The Los Angeles Child Guidance Clinic is greatly concerned about how intense community stressors are affecting the early social and emotional development of children who live in Central and South Los Angeles. Factors such as poverty, domestic and community violence, child abuse and neglect, low parent education, separation from parents, parental mental illness, teen motherhood and prenatal drug exposure can impede successful child development. Poverty is a factor of particular concern. The largest number of Americans living in poverty are ages three and younger. A number of other factors associated with poverty contribute to a child’s at-risk status, including family stress, unemployment and transitory housing. The work of Rutter (1979) informs us that a child who has more than two risk factors, compared to a child with zero or one risk factor has a much higher likelihood of having a future psychiatric diagnosis. Rutter also found that children who have four or more risk factors (like many of the children in our community) are ten times more likely to experience a future psychiatric impairment.
Reported data tells us that children living in poverty are more likely to be victims of maltreatment, as opposed to children in higher socio-economic groups. Further, the stress of poverty combined with a parent’s past history of his/her own childhood trauma, can dramatically increase a child’s at-risk status. The work of Perry et al. (1995) and Perry (1993) informs us that an infant’s developing brain can be negatively impacted by exposure to trauma including maltreatment or ongoing stressful environments. This exposure can cause a child’s brain to re-organize its activity around survival needs as opposed to learning needs. Thus, very young children exposed to maltreatment or extremely stressful environments carry a high risk for future involvement in mental health services. In addition to mental health problems, combined risk factors can also greatly hamper children’s school performance and their ability to be successful at home and in the community.
The primary protective factor for at-risk children is a significant positive adult attachment relationship. Research findings demonstrate that a child who experiences at least one significant positive attachment relationship fares better in the face of multiple risk factors, as compared to a child who lacks a healthy attachment relationship early in his/her life. (Campbell, Cohn, & Meyers, 1995)
In order to assist families like these in our community, the Clinic implemented the First Steps Program. First Steps utilizes the home-visiting, Interaction Guidance model (McDonough, 1993, 2000, & 2004) for at-risk families with infants and toddlers in order to prevent the child’s involvement in mental health services in the future. Notably the Clinic selected this model because of its focus on parents/caregivers who are difficult to reach and/or engage, including those who have failed other interventions. Because the communities served by the Clinic are historically under-served including ethnic minority members, both African American and Latino, living at or below the poverty level, it was incumbent on us to adopt a model that met the needs of our community.
In the program, mental health professionals partner with and support parents (who are often coping with mental illness, depression, domestic violence, substance abuse, isolation, poverty, and/or other stress factors) to help them develop stronger attachment bonds with their children aged 0-3. A strong attachment bond between parents and children helps prevent children from having future mental health problems, builds their resilience, gives them an increased ability to overcome challenges, increases the growth of their developmental skills, and helps them to develop healthy relationships throughout their lives.
The purpose of the First Steps Program is to enhance healthy and appropriate attachments between children and their parents through a home-based, strength-focused intervention model. Families are referred to the program through various sources, including Los Angeles Unified School District, the Department of Children and Family Services, the Department of Mental Health, the Department of Public Social Services, and a wide range of other direct service providers. In alignment with the core philosophy of the Clinic, program services are delivered with respect for each family’s cultures, values, and norms.
As a result of the program achieving successful outcomes, combined with its commitment to historically under-served ethnic minority populations, First Steps was honored with the 2006 National Award for Advancing Minority Mental Health by the American Psychiatric Foundation, the philanthropic arm of the American Psychiatric Association.
Interaction Guidance Model
Following extensive research and consideration, t he Los Angeles Child Guidance Clinic applied the treatment model of Interaction Guidance (IG) to its First Steps Program. The IG method has proven successful for treating culturally diverse families caring for infants with growth failure; pediatric regulation disorders – sleeping, feeding or excessive crying; biological vulnerabilities and genetic disorders. Additionally, IG has proven effective with depressed, isolated and substance recovering parents. This intensive home-visiting model has been highly effective in engaging and successfully treating families that have otherwise been difficult to engage and/or who have failed in other treatment models.
IG has been the subject of multiple research studies , the most recent being a randomized trial funded via the National Institute of Mental Health (NIMH Grant #5R01MH066318-03). IG is cited or listed in many studies as an effective treatment modality for families from different cultural backgrounds and with disabilities. In fact, in a recent review of available early childhood intervention programs, Zeanah, Stafford, and Zeanah (2005) included the IG as one of their clinical intervention modelsin infant mental health. The Interaction Guidance treatment method has demonstrated its effectiveness in the following representative studies:
Helping culturally diverse families caring for infants with growth failure as well as childhood disorders such as sleeping, feeding or excessive crying (Cramer et al., 1990; McDonough, 1995; Robert-Tissot et al., 1996; Stern, 1996)
- Children with biological, genetic, and substance-related disorders (McDonough & Boukydis, 1992)
- Parents who are depressed (McDonough, 1993; Robert-Tissot et al., 1996; Stern, 1996)
- Resistant parents (McDonough, 1993, 1998; Zeanah, et al., 2000)
- Parents with limited cognitive abilities (McDonough, 1995)
- As effective as the dynamically-oriented psychotherapy in improving parent-infant relationship (Cramer, et al., 1990, Cramer & Robert-Tissot, 2000)
- Long term effect in increasing depressed mothers’ sensitivity to their children (Robert-Tissot et al., 1996; Robert-Tissot & Cramer, 1998)
- Improving parent-child relationship for medically fragile children (McDonough, 1989; McDonough, 1993)
II. PROGRAM DESCRIPTION
The Los Angeles Child Guidance Clinic piloted the First Steps Program in 2002 with a one-year, private foundation grant. Following the success of the pilot, the board of directors and staff committed to raising the funds necessary to launch and sustain the program. Since 2004, private funding has been secured annually to support all personnel and operating costs associated with the program. Funding sources include private and family foundations, corporate giving programs and contributions from board members. First Steps is in its third year of operation and is institutionalized within the structure of the Clinic’s ongoing programs.
Thegoals of the First Steps Program are to:
- Increase access to early intervention mental health services for families with young children experiencing multiple stressors.
- Identify early on the development of emotional and cognitive difficulties in children.
- Develop and implement treatment strategies and goals to address issues such as parenting skills, parental mental health needs, safety concerns, and other sociological and environmental issues.
- Increase parents’ ability to appropriately and effectively respond to their children’s emotional needs and non-verbal cues.
- Improve children’s social, emotional and developmental functioning by partnering with parents and sharing in the child’s progress.
Families are referred to the First Steps Program because they demonstrate characteristics of having four or more risk factors. Some participants are identified through education and outreach efforts to community-based organizations such as Early Head Start and Head Start Centers. Once families are enrolled in First Steps, staff members work with parents to create an individual plan of goals that addresses the whole family’s needs, including the child’s. Parents commit to participate in the program at a rate of two to three times per week for six to eight months. Parent-child interactions, children’s responses and increased skills are assessed at regular intervals. Adjunctive services, including community linkages and referrals, are included in the program.
The First Steps Program utilizes the structured, home-based IG model that is geared to developing an effective partnership with parents to foster their strengths. Mental health professionals approach the family system from a relational perspective, focusing first on the therapist’s relationship with the parent as a model of support, trust and encouragement. Next, program staff supports the parent in the enhancement of his/her relationship with the child.
The home-visiting model allows staff to address several issues at once. First, parents who are struggling with chronic crises can be emotionally fragile. They are often “unavailable” to their children, and have significant limitations in their ability to participate in center-based services. Second, families may be isolated as a result of mental health issues, recent immigrant status or other factors. Finally, our target population often lacks personal transportation, and public transportation can be difficult for them for various reasons, such as the expense and the effort it takes to bring an infant and other children along. The program’s model provides a unique opportunity to provide intensive support to parents as they begin to address and recover from their complex problems. At the same time, the model fosters the development of the parent-child attachment bond in the natural setting of home. Since the attachment bond is built around daily living routines such as bathing, feeding, diapering, soothing, and putting the child to sleep, the home-visiting model is ideal, for these tasks cannot be recreated as easily or effectively in the Clinic setting. Additionally, by providing services in the home, program staff become aware of cultural needs and practices specific to the family, and can then tailor the treatment plan and service delivery accordingly.
As a method of educating parents and teaching new skills, professional staff videotape parent/child interactions during home visits. The use of videotape allows parents to observe their own behavior, provides feedback on their progress, and is an exciting means for them to observe their child’s developmental and behavioral growth and to experience their increased parenting competencies.
The Interaction Guidance model leads parents to a better understanding of how they may improve outcomes for their child, e.g. through talking, singing, reading, playing games, and interpreting infant and toddler emotional cues. Staff also help parents understand what is a normal part of child development and help them create an environment that is tolerant of a child’s normal activity. Conversely, they help parents identify what is not normal, i.e., tantrums that occur frequently or persist for too long. Program mental health professionals assess and intervene on child behaviors that indicate early aggression, hyperactivity, poor impulse control, etc.
Ongoing Supervision and Treatment Fidelity
The IG model requires a knowledge of and sensitivity to the unique developmental issues of infants and toddlers, combined with a strong clinical knowledge of family systems theory, dynamic process and the transactional model. The implementation of the First Steps Program included in-depth training in the IG model and a commitment to ongoing fidelity monitoring. To this end, the Project Director received over 32 hours of training directly from the developer of IG, Dr. Susan McDonough. The training was supported by ongoing supervision from an IG trained therapist, as well as direct consultation from Dr. McDonough that included review of videotaped client sessions.
In the Clinic’s translation of the research into an effective community-based practice, a treatment team was developed that consists of a Clinical Psychologist (Therapist) and a BA- level Child Development Specialist (Home Interventionist). The team which is bilingual and bicultural has knowledge of infant/toddler development, and psychological processes that are evident in family systems interactions. They are trained in the IG model with a specific set of underlying assumptions that guide their work, drive the treatment, and foster positive relationships between the treatment team and the family. Adherence to assumptions creates an environment where change is possible within the family system. These assumptions are:
- Embrace the position that parents/caregivers are doing the best they know how to do.
- Address what parents believe to be the problem or issue of concern.
- Ask the family what you can do to be helpful.
- Answer questions posed by the family directly; provide information when asked.
- Decide jointly with parents the definition of treatment success - make it explicit.
- Monitor treatment progress weekly with the family
To support staff adherence to the model, each IG team member participates in weekly individual and group supervision meetings with the Project Director. Additional adherence to the assumptions is ensured by the regular review of staff videotapes of home visit sessions and the family’s commitment to partner with IG staff and participate in the program.
III. PROGRAM OUTCOMES
Since 2004, a total of 20 children have completed the First Steps program. The average age of the children at admission was 16.90 months, while the average age for the mothers was 28.35 years. Among the admitted children, 8 were female, and 12 were male; 17 were Latino and 3 were African American. Regarding individual and family risk factors, children and families in the program presented with numerous medical and environmental problems, including: domestic and community violence, maternal depression substance dependency, smoking during pregnancy, parental and sibling disabilities, failure to thrive and other physical ailments such as intestinal problems and infection, kidney infection, asthma, and chronic flu and ear infections.
Results to date indicate that the First Steps Program is reaching its goals with our at-risk families in our underserved ethnic minority community by increasing access to early intervention services, identifying early on the development of emotional and cognitive deficits, developing and implementing treatment strategies that build parent competencies in effectively addressing and meeting their children’s needs, and through a partnership with parents work together to improve their children’s developmental functioning.
The Clinic measures the success of the First Steps Program via multiple measurement tools, including both process and outcome measures. This involves measuring the processes that assure access to services by the community (tracking the number of referrals, educating prospective parents about the program and obtaining agreement to participate in services, individualized treatment planning that includes parent-driven goals, and active parental participation in treatment) and the outcomes of services based on baseline and follow-up measures for children’s functioning level and safety of home environment,
Professional staff measured outcomes by assessing children’s developmental progress at the beginning of treatment, after four months of service, and again at discharge using the Home Observation Measure of Environment (HOME) and the Ages & Stages Questionnaire (ASQ). The HOME is intended to determine the amount of stimulation and resources that are present in the child’s home (Caldwell & Bradley, 1984). Scores are obtained for the following: responsivity, parent’s acceptance of their child(ren), organization of the environment, learning materials, parental involvement, and variety of experiences offered to the child. The ASQ is used to screen and monitor infants and young children for developmental delays and mental disorders (Bricker, Squires, & Mounts, 1995). Caregivers are asked to rate items related to their children’s behaviors in the areas of communication, gross motor, fine motor, personal-social and problem solving. These responses are then calculated to generate scaled scores for each developmental area.
Before intervention services began, home environments revealed a lack of stimulating and/or age-appropriate materials, limited parental responsitivity to the emotional needs of their infants and unrealistic behavior expectations. Pre-test measures on children also indicated developmental delays in the areas of gross and fine motor, communication and personal social skills. Participating families received an average of 32 hours of home-based treatment. With treatment, parents gained an increased understanding of child cues and were able to facilitate appropriate developmental improvement in their children. Post-test data from the HOME assessment demonstrated increased environmental stimulation conducive to child development and learning. Post-test data from the ASQ demonstrated improvements in communication, fine motor skills, personal-social, and problem-solving capacity. Although these findings do not reach statistical significant given the small sample size, these results do strongly suggest that the First Steps Program is building parental competencies in interpersonal skills supportive of secure attachment relationships and creating nurturing environments to support development.
IV. SUMMARY AND CONCLUSIONS
The Los Angeles Child Guidance Clinic established its First Steps Program to meet the needs of families with infants and toddlers at high risk of future involvement in bonafide mental health services. The program is well aligned with the Clinic’s mission: to ensure easy access to needed services and to promote early intervention for communities in great need. The adopted Interaction Guidance model melds the “best practices” for serving the high needs population which is targeted by the Clinic’s First Steps Program. Families served are from historically under-served ethnic minority populations within the Central and South Los Angeles communities that have long faced cultural, linguistic and economic barriers to accessing and receiving appropriate service.
Based on multiple methods of data tracking, aggregation, and analysis, First Steps has demonstrated its promise in effectively engaging and serving the target population. Included has been creating access to much needed early intervention services delivered via the Interaction Guidance model. Particularly gratifying to First Steps staff were parent reports of improved competencies in positively supporting their children’s healthy social and emotional development. One only needs to watch the videotapes which capture the movement from a distant or disturbed parent-child relationship to joyful nurturing parent-child interactions following First Steps service.
Among the Clinic’s continuum of Early Intervention and Community Wellness Services, First Steps represents a much needed prevention initiative which has the infrastructure in place to support a significant expansion. A well trained cadre of therapists, child psychiatrists and home interventionists/child development specialists skilled in infant, toddler and preschool prevention, early intervention, and mental health treatment services is available to not only support such an expansion, but to assist other interested organizations in their adoption and implementation of the First Steps model.
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American Psychological Association (APA) article on First Steps Program