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

V. PROGRESS IN IMPLEMENTING KEY CHILD DEVELOPMENT AND HEALTH SERVICES

Early Head Start and Head Start programs are designed to promote healthy development during children’s early years. In the revised Head Start Program Performance Standards, the Head Start Bureau lays out specific Head Start and Early Head Start program requirements for achieving this overall goal.1 In the domain of child health and development, the standards specify the following types of services, designed to ensure that the services are of high quality:

Child health services, including assessments of health status; developmental, sensory, and behavioral screenings that involve parents and enable staff and parents to individualize services for the child; and plans for follow-up and treatment of health conditions
Education and early childhood development services, including developmentally and linguistically appropriate services that include children with disabilities, involve parents, and support children’s development in a range of domains
Child nutrition services, including assessments of nutritional needs, meals and snacks in center-based settings and/or during group socialization activities, and nutrition education
Child mental health services, including assessments of children’s behaviors, consultations with mental health professionals to address mental health concerns, and education of parents and staff on mental health issues

In developing implementation rating scales, we focused on selected elements of the standards. We rated each program’s level of implementation of the following key aspects of the performance standards and program guidelines pertaining to child health and development:

Developmental assessments
Individualization of child development services
Parent involvement in child development services
Group socializations
Child care
Health services
Follow-up services for children with disabilities
Frequency of child development services

To be rated as “fully implemented” overall in child development and health services, programs had to be rated as fully implementing services (that is, substantially implementing the relevant program element) in most of these dimensions. In this chapter, we review the progress the Early Head Start research programs made in implementing child development and health services in relation to the requirements of the performance standards.

The number of programs rated as fully implementing Early Head Start child development and health increased slightly between fall 1997 and fall 1999. By fall 1999, 9 of the 17 research programs were fully implementing services in this area (Figure V.1), compared with 8 in 1997.2 The following sections tell the story behind this progress as we describe activities in each of the eight aspects that the implementation study examined.

FIGURE V.1

EARLY HEAD START CHILD DEVELOPMENT SERVICES IMPLEMENTATION RATINGS
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A. DEVELOPMENTAL ASSESSMENTS

The revised Head Start Program Performance Standards require programs to conduct periodic assessments of children’s motor, language, social, cognitive, perceptual, and emotional skills.

The most common tools the research programs used to assess children’s development were the Ages and Stages Questionnaires (ASQ), the Denver II Developmental Screening Test (DDST II), the Early Learning Accomplishment Profile, and the Hawaii Early Learning Profile (Figure V.2). Between fall 1997 and fall 1999, more programs adopted the ASQ and DDST II. Programs indicated that they used the ASQ because they are parent-friendly and facilitate parent participation in the assessment process; some adopted the DDST II because they believed it facilitated working with early intervention service providers (the Part C agency) to identify children with disabilities.

By fall 1999, most of the research programs (14 of the 17) had fully implemented developmental assessments as required (up from 10 programs in fall 1997) (Figure V.3). In fact, 11 research programs had reached an enhanced level of implementation in this area: all staff who worked with a child used that child’s developmental assessment results to plan services for the child and the family. Three research programs were rated as achieving a moderate level of implementation of developmental assessments, because they had given most children (but fewer than 90 percent) a developmental assessment during the year preceding the site visit.

B. INDIVIDUALIZATION OF CHILD DEVELOPMENT SERVICES

The revised Head Start Program Performance Standards require programs to implement child development services in a way that respects children’s individual rates of development, temperament, gender, culture, language, ethnicity, and family composition.

All the research programs had fully implemented a strategy for individualizing child development services by fall 1999 (up from 14 programs in fall 1997). Many programs (15) had reached an enhanced level of implementation in this area by fall 1999. These programs provided child development services to almost all children and families in their own language, usually Spanish or English. In some cases, programs provided services in three or more languages.

FIGURE V.2

TOOLS USED BY EARLY HEAD START RESEARCH PROGRAMS TO ASSESS CHILDREN'S DEVELOPMENT
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FIGURE V.3

EARLY HEAD START CHILD DEVELOPMENT SERVICES ASPECTS THAT WERE FULLY IMPLEMENTED
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aThe rating scales in these areas were changed significantly between 1997 and 1999 to reflect clarifications in guidance from the Head Start Bureau. To the rating scale for group socializations we added the requirement that most families participate in group socializations on a regular basis. We also increased the number of home or center visits required for a "fully implemented" rating on frequency of child development services from two to three times per month.

The research programs used a variety of strategies for individualizing child development services. In addition to serving almost all enrolled families and children in the language they spoke at home, many programs used the results of developmental assessments to plan future child development services and activities. Typically, home visitors and center teachers reviewed the results with parents and worked with them to plan activities appropriate for the child’s stage of development and to strengthen any areas the assessment identified as weak. Home visitors often worked with parents to select education topics based on parents’ concerns or interest in specific developmental areas (such as sleeping, nutrition, toilet training, or motor skills). Within the framework of a center curriculum or classroom theme, center teachers usually planned specific activities in response to the needs and interests of their group of children. Many even planned individualized activities that addressed specific developmental areas for each child.

C. PARENT INVOLVEMENT IN CHILD DEVELOPMENT SERVICES

According to the revised Head Start Program Performance Standards, programs should involve parents in child development services by involving them in planning child development activities, helping them improve their child observation skills, and discussing children’s development with them.

The research programs involved parents in child development services in a variety of ways. Some programs involved parents directly in conducting developmental assessments, and many involved parents in reviewing the results and planning services. In families receiving center-based services, parents participated in parent committees that planned center activities, and some parents volunteered in center classrooms.

By fall 1999, 15 of the research programs (up from 9 in 1997) had fully implemented strategies to involve parents in planning and providing child development services. All 15 involved at least one parent in most families and some fathers in child development services. Seven programs had reached an enhanced level of implementation in this area, which entailed involving at least one parent from almost all families and many fathers in child development services.

D. GROUP SOCIALIZATIONS

The revised Head Start Program Performance Standards require programs to offer at least two group socialization activities per month to families who receive home-based child development services. We rated programs with a home-based option as fully implemented if they offered these group socialization activities and most families attended them regularly.

In fall 1999, 3 of the 13 research programs that provided home-based child development services to some or all families had fully implemented group socializations for those families. Most programs offered group socializations at least twice a month, but in many programs participation was low. The apparent drop in the number of programs fully implementing group socializations (from 11 programs in 1997 to 3 programs in 1999) reflects the addition between 1997 and 1999 of the requirement that most families participate regularly for a rating of “fully implemented.”3

Programs found it very difficult to achieve high participation rates in group socialization activities. Some of the challenges related to the logistics of scheduling and conducting group socializations, and others related to lack of clear direction from the Head Start Bureau about how group socialization activities should be carried out. Scheduling these activities when most parents could attend was very difficult. Many parents had busy work schedules and lacked free time. Other parents had irregular schedules that often conflicted with group socialization schedules. Transportation problems also made it difficult for some parents to attend group socializations, so program staff had to find ways to provide transportation assistance. Some programs found it challenging to find a good location for these activities, either because of general program space limitations or because program families lived far from the program offices.

In addition to logistical challenges, lack of clear direction from the Head Start Bureau and some programs’ uncertainty about how to carry out the group socialization requirements probably hampered some programs’ efforts to achieve high participation in these activities during the initial years of program operations. Some programs were uncertain about how to staff and organize the socializations, and over time tried several different approaches. For example, one program tried convening monthly two-hour parent meetings that included parent-child activities, referring parents to play groups in the community, offering play groups twice a month at various times, holding annual parent-child events organized around a theme, and planning small group activities for families in each home visitor’s caseload. In some programs, staff and/or parents did not have a clear or common understanding of the purpose and intended content of the group socializations. Sometimes staff did not think that group socializations were appropriate for infants, because infants were thought to be too young to participate in meaningful group activities.

In striving to achieve high participation levels in group socialization activities, one program also had to address issues related to young parents’ experiences in group activities where they did not feel comfortable or accepted. In addition, staff members in some programs were hesitant to push families to participate in group socializations when families complained about the substantial time requirements for participation in other program activities such as home visits.

Throughout the evaluation period, programs were trying to meet these challenges and increase participation in group socializations by:

Changing the scheduled days and times of group socializations to make them more accessible to families
Increasing the number of group socialization opportunities at varying times and days
Hiring a part-time staff member to plan and organize group activities
Making group socialization activities more structured, for example, by focusing on a particular age group or need area, such as pregnancy

E. CHILD CARE

Since the fall 1997 site visits, the Head Start Bureau has clarified its expectation that programs are to ensure that all child care arrangements used by enrolled families meet the revised Head Start Program Performance Standards, whether the care is provided directly by the program or in another community setting. We rated programs as fully implementing the child care requirements if they helped families who needed it arrange child care, assessed and monitored the child care arrangements to ensure that they met the standards, helped families prevent interruptions in child care subsidies, and/or provided good-quality child care directly.

The proportion of children reported to be in child care arrangements increased slightly over time (Figure V.4). In six programs, fewer than half of Early Head Start children were in child care in fall 1999. In 11 programs, more than half of all children were in child care, and in 6 of these programs (4 of which were center-based), many or all of the children were in child care. This section of Chapter V focuses on program strategies to arrange for quality care, assess and monitor arrangements, and ensure continuity. We devote Chapter VIII to describing child care quality.

FIGURE V.4

ESTIMATED PROPORTION OF FAMILIES USING CHILD CARE
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SOURCE: Information gathered during visits to the Early Head Start research programs in fall 1997 and fall 1999.

In fall 1999, six programs had reached full implementation of the child care requirements, up from five in fall 1997.4 Five of these programs provided child care directly in Early Head Start centers to most families who needed it. Another program had established formal agreements with community child care providers to provide care for Early Head Start children and work toward meeting the performance standards. This program regularly assessed the quality of care that community child care partners provided.

Seven programs had reached a moderate level of implementation of the child care requirements. Some of these programs provided some child care directly to some (but not all) families who needed it. In addition, some monitored the quality of some community child care arrangements, but they did not have procedures in place to ensure that all or nearly all child care used by Early Head Start families met the performance standards.

The research programs adopted a variety of strategies to work towards ensuring that the child care arrangements in which Early Head Start children received care met the performance standards (Figure V.5). These strategies included:

Helping families identify and select high-quality child care arrangements
Making referrals to specific child care arrangements that they had determined provide high-quality child care
Referring families to local resource and referral agencies
Assessing the quality of care before making placements
Systematically monitoring at least some of the child care arrangements children were in
Visiting children in their care settings, where they could observe the care children were receiving and develop relationships with the child care providers
Offering training and/or support to child care providers caring for Early Head start children
Developing formal partnerships with child care providers that care for Early Head Start children
Helping families apply for and obtain state child care subsidy funds

FIGURE V.5

STRATEGIES USED BY EARLY HEAD START RESEARCH PROGRAMS TO MEET THE PERFORMANCE STANDARDS FOR CHILD CARE
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SOURCE: Information gathered during visits to the Early Head Start research programs in fall 1997 and fall 1999. aWe did not collect information on programs' efforts to help families obtain state child care subsidies in our 1997 site visits. Thus, we report the number of programs implementing this strategy in 1999 only.

Over time, the number of strategies that programs implemented to work on meeting the performance standards in community child care settings increased substantially. In 1997, the 17 research programs reported using a total of 29 strategies. By 1999, programs reported using a total of 62 strategies, or an average of nearly 4 per program.

In the course of implementing strategies to work with community child care partners on meeting the performance standards, programs faced a number of challenges. Programs had to start with the care that was available in the community, which in some cases was not sufficient in supply and generally not of good quality.

Program staff also found that it takes time to work toward meeting the performance standards in community child care settings, even under the best of circumstances. Community providers may not be set up to meet the performance standards quickly, even if they are eager to do so. Moreover, it takes time to build the relationships with community child care providers that serve as the foundation for solid partnerships through which compliance with the performance standards can be addressed.

For most child care providers, making the changes necessary to meet the performance standards required additional resources. For example, resources are required for staff training and for reducing child-staff ratios and group sizes. Many programs initially did not have the resources needed to pay for such changes. Some programs obtained additional funds from a variety of sources (such as expansion and quality improvement grants from ACYF and state Early Head Start grants) to support child care quality, but obtaining these resources took time.

In the past several years, new state child care initiatives and increases in state child care subsidy funds have made it easier for families to obtain financial assistance to pay for child care. In fall 1999, 11 programs helped families apply for and obtain state subsidy funds, which also helped to increase resources available to pay for good-quality care. Six helped families obtain subsidies to pay for child care in community settings, three helped obtain subsidies for center-based care provided directly by the program, and two helped obtain subsidies for extended-hours care. Four programs used child care subsidy funds to cover a portion of the cost of their Early Head Start centers.

Despite the availability of subsidies, some families still had difficulty paying for child care. In fall 1999, 10 research programs were implementing strategies to prevent interruptions in child care and help parents pay for good-quality child care. Four programs used subsidies to pay for Early Head Start center care but covered the full cost of care with program funds when families experienced interruptions in subsidies. Three programs set aside program funds to help families make co-payments, pay the difference between the provider’s rate and the subsidy rate, and/or pay for child care during gaps in subsidy coverage. Other strategies included funding community child care slots as a last resort for families who could not obtain subsidies, providing extended-hours slots for families who could not obtain subsidies, and using a state grant to pay for community child care.

Another challenge the programs sometimes faced was ensuring good quality in the child care settings that parents selected. Parents sometimes chose care without input from program staff, either because they had to find care quickly when they found a job or because they preferred a familiar arrangement with an informal provider whom they knew and trusted. These informal providers are not always interested in or even willing to work with program staff to assess or improve the quality of care they provide.

F. HEALTH SERVICES FOR CHILDREN

The revised Head Start Program Performance Standards charge programs with ensuring that all children have a regular source of health care and access to the health, dental, and mental health services they need. Programs must also track health services to ensure that children receive all recommended well-child examinations, immunizations, and needed treatments.

By fall 1999, the number of research programs that had fully implemented the health services requirements nearly doubled, from 7 programs in fall 1997 to 13 in fall 1999. Six had reached an enhanced level of implementation—they systematically tracked receipt of well-child examinations, immunizations, and treatment, and children received health services without delay. In fall 1999, four programs were rated as reaching only a moderate level of implementation of child health services. One of the four did not provide adequate access to mental health services. In three of the four, less than 90 percent of children were up-to-date on immunizations and well-child examinations, which indicates that adequate tracking systems were not in place or that program staff had not been able to work effectively with all parents to ensure that they obtained the health services their children needed. In one of these programs, problems with the management information system made it difficult to discern whether immunization rates were low or record-keeping was incomplete.

The research programs took a variety of approaches to ensuring that children received needed health services:

All programs helped families find regular sources of medical care (“medical homes”) for their children, and some helped families navigate their state’s Medicaid managed care system.
Several programs provided mental health services through agency staff and community partners to families who needed it. Some programs provided child mental health services on site at their centers.
Several programs had nurses on staff who provided some health services (especially well-child examinations), tracked receipt of health services, and helped families arrange for services.
One program held special health screening days at its centers and recruited area physicians, dentists, and other specialists to conduct the screenings.
Programs often used the HSFIS and other software packages to track receipt of health care services.
Several programs provided transportation to medical appointments when families needed it.

G. FREQUENCY OF CHILD DEVELOPMENT SERVICES

The performance standards require programs to provide one home visit per week (48 to 52 visits per year) to families receiving home-based services. For center-based services, the performance standards require programs to offer classes at least four days per week, for between 3.5 and 6 hours per day. We rated programs as fully implemented on this dimension if almost all children received child development services at least three times per month (through three completed home or center visits or regular attendance at a center) and parent education at least monthly.5

The number of programs that had reached full implementation of child development services at this frequency increased slightly, from 8 in fall 1997 to 10 in fall 1999. Although they were closer in fall 1999 than in fall 1997 to meeting the requirements for completing planned home visits with home-based families, the research programs continued to struggle with meeting these requirements throughout this period. In fall 1999, 8 out 13 programs providing home-based services reported that home-based families received an average of 3 home visits per month, whereas in fall 1997, the majority reported completing an average of 1 or 2 per month. Only one program reported completing the required four per month in fall 1999, on average. Four programs reported completing an average of two per month (Figure V.6). The research programs worked hard to increase the frequency of completed home visits. Their efforts included:

Conducting home visits during evenings and on weekends to accommodate parents’ schedules (although some programs found that evening visits are difficult because parents are tired and children want to be with their parents exclusively, and that Saturdays are difficult because parents are often busy with chores and errands)
Conducting some home visits with children (and sometimes parents) in their child care settings
Persistently and consistently scheduling home visits and inviting families to program activities
Requiring families to meet with home visitors, and terminating families who do not start meeting with their home visitor within a certain period
Reconfiguring service options so that families in the home-based option were receiving the most appropriate services for their needs
Building children’s enthusiasm for home visit activities and causing them to look forward to visits (children can be powerful agents in engaging parents in home visits)

Along with the frequency of completed home visits, the amount of time typically spent on child development during these visits also determines the intensity of child development services delivered to families receiving home-based Early Head Start services. A focus on child development means that home visitors spent time in activities with the child alone or with the child and parent together, or on parenting education with the parent. Nearly all programs reported that home visitors spent more than half the typical visit on child development (Figure V.7). In the accompanying box, Carla Peterson, a research partner with the Marshalltown, Iowa, program, gives an in-depth analysis of how home visitors spent their time during home visits.

Figure V. 5.5
Looking Closer: Interactions During Home Visits
Carla Peterson
Iowa State University

The Mid-Iowa Community Action, Inc. (MICA) Early Head Start program uses home visits as its primary mode of service delivery. All families work with two professional staff members: a family development specialist (FDS) and a child development specialist (CDS), whose roles are largely described by their titles. MICA’s theory of change, as well as its programmatic resources, are focused on facilitating child development through strengthening parents’ skills for their roles and supporting them in their parenting roles. The families being served in central Iowa are primarily Caucasian, with a few Hispanic families and even fewer of other ethnicities. Most live in small towns or rural areas, and approximately half are single-parent families.

Data to describe the process and content of home visits were collected using the Home Visit Observation Form (HVOF). The HVOF enables the observer to record information simultaneously on three major aspects of the home visit process: (1) interaction partners (parent and child; interventionist and parent; joint interaction with the parent, child, and interventionist; interventionist with another adult; parent with another adult), (2) content of interaction (child’s development, parenting issues, family relationship issues, community resources/referral, parent education/employment), and (3) nature of the interventionist’s interaction (working directly with the child, modeling for the parent, facilitating parent-child interaction, observing an interaction, asking for and/or providing information).

Within each category, data were collapsed across observed visits, and the percentages of overall time spent in each of the various interaction and activity arrangements was calculated. When the CDSs interact with the child, it is generally within the context of joint interactions with the parent and child. However, the parent spends little time interacting directly with the child. The CDSs spend about one-third to half of their time interacting with adults. The interventionists spend time on content areas that are consistent with their roles.

[Looking Closer: Interactions During Home Visits ]

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FIGURE V.6

FREQUENCY OF COMPLETED HOME VISITS IN EARLY HEAD START RESEARCH PROGRAMS FOR FAMILIES RECEIVING HOME-BASED SERVICES
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FIGURE V.7

PERCENTAGE OF TIME TYPICALLY SPENT ON CHILD DEVELOPMENT IN HOME VISITS
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Besides home visits, programs provided parenting education in a variety of settings, including group sessions for parents, group socialization activities, individual meetings or counseling sessions, and daily contacts with parents at Early Head Start centers, as well as through newsletters, resource libraries, and journal writing (Figure V.8).

H. SERVICES FOR CHILDREN WITH DISABILITIES

The revised Head Start Program Performance Standards require programs to refer families to Part C when they suspect a child has a disability. Staff must also work closely with the Part C provider to coordinate services, and the performance standards encourage them to develop joint service plans whenever appropriate. At least 10 percent of enrolled families must have a child with an identified disability. We rated programs as fully implemented in this area if (1) they referred families to Part C providers and followed up with families promptly, (2) they worked closely with Part C staff to coordinate services, and (3) at least 10 percent of enrolled families had a child with an identified disability (or the program made vigorous efforts to recruit children with disabilities).(6 ,7)

By fall 1999, 12 of the 17 research programs had fully implemented services for children with disabilities (Figure V.3). Strategies for coordinating with Part C included:

Developing joint service plans
Arranging therapy services to be provided in Early Head Start classrooms
Arranging for Early Head Start staff to serve as the service coordinator for Individual Family Service Plans (IFSPs)
Participating with parents and Part C providers in service coordination meetings
Forming Special Quest teams with local Part C providers to work on enhancing coordination between the two programs8

FIGURE V.8

STRATEGIES BEYOND HOME VISITING USED BY EARLY HEAD START RESEARCH PROGRAMS TO PROVIDE PARENTING EDUCATION
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I. SUMMARY

Between fall 1997 and fall 1999, the research programs made substantial progress in implementing the key aspects of the revised Head Start Program Performance Standards that we examined. Although implementing several aspects of child development services continued to present challenges to many of the programs (especially achieving good attendance at group socializations and ensuring good-quality child care for families receiving home-based services), most programs achieved a rating of “full implementation” for other aspects of child development services. The pathways that programs took as they progressed toward full implementation are examined in Chapter X.

1Throughout this chapter we quote appropriate sections of the standards. For the complete performance standards, go to http://www.acf.hhs.gov/programs/hsb/performance/index.htm. (back)

2Although nearly all the programs improved their implementation of child development and health services between 1997 and 1999, clarifications in program guidance from the Head Start Bureau led us to revise the rating scales in this area, so that, in effect, the “bar” for full implementation was raised between 1997 and 1999. Most notably, the 1999 rating scales require a higher number of completed home visits per month for a rating of “fully implemented” on that dimension and require that most families participate in group socializations regularly to attain a “fully implemented” rating on that dimension. See Appendix Table A.1 for a detailed description of the changes in the rating scales between 1997 and 1999.(back)

3The addition of the requirement of regular participation by most families for a rating of “fully implemented” was based on the researchers’ judgments, not a change in the requirements in the revised Head Start Program Performance Standards.(back)

4Between 1997 and 1999, the child care implementation rating scale changed in several ways. First, we added consideration of the quality of care provided by Early Head Start centers, with a rating of “full implementation” requiring the provision of good-quality care. For a rating of “full implementation,” we added two requirements: (1) that if families use child care subsidies, there must not be interruptions in child care services; and (2) that most children must be in care that the program assesses and monitors to ensure that it meets the performance standards.(back)

5This rating was designed to help us assess whether most children and families were receiving services of sufficient intensity to have an impact on child development. The frequency of child development services required for a rating of “fully implemented” was raised from two completed home visits per month in the 1997 rating scale to at least three completed home visits per month in the 1999 rating scale to reflect the Head Start Bureau’s increased emphasis on completing the number of visits required in the performance standards. For the evaluation’s purposes, we set the requirement for being “fully implemented” lower than the four per month of the performance standards based on input from consultants suggesting that three per month is more realistic.(back)

6This rating was included together with the rating of developmental assessments in the 1997 rating scales. Therefore, there was no separate rating of this aspect of child development services in 1997.(back)

7Part C providers are agencies designated under Part C of the Individual with Disabilities Education Act (IDEA) Amendments of 1997 (PL 105-17) to be responsible for ensuring that services are provided to all children with disabilities between birth and age 2.(back)

8Special Quest joined the Head Start training and technical assistance system this year as the Hilton/Early Head Start Training Program. This program, a public/private partnership between the Conrad N. Hilton Foundation and the Head Start Bureau, is administered by the California Institute on Human Services at Sonoma State University. Its mission is to help professionals and family members involved in Early Head Start and Migrant Head Start programs develop skills and strategies for working with infants and toddlers who have significant disabilities.(back)

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