HealthySteps (HS)

Babies and toddlers aged 0-3 who are insured through Medicaid, the Children’s Health Insurance Program (CHIP), Tricare, or uninsured and their parents/caregivers

HealthySteps (HS), a program of ZERO TO THREE, is designed to identify challenges early and prevent others from happening, so that young children have a strong foundation for a lifetime of healthy development, learning and growth. A population health and risk-stratified model, the program includes eight Core Components within three tiers of service responsive to family needs. Universal services (Tier 1) for all children and families in the practice include: child developmental and social-emotional/behavioral screening; family needs screening; and access to a family support line. Based on these universal screenings as well as clinical judgment and/or identified parent concerns, the practice identifies children and families in need of additional services. As needed, families receive short-term support services (Tier 2), including development and behavior consultations with the HS Specialist; care coordination and systems navigation; positive parenting guidance; and early learning resources. Children and families with the greatest needs also receive comprehensive services (Tier 3) in the form of ongoing, preventive, team-based well-child visits, where both the HS Specialist and primary care provider meet with families. The HS Specialists are child development and behavioral health prevention and promotion professionals.

Quiana Bell

• Agency/Affiliation: HealthySteps, a program of ZERO TO THREE
• Website: https://www.healthysteps.org
• Email: healthysteps@zerotothree.org
• Phone: (202) 857-2662

The goals of HealthySteps (HS) are:

For Children:

• Reduced risk for child physical and psychological co-morbidities
• Stronger, more secure relationship with parent
• Improved kindergarten readiness and consistent kindergarten attendance
• On track child development, with an emphasis on social-emotional development

For Parents/Family Caregivers:

• Stronger, more secure relationship with child
• Improved maternal health

The essential components of HealthySteps (HS) include:

• ZERO TO THREE’s HS program:
  • Provides early childhood developmental and behavioral health support to families where they are most likely to access it—the pediatric primary care office
  • Involves the entire primary pediatric office working as a team through the HS approach which includes eight Core Components that are designed to:
    • Strengthen the relationship between families and the practice
    • Support strong caregiver-child attachment
• HS Specialist:
  • A child development and behavioral health promotion and prevention professional
  • Connects with and guides families of patients aged 0-3 during and between well-child visits
  • Part of the primary care team
  • Provides dyadic services, a two-generational approach that supports the child, caregivers, and the caregiver-child relationship
  • Offers support for common and complex concerns that physicians often lack time to address, including:
    • Behavior
    • Sleep
    • Attachment
    • Perinatal depression
    • Social determinants of health
    • Adapting to life with a baby or young child
  • Trained to provide families with parenting guidance, support between visits, referrals, and care coordination—all specific to their needs
• HS offers an array of services to meet families’ needs through a resource-efficient, tiered approach:
  • Tier 1: Universal Services – For All Families With Children Age 0-3 in the Practice
    • Core Component 1: Child Developmental, Social-Emotional, & Behavioral Screening:
      • HS sites routinely monitor and screen all children age 0-3 for the following concerns on a recommended screening schedule:
        • Physical
        • Cognitive
        • Language
        • Social-emotional
        • Developmental
        • Behavioral
      • Flag possible concerns
      • Identify potential referrals to the HS Specialist
      • Serve as an entry point for communicating with families about their child
      • HS Specialists are not solely responsible for implementing universal screenings but collaborate with practice staff in developing workflows, monitoring compliance, and quality improvement
    • Core Component 2: Screening for Family Needs (i.e., maternal depression, other risk factors, social determinants of health):
      • Regular monitoring and screening all families with children ages 0 -3 for important family needs:
        • Maternal depression
        • Food insecurity
        • Housing instability or homelessness
        • Utility needs
        • Transportation needs
        • Interpersonal safety (e.g., domestic violence, interpersonal violence, community violence, etc.)
        • Substance misuse (alcohol and other drugs)
        • Tobacco use
      • Results alert the HS Specialist and practice staff to make essential referrals and may be used to educate caregivers on how their life experiences impact their child’s development and their parenting.
    • Core Component 3: Family Support Line (e.g., phone, text, email, online portal):
      • Access to the HS Specialist to address nonurgent, nonmedical questions on various topics such as:
        • Child development
        • Child behavior
        • Parenting
      • Sites may inform caregivers of this resource in various ways, including posting flyers in the waiting and exam rooms
      • Support line inquiries may lead to referrals to resources in the community or consultations with the HS Specialist as needed.
      • Sites may provide a broad range of HIPAA-compliant tools for parents to communicate with the HS Specialist, including phone calls, video chat, websites, patient portals, email, text messaging, and/or smartphone apps.
  • Tier 2: Short-Term Supports – For Families with Specific, Time-Limited Concerns
    • Core Component 4: Child Development & Behavior Consults:
      • HS Specialists provide short-term consultations (approximately 1-3 visits) to families to address specific concerns about a child’s development and/or behavior or a caregiver concern (e.g., depression, substance misuse).
      • When possible, a provider may bring the HS Specialist into the exam room during the appointment to address concerns immediately or to facilitate a “warm handoff” where the HS Specialist can briefly meet the family, assess the severity of their concerns, and schedule a follow-up appointment.
      • Based on needs or risks identified during a consultation, the HS Specialist may recommend a family participate in Tier 3—Comprehensive Services—moving forward.
    • Core Component 5: Care Coordination & Systems Navigation:
      • HS Specialists refer patients, caregivers, and families to in-house and community resources based on identified needs.
      • HS Specialists partner with community resource providers and families to help caregivers coordinate and navigate complex systems, offering close follow-up and support when barriers occur.
      • HealthySteps care coordination is designed to empower families by enhancing their health literacy and systems navigation capabilities, so they become their child and family’s own best advocates.
      • To the best of their abilities, HS Specialists and other staff develop relationships with community resource counterparts through early, frequent engagement and communication around patient needs.
      • Many HS sites convene local community resource stakeholders to address barriers to communication and information sharing.
    • Core Component 6: Positive Parenting Guidance & Information:
      • HS Specialists provide caregivers with guidance, education, information, and resources that help them support their children through the different stages of development.
      • This includes:
        • Providing regular, tailored anticipatory guidance that helps caregivers better understand their child’s developmental progress and behavior
        • Conducting timely discussions and partnering/problem solving about common parenting challenges such as:
          • Safety
          • Feeding
          • Discipline
          • Limit-setting
        • Teaching and encouraging caregivers to provide positive, responsive parenting
        • Helping caregivers build strong, healthy attachment relationships with their children
        • Exploring family risk factors and buffers of toxic stress, including caregiver self-care
        • Helping caregivers understand their own history and how it impacts their parenting
        • Providing literacy level-appropriate and culturally attuned materials and resources, including handouts, videos, text messaging services, and apps
    • Core Component 7: Early Learning Resources:
      • HS sites offer caregivers concrete strategies, activities, and tools designed to support their child’s early learning
      • Resources span a broad array of early learning subjects, such as:
        • Language
        • Literacy
        • Science
        • Technology
        • Engineering
        • Math
        • Relationships
        • Music
        • Art
        • Social-emotional competence
      • They also include information about each subject, explain how and when children develop different learning skills and faculties, and provide easy, low-cost activities parents can do at home to encourage early learning at every age.
  • Tier 3: Comprehensive Services – For Families Determined to be Most at Risk
    • Core Component 8: Ongoing, Preventive Team-Based Well-Child Visits:
      • For families in Tier 3, the HS Specialist provides support in the exam room prior to, during, and/or following a child’s routine health care maintenance visit.
      • These visits are preventive in nature and begin as early as possible, potentially at the newborn visit.
      • Meeting with families when they are already at the practice for routine visits is convenient for caregivers and ensures seamless coordination of care between the HS Specialist and medical providers.
      • A HS Specialist is expected to participate in team-based well-child visits in person, as an integrated member of the care team.
    • The HS team at the site determines which families receive this comprehensive level of intervention.
    • The HS Specialist is not limited to a patient’s routine appointments and may schedule additional visits as needed.
    • If staffing allows, this component may be provided universally.

Child/Adolescent Services

HealthySteps (HS) directly provides services to children and addresses the following:

• Poor feeding/failure to thrive/low breastfeeding rates, infant fussiness – shaken baby syndrome, attachment related concerns, temperament - poor goodness-of-fit, separation anxiety/stranger anxiety, sleep problems, developmental delays including autism spectrum disorders, incomplete referrals to Early Intervention and other community resources, tantrums, aggression, and disruptive behaviors (preschool expulsions)

Parent/Caregiver Services

HealthySteps (HS) directly provides services to parents/caregivers and addresses the following:

• Low breastfeeding rates and poor nutrition, maternal depression and anxiety, parent/child conflict – abusive parenting behaviors, interpersonal violence, substance misuse, incomplete referrals (to mental health services, and community resources), caregiver trauma, inappropriate health care utilization

Recommended Intensity

The model allows practices to streamline and enhance their implementation of the American Academy of Pediatric’ Bright Futures Guidelines, which includes approximately 12-13 well-child visits in a child’s first three years. Families also have access to the HS Specialist through behavior and development consultations, referral navigation, and the family support line.

Recommended Duration

Program Wide Level Service: Up to 48 months; for children and families receiving Tier 2 and Tier 3 services, variable depending on when identified for services, but up to 48 months.

Delivery Settings

This program is typically conducted in a(n):

• Community-based Agency / Organization / Provider
• Other
• Outpatient Clinic
• Virtual (Online, Smartphone, Zoom, Telephone, Video, etc.)

Homework

This program does include a homework component.

HS Specialists provide parents with guidance, education, information, and resources that help them support their children through the different stages of development. Parents are expected to read resources and practice techniques at home.

Languages

HealthySteps (HS) has materials available in the following languages other than English:

• Arabic
• Bengali
• Haitian Creole
• Simplified Chinese
• Spanish
• Vietnamese

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed in this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

There are several requirements to become a HealthySteps (HS) site:

• A Physician Champion (a nurse practitioner may be acceptable but should be discussed with the National Office) in a pediatric primary care practice who actively supports the program’s implementation and growth.
• Ability to have most clinic team members attend the HealthySteps Institute training.
• Adequate funds to implement and cover ongoing HS program costs which are primarily driven by the salary and benefits of the HS Specialist.
• Commitment to deliver all eight Core Components and the capacity to offer team-based, interdisciplinary health care, with parents and family members viewed as integral members of the health care team.

In addition to establishing appropriate communication protocols, workflows, and policies and procedures, practices will want to plan to ensure office space and equipment are set up to deliver HealthySteps that include an office, computer and telephone for the HS Specialist.

Prerequisite/Minimum Provider Qualifications

The HealthySteps Implementation Team should include a Physician Champion, a HealthySteps Program Manager, Practice Staff representatives (e.g. nursing, front desk) and the HealthySteps Specialist.

The HealthySteps Specialist has a master’s degree (licensed preferred) in early childhood, behavioral health, or a related field and at least two years of experience in early childhood service delivery. If not possible, a bachelor’s degree with equivalent experience is acceptable. HealthySteps Specialists are required to have reflective supervision at least monthly.

In California, the new dyadic benefits have created a strong sustainability pathway for HealthySteps. Because of this it is recommended, if possible, to align the qualifications of the HS Specialists with provider types eligible to render and be reimbursed for HealthySteps and Aligned services. Please see California Crosswalk of HealthySteps-Aligned Services with Billing Codes and Provider Types.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

• HealthySteps National Office. (2025). HealthySteps implementation guide. ZERO TO THREE.

The manual is provided to all HealthySteps sites. More information is available upon request through the training contact listed below.

Training Information

There is training available for this program.

Training Contact

Training Type/Location:

Requirements to become a HealthySteps site:  To become a HealthySteps site, all practices must:

• Indicate their interest by completing an interest form (https://zerotothree.my.site.com/HealthyStepsHub/s/interest-form) and participate in an Introduction Call.
• Explore Fit: Practice staff will complete a Goodness-of-Fit Assessment and debrief call and a Data System Overview Call to ensure that HealthySteps is a good fit and the practice has the infrastructure to successfully implement our evidenced-based model. This includes the potential for future success with data collection and reporting. Sites that align with ZERO TO THREE’s strategy to scale HealthySteps in states with current or emerging sustainable funding opportunities for HealthySteps services, and sites that address historical health inequities and serve high numbers or proportions of families with low incomes are prioritized
• Plan Onboarding: The National Office and practice staff will execute affiliate agreements and work together to recruit an implementation team and create an implementation plan.
• Attend Training: The Virtual Healthy HealthySteps Institute (VHSI) is a blend of eLearning modules and live Zoom sessions designed to introduce pediatric (and family medicine) practices to the HealthySteps model. It is divided into 3 units, each geared to different audiences. The first unit is geared towards the entire pediatric practice, the 2^nd to the site-specific implementation team, and the last towards HS Specialists and behavioral health providers.
• Receive Support: HealthySteps sites will receive technical assistance for 6-12 months to address any challenges and support practice transformation.

Complete Reporting and Achieve Fidelity: Practices will complete Annual Site Reporting and receive support to reach model fidelity. After 3 years, sites are expected to achieve fidelity.

Number of days/hours:

Virtual HealthySteps Institute Components:

• Unit A is geared towards the whole practice and is a combination of a 1-hour eLearning module and a 1-hour live Zoom call. The goal is to ensure all staff understand the what and the why of HS and are excited to be a part of the program.
• Unit B is geared to the implementation team. It is a 2-hour Zoom session and focuses exclusively on how the site will implement the HS

Unit C is geared toward the HS Specialists and behavioral health staff (including the physician champions) and focuses on the principles and strategies of meeting with families in primary care. Unit C is a series of 3 eLearning modules and one 2-hour zoom session.

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for HealthySteps as listed below.

An Exploration Guide is provided to practice staff which provides answers to common and important questions about HealthySteps. Practice staff are required to complete a Goodness-of-Fit assessment which reviews ten key implementation drivers that influence a practice’s successful adoption of HealthySteps. Upon submission of the Goodness-of-Fit assessment, the practice staff will connect with a HealthySteps National Office team member to review.

Following the Goodness-of-Fit assessment, all HealthySteps sites complete an implementation plan. The implementation plan is a codified document between the site and the HealthySteps National Office that operates as a roadmap for implementing HealthySteps. It is intended to assist the practice in thinking through important issues, such as roles and responsibilities of team members, training needs, policies and procedures, modifications to workflow, and timelines for accomplishing key tasks. The practice can also use the implementation plan to anticipate challenges that may occur and identify potential solutions for these challenges.

Contact Erica Smith, Onboarding Lead, at esmith@zerotothree.org.

Formal Support for Implementation

There is formal support available for implementation of HealthySteps as listed below:

Following the VHSI, the National Office provides up to six Technical Assistance (TA) sessions to new sites. These TA calls are used to help a practice effectively implement the program. Potential topics can include screening, integrating HS into the practice (e.g., workflow, team dynamics), and suggestions around behavioral consults and team-based well-child visits.

The National Office does not expect HS Specialists to have complete breadth and depth of all knowledge and skills and we appreciate that it can feel daunting when trying to identify focus areas and reliable, effective sources for professional development. Therefore, there is a webpage available with tools designed to provide support and direction in each individual’s journey. The tools include:

• HealthySteps Specialist Competencies which define the key knowledge, skills and attitudes necessary for responsive, culturally attuned, and clinical best practices.
• A Reflection Tool for Professional Growth and Development.
• A HealthySteps Professional Development Resource Library which includes links to a range of articles, websites, eLearning courses, and other training materials spanning topics related to infant mental health and early childhood development.

The National Office also provides evergreen resources (eLearning modules) to support both practice implementation and HS Specialist’s direct work with families. This currently includes:

• From Tiny to Toddler – This eLearning course is a series of 12 modules, each 45-60 min. in length, providing HealthySteps Specialists with discrete knowledge, skills, and resources appropriate for use during each of the 12 well-child visits scheduled for babies: newborn through 36 months of age.
• HealthySteps Core Components – The HealthySteps Core Components eLearning series includes an overview module and seven modules, focusing on the HealthySteps Model Core Components. The modules are designed to inform and support implementation of the HealthySteps Core Components at a practice. Each module includes an overview of the core component, key ingredients, sample workflows, and fidelity and data collection requirements. They also include guidance on the infrastructure, policies, personnel, and resources needed to effectively embed HealthySteps into a practice.
• Mindfulness for HS Specialists and Families – The HealthySteps Mindfulness series includes two modules: Mindfulness for HealthySteps Specialists and Sharing Mindfulness with Families.
• Site-to-Site Contact via HealthySteps Connect is available so that practice teams can ask questions and gain insights from the hundreds of other HealthySteps affiliates around the country.

Fidelity Measures

There are fidelity measures for HealthySteps as listed below:

HealthySteps practices must implement the model with fidelity. The HealthySteps Service Delivery Fidelity Requirements are tied to the eight Core Components of the HealthySteps model. Every HealthySteps site is expected to complete Annual Site Reporting (ASR) each year which requires sites to report administrative data from the sites’ electronic health record and other HealthySteps-specific databases, related to the eight Core Components. The National Office tracks service delivery fidelity metrics via ASR to ensure that sites achieve fidelity within 3 years of implementing the program. The National Office has developed a Fidelity Self-Assessment based on implementation science to inform quality delivery of HealthySteps. The tool can help sites better understand how they are implementing HealthySteps in relation to the fidelity metrics, build upon their successes, and identify opportunities for improvement. For more information, see https://www.healthysteps.org/wp-content/uploads/2023/04/HS-Fidelity-Requirements-Overview_8.22.24.pdf

Fidelity Measures Required

Fidelity measures are required to implement this program.

Implementation Guides or Manuals

There are implementation guides or manuals for HealthySteps as listed below:

As soon as a practice completes the affiliate agreements, the National Office works with the practice team to begin implementation planning. The National Office provides a comprehensive Implementation Guide to the practice team to support the development of an initial implementation plan.

• HealthySteps National Office. (2025). HealthySteps implementation guide. ZERO TO THREE.

Implementation Cost

There have been studies of the costs of implementing HealthySteps which are listed below:

Buchholz, M., Burnett, B., Margolis, K.L., Millar, A., & Talmi, A. (2018). Early childhood behavioral health integration activities and HealthySteps: Sustaining practice, averting costs. Clinical Practice in Pediatric Psychology, 6(2), 140-151. https://doi.org/10.1037/cpp0000239

Golub, E., & Hackett, K. (2024, July). Sustaining HealthySteps: States’ approaches to financing an evidence-based model for healthy early childhood development. PolicyLab. https://policylab.chop.edu/tools-and-memos/sustaining-healthysteps-states-approaches-financing-evidence-based-model-healthy

Health Management Associates. (2026, January). Case studies report: Lessons learned from HealthySteps technical assistance in California. https://www.healthysteps.org/resources/california-sustainability-resources

Modern Medicaid Alliance. (2017, June). ZERO TO THREE’s HealthySteps program. https://modernmedicaid.org/zero-to-threes-healthysteps-program/

Research on How to Implement the Program

Research has been conducted on how to implement HealthySteps as listed below:

Barth, M. C. (2010). Healthy Steps at 15: The past and future of an innovative preventive care model for young children. The Commonwealth Fund. Available here.

Guyer, B., Barth, M., Bishai, D., Caughy, M., Clark, B., Burkom, D., Genevro, J., Grason, H., Hou, W., Keng-Yen, H., Hughart, N., Snow Jones, A., McLearn, K. T., Miller, T., Minkovitz, C., Scharfstein, D., Stacy, H., Strobino, D., Szanton, E., & Tang, C. (2003). Healthy Steps: The first three years: The Healthy Steps for Young Children Program National Evaluation. Available here.

Till, L., Filene, J., Morrison, C., Leis, J., Quigley, M., Ranade, N., & Leacock, N. (2017). HealthySteps implementation and outcome study evaluation report. Washington, DC: ZERO TO THREE.

Child Welfare Outcome: Child/Family Well-Being

“What is included in the Relevant Published, Peer-Reviewed Research section?”

• Caughy, M. O., Huang, K.-Y., Miller, T., & Genevro, J. L. (2004). The effects of the Healthy Steps for Young Children Program: Results from observations of parenting and child development. Early Childhood Research Quarterly, 19(4), 611–630. https://doi.org/10.1016/j.ecresq.2004.10.004

  Type of Study: Study 1: Randomized controlled trial; Study 2: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Participants: 378 Families

  Sample / Population:

  • Age — Children: 16–37 months; Mothers: Not specified
  • Race/Ethnicity — Children: Not specified; Mothers: 234 White, 93 African American, 48 Hispanic, and 3 Other
  • Gender — Children: Not specified; Mothers: 100% Female
  • Status —

    Participants were mothers and their children ages 0–3 years.

  Location/Institution: Amarillo, Texas and Florence, South Carolina

  Summary:

  The study used the same sample as Minkovitz et al. (2001). The purpose of the study was to test the effect of the Healthy Steps for Young Children Program (HS) [now called HealthySteps (HS)] on the quality of mother–child interaction, security of attachment, and child behavior. HS was evaluated across 15 sites across the country. Study 1 sites were located in Allentown, PA; Amarillo, TX; Florence, SC; Iowa City, IA; Pittsburgh, PA; and San Diego, CA. Study 2 sites were located in Boston, MA; Chapel Hill, NC; Birmingham, AL; Chicago, IL; Grand Junction, CO; Kansas City, KS; Kansas City, MO; New York, NY; Richmond, TX; and Houston, TX. Participants were either randomized or grouped to HS or to a services-as-usual control group, depending on their study site location. Measures utilized include the Teaching Scale Score of the Nursing Child Assessment by Satellite Training (NCAST), The Parent/Caregiver Involvement Scale (P/CIS), Home Observation for Measurement of the Environment Inventory, Infant/Toddlers, Attachment Q-sort, Child Behavior Checklist/2–3 (CBCL), a toy clean-up task, direct home observations, and structured interviews. Results indicate that mothers participating in HS were more likely to interact sensitively and appropriately than mothers in the comparison group at the second assessment point (age 34–37 months) but not at the first assessment point (age 16–18 months). There were no differences in child outcomes at either time point when the cross-sectional data were analyzed. However, the results of the longitudinal analysis (which included families who participated in the home observations at both Time 1 and Time 2) indicated that HS participation was associated with greater security of attachment and fewer child behavior problems. Limitations include that child report data was based on maternal report, small effect sizes, and only a subset of the original sample was analyzed. NOTE: Although this intervention draws on an earlier version of the intervention model that included home visitation and parent group components, the home visitation and parent group components were documented and analyzed separately, allowing for meaningful examination of each core element. Because the foundational structure of the program remained consistent, the resulting data can still contribute to the scientific rating of the Infant and Early Childhood Mental Health (Birth to 5) topic area.

  Length of controlled postintervention follow-up: None.

• Minkovitz, C. S., Strobino, D., Mistry, K. B., Scharfstein, D. O., Grason, H., Hou, W., Lalongo, N., & Guyer, B. (2007). Healthy Steps for Young Children: Sustained results at 5.5 years. Pediatrics, 120(3), e658–e668. https://doi.org/10.1542/peds.2006-1205

  Type of Study: Study 1: Randomized controlled trial; Study 2: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Participants: 3,165

  Sample / Population:

  • Age — Children: 61–66 months; Mothers: Not specified
  • Race/Ethnicity — Children: Not specified; Mothers: 65% White, 21% Black, 10% Other, and 5% Asian/Native American
  • Gender — Children: Not specified; Mothers: 100% Female
  • Status —

    Participants were mothers and their children who initially participated in Healthy Steps.

  Location/Institution: Pediatric hospital-based clinics and group/clinic practices across the US

  Summary:

  The study used the same sample as Minkovitz et al. (2001). The purpose of the study was to determine whether Healthy Steps for Young Children [now called HealthySteps (HS)] had sustained treatment effects at 5.5 years, given early findings demonstrating enhanced quality of care and improvements in selected parenting practices. HS was evaluated across 15 sites across the country. Study 1 sites were located in Allentown, PA; Amarillo, TX; Florence, SC; Iowa City, IA; Pittsburgh, PA; and San Diego, CA. Study 2 sites were located in Boston, MA; Chapel Hill, NC; Birmingham, AL; Chicago, IL; Grand Junction, CO; Kansas City, KS; Kansas City, MO; New York, NY; Richmond, TX; and Houston, TX. Participants were either randomized or grouped to HS or to a services-as-usual control group, depending on their study site location. Measures utilized include the Parents’ Evaluation of Developmental Status, the Child Behavior Checklist for children, and surveys measuring child overall health and parenting practices on promotion of their child’s development and safety. Results indicate that families that had received Healthy Steps services were more satisfied with care and more likely to receive needed anticipatory guidance. They also had increased odds of remaining at the original practice. HS families reported reduced odds of using severe discipline and increased odds of often/almost always negotiating with their child. They had greater odds of reporting a clinical or borderline concern regarding their child’s behavior and their child reading books. There were no effects on safety practices. Limitations include reliance on parent-reported child outcomes, sample attrition, limited generalizability due to high-capacity participating sites, the use of both randomized and quasi-experimental designs, each with concern for spill-over bias, and finally, no significant differences were found on the RCT Healthy Steps group and control group on Infant and Early Childhood Mental Health measures. NOTE: Although this intervention draws on an earlier version of the intervention model that included home visitation and parent group components, the home visitation and parent group components were documented and analyzed separately, allowing for meaningful examination of each core element. Because the foundational structure of the program remained consistent, the resulting data can still contribute to the scientific rating of the Infant and Early Childhood Mental Health (Birth to 5) topic area.

  Length of controlled postintervention follow-up: None

• Briggs, R. D., Silver, E. J., Krug, L. M., Mason, Z. S., Schrag, R. D., Chinitz, S., & Racine, A. D. (2014). Healthy Steps as a moderator: the impact of maternal trauma on child social-emotional development. Clinical Practice in Pediatric Psychology, 2(2), 166–175. https://doi.org/10.1037/cpp0000060

  Type of Study: Other quasi-experimental

  Participants: 124 children

  Sample / Population:

  • Age — Birth and 3 years
  • Race/Ethnicity — HealthySteps: 53% Hispanic, 35% Black, and 6% White; Comparison Group: 47% Hispanic, 28% Black, and 9% White
  • Status —

    Participants were caregivers with childhood trauma and children.

  Location/Institution: Two pediatric practices

  Summary:

  The purpose of the study was to determine the relationship between maternal report of childhood trauma and child social-emotional development on the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) at 36 months, adjusting for covariates, and test for a moderating effect of participation in HealthySteps (HS) on this relationship. Participants were enrolled in HS or a comparison group that did not offer the HS program. Measures utilized include the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE). Results indicate that children of mothers with childhood trauma had higher (worse) ASQ:SE mean scores than children of mothers without childhood trauma. Differences in adjusted mean ASQ:SE scores between children of mothers with and without childhood trauma were more apparent in the comparison group than in HS. Limitations include attrition rate, from enrollment at birth to age 3, which was substantial, with a 59% loss of the intervention group and 66% loss of the comparison group; small sample size, which may limit generalizability of results; and reliance on self-reported data for both caregiver childhood trauma and social-emotional development.

  Length of controlled postintervention follow-up: None

• Note: The following study was not included in rating HealthySteps on the Scientific Rating Scale.

  Minkovitz, C., Strobino, D., Hughart, N., Scharfstein, D., Guyer, B., & Healthy Steps Evaluation Team. (2001). Early effects of the Healthy Steps for Young Children Program. Archives of Pediatrics & Adolescent Medicine, 155(4), 470–479. https://doi.org/10.1001/archpedi.155.4.470

  Summary:

  The purpose of the study was to focus on the parent perceptions and parent practices of infants aged 2 to 4 months enrolled in the Healthy Steps for Young Children Program (HS) [now called HealthySteps (HS)]. HS was evaluated across 15 sites across the country. Study 1 sites were located in Allentown, PA; Amarillo, TX; Florence, SC; Iowa City, IA; Pittsburgh, PA; and San Diego, CA. Study 2 sites were located in Boston, MA; Chapel Hill, NC; Birmingham, AL; Chicago, IL; Grand Junction, CO; Kansas City, KS; Kansas City, MO; New York, NY; Richmond, TX; and Houston, TX. Participants were either randomized or grouped to HS or to a services-as-usual control group, depending on their study site location. Measures utilized include telephone interviews. Results indicate that intervention families were considerably more likely than controls to report receiving four or more developmental services and home visits and discussing five infant development topics. They were also more likely to be satisfied and less likely to be dissatisfied with care from their pediatric provider and were less likely to place babies in the prone sleep position or feed them water. The program did not affect breastfeeding continuation. Differences in the percentage of parents who showed picture books to their infants, fed them cereal, followed routines, and played with them daily were found only at the quasi-experimental sites and may reflect factors unrelated to HS. Limitations include a lack of follow-up and a lack of reliable and valid measures. Note: This article was not used in the rating process since it did not look at direct outcomes specified in the Infant and Early Childhood Mental Health (Birth to 5) topic area definition.

• Note: The following study was not included in rating HealthySteps on the Scientific Rating Scale.

  Caughy, M. O., Miller, T. L., Genevro, J. L., Huang, K.-Y., & Nautiyal, C. (2003). The effects of Healthy Steps on discipline strategies of parents of young children. Journal of Applied Developmental Psychology, 24(5), 517–534. https://doi.org/10.1016/j.appdev.2003.08.004

  Summary:

  The study used the same sample as Minkovitz et al. (2001). The purpose of the study was to 1) examine the effects of the Healthy Steps for Young Children Program (Healthy Steps), [now called HealthySteps (HS)] in changing discipline strategies reportedly used by participants when the target child was approximately 1.5 years old and again at 3 years old and 2) evaluate whether Healthy Steps differentially influenced discipline strategies based on family and child characteristics such as race/ethnicity, social class, and birth order. Participants were from two sites in a larger randomized controlled trial of Healthy Steps (Minkovitz et al., 2001). Measures utilized include the Parental Responses to Child Misbehavior (PRCM), direct home observations, and structured interviews. Results indicate that there were significant effects in increasing inductive/authoritative forms of discipline when the target child was a toddler. By the time of the pre-school-age assessment, the effect of Healthy Steps participation on the use of inductive/authoritative discipline strategies was moderated by maternal race/ethnicity. White mothers who participated in Healthy Steps reported higher use of inductive/ authoritative discipline strategies than White mothers who were in the control group, whereas Black mothers and Hispanic mothers reported lower use of inductive/authoritative discipline than their control group counterparts. Additionally, treatment effects were moderated by birth order as well as family socioeconomic status. By the time the children were preschool-age, the effects of Healthy Steps on the use of inductive/authoritative discipline were more dramatic for families living near or below poverty than for families in more secure economic circumstances. For the families with firstborn children, Healthy Steps participation was associated with lower use of inductive/authoritative discipline at preschool age, with an inverse association seen for families of later-born children. Limitations include that only a subset of the original study sites were analyzed, potential bias inherent in the sample, as mothers who did not complete a home observation were more likely to be single, younger, less well educated, and poorer than mothers who did participate; self-report bias; and timing of data collection. Note: This article was not used in the rating process since it did not look at direct outcomes specified in the Infant and Early Childhood Mental Health (Birth to 5) topic area definition.

• Note: The following study was not included in rating HealthySteps on the Scientific Rating Scale.

  Minkovitz, C. S., Hughart, N., Strobino, D., Scharfstein, D., Grason, H., Hou, W., Miller, T., Bishai, D., Augustyn, M., McLearn, K. T., & Guyer, B. (2003). A practice-based intervention to enhance quality of care in the first 3 years of Life: The Healthy Steps for Young Children Program. JAMA: Journal of the American Medical Association, 290(23), 3081–3091. https://doi.org/10.1001/jama.290.23.3081

  Summary:

  The study used the same sample as Minkovitz et al. (2001). The purpose of the study was to determine the impact of the Healthy Steps for Young Children Program (HS) [now called HealthySteps (HS)] on the quality of early childhood health care and parenting practices. HS was evaluated across 15 sites across the country. Study 1 sites were located in Allentown, PA; Amarillo, TX; Florence, SC; Iowa City, IA; Pittsburgh, PA; and San Diego, CA. Study 2 sites were located in Boston, MA; Chapel Hill, NC; Birmingham, AL; Chicago, IL; Grand Junction, CO; Kansas City, KS; Kansas City, MO; New York, NY; Richmond, TX; and Houston, TX. Participants were either randomized or grouped to HS or to a services-as-usual control group, depending on their study site location. Measures utilized include telephone interviews, medical care visit records, and study-developed measures. Results indicate that families who participated in the HS program had greater odds of receiving 4 or more HS–related services, of discussing more than 6 anticipatory guidance topics, of being highly satisfied with care provided, of receiving timely well-child visits and vaccinations, and of remaining at the practice for 20 months or longer. Participants also had reduced odds of using severe discipline. Among mothers considered at risk for depression, those who participated in the HS program had greater odds of discussing their sadness with someone at the practice. Limitations include a lack of valid and reliable measurement tools, a lack of treatment effects in relation to injury prevention and parenting practices, and a lack of generalizability due to demographic baseline differences of participants. Note: This article was not used in the rating process since it did not look at direct outcomes specified in the Infant and Early Childhood Mental Health (Birth to 5) topic area definition.

• Briggs, R. D., Carpenter, S., Krug, L. M., MacLaughlin, S., & Perez, S. L. (2024). Population health opportunities in pediatrics to support infant and early childhood mental health promotion and prevention: The HealthySteps Model. In J. D. Osofsky, H. E. Fitzgerald, M. Keren, & K. Puura (Eds). WAIMH Handbook of Infant and Early Childhood Mental Health. Springer, Cham. https://doi.org/10.1007/978-3-031-48627-2_25
• Briggs, R. D., Carpenter, S., & MacLaughlin, S. (2023). Transforming the promise of pediatric care: Rationale, barriers, and current practices in Adverse Childhood Experience (ACEs) Screening. In S. G. Portwood, M. J. Lawler, & M. C. Roberts (Eds). Handbook of Adverse Childhood Experiences. Issues in clinical child psychology. Springer, Cham. https://doi.org/10.1007/978-3-031-48627-2_25
• Valado, T., Tracey, J., Goldfinger, J., & Briggs, R. D. (2019). HealthySteps: Transforming the promise of pediatric care. The Future of Children, 29, 122–199. https://files.eric.ed.gov/fulltext/EJ1220075.pdf