1. Laying the Groundwork in Policy and Practice: The Massachusetts Early Childhood Linkage Initiative Laying the Groundwork in Policy and Practice: The Massachusetts Early Childhood Linkage Initiative Children and Family Futures February 1, 2007 Institute for Health and Recovery The Heller School, Brandeis University

2. Laying the Groundwork in Policy and Practice Science-based policy for young children Effective implementation Collaboration Evidence-based practice Appropriate resources: funding, expertise

3. Who We Are Katharine Thomas, Assistant Director, Institute for Health and Recovery (IHR), since 2006…2001-2006, Policy Director, Part C Early Intervention, MA DPH…1991-2001, Systems Developer at IHR John Lippitt, Ph.D, Project Director, Identification and Treatment of Infants and Families (MA DPH), since 2006…2003-2006, Senior Research Associate, Heller School for Social Policy and Management, Brandeis University, Waltham, MA

4. Institute for Health and Recovery State resource for development of family focused substance abuse services History of systems work with providers, communities, state agencies Outside agency: ability to transcend perceived “turf” issues Inside agency: partner with state agencies as “arm” for specialized services

5. Institute for Health and Recovery: Core Principles Establish collaborative models of service delivery Integrate gender-specific, trauma- informed, and relational/cultural models Foster family-centered, strengths-based approaches: support resiliency Advance multicultural competency within service delivery

6. Institute for Health and Recovery 1989: Federal grant: integrate parenting support and skill-building into women’s residential substance abuse treatment 1990: Contract: state Bureau of Substance Abuse Services to build capacity in women’s SA treatment system 1994: Manage central access to Family Residential Programs

7. Institute for Health and Recovery Tobacco addiction education/policy WELL Project: Integrate substance abuse, mental health, and trauma services for women and their children WELL Child: Curriculum developed to build resilience in children of substance abusers

8. Massachusetts Department of Public Health ….“To promote healthy people, healthy families, healthy communities and healthy environments through compassionate care, education and prevention”…. Lead Agency in MA for Part C Early Intervention Services

9. Early Intervention (EI) in Massachusetts MA Department of Public Health (MDPH) Bureau of Family and Community Health Division for Perinatal, Early Childhood and Special Health Needs (DPECSHN)

10. EI Program History in MA Early 70’s: EI system in clinical settings, DMH/DMR 1983: MGL 111G 1985: EI Medicaid reimbursement begins 1986: Individuals with Disabilities Education Act, reauthorized in 1997 1990: Legislation mandating private insurance coverage of EI

11. EI Program History in MA (continued) 2001: Insurance legislation revised to include reimbursement for developmental specialists (aka early childhood educators) 2004: Annual insurance cap increased from $3200-$5200 2004: IDEA re-authorized, adds language regarding specific populations

12. MA General Law (MGL) Chapter 111G, 1983 Named DPH as Lead Agency Ensured universal access to EI Specified inclusion of staff of different disciplines Provided EI option to children with established, environmental, and biological risk

13. EI In Massachusetts: 3 Broad Categories Established Condition / Diagnosis Developmental Delay (25% in one domain) At Risk (optional category for states): 4 of 20 risk factors, including CW case, SA, DV, homeless, lacking social supports MA serves highest percentage of birth to three-year-olds nationally

14. Child Well-Being and Development “From Neurons to Neighborhoods” Published in 2000 National Research Council / Institute of Medicine Jack Shonkoff Deborah Phillips

15. Child Well-Being and Development TOXIC STRESS in early childhood Strong, frequent or prolonged activation of body’s stress management system Impacts brain architecture particularly in the absence of nurturing parent or caregiver Distinguished from: Positive stress: moderate, short-lived; normal part of life; essential to healthy development Tolerable stress: significant but infrequent; nurturing parent or caregiver helps child feel safe; calms stress response

16. Child Well-Being and Development Neurons to Neighborhoods Recommendation: “…require that all children who are referred to a protective services agency for evaluation of suspected abuse or neglect be automatically referred for a developmental-behavioral screening under Part C of the Individuals with Disabilities Education Act.”

17. Child Well-Being and Development Child safety, health, and all the developmental domains are inextricably intertwined Nurturing relationship with parents or other key caregivers is essential to safety and development Child maltreatment and parental SA put both safety and development at high risk

18. Young Children at Risk Lack of resources, substance abuse, mental health, family violence, and increased family stress impact child development: Physical (motor challenges, unsafe spaces) Social-emotional ( insecure attachment, behavior, low self-esteem) Cognitive (lack of appropriate stimulation, fears/worries may affect ability to focus) Communication (limited or inappropriate language stimulation/interaction) Adaptive (inability to develop needed independence and skills for self-care)

19. Massachusetts Early Childhood Linkage Initiative (MECLI) MECLI MA DSS MA DPH LOCAL EI Programs HELLER SCHOOL Brandeis University

20. MECLI Overview Goal: Refer all young children under three years of age involved with a newly substantiated case of child abuse or neglect to EI 3 Pilot sites in MA, Nov. 2002 – Dec. 2004 Both CW and EI were supportive Robust EI system able to handle referrals The MECLI project was funded by the U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau; The A.L. Mailman Family Foundation; The Annie E. Casey Foundation; and The Frank and Theresa Caplan Endowment for Early Childhood and Parenting Education at The Heller School for Social Policy and Management, Brandeis University. We thank these organizations for their support but acknowledge that the findings and conclusions presented in this report are those of the author(s) alone and do not necessarily reflect the opinions of these organizations.

21. MECLI Goals Support referrals through local collaborations (EI Programs and DSS Area Offices) Anticipate CAPTA/IDEA requirements to refer children from CW to EI services Collect data on offering of referral at CW and engagement in EI

22. MECLI Goals (continued) Collect data on EI eligibility and services Enhance understanding of impact of bio- psycho-social factors on young children’s development Identify strategies to engage and serve children/families

23. MECLI Results 540 children offered referral to EI 18% of parents refused the referral (99) 19% of families referred did not engage with EI (103) 40% of children were assessed (218)

24. MECLI Results (continued) 74% of children assessed were eligible (161/218) under MA broad eligibility criteria 49% had an eligible delay (107/218) 17% eligible due to 4 of 20 risk factors (37/218) 1% eligible by established condition or clinical judgment 6% eligibility criterion unknown

25. CAPTA, June 2003 New Language Highlights The Keeping Children and Families Safe Act reauthorizes CAPTA, requires states to establish: “provisions and procedures for referral of a child under the age of 3 who is involved in a substantiated case of child abuse or neglect to early intervention services funded under Part C of the Individuals with Disabilities Education Act” AND

26. CAPTA, June 2003 New Language Highlights “policies and procedures … to address the needs of infants born and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure, including a requirement that health care providers involved in the delivery or care of such infants notify the child protective services system … [and] the development of a plan of safe care for the infant”

27. IDEA, December 2004 New Language Highlights “a description of the State policies and procedures that require the referral for early intervention under this part of a child under the age of 3 who “(A) is involved in a substantiated case of abuse or neglect; or “(B) is identified as affected by illegal substance abuse, or withdrawal symptoms resulting from prenatal drug exposure;” “…..premature infants, or infants with other physical risk factors associated with learning or developmental complications….” “…underserved groups, including minority, low-income, homeless, and rural families and children with disabilities who are wards of the State…”

28. ACF-Funded Projects 2005 Model Development or Replication to Implement the CAPTA Requirement to Identify and Serve Substance Exposed Newborns (CFDA # 93.551) Denver Department of Human Services, Denver, CO University of Oregon, Office of Research Services and Administration, Eugene, OR Saint Vincent Mercy Medical Center, Toledo, OH Department of Public Health, Boston, MA

29. Substance Exposed Newborns A combination of bio-medical and environmental conditions Demonstration project builds on MECLI Uses 2 of 3 pilot sites Builds on inter-agency relationships Adds SA and other services to MECLI collaboration

30. Substance Exposed Newborns (continued) Identification and Treatment for substance exposed Infants and their Families (ITIF) A Helping Hand: Mother to Mother The Family Support Specialist: a peer mentor, support, & advocate Enhanced care coordination at CW Use one-time grant funding to do pilot to work toward full implementation

31. Systems Change Begin by Identifying: Barriers/Gaps Common values Common goals based on values Key resources system wide Stakeholders Key resources

32. Conclusions CW and SA treatment need to build linkages with developmental services Family-centered and strengths-based to engage and motivate parents AND keep families together Build collaborations for comprehensive, coordinated services

33. Conclusions (continued) Part C Early Intervention for children from birth to 3 rd birthday Part C EI needs resources: funding and enhanced expertise Part C systems’ roles and eligibility criteria vary by state Part C eligibility should address key environmental conditions

34. Conclusions (continued) Some environmental conditions present similar likelihood of developmental problems as bio-medical conditions: Child abuse or neglect Parental substance abuse Parental mental health problems, especially maternal depression Intimate partner violence

35. Conclusions (continued) WE MUST ADDRESS: Turf issues Differing systems characteristics, including eligibility and policies Resources Together we CAN do a better job of supporting child well-being including safety and healthy development, which are key to good family outcomes

36. Institute for Health and Recovery (IHR) Katharine Thomas 349 Broadway Cambridge, MA 02139 Ph 617.661.3991 Fax 617.661.7277 Email: Email: katharinethomas@healthrecovery.orgkatharinethomas@healthrecovery.orgwww.healthrecovery.org

37. Massachusetts Department of Public Health John Lippitt 250 Washington Street, 5 th Floor Boston, MA 02108 Ph 617.624.6017 Fax 617.624.5990 Email: Email: John.Lippitt@state.ma.uswww.mass.gov/dph/fch