however, with the use of students from related d i s c i p l i n e s to carry out the home v i s i t s , supervised by the coordinator for the group meetings, t h i s program i s economically f e a s i b l e in a public health s e t t i n g . In conclusion, the present study has demonstrated that an eight week infant stimulation program involving both home v i s i t s and group meetings resulted in s i g n i f i c a n t changes i n the infants* developmental quotients and home environments. These results were maintained at four month follow up. Group meetings of the mothers alone were found to have l i t t l e effect on either of the outcome measures. The re s u l t s of the home v i s i t s only program were such that no firm conclusion could be reached as to 78 i t s effectiveness. Further research i s needed to c l a r i f y the impact of such a program. 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IQs of i d e n t i c a l twins reared apart. Behaviour Genetics, 1970, XM. 133-148. Jensen, A. R. Educability and group differences. London: Methuen & Co., Ltd., 1973. Karnes, M. B., Teska, J. A., Hodgins, A. S. and Badger, E. D. Educational intervention at home by mothers of disadvantaged infants. Paper presented at the annual meeting of the American Educational Research Association, Minneapolis, March 1970. Levenstein, P. Cognitive growth in preschoolers through stimulation of verbal interaction with mothers. Amer. J. Orthopsychiat. t 1970, 40^ 462-432. Madden, J., Levenstein, P. & Levenstein, S. Longitudinal outcomes of the mother-child home program. Child Development^ 1976, 47 x 1015-1025. Painter, G. The effect of a structured t u t o r i a l program on the cognitive and language development of c u l t u r a l l y disadvantaged infants. M e r r i l l - Pa Inter Qua rt.. x 1969, 15M 279-294. , Palmer, E. H. Minimal intervention at age 2 & 3 and subsequent i n t e l l e c t i v e changes. In R. K. Parker (Ed.), The £reschool i n action: E x p l o r i n3 early childhood programs. Boston: Allyn & Bacon, 1972. Pp. 410-434. Raven, J. C. Standard progressive matrices. London: H. K. Lewis and Co. Ltd., 1958. Rheingold, H. L. The modification of s o c i a l responsiveness i n 8 4 I n s t i t u t i o n a l babies. Mpnogr. Soc. Kes^ Child Devel^j. 1956, 21 (iihole #2) . Robinson, H. B. The Frank Porter Graham Child Development Center. In L. L. Dittman (Ed.), Early c h i l d care:. The new perspectives. New York: Atherton, 1968. Pp. 302-312. Robinson, H. B. From infancy through school. In J. L. Frost (Ed.) Revisiting, early childhood education:. Readings. New York: Holt, Rhinehart & Winston, Inc., 1973. Ryan, T. J. Promoting c h i l d development through a program of home v i s i t i n g : F i n a l report. Unpublished manuscript, Carleton University, June, 1974. Ryan, T. J. Promoting c h i l d development through a program of home v i s i t i n g . Canadian Journal of Behavioural Science^ 1976, 8 X 102-105. Saltz, R. Aging persons and i n s t i t u t i o n a l i z e d youny children: Mutual e f f e c t s of a 'foster-grandparent project'. Unpublished manuscript, Merrill-Palmer I n s t i t u t e , 1969. Schaefer, E. S. & Aaronson, M. Infant Education Research Project: implementation and implications of a home tutoring program. In R. K. Parker lEd.), The preschool in action* Exploring early c h i l d hood £r og.r a ms.. boston; Allyn & Bacon, 1972. Pp. 410-434. Scheinfeld, D. R., Bowles, D., Tuck,S. and Gold, R. Parents' values, family networks and family development: working with disadvantaged families. American Journal of Orthopsychiatry, 1970, 40 A 413-425. 85 Selzer, F<. J. The disadvantaged c h i l d and cognitive development in the early years. Merrill-Palmer Quarterly.,*. 1973, 19 x 241-252. Skeels, H. M. Adult status of children with contrasting early l i f e experiences. Monger.. Soc.. Res.. Child Develop.ia.j_ 1966 31 (Whole No. 105). Spitz, H. A. Hospitalism; An inguiry into the genesis of p s y c h i a t r i c conditions in early childhood. Psychoanalytic Study of the Child,. 19 45, 1^ . 53-74. Starr, R. ti. Cognitive development in infancy: Assessment, acceleration, and a c t u a l i z a t i o n . !§£rilI-Palmer yuarterly^. 1.71, 17 x 15 3-186. Streissguth, A. P. and Bee, H. L. Mother-chrlu interactions and cognitive development in children. In W. W. Hartup (i-d.) , The young, c h i l d , Vol;. 2._ National Association tor the Education of Young Children, Washington, D.C, 1972. Wachs, T. D., Uzgyris, I. C , & Hunt, J. McV. Cognitive development i n infants of different aye l e v e l s and from d i f f e r e n t environmental backgrounds: An exploratory investigation. ^ e r r i l i - P a l m e r p_uartt._t 1971, 17 x 283-318. Meikart, D. P. And Lambie, D. Z. Early enrichment i n infants. Paper read at the American Association for the Advancement of Science, Boston, December 1969. Mhite, B. L. An experimental approach to the e f f e c t s of experience on early human behaviour. In J. P. H i l l (Ed.) , Minnesota Symposium of Child Psycholoc___._y.jt_ Vol.. 86 l x 1967, 2C1-226. Wilson, R. S. Twins: Mental development i n the pre-school years. Developmental Psychology, 1974, 580-588. i i l s o n , R. S. and Harpring, E. B. Mental and motor development in infant twins. Developmental Psychology., 1972, 2JL 277-287. Yarrow, L. J . Separation from parents in early childhood. In A. L. Hoffman & L. w. Hoffman (Eds.), Review of c h i l d development research, Vo_U 1... New York: Russell Sage, 1964. Pp. 89-136. Xarrow, L. J . , Rubenstein, J . L., Pedersen, t. k. and Jankowski, J. J. Dimensions of early stimulation and their d i f f e r e n t i a l e f f e c ts on infant development. M e r r i l l -Palmer Quarterly.*. 1972, ±8^ 205-218. 87 APPENDIX A.! EVALUATION QUESTIONNAIRE 1 . (a) If a friend of yours asked you what the Early Development Program was a l l about and what i t meant to you, what would you say? (b) What are some of the drawbacks you might mention? 2. Describe the kind of person who would benefit most from the Early Development Program. 88 3. As a result of the program, do you f e e l there have been any changes {e.g. the way you f e e l , the things you do, the way your c h i l d behaves) i n : (a) yourself (b) your c h i l d / c h i l d r e n (c) your relationship with your c h i l d / c h i l d r e n 4. L i s t the three things that you most wanted to get out of the program: Now please c i r c l e the number that represents the extent to which the program met each of your three goals {1 = not at a l l , 4 = moderately, 7 = completely) (2) (3) G O A L RATING (1) 1 2 3 4 5 6 7 (2) 1 2 3 4 5 6 7 (3) 1 2 3 4 5 6 7 89 5. There seem t o be four d i f f e r e n t a s p e c t s to the proqram. P l e a s e r a t e them i n terms of (a) ge n e r a l enjoyment and (b) usefulness (1 = not a t a l l , 4 = moderately, 7 = e x t r e m e l y ) : Meetings: p r e s e n t a t i o n d i s c u s s i o n ENJQIMENT 1 2 3 4 5 6 7 1 2 3 4 5 6 7 USEFULNESS 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Home V i s i t s : a c t i v i t i e s p e r s o n a l contact 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 6. (a) What d i d you l i k e most about the group meetings? {b) What d i d you l i k e l e a s t about the group meetings? 7. (a) What d i d you l i k e most about the home v i s i t s ? (b) What d i d you l i k e l e a s t about the home v i s i t s ? 8. If the program were to be offered in the following formats (a) group meetings only <b) home v i s i t s only (c) home v i s i t s plus group meetings Which do you think would be best? Why? Which do you think would be worst? Why? 91 Appendix B:. Home V i s i t s The following guidelines were used in planning each home v i s i t , although the contents of the v i s i t s were t a i l o r e d to each mother-child unit. 1. I n i t i a l V i s i t . In the f i r s t v i s i t , the v i s i t o r discussed the nature and rationale of the program with the mother and observed and interacted with the target c h i l d . The mother was then given a notebook and some carbon paper and asked to observe her c h i l d for a two minute period each day during the coming week and make ur i e f notes of his/her behaviour. In p a r t i c u l a r , she was asked to note the c h i l d ' s behaviour i n a number of d i f f e r e n t s i t u a t i o n s , such as when given an unfamiliar object to play with and i n a s o c i a l s e t t i n g with other children. The v i s i t o r demonstrated what was required, choosing an instance of the child's behaviour during the v i s i t . The purpose of the observations was described to the mother, notably to help her become more aware of her child's development as well as to help the v i s i t o r suggest suitable a c t i v i t i e s in the coming weeks. 2. Subsequent V i s i t s . In subsequent v i s i t s , the v i s i t o r f i r s t discussed the preceeding week's a c t i v i t i e s with the mother, explaining how these could be extended as the baby mastered each stage. The mother was then asked about any changes she had noted in the c h i l d over the preceeding week and was encouraged to think of ways of tra n s l a t i n g these observations into a c t i v i t i e s for her 9 2 c h i l d . The v i s i t o r then introduced the new a c t i v i t i e s , explaining the rationale for their choice, and modelled then with the c h i l d . When appropriate, the v i s i t o r brought the necessary materials with her to lend to the mother. A balance between the d i f f e r e n t types of a c t i v i t i e s {i.e. language, fine motor, problem solving etc.) was maintained across the weeks of the program, although an emphasis was given to those areas i n which the baby seemed to be r e l a t i v e l y weak, as evidenced by his/her performance on the Bayley and the v i s i t o r ' s observations. Choice of a c t i v i t y was also influenced by the aother's own i n t e r e s t s and a c t i v i t i e s . 3. F i n a l V i s i t . During the l a s t v i s i t the v i s i t o r reviewed the a c t i v i t i e s that had been suggested over the course of the program, emphasizing the benefits that the c h i l d was expected to derive from each one so that the mother could continue to apply the same pr i n c i p l e s i n choosing subsequent a c t i v i t i e s . 93 Appendix Cz Group Meetings The presentations f o r the two groups were i d e n t i c a l , except tor meetings 6 and 7 which were i n i t i a l l y l e f t f l e x i b l e to accomodate the s p e c i f i c interests of the groups. Meeting #1: Introduction The experimenter introduced herself and the community health nurse and described how the program had been developed and the rationale underlying i t . Any questions of a general nature about the assessments were answered. The next portion of the meeting was devoted to makinq the group members f e e l comfortable in the qroup throuqh t h e i r qettinq to know one another and becominq accustomed to talkinq in the qroup. Members of the combined proqram were paired up and each was asked to describe their c h i l d to t h e i r partner so that the partner could l a t e r describe that c h i l d to the qroup. They were asked to concentrate on psychological rather than physical c h a r a c t e r i s t i c s . While the same procedure was planned f o r the groups only meeting, the small size of the group led to a change in format with each mother being asked to describe her c h i l d d i r e c t l y to the qroup. In both cases, the discussion that followed centred on the common concerns which the members faced as mothers of younq children. Meeting #2: The Nature and Significance of Play The presentation and discussion focussed around the followinq areas: 94 a) what the mothers wanted their children to learn during the f i r s t three years; b) the ro l e of the c h i l d 1 s play i n achieving these goals; c) the importance of the caretaker*s role i n structuring the play environment and i n in t e r a c t i n g with the c h i l d in play situations and the various styles available to her; d) how the means available to the c h i l d f o r learning change over the f i r s t three years, and e) factors which may decrease the effectiveness of the caretaker as a teacher. Meetincj #3_: Language Development The presentation and discussion centred around three areas: a) a description of language development. 8) the importance of environmental influences on language development. C) discussion of concerns related to language development. As f a r as possible, the description of language development was e l i c i t e d from the mothers, with each one being asked to describe her child's language and how i t had been developing. Meeting »4; General Discussion of Child-rearing. Issues This meeting was presented by the health unit psychologist as an oppportunity for the group members to discuss concerns 95 they had about th e i r children's behaviour. The f i l m 'Child Behaviour •= You' which i l l u s t r a t e s various behavioural p r i n c i p l e s was shown at the s t a r t of the meetinq. The use of an imported group leader for t h i s meeting helped t o ensure that the primary focus of a l l the other meetings remained on c h i l d development issues. Meeting #5:. Nutrition in Early Childhood This meeting was presented by the health unit n u t r i t i o n i s t . She focussed on two areas: a) how to make eating a pleasurable event, rather than a source of tension; b) how to include food selection and preparation as an educational experience for young ch i l d r e n . The Head Start f i l m 'Jenny i s a Good Thing' which dwells on these two points was shown at the start of the meeting. fieeting # 6 A Combined Program i. Cognitive Development Using the babies in the progran to demonstrate various points, the experimenter introduced the mothers to some of Piaget's findings r e l a t i n g to the sensori-raotor period and discussed t h e i r implications for the caretaker's behaviour. fleeting |6B Groups Only Program: Cognitive and Motor Development The experimenter used the babies i n the program to demonstrate some of Piaget's findings r e l a t i n g to the sensori-motor period ( i . e . a condensed version of #6A) as well as some aspects of motor development. Toys which could be used to 96 f a c i l i t a t e d i f f e r e n t aspects of development were discussed. Selected toys were displayed and then lent to interested mothers. Meeting # 7 A Combined Program: Motor Development Slides of the childr e n i n the program which had been taken in the preceeding weeks were used to i l l u s t r a t e various aspects of motor development. In addition, toys aimed at f a c i l i t a t i n g motor development were discussed and selected toys displayed. The mothers had already had access to these toys through t h e i r home v i s i t o r s . Meeting t7B Groups Only Program: Social and Sexual Development Several group members expressed an i n t e r e s t in early s o c i a l and sexual development and as t h i s coincided with the health nurse's own i n t e r e s t s , she offered to lead t h i s meeting. Her presentation focussed on early s o c i a l and sexual development and the issues and concerns this raises for parents. Meeting #8^ Conclusion In the f i n a l meeting the experimenter employed a Gestalt-l i k e technique to help the mothers remember their own childhood experiences and fee l i n g s . The mothers were encouraged to relax and imagine themselves back with their e a r l i e s t memories. Sp e c i f i c questions were then asked to help them remember both their feelings as children towards t h e i r parents and t h e i r peers as well as towards d i f f e r e n t forms of d i s c i p l i n e and t h e i r methods of coping with d i f f e r e n t situations. To the extent that 97 they f e l t comfortable about discussing them, their memories were then used as a basis for a discussion of how th e i r childhood perceptions of their own parents related to t h e i r present behaviour as parents. In addition, by asking them to compare descriptions of themselves as children with descriptions of their own children, the discussion focussed on the issues of xndividual differences in personality and the problems they pose for parents i n understanding and getting along with their children. 

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