Child Welfare Early Intervention Initiative in Philadelphia

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Child Welfare Early Intervention Initiative in
Philadelphia

• Julia Alexander, M.S.
• Department of Human Services, Philadelphia, PA

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Session Outline

• Scientific Context Wellbeing, Risk Prevention
• Policy Law
• Models Implementation
• Responding to Challenges

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Childrens Wellbeing

• Resilience an individuals positive adjustment
  despite experiencing adversity significant
  threats to wellbeing
• Protective Factors characteristics located
  within individuals and their environments that
  serve to increase resilience and positive
  adjustment
• Garmezy, 1970 Masten and Coatsworth, 1998

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Resilience

• Early examinations of resilience focused on
  childrens characteristics e.g., good health,
  self-regulation, self-esteem, etc.
• Subsequent research examined characteristics of
  families and communities
• More recently, resilience is being viewed as
  multidimensional children can make positive
  adaptions in some domains but remain vulnerable
  in other domains
• Luthar, Cicchetti Becker, 2007

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Protective Factors

• Intelligence multidimensional!
• Temperament easy, difficult, slow to warm up
• Coping styles talking it out vs. acting out
• Positive social support
• Racial socialization and racial identity
• Luthar, Cicchetti Becker, 2007 Miller, 1999

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Scientific Context of Individuals with
Disabilities Improvement Act and Keeping Children
and Families Safe Act (CAPTA)

• Many of the risk factors that are associated with
  public child welfare system intervention are also
  associated with developmental delays among
  infants, toddlers and young children.
• Secondary conditions related to early delays
  include behavioral health problems and poor
  school achievement.
• Strong evidence-base confirming relationships
  among risk factors and childrens outcomes
  supported advocates efforts to change the law to
  drive systems collaboration.
• Aber, Jones Cohen, 2000 Anderson et al,
  2003 Bolger Patterson, 2001.

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Eligibility for Part C Infant-Toddler Early
Intervention

• Presence of a specific developmental delay
  cognitive, language, socioemotional, or
  motor.
• Medical condition with a high probability of
  delay e.g., Trisomy 21 (Down Syndrome), Failure
  to Thrive, Fetal Alcohol Syndrome,
  microencephaly, etc.
• Judy Silver, Ph.D., The Childrens Hospital
  of Philadelphia

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Risk Factors Developmental Delay

• Other conditions and environmental risk factors
  associated with delays
• Poverty
• Lead exposure
• Low birth weight
• Parental substance abuse
• Exposure to community and family violence

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Risk Factors Developmental Delay

• Risk factors are known to
• Occur in clusters
• Occur at more than one level of the ecological
  model (person, family and/or community levels)
• Have exponentially cumulative effects
• Beckwith, 2000 Bronfenbrenner, 1979

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Poverty

• Infants and toddlers are more vulnerable to the
  effects of poverty compared to individuals
  experiencing poverty at later stages of
  development.
• Family characteristics with the strongest
  relationship to poverty among children under age
  5 years are parental education, marital status
  and employment status.

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Poverty

• Poverty is also associated with several
  conditions that raise the risk of poor outcomes
• Low birth weight
• Lead exposure
• Single parent household
• Cognitive delays
• Zeanah, Boris Larrieu, 1997

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Low Birth Weight

• Neonatal weight of less than 2500 grams (5 lbs.,
  8 oz.) affects approximately 10 of live US
  births.
• Advances in neonatal medicine have resulted in
  increasing numbers surviving.
• Increased risk of poor health, sensory
  impairments, cognitive and motor delays, learning
  disorders
• Cigarette smoking, exposure to alcohol and other
  drugs, poor maternal health nutrition and
  adolescent motherhood are mechanisms linking
  poverty to low birth weight.
• Aber, Jones Cohen, 2000 Meyers, Alexander,
  Silver Vogel Minde, 2000

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Lead Exposure

• Children most often exposed by eating leaded
  paint chips or breathing the dust of old
  deteriorating urban housing.
• Urban children have lead levels up to 8 times
  higher than non-urban children.
• Exposure linked to growth stunting, hearing
  impairments, kidney damage, decreased
  intelligence scores, reading disorders,
  behavioral problems, poor achievement.
• Brookes-Gunn Duncan, 1997 Lanphear,
  Dietrich, Auinger Cox, 2000

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Parental Substance Abuse

• At least 70 of the families who enter the child
  welfare system have substance abuse as an issue
  related to impaired parental role functioning
• Families most often headed by single parenting
  women with a complex array of problems e.g.,
  abuse, poor educational and employment histories,
  inadequate housing, etc.
• Increased likelihood of child neglect
• Women more likely to relapse due to pressures of
  single parenthood
• National Center on Addiction and Substance Abuse,
  2001 Semidei, Radel Nolan, 2001

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Exposure to Violence - Child Maltreatment

• Strongest single predictor of poor outcomes
  including delays, poor achievement behavioral
  disorders
• Early discussions focused on the physical
  injuries of the battered child.
• Maltreated children now understood to be at
  greater risk due to the impact of adverse
  experiences on their maturing cognitive,
  emotional and other systems.
• Kempe et al, 1962 Kim Cicchetti, 2004

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Exposure to Violence Child Maltreatment

• Compromised capacity to resolve stage- salient
  developmental challenges at their optimal time
• Higher likelihood of developmental delays
• Higher rates of internalizing and externalizing
  symptoms, problems with peers, poor school
  adjustment
• Higher likelihood of experiencing other traumatic
  events e.g., domestic violence, loss of a
  parent, etc.
• Bolger Patterson, 2001 Kaufman Henrich,
  2000 Rogosch, Cicchetti Aber, 1995

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Cognitive Development Language Acquisition

• Maltreated children less able to using words to
  describe thoughts and feelings
• Study found that maltreated children had smaller
  vocabularies, less word knowledge and greater
  rates of syntactic delays
• Maltreating mothers language impoverished even
  after controlling for education and socioeconomic
  status
• Sequelae of speech and language problems include
  learning and behavioral disorders
• Eigsti Cicchetti, 2004

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Language Development, Maltreatment and School
Readiness

• School readiness pre-academic cognitive skills
  and socioemotional characteristics assess prior
  to beginning first grade
• Emergent literacy the precursor skills and
  behaviors that precede formal reading
• Emergent literacy facilitated in linguistically
  rich environments
• Knowledge skills children demonstrate at the
  start of first grade contributes the most to
  early academic achievement even when
  socioeconomic status is controlled
• Byrnes, 2006 La Paro Piata, 2000

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Language Development, Maltreatment
Self-Regulation

• Language acquisition has a strong relationship
  with socioemotional development
• Infants cues for care and comfort are among the
  earliest language precursors.
• Caregivers interpreting and responding
  appropriately sets the foundations for more
  complex preverbal communications.
• Insensitive or frightening caregiver responses
  impact infants developing stress regulatory
  systems.
• Fewer resources to devote to typical maturational
  challenges
• Prizant, Wetherby Roberts, 2000

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Language Development, Maltreatment
Self-Regulation

• Infants modulation of arousal is adaptive
• Reduces negative affective states
• Maintains arousal to an optimal,
  performance-enhancing range
• Supports attention to stimuli
• Helps to preserve relationships
• Reduces likelihood of behavioral problems
• Braungart-Rieker Stifter, 1996 Rothbart
  Bates, 1998

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How does early intervention help?
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Interventions as Protective Factors

• Protective factors serve to increase childrens
  resilience in high risk circumstances and help to
  avert poor outcomes.
• An empirical grasp of protective factors is
  essential to the task of focusing interventions
  on areas theory research suggest will have the
  most impact
• Masten Coatesworth, 1998 Olds, 2005

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Interventions as Protective factors

• In program planning, nodal points within the
  ecological/transactional model become the loci of
  interventions.
• Risk factors affecting the caregiving context are
  transmitted through interactions between parents
  and their children
• Understanding of the role of parents as mediators
  of risk and childrens outcomes points to the
  importance of family-focused interventions
• Sameroff Fiese, 2000

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Early Intervention Services

• An evidence-based has been established for the
  efficacy of early intervention services for
  samples of infants and toddlers who fall within
  specific disability and risk categories, e.g.,
  cognitive delays, parental substance abuse, etc.
• Guralnick, 1997

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Early Intervention Services

• Occupational, Physical, Speech/Language
  Therapies, Special instruction, Assistive
  Technology Devices, Nutrition Services
• Case management some health-related services
  such as transportation assistance
• Parent training support to enhance their
  childs development
• Respite care.
• Spiker Silver, 1999

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Early Intervention Services

• In addition to the impact of early intervention
  on specific areas of delay, services affect
  mechanisms by which risks are transmitted
• Quality of parent-child interactions (e.g.,
  intrusiveness, sensitivity, etc.)
• Parent-mediated play (e.g., developmentally
  appropriate toys, games, etc.)
• Parent-mediated social experiences (e.g.,
  supervised peer interactions, community events,
  etc.)
• Guralnick, 1997

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Early Intervention Services

• Strong philosophical orientation toward
  caregiver-child relationships and natural
  environments
• Family focus with home visiting improves access
  and participation
• Home setting helps re-distribute the balance of
  power and support the caregiving role
• Marcenko, 1999

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Objections to Developmental Screening

• Concerns about tracking minority children into
  special education
• Historic use of IQ scores to justify racial
  prejudice (Termans revision of Binet scales,
  1916)
• Mass measurement of intelligence and responses by
  minority scholars- e.g, George Sanchez, 1932
  Horace Mann Bond, 1927 protests of
  African-American psychology graduate students,
  1930s
• Guthrie, 1976

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What has changed?

• Understanding that intelligence is
  multidimensional many intelligences rather than
  a single global factor
• The role of environment on development
  educational opportunities, cultural values,
  language, discrimination
• Norms developed on more diverse samples

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Legislative Support

• Adoption Safe Families Act of 1997
• Keeping Children Families Safe Act of 2003
• Individuals with Disabilities Act of 2004

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Adoption Safe Families Act of 1997 (ASFA)

• Until the passage of ASFA, the objectives of the
  child welfare system had been child safety and
  permanency
• ASFA included wellbeing as a third objective of
  child welfare system intervention
• Achieving permanency for dependent children in a
  timely manner became a primary focus of child
  welfare system to reduce risk of pathology
  related to disrupted relationships with
  caregivers
• Zeanah Boris, 2000

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The Keeping the Children and Families Safe Act
of 2003
Amended the Child Abuse and Prevention Treatment
Act (CAPTA) (P.L. 108-36) and requires that each
state develop provisions and procedures for
referral of a child under age 3 who is involved
in a substantiated case of child abuse or neglect
to early intervention services funded under Part
C of the Individuals with Disabilities Act
(IDEA).
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Individuals with Disabilities Act Part C of
2004

• States receiving Part C funds must describe
  State policies and procedures that require the
  referral for Early Intervention services of a
  child under the age of three who is involved in a
  substantiated case of abuse or neglect

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Philadelphia Department of Human Services Child
Welfare Early Intervention InitiativeModel,
Implementation Preliminary Outcomes
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Starting Young Program Childrens Seashore
House of the Childrens Hospital of
Philadelphia- Judith Silver, Ph.D., Director

• Ages 4 to 33 months
• Open Philadelphia DHS cases
• Interdisciplinary Pediatric Developmental
  Evaluations
• Data and collaboration a major
• impetus to the Philadelphia Child
• Welfare-EI Initiative

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Systems Change in Philadelphia - 1999

• Integration of the child welfare and behavioral
  health systems
• Establishment of the Behavioral Health Wellness
  Center (BHWC) at DHS
• Increasing Department of Behavioral Health (DBH)
  interest in early identification of Pervasive
  Developmental Disorders/Autism
• Increasing opportunities for collaboration and
  scholarly discourse within DHS/DBH

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Infants Toddlers

• Higher vulnerability to the impact of abuse and
  neglect
• Efforts needed to reduce the risks related to
  cognitive, language and socioemotional delays
• Need to determine what interventions may be
  protective and increase the likelihood of more
  favorable outcomes
• In response to these needs and
• concerns, DHS and DBH proposed
• the Child Welfare Early Intervention
• Initiative.

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Development of the Model

• Informational Brochure (2001) - old unilateral
  approach
• DHS-funded position at ChildLink 2001 in response
  to anticipated increase in referrals early
  partnership of child welfare and early
  intervention systems
• Child welfare system training in EI 2002 the
  beginning of full public/private collaboration
• Policy Directive 2004 refer all children 0 5
  to EI systems for developmental assessments
• Policy Directive 2006 child welfare providers
  will perform developmental screening and
  surveillance

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Collaborative Partners

• DHS BHWC, Law, Policy
• DBH/Mental Retardation Services
• ChildLink (0-3 Early Intervention)
• Elwyn (3-5 Pre-School Special Education)
• PA Council of Children,Youth Family Services
• Private Child Welfare Providers

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Program Objectives

• DHS Early Intervention ChildFind -Identification
  of all children 0-5 using administrative database
• Developmental screening using the Ages and Stages
  Questionnaire (ASQ)
• Monitoring to ensure that children who need EI
  and preschool special education continue to
  receive services
• ASQ repeated every 6 months

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Policy

• Effective December 2004, child welfare providers
  were directed to assist parents and other
  caregivers in accessing developmental evaluations
  for infants, toddlers and young children
• Policy revised in November 2006 to require
  providers to screen (currently undergoing third
  revision in response to PA State mandate)
• Policy requires child welfare providers to
  monitor the participation of eligible children
• Efforts to engage families participation needed
  to be documented in the case record
• Collaboration with DHS social work teams when
  needed to support the participation of children
  with documented delays and disabilities
• Providers given the ASQ and provider
  directors/managers received training
• Providers responsible for training direct service
  staff

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Information Systems

• Memo of understanding from DHS permitting
  ChildLink to use DHS administrative data for
  Child Welfare Early Intervention Initiative for
  monitoring purposes
• Use of Impromptu (Cognos Corporation, 2004) to
  generate ChildFind reports for DHS social work
  teams and child welfare providers
• Ability to track referrals by provider
• Ability to generate quantitative reports

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Provider Training

• Overview of the EI and preschool special
  education systems
• Developmental delays, disabilities and the
  purpose of intervention to promote more
  developmentally typical outcomes
• How to complete referrals and promote
  participation
• ASQ training

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New State Policy

• Beginning in September 1, 2008, all 67 PA county
  child welfare systems will be required to use the
  ASQ to screen infants and toddlers under age 3
  years
• Addition of the ASQ Social-Emotional Scale
• Screening at more frequent intervals

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Program Monitoring

• DHS is in the process of exploring use of a
  vender to manage the ASQ data and provide reports
  to DHS and providers on implementation
• Vender will also have the capacity to create
  aggregate reports

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Conclusions

• DHS communication with providers
• Monitoring ones own caseload
• Call or email with questions or concerns
• 215-683-5705 or julia.alexander_at_phila.gov