Child First

About This Program

Target Population: Children prenatal to 5 years old and their parents/caregivers who are at risk of or have experienced child abuse, neglect, or trauma; have social-emotional, behavioral, or developmental problems; or live in families experiencing significant trauma and adversity.

For children/adolescents ages: 0 – 5

For parents/caregivers of children ages: 0 – 5

Program Overview

Child First is a two-generation, home-based mental health intervention for the most vulnerable young children (prenatal through age five years) and their families, who likely have current or past Child Welfare Services involvement. It is designed for young children who have usually experienced trauma and/or have social-emotional, behavioral, developmental, and/or learning problems. Most live in environments where there is violence, neglect, mental illness, substance abuse, or homelessness. The goals of Child First are to help them heal from the effects of trauma and adversity; improve child and parent mental health; improve child development; and reduce abuse and neglect.

The model uses two team members:

  • A Clinician provides a psychotherapeutic, two-generation intervention designed to build a nurturing, responsive, protective parent-child relationship, fostering the child’s cognitive and social-emotional development and improving parent mental health.
  • A Care Coordinator facilitates connections to broad community-based services and supports for all family members with the aim of achieving family stabilization, decreased parental stress, and improved executive functioning.

Program Goals

The goals of Child First are:

For Children:

  • Decreased problem behaviors
  • Improved social-emotional regulation and well-being
  • Improved communication and cognition

For Parents/Caregivers:

  • Decreased child abuse and neglect
  • Improved mental health
  • Improved executive functioning

For Families:

  • Increased nurturing, responsive, and protective parent-child relationships
  • Increased stabilization and connection to needed services and supports

Essential Components

The essential components of Child First include:

  • Intervention, Reflective Consultation & Supervision, and Community Collaboration:
    • The Child First Intervention includes:
      • Services provided in the home by a clinical team consisting of:
        • A licensed, Masters-level Mental Health/Developmental Clinician and Bachelor’s level Care Coordinator
        • Service intensity provided by each team member are tailored to the unique needs of the family, after the assessment phase
      • Eight intervention components:
        • Engagement of the family by clinical team:
          • Building a respectful and trusting relationship
          • Sustained efforts at engaging hard-to-reach families - up to 4 weeks
        • Stabilization of the family by Care Coordinator:
          • Immediate connection to community services and supports, if they are experiencing urgent challenges, like eviction, child expulsion, or child removal
        • Comprehensive assessment by clinical team:
          • Assessment components:
            • History of child and family trauma and adversity, as well as strengths and resilience – including all the social determinants of health
            • Child’s past and current health and development
            • Caregiver-child relationship, and child’s other important relationships
          • Parental and family strengths and challenges, like maternal depression, substance abuse, domestic violence, homelessness, and poverty, that directly impact a child’s healthy growth and development
          • Child First Assessment Protocol consists of standardized and Child First specific measures which are administered at baseline, 6 months, and at discharge.
            • Data is entered on each child and caregiver into an electronic health record, the Child First Comprehensive Clinical Record (CFCR).
            • Change from baseline to discharge is analyzed to determine if there is improvement, indicated by both statistical significance and effect size.
          • Occurs predominantly in the home, but also in early care and education settings, schools, and in any other environment in which the child spends significant time
        • Treatment Plan – Development of a comprehensive, well-coordinated, family-driven plan of care by clinical team:
          • Partnership with the family
          • Individually basing on family strengths, priorities, culture, and needs
        • Two-generation, trauma-informed psychotherapeutic intervention (Child-Parent Psychotherapy) and parent guidance by Clinician:
          • Enhancing the development of a secure, nurturing, protective relationship
          • Building parents’ reflective capacity to help them understand the meaning, feelings, and motivations which result in difficult child behavior:
            • Differs from learning a specific strategy to get rid of a “bad” behavior at a particular age
            • Equips parents with a method to address behaviors throughout the lives of their children
            • Creates understanding that behavior is a communication that has meaning
          • Home-based intervention provides an opportunity to respond to identified problems as they arise in their natural setting:
            • Much more convenient for family – no need for child care or transportation
            • Without the stigma of going to a mental health facility
        • Promotion of executive functioning and self-regulation capacity by the clinical team:
          • Child: Scaffolding of play, interactive caregiving, reading, activities, and routines using the Abecedarian Approach
          • Parent: Using connection to services as an opportunity to help a parent develop goals, priorities, plan, execute, and monitor
        • Mental health consultation and assessment by Clinician:
          • Within the early care and school environments
        • Connection to services and supports by Care Coordinator:
          • Referrals and hands-on assistance to connect all members of the family with community-based services and supports:
            • Facilitates the coordination of services and the family’s access to multiple resources throughout the community, based on collaborative planning with the parents
            • Provides hands-on assistance obtaining information and partnering with community providers
            • Researches program appropriateness and availability
            • Works with the parents to address barriers to service access, renewed problem solving, and revision of the plan for services
          • Eight areas of need addressed, including all social determinants of health:
            • Child
              • Development & early care and education
              • Behavior & emotions
              • Health
            • Family:
              • Parent support
              • Adult education
              • Family health>
              • Adult mental health and substance abuse
              • Social services and concrete needs
    • Reflective Supervision and Consultation is required and includes:
      • Clinical Director/Supervisor:
        • The affiliate agency’s Child First Clinical Director/Supervisor provides all clinical, reflective supervision to Child First staff (generally for 4 teams)
        • The Clinical Director must participate in individual, reflective consultation with the Child First State or Regional Clinical Director twice a month.
      • All Clinicians and Care Coordinators receive 3.5 hours of clinical, reflective supervision/week:
        • Individual: 1 hour/week
        • Clinical team: 1 hour/week
        • Group (all clinical teams together): 1.5 hours/week
        • Administrative supervision: A minimum of 1 hour/month of programmatic or administrative supervision in a group setting is required.
  • Community Collaboration is required:
    • Child First must be part of an early childhood system of care and fit within the continuum of services in the community
    • Referrals are received from and made to multiple community providers so that child and family services are comprehensive and well-integrated.
    • A Community Advisory Board is required for Child First fidelity.

Program Delivery

Child/Adolescent Services

Child First directly provides services to children/adolescents and addresses the following:

  • Child First directly provides services to children/adolescents and addresses the following:Children birth through 5 years of age at time of entry into program, who are evidencing emotional/behavior problems (e.g., externalizing or internalizing behaviors, posttraumatic stress disorder [PTSD]), difficulties in the parent-child relationship (e.g., signs of disorganized or insecure attachment, harsh or disinterested parenting), trauma exposure, high risk of child welfare involvement, or developmental/learning problems; or living within a family with challenges that are likely to impede a child’s healthy emotional or cognitive development. This includes families which have abused or neglected their children or with elevated psychosocial risk (e.g., trauma, domestic violence, maternal depression, PTSD, substance abuse, homelessness).

Parent/Caregiver Services

Child First directly provides services to parents/caregivers and addresses the following:

  • Child First directly provides services to parents/caregivers and addresses the following:Parent/caregiver of children prenatal through 5 years of age (at entry) where the children is evidencing emotional ⁄ behavior problems (e.g., externalizing or internalizing behaviors, PTSD), difficulties in the parent-child relationship (e.g., signs of disorganized or insecure attachment), trauma exposure, have experienced abuse or neglect or are at high risk of child welfare involvement, or developmental ⁄learning problems; and/or the parents/caregivers have mental health problems such as maternal depression, anxiety, PTSD, etc.; and/or the family is experiencing significant psychosocial risk (e.g., domestic violence, homelessness, substance abuse, or other traumatic events).
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Child First involves all members of the family. If there are other young children, each may have dyadic services, if appropriate. Interactions with other children in the household are also a focus of treatment. Any other caregiver, like a father (in or out of the home) or a grandparent, can be an additional focus of dyadic treatment. In addition, the primary caregiver’s partner may also be involved therapeutically or with the development of family functioning and routines. The Care Coordinator works to connect all family members with needed services. Child First works with both foster families and birth parents, especially when there is the possibility of reunification. Mental Health Consultation within early care and education and schools: If a child is routinely cared for outside of the home, the Child First Clinician must include this environment as part of the assessment and intervention process. A plan is developed in collaboration with the teacher or child care provider to address the child’s behavior and promote optimal development. The Clinician helps with implementation of the strategies. The Clinician works to develop mutual understanding and support among teachers/child care providers and parents/caregivers.

Recommended Intensity:

All home visits generally last 60-90 minutes. The Assessment phase (first month) includes visits that are usually scheduled twice per week, with both the Clinician and the Care Coordinator visiting the family together. The Intervention phase includes the Clinician visiting each family on a weekly basis (at a minimum) at a designated time for the appointment. The Care Coordinator may join these visits or come independently, based on family need and circumstances. (The Care Coordinator may have an essential role in providing therapeutic space for the dyadic treatment by playing with the other children in the family during the Clinician’s sessions.) Visits may be more frequent, if there is high family need.

Recommended Duration:

Generally 6-12 months

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Child Care Center
  • Foster/Kinship Care
  • Homeless Shelter
  • School
  • Domestic Violence Shelter

Homework

This program does not include a homework component.

Languages

Child First has materials available in a language other than English:

Spanish

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 at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Office space for Clinicians and Care Coordinators that facilitates confidentiality related to clients and health care records and allows private phone calls
  • Office space for Child First Clinical Supervisor/Director that provides appropriate environment for individual and team clinical supervision
  • Adequate space for group supervision (all agency personnel involved in delivering Child First services)
  • Computer and telecommunication capabilities
  • Cell phones
  • 1 FTE Child First Clinical Supervisor/Director for 4 Child First teams (each with a Clinician and a Care Coordinator)
  • Travel expense reimbursement (mileage) for Child First teams’ home visits and outside meetings

In addition:

  • The agency and each of its sites need to create or identify a local collaborative that can serve as a Community Advisory Board
  • A senior leader within the agency must commit to (1) overseeing and supporting the Child First program, including issues of long-term sustainability, and (2) participating in meetings 2-4 times a year with peers from other agencies in their region implementing Child First.

Education and Training

Prerequisite/Minimum Provider Qualifications

Clinical Director/Supervisor: Master’s level or Doctoral level, licensed mental health clinician, with extensive child development background, five years’ therapeutic experience with children 0-5 years, knowledge of adult mental health disorders, and three years’ experience providing reflective, clinical supervision.

Mental Health/Developmental Clinician: Master’s level or higher, licensed, with at least three years’ experience in early childhood mental health and development. A license-eligible clinician (receiving clinical supervision for licensure expected within the following 12 months, or licensed in another state and in the process of receiving licensure) with explicit permission of the Child First State Clinical Director.

Care Coordinator: Bachelor’s level or higher, with at least three years’ experience with young children and multi-challenged families and expertise in community-based services and supports.

In addition:

  • All staff must have excellent interpersonal skills and the ability to take a reflective stance with regard to self, child, and caregivers. They also must possess flexibility, empathy, and humility.
  • Each Child First site must have one team with linguistic competence appropriate for a dominant non-English speaking community that is served. All staff must display cultural humility and be culturally competent and responsive.

Education and Training Resources

There is a manual that describes how to implement this program , and there is training available for this program.

The Child First Manual and Toolkit are not published but provided online through Child First’s Distance Learning Platform, Absorb. These (and other manuals) are provided to all staff at the beginning of training.

  • Lowell, D., & Parilla, R. (2019). Child First training manual.
  • Lowell, D., Parilla, R., Killmeyer, S. (2019). Child First toolkit.

Other training guides include:

  • Soliman, S., & Parilla, R. (2019). Child First clinical directors’ guide.
  • Davino, A, DeBella Farber, K., & Johnson, S. (2019). Child First User Guide to CFCR (Child First Comprehensive Clinical Record).
Training Contact:
Training is obtained:

For an agency that is beginning implementation of Child First, all staff members who will be delivering Child First services participate in a Learning Collaborative (LC), which consists of 4 Learning Sessions over a 7-month period for a total of 10 days. This is provided in the community (or agency) which will be implementing Child First, whenever possible. Child First has a Distance Learning platform with required Distance Learning modules and reading before the Learning Collaborative begins and between each of the Learning Sessions. Services begin after the second Learning Session (approximately one month after the LC begins).

After an affiliate site has been established, Child First provides an accelerated version of the LC, Staff Accelerated Training (STAT), for new staff, which is delivered once a month over a 4-month period for a total of 6 days, with ongoing repetition (3 cycles per year). Trainers provide the training at the National Program Office (NPO), which is offered simultaneously by live videoconferencing at regional sites. That staff also completes the Distance Learning Modules between each of the sessions.

In addition, there are the following trainings for different team members:

  • Clinical Directors attend a 4-day training session before Child First begins implementation. It is offered regionally when there is a sufficiently large group to train; otherwise, Clinical Directors come to the NPO in Connecticut for training.
  • All Clinicians and Clinical Directors also receive training in Child-Parent Psychotherapy – 3 sessions totaling 7 days over a 12-month period, interspersed with the Child First Learning Collaborative. Training is offered regionally when there is a sufficiently large group to train; otherwise, training is provided at the NPO in Connecticut. There are 18 months of support calls. All clinical staff is formally rostered by CPP.
  • All Care Coordinators receive training in the Abecedarian Approach through the Learning Collaborative with quarterly support calls.

Child First also provides specialty trainings, usually regionally, to train more intensively on given topics, as needed.

Clinical Consultation by the State Clinical Director is an essential component on new and ongoing training. During the first 6 months of training, the State Clinical Director meets weekly at the new affiliate site for 2 hours of group clinical consultation and 1 hour of individual consultation with the Clinical Director/Supervisor. This decreases to biweekly after the LC, and then to biweekly with the Clinical Director/Supervisor individually for ongoing reflective clinical consultation.

Number of days/hours:

As detailed above, the total number of days of formal training varies by role and whether it is an agency new to Child First or an established site:

  • Clinical Director: New Agency – 21 days; New Clinical Director at an agency already implementing Child First – 17 days
  • Clinician: New agency – 17 days; New Clinician at an agency already implementing Child First – 13 days
  • Care Coordinator: New agency – 10 days; Care Coordinator at an agency already implementing Child First – 6 days

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Child First as listed below:

Agencies that wish to implement Child First complete an application which allows the NPO to assess agency readiness. This includes experience providing services: to young children and families, with ethnic diversity, in the home, with evidence-based models maintaining fidelity. Experience with assessment, data collection, and quality enhancement is reviewed. The organization’s capacity to implement a psychodynamic model and a commitment to reflective supervision and staff support is assessed; along with an agency’s ability to hire and retain appropriate staff. The financial health of the organization and ability to support the Child First implementation (including Medicaid reimbursement, if appropriate) is gathered. The agency’s leadership capacity and experience collaborating with other community providers.

Formal Support for Implementation

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

Child First has a robust support system for implementation, which is required as part of maintaining fidelity. During the first six months of implementation, the State or Regional Clinical Director (employed by the National Program Office [NPO] but living in the new implementation state) meets at the affiliate site weekly (3 hours) to provide clinical consultation to the agency Clinical Director/Supervisor individually and to the Child First clinical teams as a group. For months 6-12, the State or Regional Clinical Director meets twice a month with both Clinical Director/Supervisor and staff. Thereafter, the State/Regional Clinical Director meets biweekly with each agency’s Clinical Director/Supervisor to provide reflective clinical supervision. This is ongoing. The State/Regional Clinical Director is always available for consultation by teleconferencing, phone, or email whenever needed.

The Child First model has also developed an affiliate site Network in each state. This Network of all Child First Clinical Directors/Supervisors from all the agencies in a given region or state meet in person on a monthly basis to discuss clinical and management issues. NPO also has calls, teleconferencing, or in-person meetings 2-4 times a year with Senior Leaders/executive management from the affiliate agencies.

Data is collected in real time from all sites. A Database Training and Support Manager is available for technical support 40 hours per week by phone, teleconferencing, or email. Additional on-site or distance training is offered to sites by the Data and Quality Enhancement Department whenever needed.

NPO monitors site fidelity throughout the year, which includes clinical fidelity (Child First Clinical Fidelity Framework, based on the Child-Parent Psychotherapy framework) and reports of both process and outcome data (Child First Benchmarks and Assessment Reports respectively). The reports are available to each site and reviewed by the State/Regional Clinical Director on a monthly/quarterly basis. They are used for quality enhancement (implementation of small test of change at the site level) and to determine if additional training or support is needed by the affiliate sites. If an agency or one of its sites is consistently not meeting Child First fidelity standards, NPO provides additional supports to help strengthen the program.

Fidelity Measures

There are fidelity measures for Child First as listed below:

The Child First Clinical Fidelity Framework consists of a set of five fidelity forms (based on the Child-Parent Psychotherapy framework) to track different aspects of clinical implementation:

  • 1. Foundational Phase Fidelity (clinical team)
  • 2. Clinician Core Intervention Fidelity
  • 3. Care Coordinator Interventions
  • 4. Termination Fidelity
  • 5. Supervision Fidelity

For those that do not have access to the Child First Distance Learning Platform, electronic copies can be requested from the Child First National Program Office (NPO).

The Child First Clinical Fidelity Framework forms are checklists completed by individuals within the Child First teams and reviewed and discussed in reflective supervision with the Clinical Director/Supervisor.

Benchmark reports are prepared by the Data and Quality Enhancement Department at the NPO based on data entered into CFCR and reviewed monthly by affiliate sites and the State/Regional Clinical Director and Quality Department.

Assessment reports are prepared by the Data and Quality Enhancement Department at the NPO based on data entered into Assessment Database. Child and family outcomes are reviewed for each site, based on statistical significance and effect size, on a quarterly basis.

The Program Fidelity Checklist is a self-assessment completed by the staff at an agency implementing Child First and reviewed by the State Clinical Director annually

Child First Accreditation is required for each affiliate site within two years of full implementation. This is a collaborative process and includes a review of Benchmarks; Assessment outcomes; Clinical Fidelity Framework, Program Fidelity Checklist, clinical chart review; videos of parent, child, and team interaction; presence of Community Advisory Board, and training, among other factors. Based on Accreditation status, plans for continuous quality improvement are developed by the affiliate site.

Fidelity Measure Requirements:

These are completed monthly by both Clinicians and Care Coordinators and reviewed during clinical supervision. In addition, videotapes of the actual intervention are reviewed in individual, team, and group supervision sessions.

Affiliate sites are sent monthly Child First Benchmark Reports to track if they are meeting key fidelity requirements with regard to the process of implementing Child First with families.

The Child First Program Fidelity Checklist is completed on a yearly basis by the staff implementing Child First at an agency. This is specific to the organizational adherence to the model.

Implementation Guides or Manuals

There are implementation guides or manuals for Child First as listed below:

The Child First Program Fidelity Checklist is a detailed overview of the requirements for implementing Child First with fidelity. The Welcome Packet is made available before a new Learning Collaborative and gives an overview of the process to begin Child First implementation. The Child First Clinical Supervisor/Director at each agency is provided with the Clinical Directors’ Guide for start-up and implementation at an agency.

For those that do not have access to the Child First Distance Learning Platform, electronic copies can be requested from the Child First National Program Office.

Implementation Cost

There are no studies of the costs of Child First.

Research on How to Implement the Program

Research has not been conducted on how to implement Child First.

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Crusto, C.A. Lowell, D.I., Paulicin, B., Reynolds, J., Feinn, R., Friedman, S. R., & Kaufman, J. S. (2008). Evaluation of a Wraparound process for children exposed to family violence. Best Practices in Mental Health: An International Journal, 4(1), 1-18.

Type of Study: One group pretest-posttest
Number of Participants: 82

Population:

  • Age — Parents: Not specified; Children: 1- 6 years (Mean=3.3 years)
  • Race/Ethnicity — Parents: Not specified; Children: 55% Latino/Hispanic, 27% Black/non-Hispanic, 9% White, 1% Other, and 9% Unknown
  • Gender — Parents: Not specified; Children: 56% Male and 44% Female
  • Status — Participants were parents and their children who were exposed to family violence.

Location/Institution: Bridgeport, Connecticut

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined the effectiveness of Child and Family Interagency, Resource, Support, and Training (Child FIRST) [now called Child First] to address the mental health and developmental needs of high-risk children five years old and younger and the multiple challenges faced by their families. Measures utilized include the Resource and Outcome Data Form, the Traumatic Events Screening Inventory–Parent Report Revised, (TESI-PRR), the Trauma Symptom Checklist for Young Children, (TSCYC), and the Parenting Stress Index–Short Form (PSI-SF), and the Patient Satisfaction Questionnaire. Results indicate that from the time of entry into the program until program discharge, children experienced significantly fewer traumatic events, including both family and nonfamily violence events. Limitations include nonrandomization of participants, lack of control group, reliance on self-reported measures, and lack of follow-up.

Length of postintervention follow-up: None.

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. doi:10.1111/j.1467-8624.2010.01550.x

Type of Study: Randomized controlled trial
Number of Participants: 157

Population:

  • Age — Parents: Not specified; Children: 6-36 months (0.5-3 years)
  • Race/Ethnicity — Parents: 59% Latino/Hispanic, 30% African American, 8% Caucasian, and 3% Other; Children: Not specified
  • Gender — Parents: Not specified; Children: 56% Girls and 44% Boys
  • Status — Participants were from predominately inner city families that lived in poverty.

Location/Institution: Bridgeport, Connecticut

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined the effectiveness of Child and Family Interagency, Resource, Support, and Training (Child FIRST) [now called Child First]. Participants were randomly assigned to Child FIRST intervention group or to the Usual Care control group. Measures utilized include the Infant-Toddler Social and Emotional Assessment (ITSEA), the Infant-Toddler Developmental Assessment (IDA), the Brief Symptom Inventory (BSI), the Parenting Stress Index (PSI) Short Form, and the Center for Epidemiological Studies Depression Scale (CES-D). Results indicate at the 12-month follow-up, Child FIRST children had improved language and externalizing symptoms compared to Usual Care children. Child FIRST mothers had less parenting stress at the 6-month follow-up, lower psychopathology symptoms at 12-month follow-up, and less protective service involvement at 3 years postbaseline relative to Usual Care mothers, based on Child Protection records and parent report. Limitations include reliance on maternal self-report measures, inability to keep research staff unaware of group status, and use of a fidelity checklist within clinical supervision without formal analysis of intervention fidelity.

Length of postintervention follow-up: Varied. Follow-up assessments were conducted at 6 and 12 months after baseline. Mean length of treatment was 22.1 weeks (SD = 14.5, Median = 18.7). Child Protection records were obtained for 3 years postbaseline.

Additional References

Bornstein, D. (2013, Oct. 13). Protecting children from toxic stress. New York Times. Retrieved from https://opinionator.blogs.nytimes.com/2013/10/30/protecting-children-from-toxic-stress/

Diehl, D. (2013). Child FIRST: A program to help very young at-risk children. In S. L. Issacs, & D. C. Colby (Eds.). The Robert Wood Johnson Foundation Anthology: To improve health and health care. (Vol. XV, pp. 279-305). Princeton, NJ: The Robert Wood Johnson Foundation Anthology.

Osofsky, J., Weider, S., Noroña, C. R., Lowell, D., Worthy, & D’Lisa, R. (2018). Effective mental health interventions and treatments for young children with diverse needs. ZERO TO THREE, 38(3), 32-44.

Contact Information

Darcy Lowell, MD
Agency/Affiliation: Child First, Inc.
Website: www.childfirst.org
Email:
Phone: (203) 538-5225 or (203) 538-5222
Mary Peniston, MPA
Agency/Affiliation: Child First, Inc.
Website: www.childfirst.org
Email:
Phone: (203) 538-5224 or (203) 538-5222

Date Research Evidence Last Reviewed by CEBC: January 2019

Date Program Content Last Reviewed by Program Staff: July 2019

Date Program Originally Loaded onto CEBC: August 2019