Journal of Intellectual Disability Research 339
doi: 10.1111/j.1365-2788.2008.01151.x
volume 53 part 4 pp 339–352 april 2009
The effects of a home-based intervention for young children with intellectual disabilities in Vietnam J. Y. Shin,1 N.V. Nhan,2 S.-B. Lee,3 K. S. Crittenden,4 M. Flory5 & H.T. D. Hong2 1 Department of Psychology, Hofstra University, Hempstead, New York, USA 2 Office of Genetic Counseling and Disabled Children, Hue College of Medicine and Pharmacy, Hue,Vietnam 3 Department of Early Childhood Special Education, Daegu University, Daegu, Korea 4 Department of Sociology, University of Illinois at Chicago, Chicago, Illinois, USA 5 Department of Infant Development, New York State Institute for Basic Research in Developmental Disabilities, Staten Island, New York, USA
Abstract Background This study was conducted to examine the impact of a 1-year intervention for children with intellectual disabilities (ID) in Vietnam. Method Subjects were 30 preschool-aged children with ID (ages 3 to 6 years). Sixteen were assigned to an intervention group and 14 to a control group. Based on the Portage Curriculum (CESA 5 2003), the intervention trained parents to work with their children through modelling and coaching by teachers during weekly home visits. Results Comparison of pre-, mid- and postintervention assessments of the children based on the Vineland Adaptive Behavior Scales (Sparrow et al. 1984a) indicated that the intervention was promising: children in the intervention group improved significantly in most domains of adaptive behaviours, and also performed significantly better than the control group in the areas of personal care and motor skills. Conclusions The results from the Vietnam programme are discussed in terms of its implications and strategies for developing programmes for children with disabilities in developing countries. Correspondence: Jin Y. Shin, Department of Psychology, Hofstra University, Hempstead, New York, USA (e-mail: Jin.Y.Shin@ hofstra.edu).
Keywords developmental disabilities, early intervention, intellectual disability, parents, Vietnam, young children
Background Brain disorders are estimated to affect as many as 1.5 billion people worldwide, and the number is expected to grow as life expectancy increases (Institute of Medicine 2001). Most disorders affecting the brain result in long-term disability and many have an early age of onset. As these disabilities last for a lifetime, they have profound emotional and financial impacts on individuals and families. Social isolation and stigma often add to the burden borne by the affected individuals and their families (Institute of Medicine 2001). Many Western and/or industrialised countries mandate that intervention services be provided to infants and young children as soon as they are identified as disabled or at risk of developmental delay. Moreover, early intervention services typically address the needs of the family as well as those of the child. Evidence suggests that early intervention is beneficial to young children with disabilities or developmental delays and their families (Blair et al. 1995; Guralnick 1997;
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 340 J. Y. Shin et al. • Intervention in Vietnam
Wolf et al. 1998; Whipple 1999; Ramey et al. 2007). In addition, high-quality, intensive and educational efforts that begin early in life tend to lead to greater developmental gains (Blair et al. 1995; Mahoney et al. 1996; Ramey et al. 2007). Parent participation in the programme plays an important role in fostering optimal development for children with disabilities. A home-based intervention is a promising approach for early intervention that aims at improving parent–child outcomes. The family environment is a natural environment within which services can be delivered to foster mutual enjoyment, parenting skills, and the child’s social and cognitive competence. Findings suggest that home-based, relationship-based interventions improve child and family outcomes (Affleck et al. 1982; Summers 2001; Kim & Mahoney 2005). However, conventional approaches to services for children with disabilities in developed countries are not always practical in developing countries. The institutions and teams of highly specialised professionals are not affordable in the third world, which is short of professionals in every area of human service (Hsia et al. 2003; Kaul et al. 2003; Olness 2003; Teferra 2003). There is very little research that documents the effects of early intervention in developing countries (Maulik & Darmstadt 2007). Approaches that take socio-cultural and economic factors such as parental education, awareness and access to information into consideration have a greater effect than any specific intervention (Bhuiya et al. 1987; Fauveau et al. 1990). McConachie et al. (2000) found that distance training packages along with mother–child groups were beneficial in improving maternal knowledge about disabilityrelated services, reducing maternal stress and improving mothers’ interaction with their children. However, distance training packages had some problems with regards to accessibility; mothers living at a distance from the training centre cited difficulty in accessing services because of the cost of travel (McConachie et al. 2001). Among early intervention models adopted in developing countries, the Portage model CESA 5 (1984, 2003) which incorporates home-based early intervention services has been widely adopted with some reports documenting the efficacy of the early intervention.
The Portage model was originally created to provide home-based services in rural communities to young children with disabilities in the USA. It has been widely adopted internationally, especially in developing countries, and has been translated into 36 languages. It has been an effective programme in training parents to work with their children where there are no professional resources available and where no physical entity for centrebased programmes exists (Thorburn 2003). Its advantages include the availability of a ready-made curriculum, assessment materials and instruction manual. The curriculum is easy to learn and can be used by paraprofessionals. The Portage curriculum for preschoolers (CESA 5 2003, 18 months to 6 years) covers five developmental areas that include communication/language/ literacy, social and emotional development, exploration/approaches to learning (memory, problem solving and reasoning), purposeful motor activity (ability to coordinate movements of large and small muscles of the body) and sensory organisation (the process of receiving, integrating and organising sensory information) (CESA 5 2003). The curriculum also suggests age-appropriate activities, interactions, tasks and routines and explains why certain activities are necessary to promote child development. The content facilitates strategies for teachers to work with parents and knowledge of child development and parenting skills among parents. The curriculum is written to guide the ideas of implementing the programme in natural home and community environment by suggesting many activities based on daily living (CESA 5 2003). Thorborn and her colleagues, who launched successful early intervention programmes in Jamaica, adapted the Portage home-based programme to provide training for children with disabilities in the home and community. Services were mainly delivered by people from the community using fairly simple technology, manuals and assessment tools. Eighty-seven per cent of the families appreciated the home visits, 80% said they understood their child’s disability better and 76% reported that their child had done better as a result of the home training (Thorburn et al. 1992). A few additional studies in developing countries based on the Portage Program in general report positive results: Kohli
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 341 J. Y. Shin et al. • Intervention in Vietnam
(1989) evaluated the effectiveness of the Program with 120 children with developmental delays in India and reported significant gains in their development for the training ranged from 8 to 16 months. Oakland (1997) investigated the effect of the Portage Program over a 5-year period with about 400 Palestinian children and found the programme to be ineffective in advancing the children’s development, possibly because of deleterious environment and lack of an appropriate control group. Zaman & Islamd (1989) found the programme more effective for children under age 10 than for older children in Bangladesh, supporting its utility as an early intervention model. Vietnam is a country of 85 million. One of the fastest emerging economies in Asia, Vietnam is still a relatively poor country with a GDP of US $3100 per capita (Central Intelligence Agency 2007). It is estimated that 5 or 6 million Vietnamese, approximately 6% of the population, have disabilities (USAID 2005). In Vietnam, the Law on Education legally entitled people with disabilities to equal educational rights. Integrated education has been the focus of Vietnamese policy on special education. As the inclusive education model has been implemented, the number of children with disabilities attending schools appears to have been rising steadily (Center for International Rehabilitation 2005). However, only about 3–5% of children with special needs receive services. The main barrier is teacher training (Villa et al. 2003; USAID 2005); there are few special education teacher training programmes established in Vietnam. Training for teaching children with disabilities is included in the national teacher training curriculum, but teachers working with students with disabilities do not possess adequate knowledge, awareness or skills, because of insufficient training. Although there has been some increase in the number and skill level of special education teachers, educational programmes and classroom conditions do not meet the demand for special education (Center for International Rehabilitation 2005). Traditionally, Vietnamese children with disabilities have been cared for by their families, who often have viewed the children as burdens to society or sources of shame and pity (Villa et al. 2003; Hunt 2005). The city of Hue, where the project was conducted, is one of the major cities and is located in
Central Vietnam. There were few special education schools or classes at the elementary education level for children with physical and cognitive disabilities when the project was conducted in 2005 through 2006. There was no education or training available for special educators at the university level in the Central Vietnam. Most teacher training had been carried out by foreign experts or programmes run by non-governmental organisations (NGOs). In this context, we initiated our efforts to provide intervention services for young children with intellectual disabilities (ID) and their families and to explore potential ways of establishing sustainable and feasible intervention programmes where professional resources are not readily available. The purpose of the research project was to assess the efficacy of a home-based intervention programme for children between the ages of 3 and 6 years with identified intellectual delays. Assessment of programme efficacy was carried out by comparing children who received services for 1 year and those who did not. We used the 1984 Vineland Adaptive Behavior Scales (VABS) (Sparrow et al. 1984a) as an indicator of adaptive behaviour and developmental competence, and administered it before the initiation of the programme, at 6 months into the programme and at the end of the programme. Research hypotheses focused on expected differences in measures of adaptive behaviour for children who were in the programme as compared with children who were in the control group and did not receive the intervention services. It was predicted that the children in the intervention group would do better in their adaptive behaviour than the children in the control group.
Method Participants Subjects were 31 parents and their children with disabilities of age 3 to 6 who were identified as having intellectual disability/delays by teachers in kindergarten programmes the children were attending or by records of community health clinics. Initially, 37 children were recruited. After matching on gender, they were randomly assigned to the intervention and control groups. The random assign-
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
volume 53 part 4 april 2009
Journal of Intellectual Disability Research 342 J. Y. Shin et al. • Intervention in Vietnam
Table 1 Characteristics of children and families
Intervention group (n = 6) Variables Children Age (years) Gender (%) Boys (1) Girls (0) Mothers Age (years) Education (%) Primary school (1) Secondary school (2) High school (3) Junior college (4) College (5) SES (%) Very poor (1) Poor (2) Low average (3) Average (4) Rich (5) Vineland domain scores Communication Daily living skills Socialisation Motor skills† Vineland adaptive behaviour composite
Mean
4.6
SD
1.2
10 (62.5) 6 (37.5) 36.2
Control group (n = 14) Mean
4.3
SD
t
0.7
0.9 0.1*
6.6
-0.8* 2.8
8 (57.1) 6 (42.9) 6.7
38.1
6 1 4 4 1
(37.5) (6.3) (25.0) (25.0) (6.3)
4 0 7 2 1
(28.6) (0) (50.0) (14.3) (7.1)
1 6 6 3 0
(6.3) (37.5) (37.5) (18.8) (0)
0 2 5 7 0
(0) (14.3) (35.7) (50.0) (0)
4.5*
57.9 58.0 60.0 40.7† 52.3
11.1 13.8 6.2 18.9 8.2
56.9 62.9 59.6 46.3† 54.6
9.5 10.9 5.2 12.7 7.3
0.3 -0.9 0.2 -0.9 -0.8
* Chi-square is reported. † Raw scores are presented: the standard scores are not available above age 5–11. SES, socio-economic status.
ment of the children continued until the two groups were equivalent in terms of age. One pregnant mother who wanted to be in the intervention group before her new baby was born entered the intervention group after being assigned to the control group. A mother in the intervention group who was busy with her business was willing to wait and entered the control group. Among 37 children, seven children were dropped from the analysis: one child died, four children were out of the age range for the study, one child who had microcephaly performed in the normal range compared with peers on the Vineland scale and one child had physical disability too severe to receive the intervention services. The mean score of 30 children on the Vineland was 53.3 with a range of 31 to 69, which
placed them in the mild and moderate ID range according to the US norm reported for the Vineland (Sparrow et al. 1984b). The research protocol was approved by the Institutional Review Board of the institute at which the first author worked. As Table 1 shows, there were no significant differences between the intervention and control groups in any of the domains of adaptive behaviour measured by the Vineland. Children were classified as having Down syndrome (47%, intervention = 50%, control = 43%), ID (40%, intervention = 31%, control = 50%) or cerebral palsy (13%, intervention = 19%, control = 7%) by either teacher’s information or medical records. There were no significant differences in the composition of disability categories between the two groups; the number
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 343 J. Y. Shin et al. • Intervention in Vietnam
of children with cerebral palsy was too small to test for statistical differences between the groups. In the two groups combined, the majority of the families believed in Buddhism (73%) followed by no religious affiliation (23%) and Catholicism (3%). Primary school was the highest educational level of 33% of the mothers; 3% completed secondary school, 37% high school, 20% junior college and 7% college. There were no significant differences between the two groups of mothers in education or age. Most of the mothers were married (87%) with 3% (n = 1) endorsing each category of living apart, never married, widowed and remarried. The socioeconomic status (SES) of the families was rated by the interviewer who conducted an interview with the mothers by observing the physical conditions of the house. The economic status of the family was rated as being very poor, poor, average or rich by the interviewer who conducted the home visit interviews and who examined the physical environment of the house. Families were considered rich when they had a large house with multiple floors and many highquality possessions such as cars, motorcycles, air conditioners, a living room with a set of couches and a dining table set. When families had a spacious house with a robust structure and had possessions such as motorcycles, refrigerators, televisions and multi-rice cookers, they were considered middle income. Families were regarded as poor when their houses were not solid, were made of brick and had metal roofing, and some of the household materials were not of good quality. Families were considered very poor when their houses were made up of poorquality brick and bamboo wattle with metal roofing or when they were living in the house of their relatives and had very few possessions. The majority of the families were of low average (36.7%) and average economic status (33.3%), with 26.7% rated as poor and 3.3% as very poor. There were no statistically significant differences in economic status between the two groups of families. When we compared the group differences in adaptive behaviour at 0 month based on the Vineland scale, girls performed significantly better than boys, t = 2.0, P < 0.05. Maternal education was categorised as either ‘primary and secondary schools’ or ‘high school or above’. There was no significant difference in adaptive behaviour at 0 month among children from the two educational groups of
mothers, t = -0.8, P > 0.05. The family economic status was grouped into two categories by combining ‘very poor and poor’ and ‘low average and average’ economic status. There was no significant difference in SES between the two groups, t = -0.7, P > 0.05. Eighteen of the children were enrolled in kindergarten programmes and 12 stayed home. The children who stayed home were the ones refused for enrolment by the kindergarten programmes because of their lower intellectual and adaptive functioning, as the programmes did not have teachers to work with them. Those who stayed home had lower adaptive functioning (M = 51.8, SD = 10.2) than those in the kindergarten programmes (M = 54.4, SD = 5.7), but the difference was not statistically significant (t = 0.9, P > 0.05). The differential utilisation of educational services was thus a potentially confounding factor that was taken into account in the post hoc analysis of the effects of the intervention.
Procedures Protocols of parent training Eleven teachers were recruited from primary special education schools and had at least 4 years of experience working with children with intellectual and other developmental disabilities. Before they began the programme, they received 3 months of weekly training in early child development, developmental/ intellectual disabilities, the Portage Program and developing teaching objectives, task analysis and feedback on their practices with children and families. The two experienced supervisors provided support to teachers and standardised the procedures by developing teaching objectives and demonstrating the work with children and parents at the initial implementation of the programme and until the teachers felt competent to carry out the work independently. They also randomly visited the homes of children (each supervisor visited two homes weekly) to supervise the work of the teachers and held monthly sessions with teachers to review teaching objectives and address any issues, problems and questions. They were also available to answer any questions or address problems with the teachers by phone. Typically teachers hold a 1-h session each week, which can be broken down into three small compo-
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 344 J. Y. Shin et al. • Intervention in Vietnam
nents. First, they review the homework assignment by having the parents demonstrate the previously assigned homework with their children. Second, teachers review one or two new teaching objectives they wrote with the parents and demonstrate the steps to achieve a desired behaviour by demonstrating the objectives. These new objectives become the newly assigned homework for the parents, who try them with their children and receive coaching and feedback on their work. Assurance of parent compliance in carrying out the programme was made by teachers, who reviewed the daily homework checklist parents completed and who observed parents demonstrating their work with their children during their next visit. The performance and the work of teachers were in turn monitored by parents by their signing weekly teaching objectives to inform the supervisors that the teachers visited them and taught them the skills written in the teaching objectives. The supervisors paid the teachers for each weekly work when they brought the signed teaching objectives.
Measures The VABS-Parent Survey Form (Sparrow et al. 1984a) was used to assess the children’s development over the 1-year intervention period. The Vineland provides a measure of adaptive behaviour obtained through interviews with the parents. The survey form consists of 297 items that provide information about the child’s functioning in the domains of communication, socialisation, motor skills and daily living. The scale is administered in 20–60 min (Sparrow et al. 1984b). The VABS-Survey Form was standardised on 3000 individuals in the USA, from birth to 18 years, 11 months, using 1-month increment norms for ages 2 through 5 years. Reliability estimates for the VABS, using split-half reliability coefficients, range from 0.83 to 0.97 when adjusted by the Spearman formula. Test–retest reliabilities (at 2- to 4-month intervals) are in the 0.80 to 0.90 range. Inter-rater reliability coefficients range from 0.62 to 0.75 (Sattler 1989). Concurrent validity was established by correlating the Vineland with various tests. An r = 0.55 was reported with the original Vineland and the correlation was 0.52 with the Wechsler Intelligence Scale for Children and the Wechsler
Intelligence Scale for Children-Revised (Sattler 1989). The Vineland is the most widely used instrument in the USA for assessing the adaptive behaviour of children with developmental disabilities (ID) (Luiselli et al. 2001). The Vineland has been successfully used to differentiate among preschoolers with disabilities and to assess the efficacy of special education preschool programming (Shonkoff et al. 1988; Fewell & Oclwein 1991; Bruder 1993). The Vineland was translated into Vietnamese and was evaluated for content (cultural relevance) and semantic equivalence (the same meaning as the English version) by three bilingual Vietnamese. Several items in the daily living skills domain were reworded: for example, the use of a fork and knife was changed into the use of chopsticks. Using seat belts was changed into using a helmet, as motorcycles are the main transportation in Vietnam. One item in the communication domain (use of irregular plurals) was deleted because there is no Vietnamese equivalent to the grammatical usage assessed in that item. The Cronbach alpha values of the scale over three assessments are 0.94 to 0.96 for the communication, 0.95 to 0.97 for the daily living skills, 0.91 to 0.95 for socialisation and 0.95 to 0.97 for motor skills. The validity of the Vietnamese Vineland version was assessed in another study with children with typical development (Goldberg et al. in press). A third-order confirmatory factor analysis supports the construct validity of the scale. Specifically, four second-order factors (communication, socialisation, daily living skills and motor skills domains) accounted for the covariation among the 11 firstorder factors (receptive, expressive, etc. domains). Furthermore, one third-order factor (adaptive behaviour composite) accounted for the covariation among the second-order factors (goodness-of-fitindices of CFI = 0.97 and RMSEA = 0.095). These results are consistent with the proposed, underlying model of the scale. Therefore, the Vietnamese version shows the equivalent construct of the four domains as in the US version.
Results Means and standard deviations for the domains and subdomains of the Vineland scale for the interven-
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 345 J. Y. Shin et al. • Intervention in Vietnam
tion and control groups at 0, 6 and 12 months are presented in Table 2. We compared the data on these measures for the intervention and control groups at three time points. A repeated measures anova was performed to examine the difference between the groups in their improvement on the adaptive behaviour composite (the overall adaptive behaviour score) at 6 months and 1 year. The absolute increase was greater for the intervention group at both time points showing significant improvement at 12 months (F = 3.4, P < 0.05), while the control group did not. However, there was no significant group ¥ time interaction. Repeated measures manovas were computed to examine group differences on four domains of the scale. When the two groups were compared on the sum of the scores for each domain, there were no significant group ¥ time effects over the course of 1 year except in motor skills, suggesting that the intervention group did not improve significantly more than the control group in the areas of communication, daily living skills and social skills. When the sum scores of motor skills were examined, the interaction was significant, showing that the intervention group gained significantly more than the control group over 1 year (F = 3.9, P < 0.05). When the two groups were compared on the standard scores for communication, daily living skills and social skills, which compared the performance of the children to their age group, there were no significant effects in any of these areas. Neither group gained significantly over 1 year in the areas of communication and daily living skills, but both gained significantly in social skills (intervention, F = 5.8, P < 0.05, control, F = 8.3, P < 0.01). Another set of repeated measures manova was computed to examine differences between the two groups of children at three different times of the intervention on 11 subdomains of the scale. Both groups improved significantly in the area of expressive language while only the intervention group continued to improve significantly over both 6 and 12 months although the group ¥ time interaction was not significant. Among the subdomains of daily living skills, the area of personal care showed a significant interaction, revealing that the intervention group did better than the control group over the course of 1 year (F = 2.7, P < 0.05). Among the
subdomains of social skills, the two groups showed significant improvement over the course of 1 year in the areas of interpersonal relationships, play and leisure time and coping skills. However, the interaction was not significant in any of these areas, suggesting that the intervention group did not gain significantly more than the control group in social skills. Among the subdomains of motor skills, the interaction was significant in fine motor skills with the gross motor skills approaching the significant level, suggesting that the intervention group gained more than the control group over the course of the year in these areas, (F = 3.9, P < 0.05, for fine motor skills, F = 2.3, P = 0.052 for gross motor skills).
Analysis of performance patterns The small sample for this study limited the power of our research design and increased the likelihood of type II error. Because of this, we explored patterns in the performance of the two groups on each domain and its subdomains to examine whether consistent patterns emerged. As indicated in Figs 1–9 of the adaptive behaviour composite and all the areas of daily living and motor skills, the performances showed a consistent pattern; the intervention group showed greater improvement than the control group, suggesting that the intervention group gained more than the control group in the overall areas of daily living and motor skills.
Child and maternal characteristics that predict developmental outcomes There was a wide range of SDs in outcome measures, which reflected the diversity of the children’s characters and backgrounds. We conducted post hoc analyses to further explore child and maternal characteristics that might predict the outcome. We considered child’s gender and age, and whether or not they received intervention services as predictor variables in the regression analyses. We considered mother’s education and family’s SES as maternal predictors, but because of a high correlation between the two variables, r = 0.54, P < 0.001, we include only maternal education in the regression analyses. We also considered the programme status
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
20.6 10.9 5.8 14.7 1.1 21.9 13.8 13.9 4.0 5.2 13.8 6.2 7.8 5.2 1.8 18.9 10.9 8.6
42.6 57.9 19.0 22.9 0.7
48.9 58.0 38.7 3.4 4.9
40.1 60.0 25.2
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
13.7 1.2
40.7 24.7 16.0
47.6 27.8 19.8
16.9 2.7
47.1 63.1 27.6
59.0 61.4 45.3 5.4 8.3
50.0 60.0 21.0 26.7 2.3
55.6
Mean
16.8 9.5 8.3
5.0 3.7
15.5 8.0 8.0
24.4 11.4 13.6 3.9 8.6
24.4 14.0 5.1 17.1 4.7
10.5
SD
6 months
53.9 30.6 23.4
18.1 4.7
53.2 65.9 30.4
68.9 63.6 51.3 7.0 10.6
55.1 59.2 21.7 30.9 2.6
57.4
Mean
16.4 8.9 8.1
4.7 5.9
18.4 11.0 7.4
28.5 18.0 13.7 4.6 9.6
23.3 15.2 4.7 15.8 5.8
13.7
SD
12 months
Intervention group (n = 16)
8.6** 4.8* 11.9**
27.8*** 4.9*
14.1** 5.5* 3.8*
9.1** 1.1 8.4** 5.5* 4.3*
8.1** 0.8 9.5** 5.0* 2.2
2.8
6 vs. 0
F
44.2*** 38.8*** 27.3***
20.4*** 7.6**
32.4*** 5.8* 32.1***
21.4*** 1.6 29.2*** 7.1** 11.1**
26.2*** 0.0 3.9* 24.6*** 1.4
3.4*
12 vs. 6&0
43.4 28.5 17.8
14.0 0.4
39.7 59.6 24.9
48.4 62.0 42.4 3.3 4.4
40.3 56.9 19.9 20.3 0.1
54.6
Mean
†
16.3 6.5 6.6
4.2 0.6
12.1 5.2 6.1
18.9 10.9 12.2 2.0 2.3
13.5 9.5 4.0 9.8 0.3
7.3
SD
0 month
49.0 31.0 19.5
17.1 1.3
46.3 61.9 27.0
58.1 61.1 44.5 5.4 7.1
47.3 57.3 21.3 25.4 0.6
55.7
Mean
15.4 7.6 6.8
5.0 1.3
18.5 5.9 5.8
21.7 12.5 12.3 3.2 4.3
15.7 9.4 3.7 12.0 1.2
10.0
SD
6 months
52.9 30.9 20.7
18.6 2.7
52.7 64.6 30.7
66.3 60.4 49.0 5.5 8.8
52.4 57.6 21.9 29.2 1.4
56.3
Mean
16.3 8.9 8.5
3.5 1.9
13.7 7.5 5.9
24.5 14.5 12.8 4.0 7.2
18.8 11.7 4.0 13.4 3.7
11.2
SD
12 months
6.9* 6.4* 3.5*
19.2*** 18.5***
31.0*** 3.5* 4.8*
16.0*** 0.2 2.6 11.0** 7.9*
10.0** 0.7 7.1** 9.6** 2.6
0.8
6 vs. 0
Control group (n = 14) F
2.7 0.8 3.9*
17.2*** 23.6***
79.3*** 8.3** 41.5***
28.5*** 0.2 14.0*** 1.6 4.2
19.2*** 0.1 5.4* 29.7*** 1.8
0.8
12 vs. 6&0
3.9* 2.3 (.054) 3.9*
0.0 0.6
0.1 0.1 0.2
1.4 1.3 2.7* 0.8 0.2
0.0 0.2 0.3 0.2 0.4
1.0
(Treatment ¥ time)
F
Journal of Intellectual Disability Research
Motor skills domain standard scores were not computed: The Standard scores are available up to age 6–11. * P < 0.05, ** P < 0.01, *** P < 0.001, one-tailed test.
8.2
52.3
Adaptive behaviour composite Communication Sum Standard Receptive Expressive Written Daily living skills Sum Standard Personal Domestic Community Social skills Sum Standard Interpersonal relationships Play and leisure time Coping skills Motor skills 1 Sum Gross Fine
SD
Mean
0 month
Domain
Variable
Table 2 Vineland Scale Scores over time and intervention
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J. Y. Shin et al. • Intervention in Vietnam
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Journal of Intellectual Disability Research 347 J. Y. Shin et al. • Intervention in Vietnam
35.0
58.0 55.7
56.0 54.0
56.3
55.6 54.6 Intervention Control
53.0 52.0
31.0
57.4
57.0 55.0
Motor Skills – Gross Motor
52.3
51.0
Gross Motor Skills Score
Adaptive Behavior Composite Scores
Adaptive Behavior Composite
50.0 0 month
6 months Time
Intervention Control
43.4 40.7
35.0
Daily Living Skills Adaptive Score
47.6
30.0
23.4 20.7
19.5
16.0
Intervention Control
10.0
5.0
6 months Time
63.6 61.4 60.4
61.1
60.0
Intervention
58.0
58.0
Control
56.0 54.0 52.0 50.0 6 months Time
12 months
Daily Living Skills Domain (Sum)
25.0 19.8
62.0
62.0
Figure 5 Daily living skills – standard score.
Motor Skills – Fine Motor
0 month
64.0
0 month
Figure 2 Motor skills domain – sum of raw scores.
17.8
66.0
12 months*
Daily Living Skills Domain Sum Score
Motor Skills Domain Sum Scores
52.9
49.0
6 months Time
12 months
Daily Living Skills Domain (Adaptive Score)
53.9
50.0
6 months Time
Figure 4 Motor skills domain – gross motor.
55.0
0 month
Fine Motor Skills Score
Control
0 month
60.0
15.0
Intervention
15.0
Motor Skills Domain (Sum)
20.0
24.7
20.0
12 months
Figure 1 Adaptive behavior composite.
40.0
27.8
25.0
10.0
49.0
45.0
30.9 30.6
28.5
30.0
80.0 68.9
70.0 59.0
60.0 46.9
of the children as either staying home (code = 2) or attending kindergarten programmes (code = 1) as an independent variable. We conducted a hierarchical regression analysis with adaptive behaviour composite scores on Vine-
58.1 Intervention
50.0
Control
48.4
40.0 30.0 20.0 0 month
12 months*
Figure 3 Motor skills domain – fine motor.
66.3
6 months Time
12 months
Figure 6 Daily living skills – sum of raw scores.
land at 12 months as dependent variables to examine whether there were child and maternal characteristics that might have predicted the outcomes (Table 3). The adaptive functioning at 0 month was entered into a first step of the hierarchi-
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 348 J. Y. Shin et al. • Intervention in Vietnam
Daily Living Skills Domain – Community 12.0 10.6
Community Score
10.0 8.3
8.8
8.0 7.1
6.0
Intervention
4.9
Control
4.4
4.0 2.0 0.0
0 month
6 months Time
12 months
Figure 7 Daily living skills – community.
Daily Living Skills Domain – Domestic 8.0
Domestic Score
7.0
7.0
6.0
4.0 3.0
5.5
5.4
5.0 3.4
Intervention Control
3.3
2.0 1.0 0.0 0 month
6 months Time
12 months
intervention status, and mother’s education were entered into a second step of the hierarchical regression. The combination of these variables accounted for 23% of the variance beyond what the adaptive behaviour at 0 month contributed, and the change in R2 was significant (F change = 8.6, P < 0.05). After controlling for the baseline adaptive functioning, child and maternal characteristics also contributed to the outcome significantly. The adaptive functioning at 0 month was the most significant predictor of the independent variables. Children who performed better than the others at the beginning of the programme also did better at 12 months. In addition, child’s gender and maternal education were significant contributors to the outcome at 12 months, with the programme status approaching the significant level. Girls performed better than boys initially and also did better at the end of the year. By the end of the programme, those who attended kindergarten programmes did better than those who stayed home, while there was no statistically significant difference between the groups at the beginning. Children whose mothers had higher levels of education performed better at 12 months, while maternal education did not predict adaptive behaviour at 0 month.
Figure 8 Daily living skills – domestic.
Discussion Daily Living Skills Domain – Personal 60.0
Personal Score
55.0 50.0 45.0 40.0
51.3 49.0
45.3 42.4
Intervention Control
44.5
38.7
35.0 30.0 0 month
6 months Time
12 months*
Figure 9 Daily living skills – personal care.
cal regression to control for the baseline performance of the children. The adaptive functioning at 0 month alone accounted for 46% of the variance in adaptive behaviour at 12 month (F = 23.7, P < 0.001). Child’s gender, age, programme status,
In this study we examined the effects of home-visit services based on the Portage model and its manual on a sample of Vietnamese children. The intervention group made significantly greater gains in personal care skills as well as in motor skills as compared with the control group. Teachers typically set up their teaching goals by asking parents about their expectations. As children grew older, probably mothers were concerned about their children’s independent living skills, such as changing their clothes, eating properly and attending to their personal hygiene. It appears that these concerns were addressed during the discussions, which might have resulted in the teachers’ focusing on setting teaching goals in these areas. The children in the intervention group also showed significant gains in the areas of motor skills. Many of the training activities involved fine motor skills, such as cutting, drawing, writing and sorting, discriminating and matching
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 349 J. Y. Shin et al. • Intervention in Vietnam
Variable Step 1 Adaptive functioning at 0 month Step 2 Adaptive functioning at 0 month Child’s gender Child’s programme status (home stay vs. kindergarten) Child’s age Child’s intervention status (intervention vs. control) Mother’s education
B
1.1 1.3 7.2 -5.8
Standardised B
F
R2 change
23.7***
0.46***
8.6***
0.23**
Table 3 Summary of regression analysis for child and maternal characteristics predicting adaptive functioning at 12 months
0.7*** 0.8*** 0.3* -0.2 (.052)
1.3 4.3
0.1 0.2
-8.1
-0.3*
* P < 0.05, ** P < 0.01, *** P < 0.001, one-tailed test.
small objects, and gross motor skills that include physical exercise and plays. Children in the intervention group benefited more than the control group in these areas when individual attention and training was provided by teachers and parents. Both groups of children showed significant improvement in communication and social skills although the group differences were not significant. It could be that many children from both groups benefited from the kindergarten education by interacting with their peers and teachers. The kindergarten programmes in Vietnam run from 7:30 am to 4:30 pm every day except weekends. Spending the whole day with the peers, playing and interacting with them the children obtained enriched social and educational experiences, which might have affected their communication and socialisation skills. In spite of the disproportionate number of children in the intervention group (nine children in intervention and three children in control) who stayed home and did not attend kindergarten programme which put the intervention group at a disadvantage, the intervention group did as well as the control group in communication and social skills. This suggests that the weekly 1-h home-visit programme was as effective as the daily kindergarten programme. When the intervention programme was established, we could utilise teachers who were working at local special education programmes that included children with various disabilities including ID, blindness or deafness. Teachers did not have formal college training, but received ongoing training and
supervision in their local special education schools by foreign NGOs. Therefore, the teachers had had some experiences of working with children with disabilities, although not necessarily with ID. This might have helped the leaders in addressing training issues, but without formal training, it could be that the teachers focused on more concrete accomplishments, such as motor skills and daily living skills rather than on communication skills which require more advanced experience and training. Therefore, although the teachers were trained to address the immediate concerns of the parents, it could be that daily living and motor skills were easier than other areas for the teachers to work on when they did not have substantial expertise in special education. Another interpretation is that these children stayed somewhat constant in standard scores of communication and social skills areas, meaning that they stayed developmentally stable compared with their normal age groups. Therefore, it is possible that home visit training and/or kindergarten education might have prevented them from falling behind their developmental status compared with their peers. As the results of multiple regression analyses show, complex child and family background variables contributed to the significant outcomes. Whether or not the children attended kindergarten programmes appeared important with results approaching statistical significance, and studies with a larger sample size to confirm or refute would seem justified. Maternal education was important in
© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd
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Journal of Intellectual Disability Research 350 J. Y. Shin et al. • Intervention in Vietnam
explaining adaptive behaviour at 12 months but not at the beginning of the project. It appears that mothers who had higher education benefited from the training programme more than the others and were better able to train their children and to advance their development. Small sample size limited the power of our research design. While it is conceivable that the intervention had positive effects on those who had better adaptive functioning initially, a larger sample size will reveal more specifically the complex child and family background variables that determine which children benefit most from the intervention programme. In addition, we relied on parent reports to assess the adaptive functioning of the children, and the teachers who interviewed the mothers had prior knowledge of the children. There is no intellectual testing available in Vietnam, and administration of standardised intellectual testing and developmental scales demands long-term training. The Vineland scale, the mostly widely used standardised scale in the paediatric setting in the USA and many other countries, was the option we chose, as the scale was relatively easy to teach the teachers to use. More objective measures, however, such as administration of developmental scales by trained workers who are blind to the intervention status of the children, should be considered feasible to determine efficacy of the programme more objectively and accurately. The significant results on personal care and motor skills and the overall patterns of improvement of the intervention group over the control group in other areas confirm the promising results that children in the intervention group improved more than controls in daily living skills and motor skills. The results are promising in that they show that the majority of children and families benefited from the home visit programme in the areas of personal care and motor skills. These are the very skills that are most important for independent living and for relieving severe caregiving burdens. Our experiences in Vietnam demonstrate the feasibility of implementing an early intervention programme for children with ID within the context of the developing world, where resources are limited. These improvements in the majority of the children were accomplished through the use of teachers (who did not necessarily have formal college train-
ing in special education, but had some experience of working with children with intellectual and other developmental disabilities) and easy-to-follow manuals teachers could use to train families to work with their children. Additionally, trained supervisors played an important role in providing hands-on support and training on a regular basis. In future studies, objective measures of the fidelity of the implementation of the intervention should be considered to validate the level of expertise. The programme could not meet the needs of all children with different levels and types of disabilities. However, it appears a promising approach for training the majority of children with disabilities in adaptive skills that will increase their independence and relieve the demanding caregiving burden on their families.
Acknowledgement This project was partially supported by funding from KFR-2005-J01702 in Korea and a travel grant by the Center for International Rehabilitation and Research Information Exchange in the U.S.
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Accepted 22 December 2008
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