Developmental and Behavioral Screenings

UPDATE: A final rule based on the Child Care and Development Block Grant Act of 2014 (PDF) was published on September 30, 2016. See 45 CFR 98.33(c) regarding developmental and behavioral screenings.

To                

State, territorial, and tribal lead agencies administering child care programs under the Child Care and Development Block Grant (CCDBG) Act, as amended, and other interested parties.

Subject

Provisions in the CCDBG Act of 2014 related to developmental and behavioral screenings in child care and afterschool care programs, and potential policies for implementation.

References

The CCDBG Act of 1990, as amended, 42 U.S.C. § 9858 et seq., as further amended by the CCDBG Act of 2014, Pub. L. No. 113-186; Patient Protection and Affordable Care Act of 2010; Social Security Act, Title XIX; Birth to 5: Watch Me Thrive!; Head Start Performance Standards; Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education Settings; Race to the Top-Early Learning Challenge; Early Educator Central; Learn the Signs, Act Early.

Purpose

To encourage lead agencies to adopt policies to promote developmental screenings in child care programs.  States should consider these recommendations as they prepare their Child Care and Development Fund (CCDF) state plans.

Background

The CCDF provides funding to states, territories, and tribes to support low-income working families through child care assistance for children from birth through age 13.  CCDF also promotes children’s healthy development and learning by supporting child care licensing, quality improvements systems to help programs meet higher standards, and child care workers to attain more training and education.  With bipartisan support, the CCDBG Act of 2014 reauthorized CCDF and made expansive changes focused on improving the health and safety of children in child care, improving subsidy policy for families and providers, promoting consumer education, and improving the overall quality of programs.  Congress amended the purposes of the new law, including “to encourage states to provide consumer education information to help parents make informed choices about child care services and to promote involvement by parents and family members in the development of their children in child care settings.”    

Specifically, the CCDBG Act of 2014 requires states to provide consumer education information to families, the general public, and providers, where applicable, regarding developmental screenings.  States must provide information on existing resources and services to support developmental screenings and providing referrals to services, including the use of Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) under Medicaid as well as section 619 and part C of the Individuals with Disabilities Education Act.  In addition, states must provide a description of how families or eligible child care providers may use resources for children who may be at risk for developmental delays, which may include cognitive, social, emotional, physical, and linguistic delays.  These requirements will raise awareness of child development and developmental milestones as well as contribute to the early detection of developmental delays in order for interventions to be most effective.

Neuroscientists confirm that the first 5 years of a child’s life are critical for building the early foundations of learning, health, and wellness needed for success in school and later in life.^[1]  Starting at birth and continuing throughout childhood, children reach milestones in how they play, learn, speak, act, and move.  Skills such as taking a first step, smiling for the first time, and waving "bye-bye" are examples of developmental milestones. Because children develop at their own pace, it can be difficult to predict exactly when a child will learn a given skill.  However, developmental milestones give a general idea of the changes to expect as a child gets older.  Developmental and behavioral screening plays an important role in early detection and an opportunity to provide appropriate supports for children who may be experiencing delays or challenges for any number of reasons.  Recent statistics indicate that as many as 1 in 4 children aged 0 to 5 years is at moderate or high risk for developmental, behavioral, or social delay.^[2]

Child care providers watch and nurture the development of children in their care and may be the first to observe potential delays or challenges.  In 2011, approximately 13 million children under the age of 5 were in some type of child care arrangement for an average of 33 hours a week.^[3]  Because child care providers are well-positioned to watch and support children as they develop, they play a key role in administering developmental and behavioral screenings and supporting families as they celebrate developmental milestones, identify potential delays and challenges, and seek additional support.

Guidance

The Administration for Children and Families (ACF) encourages lead agencies to consider opportunities to work toward universal access to developmental screenings in child care settings in implementing the CCDBG Act of 2014. The following policies and practices can help states, territories, and tribes in engaging families in developmental screening and celebrating developmental milestones; building workforce capacity; disseminating existing resources to support outreach efforts; implementing universal developmental and behavioral screening; strengthening licensing and quality rating improvement systems; and supporting the enrollment of families in health insurance.  These examples are not a required checklist, but rather a menu of options and models that lead agencies should consider when developing state plans to implement the consumer education and family engagement provisions in the law.  

Provide Information to Engage Families and Providers in Developmental Screening and Celebrating Milestones:  The CCDBG Act requires states to provide consumer and provider education about policies regarding developmental screenings for children at risk of cognitive or developmental delays.  Child care providers should discuss healthy development with all families in culturally and linguistically appropriate ways on a regular basis.  Regular screenings help raise awareness of a child’s development, making it easier to expect and celebrate developmental milestones.  The Centers for Disease Control and Prevention’s (CDC) Learn the Signs, Act Early is an initiative to improve early identification of children with autism and other developmental disabilities so that children and families can get the services and support they need.  The CDC has developed tools and resources to help families keep track of their child’s development and get help if concerns arise.

Child care providers should also encourage families to talk to their primary health care provider about their child’s development at every well child visit.  In the state of New Mexico, New Mexico Project LAUNCH partnered with Envision New Mexico and Parents Reaching Out to print and distribute developmental screening record booklets in English and Spanish.  Created by a developmental-behavioral pediatrician, these booklets act as a guide for parents to follow and talk about their child’s development with his or her primary health care provider.  The New Mexico booklets have been used by other states as a template for their own developmental screening passports.  More than 15,000 booklets have been distributed by multiple organizations throughout the state.  The Watch Me Thrive! Developmental Screening Passport (PDF) is a similar tool for parents to keep track of their child’s screening history and results.

Build Workforce Capacity:  The CCDBG Act of 2014 requires states to establish training and professional development requirements that enable child care providers to promote the social, emotional, physical, and cognitive development of children served by CCDF.  Ongoing training that provides a progression of professional development must reflect current research and best practices necessary for the workforce to meet the developmental needs of children.  The law also provides that states may use CCDF quality funds for providing training and outreach on engaging parents and families in culturally and linguistically appropriate ways.  For example, child care providers may need appropriate training and support to administer developmental screening instruments and support families as they learn more about their child’s development.  To improve the quality of child care services, states may use the CCDBG quality set-aside to fund the training and professional development of the child care workforce.  States may choose to:

• Strengthen Workforce Preparation Programs:  States should ensure that early childhood educator preparation programs, or other trainings, incorporate the latest research-informed content on child development, family engagement, developmental screenings and referrals to specialized services, and positive behavioral guidance.  Training should provide ample opportunities to apply lessons learned through practicum experiences.

• Enhance Entry Level Personnel Requirements and Credentials:  Many states have established their own entry-level early childhood staff requirements, which may include credentials and postsecondary degrees.  States could require that staff have demonstrated competencies in social and emotional development, early childhood development, and meaningful parent and family engagement, and include training and professional development in such competencies with entry-level and more experienced staff. 

• Require Pre-Service and In-Service Professional Development on Child Development as well as Developmental and Behavioral Screening Practices:  States should ensure that early childhood providers have opportunities for continuous professional development (through training, coursework, coaching, and mentoring) that includes the knowledge and skills to enhance children’s social-emotional and behavioral health, positive behavior management, and referrals to screening assessments as appropriate.

Early Educator Central is a new effort jointly administered by the Offices of Child Care and Head Start at ACF.  The project promotes infant-toddler educators gaining degrees and credentials using existing federally funded resources.  The site has many exciting resources, including the CDC free online training, Watch Me! Celebrating Milestones and Concerns .  In this 1-hour, 4-module course, early educators learn why monitoring children’s development is important; why early educators have a unique and important role in developmental monitoring; how easy it is to monitor each child’s developmental milestones; and how to talk with parents about their child’s development.  Continuing education units may be available depending on state requirements.  The CDC has been approved as an Authorized Provider by the International Association for Continuing Education and Training.

Disseminate Existing Resources to Support Child Care Providers in Developmental Screening, Monitoring, and Family Outreach:  Lead agencies can leverage federal resources to provide consumer education and family engagement resources via states’ service systems that work with parents of young children seeking or in child care, including state subsidy staff, child care resource and referral agencies, parent associations, local early childhood advisory councils, and other existing state networks.  Research shows roughly 4 million child care providers see parents every day and are well situated to be trusted resources of support and information for parents on opportunities to promote their child’s development.  Combining the love and knowledge families have of their children with tools, guidance, and tips recommended by experts can make the most of the developmental support children receive.

Complementing and supporting professional development and community outreach efforts, the U.S. Departments of Health and Human Services and Education launched Birth to 5: Watch Me Thrive!, a coordinated federal effort to encourage healthy child development, universal developmental and behavioral screening for children, and support for the families and providers who care for them.  The public campaign helps families and providers to (1) celebrate milestones, (2) promote universal screening, (3) identify possible delays, and (4) to enhance developmental supports.

Birth to 5: Watch Me Thrive! draws heavily on previous developmental and behavioral screening efforts by consolidating free, publicly available materials from a wide array of federal agencies and their non-federal partners.  For example, ACF created a compendium of research-based developmental screening tools appropriate for use with children under the age of 5 across a wide range of settings, including early care and education.  Child care providers can use this reference to learn cost, administration time, quality level, training required, and age range covered for each screening tool.  In addition, a tailored guide for early care and education providers is available that addresses the importance of developmental and behavioral screening, how to talk to families, where to go for help, and how to select the most appropriate screening tool for the population served.

The Race to the Top — Early Learning Challenge (RTT-ELC) is designed to improve the quality of early learning and development programs for young children.  Some states receiving the grant chose to focus on identifying and addressing the health, behavioral, and developmental needs of children to improve school readiness.  Based on the work of Birth to 5: Watch Me Thrive!, California used RTT-ELC funding to create developmental screening toolkits and train-the-trainer sessions on the Ages and Stages Questionnaire (ASQ) and ASQ-Social Emotional as well as using screening results to access appropriate services.  Targeted, county-level technical assistance plans were put into action to better focus trainings to meet provider needs.

Build Local Program Capacity to Provide Comprehensive Services by Partnering with Community Partners:  ACF has awarded $500 million for Early Head Start-Child Care (EHS-CC) Partnerships.  These awards will enable new or existing Early Head Start programs to partner with local child care centers and family child care providers serving infants and toddlers from low-income families.  EHS-CC Partnerships will support working families by providing a full-day, full-year program so that low-income children have the healthy and enriching early experiences they need to realize their full potential.

Early Head Start programs provide comprehensive services that benefit children, families, and teachers, including health, developmental, and behavioral screenings; higher health, safety, and nutrition standards; increased professional development opportunities for teachers; and increased parent engagement opportunities.  States may choose to leverage and expand upon new EHS-CC Partnerships with CCDBG funding to build the capacity of local Early Head Start and Head Start grantees to enhance family engagement and developmental screening activities by partnering with child care settings in their communities.  For example, states could provide funding for grantees to manage and hire additional family service workers and health managers that work with child care partners.

Developmental screening initiatives are most effective when coordinated across systems, programs, and agencies.  Within the health and early learning sectors, many states and communities are working together to raise awareness of early child development, positive parenting practices, parents as first teachers, and the importance of developmental screening for all.  The Birth to 5: Watch Me Thrive! Guide for Communities (PDF) is one resource that can provide strategies to build a unified system for ensuring that all children develop in a healthy way and reach their full potential.

Strengthen Licensing and Quality Rating Improvement Systems to Support Universal Screening:  Currently, 19 states have quality standards as part of their Quality Rating Improvement Systems (QRIS) that address developmental screening.  Under the Act, states may use CCDF quality improvement funds both for developing, implementing, or enhancing a QRIS, and for developing or implementing early learning guidelines.  States may choose to use the recently released Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education (PDF) to improve health and safety standards in licensing and QRIS.  Caring for Our Children Basics represents the minimum health and safety standards experts believe should be in place where children are cared for outside of their homes.  Standards regarding programmatic activities to support the healthy development of children, including developmental and behavioral screening, are discussed.

New state policies in Oregon have extended the practice of developmental screening to child care providers with the implementation of Oregon’s QRIS.  For example, a 3-star quality rated program conducts a developmental screening, using the ASQ, within 45 days of when the child enters the programs and on an annual basis in order to refer children for specialized assessment when indicated.  Oregon has leveraged state and local resources that include Project LAUNCH; Early Childhood Comprehensive Systems; State Innovation Model; Maternal, Infant, and Early Childhood Home Visiting; RTT-ELC; and the Title V Maternal and Child Health Block Grant to support implementation of screening, monitoring, referral, and follow-up with greater coordination between early learning and health efforts.  They have recently developed shared guidelines for developmental screening that aligns their state-wide developmental screening training curriculum for early care and education providers, home visitors, and other early childhood professionals with QRIS.

Take Advantage of Opportunities to Support Preventive Screenings and Child Well-Being under Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act:

• Encourage Enrollment in Health Insurance:  Children who receive CCDF subsidies may qualify for free or low-cost health insurance coverage through Medicaid and the Children’s Health Insurance Program (CHIP) .  Depending on the state, many parents and child care providers may be eligible for Medicaid, too.  Medicaid and CHIP are examples of two public coverage options that support developmental screening, referral, and follow-up.  Medicaid requires states to provide developmental and behavioral screening, vision, hearing, dental, and other necessary health care services at regular intervals, based on state-specific periodicity schedules, under EPSDT.  CHIP programs may also cover screening services, including developmental and behavioral screening.  CHIP programs are required to cover well-baby and well-child health care services that follow a periodicity schedule determined by the state Medicaid agency.

For children and adults who are not eligible for public health insurance, the Affordable Care Act (ACA) has provided new opportunities for Americans to obtain affordable health insurance under a qualified health plan in the Marketplace , regardless of income, job, age, or health status.  All children and families have access to preventive care without a copayment or coinsurance as part of their private insurance plan, even if the yearly deductible has not been met.  Children’s preventive health coverage includes services like vision, hearing, developmental, behavioral, and autism screenings.

As previously discussed, the CCDBG Act of 2014 requires states to provide consumer education information to families, the general public, and providers, where applicable, regarding existing resources and services to support developmental screenings and providing referrals to services, including the use of EPSDT under Medicaid.  To learn more about Medicaid and CHIP, please visit www.medicaid.gov .  For helpful resources from the Insure Kids Now campaign, please visit www.insurekidsnow.gov .  For more information on essential benefits covered under the ACA, please visit www.healthcare.gov .

To learn more about what early care and education providers can do to support families in obtaining health care coverage, please visit the Early Childhood Development website.

• Partner with State Medicaid Agencies:  Lead child care agencies may consider partnering with State Medicaid Agencies to explore the Express Lane Eligibility and/or presumptive eligibility options as a strategy to make it easier for children who are eligible for Medicaid or CHIP to have their eligibility determined or renewed.  In order for Express Lane Eligibility or presumptive eligibility options to be implemented at the local program level, the State Medicaid Agency must elect to provide Express Lane Eligibility or presumptive eligibility for children in Medicaid and/or CHIP.

Express Lane Eligibility permits states to rely on findings for eligibility factors like income, household size, or other factors of eligibility from another program designated as an Express Lane agency, to facilitate enrollment in health coverage.  Express Lane agencies may include Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Special Supplemental Nutrition Program for Women, Infant, and Children (WIC), Head Start, and child care under CCDBG, among others.  State, territorial, and tribal lead agencies administering child care programs may also be eligible to become an Express Lane agency.  For more information about how states are implementing Express Lane Eligibility and learn about requirements for participation, please visit the Express Lane Eligibility for Medicaid and CHIP Coverage page of the Medicaid website .

Child care programs can play an important role in finding and enrolling uninsured children through presumptive eligibility.  State Medicaid Agencies can authorize “qualified entities” — health care providers, community-based organizations, and schools, among others — to screen for Medicaid and CHIP eligibility and immediately enroll children who appear to be eligible.  Presumptive eligibility allows children to get access to Medicaid or CHIP services without having to wait for their application to be fully processed.  Qualified entities can also help families gather the documents needed to complete the full application process, thereby reducing the administrative burden on State Medicaid Agencies to obtain missing information.  For more information about presumptive eligibility and which states are currently implementing this enrollment option, please visit the Presumptive Eligibility for Medicaid and CHIP Coverage page of the Medicaid website .

Finally, lead child care agencies may choose to work with State Medicaid Agencies to create one simplified application for CCDF subsidy and Medicaid or CHIP receipt.  The CCDBG Act of 2014 establishes a minimum 12-month eligibility re-determination period for CCDF families, regardless of changes in income (as long as income does not exceed the federal threshold of 85 percent of state median income) or temporary changes in participation in work, training, or education activities.  Similarly, states may provide children with 12 months of continuous health care coverage through Medicaid and CHIP, even if the family's income changes during the year.  Guaranteeing ongoing coverage ensures that children get appropriate care as well as needed screenings, and helps doctors develop relationships with children and their families.  Continuous eligibility eliminates cycling on and off of coverage during the year.  This also reduces state time and money that would be spent on unnecessary paperwork and preventable care needs.  For more information on about continuous enrollment and which states are currently implementing this enrollment option, please visit the Continuous Eligibility for Medicaid and CHIP Coverage page of the Medicaid website.

/s/
  _________________________
Rachel Schumacher
Director
Office of Child Care