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Intervention Summary

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Legacy for Children

Legacy for Children (Legacy) is a curriculum-driven parenting intervention designed to positively impact the early development of children of limited-resource mothers. Specifically, this primary prevention strategy aims to improve child outcomes by increasing positive parenting among low-income mothers of infants and young children by (1) promoting the mother's responsibility, investment, and devotion of time and energy for her child; (2) promoting responsive, sensitive mother-child relationships; (3) supporting the mother as a guide in her child's behavioral and emotional regulation; (4) promoting the mother's facilitation of her child's verbal and cognitive development; and (5) promoting the mother's sense of belonging to a community.

The Legacy model offers two curriculum versions for use during implementation: (1) the University of California at Los Angeles (UCLA) curriculum, with implementation beginning prenatally and ending when the child is 3 years old, and (2) the University of Miami (Miami) curriculum, with implementation beginning at birth and ending when the child is 5 years old. Each implementing site selects the version that is most appropriate for its clients. The content of each curriculum capitalizes on accomplishments and challenges at different child ages (e.g., walking and talking milestones, sleeping and feeding issues), providing mothers with information and skills at times of high relevance and motivation. Specific parenting topics include sensitive responding, affection, establishing and maintaining routines, discipline, play and creativity, language, and fostering school readiness.

The selected curriculum is delivered by a trained intervention specialist through group sessions that are 2.5 hours (UCLA curriculum) or 1.5 hours (Miami curriculum) each and held weekly over the course of the intervention, for a total of 101 or 250 possible sessions, respectively. The group sessions also provide emotional, practical, and informational support to mothers, and they include both mother-only time (e.g., talking about current milestones, discussing new or alternative parenting behaviors, reinforcing the mother's role in her child's development) and mother-child interactive time (e.g., practicing skills, reinforcing the mother's positive behaviors).

Periodic one-on-one sessions for each mother with the group leader are scheduled to reinforce the curriculum content and concepts presented at the group sessions and to address the mother's individual parenting concerns. These sessions can be delivered through home visits or by meeting separately with each mother-child dyad within the group setting. All mothers also participate in group social outings (e.g., field trips, birthday celebrations) to build a sense of community among participants, help them maintain interest and investment in the intervention, and extend opportunities for mothers to discuss topics covered in the group sessions.

Before implementing the Legacy model, intervention specialists must complete a 5-day training workshop, have at least a bachelor's degree in social science or education, have experience working with low-income mothers, and have at least 2 years of experience working with children.

Descriptive Information

Areas of Interest Mental health promotion
Outcomes Review Date: November 2013
1: Behavioral concerns
2: Socioemotional problems
3: Hyperactivity
Outcome Categories Social functioning
Ages 0-5 (Early childhood)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Home
Other community settings
Geographic Locations Urban
Implementation History Legacy for Children was first implemented and tested through a set of randomized controlled trials with 574 mother-child dyads in two urban sites in California and Florida. The program also has been implemented with 165 mother-child dyads in five sites across Florida, Georgia, Kentucky, and Mississippi.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Selective

Quality of Research
Review Date: November 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Kaminski, J. W., Perou, R., Visser, S. N., Scott, K. G., Beckwith, L., Howard, J., et al. (2013). Behavioral and socioemotional outcomes through age 5 years of the Legacy for Children public health approach to improving developmental outcomes among children born into poverty. American Journal of Public Health, 103(6), 1058-1066.  Pub Med icon

Perou, R., Elliott, M. N., Visser, S. N., Claussen, A. H., Scott, K. G., Beckwith, L. H., et al. (2012). Legacy for Children: A pair of randomized controlled trials of a public health model to improve developmental outcomes among children in poverty. BMC Public Health, 12, 691.  Pub Med icon

Supplementary Materials

Wallace, I., Fraser, J. G., Dempsey, T., Borntrager, K., & Lasaster, B. (2009). Legacy for Children: Process evaluation final report. Research Triangle Park, NC: RTI International.

Outcomes

Outcome 1: Behavioral concerns
Description of Measures This outcome was measured by the parent-rated, 10-item behavioral concerns subscale of the Devereux Early Childhood Assessment (DECA). The behavioral concerns subscale assesses a variety of challenging and problem behaviors seen in some preschool children, such as becoming upset or crying easily, having temper tantrums, and fighting with other children. Mothers completed the DECA when their children were 24, 36, 48, and 60 months old. A child met the criterion for behavioral concerns if the subscale score was at least 2 standard deviations from the mean behavioral concerns subscale score.
Key Findings The Legacy program was evaluated through a 5-year study with two randomly controlled trials: one conducted at UCLA and the other at the University of Miami, Florida. Mother-child dyads were randomly assigned to an intervention group or a usual care group. Those in an intervention group received the site-specific Legacy curriculum; those in a usual care group did not receive any core components of the Legacy model, but they were not prevented from using any service that would otherwise be available, even if the service was similar to those received by the intervention group. All analyses were intent to treat.

In the University of Miami trial, children in the intervention group were less likely than children in the usual care group to meet the criterion for behavioral concerns at 24 months of age (36.0% vs. 52.5%; odds ratio = 0.51; p < .05). This finding was associated with a small effect size (Cohen's d = -0.37). In addition, an analysis of group-averaged effects over time indicated that from 24 to 60 months of age, children in the intervention group were less likely than children in the usual care group to meet the criterion for behavioral concerns (odds ratio = 0.56; p = .006).

In the UCLA trial, there were no significant differences in behavioral concerns between children in the intervention and usual care groups at any assessment period.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Socioemotional problems
Description of Measures Socioemotional problems were measured by the parent-rated, 27-item protective factors subscale of the Devereux Early Childhood Assessment (DECA). The protective factors subscale assesses the socioemotional competence domains of initiative, self-control, and attachment, as well as positive behaviors exhibited by preschool children, such as choosing to do tasks that are challenging, showing patience, and asking adults to play with or read to her or him. Mothers completed the DECA when their children were 24, 36, 48, and 60 months old. A child met the criterion for socioemotional problems if the subscale score was at least 2 standard deviations from the mean protective factors subscale score.
Key Findings The Legacy program was evaluated through a 5-year study with two randomly controlled trials: one conducted at UCLA and the other at the University of Miami, Florida. Mother-child dyads were randomly assigned to an intervention group or a usual care group. Those in an intervention group received the site-specific Legacy curriculum; those in a usual care group did not receive any core components of the Legacy model, but they were not prevented from using any service that would otherwise be available, even if the service was similar to those received by the intervention group. All analyses were intent to treat.

In the University of Miami trial, children in the intervention group were less likely than children in the usual care group to meet the criterion for socioemotional problems at 48 months of age (7.1% vs. 16.1%; odds ratio = 0.40; p < .05). This finding was associated with a medium effect size (Cohen's d = -0.51).

In the UCLA trial, there were no significant differences in socioemotional problems between children in the intervention and usual care groups at any assessment period.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 3: Hyperactivity
Description of Measures This outcome was measured by the 5-item hyperactivity subscale of the Strengths and Difficulties Questionnaire (SDQ), a parent-reported behavioral screener that assesses positive and negative psychological attributes of children. Mothers completed the SDQ when their children were 48 and 60 months old. A child met the criterion for hyperactivity if the subscale score was beyond a research-based cutoff for the demonstration of the subscale's acceptable sensitivity in predicting the DSM-IV attention-deficit/hyperactivity disorder phenotype.
Key Findings The Legacy program was evaluated through a 5-year study with two randomly controlled trials: one conducted at UCLA and the other at the University of Miami, Florida. Mother-child dyads were randomly assigned to an intervention group or a usual care group. Those in an intervention group received the site-specific Legacy curriculum; those in a usual care group did not receive any core components of the Legacy model, but they were not prevented from using any service that would otherwise be available, even if the service was similar to those received by the intervention group. All analyses were intent to treat.

In the UCLA trial, children in the intervention group were less likely than children in the usual care group to meet the criterion for hyperactivity at 60 months (odds ratio = 0.50; p < .05). This finding was associated with a small effect size (Cohen's d = -0.38).

In the University of Miami trial, there were no significant differences in hyperactivity between children in the intervention and usual care groups at any assessment period.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 0-5 (Early childhood) 50.1% Male
49.9% Female
57.1% Black or African American
24.9% Hispanic or Latino
14.3% Race/ethnicity unspecified
3.8% White

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Behavioral concerns 4.0 3.5 2.5 2.5 2.3 2.8 2.9
2: Socioemotional problems 4.0 3.5 2.5 2.5 2.3 2.8 2.9
3: Hyperactivity 4.0 3.5 2.5 2.5 2.3 2.8 2.9

Study Strengths

The psychometric properties of both questionnaires were adequate to high, with analyses conducted by independent investigators. Fidelity efforts included intervention specialist training, technical assistance activities, participant focus groups and satisfaction surveys, and a review of program records. Additionally, ethnographers observed over 800 groups and coded these observations as a means of measuring intervention fidelity. Activities at both the UCLA and University of Miami sites were delivered to participants more than 90% of the time. Attrition patterns were similar across intervention and usual care groups. Acceptable statistical procedures were used to handle missing data. Participants were randomly assigned, resulting in data demonstrating no baseline differences between intervention and usual care groups. The statistical methods used to analyze the data and account for multiple analyses were generally sound. The sample size was sufficient.

Study Weaknesses

Mothers at the UCLA site only attended an average of 17 out of 93 possible sessions, and mothers at the University of Miami site attended an average of 68 out of 231 possible sessions; thus, it is questionable whether mothers received the planned intervention. Dose-response analyses to address the low attendance rates were not reported. Attrition at both study sites was substantial at the 12- and 60-month assessments. Rates of attendance differed across sites. The two study populations differed: compared with mothers at the University of Miami site, the mothers at the UCLA site were significantly older, had more education, were more likely to be married, were more likely to be employed, and were more likely to speak a language other than English at home.

Readiness for Dissemination
Review Date: November 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Centers for Disease Control and Prevention. (n.d.). The Legacy for Children feasibility project and executive summary. Atlanta, GA: Author.

National Center on Birth Defects and Developmental Disabilities. (2011, Fall). Legacy for Children brochure. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children implementation guide. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, Miami year 1. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, Miami year 2. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, Miami year 3. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, Miami year 4. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, Miami year 5. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children program orientation and training [PowerPoint slides]. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, UCLA binder 2. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, UCLA binder 3. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, UCLA binder 4. Atlanta, GA: Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities. (n.d.). Legacy for Children, UCLA binder 5. Atlanta, GA: Centers for Disease Control and Prevention.

Program Web site, http://www.cdc.gov/ncbddd/childdevelopment/legacy.html

Other program materials:

  • Agency Fidelity Instrument
  • Fidelity Assessment Monitoring Tool
  • Legacy for Children Fact Sheet
  • Legacy for Children Feedback and Learner Questionnaire
  • Legacy for Children Head Start Standards Document
  • Legacy for Children Posters
  • Legacy for Children Training Evaluation
  • Legacy for Children Training Workshop Agenda
  • Organizational Survey
  • Parent Engagement Form, 10-Week Parent Engagement Assessment
  • Parent Group Summary Forms

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

The implementation guide is comprehensive and covers a full range of topics, including program philosophy, planning for implementation, staffing, facilitating groups, ensuring fidelity, and making cultural adaptations. A readiness checklist assists potential implementers in determining whether the program is a good fit, and an implementation tool assists with the completion of program readiness activities. The curriculum thoroughly covers the implementation of each program session. Training is required for intervention specialists and supervisors, and it is optional for other program staff. To complete the training, participants are required to pass a test on acquired knowledge. A master trainer certification is required for intervention specialists who want to train others to implement the program model. Several tools for program fidelity and quality assurance are available, including an annual organizational survey that is completed by implementing sites and used to guide technical assistance during site visits. Core components of the model, which cannot be adapted, are identified, and examples of adaptations that can be made are clearly outlined.

Dissemination Weaknesses

No weaknesses were identified by reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Curriculum--Miami version Free online, or $100 for a 5-binder, hard-copy set Yes, one curriculum version is required
Curriculum--UCLA version Free online, or $80 for a 4-binder, hard-copy set Yes, one curriculum version is required
Implementation guide Free online, or $20 per hard copy Yes
Promotional brochure Free online, or $25 for 50 hard copies No
Promotional posters Free online, or $25 for 2 hard copies No
5-day, off-site training workshop in Atlanta, GA, at the Centers for Disease Control and Prevention Free Yes
On-site master trainer training, with certification Free No
Weekly phone-based technical assistance for individual implementation sites Free Yes
Biweekly phone-based group technical assistance for all implementation sites Free Yes
Phone-based technical assistance for groups or individual implementation sites as needed Free Yes
Quality assurance forms and tools (including parent engagement forms, parent group summary, fidelity assessment, and organizational survey) Free Yes
Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation or research, contact:
Ruth Perou, Ph.D.
(404) 498-3005
rperou@cdc.gov

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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