Factors Associated With Service Referrals and Uptake in Early Head Start: The Importance of Care Setting

Secondary analysis of the Early Head Start Family and Child Experiences Survey 2018 data set (Baby FACES 2018) explored links between family risk events and referral-making and referral uptake among families receiving Early Head Start (EHS) services. Referrals to both behavioral health and entitlement programs were considered. Results showed that referrals to behavioral health programs were much more likely to be given to families receiving care from home-based care than center-based care, and that referrals were slightly more likely to be given to families who did not have any family risk events. Several factors also moderated the relationship between family risk and referrals, including perceived closeness of the parent/caregiver-EHS staff relationship, family conflict, and caregiver depression. There were no observed effects for referrals to entitlement programs. Caregiver depression weakened the link between family risk and service uptake for entitlement programs.

Optimizing health services for young children in poverty: enhanced collaboration between Early Head Start and pediatric health care

Given the importance of health to educational outcomes, and education to concurrent and future health, cross-systems approaches, such as the Whole School, Whole Community, Whole Child (WSCC) framework, seek to enhance services typically in K-12 settings. A major gap exists in cross-systems links with early care and education serving children birth to age 5. Both pediatric health systems and early family and child support programs, such as Early Head Start (EHS) and Head Start (HS), seek to promote and optimize the health and wellbeing of infants, toddlers, preschoolers, and their families. Despite shared goals, both EHS/HS and pediatric health providers often experience challenges in reaching and serving the children most in need, and in addressing existing disparities and inequities in services. This paper focuses on infant/toddler services because high-quality services in the earliest years yield large and lasting developmental impacts. Stronger partnerships among pedicatric health systems and EHS programs serving infants and toddlers could better facilitate the health and wellbeing of young children and enhance family strengths and resilience through increased, more intentional collaboration. Specific strategies recommended include strengthening training and professional development across service platforms to increase shared knowledge and terminology, increasing access to screening and services, strengthening infrastructure and shared information, enhancing integration of services, acknowledging and disrupting racism, and accessing available funding and resources. Recommendations, including research-based examples, are offered to prompt innovations best fitting community needs and resources.

Parenting and family self-sufficiency services contribute to impacts of Early Head Start for children and families

Introduction

There is evidence that two-generation early childhood programs, those that strive to support not only child development, but also optimal parenting and family wellbeing, help to foster resilience for young children and their families in the face of adversity.

Methods

Using data from a large experimental evaluation, the Early Head Start Research and Evaluation Project, this paper explores how parenting and family self-sufficiency services embedded in Early Head Start (EHS), a federally funded, nationally implemented two-generation early childhood program for low-income families lasting from pregnancy and until children are three, contribute to the impacts of the program for both the children and their families.

Results

Parenting support in any modality (home visiting, case management or parent education) contributed to program impacts on important child and family outcomes, but not parent employment. Somewhat surprisingly, family receipt of employment services did not lead to any of the impacts of the program, while education and job training services did. When EHS parents received education or job training services, it led to impacts not only on mother employment, but also on other important family and child outcomes.

Discussion

These findings validate and reinforce the two-generation approach of EHS, specifically supporting the focus on parenting and parent education and job training.

University-Community Partnerships to Support Responsive Caregiving: The Hearts and Minds on Babies Implementation Story

Consistent, sensitive caregiving across home and childcare contexts supports optimal development. In this paper, we share the story of the development of Hearts and Minds on Babies (HMB) for Early Head Start (EHS) administrators, teachers, and parents. HMB was designed to support caregiver reflective functioning and sensitivity and reduce caregiver stress. This paper describes a series of Plan-Do-Study-Act cycles used to adapt an existing parenting intervention into the HMB programming for EHS. Throughout the paper, we present HMB concepts and learning objectives and share teachers' and parents' feedback and adaptations to content and delivery options that support implementation by EHS programs. Feedback from the final cycle suggests that HMB supports EHS administrators, teachers, and parents in their roles and improves relationships. The paper highlights the importance of research-practice partnerships in developing programming that meets the needs of EHS.

Child Temperament as a Moderator of Promoting First Relationships Intervention Effects Among Families in Early Head Start

As availability of parent-child interaction curricula increases, Early Head Start (EHS) provides a relevant context to test research-based parenting models as part of everyday practice. We trained EHS staff to incorporate the Promoting First Relationships (PFR) intervention into ongoing weekly home visits with mothers and their young children (n = 102) enrolled in EHS. Children had a mean age of 19.75 months and were 56% Hispanic, 23% Black, and 14% White. Families were randomly assigned to an intervention group where they participated in PFR as an EHS enhancement, or to a waitlist-control group where they received only typical EHS services. To explore the possibility that effectiveness of parent-child curricula may differ based on child characteristics, we used linear regression to examine children's temperament as a potential moderator of PFR efficacy on outcomes related to parenting stress, family functioning, and parent-child interaction. While we did not find a significant main effect of PFR for the full sample, there were several significant moderated effects. For families where children showed higher levels of surgency, mothers' parenting stress was significantly reduced after PFR participation. Also, when children showed higher levels of negative affect, mothers demonstrated higher sensitivity in parent-child interactions after participating in PFR. Given findings from our exploratory study, agencies should consider the characteristics of families served and the match with intervention priorities, when selecting intervention programs. When delivered as a home visitation enhancement, PFR may be a valuable support for certain enrolled families, based on child characteristics including high levels of surgency or negative affect.

Promoting Child Development During the COVID-19 Pandemic: Parental Perceptions of Tele-Home Visits in Early Head Start Programs

OBJECTIVE

The COVID-19 pandemic prompted families to receive Early Head Start (EHS) home-based services virtually. This qualitative study evaluated parental perceptions of EHS tele-home visits.

METHODS

EHS parents who had transitioned to tele-home visits using any video-chat platform were recruited to participate in a Spanish or English virtual focus group that assessed their perceptions of tele-home visits. Using an iterative, consensus-seeking inductive content analysis approach, themes and subthemes were identified.

RESULTS

Thirty-five mothers of children newborn to 3-years-old, where the majority were Latino and Spanish-speaking, participated in four focus groups. Several patterns pertaining to technology, child engagement, child learning and development, and parent-home visitor relationship emerged in the qualitative analysis. Mothers revealed varying degrees of digital proficiency, device preference, and technology challenges. Mothers reported variability in child engagement and concerns with missed socialization opportunities for children as a results of tele-home visits, but also reported increased self-efficacy in supporting child development, positive relationships with their home visitor, and overall satisfaction with services.

CONCLUSION

Parents revealed tele-home visits have the potential to be a viable service delivery method for EHS home-based programs. While parents perceived increased engagement and an uncompromised parent-home visitor relationship, they revealed areas of needed support that would optimize the use of tele-home visits.

Evaluation of the Feasibility and Perceived Value of Integrating Learn the Signs. Act Early. Developmental Monitoring Resources in Early Head Start

Many children with developmental disabilities are not identified before age 3 years old preventing them from being able to fully benefit from early intervention services. Early childhood educators, particularly those in Early Head Start (EHS) programs, are important partners in the early identification of children with developmental delays. Learn the Signs. Act Early. (LTSAE) is a program of the U.S. Centers for Disease Control and Prevention that provides free developmental monitoring resources to increase the early identification of children with developmental delays and disabilities. This paper presents findings from the first evaluation of the use of LTSAE resources in EHS, which was conducted across four states and 11 EHS programs from fall 2018 through spring 2019. Surveys (n=448) and interviews (n=39) with EHS management, staff, and parents indicated that LTSAE resources were valued and accepted, and their use in EHS considered feasible. Importantly, families and staff reported the LTSAE materials provided shared language to help them more effectively discuss development. These findings inform EHS and other early education programs that wish to enhance developmental monitoring, screening, and referral.

Characterizing Family Contextual Factors and Relationships with Child Behavior and Sleep Across the Buffering Toxic Stress Consortium

The Buffering Toxic Stress (BTS) consortium included six sites in locations that varied widely in racial/ethnic composition and population density. Each site tested a promising parent-child intervention designed to supplement Early Head Start (EHS) services and prevent "toxic stress." To better understand family risk in a large and diverse EHS sample, studies gathered extensive data on family risk exposure, including demographic risk factors (single mother, unemployed, less than high school education or its equivalent, and neighborhood safety), income-to-needs ratio, household resource constraints, perceptions of economic hardship and pressure, caregiver mental health, and caregiver-reported dysfunctional parent-child interactions. Results presented here for all six sites offer context for the more targeted studies in this special issue. Average levels of family characteristics and child behavior varied by site. We also characterized associations between family characteristics, observer-rated child temperament, and child outcomes (i.e., caregiver-reported child behavior problems and behavioral sleep quality), controlling for child age; these relationships were similar across sites. Demographic risk and caregiver mental health problems were positively associated with child behavior problems, with low income-to-needs ratio and increased financial strain relating to behavioral problems in infancy and toddlerhood. Caregiver mental health problems, financial strain, and social and affect temperament dimensions were related to increased behavioral sleep problems. Dysfunctional parent-child interactions and household resource constraints did not demonstrate statistically significant associations. Findings suggest helpful targets to increase effectiveness of parent-child interventions in early childhood on behavior and sleep outcomes.

Development and testing of a patient-centered dental home assessment for low-income families

OBJECTIVES

The purpose of this study was to develop an instrument in English (ENG) and Spanish (SPA) for use in assessing perceptions of dental home characteristics among low-income adults.

METHODS

An expert panel selected 21 items from a pool of 81 items mapped to domains in the American Academy of Pediatrics' medical home. Pilot testing with mothers (n = 795) of children in Early Head Start (EHS) resulted in an expanded 36-item scale, which was field-tested in interviews with ENG- (N_ENG = 665) and SPA-speakers (N_SPA = 116). An exploratory factor analysis of 23 usable items was carried out in an EHS reference group (N_ENG-EHS = 272). The selected model was evaluated by confirmatory factor analysis (CFA) in two other subgroups (N_ENG-NonEHS = 393; N_SPA = 116). We tested measurement and structural invariances using a multiple-group approach. Known-groups validity was examined by testing factor mean differences between two groups defined by whether or not the mother used a single dental office.

RESULTS

A three-factor CFA model with 10 items was retained for its close fit for all three subgroups. Invariance tests found the two ENG subgroups to be homogenous and were combined. Several item and factor parameters in the SPA group differed from the combined ENG group. The proposed dental home measure demonstrated good known-group validity in that people who used the same dental office reported better dental care experiences.

CONCLUSIONS

An instrument to measure the dental home concept among low-income adults was developed with three domains (accessible-comprehensive, compassionate, and health literate care) that demonstrated good validity and reliability.

A LONGITUDINAL, PERSON-CENTERED ANALYSIS OF EARLY HEAD START MOTHERS' PARENTING

This study used a person-centered approach to examine stability and change in parenting typologies across early childhood. Profiles were associated within and across time with contextual covariates, including demographic characteristics, risk factors, and Early Head Start participation. Participants were drawn from the Early Head Start Research and Evaluation Project (N = 2, 876). Parenting profiles were identified based on observed parenting dimensions at 14, 24, and 36 months, and pre-Kindergarten (pre-K). Results suggested a four-profile solution at each time point: Supportive, Lukewarm (14 & 24 months)/Sufficient (36 months and pre-K), Harsh, and Detached. Supportive was the largest, most stable, and most likely transitioned into profile while Harsh and Detached represented rare profiles with moderate to low membership stability across time. Depression and family conflict emerged as important correlates of unsupportive parenting profiles both within and across time. Findings are discussed in terms of their relevance for both policy and implementation practices for low-income mothers with young children.

Engaging Parents in Early Head Start Home-Based Programs: How Do Home Visitors Do This?

Parental engagement is considered elemental to successful outcomes for parents and their children in early childhood home visiting programs. Engagement is that piece of parental involvement that refers to the working relationship between the parent and the home visitor. Multiple papers have called for research to pinpoint the ways in which home visitors work with parents to form these working relationships, and form partnerships to achieve positive outcomes. Analysis revealed that in individualizing their efforts to each family, home visitors follow semi-sequential steps in implementing engagement. This article presents a model of the process home visitors describe that resulted from analysis. Grounded theory techniques were used to analyze 29 interviews with Early Head Start (EHS) home visitors and 11 supervisors across four EHS programs in one region of the United States. The process of engagement as described emerges in three phases: (1) learning the parent's culture and style; (2) deepening the working partnership; and (3) balancing the ongoing work. Analysis further revealed specific strategies and goals that guide the work of home visitors in each of these three phases. This not only adds rich detail to the literature, but also provides a useful guide for programs and policy makers through identifying the areas where training and support will increase home visitor ability to engage parents.

Propensity score weighting: an application to an Early Head Start dental study

OBJECTIVES

Nonrandomized group assignment in intervention studies can lead to imbalances in preintervention covariates and biased effect estimates. We use propensity score estimation to account for such imbalances in an Early Head Start (EHS) dataset with rich pretreatment information. We compare propensity score results using standard logistic regression models (LRMs) versus generalized boosted models (GBMs).

METHODS

We estimated propensity scores using 47 socio-demographic characteristics and EHS enrollment criteria obtained by parent interviews from a state-wide sample of 637 EHS and 930 Medicaid-matched control children. LRMs and GBMs were used to estimate propensity scores related to EHS enrollment. Performance of both approaches was evaluated via a) measures of balance of pretreatment covariate distributions between treated and control subjects, and b) stability of propensity score weights measured by the effective sample size.

RESULTS

Distributions of all variables were balanced for EHS and non-EHS groups using propensity score weights calculated with LRM and GBM. Compared with LRM, GBM resulted in better balance between treated and propensity score-weighted control distributions. The effective sample size of the controls decreased from 930 subjects to 507 with GBM and to 335 with LRM.

CONCLUSION

Although propensity scores derived from GBM and LRM both effectively balanced observed preintervention covariates, GBM resulted in better covariate balance compared with LRM. GBM also resulted in a larger effective sample size of the control group compared with LRM. Propensity score weighting using GBM is an effective statistical method to reduce confounding due to imbalanced distributions of measured preintervention covariates in this EHS intervention study.

Effect of a URI-related educational intervention in early head start on ED visits

OBJECTIVES

To evaluate the effectiveness of an educational intervention to decrease pediatric emergency department (PED) visits and adverse care practices for upper respiratory infections (URI) among predominantly Latino Early Head Start (EHS) families.

METHODS

Four EHS sites in New York City were randomized. Families at intervention sites received 3 1.5-hour education modules in their EHS parent-child group focusing on URIs, over-the-counter medications, and medication management. Standard curriculum families received the standard EHS curriculum, which did not include URI education. During weekly telephone calls for 5 months, families reported URI in family members, care sought, and medications given. Pre- and post-intervention knowledge-attitude surveys were also conducted. Outcomes were compared between groups.

RESULTS

There were 154 families who participated (76 intervention, 78 standard curriculum) including 197 children <4 years old. Families were primarily Latino and Spanish-speaking. Intervention families were significantly less likely to visit the PED when their young child (age 6 to <48 months) was ill (8.2% vs 15.7%; P = .025). The difference remained significant on the family level (P = .03). These families were also less likely to use an inappropriate over-the-counter medication for their <2-year-old child (odds ratio, 0.29; 95% confidence interval, 0.09-0.95; 12.2% vs 32.4%, P = .034) and/or incorrect dosing tool for their <4-year-old child (odds ratio, 0.24; 95% confidence interval, 0.08-0.74; 9.8% vs 31.1%; P < .01). The mean difference in Knowledge-Attitude scores for intervention families was higher.

CONCLUSIONS

A URI health literacy-related educational intervention embedded into EHS decreased PED visits and adverse care practices.