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Key overview details

Classification
  • Universal
  • Targeted
Mental Wellbeing Need
  • Conduct Problems
  • Prosocial behaviour
  • Emotion Regulation / Emotional literacy
  • Parenting
  • Parent-child relationship / Attachment
Target Age
  • Infants and Toddlers: 0-36 months
  • Preschool: 3 to 5 years
Provision
Usability Rating
5
Supports Rating
5
Evidence Rating
3 - 4
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Child First

Summary

Child First is a home-based programme for families with young children (from pregnancy to when the child turns six years old), targeting families who face multiple adversities and/or have experienced trauma.

The programme is delivered by a two-practitioner team, comprised of a clinician and a care coordinator, usually over a period of 6-12 months. Following an initial period of engagement and assessment which facilitates the development of a tailored plan of care, the clinician delivers Child-Parent Psychotherapy alongside the care coordinator’s emphasis on establishing links for the family with existing local services.

Positive programme outcomes have been demonstrated in an randomised controlled trial and across multiple service evaluations, with long term maintenance of improvements in child externalising behaviours as well as improvements in maternal mental health sustained at 6-months post-intervention. Families who receive Child First also demonstrate significantly more engagement with local services compared to those who have not received this input.

Child First has been established in a number of sites across the US, however there has been no implementation outside of the US to date.

Website: https://www.childfirst.org/

Usability - Rating: 5

Core Components

Child First is available to families from pregnancy or at any time until the child turns six years old. The intervention is particularly targeted at children with social, emotional and/or behavioural difficulties, and families who face multiple adversities such as poverty, parental mental health difficulties, domestic violence and neglect, however the programme has no exclusion criteria.

Child First is designed to be embedded within a continuum of services for young children and their families and to work collaboratively with supports already in place to ensure families receive a holistic, joined-up model of care.

The programme is clearly operationalised and carried out by a two-practitioner team consisting of a mental health clinician and a care coordinator. Intervention takes place in the home on a weekly basis generally over a six-twelve month period and consists of core stages:

• Following the period of engagement, which employs motivational interviewing techniques, a comprehensive assessment is undertaken which focusses across all aspects of child development, the child-caregiver relationship and caregiver wellbeing and capacity. (Visits are twice weekly over these initial 4-6 weeks of assessment).
• From this assessment, a child & family plan of care is developed which is specifically tailored to the needs of each individual family.
• All families receive the intervention of Child-Parent Psychotherapy, the specific focus of which is shaped by the family’s strengths and needs.
• All families also receive care coordination (based on the Abecedarian Approach which integrates basic principles of human learning and development in to an early childhood education approach) to facilitate awareness and access to appropriate community resources.
• Throughout the intervention the practitioner team also focuses on the enhancement of parental, and in turn child, executive function, and on providing mental health consultation to the child’s teacher or childcare provider.

The structure of the intervention is supported by a manual and ongoing supports with the specific aim of building capacity and sustainability for the agencies providing the programme.

Fidelity

Fidelity to the Child First model is assessed through a range of mechanisms, with benchmark data and clinical fidelity monitored on a monthly basis by the National Program Office (NPO). Outcome data for measures across all assessment targets are analysed quarterly for comparison between baseline and discharge ratings.

Child First operates an accreditation process by which NPO can determine whether sites are implementing the programme with fidelity to the model. A collaborative assessment takes place no sooner than one-year post-training completion, across which sites must demonstrate they have achieved benchmarks and evidence of adherence to all aspects of intervention model including meeting standards of clinical fidelity through review of videotaped intervention sessions.

Modifiable Components

Each family receives a tailored plan, targeted at the needs identified through the assessment process and agreed in collaboration with the family. Consequently, the specific emphasis of the therapeutic intervention and care coordination approaches, along with the duration of intervention, will be modified depending on the agreed focus.

The programme has been delivered across a range of cultural populations, with most materials available in Spanish as well as English, and an essential stipulation for an implementation site is that there are practitioners fluent in the local languages.

Supports - Rating: 5

Child First training is delivered by the National Program Office (NPO) through both on-site and distance learning components.

Support for Organisation / Practice

Implementation Support

The Child First NPO provides an extensive model of integrated support from initial readiness assessments and the establishment of teams, protocol and data management processes, to ongoing technical and implementation consultation. Although Child First has not yet been implemented in the UK, the model of implementation and supports would be transferable, with a locally-based Child First intermediary facilitating this process.

Child First NPO supports implementing agencies to establish appropriate data systems and liaises with these on a monthly basis to produce local and wider outcome reports. Child First affiliate agencies receive weekly reflective consultation from a National Program Office (NPO) clinical director, during the training period.  Thereafter, the agency’s Child First clinical supervisor continues to receive clinical consultation twice a month.

Within the US, agency Child First clinical directors/supervisors in a region/state meet in person on a monthly basis to share cases and administrative challenges, and improve clinical and supervisory skills. This is an opportunity for the clinical directors to share both their challenges and successes with their colleagues, in order to facilitate peer learning and quality enhancement. This meeting is facilitated by the NPO state clinical director.

Licence Requirements

Child First is delivered under a licence agreement with Child First NPO.

Start-up Costs

• Start up and training of new affiliate agencies - $390,000 – all inclusive of pre-launch and launch – based on 16-32 teams (small incremental cost for food and materials when over 16 teams)
• Annual fees - $16,000/team (i.e. clinician & care coordinator) – includes biweekly clinical consultation, training of new staff that are hired after initial whole-team training, monthly meeting of regional directors, data package, and accreditation
• Estimated overall annual cost - $750,000-$900,000 – based on minimum 4 teams + 1 full time clinical supervisor (includes Child First annual fees)
(Costs are based on the current US model of integration in to a large system – please contact developers for discussion of smaller scale implementation costs.)

Building Staff Competency

Qualifications Required

Each Child First team consists of a professionally qualified mental health clinician and a care coordinator who will have at least a bachelors level qualification, both with experience working with very young children and vulnerable families. Each team must also have a clinical director or supervisor who must be a licensed mental health clinician, ideally with at least five years’ experience with psychotherapeutic work with very young children and adults.

The reflective capacity, experience and maturity of staff is critical and significant support is provided by the programme for appropriate recruitment, including the provision of relevant case studies at interview.

Training Requirements

Training takes place in a combination of on-site and distance learning components. Distance learning can commence while teams are being recruited in order that the whole team undergoes in-person training together as a ‘Learning Collaborative’. This encompasses 8 days of face-to-face team training over a seven-month period, interspersed with further distance learning and reflective consultation.

Clinicians and supervisors are both trained in Child-Parent Psychotherapy (Lieberman model - 12 months training and 18 months of supervisory telephone calls which run concurrently with training).

Care coordinators are trained in the Abecedarian Approach so they can promote opportunities for positive parent-child interaction when the Child First team is not interacting with the family. The related activities promote the development of executive function for parent and child.

Supervision Requirements

Child First places a strong emphasis on appropriate supervision across all levels of programme delivery. Reflective, clinical supervision must be provided to each individual, team, and group (all teams at affiliate site) on a weekly basis.

A full time Clinical Director supervises four teams and they themselves receive ongoing regular consultation from a Senior Clinical Consultant within the Child First organisation.

Evidence - Rating: 3 - 4

Theory of Change

Child First employs an ecological approach to work with families to ameliorate the emotional and cognitive impact of early adversity, as well as to promote positive child development. Grounded in research evidence regarding the potential profound impact of early trauma, the intervention aims to directly reduce the extent of toxic stress experienced by young children and their families, as well as to provide parent-child psychotherapy to repair and strengthen the parent-child relationship. Through connecting parents with local support services, as well as building on the parents’ capacity for executive function and self-regulation, with the combination of Child-Parent Psychotherapy and the Abecedarian Approach, the ultimate goal is for child development to be nurtured in a safe, growth-enhancing environment.

Infants and Toddlers: 0-36 months - Rating: 4

Research Design & Number of Studies

• 1 rigorous (internal) RCT in 2011 (n=157, age range 3-36 months - intervention mean age=18.0 months) (Lowell et al., 2011)
• 1 (internal) evaluation in peer reviewed journal (2008), age range 0-6 years, mean age=3.3 (Crusto et al., 2008)
• Further RCT due for completion 2021/2 and evaluation of cross-site data is ongoing.

Outcomes Achieved

Child Outcomes

• Significant reduction in child externalising difficulties at 12 month follow-up for Child First intervention families (Lowell et al, 2011; RCT)
• A significant decrease over time in post-traumatic stress intrusive thoughts and avoidance behaviours (NB this is an outcome of evaluation with mean age 3.3 years – no separate data available for 0-36 month specific outcomes)
• Significant improvements in child language development – remission of existing problems and prevention of new difficulties (Lowell et al, 2011; RCT)

Parent Outcomes

• Significant intervention effects on total/difficult child/parent distress scores on Parenting Stress Index at 6-month follow-up (Lowell et al., 2011; RCT)
• Significant impact of intervention on maternal psychopathology symptoms at 12-month follow-up (Lowell et al., 2011; RCT)
• Enhanced connection with local services (91% for Child First families compared with 33% for usual care) (Lowell et al., 2011; RCT)

Key References

Lowell, D., Carter, A., Godoy, L., Paulicin, B. & Briggs-Gowan, M. (2011). A Randomized Controlled Trail of Child FIRST: A Comprehensive Home-Based Intervention Translating Research into Early Childhood Practice. Child Development, 82(1): 193-208.

Crusto, C., Lowell, D., Paulicin, B., Reynolds, J., Feinn, R., Friedman, S. & Kaufman, J. (2008). Evaluation of a Wraparound Process for Children Exposed to Family Violence. Best Practices in Mental Health, 4(1): 1-18.

 

Preschool: 3 to 5 years - Rating: 3

Research Design & Number of Studies

The best evidence relevant to the 3-5 year old population is an internal evaluation in peer reviewed journal (Crusto et al., 2008), conducted with caregivers of children 0-6 years old who received the Child First intervention. 

Outcomes Achieved

Child Outcomes

• Significant decrease over time in post-traumatic stress intrusive thoughts and avoidance behaviours

Parent Outcomes

• Significant decrease in all assessed aspects of parenting stress and distress, regardless of level of parenting stress at programme entry

Reference

Crusto, C., Lowell, D., Paulicin, B., Reynolds, J., Feinn, R., Friedman, S. & Kaufman, J. (2008). Evaluation of a Wraparound Process for Children Exposed to Family Violence. Best Practices in Mental Health, 4(1): 1-18.  

Fit

Values

Child First is designed to be embedded within a community’s system of care and offered through an organisation known in the community as a strong collaborative partner and community leader.

  • Do these values fit with the nature of existing services and the community role of your organisation?

Priorities

Child First is aimed at families who have experienced or who are at risk of multiple emotional and social adversities, to enhance the parent-child relationship, foster executive function capacity in child and parent, and to link families in with appropriate local resources.

  • Is working with these families to elicit positive outcomes a core priority for your organisation?

Existing Initiatives

  • Does your service already provide initiatives to support families in building positive relationships with each other and their local community resources?
Capacity

Workforce

Each Child First team consists of a professionally qualified mental health clinician and a care coordinator who will have at least a bachelors level qualification. These practitioners must have experiencing in working with young children and families as well as a high reflective capacity. Each team will undertake 10-14 home visits per week (based on a full-time caseload of 12-16 families).

Each site requires a Clinical Director/Supervisor who must themselves have extensive experience working with families and have active links with local child services. They will provide weekly supervision for 4 teams on an individual, team and whole group basis.

  • Do you have existing staff or capacity to recruit staff with these specific skills?
  • Will you be able to protect time for these staff to undergo the appropriate training and supervision for this role?

Technology Support

Child First requires the use of video cameras to tape sessions for practitioner supervision.

  • Do you have access to video cameras and the appropriate site-level permission in place to facilitate the storage and review of video footage?

Administrative Support

Child First will require appropriate administrative support to the Clinical Supervisor and teams which may include office support, data completion, support for referrals, etc.

  • Do you have administrative capacity within your organisation to meet these requirements?

Financial Support

Start-up costs to establish Child First, including all initial training, are approximately $390,000 for a cohort of a 16-32 teams, with annual costs for clinical consultation and implementation and data support of $16,000 per team after the first year. (Costs for smaller scale implementation can be discussed directly with programme developers.)

  • Does your service have the finances to meet initial and annual costs?

Programme delivery may incur running costs including travel expenses and materials for practitioners.

  • Does your service have finances to cover these running costs?
Need

Comparable Population

Child First is delivered within the home to families with a child or children under six years of age, specifically those who have faced or are currently facing individual and environmental adversities. The evidence is based on families with children demonstrating high levels of social/emotional/behaviour difficulties and/or parents with high risk of psychosocial difficulties.

  • Does your organisation have existing contact with families in this population?
  • Is the delivery of a home-visiting service in line with the set-up of your service?

Desired Outcome

Child First aims to facilitate positive child development through supportive and nurturing parent-child relationships.

  • Does this aim fit with the core priorities for your organisation?

Child First also focusses on linking families in with appropriate existing organisations to enhance parental capacity and sustain positive change.

  • Does your organisation have strong existing links with local child services?
Developer Details

Mary Peniston (Chief Program Officer):

mpeniston@childfirst.org or info@childfirst.org