SCRD 07 PALS II Combine

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What is the optimal timing for supporting responsive parenting? The importance of infancy vs. the toddler/preschool period for supporting maternal responsive parenting and child outcomes NIH funding: HD 36099 1997 – 2006


Investigators Susan H. Landry, Ph.D., PI1 Karen E. Smith, Ph.D., Co-PI2 Paul R. Swank, Ph.D., Co-PI1 Cathy Guttentag, Ph.D., Co-PI1 1 Children’s Learning Institute, Dept. of Pediatrics, University of Texas-Houston Health Science Center 2 Dept. of Neurology, University of Texas Medical Branch at Galveston


Abstract This study examined whether there was a more optimal time (i.e., infancy vs. toddler/preschool) for facilitating mothers’ responsive parenting behaviors and their influence on children’s social and communication skills. Previously, a responsiveness intervention during infancy showed strong changes in four aspects of maternal responsiveness and, in turn, infants’ development. However, it was hypothesized that a second intervention “dose” in toddler/preschool period was needed for optimal results. Families from the first intervention phase were re-randomized into either the Playing and Learning Strategies – II or a Developmental Assessment condition (DAS –II) (term, n = 80, VLBW, n = 86) resulting in four groups: PALS I/DAS II, n = 33; PALS I/PALS II, n = 34; DAS I/PALS II, n = 50; DAS I/DASII, n = 49). Intervention influences were found for all aspects of responsiveness and child outcomes, but the most optimal timing of PALS was dependent on factors such as the type of support the maternal behavior provided to a child and the child’s biological risk status. Comparable enhancement in social and communication skills was found for children born term or very low birth weight.

Advances in the neuroscience of brain development support the need for quality caregiving environments: 

Advances in the neuroscience of brain development support the need for quality caregiving environments Critical nature of development in the early years Role of child’s environment Unique importance of environment for children with special learning needs. Two theoretical frameworks for understanding influences Attachment theory: early nurturing establishing a foundation allowing child to feel secure and trust in caregivers and environment Socio-cultural framework: emphasis on early learning being embedded and supported by a social context; “zone of proximal development” (e.g. parents, teachers)

Key Aspects of Responsiveness Across Theoretical Frameworks: 

Key Aspects of Responsiveness Across Theoretical Frameworks Contingent responding (e.g., prompt, sensitive response to signals) Emotional/affective support (e.g. warmth, positive affect) Support for child’s attentional focus (e.g., maintain & build on interests) Rich stimulation (e.g. quality of language input) Can caregivers be supported to learn these key aspects?

Impact of Maternal Responsiveness: Longitudinal, Experimental Study: 

Impact of Maternal Responsiveness: Longitudinal, Experimental Study Play & Learning Strategies (PALS) PALS I = infancy; PALS II = toddler/ preschooler 10 – 11 sessions Components adapted for developmental period Use of adult learning theory approaches Trusting, coaching relation No information on child’s current development Developmental information Assessment of developmental progress Multiple skill areas No information on how to help child develop PALS I report, 2006 Developmental Psychology, 42(4):627-642


Short education videotapes with mothers demonstrating parenting concepts with their infant/child. Discussion of concepts throughout videotape between facilitator and mother. Mother videotaped trying concept with their infant/child. Review of videotaped interaction with mother critiquing how her infant/ child responded to her interactive styles. Intervention format


For Change in Maternal Behaviors: Mothers who received PALS I & II will show the most optimal change in behaviors across the four aspects of responsive parenting Mothers who received the intervention either early or later would show more positive change than mothers who never received the intervention. Hypotheses For Mediators of Intervention Effects: Responsive behaviors across both an attachment and a socio-cultural framework together would explain the intervention effect on social and language outcomes.


Change in Child Outcomes: Children whose mothers received PALS I & II were expected to show the most optimal change: in social and communication skills in mother-child interactions on standardized measures of language development. No differences were expected for children of different risk status as PALS was developed to facilitate responsive behaviors that are sensitive to children’s individual developmental needs.

Assessment of Intervention Effect:: 

Assessment of Intervention Effect: Evaluation of maternal and child behaviors pre, interim, post, and follow-up Change in four key maternal responsiveness behaviors from videotaped mother-child interactions during daily activity and toy play situations Change in child and social communication behaviors during these interactions Administration of the PreSchool Language Scale and Peabody Picture Vocabulary Test Assessments occurred in family’s home language; English or Spanish


Procedures Phase I - infancy Random assignment to PALS I vs. DAS I stratified by risk status Phase II – toddler/preschool Random assignment to PALS II vs. DAS II stratified for phase I condition and risk status Four assessments, blind to study condition Pre – 2 wks prior to intervention Interim – after Session 5 Post – 2 wks after last session Follow – up – 3 mos after last session

Description of PALS sessions: 

Description of PALS sessions


Groups Term Normal pregnancy and birth history High Risk Preterm, very low birthweight with significant neonatal medical complications Low Risk Preterm, very low birthweight with less severe neonatal medical complications

Participants – Phase II: 

Participants – Phase II


Number of children available when Phase 2 funding allocated, n = 222; 75% recruited for Phase 2, n = 166

Coding Definitions: Maternal Behaviors: 

Coding Definitions: Maternal Behaviors Contingent Responsiveness Contingent Responsiveness - Degree of responsiveness to child cues including promptness and appropriateness of maternal reactions, appropriate pace that fits child’s abilities and patience. Restrictiveness – Physical or verbal attempts to interrupt activity in which child is engaged (e.g., “put that down”, “stop”) Positive Emotional Support Positive Affect - Degree to which mother displays smiles, laughs, facial animation. Warm Sensitivity - Degree of sensitivity to child cues including acceptance of interests & needs, physical affection, enthusiasm, positive voice tone, & avoid negative comments. Support of Children’s Attentional Focus Maintaining- Behavior relates to the activity/object in which the child visually/physically engaged (e.g., child manipulating toy, mother talks about what can do with toy), or is direct response to child’s attempts to attract mother’s attention (e.g., “Do you want to throw the ball to me?”, while child is holding ball in hand). Redirecting - Interactive behavior that is unrelated to the child’s focus of visual and physical attention. Quality of language input Verbal Scaffolding - Verbal hints/prompts that provide conceptual links between objects, persons, activities, or functions that may occur in relation to objects, activities, and topics of conversation. Labeling – Provides specific names of objects and actions (e.g., “Ball can roll”) Verbal Encouragement- Statements praising child’s efforts (e.g., “way to go”) or serve to encourage child’s involvement with objects or people (“yeah”, “that’s it”).

Coding Definitions: Child Behaviors: 

Coding Definitions: Child Behaviors Social Cooperation – Words used in response to maternal request for information (e.g., mother, “What is the name of it” while points to picture in book, child tries to label) Engagement – Degree to which postively engaged with mother (e.g., use of affect, eye gaze, gestures, joint attention, verbal communication) Positive affect – Displays of smiles, laughs Communication Gestures – Behaviors that orient mother’s attention (e.g., pointing, showing, giving) Words – Two levels coded: vocalizations, word approx/words Coord of attention & use of language – Able to coordinate attention between mother & objects in combination with language use.

Data Analyses: 

Data Analyses Examination for differences in maternal and child behaviors at pre-test No differences found. Growth curve modeling conducted to examine for change in maternal and child behaviors in relation to the most optimal timing of PALS Intercept set at post-test examined for differences in levels at end of PALS II intervention Slope examined for differences in rates of change over the post & follow-up assessments For intercept and slope of maternal and child behaviors: Main effects: PALS I, PALS II Interactions: PALS I x Risk status, PALS II x Risk status, PALS I x PALS II, PALS I x PALS II x Risk status Clinical significance: Cohen’s d Small, d = .2, moderate, d = .5, large, d = .8


LS Means at end of PALS II 2 2.5 3 3.5 DAS I PALS I Warm Sensitivity Results of Change in Maternal Behaviors: Best Supported with PALS I


% Maintaining at end of PALS II Maintaining Child’s Attentional Interest


LS Means at end of PALS II Results of Change in Maternal Behaviors: Best Supported with PALS II


LS Means at end of PALS II 12 14 16 Labeling DAS II PALS II


LS Means at end of PALS II Results of Change in Maternal Behaviors: Best Supported with PALS I & II


Change in % Maintaining Results of Change in Maternal Behaviors: Best Supported with PALS I & II Pre-Test Post-Test Follow-up


Social Engagement Rating Pre-Test Post-Test Follow-up


LS Means at end of PALS II Results of Change in Child Outcomes: Best Supported with PALS II


LS Means at Post - Test


LS Means at Post - Test


PLS Auditory Comprehension Raw Score Pre-Test Post-Test Follow-up

Results of Mediation Models: 

Results of Mediation Models Preschool Language Expressive Scale Scores Maternal predictors: Language Scaffolding Frequency of verbal requests Contingent responsiveness


Conclusions Higher levels and/or increases in four key aspects of a responsive parenting style were facilitated by an intervention targeting these behaviors using an adult learning theory framework. Changes in mothers’ behaviors resulted in changes in children’s social & communication skills. The most optimal timing of the intervention for changes in mothers’ behaviors (infancy vs. toddler/preschool) depended on factors such as the type of support a maternal behavior provided. PALS – I (infancy) promoted warmth & sensitive nurturing PALS – II (toddler/preschool) promoted language stimulation PALS I & II promoted contingent responsiveness (i.e., required adaptation to changing signals


The most optimal changes in the child’s social and communication skills was dependent, in part, on the skill complexity and age at which the skill would naturally be emerging. PALS – I (infancy) promoted gestures PALS – II (toddler/preschool) promoted composite language skills Social engagement required both PALS I & II. The impact of the intervention’s on children’s skills was comparable across risk groups w/ few exceptions. A responsive style that combined sensitivity & prompt responses to children’s signals w/ rich verbal input mediated the intervention’s effect on both social and language skills.

Informing policy & practice: 

Informing policy & practice Facilitate parenting behaviors known to support school readiness Use adult learning approaches Attend to factors beyond behaviors (e.g. belief systems, social support) Tailor program to meet needs of specific families (multi-faceted vs. single focus)

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