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Promising Program Seal

Child First

Blueprints Program Rating: Promising

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 psychotherapeutic 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.

  • Child Maltreatment
  • Early Cognitive Development
  • Externalizing

    Program Type

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

    Program Setting

    • Home

    Continuum of Intervention

    • Selective Prevention (Elevated Risk)
    • Indicated Prevention (Early Symptoms of Problem)

    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 psychotherapeutic 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.

      Age

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

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity

      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).

      • Individual
      • Family
      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, Non-violent 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)

      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.

      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.

      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.

      • Attachment - Bonding
      • Person - Environment
      • Skill Oriented

      The study employed a randomized control trial design. Pre-screened families (n = 157) from Bridgeport, Connecticut, were randomly assigned to the Child Firat 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.

      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.

      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 were not analyzed.

      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.

      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.

      • 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).

      • Blueprints: Promising
      • Coalition for Evidence-Based Policy: Near Top Tier

      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.

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

      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.

      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.

      This study constitutes the first randomized controlled trial to investigate the effectiveness of the Child FIRST program in a real-world context.

      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.