Research-based policies, practices and programs

Continue to review primary care practice and county ABCD screening rates. Expand investment in the ABCD developmental screening program to reach all Medicaid-eligible children participating in EPSDT-recommended well-child visits. Disaggregate data by county and by race/ethnicity to determine where more focus is needed.

The American Academy of Pediatrics (AAP) has begun a multi-year project called Screening In Practices. The project provides guidance on how to implement screenings, including developmental, social-emotional, autism, maternal depression, and social determinants of health. Screening In Practices focuses on:

• Increasing and improving screening
• Engaging families to increase screening and treatment rates
• Linking families to resources to address issues found during screening
• Tracking outcomes to ensure that children receive effective follow up treatment

The North Carolina 2016 Health Check Program Guide, in keeping with AAP guidance, does not specify the developmental screening tools to be used in the Health Check process, but requires a validated tool. The new STAR (Screening Technical Assistance & Resource) Center website provides information on valid, reliable screening tools and implementation, including materials from the successful ABCD project in North Carolina.¹

Work with the North Carolina Interagency Coordinating Council to explore feasibility and cost for expanding eligibility for IDEA Part C (Early Intervention services) to include children at risk of conditions based on the current science of trauma and toxic stress.

Five states have adopted IDEA Part C eligibility criteria that include at-risk circumstances: Illinois, Massachusetts, New Hampshire, New Mexico, and West Virginia.¹ Examples of risks that could qualify a child for early intervention services in these states include:

• Parents’ age or education level
• Parents’ chronic illness or disability affecting their caregiving ability
• Parents lack of social supports
• Inadequate food, clothing, or shelter, including homelessness
• Substance abuse or domestic violence in the home

Usually several of these risk factors are required to be present for the child to be eligible for services. North Carolina does not currently include an at-risk determination in its IDEA Part C eligibility guidelines.

The National Early Childhood Technical Assistance Center (NECTA) at the University of North Carolina’s Frank Porter Graham Child Development Institute created the Interactive Guide to Implementing and Sustaining Effective Service Delivery Approaches: Stages and Steps.² The guide, anchored in effective national, state, and local service delivery approaches and strategies, may be a useful tool to assess North Carolina’s infrastructure, capacity, and areas for greater IDEA Part C investment, including expanding services to at-risk children.

Expand North Carolina’s Community Cares for Children care coordination to at-risk children.

Many young children with health problems, developmental issues or who are living with toxic stress may not be eligible for Early Intervention services, but may benefit from care coordination. In North Carolina, such care coordination is provided through Community Cares for Children (CC4C), with the goal of improving children’s health outcomes and reducing costs for enrolled children. The program works with families of at-risk children from birth through age five to:

• Promote family strengths
• Support families in identifying and linking to community resources
• Communicate with children’s medical homes

CC4C plays a significant role in care and service coordination for young children in the foster care system.

Partner with CCNC and health researchers to determine, as data is now available, whether:

• Mothers are being screened for maternal depression at well-baby visits
• Services for maternal depression are sufficient and effective
• There are racial/ethnic and/or geographic disparities in screening and treatment for maternal depression

Maternal depression following the birth of a child can negatively impact children’s early development. Maternal postpartum depression screening is available statewide through the North Carolina Health Check program¹, and the ABCD program trains pediatric practices on screening, referral and linking families to resources.²

In July 2016, North Carolina Medicaid began to reimburse providers for maternal depression screens administered to mothers during well-baby visits.³ The first round of data collection on that project shows a 73 percent screening rate statewide at the one-month well-baby visit.⁴

Families need support to ensure their children get needed preventive care visits, which include important screening. North Carolina can support the efforts of Health Check Coordinators, pediatricians and primary care practices in:

• Reaching out to families to schedule well-child visits according to the American Academy of Pediatrics’ Bright Futures schedule
• Promoting community awareness of the importance and benefits of well-child care, screening and healthy development
• Addressing barriers to accessing services, such as transportation to the doctor’s office

Engaging pediatricians in developmental screenings and early literacy development during well-child visits has been shown to be very effective. Initiatives like Reach Out and Read build those connections and could be expanded in North Carolina.¹

Reach Out and Read is a practice used by physicians to promote young children’s literacy skills as part of the well-child visit. Doctors offer each child a book and talk with parents about child development and the importance of reading with children. Reach Out and Read operates across North Carolina.²

For children with special needs and vulnerabilities, support transitions from family to school, and from early developmental services (birth through age two) to public preschool and elementary school (ages three and up).

As children age, they move from IDEA Part C services to IDEA Part B services, or transition out of the system if they don’t need further services. IDEA defines the transition process¹, but if not supported, this transition can be a place where children fall through the cracks.

The North Carolina General Assembly’s 2016 budget required that each child enrolled in NC PreK or receiving child care subsidies have a preschool-to-kindergarten transition plan. The plan should document the child’s strengths and needs based on the NC Foundations for Early Learning and Development.² A similar level of transition planning would be helpful for children enrolled in IDEA Part C and IDEA Part B preschool special education services. Current individualized child outcome data could be provided to teachers and other service providers as children transition.

Key Principles for Providing Early Intervention in Natural Environments¹ offers guidance on integrating early intervention best practices into other settings serving children and families. It is a consensus document created and informed by a national workgroup of researchers and practitioners. Guidance includes:

• Use Every Day Experiences. Infants and toddlers learn best through everyday experiences and interactions with familiar people in familiar contexts.
• Focus on Families. All families, with the necessary supports and resources, can enhance their children’s learning and development.
• Providers are Supporters. The primary role of a service provider in early intervention is to work with and support family members and caregivers in children’s lives.
• Create a Dynamic, Individualized Process. The intervention process, from initial contacts through transitions, must be dynamic and individualized to reflect the child’s and family members’ preferences, learning styles, and cultural beliefs.
• Functional Outcomes. Service plan outcomes must be functional and based on children’s and families’ needs and family-identified priorities.
• Family Priorities are Central. The family’s priorities, needs and interests are addressed by a primary provider who represents and receives team and community support.
• Use Implementation Science. Interventions with young children and family members must be based on explicit principles, validated practices, best available research, and relevant laws and regulations.²

The document also provides resources for integrating early intervention in specific family service contexts, including early childhood, education, school psychology, speech pathology, physical and occupational therapy, and medicine.

Analyze, share and use data from IDEA and other large administrative service and benefits databases on

• Waitlists
• Transitions between Part C and Part B
• Children and family outcomes
• Service gaps
• Disparities and disproportionality by race/ethnicity, geography, or disability status

A shared database and standardized communication among primary care medical homes, Part B and Part C, and families could reduce gaps in service provision.

Data analysis can:

• Provide valuable insight into real or perceived gaps in service
• Be used to devise strategies to improve referrals, access or service delivery

For example, time spent on a wait list for early intervention services can result in the loss of critical developmental opportunities for a child. Since preventative services are more cost-effective and impactful than remediation services down the line, analyzing data on waitlists and using it to shorten or eliminate children’s waits for services can both result in better outcomes for children and be more cost effective for the state.

A toolkit, entitled B6 Data Reporting Tools: Educational Environments, Ages 3-5 provides training and technical assistance resources to assist states in accurately reporting educational environment data for children ages 3-5 with disabilities.¹

The federal IDEA requires that children with disabilities be educated in the least restrictive environment possible, preferably in natural environments (settings that are natural or typical for a same-aged infant or toddler without a disability).¹ Federal fiscal year 2013 data reveals that 24 percent of all young children with disabilities (i.e., three-, four- and PreK five-year old children) do attend classroom settings with their peers.

The inclusion of young children with disabilities as full participants in high quality early childhood settings has been shown to increase positive outcomes for all children and to provide academic and social-emotional benefits for children identified with disabilities.² Evidence demonstrates that children with special needs served in regular education settings had better post-secondary education, employment, and independent living outcomes.³

The North Carolina Inclusion Planning Guide, published by the NC Inclusion Initiative, provides steps for a collaborative process at the community level to plan for and implement inclusion of young children with disabilities in high quality early childhood programs.⁴ As NC PreK expands, best practices for inclusion as articulated in the Guide can be considered.

Infant and early childhood mental health consultation is an evidence-informed practice that places a specially-trained mental health consultant within early childhood programs, such as home visiting and early education. The mental health consultant builds the capacity of program staff to recognize young children’s social-emotional needs and challenges and to engage with children and their families in trauma-responsive ways.¹

Infant and early childhood mental health consultants come from a variety of fields. Formal training and licensure is required, along with demonstrated skills in:

• Mental health assessment
• Infant health
• Community programs
• The cultural context of children, families, and providers served²

There is strong evidence that this type of consultation to program providers improves the social, emotional and behaviors outcomes of young children, and benefits both providers and programs.³

Increasing access to mental health consultation would also require increasing the pool of trained mental health specialists who are competent to work with infants and very young children and their families.

The following programs provide intervention services (i.e., treatment and support) for infants with mental health challenges and their families, when developmental screening and assessment identify them as in need of service. In addition, trauma-informed practice should pervade the child- and family-serving system. See our Programs webpage for program descriptions.

• Attachment Bio-Behavioral Catch-up (ABC)
• Parent-Child Interactive Therapy (PCIT)
• Trauma Informed Child-Parent Psychotherapy (TI-CPP)
• Child First