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III. IMPLEMENTATION OF EARLY CHILDHOOD DEVELOPMENT AND HEALTH SERVICES
The central goal of Early Head Start is to foster children’s healthy development during their early years. In the revised Head Start Program Performance Standards, the Head Start Bureau lays out specific program requirements intended to ensure that Early Head Start programs achieve this goal. U.S. Department of Health and Human Services (DHHS) Secretary Donna Shalala’s Advisory Committee on Services for Families with Infants and Toddlers, which provided broad guidelines for the new Early Head Start program, identified a commitment to high-quality services, both services provided directly and those provided through referral, as a key program principle. In the Early Head Start grant announcement, the Head Start Bureau requires programs to provide early childhood development and health services that are of high quality (U.S. Department of Health and Human Services 1995). In this chapter, we examine the extent to which the research programs implemented key elements of the revised Head Start Program Performance Standards for providing high-quality early childhood development and health services during their first year of serving families (before the performance standards took effect and before the programs received monitoring visits from the Head Start Bureau). We also examine service quality in one aspect of early childhood development services in more depth by presenting preliminary data from observations of the center-based child care settings used by Early Head Start families in the research sample.
A. IMPLEMENTATION OF EARLY CHILDHOOD DEVELOPMENT AND HEALTH SERVICES
To rate the extent of program implementation in the area of early childhood development and health services, we examined seven aspects of each research program’s child development and health services component: (1) developmental assessments, (2) individualization of services to children’s and parents’ specific needs, (3) parent involvement in child development services, (4) child care, (5) health services for children, (6) frequency with which child development services--whether home-based or center-based--were provided, and (7) group socialization activities for families that receive services through the home-based option.1 After examining the extent of implementation in each of these specific areas, we produced an implementation rating for each research program’s early childhood development and health services component.
About half of the research programs reached full implementation of Early Head Start child development and health services by fall 1997 (Figure III.1). An additional six programs reached a moderate level of implementation, because some aspects of the child development and health services component were not yet fully implemented. Across program options, center-based programs were most likely to be fully implemented; 75 percent of center-based programs, compared with only 25 percent of home-based programs, had reached full implementation. Among mixed-approach programs, 60 percent had reached full implementation.
In fall 1997, the majority of research programs had fully implemented four aspects of child development and health services: (1) developmental assessments, (2) individualization of services, (3) parent involvement in child development services, and (4) group socializations2 (Figure III.2).
[D] |
| Source: Site visits conducted in fall 1997
to 17 Early Head Start research programs. Note: Implementation ratings for early childhood development and health services represent the average rating across all the dimensions we examined. Programs rated as fully implemented achieved full implementation in most of the dimensions we examined, but did not necessarily achieve full implementation in every dimension (see Figure III.2 for a list of dimensions). |
[D] |
| Source: Site visits conducted in fall 1997
to 17 Early Head Start research programs. aWe rated programs as reaching full implementation in this area if they offered the group socialization activities required by the revised Head Start Program Performance Standards. This rating is based on the offer of services, rather than the number of families that participated regularly. |
Other elements of early childhood development and health services--child care, health services for children, and frequency of child development services--presented greater challenges in the early stages of program implementation.
1. Developmental Assessments
The revised Head Start Program Performance Standards require programs to conduct developmental assessments that evaluate children’s motor, language, social, cognitive, perceptual, and emotional skills. Furthermore, the standards encourage programs to conduct these assessments in collaboration with parents and in a manner that is sensitive to children’s cultural backgrounds. When assessments indicate a potential disability or delay, programs must refer families to an early intervention (Part C) service provider and support families’ participation in these services. We rated programs as fully implemented if they conducted or arranged for periodic developmental assessments and coordinated closely with Part C providers to make referrals and provide services to families and children.
In fall 1997, 10 of the 17 research programs had fully implemented a strategy for conducting developmental assessments and coordinating with Part C providers. These programs conducted or arranged for regular developmental assessments with all or almost all enrolled children. Research programs used a variety of screening and assessment tools, including the Ages & Stages Questionnaires, the Denver Developmental Screening Test II, the Early Learning Accomplishment Profile, and the Hawaii Early Learning Profile. These programs involved parents in the evaluation process by encouraging them to be present during the assessment, by helping them to participate directly in the assessment (for example, by completing the Ages & Stages Questionnaires), and by discussing with them the results of the assessment and activities recommended to strengthen weak areas. Some programs referred children to early intervention programs or other agencies for further assessment if they suspected a disability or delay, and some programs conducted additional assessments themselves before making a referral. Nevertheless, all of these programs referred children with suspected disabilities to a Part C service provider and worked closely with families throughout the Part C assessment and service planning process. They also collaborated closely with Part C providers to coordinate services for the family and child, and in some cases they worked together with the Part C provider to develop joint service plans for the family.
Seven research programs had only partially implemented developmental assessments and appropriate referrals by fall 1997. Some of these programs had not yet conducted developmental assessments with some enrolled children. In other cases, programs referred children to Part C providers when staff suspected a delay or disability, but they did not coordinate Early Head Start services with the Part C provider.
2. Individualization of Services
To ensure that services are individualized to children’s distinct rates of development and backgrounds, the revised Head Start Program Performance Standards require programs to implement an approach to child development that respects children’s individual rates of development, temperament, gender, culture, language, ethnicity, and family composition. Fourteen of the 17 research programs had fully implemented a strategy for individualizing child development services in fall 1997. Almost all families enrolled in these programs received child development services in the language they spoke at home, usually English or Spanish. In addition, these programs provided child development services to families according to their individual needs, taking into account the child’s developmental progress, the family’s cultural background, and other aspects of the family’s circumstances.
Research programs used a variety of methods for individualizing services according to need. For example, several programs used the results of developmental assessments to plan future child development services and activities. Programs also responded to needs expressed directly by parents. Many programs focused their parent education activities and, to some extent their child development activities with children, on concerns raised by parents about specific developmental issues such as motor skills, language, or sleeping patterns. Finally, these programs planned their home-based and center-based child development activities to accommodate children’s special needs for physical care, equipment, or early intervention services.
3. Parent Involvement in Child Development Services
According to the revised Head Start Program Performance Standards, programs should involve parents in child development services by encouraging their involvement in planning the program’s child development curriculum and approach, helping parents to improve their child observation skills, and discussing children’s development with parents during staff-parent conferences and home visits. Nine research programs had fully implemented these parent involvement requirements by fall 1997. These programs involved parents in the planning and delivery of child development services through a variety of methods. For instance, several programs involved parents directly in conducting developmental assessments, especially those using the Ages and Stages Questionnaires, and then worked with parents to plan services to address any potential weaknesses identified. Many parents participated in planning activities and parent education topics for child development home visits. Center-based programs involved parents by forming Parent Committees to help design the center’s program and by encouraging parents to volunteer in center classrooms.
4. Group Socialization Activities
The revised Head Start Program Performance Standards require programs to provide two group socialization activities per month for families that receive services through the home-based option. We rated research programs as fully implemented if they offered these activities to families on a regular basis, regardless of participation rates. Of the 13 research programs offering home-based services, 11 invited families to attend regular group socialization activities in fall 1997. The frequency of group socialization activities offered by these programs ranged from weekly to monthly. All of these programs offered at least two hours of group socialization activities per month; a few programs offered as many as eight hours per month. Types of group activities for parents and children included play groups, food festivals, picnics, outings, special events on particular themes, and parent-child events that focused on a variety of health and development topics.
While these programs offered regular group socialization activities to all families, many programs reported that attendance at these activities was fairly low. In fact, only two research programs were able to achieve regular participation by half or more of the families receiving homebased services. Program staff cited parents’ work schedules and other demands on parents’ time as barriers that prevented some families from attending. In addition, some parents were reluctant to socialize and get involved in these events. Several programs found that it took a while for some parents to feel comfortable in group activities.
5. Child Care
Whether Early Head Start programs provide child care directly or broker child care services in the community, they are responsible for ensuring that the child care settings meet the revised Head Start Program Performance Standards. For example, the standards require group care settings for infants and toddlers to maintain child-caregiver ratios of 4 to 1 or less and group sizes of 8 or fewer children (U.S. Department of Health and Human Services 1996). Since fall 1997, the Head Start Bureau has given programs further guidance about their responsibilities for brokering child care services in the community. Programs must ensure that community child care settings meet the standards for group care established in the revised Head Start Program Performance Standards and should ideally establish agreements with child care providers that require adherence to these standards. Because this additional guidance had not been clarified at the time of our fall 1997 site visits, we did not incorporate these requirements for agreements to adhere to the performance standards in community child care settings into the implementation rating scales we used. We rated research programs as fully implemented if they either provided child care directly or brokered community child care services for all families that needed it, assessed the quality of community child care settings before making referrals, and monitored child care settings regularly to ensure that they met standards for high quality.
In the early stages of implementation, research programs experienced difficulty meeting the Head Start Bureau’s child care requirements, as defined in our implementation rating scale. Only five of the research programs had fully implemented their child care components in fall 1997.3 Of these, three were mixed-approach programs, one was a home-based program, and one was a center-based program. These programs either provided child care directly or helped families arrange child care. If they helped families arrange child care, they systematically assessed the quality of care before making placements, regularly monitored the quality of child care arrangements after placements were made, and provided training and support to child care providers caring for Early Head Start children. The mixed-approach programs served some families that needed child care through the center-based option and some families through the home-based option. In the latter case, they monitored the quality of community child care that families used. In addition, some mixed-approach programs offered some families both of these services. The home-based program offered home-based services, but it was also actively involved in arranging and supporting high-quality child care arrangements for families that needed them. The center-based program offered high-quality child care that met the performance standards to almost all families that needed child care.
Three additional research programs (two center-based and one mixed-approach) achieved moderate levels of implementation of child care services in fall 1997. Each of these programs provided child care that met the performance standards to some families directly, and two also assessed the quality of other child care arrangements prior to making referrals. However, these programs were either unsuccessful in finding high-quality arrangements for families that needed community child care outside program hours, or they did not conduct ongoing monitoring and training with all providers to whom they referred families.4
In nine research programs, staff provided only limited help to families that needed child care, and programs had not yet reached moderate or full implementation in this area. Seven of these were home-based programs, one was a mixed-approach program, and one was a center-based program.5 Most of these programs either provided some child care directly or referred families that needed child care to individual providers or local resource and referral agencies, but they did not systematically assess, monitor, and support the quality of community child care arrangements used by Early Head Start families.
6. Health Services for Children
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. In addition, programs must keep track of health services provided to ensure that children receive all recommended well-child examinations, immunizations, and treatment for identified conditions.
Seven research programs had fully implemented Early Head Start child health services in fall 1997. Fourteen research programs worked with families to ensure that children had medical homes or primary care physicians, and many of these programs helped parents and children obtain needed dental and mental health services as well. Fewer research programs, however, had implemented tracking and follow-up procedures to ensure that children received well-child visits, immunizations, and treatment for illnesses according to recommended schedules.
Seven research programs made some effort to follow up on health services, but only four of them had implemented procedures to ensure systematic tracking and followup for every child. Several of these programs used databases to record and track immunizations and other health services received by enrolled children. Typically, programs that used systematic tracking procedures asked parents to sign consent forms permitting program staff to contact their health care providers to obtain the medical records necessary for tracking. Across all research programs, center-based and mixed-approach programs were more likely than home-based programs to implement these systematic tracking procedures. Because center licensing standards require participating children to have up-to-date immunizations, programs providing center-based services were perhaps more likely to implement the tracking procedures necessary for ensuring compliance with state licensing requirements.
7. Frequency of Child Development Services
The revised Head Start Program Performance Standards contain specific requirements for the center-based and home-based options about the frequency with which child development services must be provided. Center-based programs must provide at least half-day services, and home-visiting programs must provide weekly, 90-minute home visits, completing at least 48 home visits per year. Mixed-approach programs must provide either a prespecified combination of center-based and home-based services or center-based services to some families and home-based services to others. Because we were not able to systematically review program attendance and home-visiting records, we simplified these requirements and rated research programs as fully implemented if almost all children received child development services at least two times per month and almost all parents received parent education services at least once per month. We considered children to have received child development services at least two times per month if they participated in two child development home visits per month or attended an Early Head Start child care center. While the performance standards clearly require programs to complete at least four child development home visits per month, the rating panel chose two completed child development home visits per month with almost all families as the minimum requirement for full implementation at this initial stage of program development. At the time, this seemed justified because of multiple services connected with home visits and lack of clarity with respect to criteria for combining other services with home visits.6
Eight research programs had achieved this level of service frequency in fall 1997, including five home-based programs, two center-based programs, and one mixed-approach program. Although 6 of the 13 research programs providing services through the home-based option completed at least two child development home visits per month with almost all families, almost all home-based programs faced challenges in trying to complete the number of child development home visits required by the performance standards (at least four per month). Parents or home visitors sometimes canceled home visits due to illness or scheduling conflicts and found it difficult to reschedule and make up missed visits within the same week. In some locations, weather conditions sometimes prevented program staff from traveling to families’ homes. Moreover, in the wake of welfare reform, many parents began working during the day, making it more difficult for staff members to complete child development home visits during traditional working hours. While some programs attempted to conduct evening home visits, many found that parents and children were often too tired and busy preparing for the next day’s activities to focus on child development activities. Finally, some programs reported facing challenges in trying to complete planned child development activities during home visits, because parents placed greater emphasis on family development needs.
Programs implementing the center-based option faced a different set of challenges in providing child development services. Because most children attended the centers on a daily basis, these programs were able to provide regular child development services to children. Several center-based and mixed-approach programs, however, faced challenges to providing regular parent education to all parents. Because these programs did not conduct child development home visits for children receiving full-time center-based care, in some programs the staff found it challenging to arrange group or individual meetings with parents to provide parent education. For example, parents’ work schedules sometimes interfered with staff members’ ability to meet with parents individually or to schedule group parent education workshops during the day. At the same time, research programs sometimes found it difficult to achieve good attendance levels at evening parent meetings and parent education sessions. Working parents faced many demands on their time, and attending evening parent education meetings was not always a high priority. Logistic problems, such as lack of child care or transportation, sometimes posed barriers to parents’ attendance at evening meetings.
B. OBSERVATIONS OF QUALITY IN CENTER-BASED CHILD CARE SETTINGS
The Head Start Bureau requires that programs either provide child care directly or broker child care services in the community for all families that need it, and that programs take steps to ensure that child care used by Early Head Start families meets the revised Head Start Program Performance Standards. As described in Chapter II, we conducted observations of the center-based child care settings Early Head Start families used when their children were 14 and 24 months old and employed the Infant/Toddler Environment Rating Scale (ITERS) to assess the level of quality of these settings. This section describes preliminary data from observations of center-based child care provided directly by Early Head Start research programs and observations of Early Head Start children’s classrooms in community child care centers.
1. Child Care Quality in Early Head Start Centers
Nine of the 17 research programs provided center-based child care directly to some or all families. These services were almost always full-time, were based on a variety of curriculum resources, and according to staff reports during site visits, were usually provided to infants and toddlers with relatively small child-staff ratios (4 to 1 or smaller) and often in small group sizes (8 or fewer children), as required by the revised Head Start Program Performance Standards (Figures III.3 and III.4). These ratios and group sizes are generally associated with more positive child outcomes.
The preliminary ITERS data suggest that on average, the quality of center-based child care provided by the nine center-based and mixed-approach research programs during their first two years of serving families was good (5.4).7 The average quality of care observed in these Early Head Start centers was well above minimal (above 4) in all nine research programs that provided center-based care (Figure III.5). These preliminary findings are consistent with findings of the Head Start Family and Child Experiences Survey (FACES), which found that the average quality of center-based care provided by Head Start programs was good (Early Childhood Environment Rating Scale [ECERS] score of 4.9) (U.S. Department of Health and Human Services 1998). Although the average quality of center-based child care was good in all of the research programs, it varied across Early Head Start programs from the lower end of the good range to excellent.
Average program ITERS scores ranged from 4.1 to 6.3. In five programs, the average ITERS score was 5.9 or higher, indicating that the quality of care observed was in the good-toexcellent range.
[D] |
| Note: These data were collected in fall 1997, prior to the enactment of the revised Head Start Program Performance Standards and before Head Start Bureau staff conducted monitoring visits. The ratios reported in this figure were reported by programs and were not observed during child care quality assessments. |
[D] |
| Note: These data were collected in fall 1997, prior to the enactment of the revised Head Start Program Performance Standards and before Head Start Bureau staff conducted monitoring visits. The group sizes reported in this figure were reported by programs and were not observed during child care quality assessments. |
[D] |
| Note: Based on 162 classroom observations in
9 programs conducted in 1997 and 1998. The numbers in parentheses
represent the number of classrooms observed at each research program.
ITERS = Infant/Toddler Environment Rating Scale. |
Early Head Start centers tended to receive the highest scores in the personal care routines, interactions, and program structure categories of the ITERS and the lowest scores in the adult needs, learning activities, and furnishings categories. The strength in the personal care routines and interactions categories may reflect the strong emphasis in the performance standards on safety and child-teacher interactions and relationships.
The quality of care in Early Head Start centers also varied across classrooms within programs. In three programs the minimum and maximum ITERS scores were more than one level apart, while in six programs the minimum and maximum ITERS scores were within one level of each other (Figure III.5). No ITERS scores for Early Head Start centers, however, fell below the minimal-togood range.
The good quality of center-based care provided by the Early Head Start research programs stands out in contrast to the poorer quality of center-based care provided to infants and toddlers in many community centers across the nation. The Cost, Quality, and Outcomes Study found that infant/toddler classrooms in two-thirds of centers in the five study sites did not provide good-quality care (that is, received ITERS scores under 4) (Cost, Quality, and Outcomes Study Team 1995). Observational data from the National Child Care Staffing Study also showed that a significant proportion of centers provided poor-quality infant and toddler care. Although teacher characteristics and global indexes of child care quality did not differ significantly between centers serving predominantly low-income children and those serving high-income children, teacher sensitivity was significantly lower and detachment significantly more common in low-income than in middle- or upper-income centers (Phillips, Voran, Kisker, Howes, and Whitebook 1994).
2. Child Care Quality in Community Child Care Centers Used by Early Head Start Families
Many parents of children in the Early Head Start research programs sought child care in their communities. In some cases program staff helped them find child care, and in other cases the families found it on their own.
Based on early observations in community child care centers used by Early Head Start families in the research sample when children were 14 and 24 months old, and irrespective of whether programs were assessing, monitoring, or seeking to improve the quality of community child care, the average quality of child care provided to Early Head Start children by community centers ranged from minimal to excellent. Across the 14 research programs where observation data have been collected in community child care centers used by program families, the average ITERS score was 3.8 (in the minimal-to-good range) (Figure III.6). Average ITERS scores ranged from 2.4 (less than minimal) to 6.1 (good-to-excellent) across classrooms in community child care centers where Early Head Start children were receiving care. In six research programs, community child care centers caring for Early Head Start children provided care that was, on average, of good or excellent quality (ITERS scores above 4).
The research programs where community child care centers used by Early Head Start families provided the highest quality care, on average, were programs that provided home-based services. The average ITERS score for child care centers in communities where home-based research programs are located was 4.1, ranging from 2.4 to 6.1 (Figure III.7). ITERS scores ranged from 2.7 to 4.0, with an average score of 3.3, in communities where center-based research programs are located (Figure III.8).8 In communities with mixed-approach research programs the average ITERS score was 3.8, ranging from 2.6 to 4.7 (Figure III.9).
|
[D] |
| Note: Based on 79 classroom observations in
14 programs sites--in 1997 and 1998. The numbers in parentheses represent
the number of community child care centers observed at each research
program. ITERS = Infant/Toddler Environment Rating Scale.
* Early Head Start program assessed and/or monitored care. |
The quality of care observed in community child care centers used by Early Head Start families was highly variable. In most research programs with more than three classroom observations in community child care centers, the minimum and maximum ITERS scores differed by more than two levels. This wide variation may reflect the variation in the quality of the available center-based child care in the community. It is notable that the ITERS scores in center-based community child care settings were more variable than the scores in the Early Head Start centers, which were more consistently good.
The average ITERS scores for classrooms in community settings were in the minimal-to-good range(ranging from 4.0 to 4.7) for all resea rch programs that were assessing and/or monitoring the quality of child care that enrolled children received in community settings.9 Some ITERS scores for community child care centers used by children in those programs, however, fell below the good range, possibly reflecting the fact that some families chose child care arrangements independently of the Early Head Start program.
[D] |
| Note: Based on 40 classroom observations in 28 centers across 7 Early Head Start research sites conducted in 1997 and 1998. The numbers in parentheses represent the number of community child care centers observed at each research program. |
[D] |
| Note: Based on nine classroom observations in seven community centers across three Early Head Start research sites. The numbers in parentheses represent the number of community child care centers observed at each research program site. |
[D] |
| Note: Based on 31 classroom observations in 26 centers across 4 Early Head Start research sites. The numbers in parentheses represent the number of community child care centers observed at each research program site. |
Community child care centers used by Early Head Start families tended to receive the highest scores in the interactions and program structure categories of the ITERS and the lowest scores for the adult needs, learning activities, and furnishings categories. Although the scores are higher for the Early Head Start centers, the relative differences among ITERS categories are consistent across Early Head Start centers and community centers and suggest that obtaining adequate materials and implementing the full range of activities assessed in the ITERS is especially challenging.
1Appendix B contains a detailed description of the rating criteria we developed for each of these dimensions of early childhood development and health services.(back)
2We rated programs as fully implemented in the area of group socializations if they offered these activities to families on a regular basis. We did not consider the extent of regular participation among families that received home-based services because the revised Head Start Program Performance Standards specified the offer of services; we added participation levels to the scale criteria in 1999.(back)
3Because this volume focuses on implementation, readers may wish to consult Volume I for greater detail about the nature of child care services in different program designs.(back)
4In one center-based program, the grantee offered non-Early Head Start child care outside of program hours, but the child care subsidies that were available to pay for the care were not sufficient for maintaining the ratios and group sizes maintained in the Early Head Start program. In another center-based program, one center had not yet opened in fall 1997, and program staff referred families that needed child care to the local resource and referral agency but did not monitor the quality of the arrangements that families used.(back)
5The center-based program was providing part-time child care in fall 1997 and did not help families that needed additional child care find arrangements or monitor the quality of their arrangements.(back)
6For the final round of implementation ratings, based on program information collected in fall 1999, we revised our definitions for full and enhanced implementation in this area to more accurately reflect the performance standards. We rated research programs as fully implemented if almost all children received child development services at least three times a month and parents received parent education at least monthly. Programs’ levels of implementation were rated as enhanced when almost all children received child development services at least four times per month and parents received parent education at least monthly.(back)
7Average scores of 5.0 and above on the 7-point ITERS scale are generally interpreted as good to excellent quality. Scores of 3.0 to 5.0 are considered minimal to good quality, and scores of 1.0 to 3.0 are considered inadequate quality.(back)
8Small numbers of children in center-based research programs had other (non-Early Head Start) primary child care arrangements, or they were being cared for in a community center while construction of the Early Head Start center was completed.(back)
9As noted earlier, the Head Start Bureau’s expectation that programs are responsible for ensuring all community child care settings used by Early Head Start families adhere to the revised Head Start Program Performance Standards for center-based services was not initially clear to all research programs. Some did not begin taking steps to ensure that child care quality adhered to the performance standards until after Head Start Bureau monitoring visits that occurred in spring 1998.(back)
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