Health Promotion

An Impressive Reminder That All Measures Matter

By: Paul H. Dworkin, MD and Erin Cornell, MPH

A recently published article, Protective Prevention Effects on the Association of Poverty With Brain Development by Brody and colleagues, in the January issue of the journal, JAMA Pediatrics, has stimulated and even challenged our thinking on strategies to evaluate the effectiveness of interventions to promote children’s healthy development. As we have cited on many occasions, Connecticut Children’s Office for Community Child Health embraces the use of proximate measures to expand our capacity to assess the impact of developmental interventions such as Help Me Grow. Our work has focused, albeit not exclusively, on strengthening protective factors to enable families to better support their children’s healthy development. Despite the importance of this approach, we are mindful of the inherent limitations of employing proximate measures to support the long-term, highly desirable developmental outcomes we ultimately seek. To complement our use of proxy measures to assess the impact we are having on family-level protective factors, we also seek the capacity to build a broader set of measures at the community and system levels to capture our impact across the early childhood spectrum. Such efforts ensure that we adopt a comprehensive approach to measurement that offers a variety of lenses through which to view our impact.

In their impressive study, Brody and colleagues examine whether a preventive intervention focused on enhancing supportive parenting, the Strong African American Families (SAAF) program, could ameliorate the association between exposure to poverty and brain development in low socioeconomic status African American individuals from the rural South. The researchers confirmed prior findings that years in poverty forecasted diminish size of key structures in the temporal lobe of the brain, the hippocampus and amygdala, which are particularly important to academic learning and social development. Remarkably, they found no reductions in brain size among the children who participated in the SAAF program. The authors suggest that, if confirmed, these findings are consistent with a possible role for supportive parenting in narrowing social disparities.

The details of this study, including its limitations, are worthy of careful inspection and beyond the scope of this brief commentary. However, several aspects of this study demand our careful attention. In our advocacy to utilize proxy measures, such as families’ resiliency, to assess the impact of our interventions, we do not suggest doing so at the expense of simultaneously pursuing strategies to measure the direct, long-term impact of our work. However, such outcomes as academic achievement and occupational status accrue over years and pose considerable measurement challenges. Brody and colleagues recruited subjects at age 11 and later assessed those participants at age 25, achieving a retention rate of greater than 60 percent across 14 years. How encouraging! Furthermore, their use of MRI imaging data to document brain size is perhaps the penultimate mediating factor, as research demonstrates the importance of both the amygdala and hippocampus to healthy mental and physical functioning.

Several other aspects of this study deserve our consideration. In the SAAF program, the intervention to improve the association between poverty and brain development is parenting-focused. Caregivers receive instruction on the importance of the consistent provision of support, the need for monitoring and control, and methods for communicating about such risky behaviors as sex and alcohol use. In fact, such interventions strengthen families and their capacity to support their children’s healthy development, reinforcing our focus on the application of the Strengthening Families Framework developed by the Center for the Study of Social Policy. The framework enhances protective factors in families to enhance child development and reduce the likelihood of child abuse and neglect. Note that the SAAF intervention involved families of children beginning at age 11, well beyond our more typical emphasis on young children in the preschool and early elementary years. Results suggest that we should be mindful of the potential benefit of parenting-focused intervention during early adolescence. Are we thinking too narrowly about our window of opportunity?

Coincidentally, the following article in the same issue of JAMA Pediatrics, by Katherine Theall, PhD, and colleagues, examined the association between neighborhood violence and biological stress in children, another study highly relevant to our work. This research also employed biological outcomes and measured both cellular and physiological markers of stress. Even the casual reader will be impressed with the current capacity to measure markers of short-term biological change that lead to long-term health outcomes.

A recent commentary by Paul Chung, MD, and colleagues, in the journal, Pediatric Research, concluded with, “…ultimately, the most important thing we can do is to demonstrate, through our work, how pediatric research makes children and families stronger, and to advocate passionately for all innovations, activities, and programs that research informs us will make children and families stronger.”

Our efforts ensure families have access to a comprehensive system of community programs and services that support them in promoting their children’s healthy development. We recognize there are many approaches to evaluate the efficacy and impact of such innovations, activities, and programs. Just as a comprehensive early childhood system is critically dependent on cross-sector collaboration and alignment, we also benefit from strong partnerships between those of us conducting research across biological, translational, and community-based settings. Our own innovations in early childhood seek to strengthen families and systems, and so our measurement approaches reflect this. While we will continue to embrace protective factors as key proxy measures, we recognize the need to continue to pursue long-term efforts to measure developmental and other outcomes. Our focus on family capacity and functioning does not minimize the importance of examining impressive and sophisticated biological (e.g., anatomical, cellular, and physiological) measures and markers. We increasingly recognize that with respect to evaluating our impact on children’s optimal health development, all measures matter.

Paul H. Dworkin, MD, is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine. Learn more »

Erin Cornell, MPH, is the program manager for research, innovation and evaluation at the Help Me Grow National Center.

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