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Page 1: Child Welfare Early Intervention Initiative in Philadelphia

Child Welfare Early Child Welfare Early Intervention Initiative Intervention Initiative

in Philadelphiain 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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Children’s Wellbeing

Resilience – an individual’s 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 children’s 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 identityLuthar, 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 children’s 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 Children’s Hospital of Philadelphia

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Risk Factors & Developmental Delay

Other conditions and environmental risk factors associated with delays:

PovertyLead exposureLow birth weight Parental substance abuseExposure to community and family violence

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Risk Factors & Developmental Delay

Risk factors are known to:

Occur in clustersOccur 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 weightLead exposureSingle parent householdCognitive 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 parenthoodNational 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 adaptiveReduces negative affective statesMaintains arousal to an optimal, performance-

enhancing rangeSupports attention to stimuliHelps to preserve relationshipsReduces 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 children’s 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 children’s 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 child’s 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 (Terman’s 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, 1930’s

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 Initiative

Model, Implementation & Preliminary Outcomes

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Starting Young Program – Children’s Seashore House of the Children’s 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 proposedthe Child Welfare Early InterventionInitiative.

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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 one’s own caseload Call or email with questions or concerns

215-683-5705 or [email protected]


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