Flying High on Life

Tania R.
Edghill
Kennedy Krieger Researcher Helps Implement Substance Abuse Prevention Programs Targeting Preschoolers in Baltimore

Peggy McNally at Dayspring Early Head Start CenterEvery morning, 3-year-old La'Nell Alewine and her 4-year-old sister, Ja'Nell, get dressed and make their way to preschool at the Dayspring Head Start Center in East Baltimore. There, the girls eat a healthy breakfast, play with their classmates and learn about the alphabet, colors and numbers. While they are preparing for kindergarten, the sisters, at very early ages, also are learning some of the most valuable lessons in life, lessons that teach them that they are in control of themselves and the choices they make.

For children like Ja'Nell and La'Nell, who live in the inner city surrounded by drug and alcohol abuse, these lessons are relevant and necessary. "We have a large problem with substance abuse in Baltimore, where we estimate that 65,000 residents need treatment," says Harolyn Belcher, M.D., a neurodevelopmental pediatrician and research scientist at Kennedy Krieger Institute. Unfortunately, children who grow up in such bleak conditions are prone to stress and anxiety and are at great risk for continuing the cycle of abuse.

Prevention, Dr. Belcher believes, should begin early when children are most impressionable and open to learning about the negative effects of substance abuse. "You can start at the preschool level to stop the cycle of drug abuse and to help young children learn about healthy lifestyles," Dr. Belcher says. Kennedy Krieger, located in the heart of the East Baltimore community, is helping to break the cycle.

Leading the fight against substance abuse, Dr. Belcher has conducted several groundbreaking studies focusing on the effectiveness of prevention programs targeting preschoolers in Baltimore. Her primary goal is simple: to reach young children at high risk for exposure to drug trafficking, drug paraphernalia, drug-related violence and, consequently, drug abuse and to help them become successful adults.

Teaching healthy habits to young children

Children exposed to substance abuse in the home or community live in turmoil. They often cannot understand their loved ones' erratic behaviors and are frustrated because they cannot express their feelings. "They hear all the time that drugs are bad, yet they see it in their households being used by people they love. They need to know in very simple terms that drugs change how the brain works, thereby changing how people act," says Peggy McNally, M.S., C.P.S., a certified prevention specialist and substance abuse prevention instructor working with Dr. Belcher to combat drug abuse in Baltimore. "They also need to know that abusing drugs and cigarettes is a very difficult behavior to stop."

Providing a consistent environment where children have the resources and the safety to grow and develop is vital to preventing substance abuse. Such a surrounding helps boost children's coping skills, encourages development of social support networks, promotes academic achievement and fosters positive self-esteem.

One program that offers a nurturing environment to young children is Head Start, a federally funded program launched in 1965 to help give preschoolers from low-income families an early advantage and the foundation for academic achievement and success in life. While its programs traditionally foster self-esteem, good nutrition, immunizations, and academic achievement, they have not typically promoted substance abuse prevention geared to preschoolers. Through her work, Dr. Belcher has aimed to encourage implementation of effective prevention programs in Head Start settings in cities around the country where there are high incidences of substance abuse. She also has worked with Head Start to bring preschoolers and their families mental health intervention services that address emotional and behavioral problems stemming from poverty and substance abuse. "We want them to have a firm, solid foundation," Dr. Belcher says. "We want them to have dreams and believe that they can do anything they try to do."

With support from the St. Agnes Healthcare System Mission Fund, the National Institute of Mental Health and the United Way of Central Maryland's Success By 6,® Dr. Belcher and her team launched a new curriculum at four Head Start centers in West Baltimore. The PANDA (Preventing the Abuse of Tobacco, Narcotics, Drugs and Alcohol) curriculum helps children gain a sense of control and safety by teaching them about healthy lifestyles, identification of safe persons and avoidance of harmful substances. The program was developed by Pat Biggar, an educator at the Chapel Hill Training-Outreach Project, Inc., a nonprofit organization in North Carolina that develops programs and strategies to enhance the lives of children and families.

The PANDA curriculum uses cartoon characters, such as BoBo the Bunny, in vignettes, play activities and songs to convey healthy lifestyle messages in ways that preschoolers from all cultures can understand. According to Dr. Belcher, it is a drug explicit program that begins by teaching young children about healthy lifestyles and eating properly. It then teaches them about avoiding legal drugs such as cigarettes and alcohol and then about avoiding very illicit drugs such as heroin and cocaine.

Dr. Belcher found that a drug explicit program, such as PANDA, is not difficult for young children living in neighborhoods where there is drug abuse, trafficking and related violence to understand. The children are exposed to the negative behaviors and witness their consequences daily. "One thing child care workers and parents were concerned about was whether the program would scare the children and make them feel more vulnerable if drugs were mentioned to them," Dr. Belcher says. "To the contrary, we were pleased to find that children's self-concepts improved following the PANDA curriculum."

Boosting preschoolers' self esteem

Dr. Harolyn Belcher with Ja'Nell AlewineOnce the PANDA curriculum was implemented in the Head Start centers, Dr. Belcher conducted a study to test its effectiveness. She looked at whether the curriculum fostered positive self-concepts in African American preschoolers and if it was successful in teaching them about healthy lifestyle behaviors. Over a 10-week period, 41 children, ages 3 to 5 years, were taught the PANDA program in addition to the traditional Head Start curriculum. More than half of them came from single-family homes in West Baltimore with an average annual income of $9,321.

At completion of the PANDA curriculum, the children's self-concepts were evaluated. "They actually seemed to feel much better about themselves and more in control," Dr. Belcher says. The children, who also were tested on the subject matter, successfully demonstrated retention of safety rules, healthy foods and drug awareness. "After the PANDA curriculum, we saw a large improvement in substance abuse awareness. Eighty-four percent of the questions were answered correctly. This showed that the children retained the knowledge about the subject and really understood it," Dr. Belcher says.

McNally, who taught the PANDA curriculum to the children and instructed the teachers on how to use it, has never met a child who did not respond favorably to it. "They love it!" she says. Working with the children each week, McNally's goal was to help them make sense of the chaos in their worlds. Ja'Nell and La'Nell, who both participated in the program, enjoyed and learned a very important lesson from it, all while gaining self-respect. "The program is good for children their age," says their mother, Lakeshia Walker, who has personally known the devastation that drugs and alcohol can wreak. "Children are very smart. The earlier they learn about the effects of drugs, the better."

With promising preliminary findings, Dr. Belcher now plans to provide further evidence in support of PANDA. In a follow-up study, which she hopes to begin later this year, she will randomize and compare two groups of children. One group will receive the basic Head Start program, while the other will be given the PANDA curriculum in conjunction with Head Start. "We hope to start out teaching healthy lifestyles in preschools and continue the trend of using effective programs in elementary schools," Dr. Belcher says. Since completion of the study in 2002, McNally has contracted with private preschools in Baltimore to teach the PANDA curriculum.

Addressing behavioral health

Eighteen-year-old Jamie Bowman's life is a challenging one. As her mother battles substance abuse, Jamie is helping her grandmother raise her three siblings while she completes high school and prepares for college. With such pressures, she and her siblings are at risk for emotional stress and anxiety. According to Dr. Belcher, there is a need to integrate mental health services with academic programs in underserved communities. Such services would address behavioral health problems stemming from poverty, drug exposure and poor parenting practices and promote child development and emotional well-being.

In collaboration with Head Start and other community, school and federal agencies, Dr. Belcher, principal investigator Philip Leaf, Ph.D., and a team of investigators from The Johns Hopkins Bloomberg School of Public Health developed a program to introduce behavioral health services in the academic setting and to increase access to care. With funding from the Substance Abuse and Mental Health Services Administration and the Casey Family Foundation, a new program The Baltimore Behavioral Enhancement through Training and Treatment to Expand Resiliency (BETTER) Family and Community Partnership was initiated at two Head Start sites in East and West Baltimore. Children who received services were compared to those enrolled in two nonparticipating Head Start sites. In total, 548 children and families participated in a 24-month study on the program's effectiveness.

Preschoolers in the BETTER program received several types of services, including individual play therapy, parent-child counseling and social skills development. These services helped promote school achievement, self-esteem and emotional stability. "Those are the foundations to being successful in life," Dr. Belcher explains. "Children with healthy social skills, for example, are more successful in their communication with their peers and adults and can take full advantage of learning situations. There wouldn't be any distraction from discipline." Parents also received services, including individual therapy, behavior management instruction, substance abuse counseling and culturally-based parent education. Other services also were available for the entire family, including FAST (Families in Schools Together), which helps encourage communication within the family and promote parents' participation in their children's education and development.

Jamie and several relatives, including her now 6-year-old sister, Summer, participated in the BETTER program at the St. Bernadine Head Start Center in West Baltimore during the 1999-2000 school year. Through the program, they received and benefited from many services, including individual, peer group and family counseling. "We talked about any issues we had that week. We learned how to deal with the children," says Jamie, who plans to study early childhood development in college. "I also gained insight from other parents. It really helped to know that I'm not the only one going through this."

Summer also received immeasurable benefits from the BETTER program. She and other preschoolers who received the mental health services improved their social skills and had fewer behavior problems. According to Dr. Belcher, teachers at the intervention sites found improvements in all areas of the children's behavior. "Before the FAST program, Summer fought a lot. At home, she'd act out to get my attention," Jamie says. "Through the program, she learned to express herself, rather than fight."

Dr. Harolyn Belcher with La'Nell AlewineIndividuals who have completed the BETTER program support the need to increase behavioral health services elsewhere. "They really should add the program in other schools, because it's uplifting," Jamie says. "They praise not only the children, but the parents, too." Community and federal agencies are encouraged by the findings of the BETTER program study. Through BETTER grant funding, Head Start centers in Baltimore have implemented new on-site services, including substance abuse prevention and counseling, psychological assessments and training programs for social workers and mental health clinicians. Recently, Dr. Leaf received funding from the Casey Family Foundation and the federal government to expand the BETTER programs in Early Head Start centers throughout the city.

"The study helped to set the premise that such a program is effective," Dr. Belcher says. "Prevention is key. The earlier we get involved the better. If we can coordinate with the community and bring some of the talent at Kennedy Krieger into the community, we'll be better able to make a difference for the children."