PROTOCOL: Home based child development interventions for pre-school children from socially disadvantaged families

Description of the condition

Social disadvantage is not simply a question of income poverty but is a combination of deprivation and social exclusion (Saunders 2006). Those living in poverty, lone parents (Saunders 2006) and minority ethnic groups (which is often confounded with poverty) are all at risk of social disadvantage (Bradley 2001a).

Social disadvantage can have a significant impact on early child development, health and well being (Siddiqi 2007; Lucas 2008) and what happens during this critical period is important for all aspects of development (Thompson 2001). Access to resources (Evans 2004) and the quality of care giving (Olds 2006) and the home learning environment have been highlighted as crucial elements in the intellectual and social development of children (Thompson 2001; Waterston 2003: Siddiqi 2007; Sammons 2004; Bradley 2001a. Bradley 2001 b). The developmental deficits that may be experienced by children from socially disadvantaged backgrounds can have implications for their life course, including their social and cognitive functioning in adulthood (Najman 2004; Schoon 2003; Kaplan 2001).

Children who grow up in poverty - a significant dimension of social disadvantage - are more likely to be exposed to cumulative, multiple stressors. Their housing is more likely to be noisy, overcrowded and of poor quality; they are at higher risk of experiencing more family turmoil, greater child-family separation and higher levels of violence (Evans 2002; Evans 2004). Socially disadvantaged children are at greater risk of a chaotic family life that can lack stability and structure with fewer supportive networks (Bradley 2001a). They are likely to be exposed to fewer developmentally enriching materials and opportunities, have fewer books and are less likely to be read to or taught school related concepts than non-socially disadvantaged children. As conditions associated with living in poverty worsen, and stress mounts, home environments can become less stimulating (Ramey 2004).

Children are at increased risk of adverse outcomes as a consequence of social disadvantage but there is also an impact mediated by parent behaviour (Eckenrode 2001; Repetti 2002). Parents living in poverty are at increased risk of mental health problems and their parenting behaviours tend to be less consistent, less stimulating and more punitive than those not living in poverty. Socially disadvantaged mothers are less likely than their better off peers to communicate effectively with their children or show affection, either verbally or physically (Crosier 2007; Kohen 2008; Bradley 2001 a; McLovd 1998), and they are more likely to perceive themselves as having less social support. Bronfenbrenners and Morris' bio-ecological Person-Process-Context-Time (PPCT) model posits that parental processes interact with child characteristics to influence development. According to this model, proximal processes (activities in which the child interacts with people, objects or symbols, for example, mealtimes, being read a story, parenting) and the quality of such processes influence developmental outcomes. Proximal processes vary according to the child (Person), their environment (Context) and duration and historical setting (Time) and are considered to be ‘the primary engines of development’ (Bronfenbrenner 1998). As such, proximal processes such as parenting are at risk of being less than optimal in the context of poverty and social disadvantage.

Adverse child outcomes associated with social disadvantage are wide ranging and can include: poorer physical health (Sequin 2007; Bauman 2006); emotional dys regulation; poorer or fewer social skills; more behavioural difficulties (Webster-Stratton 2008); cognitive delay (Dowdney 1998), impaired intellectual development (Croft 2001; Otero 2003), poor language skills (McPhillips 2007) and low educational attainment (Sammons 1995). The focus of this review is the specific impact of an impoverished intellectual environment on cognitive and socio-emotional development. There is a strong relationship between cognitive and emotional functions and this is an area of study that is increasingly receiving much attention. It is not yet fully understood, but it is thought that emotional processes underpin decision making and learning. Learning to control impulses related to negative emotions, as well as encouraging helpful, healthy emotions, is a crucial aspect of development. A lack of emotional regulation can impair learning and social judgements through reducing the ability to attend to the learning task and inadequately assessing the ‘value’ of incoming information (Immordino-Yang 2007; Diamond 2007 ; Goswami 2004; Blair 2002; Lewis 2006).

Ramey and Ramey (Ramey 2004) have summarised the crucial experiences that are necessary to provide opportunities for stimulating learning and required for normal early brain development and improving the quality of the parent-child interaction: 1.

encourage exploration

Caregiving competence and the quality of the environment play an important role in supporting the development (including emotional regulation) in young children (Blair 2002). Improved parenting skills and patterns that are highly supportive and as well as provision of appropriate developmental stimulation in the home are related to improved development in children (Ryan 2006; Bradley 2001b; Croft 2001; Herbst 2000; Bronfenbrenner 1998; Blair 2002) and can ameliorate the differences in academic achievement within and between income groups (McLovd 1998). It is clear that what happens in the home and with the caregivers is an important aspect of limiting the impact of deprivation and promoting child development.

Description of the intervention

Home based child development programmes aim to optimise children's developmental outcomes through educating, training and supporting parents in their own home to provide a more nurturing and stimulating environment for their child. Many disadvantaged parents have less understanding or time to provide the emotional support and types of stimulation that are important to their child's development. Some interventions are broad based and others, such as those which are the focus of this review, try to remedy this information gap by equipping parents with information, resources and support.

The intervention is delivered by a family visitor or practitioner directly to parents in their own home and consists of:

age appropriate information (either written, verbal or both) related to child development and competent care giving

The family visitor provides information that addresses children's physical, intellectual, social and emotional development, explains it to the parent and helps them to use it in their everyday parenting. Parents are encouraged by the family visitor to engage in practical activities with their child that will reinforce the parent-child relationship, provide new learning experiences and thereby promote development. Parents are shown how to make best use of any resources provided and how they can be used to aid activities including reading to the child, singing nursery rhymes or playing games with household objects.

The information that the practitioner gives can also include advice and support that targets parental attitudes, knowledge and skills to promote parental behaviours that will facilitate child development. Such information includes specific knowledge related to child development appropriate to their child's age so that parents know what to expect at different stages of their child's development. The family visitor provides support to the parent through the discussion of child development and other child related issues that may be raised by the parent and will often signpost the parent to appropriate support agencies or additional programmes.

The practitioners who deliver the programme can be professional, para-professional or lay people and the parent is typically the recipient of the intervention (Olds 2006; Korfmacher 1999; Johnson 1993). The type of home visitor and their background, whether it is professional or para-professional, can have an impact on: how the programme is delivered; home visitors' engagement with families; and attrition of parents from the programme (Korfmacher 1999). However, while professional home visitors can achieve larger gains in some parent and child outcomes this is not thought to be due to differences in programme delivery. Instead it may be due to the perceived legitimacy of the home visitor by the parent during pregnancy and infancy (Olds 2006).

How the intervention might work

Programmes directly target parents' knowledge and skills, seeking to enhance their ability to facilitate and encourage their child's development and provide enriched learning opportunities. The family visitor is the primary mechanism through which the programme is delivered to the parent and is an important element of programme delivery as the success of such interventions has been linked to the skill and ability of the staff to motivate and empower the parent to change (Olds 2007; Sweet 2004). It is through changes in parental attitudes and behaviour that changes in child outcomes are achieved. Furthermore the link between the number of visits a parent receives and the success of the programme in achieving its goals is not thought to be a simple dose-response relationship. While intensive programmes are considered to be important there is no accepted threshold number of visits that should be completed by parents to ensure success (Olds 2007).

Why it is important to do this review

Parents have an important role to play in optimising child development and mitigating the negative effects of social disadvantage. As such, there is a need to examine the specific effects and benefits of interventions targeted at pre-school disadvantaged children that are delivered in the home and seek to provide parents with the requisite skills to achieve a nurturing and stimulating home environment that promotes child development, specifically their cognitive and socio-emotional development.

Methods