Columbia University Mailman School of Public Health

Connecticut

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Strategies

IECMH for Vulnerable Children: Home Visiting, Dyadic Treatment, and Workforce Development

Connecticut is addressing the mental health and developmental needs of exceptionally vulnerable children through the implementation of Child First, an evidence-based model delivered in families’ homes by 15 agencies across the state. Child First targets families with children prenatal through age five who have social-emotional or developmental problems and are experiencing multiple adverse circumstances, including extreme poverty, homelessness, domestic violence, incarceration, maternal depression, and abuse and neglect. The model incorporates Child-Parent Psychotherapy dyadic treatment (see research summary on dyadic treatment) in its home-based services, as well as care coordination to connect families to community-based resources and bolster parental executive functioning.

Families receive home-visits twice a week during an initial period when a comprehensive assessment of family well-being and needs is conducted. For the child, the key areas of focus in this assessment are child development and early education; child behavior and emotions; and child health services. The assessment also focuses on adult mental health, parent support, adult education and employment, family health services, and social services and other concrete needs. Based on the comprehensive assessment, an individually tailored child and family plan is developed in collaboration with the family. This plan reflects family strengths, goals, cultural background, and needs. The plan is continually revised as the family’s circumstances change.

Child First clinicians and care coordinators visit families weekly either together or individually over six to 12 months. When necessary, the Child First Team may visit more frequently or work with families longer than 12 months. The visits focus on developing a trusting relationship with families, helping reduce family stress, promoting nurturing parent-child relationships, and connecting families to services that meet families’ needs and align with their goals. Clinicians provide dyadic treatment using the Child-Parent Psychotherapy Model (see research summary on dyadic treatment). The goals of CPP are to help the parent understand normal development, the effects of trauma on the child, and the meaning of child behaviors, as well as to increase use of a responsive, nurturing style of interaction that helps build a positive, secure relationship between the parent and child.

Child First Care Coordinators work with families to connect them to a range of community services that can address conditions creating stress, help children with developmental needs, and advance parents’ personal goals (e.g., high quality early care and education, medical services, adult mental health treatment, job training). Through outreach to programs and agencies in the community, Care Coordinators develop a network of services that can support families in Child First, based on individual family needs. Both the Care Coordinators and clinicians help parents develop skills in assessing their needs and taking steps to secure needed services for their child and themselves.

An extension of Child First home-based services is early childhood mental health (ECMH) consultation to teachers and providers for children in early care and education (ECE) settings (e.g., Head Start, child care). Child First often receives referrals from these settings concerning children’s challenging behavior and development in the ECE setting during the assessment process. The Child First clinician providing ECMH consultation helps the teacher or provider create a classroom environment that supports the child’s social-emotional growth and use supportive strategies for addressing challenging behavior that is often related to trauma and difficult family circumstances.

The National Program Office (NPO) works in partnership with local affiliate agencies to establish Child First services in a new community. A Child First Clinical Director/Supervisor within the local agency typically oversees four Child First Teams, which consist of a Mental Health Clinician and a Care Coordinator. Each Child First Team works with 12 to 16 families at a time. Site Clinical Directors receive biweekly reflective consultation by a state-level Child First Clinical Director employed through the NPO, as well as clinical supervision from a senior clinician within their local agency.

An agency approved by NPO to deliver Child First services must hire staff that meet a number of requirements. A local agency’s Child First Clinical Director/Supervisor is expected to have at least a master’s degree in a mental health field and five years of experience providing relationship-based dyadic psychotherapy with young children. Child First team mental health clinicians must have a master’s degree or higher, be licensed in a mental health specialty, and should have at least three years of experience providing relationship-based dyadic psychotherapy with young children. A care coordinator must have a bachelor’s degree, experience working with diverse racial and ethnic communities, and familiarity with community services. Child First NPO requests that the affiliate agency consult with the NPO State Clinical Director about any potential hire that does not meet these expectations.

Workforce Development

Child First NPO trains staff from new affiliate agencies through a Child First Learning Collaborative. Through four multi-day sessions over seven months, the learning collaborative covers a range of topics, including key elements of the model’s relationship-based approach, dynamics of early adversity and trauma, and strategies for supporting healthy executive functioning in both children and adults. Sessions provide case examples to help participants learn about and practice aspects of assessment, treatment planning, intervention, and termination.

Between learning sessions, staff complete Distance Learning modules, which are delivered online and through video conferencing. Online training modules are largely completed individually, with opportunities for reflection through discussion questions embedded throughout the presentations and administration of quizzes at the end of each presentation to assess ongoing learning. These are supplemented by group discussion with the affiliate site Clinical Director. Distance learning topics include fundamentals of early childhood development, implementing the Child First assessment process with families, and intervening with families coping with specific challenges such as substance use disorders, homelessness, or depression.

Child-Parent Psychotherapy training for Child First Clinicians is conducted by a national CPP trainer also using a learning collaborative format that includes three multi-day sessions over 12-months. There are biweekly consultation calls with the CPP trainer over 18 months.

Child First team members receive at least 3.5 hours of clinical supervision per week from the Child First affiliate Clinical Director/Supervisor. The work of Child First staff is highly challenging. It requires a high level of reflective capacity, understanding of complex issues facing families, and ability to manage multiple demands. In rural areas, it is difficult to find licensed clinicians. Child First has met these challenges by supporting its staff through responsive training initiatives that blend distance learning and in-person training. Child First in-person training for new hires at existing sites is called Staff Accelerated Training (STAT) and consists of four consecutive monthly training sessions that support new Clinicians and Care Coordinators as they learn the Child First model. This has allowed Child First to train new staff coming into existing sites in a rapid, efficient, and effective way, yielding positive experiences by new staff and maintaining strong outcomes over time.

Financing

To implement Child First, local champions or regional/state agencies (which may work with local affiliate agencies) must identify and secure funding for a minimum of three years for initial start-up and early implementation within affiliate agencies. Agencies typically commit to hiring a minimum of four Child First teams. These affiliate agencies pay ongoing annual fees to the National Program Office for periodic specialty training; training with staff turnover; database use, data analysis, and reporting; reflective clinical consultation (biweekly); technical assistance; and accreditation.

In Connecticut, the start and expansion of the Child First program have been funded by a mix of philanthropy, state general funds from the Department of Children and Families and the Office of Early Childhood, and federal Maternal Infant Early Childhood Home Visiting (MIECHV) funds; Child First is recognized as an evidence-based model as part of HRSA’s federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) program.

As Child First expands to new states, other funding strategies have been used. Medicaid funds are used in North Carolina to pay for services. In Palm Beach County, Florida, services are funded by the Children’s Services Council of Palm Beach County, whose primary source of revenue is county property taxes. In all three states, start-up and training have been funded by philanthropic or public agency grant dollars.

Monitoring and Evaluation

All Child First affiliate sites report to the National Program Office on two types of data: (1) Benchmarks (process data) and (2) Outcomes (assessment data). The Child First NPO has established reporting rules for both types of data. Through a combination of reports that sites access directly through Child First’s electronic health record, as well as reports distributed by the NPO, affiliate sites use data to assess the ongoing implementation of the model and make practice modifications accordingly. The Child First NPO regularly reviews data to assess data quality and address any problems with data, to support the implementation of the model at the affiliate sites, to enhance services throughout the Child First Network, and to accredit Child First sites.

Local affiliate agencies that have completed initial training and have been operating for at least two years undergo a Child First Accreditation review process in collaboration with the National Program Office’s Quality Enhancement Team. Accredited local affiliate agencies are those providing Child First services in adherence to the program model. The Accreditation Process involves an in-depth review of an affiliate site’s adherence to the Child First model throughout the one-year period prior to the Accreditation review. A variety of mechanisms are used to collect information and assess performance, including reviews of data from the Child First Comprehensive Clinical Record (CFCR) and the Assessment Scoring Database (Benchmarks and Outcomes), Self-Study, chart reviews focusing on formulation and treatment plans, collection and review of the Child First Clinical Fidelity Framework and Programmatic Fidelity Checklist, video reviews, and in-person interviews with Child First staff.

A randomized controlled trial (RCT) of Child First in Bridgeport, Connecticut, showed significant positive outcomes for participating children and families, including fewer externalizing problems for children, improved child language skills, fewer mental health symptoms for mothers, and decreased child abuse and neglect. Child First is currently involved in a second RCT that is incorporating sites in both Connecticut and North Carolina. Child First is recognized as an evidence-based model as part of HRSA’s federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) program.

Special thanks to Mary Peniston, Chief Program Officer at Child First, and her colleagues at Child First for providing information for and reviewing this profile.