Kansas – NCCP

Kansas Strategies

Kansas: Statewide Attachment and Biobehavioral Catch-up (ABC) in Home Visiting and Part C Early Intervention

The Kansas ABC Early Childhood Initiative aimed to expand support for social-emotional development through Attachment and Biobehavioral Catch-up (ABC) in agencies offering home visiting. ABC is an evidence-based, 10-week in-home dyadic treatment program designed for parents of children from 6 to 48 months old who have experienced early adversity. ABC providers coach parents and other caregivers during in-person sessions using in-the-moment feedback and review of videos of caregiver-child interactions to support sensitive, nurturing parenting that helps children develop attachment, self-regulation, and coping skills. Three types of behavior are encouraged: nurturing the distressed child, following the child’s lead with delight, and avoiding harsh or frightening behavior. While ABC is standardized, it allows for tailoring and flexibility, particularly through clinical supervision that helps coaches work with families from diverse cultural backgrounds. ABC is available in English and Spanish.

In 2016, after the success of a small ABC trial in Kansas, a group of five foundations led by the United Methodist Health Ministry Fund expanded access to ABC through a larger pilot initiative serving communities across the state. During the first phase of the pilot initiative expansion, from 2017-2020, the funders selected five organizations that were already delivering home visiting services in 36 counties across the state:

Horizons Mental Health Center, a mental health agency serving Reno County in central Kansas;
LiveWell Northwest Kansas, an agency focused on early childhood development and health serving 13 counties in northwest Kansas;
Project Eagle, serving pregnant women and families with young children, including with Early Head Start Home Visiting, based at the University of Kansas Medical Center in Wyandotte County, which includes Kansas City;
Rainbows United, an agency for children with special needs serving Butler County and Sedgwick County, which includes Wichita;
Russell Child Development Center, a multiservice agency including Part C Early Intervention serving 19 counties in southwest Kansas.

Each organization used scores on the 27-item Household Strength and Strain Inventory (HSSI) screening tool to refer families at high potential risk for experiencing toxic stress to ABC. The HSSI has three risk factor subscales (financial stress, family health stress, and relational stress) and one subscale on family protective factors. Families were referred if they scored high on any one risk factor subscale or moderately across the scale; agency staff administering the tool could also refer families based on their clinical judgment. During the first three-year phase of the pilot initiative, of the 536 families who completed screens, 507 had positive screens and 402 were enrolled to receive ABC. Over the three years, 682 caregivers and 907 children were supported by ABC.

Providers and families reported that they valued the positive, strengths-focused approach of ABC, which helped ABC engage families and serve as an entry point for families to access longer-term supports, such as additional home visiting and other services. Part C Early Intervention providers delivering ABC noted that children were making quicker gains even in skills outside the social-emotional domain because behavioral concerns and the parent-child relationship was being addressed. However, programs found that because families in the pilot initiative were high-risk, they had greater demand for wraparound services to address social determinants of health needs and also struggled to complete ABC in 10 weeks, taking an average of five months to complete the 10 sessions.

To address families’ needs for supports beyond the ABC home visits, agencies referred families to additional services. These needs were identified using the HSSI during the agency’s intake process, which was conducted by a care coordinator; prior to the pilot initiative most agencies were not conducting formal screening of family needs. Incorporating the HSSI into agencies’ everyday routines was a significant undertaking during phase one. As part of the pilot initiative evaluation, ABC coaches conducted the North Carolina Family Assessment Scale, which could serve as the basis for additional referrals. Families were often referred to additional services offered by the agency, such as longer-term home visiting programs. Most families were receiving other supports concurrently with ABC or transitioned to them after.

Of the families served, 41 percent were Latinx or Hispanic, and 22 percent primarily spoke Spanish in the home. Bilingual ABC coaches reported that ABC was culturally relevant to the Spanish-speaking families they worked with and sharing a linguistic and cultural background contributed to families’ positive experiences with ABC. However, they also observed that translations of ABC materials did not always reflect colloquial Spanish or translate into concepts that resonated with families. A lack of bilingual supervisors meant that coaches had to translate their videos into English for clinical supervision.

During phase 2 of the pilot initiative, which three of the original agencies participated in from 2020-2023, sites began to offer ABC Toddler in addition to ABC Infant. Following the end of the pilot initiative in 2023, Russell Child Development Center and LiveWell Northwest Kansas offered ABC Toddler through April 2024 to support continuing data collection for the pilot evaluation. Each site anticipates continuing to deliver ABC through other funding streams while exploring longer term sustainability solutions. In addition, during the pilot initiative period, United Methodist Health Ministry Fund helped to fund and coordinate training of ABC coaches at four additional Part C Early Intervention providers that were not formally part of the pilot initiative. These Part C providers continue to support the use of ABC with the families they serve.

Workforce Development

United Methodist Health Ministry Fund coordinated training of ABC coaches at the participating pilot initiative sites. ABC coaches are not required to have a college degree. Training consisted of a two-day virtual training with the model developers at University of Delaware, which covers ABC and in-the-moment commenting, a key method used by ABC coaches to highlight parents’ use of targeted behaviors. Each week for the first year, coaches received 60 minutes of clinical supervision to review ABC sessions and 30 minutes of individual supervision on the use of in-the-moment commenting. Coaches who completed this year of supervision became certified in the ABC infant model, for children 6-24 months old. To become certified in toddler ABC, for children 24-48 months old, coaches completed an additional year of supervision. University of Delaware also offers a Spanish support workshop for bilingual coaches delivering ABC in Spanish.

During the pilot initiative, 39 infant coaches and 10 toddler coaches were trained. Prior to the ABC training, some were delivering home visiting and others were Part C Early Intervention providers, including occupational therapists and social workers. One site’s ABC-trained home visitors left after a year, and so the agency had to hire and train a new cohort, including two bilingual Spanish-speaking coaches. One Spanish-speaking coach became certified after having participated in ABC as a parent. To address challenges of retention and burnout, which were greater among home visitors than Part C providers, leaders of the pilot initiative from the consortium of funders held a one-day annual retreat focusing on self-care and staff support, and introduced retention bonuses. ABC coaches also emphasized the value of the year of weekly clinical supervision provided by the University of Delaware in helping them to maintain enthusiasm and prevent burnout.

The pilot initiative included a learning community for the five participating agencies, with quarterly meetings held over the course of the pilot initiative. With a regular attendance of 15-20 participants, including ABC coaches and supervisors, the learning community fostered relationship-building and support beyond what was provided by participants’ agencies. Supervisors particularly valued the connections and ability to share experiences with other supervisors, including discussions around the referrals process, sustainability, and billing.

Financing

Funding for the pilot initiative came from a consortium of five philanthropies and covered the ABC coaches’ training, ongoing support, and supervision, delivery of ABC services, and a formal evaluation. Funding for the pilot initiative ended in 2023, and sites have been engaged in sustainability efforts.

Agencies delivering ABC to families receiving Part C Early Intervention services have had the greatest success in finding a sustainable public funding model by billing Medicaid. In Kansas, Part C Early Intervention has been carved out from the state’s managed care system and providers bill the state directly using a fee-for-service model. Every child eligible for early intervention receives a diagnosis of developmental delay, which allows for billing under a case management code (T1027) for Developmental Intervention Services. All Medicaid-eligible Part C Early Intervention providers can bill using this code regardless of their professional discipline. To be eligible to bill Medicaid, an early intervention provider must meet qualification standards (for instance, being a licensed, Master’s-level Early Childhood Special Education professional) and employed by a network approved to provide Part C Early Intervention services. One organization, Greenbush, helps employees of six of these networks bill the state Medicaid program for services. Greenbush has been able to bill Medicaid on behalf of these Medicaid-eligible employees when they deliver ABC, which falls under the T1027 billable activity: “Providing families with information, skills, and support related to enhancing the skill development of the child.” T1027 is billed in 15-minute increments at $11-12. While this rate does not fully cover the cost of delivering ABC, such as its associated administrative time (e.g., scoring assessments), reflective supervision, and reduced caseloads, Greenbush is able to supplement the Medicaid reimbursement with grant funds to meet the full cost. Through this approach, Greenbush is able to support two full-time ABC coaches across the networks it supports, though demand for ABC could sustain an additional full-time coach.

Some sites have been able to secure home visiting funds associated with the state appropriations for early childhood programs. Mental health professionals associated with Community Mental Health Centers are able to bill for services as well.

Monitoring and Evaluation

An evaluation of phase one of the initiative, from 2017-2020, examined successes and challenges related to implementation (some of which were discussed in the first section above), as well as caregiver and child outcomes. Pre- and post-intervention measures examined children’s social-emotional difficulties and overall well-being; caregivers’ attitudes toward children’s crying, caregiver self-efficacy, and parental capabilities; observed parent-child interactions; and family functioning. Children’s cortisol levels were measured pre-, post-, and at six-months post-intervention. Key findings[i] included:

Parent concerns about children’s social-emotional well-being decreased
Children’s stress (reflected in cortisol levels) was reduced[ii]
ABC coach ratings showed increases in children’s overall well-being
Parent knowledge and belief in caregiving abilities increased
In interactions with their children, parents were observed to be less intrusive and demonstrated more sensitivity and enjoyment.

The evaluation of phase two, from 2020-2023, added instruments to measure parental stress, family empowerment, as well as child development and executive functioning. Data collection for phase two ended in April 2024.

Evaluators worked with the sites throughout the pilot initiative on fidelity and quality improvement efforts. They occurred primarily at learning community events where sites could share information on lessons learned and successful adaptations on topics such as the referral process for families and working with families involved in the child welfare system.

Special thanks to the following individuals for providing information for this profile: Katie Schoenhoff, Director of Programs at United Methodist Health Ministry Fund; Whitney Grube, Assistant Professor at University of Kansas, School of Social Welfare; and Monica Murnan, Director of Community Support Services at Greenbush

Last updated April 2024

[i] Mendenhall, A. N., Byers, K., Grube, W., & Sattler, P. (2021). Kansas ABC Early Childhood Initiative: Phase 1. May 2017-April 2020 evaluation report. KU School of Social Welfare. https://reachhealth.org/wp-content/uploads/2021/11/ABC_Final-Report.pdf

[ii] “Though cortisol level patterns became more normalized, the change was not statistically significant for the entire sample.”