New York – NCCP

New York Strategies

Home Visiting Dyadic Treatment with Attachment and Biobehavioral Catch-up: Power of Two

Power of Two (PO2) is a home visiting program serving families in New York City by delivering Attachment and Biobehavioral Catch-up (ABC) in combination with other family supports. 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.

Early in the program’s implementation, PO2’s ABC coaches were finding that family stressors such as housing instability, food insecurity, mental health challenges, and domestic violence were disrupting efforts to maintain the model’s fidelity and the effectiveness of ABC. In response, PO2 developed the additional role of the Community Resource Specialist (CRS). The CRS works with families to connect them to a range of resources to help address their concrete and mental health needs, which are identified through questionnaires during program intake. If the intake questionnaires identify possible family mental health needs, the CRS follows up right away and provides at least three resources for mental health services. While these services are optional, the CRS will attempt to engage the parent in trying mental health support and can help with scheduling appointments. CRSs follow up with all families within a few days of intake, at 2-3 weeks, and at the end of the program. In part, CRSs use these follow-up calls to ask families if services they have been referred to are helpful, which allows CRS refine their local resource referral guides. CRSs are available to families for the duration of their participation in the program as needs arise.

PO2 serves community families and families involved in foster care. Community families live in zip code-based catchment areas in two neighborhoods in the Bronx (Hunts Point and Highbridge/Concourse) and four neighborhoods in Brooklyn (Ocean Hill Brownsville, Williamsburg, Greenpoint, and Bedford-Stuyvesant). Children are eligible if they are six to 48 months old, live in the catchment area, and live with their primary caregiver. PO2 outreach teams recruit families directly through community events, in parks, and during events held by partner organizations. While ABC is for children facing early adversity, the outreach messaging focuses on how ABC can benefit all parents, because parenting is difficult for everyone, and on the opportunity to have fun playing with their child during weekly sessions.

Referrals also come from partner organizations and via word of mouth from program graduates. PO2 has developed a community ambassador program for program graduates that involves training to become community advocates and to conduct community outreach. Ambassadors receive training on child development, PO2’s work, and community engagement that allows them to participate in various projects throughout the organization. Additionally, in the past, cohorts have received workshops on community advocacy from partners at the Citizens Committee for Children for New York City, which has culminated in participation in statewide advocacy days, as well as letter writing campaigns to local elected officials. The program formalizes the ongoing involvement that families who complete ABC continue to have with PO2. Parents are welcome to stay in touch with PO2, and PO2 can assist graduated families who have needs after the program in connecting with community partners.

PO2 also receives funding from the NYC Administration for Children’s Services (NYC ACS) to serve children in the foster care system in all five boroughs and, more recently, for prevention and primary prevention in order to avoid child welfare involvement. An ABC champion at each of 20 foster agencies refers both birth and foster parents directly to PO2.

Workforce Development

While a college degree is not required for ABC parent coaches, many of PO2’s coaches have a bachelor’s degree in a social service field or a master’s degree in social work. PO2 hires many of its coaches from the communities it serves and looks for those with lived experiences similar to the families PO2 serves and a connection to the community (e.g., grew up in the neighborhood, has friends or family in the community, is familiar with Black and Brown family and community dynamics, and shares racial and ethnic backgrounds with PO2 families). A small percentage of coaches are PO2 program graduates. A two-day virtual training with the University of Delaware covers ABC and in-the-moment commenting, a key method used by ABC coaches to highlight parents’ use of targeted behaviors. This training is followed by an orientation with PO2 that provides background on the communities where coaches will work, data entry, and the handling of videos.

Each week for the first year, PO2 coaches receive hour-long group supervision focused on delivering the program model, 60-90 minutes of clinical group supervision to review ABC sessions, and 30 minutes of individual supervision on the use of in-the-moment commenting. Coaches who complete this year of supervision become 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 complete an additional year of supervision. University of Delaware also offers a Spanish support workshop for bilingual coaches delivering ABC in Spanish. Also, each member of staff is allotted funding for professional development to use on trainings and workshops of their choosing.

Financing

Originally, 75 percent of funding for PO2 came from NYC ACS to serve families in foster care; this funding included federal Title IV-E Child Welfare Waiver funds. Over the past six years, as the percentage of community families has grown to 50 percent, PO2 now also receives NYC ACS prevention funds to work with these families. Additional funds from foundations and private donations contribute to PO2’s community-based work.

Monitoring and Evaluation

For fidelity monitoring, coaches send video recordings of coaching sessions with a parent to ABC at the University of Delaware for analysis. The results include the number and quality of coaching comments to parents during a five-minute clip and are used as the basis for discussion in clinical group supervision sessions.

PO2 has a standard data collection procedure as part of intake that includes basic demographic information, a baseline screening for parent depression, Adverse Childhood Experiences (ACEs), a standardized observation on parental sensitivity, the Life Experiences Survey (LES), and the Ages and Stages Questionnaire: Social-Emotional (ASQ:SE) screener for the child. After the family completes the program, PO2 repeats the administration of the parent depression and child social-emotional screening and the parent sensitivity observation to capture any changes that may be related to program participation. PO2 uses these data for ongoing program evaluation and reporting.

An evaluation of NYC’s ACS Title IV-E Waiver Demonstration Project, which included PO2’s delivery of ABC, found that “Caregivers who participated in ABC exhibited significant improvements in ABC-relevant skills, such as following the lead, recognized intrusive behaviors that may be frightening to a child, and assessing a child’s development and behavior problems.” Additionally, researchers affiliated with PO2 have used National Institutes of Health grant funding to conduct a random-assignment study of the impact of ABC. The findings demonstrated an increase in parent sensitivity for program participants as well as reductions in parent depression.

Last updated December 2022

Special thanks to the following individuals for providing information for and/or reviewing this profile: Kristin Bernard, Assistant Professor, Stony Brook University Department of Psychology; and at Power of Two, Logan Brennan, Development and Communications Associate; C. Seth Lamar, Brooklyn Borough Director; Fatima Malik, Chief Advancement Officer; Titilope Oladele, Bronx Borough Director.

IECMH in Pediatric Care: Risk Factor, Child Social-Emotional Development, and Maternal Depression Screening and Response

HealthySteps (HS) is an evidence-based national model that integrates supports for young children’s optimal development, including IECMH, into primary care. New York State currently has 46 HealthySteps sites, including 20 operated in the New York City area by the Bronx-based Montefiore Medical Center, 17 sites across the state supported by the state’s Office of Mental Health, and at three Federally Qualified Health Centers (FQHC) in New York City funded by the Robin Hood Foundation. The HealthySteps National Office is housed at Zero to Three.

HS programs integrate a child development expert, the HealthySteps Specialist (HS Specialist), into the pediatric primary care practice or any clinic where well-child visits are provided. HS provides three tiers of services. Tier 1 is available to all families in the practice and consists of child development and social-emotional/behavior screening, maternal depression and family needs screening, and a family telephone support line to address questions on a variety of topics including child development, parenting, and behavior. The HS Specialist manages the screening and referral process for the practice and the support line.

The second tier of services, for families with mild concerns, includes HS Specialist consultations with families about child development and behavioral concerns, care coordination, positive parenting guidance, and early learning resources. The third tier of services, for families in need of more intensive services, consists of preventive services, including those in Tiers 1 and 2, as well as regular contact with the family during each well-child visit and at other times, as needed. The HS Specialist also makes referrals to community resources as needed, including to infant and early childhood mental health services, such as evaluation and dyadic treatment, and for maternal depression evaluation and treatment.

HS provides a recommended child screening schedule based on the AAP’s Bright Futures guidance, which includes child social-emotional screening. Family needs screening, or family risk factor screening (see research summary on risk factor screening and response), is also included in the required screenings. To maintain their HS status, sites must meet fidelity requirements for family needs screening, with at least 75 percent of children age 0-3 having at least one family member screened each year for needs related to food insecurity, housing instability or homelessness, utilities, transportation, interpersonal safety, substance misuse, and tobacco use. HS programs can use a HS-developed family needs screener, which is comprised of items taken from validated screening instruments. Sites may also screen for the seven family needs above using their own tools, such as the SEEK Parent Questionnaire. In the HS planning and implementation process, sites develop comprehensive lists of community resources, which are used when families require referrals for needs identified in the screens.

Sites must meet fidelity metrics related to child social-emotional screening (see research summary on child social-emotional screening and response) and may use either the Ages & Stages Questionnaire: Social-Emotional, Second Edition (ASQ:SE2) or the Baby Pediatric Symptom Checklist (Baby PSC), which is part of the SWYC, the Survey of Well-Being of Young Children. Sites must also meet fidelity metrics related to maternal depression screening (see research summary on maternal depression screening and response) and may use either the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire (PHQ)-2/9.

After expressing interest and securing funding, potential HS sites work with the HS National Office at a two- to three-day HealthySteps Institute to train the site and plan implementation. The HS Specialist, physicians, practice managers, and other site staff attend the institute. After the HealthySteps Institute, the site begins implementing the model with the support of six additional technical assistance sessions provided by the National Office.

New York’s current 46 sites grew from an initial site developed at Montefiore Medical Center in the Bronx in 2006. Its success there led to the expansion to 19 additional sites within the Montefiore Health System in the New York City area. Inspired by the achievements at Montefiore, in 2016 the state’s Office of Mental Health provided three-year grant funding to start 17 sites across the state. Expansion to other sites in New York State has likewise occurred organically, often through word of mouth or growth within a health system that already had a HealthySteps site. The National Office focuses on supporting this network of sites to ensure sustainability.

Financing

Start-up costs, including the training institute and TA, are typically $25,000. Once the model is being implemented at a site, a full-time HS Specialist can usually support the provision of Tier 1 services to 2,000 children annually, and offer Tier 2 and 3 services to 300 of those children in each tier. The cost of providing services to the 300 children in Tier 3 can average up to $450 annually per child, which covers the HS Specialist salary, administrative costs, and any site-specific enhancements or adaptations such as optional home visits and parenting groups. HS sites vary in their sources of funding for covering the cost of providing these services, and the National Office supports sites in identifying and pursuing sustainable sources of funding.

In New York, 17 sites have been funded with state general funds from the state Office of Mental Health for a three-year grant period starting in 2016. As this period has drawn to a close, the National Office has convened a learning collaborative with sites on how to bill Medicaid for services. The National Office is also working with each site individually to identify additional sources of funding, including grants and reallocation of systems funds, in which the health system reroutes surplus revenue from other departments to fund HS services. To support the reallocation of system funds, the National Office helps sites make the case to health system leadership for funding HS because of its contribution to cost savings, service quality, and meeting targets such as child screening rates. One site is now 90 percent funded through Medicaid. Other sites combine Medicaid funding and reallocation of system funds.

Montefiore sites have been funded predominantly through reallocation of system funds, as well as grant funding and through Medicaid reimbursement. New York will also look to funding strategies used in other states. For example, in Texas, sites are supported by state funds for child abuse and neglect prevention efforts. In Colorado, there have been dedicated state funds in the State budget for two years in a row.

In New York, there are multiple payment methods for billing Medicaid, including variations related to the credentials of the service provider. These variations, along with HS Specialists having a range of credentials, affect how they can be reimbursed by Medicaid, which creates a challenging and inconsistent payment landscape for sites. HS Specialists are frequently social workers with mental health training, psychologists, early childhood educators, and/or nurses with experience in early childhood development (the minimum requirement is a bachelor’s degree, although a master’s degree is preferred).

Monitoring and Evaluation

National- and site-level evaluation research on HS has been conducted for more than 20 years. Beyond the national randomized controlled trial, researchers at HS sites in New York found that children who had screened at risk for social-emotional difficulties and received HS services showed significant improvements in subsequent social-emotional screenings compared to children in need of services whose caregivers declined services. Researchers also found that HS reduced the gap in risk of social-emotional difficulties between children whose mothers had experienced childhood trauma and those whose mothers had not.

In 2015, oversight of HealthySteps sites was transferred to a newly-created National Office, based at Zero to Three. The National Office formally revised the model and identified its core components. They also created fidelity metrics that sites must meet to call themselves HealthySteps sites.

Sites must submit annual reports that include fidelity information. From 2019, new sites have three years to meet the fidelity metrics, and existing sites have five years. The National Office is currently waiting to receive the second year of the new annual reports, which will help the National Office develop technical assistance to support sites so that they deliver HS with fidelity.

One challenge is that HS has not developed its own data system, which means all the sites’ monitoring data are drawn from their own electronic medical records. Consequently, sites have found it easier to track screenings than to track referrals and follow-ups for positive screens, since extracting this information typically involves examining text fields. Sites are interested in exploring ways to develop more effective tracking, which would also support efforts to bill for services. The National Office is developing a client-level data system designed specifically for HS Specialists, which will help address these challenges.

Last updated October 2019

Special thanks to Suzanne Brundage, Director, Children’s Health Initiative, United Hospital Fund, for providing information for this profile, and to the following individuals at HealthySteps for providing information for and reviewing this profile: Rahil D. Briggs, National Director; Johanna Lister, Director of Policy; Jennifer Tracey, Senior Director of Growth and Sustainability; and Danielle Robbio, Communications Manager.