Sign Up For Newsletter

Blueprints For Healthy Youth Development logo

Child First

A two-generation home visitation program which works to heal and protect young children and their families from the devastating effects of chronic stress and trauma. It provides psycho-therapeutic services and intensive care coordination, while building adult reflective and executive capacity, to prevent or diminish serious emotional disturbance, developmental and learning disabilities, and abuse and neglect among young children.

Program Outcomes

  • Child Maltreatment
  • Cognitive Development
  • Externalizing
  • Internalizing

Program Type

  • Cognitive-Behavioral Training
  • Family Therapy
  • Home Visitation
  • Parent Training
  • Social Emotional Learning

Program Setting

  • Home

Continuum of Intervention

  • Indicated Prevention
  • Selective Prevention

Age

  • Early Childhood (3-4) - Preschool
  • Infant (0-2)

Gender

  • Both

Race/Ethnicity

  • All

Endorsements

Blueprints: Promising
SAMHSA (New System): Effective
Social Programs that Work:Near Top Tier

Program Information Contact

Child First
35 Nutmeg Dr., Suite 385
Trumbull, CT 06611
(203) 538-5222
www.ChildFirst.org

Program Developer/Owner

Mary Peniston and Darcy I. Lowell, M.D.
Child First, Inc.


Brief Description of the Program

Child First is a two-generation, home-based intervention that works with very vulnerable young children, prenatal through age 5 years, and their families in order to decrease serious mental health concerns in child and parent, child development and learning problems, and abuse and neglect. It has two core components: (a) a system of care approach to stabilize and provide comprehensive, integrated services and supports to the child and his/her family (e.g., early education, housing, substance abuse treatment), while enhancing adult executive capacity and (b) a relationship-based, psychotherapeutic approach to enhance nurturing, responsive parent-child relationships and promote positive social-emotional and cognitive development. The program is implemented by a team of a master's level mental health clinician and a bachelor's level care coordinator. Duration is adjusted based on families' needs with an average length of 6 to 12 months. Mental health consultation to early care and education is included. All staff receive intensive reflective clinical supervision.

Outcomes

Comparing the Child First intervention to a control group, the following significant program effects were reported by Lowell et al. (2011):

  • Decrease in externalizing behavior (at the 6-month follow-up),
  • Improvement in language skills (at both posttest and 6-month follow-up),
  • Among parents, improvement in overall psychiatric well-being, lowering of depression symptoms (at 6-month follow-up), and reduction in stress (at posttest),
  • Lower levels of involvement with Child Protective Services (at the 30-month follow-up),
  • Increased access to community-based services (at both posttest and 6-month follow-up).

Brief Evaluation Methodology

The study employed a randomized control trial design. Pre-screened families (n = 157) from Bridgeport, Connecticut, were randomly assigned to the Child First intervention group (n = 78) or a Usual Care control group (n = 79). The Child First intervention lasted on average 22.1 weeks with weekly visits of 45-90 minutes. Families were assessed at baseline, posttest and 6-month follow-up. The study measured child behavior (e.g., externalizing and internalizing behavior, language skills), parental psychological well-being (e.g., depression, parenting stress), connection with community-based services, and involvement with Child Protective Services.

Study 1

Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs-Gowan, M. J. (2011). A randomized controlled trial of Child FIRST: A comprehensive home-based intervention translating research into early childhood practice. Child Development, 82(1), 193-208.


Risk Factors

Individual: Antisocial/aggressive behavior*, Early initiation of antisocial behavior*, Physical violence*

Family: Family conflict/violence*, Family history of problem behavior, Family transitions and mobility, Low socioeconomic status, Neglectful parenting*, Parent history of mental health difficulties*, Parent stress*, Poor family management, Unplanned pregnancy, Violent discipline*

Protective Factors

Individual: Problem solving skills, Prosocial behavior*

Family: Attachment to parents, Nonviolent Discipline*, Parent social support

Neighborhood/Community: Opportunities for prosocial involvement


* Risk/Protective Factor was significantly impacted by the program

See also: Child First Logic Model (PDF)

Race/Ethnicity/Gender Details

The study conducted no subgroup analysis. However, the results indicate that the program is generalizable to a variety of ethnic groups and has been proven effective among a sample of diverse racial/ethnic composition (8% Caucasian, 30% African American, 59% Latino, 3% Other) with children of both genders equally represented (56% male, 44% female).

Overview of Child First Training

Training staff at new affiliate Child First agencies or for a major expansion extends over a 12-month period and integrates five major training components: (1) A Learning Collaborative, which is a year-long process with four in-person Learning Sessions, (2) Trauma-informed Child-Parent Psychotherapy (CPP) training, (3) On-line Distance Learning, which combines guided web-based modules, video-conferencing, and readings, (4) Reflective clinical consultation from the State Clinical Director or an expert Child First Senior Clinical Consultant, and (5) Specialty Trainings and Annual Conference. The Learning Sessions and CPP training are scheduled in tandem. Distance Learning is interspersed between the Learning Sessions. The clinical consultation begins with the Child First affiliate site Clinical Directors prior to the first Learning Session and continues intensively throughout the training year.

Child First also provides training for new staff due to staff turnover at established affiliate agencies. This training is a combination of Distance Learning and periodic Brief Intensive Training.

I. Learning Collaborative

Child First uses Learning Collaborative methodology for start-up training at agencies new to Child First or for major expansion of capacity. This is generally a 12-month process which brings together staff from multiple new affiliate sites (including the Clinical Director, Clinical Supervisors, Mental Health/ Developmental Clinicians, Care Coordinators, and a "Senior Leader" who is in a senior position within the agency) in a single location to learn together. Child First Clinical Faculty provide the training. This includes current members of our National Program Office Clinical Leadership Team (National Clinical Director, Training Director, State Clinical Director, Child First CEO), Child First Clinical Faculty (who are guest presenters), and may include regional Clinical Faculty who reside in the geographic location where replication is occurring.

There are several components of the Learning Collaborative:

A. Child First Affiliate Site Clinical Directors/Supervisor Training:

This four-day training is designed to help new Clinical Directors and Supervisors learn the skills necessary to lead a Child First affiliate site. Training includes Fundamentals of the Child First model and underlying theory of change; roles of the State Clinical Director, site Clinical Director, and Clinical Supervisors; reflective clinical supervision; use of video in intervention and supervision; implementation of Distance Learning with on-site discussions, activities, and observations; the referral process and prioritization; accessing community services; staff safety within the community; and the development of the Child First Community Advisory Board.

B. Learning Sessions:

Learning Session 1: The first Learning Session is a 2-day training designed to help new Child First providers understand the basic components of the model, provide foundational knowledge around toxic stress and ACEs, understand the importance of early relationships, understand how Child First is integrated into the local early childhood system of care, and provide training in the use of Distance Learning tools. The importance of culture is infused throughout.

Learning Session 2: This is an intensive 5-day session which follows a 3-week period of online learning (see Online Section 1 below) in which the staff learn fundamental content. This is a highly interactive training that includes the basics of attachment theory and the relationship-based, psychodynamic approach used in infant- and child-parent psychotherapy. It covers motivational interviewing, use of video in intervention with families, therapeutic and interactive play, executive functioning, mental health consultation in early care and education, understanding the strengths and vulnerabilities of families, and the development of the formulation and treatment plan. It also includes working with caregivers affected by depression, substance abuse, and interpersonal violence, with strategies to help them with emotional regulation.

Learning Sessions 3 and 4: Reinforcement of basic model tenets and procedures, plus additional technical and theoretical didactic and experiential sessions constitute the core of these two-day sessions. This is an opportunity for further in-depth training around some of the online topics.

C. Materials:

1) All staff receive the Child First Training Manual and Child First Toolkit (which provides all assessments and procedures) prior to the first training.

2) All Child First affiliate sites receive a library of child development and early childhood mental health articles and books. Child First staff are directed in their reading by discussion questions presented by their Clinical Director and during their online training modules. Discussions are facilitated by both their Clinical Director and the State Clinical Director.

3) At each Learning Session, staff receive an agenda and curriculum for that session, including all PowerPoints, additional readings, and handouts (with the purpose of providing a comprehensive reference resource in the form of a Learning Collaborative Notebook).

4) Each site receives an Assessment Notebook (with samples of each assessment used in the Child First Assessment Protocol) and copies of each assessment as a "start-up kit" for the Child First intervention.

II. Trauma-Informed Child-Parent Psychotherapy

Trauma-informed Child-Parent Psychotherapy (CPP) is taught by a certified CPP trainer. There are three sessions (the first lasting four days, and two other boosters lasting two days each) which are embedded within the Child First Learning Collaborative over the 12-month period. The first day of the first session is provided for all staff, and the subsequent training is for Clinicians and Clinical Directors only. The training also includes 18 months of biweekly phone consultation with the CPP trainer. (If staff have already had formal trauma-informed CPP training and are eligible to be "rostered" - meaning included on the national CPP roster of trained clinicians - they do not have to attend this component of the Child First training.)

III. Distance Learning

Child First is developing a blended training model that incorporates distance learning using web-based technology between Learning Sessions. During each Online Training Period, staff will utilize narrated PowerPoints, videos, guided discussions, observations, exercises, activities, process notes, and readings. The online training will be delivered in three ways:

1) Online training modules covering foundational information completed by each individual independently. These are self-guided, narrated modules with PowerPoint and video. They include additional written material and questions for reflection or subsequent discussion.

2) Online training modules covering foundational information completed by site staff together as group, with the guidance of the affiliate site Clinical Director, or as a Network, with the guidance of the State Clinical Director. They include PowerPoints with video and narrative. They will be accompanied by group discussion and group exercises and activities.

3) Video-conferencing with live trainers at the National Program Office will supplement the above training for specific subject matter, with discussion and local exercises and activities.

The Online Training Periods occur between Learning Sessions. These provide foundational knowledge which will prepare all staff for the subsequent Learning Session and for the work with children and families. All modules will be able to be reviewed at any future time to reinforce learning or when the topic is especially relevant to a specific family. PowerPoints presented in person will also be available online for future review.

Online Training Period 1 is completed between Learning Sessions 1 and 2. It covers the Child First process, the roles of the Mental Health Clinician and Care Coordinator, infant and early childhood development and normal developmental challenges, the psychological transition into parenthood, attachment, psycho-social risk and protective factors, and the Child First Assessment Protocol.

Online Training Period 2 is completed between Learning Sessions 2 and 3. Training Period 2A is covered immediately after Learning Session 2, prior to beginning work with families. It includes the Child First Fidelity Framework, quality enhancement, and safety for both staff and family. Online Training Period 2B should be completed before Learning Session 3, but may be accessed at any time as needed. It covers more in depth content about working with caregivers and children in the child welfare system and with specific vulnerabilities, including mental health, cognitive limitations, teen parenting, court involvement, and autistic spectrum disorders. It also includes diagnosis with DC: 0-3, diagnosis of adult mental health disorders, and psychotropic medication.

IV. Brief Intensive Training

This five day training is provided to newly hired staff of existing Child First affiliate sites when they cannot be incorporated into a Learning Collaborative in a timely fashion.

1) Topics covered include the same topics covered in Learning Sessions 1 and 2 of the Child First in-person Learning Collaborative

2) A Brief Intensive Training is held every six to twelve months, depending on the need.

V. Child First Reflective Consultation

A. Reflective, Clinical, Site-based Consultation:

Each new Child First affiliate site receives reflective, clinical consultation by the State Clinical Director or a Senior Clinical Consultant weekly for 6 months and then biweekly for 6 months. This includes working both individually with the affiliate site Clinical Director for 1 hour and with all teams in a group format for 1 ½ hours. After 12 months, the affiliate Clinical Director assumes full responsibility for the ongoing group reflective supervision at his/her site. He/she will continue to receive biweekly individual consultation from the State Clinical Director or Senior Clinical Consultant. (If the Clinical Director is receiving weekly, individual, reflective clinical supervision from a senior clinician who has knowledge of infant and early childhood mental health and the Child First model and is employed by his/her agency, this consultation may be monthly.)

B. Clinical Directors' Network Meeting:

All Clinical Directors/Supervisors meet on a monthly basis for a combination of clinical consultation around their own cases and the reflective supervisory process, and administrative consultation around the Child First implementation process. This is an opportunity for the Clinical Directors to share both their challenges and successes with their colleagues, in order to facilitate peer learning and quality enhancement. This meeting is facilitated by the State Clinical Director.

VI. Specialty Trainings and Annual Conference

The Learning Sessions are supplemented by specialty trainings, usually provided by outside experts. The content of these sessions is based on the specific needs of the Child First staff of the affiliate agencies. There are 3-4 sessions per year. Each year, there will be a Child First Annual Conference with a topic of relevance for all Child First staff.

3/30/15

Program Benefits (per individual): $7,955
Program Costs (per individual): $8,997
Net Present Value (Benefits minus Costs, per individual): ($1,042)
Measured Risk (odds of a positive Net Present Value): 44%

Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.

Start-Up Costs

Initial Training and Technical Assistance

  • Start-up fee for new agencies: $25,000
  • Start-up training fees: $16,000 for Clinical Director/Supervisor; $10,000 for each Clinician and Care Coordinator

Curriculum and Materials

  • All curricula are included in training fees
  • Sites must purchase copyrighted assessment forms

Materials Available in Other Language: All assessments and family materials are available in Spanish, however, the Manual, Toolkit, Distance Learning, and Learning Collborative materials are only in English.

Licensing

Once initial training is completed, $15,000 annually plus $5,000 for each Clinician Team (a Clinical Team includes a Clinician and Care Coordinator)

Other Start-Up Costs

  • Computers and other setup for new employees (will vary depending on what the agency need to purchase)
  • Child First data system (Child First Comprehensive Clinical Record-CFCR) planning and setup
  • Child First Clinical Teams from an affiliate agency should be located together. Space requirements include officers for confidential conversations and an available meeting room for group supervision. Children and families are not seen in the office.
  • Staff time for participation in training
  • Video cameras for Teams
  • Therapeutic toys for home visits

Intervention Implementation Costs

Ongoing Curriculum and Materials

Assessments that are administered at baseline, 6 months, and discharge. The cost for assessments per team is estimated at a high of $900/year.

Staffing

Qualifications:

  • Master's level licensed Clinical Director/Supervisor, with 5 years' relevant experience
  • Master's level licensed Mental Health/Child Development Clinician, preferably with 3 years' experience
  • Bachelor's level Care Coordinator, who is familiar with community to be served and available services.
  • Staff must be multicultural/multilingual reflecting population to be served. Salaries vary depending on local labor market.

Ratios:

  • A full-time Clinical Director/Supervisor can oversee 4-5 teams
  • A Child First Team (includes a full-time Mental Health/Child Development Clinician and a full-time Care Coordinator working together) typically carries a caseload of 12-16 families

Time to Deliver Intervention:

  • Families receive visits twice per week during the assessment period (first month) and then once a week or more, depending on the needs of the child and family. Visits last 1-1.5 hours.
  • After assessment, Clinicians and Care Coordinators may visit together or separately, based on the individual family needs.
  • Services generally continue for six to twelve months but can go longer depending on the needs of the family.

Other Implementation Costs

  • Clinician and Care Coordinator travel for weekly visits with each family reimbursed on a per mile basis.
  • Child First expects some involvement of the agency leadership. Senior leaders are invited to attend training and are expected to participate in quarterly calls or in-person meetings with other Sr. Leaders.
  • Site will likely require some administrative support for data systems and reporting (up to .5 FTE) and for inquiries and referral (.25 - 1.0 FTE).

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

Training cost is included in annual licensing fees, except in the case of training for new staff due to turnover where a fee may be charged.

Fidelity Monitoring and Evaluation

Currently included in annual licensing fees. Child First system user fees may be charged to sites in the future.

Ongoing License Fees

No information is available

Other Implementation Support and Fidelity Monitoring Costs

No information is available

Other Cost Considerations

Child First works with a regional or state partner to build and support the infrastructure necessary to support a regional or state Child First network of sites. Replication of the Child First model usually occurs at various sites simultaneously for two reasons: (1) so there is a critical mass of teams to be trained as part of a Learning Collaborative, and (2) so that Child First is implemented as part of a larger early childhood system.

Year One Cost Example

The following Year 1 costs are based on an affiliate agency that trains one Clinical Director/Supervisor and four Child First Teams to serve 60 families in the first year of implementation. The example assumes that the program is implemented in a community service agency with appropriate space for private and group meetings and equipment for clinicians. Staffing costs include estimated salary and benefits for the level of experience required for the position. Staffing expenses will vary based on the local labor market.

Start-up Fee $25,000.00
Start-up Training Cost - Supervisor $16,000.00
Start-up Training Cost - Clinical Teams ($10,000 x 8 staff) $80,000.00
Assessment - $900 x 4 $3,600.00
Staffing Costs for Full-Time Clinical Director $100,000.00
Staffing Costs for Full-Time Child Development Clinician ($75,000 x 4) $300,000.00
Staffing Costs for Full-Time Care Coordinator ($55,000 x 4) $220,000.00
Travel $10,000.00
Overhead and Office at 20% of staff $124,000.00
Total One Year Cost $878,600.00

For one community agency serving 60 families, the first year expense would be $14,643 per family. The costs would decrease significantly in subsequent years as the initial start-up and training fees are start-up costs that would not be incurred beyond year 1. Child First analysis of average cost per family in Connecticut implementation is $8,000 per family.

Funding Overview

Child First sites are expected to participate in local early childhood and other collaboratives so that Child First is well integrated into the array of available services and families receive the most needed and appropriates services.

While philanthropy is an important source of start-up funding, regional and state networks should seek public funding streams, especially in health, child welfare, and early childhood sustainability. At this point in time, the major funding streams for Child First appear to be Medicaid (Rehabilitation Option, EPSDT, Managed Care, waivers), MIECHV and other federal grant programs, and state budgets especially Child Welfare. Social Impact Bonds (Pay for Success) are a funding option that could be explored given Child First two-generation outcomes and the cost savings that could be realized by jurisdictions/states.

Funding Strategies

Improving the Use of Existing Public Funds

No information is available

Allocating State or Local General Funds

  • In Connecticut, CT Department of Children and Families and Start-up funding from the Early Childhood Cabinet (State Department of Education).
  • In Florida, funding through the Children's Services Council of Palm Beach County (funded primarily through local property taxes).

Maximizing Federal Funds

Formula Funds:

  • Child First is an evidenced-based model designated by the Health Resources and Services Administration (HRSA) and eligible for funding under the Maternal Infant and Early Childhood Home Visiting (MIECHV) program. Connecticut has utilized this funding for Child First expansion.
  • Child First has been funded by Project LAUNCH and other SAMHSA grants (e.g., Early Childhood System of Care grant).
  • TANF.

Entitlement Funds:

  • Child First has been funded by Medicaid in Bridgeport, CT and is being considered for expansion to other CT locations. It is anticipated that it will be included in the North Carolina Medicaid Managed Care plan.

Foundation Grants and Public-Private Partnerships

  • National foundations including the Robert Wood Johnson Foundation.
  • State, regional, and local foundations such as the CT Health Foundation, Children's Fund of CT, William C. Graustein Memorial Fund, various community foundations (Fairfield County Community Foundation; New Haven Community Foundation, CT Community Foundation, Hartford Foundation for Public Giving), United Ways across CT, and Family Foundations such as the Grossman Family Foundation and the William C. Bullitt Foundation.

Debt Financing

No information is available

Generating New Revenue

No information is available

Data Sources

No information is available

Program Developer/Owner

Mary Peniston and Darcy I. Lowell, M.D.Associate Clinical Professor, Department of Pediatrics and Child Study Center, Yale University School of MedicineChild First, Inc.35 Nutmeg Dr., Suite 385Trumball, Connecticut 6611U.S.A.203-538-5222mpeniston@childfirst.orgdlowell@childfirst.org www.childfirst.com

Program Outcomes

  • Child Maltreatment
  • Cognitive Development
  • Externalizing
  • Internalizing

Program Specifics

Program Type

  • Cognitive-Behavioral Training
  • Family Therapy
  • Home Visitation
  • Parent Training
  • Social Emotional Learning

Program Setting

  • Home

Continuum of Intervention

  • Indicated Prevention
  • Selective Prevention

Program Goals

A two-generation home visitation program which works to heal and protect young children and their families from the devastating effects of chronic stress and trauma. It provides psycho-therapeutic services and intensive care coordination, while building adult reflective and executive capacity, to prevent or diminish serious emotional disturbance, developmental and learning disabilities, and abuse and neglect among young children.

Population Demographics

Child First is for parents with multiple challenges and young children (prenatal through 5 years) that have experienced trauma or display social-emotional/behavioral or developmental/learning problems. The program developers provide the program to children through age 5, but evaluation has only been conducted through age 3. Therefore, Blueprints only certifies the program for children through age 3.

Target Population

Age

  • Early Childhood (3-4) - Preschool
  • Infant (0-2)

Gender

  • Both

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

The study conducted no subgroup analysis. However, the results indicate that the program is generalizable to a variety of ethnic groups and has been proven effective among a sample of diverse racial/ethnic composition (8% Caucasian, 30% African American, 59% Latino, 3% Other) with children of both genders equally represented (56% male, 44% female).

Risk/Protective Factor Domain

  • Individual
  • Family

Risk/Protective Factors

Risk Factors

Individual: Antisocial/aggressive behavior*, Early initiation of antisocial behavior*, Physical violence*

Family: Family conflict/violence*, Family history of problem behavior, Family transitions and mobility, Low socioeconomic status, Neglectful parenting*, Parent history of mental health difficulties*, Parent stress*, Poor family management, Unplanned pregnancy, Violent discipline*

Protective Factors

Individual: Problem solving skills, Prosocial behavior*

Family: Attachment to parents, Nonviolent Discipline*, Parent social support

Neighborhood/Community: Opportunities for prosocial involvement


*Risk/Protective Factor was significantly impacted by the program

See also: Child First Logic Model (PDF)

Brief Description of the Program

Child First is a two-generation, home-based intervention that works with very vulnerable young children, prenatal through age 5 years, and their families in order to decrease serious mental health concerns in child and parent, child development and learning problems, and abuse and neglect. It has two core components: (a) a system of care approach to stabilize and provide comprehensive, integrated services and supports to the child and his/her family (e.g., early education, housing, substance abuse treatment), while enhancing adult executive capacity and (b) a relationship-based, psychotherapeutic approach to enhance nurturing, responsive parent-child relationships and promote positive social-emotional and cognitive development. The program is implemented by a team of a master's level mental health clinician and a bachelor's level care coordinator. Duration is adjusted based on families' needs with an average length of 6 to 12 months. Mental health consultation to early care and education is included. All staff receive intensive reflective clinical supervision.

Description of the Program

Child First is a two-generation, home-based, psychotherapeutic intervention that works with very vulnerable young children, prenatal through age 5 years, and their families, most of whom have experienced significant trauma and adversity (including poverty, domestic violence, maternal depression, substance abuse, and homelessness). The goal is to decrease serious mental health concerns in child and parent, child developmental and learning problems, and abuse and neglect. It has two core components: (a) a system of care approach to stabilize and provide comprehensive, integrated services and supports to the child and his/her family (e.g., early education, housing, substance abuse treatment), thereby both decreasing stress and enhancing child development, and (b) a relationship-based approach to heal the effects of trauma and adversity by enhancing nurturing, responsive parent-child relationships and promoting positive social-emotional and cognitive development. The program is implemented in subject's homes to increase effectiveness and reduce barriers to treatment. The program implementation period is adjusted based on families' needs with an average duration of 6-12 months. Unique to the Child First intervention is that it provides intervention based on parental needs rather than based on a fixed curriculum. Each family is assigned to a clinical team, consisting of a licensed, master's level mental health clinician and a bachelor's level care coordinator. The care coordinator facilitates family engagement with multiple community services, while promoting adult executive capacity, including child development and early care and education, child and family health, parent support, adult education and employment, adult mental health and substance use, and social services and concrete needs. In contrast, the mental health clinician is responsible for therapeutic assessment and intervention, using a relationship-based, trauma-informed child-parent psychotherapy approach. This enhances parental reflectivity and empathy in order to improve parents' sensitivity and responsiveness to the child. Mental health consultation to early care and education is included for all children. All staff receive intensive reflective clinical supervision. The ultimate goal is to protect and heal young children and families from the impact of trauma and chronic stress.

Theoretical Rationale

Theoretically the program builds on an ecological framework and tries to improve the child's emotional well-being through a flexible mixture of psychotherapeutic intervention and connection to child and parent community-based services. The program was informed by a body of literature indicating that cumulative environmental adversity (e.g., poverty, maternal depression, domestic violence) damages the developing brain and is associated with increased incidences of social-emotional and behavioral problems. In contrast, responsive nurturing relationships are able to buffer the brain from this impact, providing a healthy foundation for both cognitive and social-emotional development. A well-functioning parent-child relationship has been shown to increase self-reliance, adaptation to novel and challenging situations, empathy, curiosity, emotional regulation, and social competence.

Theoretical Orientation

  • Skill Oriented
  • Person - Environment
  • Attachment - Bonding

Brief Evaluation Methodology

The study employed a randomized control trial design. Pre-screened families (n = 157) from Bridgeport, Connecticut, were randomly assigned to the Child First intervention group (n = 78) or a Usual Care control group (n = 79). The Child First intervention lasted on average 22.1 weeks with weekly visits of 45-90 minutes. Families were assessed at baseline, posttest and 6-month follow-up. The study measured child behavior (e.g., externalizing and internalizing behavior, language skills), parental psychological well-being (e.g., depression, parenting stress), connection with community-based services, and involvement with Child Protective Services.

Outcomes (Brief, over all studies)

An evaluation of Child First (Lowell et al., 2011) showed lower externalizing behavior (at the 6-month follow-up) as well as improved language skills (at both posttest and 6-month follow-up) for children in the intervention group relative to a control group. As for maternal symptoms, the intervention improved overall psychiatric well-being, lowered depression (at 6-month follow-up), and reduced parental stress (at posttest), compared to a control group. Finally, families in the intervention group evidenced lower involvement with Child Protective Services (at the 30-month follow-up), and increased access to community-based services (at both posttest and 6-month follow-up) relative to a control group.

Outcomes

Comparing the Child First intervention to a control group, the following significant program effects were reported by Lowell et al. (2011):

  • Decrease in externalizing behavior (at the 6-month follow-up),
  • Improvement in language skills (at both posttest and 6-month follow-up),
  • Among parents, improvement in overall psychiatric well-being, lowering of depression symptoms (at 6-month follow-up), and reduction in stress (at posttest),
  • Lower levels of involvement with Child Protective Services (at the 30-month follow-up),
  • Increased access to community-based services (at both posttest and 6-month follow-up).

Mediating Effects

Mediating effects were not analyzed.

Effect Size

Overall the study reports small to medium effect sizes (reported in eta-squared). Strongest effects were observed for a reduction in externalizing behavior at the 6-month follow-up assessment with a medium effect size of .094. Most of the significant parental outcomes ranged in effect size from .050 for maternal depression to .076 for general psychiatric well-being. For child language outcomes (6-month follow-up, OR=4.4) and family CPS involvement (30-month follow-up, OR=2.1), odd ratios indicate medium to strong program effects. Access to community-based services showed a large effect size of .811.

Generalizability

The results can be generalized to multiple risk families with young children in urban areas. The sample was comprised predominantly of low-SES families with racial/ethnic minority status.

Potential Limitations

  • Research assistants were not blind to families' study conditions and frequently learned about group status during the interviews.
  • Imperfect service delivery in the intervention condition due to "many missed and canceled appointments."
  • Although the authors stated that the scales demonstrated "acceptable reliability and validity," alpha reliabilities were not reported.
  • The recoding of outliers might have impacted the results.
  • Long-term effects were not investigated by the study (with the exception of CPS involvement).
  • An analysis of the data obtained from the intervention fidelity checklist was not reported.
  • Inconsistency in the timing of the emergence of certain program effects (some effects were significant only at post-test and not at follow-up while others were only significant at the follow-up assessment).
  • No comprehensive theoretical rational for the anticipated intervention mechanism is provided.
  • Baseline equivalence was not fully established, with groups differing on one control variable (mother's education).

Endorsements

Blueprints: Promising
SAMHSA (New System): Effective
Social Programs that Work:Near Top Tier

Program Information Contact

Child First
35 Nutmeg Dr., Suite 385
Trumbull, CT 06611
(203) 538-5222
www.ChildFirst.org

References

Study 1

Certified Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs-Gowan, M. J. (2011). A randomized controlled trial of Child FIRST: A comprehensive home-based intervention translating research into early childhood practice. Child Development, 82(1), 193-208.

Study 1

Evaluation Methodology

Design:
Recruitment /Sample size:
Families were recruited for study participation within the Bridgeport Hospital Pediatric Primary Care Center (PCC) and at the Supplementary Nutrition Program for Women, Infants, and Children (WIC). The screening sites were chosen because Child FIRST had not been implemented at these sites. A total of 642 families were screened for eligibility to participate in the study. Families were eligible to participate if a number of criteria were met: (a) the child was between 6 months and 3 years of age, displayed social-emotional/behavioral problems, and/or parents showed psychosocial problems; (b) the family lived in the city of Bridgeport, Connecticut; and (c) the child was in a permanent care-giving environment. Of the 642 screened families 464 families met the inclusion criteria. The researchers made attempts to contact all eligible families and were successful in 363 cases (78%). About 80% (n = 290) of the contacted families agreed to be visited in their homes and 254 consented to enroll in the study. Families were visited twice before randomization in order to obtain baseline measures. Only those 157 families who completed the two baseline assessment visits were finally randomized.

Study type/Randomization/Intervention:
The study employed a randomized control trial design. Pre-screened families that had completed baseline assessments were randomly assigned to the intervention group (n = 78) and control group (n = 79). To facilitate group comparability, families were stratified prior to randomization according to child age and psychosocial problem ranking. Families in the intervention group received the full Child FIRST program while families assigned to the control group received Usual Care. Families in the intervention group received on average weekly visits of 45-90 minutes by the mental health clinician and care coordinator. The Child FIRST intervention lasted on average 22.1 weeks, comprising about 24 contacts per family.

Assessment/Attrition:
Families were assessed at baseline, 6 months, and 12 months after completion of baseline assessment, using self-report questionnaires and interviews. Given an average treatment period of 22.1 weeks (approximately 5.5 months), the 6-month assessment was labeled posttest and the 12-month assessment was labeled 6-month follow-up to keep with Blueprints conventions (these labels are used in the following). Research assistants were not blind to group assignment and frequently learned about group status of families based on families' responses to particular interview questions. Only 131 families participated at the posttest assessment, and 117 completed the 6-month follow-up assessment, constituting a substantial attrition rate of 17% and 25%, respectively.

Sample characteristics:
Children in the study sample were between 6 months and 3 years of age (mean 1.5 years). Slightly more girls (56%) than boys (44%) were randomized. Many children evidenced language delays and/or social-emotional and behavioral problems. Mother's age ranged from 17 to 47 years (mean 27 years). Most mothers were Hispanic (59%) followed by African Americans (30%), Caucasians (8%), and Others (3%). A large proportion of mothers (59%) were single/never married and about 10% were classified as teenage mothers. About 13% of mothers in the intervention and 28% in the control group had more than a high school degree. The majority (64%) of mothers were unemployed and about 93% received some type of public assistance. Close to half (44%) of the study subjects belonged to families with a substance abuse history and about a quarter had been homeless at some point. Study participants belonged to households that had on average 5 members.

Measures:
Validity of measurements:
For most measures the authors stated that the scales demonstrated "acceptable reliability and validity."

Primary outcomes:

  • Psychosocial risk for eligibility was assessed using the Parent Risk Questionnaire (PRQ), a 25-item questionnaire completed by the parent. The PRQ assesses risk in 12 areas including depression, domestic violence, substance use, homelessness, incarceration, isolation, single and teen parenthood, education, and employment.
  • Social-emotional/behavioral problems for eligibility were assessed using the BITSEA, a 42-item questionnaire.
  • Child language status was assessed with the Infant-Toddler Developmental Assessment (IDA).
  • Child social-emotional⁄behavioral problems were assessed with the Infant-Toddler Social and Emotional Assessment (ITSEA), which is composed of subscales for internalizing, externalizing, and dysregulation.
  • The Parenting Stress Index (PSI) Short Form was completed by all parents.
  • Parental depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CES-D).
  • Global psychiatric symptoms were assessed using parent self-report on the global severity index of the Brief Symptom Inventory (BSI).
  • Involvement with Child Protective Services (CPS) was assessed based on parental report and/or public CPS records. A variable was created that reflected CPS involvement (a) prior to or at baseline and (b) at any time from baseline to 3 years post baseline.

Controls:

  • Information on sociodemographic characteristics was collected at baseline.

Analysis:
The authors employed repeated measures analysis of covariance (ANCOVA) or logistic regression models for continuous and categorical outcome variables, respectively. The models either included information from individuals that completed assessments on all three time points (baseline, posttest, 6-month follow-up, n=117), or for individuals that had complete records for two time points (baseline and posttest, n=131). As such, all models controlled for baseline scores of the respective outcome variable. In addition, all models included maternal education as a covariate.

Outliers were defined as scores > 3.29 standard deviations from the mean. Outliers on individual measures (n = 7) were subsequently recoded (assigned values at 3.29 standard deviations above the mean).

In order to measure effect sizes the authors calculated eta-squared values. For this measure, values below .056 are considered to be small, .056 to .139 medium, and > .139 large.

Intention-to-treat: The study followed the intent-to-treat principle. Statistical models included all participants with data on the outcome variable, irrespective of treatment received.

Outcomes

Implementation fidelity:
The study employed a fidelity checklist, which was completed by the clinician after each visit and was used to monitor implementation fidelity. However, quantitative findings for these fidelity checks were not reported. Instead, the authors point out that service delivery in the intervention group was sometimes not accomplished completely due to "many missed and canceled appointments." Nevertheless, Child FIRST families received higher levels of wanted services compared to the Usual Care control group (91.2% vs 33.2%). In addition, families in the Child FIRST group had significantly greater numbers of needs met in all domains identified for treatment (e.g., child mental health, child development, early education, family support, etc.).

Baseline Equivalence:
The intervention and control groups were similar on all baseline measures of sociodemographic and psychosocial risk, service needs and history of Child Protective Services involvement with one exception: maternal education was significantly lower in the intervention group compared to the control group. Thus, the authors controlled for maternal education in all models.

Differential attrition:
A test for differential attrition was performed. The groups of attritors and completers did not differ significantly on any sociodemographic characteristic or outcome variable. The authors also analyzed baseline equivalence for the reduced post-test and 6-month follow-up sample, after attrition occurred. The difference between intervention and control group on maternal education remained significant at posttest but became insignificant at the 6-month follow-up. As such the drop-out of certain subjects did not compromise the randomization.

Posttest:
Child outcomes: For one (33%) of the 3 child outcomes (externalizing behavior, internalizing behavior, and dysregulation) significant results were obtained for at least one time point. ANCOVAs demonstrated a beneficial program effect for externalizing behavior at the 6-month follow-up assessment (ES=.094, p<.05) but not at posttest.

For a fourth child outcome, language skills, no repeated measure ANCOVA was conducted. However, an investigation of clinically concerning problems for this variable demonstrated some beneficial program effects (see Table 2). The Child FIRST intervention significantly improved children's language problems compared to the control group at both posttest (OR=3.0, p<.05) and 6-month follow-up (OR=4.4, p<.05).

Parental outcomes: For 6 parental outcome variables, 5 (83%) showed a significant effect either at posttest or at the 6-month follow-up assessment. Beneficial program effects were observed for psychiatric well-being as measured by the Brief Symptom Inventory (BSI) and the Center for Epidemiological Studies Depression Scale (CES-D). For both measures, ANCOVAs demonstrated that mothers in the intervention group had better mental health at the 6-month follow-up assessment (BSI: ES=.076, p<.01; CES-D: ES=.050, p<.05) but not at posttest, when compared to the control group.

Some evidence was found that Child FIRST had a notable impact on parental stress, as measured by the total parental stress (PSI) scale, the difficult child subscale, and the parent distress subscale. For these measures, ANCOVAs showed significant effects at posttest but not at the 6-month follow-up assessment (total scale: ES=.059, p<.05; difficult child: ES=.055, p<.05; parent distress: ES=.056, p<.05), an inverse pattern compared to findings for the BSI and CES-D.

Child protective services (CPS): CPS data were available for the period from enrollment to 2.5 years after program completion. Logistic regressions, controlling for baseline CPS involvement, revealed no significant intervention effects at posttest, 6-month follow-up, or 18-month follow-up. However, a significant effect emerged for the 30-month follow-up assessment, at which point intervention families showed lower levels of involvement with CPS than families in the control group (OR=2.1, p<.05).

Long-term effects:
With the exception of CPS involvement, long-term effects were not investigated by the study.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

Sign up for Newsletter

If you are interested in staying connected with the work conducted by Blueprints, please share your email to receive quarterly updates.

Blueprints for Healthy Youth Development is
currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.