ACF OPRE: Early Head Start Research and Evaluation Project (EHSRE)

III. PARTICIPATION IN EARLY HEAD START SERVICES

Early Head Start is a complex intervention program that is challenging to implement. As a first step toward understanding the intervention’s impacts on children and families, we document program accomplishments and the services families received. Did the 17 research programs provide a fair test of the Early Head Start concept? Evidence from the implementation study shows that, overall, the research programs succeeded in implementing Early Head Start services and delivering core services to most families while they were enrolled in the program (Administration on Children, Youth and Families 2002).

To set the context for examining program impacts, this chapter describes in detail families’ participation in program services and levels and intensity of service use during 28 months, on average, after families’ enrollment in Early Head Start. The chapter also describes variations in program participation and the intensity of services received by families across program types and patterns of program implementation. The first section describes the data sources we used and the terms we use to discuss levels of service use and intensity during various time periods. The sections that follow describe families’ levels of overall program participation and participation in specific child development and family services. The final section summarizes our conclusions about the levels and intensity of program participation. The next chapter contrasts the services that program families received with those received by control group families.

A. DATA SOURCES

We drew on the following data sources to analyze families’ participation in program services:

Head Start Family Information System application and enrollment forms completed at the time of enrollment.
Parent services follow-up interviews targeted for 6, 15, and 26 months after program enrollment (and completed an average of 7, 16, and 28 months after enrollment). We included in our analyses families for whom data were available for all three of these follow-up periods (71 percent of program group members).
Exit interviews conducted when children were approximately 3 years old and families became ineligible for Early Head Start.1
Ratings of each family’s engagement with the program provided by program staff in summer 2000, after most families had left the program.
Data from the implementation study on Early Head Start programs’ three main approaches to providing child development services—home-based, center-based, and mixed-approach (combination of home- and center-based).2
Ratings of program implementation developed as part of the implementation study, in which programs were classified as early implementers (fully implemented in 1997 and 1999), later implementers (fully implemented in 1999 but not in 1997), or incomplete implementers (not fully implemented in 1997 or 1999).3

The length of the follow-up period and children’s ages at the time of the interviews varied over a wide range for each wave of parent services interviews. The length of followup ranged from 4 to 15 months after enrollment for the first follow-up interview, 9 to 27 months for the second interview, and 24 to 59 months for the third interview.4 Because the interviews were conducted according to the length of time since families enrolled, the ages of the children in the research sample at the time of the interview also varied. On average, focus children were 10 months old when the first follow-up interview was completed, 20 months old at the second interview, and 32 months old at the third interview.

In this and the next chapter, we report primarily on cumulative levels of service use across all three follow-up periods covered by the parent services follow-up interviews. We use the term “combined follow-up period” to refer to the entire period covered by these cumulative measures. We also report some measures of service receipt and intensity of services received in at least one or two of the three follow-up periods. Occasional deviations from the use of these terms are explained in the text. Unless otherwise noted, the measures are based on parent reports.

B. LEVELS OF OVERALL PARTICIPATION IN PROGRAM SERVICES

Almost all program group families participated in Early Head Start at least minimally during the combined follow-up period. Overall, 91 percent of program families received at least one Early Head Start home visit, participated in Early Head Start center-based child care, met with an Early Head Start case manager at least once, and/or participated in Early Head Start group activities (group parenting education, group parent-child activities, or parent support group). Moreover, nearly all these families (90 percent of program group members) participated beyond this minimum level, receiving more than one home visit or case management meeting, center-based child care, and/or group parenting activities.5

Although participation levels exceeded 90 percent in 15 of the 17 research programs, two center-based programs had lower participation rates (64 and 75 percent). Several factors contributed to these low rates. In one program, some families needed full-time child care before the program expanded to offer it. In the other, a very rapid initial recruiting process and a delay in opening one center may have led some program families to find child care elsewhere.

C. DURATION OF PROGRAM PARTICIPATION

According to staff, program group families participated in Early Head Start for an average of 21 months, with nearly half of the families participating for at least two years (Table III.1). Families in the research sample could have enrolled in Early Head Start at any time after the mother became pregnant with the focus child until the child’s first birthday. Thus, families’ length of eligibility for program services varied, ranging from more than three years (if the family enrolled before the focus child’s birth) to about two years (if the family enrolled when the focus child was nearly a year old). Therefore, families who participated in Early Head Start for less than 24 months (49 percent of program families) left the program before their eligibility ended.

Research families left the programs for a variety of reasons. When staff rated the families’ engagement in summer 2000 (see section III.H. below, on program engagement ratings), they indicated the reasons families left the programs. Of the three quarters of families who had left the program by summer 2000, approximately one-third had graduated or transitioned out of the program when their eligibility ended. One-fourth had moved out of the service area before completing the program. Nearly one-third were terminated by staff because of poor attendance or lack of cooperation, or they asked to be removed from the program rolls. Home-based programs were much more likely to report that they terminated families’ enrollment for poor attendance or lack of cooperation, while center-based and mixed-approach programs were more likely to report that families had asked to be removed from program rolls.

TABLE III.1

DURATION OF EARLY HEAD START PARTICIPATION BY PROGRAM FAMILIES, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center-Based	Home-Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
	Program Approach				Pattern of Implementation
Percentage of Families Who Were Enrolled in Early Head Starta:
Less than 1 month	2	1	2	2	2	2	2
1 to less than 6 months	11	18	10	7	9	13	10
6 to less than 12 months	13	13	13	12	13	13	12
12 to less than 18 months	11	11	11	13	10	10	13
18 to less than 24 months	12	9	13	13	12	11	12
24 to less than 30months	20	22	16	19	22	18	19
30 to less than 36 months	17	12	20	18	18	17	16
36 months or longer	16	14	15	16	13	17	17
Average Number of Months Families Were Enrolled in Early Head Start	21	20	22	23	22	19	22
Sample Size	1,214	252	554	408	455	410	283
SOURCE: Exit interviews conducted near the time of the focus child’s third birthday and information on dates of last contact with the family obtained from program staff in Summer 2000. Excludes one site that did not provide a date of last contact for most families. NOTE: The percentages are average percentages across programs in any given group. aBased on the date of the program’s last contact with the family as reported by program staff in summer 2000 if the family had left the program by then or if no exit interview was completed, and on the number of months of participation reported by the family in the exit interview if the family left the program after the summer of 2000 and completed an exit interview.(back)

D. LEVELS OF PARTICIPATION IN CORE CHILD DEVELOPMENT SERVICES

The Early Head Start programs took three main approaches to providing core child development services. Home-based programs provided these services primarily through home visits. Center-based programs provided child development services primarily through child care in Early Head Start centers. Mixed-approach programs provided home-based services to some families, center-based services to some families, and a mix of home- and center-based services to some families. Thus, home visits and child care in Early Head Start centers were the programs’ primary vehicles for delivering child development services.6

Nearly 9 in 10 program group families received core child development services—either home visits, Early Head Start center care, or both (Table III.2). This percentage may underestimate the proportion of families who received core child development services, because some families received child development services in other child care settings under contract with an Early Head Start program during the combined follow-up period and our measure of core child development services captures only the services provided by Early Head Start directly.

The Head Start Program Performance Standards require programs to provide child development services through weekly home visits, at least 20 hours per week of center-based child care, or a combination of the two. Nearly two-thirds of families received core child development services at the required intensity during at least one of the three follow-up periods, and one-quarter received these services throughout the combined follow-up period. Families in home-based and mixed-approach programs were the most likely to receive core child development services at the required intensity level for at least one follow-up period (70 percent), compared with families in center-based programs (53 percent).

TABLE III.2

LEVELS OF PARTICIPATION IN CORE EARLY HEAD START CHILD DEVELOPMENT SERVICES, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
	Program Approach				Pattern of Implementation
Percentage of Families Who Received:
At least minimal core servicesa	89	80	91	92	94	88	83
More than minimal core servicesb	87	77	90	90	93	86	80
Percentage of Families Who Received Core Services at the Required Intensity Level forc:
At least 1 follow-up period	66	53	70	70	79	62	56
At least 2 follow-up periods	43	40	47	40	57	37	33
Combined follow-up period	25	26	26	23	37	19	18
Sample Size	940-1,020	166-205	476-478	298-338	310-351	330-359	301-311
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in any given group and are weighted for nonresponse. aAt least one Early Head Start home visit and/or at least two weeks of Early Head Start center-based child care.(back) bMore than one Early Head Start home visit and/or at least two weeks of Early Head Start center-based child care.(back) cWeekly Early Head Start home visits for home-based sites, at least 20 hours per week of Early Head Start center-based child care for center-based sites, and weekly Early Head Start home visits or at least 20 hours per week of Early Head Start center-based child care for mixed-approach sites.(back)

The 75 percent of families who did not receive core child development services at the required intensity throughout the combined follow-up period does not necessarily indicate program failure to comply with the performance standards. The combined follow-up period covers the 28 months, on average, after families enrolled in Early Head Start. Families’ length of participation in the program, however, averaged 21 months, with nearly half of the families participating for less than 24 months (Table III.1). Thus, the majority of families who did not receive core child development services at the required intensity during all three follow-up periods (the combined period) were not actually enrolled in the program throughout this entire period.

Early, full implementation appears to be associated with receipt of core child development services at the required intensity level. Early implementers provided these services to 79 percent of families for at least one follow-up period, compared to 62 percent of families in later implementers and 56 percent in incomplete implementers. Likewise, early implementers provided these services to nearly 40 percent of families throughout the combined follow-up period, compared to less than 20 percent of families served by later and incomplete implementers.

1. Early Head Start Home Visits

All Early Head Start programs are required to complete home visits, whether they are home-based, center-based, or provide a mix of services. In center-based programs, services are delivered primarily in Early Head Start child care centers, but staff are required to complete home visits with children and their families at least twice a year. They may meet with families in other places if staff safety would be endangered by home visits or families prefer not to meet at home.7 Home visitors are required to visit families receiving home-based services at home weekly, or at least 48 times per year. In mixed-approach programs, some families receive home-based services, some receive center-based services, and some receive a combination of the two.

Across all three program types, 84 percent of families received at least one Early Head Start home visit, and almost all of these families received more than one visit (Table III.3). As expected, families in home-based and mixed-approach programs were most likely to receive at least one home visit (90 and 89 percent, respectively, compared with 65 percent of center-based programs). Across programs with different patterns of implementation, early implementers were most likely to provide at least one home visit (90 percent), followed by later implementers (84 percent), and incomplete implementers (76 percent).

Most families received home visits at least monthly. More than two-thirds received home visits monthly or more often during at least one of the three follow-up periods, and one-third received home visits at least monthly throughout the combined follow-up period. In home-based programs, 86 percent received monthly visits during at least one follow-up period, and nearly half received visits at least monthly during the combined follow-up period. Almost all of these visits lasted an hour or longer.

According to the revised Head Start Program Performance Standards, programs serving families through home-based services must provide weekly home visits to families. As noted in the implementation study, however, programs found it very challenging to complete visits with some families weekly.8 Nevertheless, home-based programs were able to deliver weekly home visits to many families. Seventy percent of families in home-based programs reported receiving weekly visits during at least one follow-up period, nearly half received weekly visits during at least two periods, and one-quarter received weekly visits throughout the combined follow-up period.9

TABLE III.3

LEVELS OF PARTICIPATION IN EARLY HEAD START HOME VISITS, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Families Who Received: Any Early Head Start home visits	84	65	90	89	90	84	76
More than 1 Early Head Start home visit	78	46	89	86	82	81	70
Percentage of Families Who Received Early Head Start Home Visits at Least Monthly for:
At least 1 follow-up period	69	23	86	82	72	71	65
At least 2 follow-up periods	53	12	72	58	56	51	52
Combined follow-up period	32	4	47	34	38	27	32
Percentage of Families Who Received Early Head Start Home Visits at Least Weekly for:
At least 1 follow-up period	52	5	70	62	56	51	48
At least 2 follow-up periods	31	0	47	34	38	28	27
Combined follow-up period	16	0	26	16	23	12	14
Percentage of Families Who Received Monthly Early Head Start Home Visits Lasting At Least One Hour for:
At least 1 follow-up period	64	17	80	78	66	64	62
At least 2 follow-up periods	45	6	61	53	52	40	43
Combined follow-up period	25	2	36	29	33	18	24
Percentage of Families Who Received Weekly Early Head Start Home Visits Lasting At Least One Hour for:
At least 1 follow-up period	48	3	64	60	54	45	45
At least 2 follow-up periods	29	0	43	31	37	24	25
Combined follow-up period	15	0	24	15	21	11	12
Sample Size	1,007-1,029	206-210	470-480	331-339	346-351	353-364	308-314
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse.

Based on the frequency of home visits families reported receiving during each of the three waves of follow-up interviews, we estimate that families received roughly 52 Early Head Start home visits, on average, during the 26 months after program enrollment (not shown).10 As expected, families in home-based programs received the most home visits, on average (71 visits), followed by families in mixed-approach and center-based programs (65 and 11 visits). While these estimates are useful in providing a rough sense of the number of home visits families typically received, caution should be used in interpreting their precision. The estimates are based on families’ reports of the typical home visit frequency during the relevant follow-up period, not on respondent reports or program records on the completion date of each home visit.

To better understand the reasons for variation in home visit frequency across families, local research partners at the University of Washington and the University of Missouri-Columbia examined associations between home visit frequency and various family characteristics. Boxes III.1 and III.2 describe their findings.

2. Early Head Start Center-Based Child Care

The revised Head Start Program Performance Standards require programs serving families through the center-based option to provide center-based child development services to children for at least 20 hours a week. This section describes families’ participation in this core child development service during 26 months after they enrolled in the program. The next section describes program families’ use of all types of child care, including care provided by Early Head Start and other providers in the community. Because the parent services follow-up interviews collected detailed information on families’ use of child care services, including dates of arrangements, we constructed a 26-month timeline that contains information on all the child care arrangements reported during the three waves of parent services follow-up interviews. The follow-up period for child care services is 26 months (the period covered for nearly all families who completed the interviews) for all families, unless otherwise noted.

During their first 26 months in the program, 28 percent of all program group children received care in an Early Head Start center, including 71 percent of children in center-based programs and 30 percent of children in mixed-approach programs (Table III.4).11 For 21 percent of all families in the sample, an Early Head Start center was their child’s primary child care arrangement (the arrangement the child was in for the greatest number of hours during the 26 months after program enrollment). In center-based programs, 57 percent of families used an Early Head Start center as their child’s primary arrangement. Early Head Start centers served as the primary arrangement for 20 percent of families in mixed-approach programs.

On average, program group children received 450 hours (about 4 hours a week) of care in an Early Head Start center.12 As expected, children in center-based programs received more than three times as many hours of Early Head Start center care—1,391 hours (about 12 hours per week), on average. In mixed-approach programs, children received 336 hours (about 3 hours a week, on average) of Early Head Start center care. In addition to receiving more hours of Early Head Start center care, on average, children enrolled in center-based programs were more likely to receive this care continuously. Nearly a third of families in center-based programs used care in an Early Head Start center continuously during the 26 months after enrollment, and more than half used it for at least half of this period.

Children served by early implementers were most likely to receive care in an Early Head Start center (38 percent), compared to later implementers (27 percent) and incomplete implementers (17 percent). Children served by early implementers also received more than twice as many hours of care in an Early Head Start center, on average, than children served by later and incomplete implementers.13 In the two center-based programs that were early implementers, children received an average of 2,028 hours of Early Head Start center care (about 18 hours per week, on average).

BOX III.1

PATTERNS OF PARTICIPATION IN HOME-BASED SERVICES

Fredi Rector and Susan Spieker
University of Washington

We examined home visitor records to determine whether this suburban, Pacific Northwest Early Head Start program showed particular patterns of program participation. Of the 90 families recruited for the research program, 76 (84 percent) participated in three or more home visits (more than simply enrollment). All participants were expected to take part in weekly home visits. However, when participation results were analyzed, we identified two groups. The low-participation group (n = 46) had at least one visit per month for an average of 10.33 (SD = 5.41) months, while the high-participation group (n = 30) had at least one home visit per month for an average of 25.43 (SD = 6.76) months. Only 17 of these families, however, remained active until the focus child was 36 months old.

Content analysis of home visit records revealed 14 target content topics for home visits.1 The percent of home visits that focused on target content topics varied between the high- and low-participation groups. For example, 58 percent of the home visits to the high-participation group included specific content on the growth and development progress of the focus child, while only 33 percent of the low-participation group visits focused on this topic (p<.01). Similarly, 47 percent of the home visits to the high-participation group included child play activities, compared with 21 percent of the home visits to the low-participation group (p<.01). The topic of housing was also associated with longevity in the program. In the high-participation group, 9 percent of home visits included discussions of housing issues, compared with 18 percent in the low-participation group (p<.05).

A primary goal of this program was to facilitate a secure parent-child attachment relationship. To that end, the research team and the home visitors developed 10 parent-child communication intervention (PCCI) protocols, which the home visitors delivered. They delivered these protocols in home visits to 44 percent of the low-participation group and 32 percent of the high-participation group (p<.05). However, the high-participation group completed more PCCI protocols than did the low-participation group (3.3 versus 1.5, p<.01). In addition, caregivers whose adult attachment representations, as measured by the Adult Attachment Interview2were classified as insecure and unresolved due to trauma/loss (28 participants) completed fewer PCCI protocols than did caregivers who were not unresolved, regardless of their security classification (1.8 versus 2.7, p<.05).

Caregiver adult attachment classification and housing needs at the time of enrollment were both related to patterns of program participation. Caregivers who had insecure attachment (see Hesse 1999) were more likely to be in the low-participation group (p<.05), as were participants who initially identified housing as a need (p<.1). However, housing needs identified at enrollment were not significantly related to the discussion of housing issues during home visits. These findings suggest that assessment at enrollment should include a measure of post-traumatic stress, since 37 percent of the sample was coping with unresolved trauma and loss, and this factor was related to their level of participation in the program. Early Head Start programs also need to address effectively the issue of safe, adequate housing. Further research is needed to understand the relationships between unresolved trauma and loss, housing problems, and program participation.

1The target content topics were observations of child growth and development, child play/recreation, child health, child assessment, child care, parent development, PCCI protocols, employment, caregiver health, caregiver assessment, education, family recreation, housing, and information and referral.(back)

2Hesse, E. “The Adult Attachment Interview: Historical and Current Perspectives.” In Handbook of Attachment: Theory, Research, and Clinical Applications, edited by J. Cassidy and P.R. Shaver. New York: The Guilford Press, 1999, pp. 395-433.(back)

BOX III.2

RELATIONS AMONG MOTHER AND HOME VISITOR PERSONALITY TRAITS, RELATIONSHIP QUALITY, AND AMOUNT OF TIME SPENT IN HOME VISITS

Elizabeth A. Sharp, Jean M. Ispa, Kathy R. Thornburg, and Valerie Lane
University of Missouri-Columbia

In response to the low frequency of home visits in programs across the country (Gomby et al. 1999), the current study examined associations between mother and home visitor personality, the quality of mother-home visitor relationships, and the amount of time spent in home visits. We hypothesized that the quality of the mother-home visitor bond mediates links between their personality characteristics and time in home visits.

The participants were 41 African American, low-income, first-time mothers enrolled in an Early Head Start program in a large, Midwestern city, and five home visitors. Most of the mothers were in their late teens or early 20s and had limited education.

The mothers and home visitors completed the Multidimensional Personality Questionnaire, Form NZ (Tellegen 1982). Home visitors also completed the Bond Subscale of the Working Alliance Inventory (Short Form) (Horvath and Greenberg 1989). The dependent variable was participation, defined as the mean number of minutes per month spent with each mother in home visits, based on three months to two years of visits.

The results of hierarchical linear modeling did not support our mediational hypotheses. However, significant associations emerged among the personality, relationship, and participation variables. Maternal personality traits that showed orientation toward control and achievement were negatively related to home visit participation. On the other hand, maternal tendencies to feel vulnerable or taken advantage of (for example, high stress reaction and alienation) were positively related to participation. Maternal stress reaction and alienation were also positively linked to home visitor ratings of bond quality. Home visitor stress reaction was negatively related to participation. Finally, the quality of mother-home visitor bond was positively related to participation.

One explanation for these findings may be that home visitors thought home visits were especially important for highly stressed mothers who are low in control and in striving for achievement, because the services come to the mothers; the mothers do not have to take the initiative to go to the services. Moreover, highly stress-prone mothers may have been more likely to draw the home visitors into personal relationships because they had more issues to address. If home visitors perceived achievement-oriented mothers as more capable of meeting their own needs, they may have made fewer attempts to schedule visits to them.

The stress-proneness of home visitors may be related to their skills in establishing relationships. It may be especially important for social service providers whose work takes them into high-stress situations to have a positive, less stress-prone personality. Individuals with a negative, more stress-prone personality may find the difficult circumstances of parents like those in our sample overwhelming.

References

Gomby, D.S., P.L. Culross, and R.E. Behrman. “Home Visiting: Recent Program Evaluations—Analysis and Recommendations.” Future of Children, vol.9, 1999, pp. 4-26.

Horvath, A.O., and L.S. Greenberg. “Development and Validation of the Working Alliance Inventory.” Psychological Assessment, vol. 1, 1989, pp. 207-210.

Tellegen, A. Brief Manual for the Multidimensional Personality Questionnaire. Unpublished manuscript. University of Minnesota, Minneapolis, 1982.

TABLE III.4

LEVELS OF PARTICIPATION IN EARLY HEAD START CENTER-BASED CHILD CARE, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Children:
Who ever received Early Head Start care	28	71	1b	30	38	27	17
For whom Early Head Start care was the primary arrangementa	21	57	1	20	30	18	12
Percentage of Children Who Were In Early Head Start Care For:
0 hours per week	75	31	99	76	66	76	85
1-9 hours per week	10	25	0	12	12	11	7
10-19 hours per week	7	16	0	8	9	6	4
20-29 hours per week	4	14	0	2	7	4	1
30-39 hours per week	2	6	0	0	3	1	1
40 or more hours per week	2	6	0	1	3	0	1
Average hours per week	4	12	0	3	6	3	2
Average Total Hours That Children Were In Early Head Start Care	450	1,391	9	336	701	347	273
Percentage of Children Who Were in Early Head Start Care For:
0% of the follow-up period	72	29	99	70	62	74	83
1-19% of the follow-up period	3	4	0	5	4	2	3
20-39% of the follow-up period	3	8	0	6	3	5	4
40-59% of the follow-up period	3	5	0	4	4	3	1
60-79% of the follow-up period	3	7	0	4	5	2	2
80-99% of the follow-up period	7	15	0	8	6	8	4
100% of the follow-up period	9	31	0	4	16	6	3
Sample Size	918-1,010	175-211	444-458	297-341	308-346	316-375	284-302
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse. aArrangements that children were in for the largest number of hours during the follow-up period.(back) bThese child care arrangements were identified by respondents as Early Head Start center-based child care. The arrangements may be slots that were provided by an Early Head Start program through contracts with community providers or slots in another Early Head Start program in the community, or respondents may have reported them as Early Head Start arrangements in error.(back)

E. USE OF CHILD CARE SERVICES

Rates of child care use were high across all three program types and patterns of implementation. Almost all program group families used child care (86 percent) for the focus child at some point during the 26 months after enrollment in Early Head Start (Table III.5) In this section we describe program families’ use of center-based care; use of multiple care arrangements; types of primary care providers; care during nonstandard work hours; total hours children were in child care; duration of child care use over the 26-month follow-up period; and out-of-pocket costs of child care to families.

More than half of program group children received care in a child care center for at least two weeks during the 26 months after enrollment. As expected, families in center-based programs were most likely to receive center-based care (79 percent), followed by those in mixed-approach programs (52 percent) and home-based programs (33 percent). Families served by early implementers were also more likely to use center-based care (56 percent), compared with later and incomplete implementers (50 and 45 percent).

During the 26 months after enrollment, 64 percent of children received care in more than one child care arrangement, and over half received care in more than one arrangement concurrently. On average, program group children received care in two child care arrangements during their first 26 months in Early Head Start. Fifty-two percent received care in more than one arrangement concurrently at some point during this period. Nearly three-quarters of the children in center-based programs were cared for in concurrent arrangements, suggesting that Early Head Start centers did not provide care during all the hours that families needed it.

TABLE III.5

CHILD CARE ARRANGEMENTS USED BY EARLY HEAD START FAMILIES, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
Percentage of Children:
		Program Approach			Pattern of Implementation
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
Who received any child care	86	93	80	89	87	82	90
Who received any center-based child care	51	79	33	52	56	50	45
Percentage of Children Who Received Care in the Following Number of Arrangements:
0	14	7	20	11	13	18	10
1	22	15	24	23	21	20	25
2	25	25	24	26	24	23	28
3	20	26	17	20	21	18	21
4 or more	20	27	16	20	21	22	16
Average number of arrangements used	2	3	2	2	2	2	2
Percentage of Children Who Received Care in More than One Arrangement Concurrently	52	73	39	53	56	48	50
Percentage of Children Whose Primary Child Care Arrangement Wasa:
Not in child care	14	7	20	11	13	19	10
Early Head Start/Head Start	21	57	1	20	30	18	12
Other child care center	17	10	20	17	16	17	19
Nonrelative	14	5	19	14	12	10	22
Parent or stepparent	8	5	9	7	8	5	10
Grandparent or great-grandparent	18	12	19	21	16	20	19
Other relative	8	3	10	9	3	11	8
Parent at school or work	0	0	1	0	1	0	0
Percentage of Children Whose Primary Arrangement Included Care During:
Evenings	30	25	31	32	31	29	31
Early mornings	49	42	53	50	47	49	52
Weekends	17	11	18	21	15	17	21
Overnight	22	12	33	16	13	37	15
Sample Size	920-988	189-206	410-459	306-323	311-330	330-388	273-293
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse. aArrangements that children were in for the largest number of hours during the follow up period.(back)

Program families used a wide range of providers for their primary child care arrangement (the arrangement focus children were in for the greatest number of hours) during the 26 months after program enrollment. Thirty-eight percent of families used a child care center as their primary child care arrangement, including 21 percent who used an Early Head Start center and 17 percent who used other child care centers in the community. One-third of families used child care provided by a relative—most often, a grandparent or great-grandparent—as their primary child care arrangement. Fourteen percent of families used care provided by an unrelated family child care provider. Finally, 14 percent of families did not use any child care for the focus child during the 26 months after program enrollment.

Families reported that a substantial proportion of the primary child care arrangements they used offered care during nonstandard work hours. Nearly half of the primary child care arrangements used by program families offered care during early morning hours. Nearly a third offered care during evenings hours. Smaller proportions offered care during weekends (17 percent) and overnight (22 percent).

Most program children received child care for substantial amounts of time during the 26 months after program enrollment. On average, program group families used 1,483 hours (about 14 hours per week) of child care during the 26 months following enrollment; one-quarter used child care for at least 20 hours a week (a total of 2,253 hours) during this period (Table III.6).14 Program group children received 688 hours of center care, or about six hours per week, on average. As expected, families in center-based programs used the most child care (2,354 hours, or 21 hours per week), on average, followed by mixed-approach programs (1,458 hours or 14 hours per week), and home-based programs (1,007 hours or 9 hours per week). Families in center-based programs also used the most center care, on average (1,580 hours).15

TABLE III.6

INTENSITY OF CHILD CARE USE BY EARLY HEAD START FAMILIES, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
	Program Approach				Pattern of Implementation
Average Number of Hours That ChildrenWere In:
Any child care	1,483	2,354	1,007	1,458	1,466	1,251	1,782
Any center-based child care	688	1,580	266	586	894	549	609
Percentage of Children Who Were in Any Child Care For:
0 hours per week	14	7	21	12	13	19	10
1-9 hours per week	39	28	45	41	42	39	37
10-19 hours per week	22	24	19	23	18	22	26
20-29 hours per week	11	15	8	12	11	12	9
30-39 hours per week	6	11	4	6	8	4	8
40 or more hours per week	7	15	4	7	8	5	10
Average hours per week	14	21	9	14	14	12	16
Percentage of Children Who Were in Any Center-Based Child Care For:
0 hours per week	58	23	79	58	50	61	65
1-9 hours per week	18	27	12	21	21	17	16
10-19 hours per week	12	22	5	12	13	13	9
20-29 hours per week	6	13	2	6	8	7	3
30-39 hours per week	2	8	1	1	4	1	3
40 or more hours per week	3	8	1	2	4	1	4
Average hours per week	6	14	3	5	8	5	5
Percentage of Children Who Were in Any Child Care For:
0% of the follow-up period	15	7	22	12	13	20	10
1-19% of the follow-up period	7	2	11	6	7	9	5
20-39% of the follow-up period	10	4	11	14	10	11	10
40-59% of the follow-up period	10	7	11	12	12	9	10
60-79% of the follow-up period	11	9	15	14	12	13	14
80-99% of the follow-up period	18	16	15	21	18	14	23
100% of the follow-up period	26	53	16	20	28	22	29
Percentage of Children Who Were in Any Center-Based Child Care For:
0% of the follow-up period	50	21	68	48	44	52	55
1-19% of the follow-up period	8	4	10	8	7	7	9
20-39% of the follow-up period	8	8	7	10	9	8	9
40-59% of the follow-up period	6	5	5	10	7	8	5
60-79% of the follow-up period	8	8	6	8	7	8	7
80-99% of the follow-up period	10	19	3	10	11	9	10
100% of the follow-up period	10	35	1	5	17	8	5
Sample Size	818-1,005	172-211	380-459	266-338	285-343	286-388	247-289
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse.

In addition, most program children were in child care during a large proportion of the 26 months following enrollment in Early Head Start. More than half of families used child care for at least half of the 26-month period, and one-quarter used child care continuously throughout the 26 months following enrollment. Families in center-based programs were most likely to use child care continuously throughout the 26 months following enrollment. More than half used child care continuously, and more than one-third used center-based child care continuously.

On average, program families spent $513 out of their pocket for child care during the 26 months after program enrollment (Table III.7).16 Some received free child care from relatives or in an Early Head Start child care center. Thirty percent of program families received individual child care subsidies or vouchers to help pay for child care.17 Families in home-based programs were most likely to use a child care subsidy or voucher (37 percent), followed by families in mixed-approach programs (29 percent) and center-based programs (19 percent). Most families whose children received care in an Early Head Start center did not obtain individual child care subsidies or vouchers to help to pay for the care. Only seven percent of families in center-based programs and seven percent in mixed-approach programs reported obtaining an individual child care subsidy or voucher to pay for care in an Early Head Start center.

TABLE III.7

OUT-OF-POCKET CHILD CARE EXPENSES AND RECEIPT OF CHILD CARE SUBSIDIES, FOR THE FULL SAMPLE OF EARLY HEAD START FAMILIES AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Average Total Out-Of-Pocket Child Care Expenses	$513	$481	$469	$584	$482	$398	$686
Percentage of Families Who Ever Received a Subsidy to Pay for the Focus Child's Care In:
Any child care arrangement	30	19	37	29	27	27	37
Any child care center	17	16	15	20	18	17	16
An Early Head Start center	4	7	0	7	7	5	1
Sample Size	731-988	165-206	309-459	257-323	251-327	252-388	228-295
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse.

F. RECEIPT OF OTHER CHILD DEVELOPMENT SERVICES

In addition to home visits and center-based child care, the research programs provided a range of other child development services to families. This section describes levels of service use and the intensity of these other child development services, including parenting education, parent-child group socializations, health services for children, and services for children with disabilities.

1. Parenting Education and Parent-Child Group Socializations

Almost all families (94 percent) received parenting education services from Early Head Start or other programs, often from home visitors (85 percent) or case managers (82 percent) (Table III.8). Most families also reported participating in group parenting activities (71 percent). Parents most often reported participating in parenting classes (62 percent), followed by parent-child group socialization activities (41 percent), and parent support groups (20 percent). Families in mixed-approach programs were most likely to report receiving parenting education services (97 percent), followed by families in home-based and center-based programs (94 and 88 percent). In addition, early implementers provided parenting education services to a higher proportion of families (98 percent) than did later and incomplete implementers (93 and 89 percent).

To illustrate the important role that Early Head Start programs play in linking families with opportunities to learn about their children’s development, the local research report in Box III.3 describes the role that one research program played in helping monolingual Spanish-speaking families access parenting education services.

TABLE III.8

LEVELS OF PARTICIPATION IN PARENTING EDUCATION SERVICES AND PARENT-CHILD GROUP SOCIALIZATION ACTIVITIES, FOR THE FULL SAMPLE OF EARLY HEAD START FAMILIES AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Families Who Received:
Any parenting education services	94	88	94	97	98	93	89
Parenting education from a home visitor	85	66	92	90	90	85	78
Parenting education from a case manager	82	65	87	88	86	81	79
Percentage of Families Who Ever Participated In:
Any group activities for parents/parents and children	71	68	72	71	77	68	66
Parenting education classes	62	60	63	63	70	58	58
Parenting support groups	20	20	21	20	21	21	18
Group socialization activities for parents and children	41	29	45	46	44	45	33
More than one group socialization activity	37	23	42	42	40	42	29
Percentage of Families Who Participated in Group Socialization Activities At Least Monthly During:
At least 1 follow-up period	26	12	32	30	28	30	21
At least 2 follow-up periods	9	3	14	8	14	9	5
Combined follow-up period	2	0	3	1	4	1	0
Sample Size	956-1,031	193-211	448-481	314-339	327-352	336-365	293-314
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse.

BOX III.3

PARENTS’ PERCEPTIONS OF TRAINING AND SERVICE ACTIVITIES REGARDING THEIR CHILD’S NURTURING AND DEVELOPMENT: IMPLEMENTATION AND BENEFITS OF EARLY HEAD START

Joseph J. Stowitschek and Eduardo J. Armijo
University of Washington

Among the predominantly Mexican and Mexican American families of the rural areas served by the Washington State Migrant Council’s Early Head Start Program (WSMC-EHS), la familiá (the family) is extremely important in WSMC-EHS’s mission to enhance the families’ contributions to their communities. The impact of Early Head Start in supporting and strengthening the family unit was considered a crucial element and fundamental to increasing parents’ abilities to nurture their children’s early development. Further, the interplay of cultural variables, particularly language and acculturation, were seen as some of the more prominent potential moderators of that impact. The Yakima Valley Early Head Start Research Project wanted to determine whether families participating in Early Head Start partook of child nurturing and development services that they would not have received otherwise and whether they thought they and/or their children had benefited from those services.

We found that distances, limited tax bases, and sparse population distributions present challenges for providing child care and child development, social, and health services in rural areas. An array of services are available in the Lower Yakima Valley, however. These include state-funded child development and child care, privately supported child care programs, mental health services, and a county cooperative of agencies. While available, it is difficult for low-income families who depend on seasonal agricultural work, experience language or cultural barriers, and have limited educational backgrounds to access them. These limitations were important factors in the evaluation of WSMC-Early Head Start.

Few control group families reported involvement in education, training, or support pertaining to child care or child nurturing. Most did not obtain center- or home-based services on their own initiative. On the other hand, most Early Head Start families reported frequent opportunities for, and participation in, activities pertaining to their child’s care and development, in some cases attaining an eight-fold advantage. Early Head Start staff carried out or arranged most of these activities, and activities usually occurred in the home. The Early Head Start program staff gave the most attention to monolingual Spanish-speaking families.

Early Head Start participation produced considerable benefits. Early Head Start families showed a trend toward greater confidence in child care and child development abilities. While a standard index of acculturation showed little change and few group differences, indicators of functional acculturation—family and community participation—suggested Early Head Start families had enhanced involvement in selected areas.

Studies of child development programs often focus on the content and character of training, services, and support pertaining to child care and child nurturing. Although these studies may address substantive aspects of the implementation of best practice, the “how” of service delivery is of little importance if it is too limited in frequency, uneven, or not sustained. The WSMC-EHS program’s effort is aimed at complying with Head Start guidelines, and the families it serves have demonstrated a level of involvement and benefit they would not likely have attained otherwise.

The revised Head Start Program Performance Standards require programs providing home-based services to provide families with two parent-child group socialization activities each month. As noted in the implementation study, programs found it very challenging to gain families’ participation in regular parent-child group socialization activities.18 Less than half of families in home-based and mixed-approach programs (45 and 46 percent) reported participating in parent-child group socialization activities. Less than a third of families in center-based programs (29 percent) reported participating in these activities. Moreover, only a third of families in home-based programs participated in parent-child group socialization activities monthly or more often during at least one follow-up period, and only three percent participated at least monthly throughout the combined follow-up period.

2. Child Health Services

The revised Head Start Program Performance Standards require programs to ensure that all children have a regular health care provider and access to needed health, dental, and mental health services. Within 90 days of enrollment, programs must assess whether each child has an ongoing source of health care, obtain a professional determination as to whether each child is up-to-date on preventive and primary health care, and develop and implement a follow-up plan for any health conditions identified.

All children received some health care services during the combined follow-up period, and nearly all children (99 percent) received immunizations (Table III.9). Moreover, nearly all children visited a doctor (99 percent); 95 percent had at least one check-up and 83 percent were treated for an illness. On average, program group children visited a doctor seven times for a check-up and six times for treatment of an illness during the combined follow-up period. In addition, more than half of the children (54 percent) visited an emergency room.

Twenty-nine percent of the children visited a dentist during the combined follow-up period. Children in center-based programs were more likely to visit a dentist than those in home-based and mixed-approach programs (38 percent, compared with 28 and 24 percent). Children served by early implementers also were more likely to visit a dentist than children served by later implementers or incomplete implementers (32 percent compared with 29 and 24 percent). Two-thirds of the children received at least one health screening test during the combined follow-up period, such as a hearing test, a lead test, or a urinalysis. Children in center-based and mixed-approach programs were more likely to receive a screening test than children in home-based programs (70 and 71 percent compared with 62 percent).

TABLE III.9

RECEIPT OF CHILD HEALTH SERVICES BY EARLY HEAD START CHILDREN, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Children Who Received Any Health Services	100	100	100	100	100	100	100
Percentage of Children Who Ever Visited:
A doctor	99	99	99	98	100	98	99
A doctor for a check-up	95	95	96	94	97	93	95
A doctor for treatment of an illness	83	84	76	90	93	80	74
A dentist	29	38	28	24	32	29	24
An emergency room	54	58	53	53	62	46	55
Average Number of Visits To:
A doctor for a check-up	7	6	7	7	7	6	7
A doctor for treatment of an illness	6	7	6	6	8	5	6
An emergency room	2	2	2	1	2	1	2
Percentage of Children Who Ever Received:
An immunization	99	99	99	99	99	98	99
Any screening or testing	67	70	62	71	65	64	73
A hearing test	41	52	34	41	38	43	41
A lead test	28	28	27	30	22	23	42
Sample Size	972-1,031	203-211	454-481	313-340	341-352	326-358	304-314
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse.

3. Services for Children with Disabilities

According to the revised Head Start Program Performance Standards, at least 10 percent of programs’ caseloads must consist of children with identified disabilities. In Box III.4, a local researcher from Catholic University describes the opportunities and challenges Early Head Start programs face in serving children with disabilities. Eight percent of families in the research sample ever reported that their child was eligible for early intervention services during the combined follow-up period (Table III.10). The proportion of children ever reported to be eligible for early intervention services ranged from 2 to 22 percent across programs (not shown). In five programs, at least 10 percent of children were ever reported to be eligible for early intervention services (not shown).

These percentages are based solely on parents’ reports. It is possible that parents underreported their children’s eligibility for early intervention services (they may have been unaware of their child’s eligibility or may not have recognized the name of the local Part C program). According to reports by program staff in summer 2000, 12 percent of children in the research sample had been identified as eligible for Part C, ranging from 4 to 30 percent across programs.19 In nine programs, at least 10 percent of children in the research sample had been identified as eligible for Part C (not shown).

BOX III.4

OPPORTUNITIES AND CHALLENGES IN PROVIDING SERVICES TO CHILDREN WITH DISABILITIES WITHIN EARLY HEAD START

Shavaun Wall
The Catholic University of America

The Head Start Program Performance Standards require programs to use at least 10 percent of their available spaces to serve children with disabilities and to make intensive efforts to recruit children with disabilities. Services for children under age 3 are mandated by Part C of IDEA 1997 (Individuals with Disabilities Education Act). To assist in identifying and serving infants and toddlers with disabilities, Early Head Start is participating in new initiatives to help communities refine coordination at the local level. The Hilton/EHS Training Program (sometimes known as Special Quest), sponsored by the Conrad Hilton Foundation in partnership with the Head Start Bureau, trains community teams to develop systems to identify, refer, and serve children with special needs that are sensitive to community context. Identifying, referring, and providing services to children with disabilities brings a number of opportunities but also introduces special challenges for Early Head Start programs.

Opportunities

Early Head Start offers an enhanced opportunity to identify children at the youngest ages. In some cases, very early identification may prevent later problems for the child and/or may make it possible for some of the contributing conditions to be mitigated. A national study of children and families who are receiving Part C services found that low-income children and children who are members of minority groups are least likely of all groups to be identified for special education services at the youngest ages. Early Head Start has the opportunity to close this gap in services.

Early Head Start and Part C service providers have new opportunities to coordinate services, develop partnerships, and thus maximize services according to family needs and community resources. The Hilton/EHS Training Program is assisting communities in building partnerships that provide a lasting foundation for improving services for children with disabilities. Teams in 237 communities have been trained to date.

Early Head Start works with many community partners in addition to Part C, for example, community child care providers. Early Head Start can work with Part C in enabling children’s special education services to be delivered in children’s natural settings, such as their child care environments and at Early Head Start programs.

Challenges

Usually only the most severe disabilities are identified at birth; most delays and disabilities emerge over time. The period from birth to age 3 is characterized by rapid growth and change, and children grow at their own unique rates, so a broad range of developmental variety is encompassed by notions of “typical” growth. Thus, staff in Early Head Start programs must be very vigilant in observing children’s early development in order to identify conditions that may qualify children for Part C services.

It is more difficult to define disability for infants and toddlers than might be assumed. The performance standards themselves do not define disability but rely upon eligibility as defined under Part C. However, definitions vary dramatically across states, for example, in the degree of developmental delay that delineates eligibility for Part C. Referral procedures also vary considerably across states.

Communities are in the early stages of learning to coordinate Early Head Start and Part C services, and Part C providers may not be aware of the services offered by Early Head Start. One recent study revealed that while Early Head Start staff interviewed clearly understood Part C eligibility requirements in the five jurisdictions studied, the purpose of Early Head Start and the benefits children and families might derive from being served by both Early Head Start and Part C were often not equally apparent to Part C program staff.1

It is sometimes challenging for Early Head Start programs to identify children with delays or disabilities. The performance standards emphasize ongoing screening for emerging health issues and “developmental, sensory and behavioral concerns.” This establishes a primary role for Early Head Start in serving as an early warning system that identifies potential developmental problems in very young children from economically disadvantaged families. These children are at higher risk for developing delays or disabilities and much less likely to access early intervention services than children from more affluent families. This role is consistent with the history of Head Start, which had as its inspiration successful experimental early intervention programs for children with mental retardation. In addition, there is no universal agreement about criteria for developmental delay among children under age 3.

Staff must be skilled in conducting culturally-sensitive screenings, monitoring ongoing child development, and supporting the active participation of disadvantaged families. Staff may need to balance the needs of children with disabilities with other urgent needs of economically disadvantaged families. Many of these needs also pose barriers to acting on behalf of an individual child. Finally, it takes intensive effort for Early Head Start staff to help families navigate as independently as possible unfamiliar and complicated service systems, secure referrals and assessments, and access early intervention services provided through Part C.

1Summers, Jean Ann, Tammy Steeples, Carla Peterson, Lisa Naig, Susan McBride, Shavaun Wall, Harriet Liebow, Mark Swanson, and Joseph Stowitschek. “Policy And Management Supports For Effective Service Integration in Early Head Start and Part C Programs.” Topics in Early Childhood Special Education. 21(1):16-30, 2001.(back)

TABLE III.10

DISABILITY INDICATORS AND RECEIPT OF EARLY INTERVENTION SERVICES BY EARLY HEAD START CHILDREN, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Children Who Were Ever Reported By Parents to:
Be eligible for early intervention services	8	8	8	7	7	6	10
Have received early intervention services	6	5	6	4	5	5	7
Percentage of Children Whose Parents Reported Indicators of Disabilities:
Level 1: Eligibility for early intervention services or first-level diagnosed condition	14	16	14	13	13	12	14
Level 2: Functional limitation or second-level diagnosed condition	18	18	20	18	20	18	15
Percentage of Children Reported by Program Staff to Be Part C-Eligible by Summer 2000	12	14	12	12	15	9	13
Sample Size	1,028-1,075	216-234	427-490	318-358	331-368	301-401	274-304
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse. Level 1 diagnosed conditions indicate eligibility for early intervention services and include a diagnosed hearing problem, severe or profound hearing loss, difficulty hearing or deafness, vision problem, difficulty seeing or blindness, speech problem, mobility problem, mental retardation, emotional disturbance, cleft palate, or a serious condition that showed up at birth or soon after, such as Down Syndrome, Turner’s Syndrome, or spina bifida. Level 2 diagnosed conditions, which may indicate eligibility for early intervention services, include crossed eyes or nearsightedness, epilepsy or seizures, hyperactivity, or a developmental delay. Functional limitations include possible hearing and vision problems, communication problems, trouble with arm/hand or leg/foot, and use of special equipment to get around.

These percentages do not necessarily reflect the percentage of children with identified disabilities served by the programs at any given point in time. Follow-up interviews occurred over a 28-month period, on average, during which programs also served other families who were not in the research sample but who may have had children with identified disabilities.

Not all families who reported that their child was eligible for early intervention services reported that they had received early intervention services by the time of the third parent services follow-up interview. This may reflect, in part, the time required to set up services after identification. On average, 6 percent of families reported receiving early intervention services, ranging from 0 to 16 percent across programs (not shown). Four percent also reported that their child’s early intervention services were being coordinated with the Early Head Start program, ranging from 0 to 12 percent across programs (not shown). Some parents with children who had been identified as eligible for Part C may not have recognized that their child was receiving early intervention services because the services were well-coordinated with Early Head Start services.

In addition to parents’ reports of their child’s eligibility for, and receipt of, early intervention services, parents’ reports of diagnosed impairments provide another indication of children’s disability status that is not tied to parents’ awareness of their child’s eligibility for, and receipt of, early intervention services (which may be coordinated with Early Head Start services and are not easily distinguishable to some parents). We defined two levels of indicators of potential disabilities to summarize the information that parents provided. The first level indicates whether the parent ever reported that the child was eligible for early intervention services or a doctor ever told the parent that the child had one or more of the following conditions (which would indicate eligibility for early intervention services): hearing problem, severe or profound hearing loss, difficulty hearing or deafness, vision problem, difficulty seeing or blindness, speech problem, mobility problem, mental retardation, emotional disturbance, cleft palate, or a serious condition that showed up at birth or soon after, such as Down Syndrome, Turner’s Syndrome, or spina bifida. The second level indicates whether the parent ever reported that the child had various functional limitations or ever had other diagnosed conditions, including crossed eyes or nearsightedness, epilepsy or seizures, hyperactivity, or a developmental delay, which might make the child eligible for early intervention services.

According to the first-level indicator (based on parents’ reports of children’s eligibility for early intervention services and information on children’s diagnosed conditions), 14 percent of children, on average, may have had disabilities at some time by the third followup (an average of 28 months after enrollment, when children were, on average, 32 months old) (Table III.10). According to this indicator, the proportion of children whose parents ever reported potential disabilities ranged from 3 to 34 percent across programs; this proportion was at least 10 percent in 10 programs. The proportion did not differ substantially among center-based, home-based, and mixed-approach programs, nor did it vary substantially among early, later, and incomplete implementers.

According to the second-level indicator (based on parents’ reports of functional limitations and other diagnosed conditions), approximately 18 percent of children, on average, ever had potential disabilities by the time of the third followup (Table III.10) As in the case of the first-level indicator, the proportion of children with a second-level indicator of a potential disability varied widely among programs, ranging from 7 to 40 percent across programs. The proportion was at least 10 percent in 14 programs. However, as before, the average incidence was similar among center-based, home-based, and mixed-approach programs and among early, later, and incomplete implementers.

The most commonly reported first-level diagnosed conditions were a diagnosed speech problem (6 percent of all children), difficulty hearing or deafness (2 percent), or difficulty seeing or blindness (2 percent). The most commonly reported second-level diagnosed conditions and functional limitations were that the child was very difficult for others to understand (9 percent of all children), a hearing problem (4 percent), difficulty communicating (3 percent), or a vision problem (3 percent).

G. FAMILY DEVELOPMENT SERVICES

The revised Head Start Program Performance Standards require programs to help families access needed family development services, either by providing them to families directly or helping families access other services available in the community. This section includes services that Early Head Start programs provided directly, as well as other community services that families reported receiving.

1. Case Management

Home visits and case management services overlapped substantially. Most of the program families who reported receiving home visits during the combined follow-up period also reported receiving case management services. Among those who reported receiving both Early Head Start home visits and Early Head Start case management, more than 90 percent reported that the person they met with for case management was the same person who visited them at home. Thus, the patterns of case management receipt are very similar to those of home visit receipt.

More than 80 percent of program families reported meeting with a case manager, and almost all of these reported more than one meeting (Table III.11). Nearly three-quarters of families reported meeting with a case manager monthly or more often during at least one follow-up period. Half reported monthly case management meetings in at least two follow-up periods, and nearly one-third reported monthly meetings continuously throughout the combined follow-up period. Families in home-based and mixed-approach programs were more likely to report monthly case management meetings in at least one follow-up period (83 and 80 percent) than center-based programs (41 percent). Families served by early implementers were more likely to receive case management than were later or incomplete implementers. As expected, these patterns of case management receipt mirror the patterns of home visiting receipt across program types and programs with different implementation patterns.

2. Family Health Care

Nearly all families (97 percent) reported that at least one family member other than the focus child received health services during the combined follow-up period (Table III.12). At least one family member in 94 percent of families visited a doctor, 77 percent visited a dentist, and 56 percent visited an emergency room. Families in home-based programs and early implementers were most likely to visit doctors and dentists; families in mixed-approach programs and early implementers were most likely to visit an emergency room.

3. Family Mental Health Care

At least one family member in nearly one-quarter of families received mental health services, including 21 percent who received treatment for an emotional or mental health problem and 5 percent who received treatment for drug or alcohol use. Families in home-based and mixed-approach programs (24 percent) were more likely to receive mental health services than those in center-based programs (19 percent). Families in early implementers were also more likely to receive these services (31 percent), compared to later and incomplete implementers (17 and 20 percent).

TABLE III.11

RECEIPT OF CASE MANAGEMENT SERVICES BY EARLY HEAD START FAMILIES, FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Families Who Received:
Any Early Head Start case management	82	66	87	88	87	78	79
More than one Early Head Start case management meeting	78	58	85	85	83	75	77
Percentage of Families Who Received Early Head Start Case Management at Least Monthly During:
At least 1 follow-up period	72	41	83	80	76	69	71
At least 2 follow-up periods	50	21	62	55	55	41	54
Combined follow-up period	30	7	41	31	35	20	35
Percentage of Families Who Received Early Head Start Case Management at Least Weekly During:
At least 1 follow-up period	53	20	65	62	62	46	52
At least 2 follow-up periods	31	5	43	33	37	26	29
Combined follow-up period	16	0	26	15	21	12	13
Sample Size	1,015-1,030	208-209	473-481	334-340	348-351	357-365	310-314
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse.

TABLE III.12
RECEIPT OF FAMILY HEALTH CARE SERVICESa BY EARLY HEAD START FAMILIES,
FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Families in Which at Least One Family Member Received Health Services	97	97	98	97	100	96	96
Percentage of Families in Which at Least One Family Member Visited:
A doctor	94	94	95	94	98	91	94
A dentist	77	74	81	74	80	74	77
An emergency room	56	57	51	60	62	55	49
Percentage of Families in Which at Least One Family Member Received:
Any mental health services	23	19	24	24	31	17	20
Treatment for an emotional or mental health problem	21	17	22	23	29	15	19
Drug or alcohol treatment	5	4	5	5	6	5	3
Sample Size	1,019-1,032	207-211	476-481	335-340	349-352	357-365	311-314
SOURCE: Parent Services Follow-Up Interviews completed an average of 7, 16, and 28 months after enrollment. NOTE: The percentages are average percentages across programs in the given group and are weighted for survey nonresponse. aFamily health care services include services received by all family members except the focus child.(back)

4. Other Family Development Services

Families reported receiving a variety of other services either directly from Early Head Start or through referrals to other community services providers. This section describes other family development services received from both of those sources, including education-related services, help finding a job, transportation services, and housing services. Nearly two-thirds of primary caregivers reported attending a school or training program, and nearly three-quarters reported discussing education services with a case manager (Table III.13). One-third of families reported that at least one adult family member received job search assistance, and two-thirds reported that they discussed finding a job with a case manager. One-third of families reported receiving transportation services. Families in mixed approach programs (38 percent) were more likely to receive transportation services than those in home-based and center-based programs (32 and 29 percent). Nearly 60 percent of families reported receiving housing services, such as public housing, rent subsidies, help finding housing, energy assistance, or emergency housing. Families in home-based programs (66 percent) were more likely to receive housing services than those in center-based and mixed-approach programs (56 and 53 percent).

H. ENGAGEMENT IN PROGRAM SERVICES

In summer 2000, program staff rated each family’s engagement with the program according to the following definitions:

Consistent High Engagement: The family was consistently highly engaged in the program throughout its enrollment—the family kept most appointments, was actively engaged in home visits and group activities, and (when applicable) the child attended an Early Head Start child care center regularly.
Variable Engagement: The family’s engagement varied during its enrollment—the family was sometimes highly engaged in the program, and at other times, the family’s engagement was low.
Consistent Low Engagement: The family’s engagement in the program was consistently low throughout its enrollment—the family kept some appointments but missed and canceled frequently, did not engage actively in home visits and group activities, and (when applicable) the child was often absent from the Early Head Start child care center.
No engagement: The family was not engaged in the program at all.
Can’t remember: Staff could not remember how engaged the family was.

TABLE III.14

PROGRAM FAMILIES' ENGAGEMENT IN EARLY HEAD START SERVICES FOR THE FULL SAMPLE AND KEY PROGRAM SUBGROUPS
	Full Sample	Center- Based	Home- Based	Mixed- Approach	Early Implementers	Later Implementers	Incomplete Implementers
		Program Approach			Pattern of Implementation
Percentage of Families Who Were Rated As:
Consistently highly engaged	37	47	39	38	44	31	37
Engaged at varying levels over time	32	32	29	32	29	38	27
Consistently engaged at a low level	18	7	24	20	19	17	15
Not engaged at all	7	5	8	8	8	7	7
Staff could not recall family's engagement level	6	8	10	3	1	6	14
Sample Size	1,408	306	603	499	521	528	457
SOURCE: Ratings of program engagement provided by program staff in Summer 2000. NOTE: The percentages are average percentages across programs in any given group.

According to the engagement ratings, more than one-third of the program families were highly engaged in program services (Table III.14). Consistent with families’ reports of their participation in program services, program staff reported that only seven percent of families, on average, did not become involved in the program at all. Program staff were unable to rate the engagement of six percent of program families.

The extent to which staff rated families as highly engaged varied substantially across sites, however, ranging from 20 to 74 percent (not shown). In three programs, staff reported that at least half of the families were highly engaged. Two of these were early implementers, and one was a later implementer. Two had implemented a mixed approach to service delivery, and one was center-based. Center-based programs reported the highest proportion of families who were highly engaged (47 percent), compared with home-based and mixed-approach programs (39 and 38 percent). Early, full implementation was associated with higher levels of program engagement. Early implementers reported a higher proportion of highly engaged families (44 percent), compared with later and incomplete implementers (31 and 37 percent).

Several local research teams examined engagement in Early Head Start services in depth. Box III.5 describes analyses conducted by local researchers from the University of Colorado of parent and child engagement in a Montessori Early Head Start program. In Box III.6, researchers from New York University report on associations between baseline measures of parent-child interaction and parent psychological variables and families’ participation in an Early Head Start center.

I. SUMMARY AND CONCLUSIONS

The 17 Early Head Start research programs succeeded in getting almost all families to participate in some program services and in core child development services. Although a large fraction of families received some services, however, less than half of the families participated intensively in program services for the full time period in which they were eligible to participate. On average, families participated in Early Head Start programs for 21 months. According to staff ratings, 37 percent were highly engaged in the program, and about one-third of families completed the program without moving away or dropping out before their eligibility ended. Across several measures of program intensity, fewer than half of program families received services at the required intensity level during at least two of the three follow-up periods. In addition, as discussed in the implementation study, programs faced challenges in delivering some services at the intensity required by the Head Start Program Performance Standards, especially weekly home visits and biweekly parent-child group socialization activities. Thus, the evaluation data confirm, as other studies of home visiting programs have found, that the goals contained in the Head Start Program Performance Standards for the duration and intensity of services are challenging to attain (Gomby 1999).

Variation in levels and intensity of service use across programs with different implementation patterns indicates that programs that achieved full implementation early were more successful in gaining families’ participation in services. Early implementers consistently provided services to a larger fraction of the families in their caseloads, and they consistently provided intensive services to a larger fraction of families.

BOX III.5

THE CHILD’S EXPERIENCE IN A MONTESSORI EARLY HEAD START PROGRAM

Jon Korfmacher, Erikson Institute, and
Paul Spicer, University of Colorado Health Sciences Center

While the literature on program evaluation has been focusing more on questions of program process, methods to explore individual variation in program response are still fairly undeveloped. In the national Early Head Start evaluation, researchers affiliated with the University of Colorado explored ways of examining this concern through the joint use of qualitative and quantitative data to better understand child and family responses to Family Star, a Montessori-based Early Head Start program in Denver, Colorado.

We used teacher ratings to capture five dimensions of child and family response to the Montessori environments of the program. These dimensions are:

Positive Classroom Engagement: Child orientation and attention to objects, sense of pleasure in activities, and positive social interactions with peers
Distress and Upset: Child crying and fussing during transition times or daily routines, such as eating, toileting, or napping
Tantrum and Fighting: Strongly adverse reactions when limits were set or when interacting with peers
Child Seeks Help: Child use of teacher for comfort, help, or company
Parent Seeks Help: Parent requests assistance with child’s behavior or development

As qualitative work, we used ethnographic participant observation in the program classrooms and in the homes of 12 families. We used this work to develop studies of the experiences of individual children and their families with the program intervention.

The qualitative and quantitative data were combined at the level of individual cases. We examined patterns of teacher ratings for children over time and used ethnographic data to provide context and understanding of the trends noted in the ratings (in the paper presented in Volume III, data from two children are highlighted). For example, examining individual cases helped us appreciate the significance for children of the transition between classrooms (such as the move from the infant to the toddler classroom). The teachers and the ethnographer often observed marked decreases in the child’s classroom engagement. Without information from the ethnographic work, we could not have known whether the patterns evident in teacher ratings were due to actual changes in child behavior or the biases of a new rater. Because we combined these two sources of data, we are much more confident about our interpretation of the significance of the transition for the child. Our combined data also helped us appreciate that these transitions have a significant impact on parents, because they may develop a special relationship with the staff of one classroom that is not easily transferred to the staff of a new classroom.

A multimethod approach to understanding program process is promising. Together, ethnographic and quantitative report data can tell more-complete stories about children’s experiences of the intervention than could a single method.

BOX III.6

PREDICTORS OF PROGRAM PARTICIPATION AT THE EDUCATIONAL ALLIANCE’S EARLY HEAD START

Mark Spellmann, Ph.D., Catherine Tamis-LeMonda, Ph.D., Maria Yarolin, Lisa Baumwell, Ph.D.,
Joanne Roberts, Ph.D., and the NYU Early Childhood Research Team
New York University

Do parent characteristics predict participation in the Early Head Start program? To explore this question, we tested baseline measures of parent-child interaction and parent psychosocial variables as predictors of Early Head Start program participation. We gathered baseline data when children were 6 months old. Program participation was defined as child attendance at the Educational Alliance’s Early Head Start child care centers and parent involvement with Early Head Start social service staff.

Three categories of baseline measures predicted lower levels of children’s attendance at the Early Head Start centers:

Exposure to domestic and community violence (this included domestic violence suffered in the past year, awareness of domestic violence toward others, and experience of community violence within the past five years)
Lack of father involvement
Harsh rejection of Early Head Start mothers by their own fathers while growing up

Parent involvement with Early Head Start social service staff was predicted by:

Exposure to domestic and community violence
Father involvement
Maternal efficacy
Modern (versus traditional) cultural child-rearing values

Observational ratings of quality of parenting, quality of parent-infant interaction, and parent mental health did not predict attendance or involvement.

Of the wide range of variables tested as potential predictors of program participation, few tapped father involvement. Yet factors associated with fathering dominated the array of significant predictors. Positive factors—“social support mothers received from babies’ fathers,” “living with partner/husband,” and “baby’s father was a caretaker”—promoted program participation. Harsh, rejecting fathers in mothers’ families when they were growing up and domestic violence were negative predictors of participation.

The finding that higher maternal efficacy predicted involvement with family social service staff suggests that more confident mothers were more able to open up to social service staff. The finding on cultural child-rearing values suggests that a match of mother-staff values was important for involvement.

These findings suggest that Early Head Start programs should carefully look at the reasons for a family’s withdrawal or failure to engage. When families withdraw because the child-rearing values of the program and of the family are not a good fit, programs may question whether they are sufficiently inviting and inclusive toward all segments of the communities they serve.

When a family withdraws from an Early Head Start program because of a lack of father involvement, Early Head Start programs might see this as an indication that families new to Early Head Start may need extra attention and support if they are to maintain attendance and involvement.

Exposure to violence is the most serious reason (of those found in this study) for a family to withdraw from Early Head Start. Children and families in these situations are clearly at high risk. Early Head Start programs cannot always know whether domestic or community violence plays a role in a family’s withdrawal. However, Early Head Start staff members could ask themselves whether any warning signs of violence were evident when families withdrew. Further research is needed to explore the magnitude of this problem and, if necessary, to increase Early Head Start staff awareness of its dimensions.

Levels of participation and intensity of service use also varied across program approaches, usually in expected ways. For example, families enrolled in center-based programs were most likely to use Early Head Start center care and used more hours of center-based care. Likewise, families in home-based programs were most likely to participate in frequent home visits, case management meetings, and parent-child group socialization activities. Levels of participation among families in mixed-approach programs usually fell between the levels reported by families in center-based and those in home-based programs. The duration of participation, however, was longest in mixed-approach programs.

Thus, while fewer than half of program families were involved intensively in the Early Head Start programs for the full period of time in which they were eligible to receive services, almost all families received some services, and the majority received fairly intensive services during at least one of the three follow-up periods. In the next chapter, we examine the extent to which program families’ levels of service use and the intensity of services they received were greater than what they would have received in the absence of Early Head Start.

1The exit interview was conducted at the time of the 36-month child and family assessment. If the family had recently completed the final Parent Services Follow-Up Interview, then only the portion of the exit interview related to program experiences was conducted with program families in conjunction with the 36-month child assessment and parent interview. For this report, we used information on duration of program participation from the exit interview. (back)

2Chapter I gives a more detailed description of the Early Head Start programs’ approaches to providing child development services.(back)

3Chapter I provides a more detailed description of these ratings, and Pathways to Quality (Administration on Children, Youth and Families 2002) includes an in-depth analysis of programs’ implementation patterns.(back)

4Nearly all interviews were completed by 38 months after enrollment.(back)

5The initial home visit or case management meeting was often used to complete enrollment and not to provide services. Thus, it can be assumed that the outcomes for families who received only one or no home visits or case management meetings could not have been affected. We used this percentage to translate impacts on eligible applicants into impacts on program participants (see Chapter II for a more detailed explanation). By reporting the percentage of families who received at least this minimal level of services, we do not intend to imply that this level represents a programmatically meaningful amount of Early Head Start services.(back)

6Parenting education was another important component of programs’ child development services. We discuss participation in these services later in this chapter.(back)

7Because our data on home visits do not include these out-of-home meetings, our estimates of home visit services may slightly underestimate the proportion of families who received these services.(back)

8See Pathways to Quality (Administration on Children, Youth and Families 2002) for a more detailed discussion of the challenges program faced in completing home visits.(back)

9As noted earlier, failure to provide services, such as weekly home visits, at the required intensity throughout the combined follow-up period should not be interpreted as failure to comply with the performance standards in serving these families. Because more than 40 percent of families participated in the program for less than 24 months, many families receiving home-based services did not participate in the program for the entire combined follow-up period (28 months after enrollment, on average).(back)

10We calculated this estimate by adding together the estimated number of home visits received during each of the three follow-up periods and then prorating the estimate to 26 months after program enrollment (by multiplying the estimated number of home visits by 26 divided by the actual length of the follow-up period). Estimates for each follow-up period were derived by multiplying the reported frequency of home visits by the length of the follow-up period.(back)

11As stated previously, these percentages do not include children who received center-based child development services in other child care settings under contract with an Early Head Start program. The percentage receiving care in an Early Head Start center reflects the lower participation rates in two center-based programs, as discussed above in Section B.(back)

12The average total number of hours of Early Head Start care is the number of hours averaged across all program group focus children, including those who did not receive any Early Head Start center care.(back)

13Two of the four center-based programs were early implementers, one was a later implementer, and one was an incomplete implementer.(back)

14The average total number of hours in child care is the number of hours averaged across all program group children, including those who did not use any child care during the 26 months after program enrollment.(back)

15The discrepancy between overall use of center care and use of Early Head Start center-based care by families in center-based programs is probably due to use of other community centers by families who moved or left Early Head Start for other reasons.(back)

16The average out-of-pocket child care cost during the 26-month follow-up period is the cost averaged across all program group children, including those who did not use any child care and those who received free child care during the 26 months after program enrollment.(back)

17On follow-up surveys, parents were asked if they received a special check or voucher to pay for each child care arrangement. Thus, the percentages reported here include child care subsidies that parents received in the form of vouchers, but do not include subsidized child care provided through slots contracted directly by the state or free care provided by Early Head Start.(back)

18See Pathways to Quality (Administration on Children, Youth, and Families 2002) for a more detailed description of the challenges programs encountered in gaining families’ participation in regular parent-child group socialization activities.(back)

19Early intervention services are provided by agencies designated under Part C of the Individuals with Disabilities Education Act (IDEA) Amendments of 1997 (PL105-17) to be responsible for ensuring that services are provided to all children with disabilities between birth and age 2.(back)

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