child first by lindash

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									Child FIRST Summary / February 2005



                                      CHILD FIRST
          Child and Family Interagency Resource, Support, and Training Program


INTRODUCTION:

         All children need to have the chance to succeed. Yet, today, a baby born to an inner city
mother faces multiple barriers to success from the very beginning. Poverty, teen parenting,
domestic violence, depression, substance abuse, inadequate health care, poor education,
illiteracy, unemployment, and crime are common risks in the environments in which these babies
live. Too often, these mothers are not able to nurture and support the development of their
children. Delays in language and cognition, learning problems, behavioral and emotional
disturbances, and health problems are frequent consequences. We can change this pattern. A
new and innovative model program, Child FIRST, intervenes at the very first sign of problems,
and takes a comprehensive, integrated approach to the needs of these very young children and
their families. It is called an “early childhood system of care.” Through close partnerships with
over 70 community providers and through comprehensive assessment, targeted intervention,
consultation, and care coordination, Child FIRST can make a major difference. We work to
prevent developmental delay and learning difficulties, serious emotional disturbance, chronic
health problems, and abuse and neglect. Our next generation of citizens has the potential to grow
up as healthy, productive, and contributing members of our society.


DOCUMENTATION OF NEED:

        Developmental delay and learning difficulties, serious emotional disturbance, and child
abuse and neglect have many common roots. These alarming childhood problems are all
increasing in Bridgeport. Scientific research has made it absolutely clear that the first three to
five years of life is one of tremendous brain growth, and that the environment in which a child
develops profoundly impacts his cognitive and emotional development. By eight months of age,
brain synapses or connections have increased from 50 to 1,000 trillion, and by age three years,
ninety per cent of brain growth has occurred. It is early experiences that determine not only
which connections are made, but which are hard wired and which are pruned away. Up to 25 per
cent of synaptic connections may be eliminated if not used. Children who are not touched,
stimulated, or played with have brains which are 20-30 percent smaller on MRI, much like
Alzheimer’s patients. Approximately 40 per cent of infants of depressed mothers have decreased
brain activity. Repetition of traumatic or stressful experiences leads to a hardwiring of neuronal
pathways for fear, anxiety, and hyper-vigilance, clear precursors of later emotional disturbance.

        Research has clearly associated the number of environmental risks experienced by the
child with an increased incidence of serious emotional disturbance. Less than two risks has been
associated with a seven per cent incidence of behavioral problems, while greater than eight risks
has been associated with an alarming forty per cent incidence. This is entirely consistent with the
information that has been gathered in Bridgeport. Growing numbers of children have been
expelled from childcare and suspended from kindergarten for behavioral problems. The two
largest early care and education providers in Bridgeport reported that of the combined 1,800


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Child FIRST Summary / February 2005


children served, about 25 – 40 per cent or 400 – 720 children would benefit from consultation
and assessment due to emotional concerns. This is consistent with a 1996 study of preschool age
children which found that 21 per cent met criteria for a psychiatric disorder. The Chief of Child
Psychiatry at Yale-New Haven Hospital has indicated that 70 – 75 per cent of children
hospitalized in the child and adolescent unit would not be there if there had been effective
programs to address their needs during early childhood.

        Developmental and learning problems are also increasing, with greater numbers referred
to early intervention (Birth to Three) and the Bridgeport Schools. In fact, the Bridgeport Schools
Consultation Center has had a steady increase in the numbers of children referred, with almost
300 per cent increase in request for assistance over the past fifteen years. Bridgeport Schools
reported a 21 per cent increase in special education last year. Many of these children have a
combination of developmental and emotional concerns.

        It is therefore essential to examine the multitude of environmental risks experienced by
the children of Bridgeport families. Sixty-three per cent receive TANF (Temporary Assistance
to Needy Families). Eighty-four per cent of school age children fall below 185 per cent of
poverty. Per capita income in Bridgeport is $16,306 compared to $41,930 for the state of
Connecticut. Ten per cent of the Bridgeport population, which equals13,635 children, are under
six years of age. Over 25 per cent of these children live in poverty. In 1999, the violent crime
rate was nearly four times the state average. In 2003, 936 (23.5 per 1,000 children) young
Bridgeport children were substantiated as abused or neglected. A great majority of Bridgeport
families face other very significant challenges including substance abuse, mental health issues,
inadequate health care, inadequate education and illiteracy, unemployment, inadequate housing,
and single and teen parenthood. It is imperative that children be identified as early as possible,
and that interventions be directed to those factors which can be changed, in order to decrease the
risk that these young children experience.


HISTORY AND DEVELOPMENT OF CHILD FIRST:

        Child FIRST developed out of community need. It was clear that many young children
and families were “falling through the cracks,” and not receiving critically needed services.
Many of these families were overwhelmed by the multiple challenges they faced. Although they
wanted to do what was “right” for their children, they were not able to access the services and
supports which were necessary to promote their children’s development. Service providers were
eager to help, but often found the process of researching and coordinating services
extraordinarily challenging, expensive, and time consuming, as they were operating outside their
knowledge, expertise, and program mandate. The creation of Child FIRST was a direct
community response to the need for a coordinated, comprehensive, family centered approach to
enable high risk families and young children to access necessary services and supports. In 1998,
Child FIRST received a small amount of discretionary funding from the Department of Social
Services. In 2001, it was recognized as an extremely promising model, “early childhood system
of care,” and received one of five federal Starting Early / Starting Smart grants from SAMHSA
(Substance Abuse and Mental Health Service Administration) for over one million dollars, a
grant of nearly one half million dollars from the Connecticut Health Foundation, and a grant



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Child FIRST Summary / February 2005


from Bridgeport Safe Start Initiative (Office of Juvenile Justice and Delinquency Prevention).
These grants facilitated rapid expansion and the development of the present service model
including:
1) Comprehensive assessment of both the child and family within the home and early care and
education settings;
2) Targeted psycho-educational and psychotherapeutic intervention;
3) Integrated, comprehensive family plans of supports and services reflecting family priorities,
culture, and needs;
4) Care coordination to facilitate access to services and supports and address any barriers to
successful service utilization; and
5) Developmental and mental health consultation to community providers, especially early
education and pediatric health care, embedded seamlessly in an early childhood system of care.


TARGET POPULATION:

        Child FIRST targets young children, prenatal to age six years, their parents, and their
siblings who live within the Greater Bridgeport area. The target children are those exhibiting
developmental delays or learning problems, have emotional and behavioral disturbances, or have
parents with multiple challenges which impede their ability to support and nurture children.
Specifically, parents frequently are suffering from mental health problems (including depression,
anxiety, and post traumatic stress disorder), substance abuse, domestic violence, inadequate
education, unemployment, lack of childcare, poor health care, homelessness, and poverty. These
families have multiple, extensive needs which are unmet. Families of all languages and
ethnicities are served, with capacity to communicate directly in Spanish, French, and Creole.

        From October, 2003 – September, 2004, Child FIRST was referred 271 children.
Referrals came from over 70 different community providers as well as families, most
significantly the Bridgeport Schools, Bridgeport health providers, DCF, Birth to Three early
intervention services, early care and education providers, child and adult mental health services,
family support and education programs, and parents. Data through September, 2003 indicates
that over 60 per cent of families served have been involved with DCF at some point, reflecting
the level of risk of the target families. The ethnic breakdown of the families served by Child
FIRST was 46 per cent Hispanic, 33 per cent African-American, 16 per cent Caucasian, and 5
percent other ethnicities. Ninety-one per cent of the families had one or more indicators of
poverty. Seventy-five per cent of children had behavioral or emotional concerns and 73 per cent
had developmental or educational concerns. Eighty-two per cent of the mothers of these children
had mental health concerns, including depression, anxiety, and PTSD.


PROGRAM DESCRIPTION:

        Child FIRST currently has five program components:
1) Comprehensive assessment of child and family needs: This is an assessment by a Masters
level mental health and child development clinician (usually MSW) within the home and in the
early care and education setting. Both informal and standardized measures are used to



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Child FIRST Summary / February 2005


understand the child’s health and development; the relationship between the child and parent, (as
well as any other important adults in the child’s life); and the multiple challenges experienced by
the parents, which prevent them from being available to nurture and support their child’s
development.

2) Targeted, parent-child, mental health intervention: This is begun early in the assessment
process for children with emotional and behavioral problems. It uses those “teachable moments”
which present within the home environment. This intervention begins “where the parent is” and
operates at multiple levels, among them: normal developmental challenges and expectations;
parental reflection on the meaning and feelings motivating a child’s behavior; reframing the
child’s behavior; problem solving new strategies; and the relationship between parental feelings
and past history and the parental response to the child. This intervention currently lasts an
average of two to three months, but could be extended to four to six months, when indicated, if
staff capacity could be increased. This home based intervention is unique in that it provides an
opportunity to respond to identified problems as they arise in their natural setting, it is much
more convenient for parents with young children who have no transportation or childcare; and it
is without the stigma of going to a mental health facility.

3) Family Plan development: A family plan of comprehensive, integrated supports and
services is developed with the family, which reflects the parents’ goals, priorities, strengths,
culture, and needs. This plan includes services and supports not only for the identified child, but
for the parents and siblings as well. It utilizes the broad resources of the community in order to
support the family and decrease risk. Referrals to over seventy different agencies have been
made, averaging eight per family.

4) Care coordination: This is provided by a bachelor’s level professional who teams with the
mental health and child development clinician and facilitates the family’s access to multiple
services and resources throughout the community. She provides hands on assistance obtaining
information and partnering with community providers; researching program appropriateness and
availability; obtaining and completing forms for entitlements and social services (e.g. HUSKY,
WIC, DMR, CSHCN, SSI, food stamps, Section 8); making referrals to provider agencies as
housing/shelters, health care, educational programs, Birth to Three, special education, mental
health services, etc., and accessing furniture, toys, books, and clothing. The care coordinator is
responsible for addressing barriers to service access, renewed problem solving, and revision of
the family plan.

5) Community Mental Health and Developmental Consultation:
A. Early Care and Education – There are two formats for consultation: 1. Child FIRST is
referred children from early care and education providers who have been identified by their
caregivers, or children have been referred from their parents or other providers who attend early
care settings. Masters level mental health and child development consultants not only work
within the home (as above) but within the early care settings as well, helping teachers and
caregivers understand the child’s emotions and the meaning of the child’s behavior. They
facilitate strategies which promote growth and remediate challenging behaviors. 2. Child FIRST
has recently (March, 2004) begun a pilot project, “Classroom Consultation for Early Childhood
Educators” (supported by Bridgeport Safe Start Initiative (BSSI) and Discovery Initiative) in ten



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Child FIRST Summary / February 2005


Bridgeport early care and education classrooms, which provides a full time consultant dedicated
to these classrooms. The goal of this project is to universally screen and identify those children
who have social-emotional concerns, and to provide support and consultation to teachers so that
they can implement best practice strategies which will benefit the emotional development and
learning of all children, as well as individual strategies for those with sustained behavioral and
emotional problems. Twenty-seven per cent of children within these classrooms had positive
screens for concerns using the Devereux Early Childhood Assessment (DECA). In addition to
universal classroom consultation, individual strategies were implemented within the classrooms
to address the concerns of these children. After a four month period, 61 per cent of the children
with positive DECA’s were no longer exhibiting emotional and behavioral concerns, according
to their teachers. Families of children with persistent difficulty were offered Child FIRST
services including comprehensive home based child and family assessment, targeted home-based
intervention, family plan development, and care coordination to access needed community
services and supports. Analysis of baseline and follow-up data shows teachers receiving this
consultation reporting a marked, statistically significant increase in feelings of effectiveness in
their understanding of emotional and behavioral issues as well as their ability to implement
strategies to help the children in their care.
B. Medical home and expanded community consultation: Child FIRST plans to bring early
childhood mental health and child development consultants into the pediatric health care settings.
Child FIRST conducted mental health screening of children 6 to 36 months, in the Bridgeport
Hospital pediatric clinic over the past year. Fifty-one per cent of children screened positive for
behavioral problems or low competence. Sixty-nine per cent of all families were considered
high risk, confirming the need in this pediatric population. The mental health consultation in the
pediatric setting will provide a combination of mental health screening, mentoring of pediatric
providers, on-site consultation directly to parents, comprehensive home-based assessment for
more complex families, and care coordination to facilitate access to services. In this way,
pediatric providers will have access to the full array of comprehensive, community based
services to promote the development of the children in their care, thereby facilitating the Medical
Home model. Consultation services also will be offered to other community providers serving
young children and families, including family resource and support centers, early intervention
providers, elementary education, home visitors, and shelters. The goal is to ensure that
comprehensive assessment and services are possible for each child and family.


COLLABORATIVE STRUCTURE:

        Child FIRST began as a collaboration of concerned early childhood providers, and
therefore, is intrinsic to the structure of Child FIRST. There are four levels of collaborative/team
meetings:
1) Core Team is comprised of Child FIRST clinical staff (see below) as well as the senior
pediatric social worked from Bridgeport Hospital, a therapist from Child Guidance, and the
special needs consultant from A.B.C.D. (once per month). This Team meets in group
supervision on a weekly basis to discuss both clinical and care coordination needs of complex
children and families. Community providers are invited to join the Team to present a newly
referred family or to brainstorm around needs of a particularly challenging family who is a
jointly served.



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Child FIRST Summary / February 2005


2) Child and Family Specific Meeting is convened around the needs of a particularly complex
child and family in order to bring all providers who are providing services, or could potentially
provide services, around the table. In this way, all providers can work toward common, agreed
upon goals, without conflict or duplication.
3) Child FIRST Collaborative Team is a meeting of providers once per month. (This “FIRST
Team” was the beginning of Child FIRST ten years ago.) This meeting has three major
functions: Case conference in which providers present challenging children and families to their
colleagues, and together brainstorm potential resources and solutions; training around issues of
importance to community providers or presentations of new services available in the community;
discussion of gaps in services and barriers to service access with potential solutions. Three
subcommittees have been developed to research pressing community needs, including Child and
Adult Mental Health, Transportation, and Resource Directory.
4) Collaborative Children’s Advisory Board (CCAB) is a board overseeing four early childhood
prevention and early intervention programs for high risk families with young children from
Bridgeport Hospital and Greater Bridgeport Child Guidance, including Child FIRST, Nurturing
Connection and Group, Nurturing Home Visiting (Healthy Families), and Family Support
Network (Family Resource and Support Centers). This was to promote efficient use of
professional time and to ensure continuity and integration among the programs.
        At present, there are efforts to reorganize the early childhood collaborative structures in
Greater Bridgeport into one structural group with a unified voice. It is anticipated that the
CCAB and Collaborative Team will be merged with other collaborative groups in this process.


EVALUATION PROCESS:

         Child FIRST has a very strong evaluation and research component which is currently
underway. It is one of five Starting Early / Starting Smart - Prototypes (SESS-P) nationally
funded by SAMHSA (Substance Abuse and Mental Health Services Administration). SAMHSA
is interested in a comprehensive, integrated approach to preventing emotional disturbance in
young children as well as ensuring that their parents, especially those with mental health and
substance abuse issues, are identified and involved in treatment. A rigorous randomized trail is
currently being supported. Outcomes of particular interest include decreasing emotional and
behavioral problems, decreasing child abuse and neglect and out of home placement, increasing
language acquisition, decreasing need for special education services, increasing appropriate
health care usage, decreasing parental stress, and increasing access to a broad array of services.
At present, enrollment of approximately 160 children and families is complete, and follow-up at
six and twelve months is underway.

         A second evaluation component focuses on the subset of children who have been exposed
to violence. A group of 74 children served from October, 2002 – September, 2003 were
analyzed independently by the Yale Consultation Center as part of the Bridgeport Safe Start
Initiative. Results were extremely favorable. Overall, more than 70 per cent of desired services
existing within the community were received at three month follow-up. Child mental health,
child development, child protection, and operational services were accessed at a rate of 74 – 100
per cent. Parents/caregivers reported that they were “very to extremely satisfied” with Child
FIRST services.



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Child FIRST Summary / February 2005


       The third evaluation component was also conducted by the Yale consultation Center. It
focused on the Classroom Consultation for Early Childhood Educators, in which 173 children
from 10 classrooms were screened with the DECA. As indicated above, 61 per cent of children
with positive DECAs were without concern at follow-up assessment, after four months of
consultation. The teachers showed very significant increase in self-efficacy with regard to
knowledge and competence when working with young children with social-emotional and
behavioral concerns.


CHILDREN’S RESOURCE BANK:

        The Children’s Resource Bank (CRB) is another component of the Child FIRST
program. It enables gently used books, toys, child equipment, clothing, and child furniture for
children ages birth through age 5 years to be recycled from more affluent homes into the homes
of inner city children and to providers who serve these families. The CRB is open to any
community provider who works with families in need. In addition, Family Centers, early
education centers, etc. may establish mini CRB’s so that their families have ready access to these
necessary tools of early learning.


CHILD FIRST OVERSIGHT AND STAFFING:

         Child FIRST staff consists of a full time Director, Darcy Lowell, MD, who is a
Developmental and Behavioral Pediatrician at Bridgeport Hospital, and an Assistant Clinical
Professor in the Yale Department of Pediatrics and the Child Study Center. She was a Robert
Wood Johnson Fellow and a Fellow of Zero to Three. She was Director of the Children with
Special Health Care Needs Program for sixteen years, and developed multiple programs in the
Bridgeport region. She has served on multiple boards and committees on city, regional, and state
level, including Birth to Three Medical Advisory Board, Connecticut Child Health and
Development Institute’s Early Childhood Task Force, Connecticut Early Childhood Partners
Core Planning Committee, the Birth to Three Autism Task Force, Connecticut Association for
Infant Mental Health Board of Directors, Bridgeport Success by Six Advisory Board, Bridgeport
Collaborative Children’s Advisory Board, Bridgeport School Readiness Council, Bridgeport
Discovery Initiative Steering Committee, Bridgeport Safe Start Initiative, BCAC Steering
Committee, and BCAC Early Childhood Task Force. She has been working in Bridgeport with
high risk children birth through age five years for 20 years.

        The Child FIRST Program Coordinator is an LCSW who is Caribbean-American,
trilingual Creole and French, with extensive clinical experience with high risk families,
supervision, and administration. Her time is divided between direct service as mental health
consultant/child development specialist and program manager. She is also Co-chair of the
Bridgeport Community Resource Collaborative of Systems of Care. There are four (3.35) FTE
Masters level mental health consultants/child development clinicians. Two are bilingual Spanish
LCSW’s with extensive experience with direct therapeutic work with young children and
families. One has a Masters in Early Childhood and Special Education with added mental health
training and experience with very young children. One has over twenty years experience within



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Child FIRST Summary / February 2005


the Head Start system before she obtained her MSW. She is currently working as a mental
health/child development consultant in ten early care and education classrooms as part of a
collaborative project with Discovery 2004 (Graustein) and BSSI. There are three (2.5 FTE)
bachelors level care coordinators, two of whom are bilingual Spanish. They have extensive
experience with inner city families, including background in Healthy Families and Parents as
Teachers. There are 2.0 FTE research assistants, one of whom is bilingual Spanish. In addition,
Alice Carter, Ph.D., Professor of Clinical Psychology, serves as the senior research consultant
and analyst.


SUMMARY OF UNIQUE ASPECTS OF CHILD FIRST

      Child FIRST is an early childhood prevention/early inervention system of care. This
comprehensive, integrated approach to the needs of young children and families is unique in a
number of ways:
   1) Child FIRST targets the children and families at highest risk for emotional,
      developmental, and learning problems, and for abuse and neglect.
   2) Over two million dollars in past support has been granted to Child FIRST for program
      development and rigorous evaluation.
   3) A comprehensive, three level assessment is conducted in order to fully understand the
      child: biologic and developmental issues, critical early parent/caregiver – child
      relationships, and parental and environmental challenges.
   4) The assessment and intervention is within the home and in early care settings, providing
      natural opportunities to understand and intervene with challenging behaviors.
   5) A comprehensive, integrated family plan is developed in partnership with the family,
      reflecting family goals, priorities, culture, and needs.
   6) Care coordination is an intrinsic part of the program. When resources are identified, it is
      critical to help families access these services and supports, and problem solve when
      barriers are identified.
   7) Community mental health and developmental consultation is embedded seamlessly
      within the early childhood system of care. This consultation model is able to service
      early care and education, elementary education, pediatric health care, family resource and
      support centers, early intervention providers, home visitors, shelters, etc.
   8) Results of careful outcome research and evaluation will be submitted to the National
      Registry of Effective Programs for recognition as a model program.

        Child FIRST is an early childhood system of care which is in accord with the newest
efforts by experts throughout the country. This comprehensive, integrated approach to
prevention and treatment of high risk children and families can help our youngest children
achieve optimal health and development so they are ready to learn in school and realize their full
potential.


2/05




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