BUILD Arizona Initiative

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1 Intervening Early in Arizona BUILD Arizona Initiative by Charles Bruner May 2013 BUILD Arizona is a coalition of children s champions who are working together to enhance opportunities for all young children in Arizona, so that they can meet our state s increasingly rigorous educational standards and become productive members of the workforce. Specifically, we are supporting the continued development of a coordinated system of programs, policies and services that responds to the needs of families. We are business leaders, nonprofit executives, public sector representatives, educators, health and other practitioners working toward the shared goal of making and keeping Arizona competitive in the years ahead. BUILD Arizona s longest term goals are: All children, by age 5, have a solid foundation for success in school and in life. All children read on/at the highest grade level, based on their ability and development, by the end of third grade (age 8). To reach these goals for children, BUILD Arizona is working toward the following long-term system outcomes: Arizona has a culture that supports early childhood as a critical component of the state s education continuum. Arizona s early childhood system is coordinated, integrated and meets the comprehensive needs of children and families. Arizona makes adequate and sustained investments in proven health, development and early learning supports for children ages birth through 8. As a first step toward these outcomes, BUILD AZ has identified a series of recommendations and incremental steps in four key priority areas including Children s Health, Quality Early Learning, Early Grade Success and Professional Development. The following brief provides background on the area of Children s Health and the key elements our state needs to build on and strengthen to ensure a solid foundation for success for all young children and a promising future for Arizona. To ensure Arizona s children are prepared to be successful in the global workforce of the future, BUILD Arizona has identified the following high level recommendations in the area of Children s Health Early Screening, Referral and Intervention to enhance Arizona s ability to meet the developmental needs of all children: 1. Inventory and map the array of early intervention services currently available to children 0-5 who are at risk of developmental delay. 2. Develop a data system with the ability to share information and track child progress and outcomes on relevant developmental indicators. 3. Identify financing mechanisms for early intervention services and maximize opportunities for coordination and leverage. 4. Support efforts to increase access to and use of developmental screenings, with particular attention to and building on opportunities available within the Affordable Health Care Act. 5. Identify, support and diffuse exemplary practices in care coordination and service provision. 6. Educate the broader community around impacts and long term outcomes of intervening early. 7. Support efforts to sustain and integrate home visiting programs as a core element of a statewide early intervention system. 1

2 Failure to respond to child hearing difficulties in infancy is known to affect not only speech development but future cognitive and social development. A growing body of literature shows that intervening early establishes a higher trajectory of development with implications to success in school and social and emotional development. For all children to enter school ready to learn and to be reading by the end of third grade requires early identification and response to physical and emotional-behavioral conditions. Definition of Need: Why Intervening Early Is Key The first years of life are ones of rapid growth and development, where both the child s environment and the child s constitution (nature and nurture) play critical roles. Intervening early means identifying child-specific conditions and family- and community-vulnerabilities which affect healthy development and responding to these conditions and vulnerabilities in ways which address those specific needs and improve the trajectory of child health. This involves both needs identified specific to the child and needs identified regarding the family and environment and requires responses which support inclusion and normative development to the extent feasible. Identification and response to children s specific physical and emotional-behavioral conditions such as speech delays, hearing difficulties, and autism spectral disorder are most effective when they occur very early in life. National studies show that one in eight very young children (six months to two years old) has an identifiable learning disability or delay, most of which can be responded to very effectively. National studies also show that between one in seven to one in five young children (two to five years old) have emotional or behavioral conditions, including AD/HD, autism spectral disorder, and depression/anxiety disorder, which are amenable to treatment and response. The same holds regarding the identification and response to environmental conditions which affect child development. All young children need consistent and continuous nurturing from and bonding with their parent(s) or primary caregiver, which also shapes their physical, emotional, and social development. Particularly in the first years of life, where brain growth is most rapid and hard-wiring occurs regarding basic responses, strengthening the protective factors around the family is critical. Family stress, parental depression, lack of parental knowledge of child development, and other social determinants adversely affect child development. When there is toxic stress, the impacts can be profound. Identification and response here can begin even before the birth of the child and involves strengthening protective factors in the family which support consistent nurturing. This can include home visiting, care coordination which connects families up to community supports, and both professional and community counseling and parent education which do not require a diagnosis of a specific child condition but can be powerful in preventing such conditions and improving the child s growth trajectory. Children grow and develop through a serve and return system of interactions with their parents and this ultimately affects their overall bio-physical make-up. Again, providing a good start in a nurturing home is one of the most essential conditions to ensuring that children enter school ready to succeed and are reading by the end of third grade. 2 Intervening Early in Arizona BUILD Arizona Initiative

3 What Success Looks Like Optimally, there would be an integrated system of services and supports for young children and their families which identify and respond to both child conditions and family vulnerabilities in ways that minimize children s difficulties with learning and development and avoid exclusion from normative developmental activities. This would result in much higher levels of school readiness, early elementary success (including third grade literacy), and overall social, emotional, and educational advancement. From a systems perspective, success would involve, for children living throughout the state, the following five general components: 1. Early identification (through screening and surveillance) of both child and family needs; 2. Professional, evidenced-based service responses to identified child needs (through medical, educational, and other treatment services); 3. Professional, evidenced-based responses to identified family vulnerabilities which strengthen families to provide consistent nurturing and avoid toxic stress (through treating parental depression and stress and adversity, providing individual/parentchild dyadic and group counseling and therapeutic interventions, and stabilizing families); 4. Community responses to strengthen protective factors related to social development and education (making family support, home visiting, parenting education, and peer support available for those who need and want it), and 5. Ongoing engagement to ensure continuing responses and improvement (through care coordination, targeted case management, and family advocacy). Optimally, all children would be screened for developmental delays or disabilities and for emotionalbehavioral concerns as part of well-child visits. Such screening can be covered under Medicaid and it is Optimally, all children would be screened for developmental delays or disabilities and for emotional-behavioral concerns as part of well-child visits. now required that preventive services for children be provided without co-payments through all private insurance coverage, based upon Bright Futures, a set of comprehensive guidelines for providing such primary and developmental health screenings and guidance to parents. These screens would lead to appropriate responses to address identified conditions in the child. Further, formal child care and preschool programs would be equipped to engage in similar developmental screening and surveillance, with staff trained regarding identifying developmental and mental health concerns and issues and providing appropriate responses to them. Many of the services to address children s identified developmental delays would be provided under Arizona s Early Identification Program (AZEIP also referred to as Part C of the federal Individuals with Disabilities Education Act/IDEA), and there would be established protocols and practices to ensure appropriate and effective referrals to AZEIP and to other community services and supports that can contribute to healthy development. Further, there would be early identification, ideally initiated during pregnancy but at least at the birth of the child, which would identify families most likely to struggle providing a nurturing home environment for their children, with engagement of those families through care coordination and home visiting to strengthen those families and the protective factors around the child. Success would include far fewer children starting school with undiagnosed health and development conditions, much more equipped for success in school across the five domains of school readiness, and much more likely to progress in school and meet, among other sentinel markers, proficiency in literacy by the end of third grade. Families overall would be more engaged with their children, and productivity in the early elementary classrooms would improve, with fewer children requiring attention for social and behavioral concerns and fewer children being involved in special education. 3

4 Where Arizona Stands Today Currently, Arizona expends its largest share of resources in the early elementary years on children with very significant health conditions or family vulnerabilities, through its developmental disability and child welfare systems. These children constitute less than 2% of all Arizona children but represent a very considerable share of all program expenditures (and needs for intensive and long-term intervention). Arizona has far fewer services available to serve the much larger group of children with diagnosable needs which do not fall into this highest category of severity, however, with AZEIP for infants and toddlers and special education services under Part B of IDEA for preschoolers being the most often recognized services. Arizona also has a number of exemplary programs which screen children for developmental needs, link those children and their families to services, and provide ongoing support both through care coordination and home visiting. These usually are provided on a demonstration and site-specific basis and not incorporated into routine or mainstream practice or available throughout the state, however. Even compared with other states, Arizona serves fewer children through programs and services designed to identify and respond to child conditions and to identify and respond to family vulnerabilities. One possible nexus for Arizona in expanding such programs and services is its First Things First Initiative and funding stream, which not only provides substantial funding for services to young children, but also helps develop exemplary practices and communitybased responses which intervene early and effectively. At the same time, First Things First has finite funding itself and sometimes has been called upon to compensate for the lack of service capacity within other systems. It certainly does not have the resources needed to build a strong system of needed services and supports statewide. Even compared with other states, Arizona serves fewer children through programs and services designed to identify and respond to child conditions... Information on Arizona s young child population and administrative data on the public services provided to that population generally show both a greater need in Arizona for services and supports to young children and their families (given Arizona demographics) and a generally lower reach of services to young children and their families than occurs in other states. Moreover, when compared with the underlying presence of children and families who can benefit from intervening early, Arizona has a long way to go. The Table below shows some of the data regarding service use and need in Arizona, while also providing some national comparative information. 4 Intervening Early in Arizona BUILD Arizona Initiative

5 Comparison of Arizona and the U.S. on Early Childhood Population and Service Use Demographics Arizona U.S. Young children (0-5) as share of population, % 7.9% Child population (0-17) growth rate, % 16.6% Diversity of the young child (0-5) population, 2010 White, non-hispanic 39.1% 51.0% Hispanic 44.9% 25.2% Native American 6.2% 1.2% African American 4.6% 14.3% Asian 2.6% 4.5% Young child (0-5) poverty and low-income status Under 100% of poverty 27.5% 24.8% Under 200 % of poverty 55.7% 48.0% Education level of mothers of young children (0-5) Less than high school 18.5% 13.9% Bachelor s degree or above 23.5% 31.2% Use of Public Services Arizona U.S. Child care subsidy use by 0-5 population 3.6% 4.7% Part C of IDEA use by 0-2 population 1.8% 2.7% Part B of IDEA use by 3-5 population 5.5% 6.1% Head Start use by 3-4 population 10.2% 11.1% Public preschool participation by 4 year-olds 20% 42% Foster care placements of 0-5 population.8%.6% TANF participation by 0-17 population 1.7% 4.3% WIC participation of 0-4 population 32.4% 35.1% Medicaid/EPSDT participation of 0-2 population 56.4% 56.0% Medicaid/EPSDT participation of 3-5 population 53.1% 51.5% Uninsurance for 0-17 population 12.7% 7.5% Uninsurance for 0-17 population under 200% of poverty 17.4% 10.7% 5

6 Incremental Steps to Get There Intervening early requires programmatic responses, but there is no one program or service which will meet all the diverse needs of children and their families in Arizona. Similarly, there is likely to be no one screening and identification site or care coordination program to enable children and families to secure the programs and services they need. Because of the detailed inventory of public services for young children and their families developed by First Things First, Arizona has a better picture than many states both of promising and exemplary program approaches and of existing service gaps. Many of these promising and exemplary programs, if expanded and diffused with attention to their role in building an overall system, would contribute to achieving success. At the same time, these should not be viewed as free-standing efforts (either as silver bullets or as contributions to system fragmentation ). A key to both making the case for and ultimately finding the resources to continue to expand such efforts is in being intentional in estimating (and then monitoring) their impacts and outcomes. A further key is to broaden the base of experts and champions in the state who see that their contributions are recognized and used and a vital part of an overall strategy to intervene early and effectively. Intervening early requires programmatic responses, but there is no one program or service which will meet all the diverse needs of children and their families in Arizona. Developing a successful system for intervening early is a complex undertaking, involving changes in practice from those in the health, early care and education, early intervention and special education, and family support fields coupled with significant scaling up of activities. Among health practitioners (pediatricians, family physicians, nurse practitioners), it involves incorporating development screening and surveillance across both biomedical and social determinants of health to a much greater extent than practiced today coupled with starting a referral process which leads to young children and their families being connected to sources of care and support relevant to their needs. Among early care and education providers, it means greater capacity both to identify special needs and to be part of a process of responding to those needs within the early childhood setting. For those in special education, it means giving attention to and being able to respond to family vulnerabilities and needs as well as child conditions. For all practitioners, it means additional support in engaging families and being culturally and linguistically responsive and inclusive in their actions. Since these all involve fundamental practice changes as well as new programmatic responsibilities, the diffusion of innovation literature is relevant in promoting that change. That literature speaks to first supporting and showcasing those innovators who are developing new practices with attention to their creating some of the tools for successful replication. It then speaks to enlisting early adopters in the field to take on those practice changes, with an emphasis upon fidelity of replication. This helps to build the base of knowledge and expertise and practice leadership to move into mainstream practice. There are many potentials for incremental steps in building such new practices within Arizona, within all systems which can contribute to intervening early. One of the next steps is to systematically inventory them and assess their current potential for further development and diffusion. An objective should be to view these not as competing, but as complementary and synergistic, efforts. 6 Intervening Early in Arizona BUILD Arizona Initiative

7 In instances where there are sufficient high quality demonstration programs and or early adopters of practice, there will be opportunities to take the next step to expand them into mainstream practice. This requires attention to fidelity of replication that ensures that programs demonstrating efficacy in select practice ensure effectiveness in mainstream practice. Attention needs to be given both to ensuring sufficient resources are available for the dosage and intensity of the original program or service and to the training and professional development needed to ensure fidelity to the attributes which made the original program or service efficacious. Key to taking continued incremental steps is providing evidence and feedback on prior steps and producing an overall push toward continuous improvement in achieving improved child (and family) outcomes. Costs/Financing Achieving success in building a strong system that intervenes early will take time and require resources and financing. It also will produce gains through selective short, and many more intermediate and long-term, child outcomes which themselves can to some extent be quantified in terms of public returns on investment in improved health (and reduced costs for episodic and chronic health expenditures), educational success (and reduced costs for special and compensatory education and, in the long-term, greater economic productivity and reduced reliance upon public programs), and social integration and success (and reduced juvenile and adult correctional costs and social costs associated with risky behaviors, including such things as substance use and adolescent parenting). While it may not be possible to directly re-allocate estimated savings from intervening early, such connections can be made and employed when new allocations for public funds are being promoted. Current public investments in young children s healthy development are small in comparison with those for school-aged children. Nationally, for every dollar invested in the education and development of a school-aged child, only 6 cents is invested in an infant or toddler and 24 cents in a preschooler, according to the latest Early Learning Left Out report. While more effective use might be made of the funding which is available, developing a system that truly intervenes early almost certainly will require new or redirected public investments. While there may be some immediate cost-offsets (in health through reduced high cost services such as neonatal intensive care services and hospitalizations for asthma or allergies and in child welfare from reduced foster care placements), the actual incidence of such high costs is for a very small segment of the young child population while the opportunity for intervening early is much larger. Expenses and financing for young children and their families are not current major public system cost drivers, yet the conditions children acquire if early and effective intervention does not occur are substantial. In one way to frame this, children are not part of the health cost problem, but they must be part of the health cost solution. The same holds in the education, justice, and social welfare worlds. One of the strategies to secure and scale up financing over time is to demonstrate impact and to provide sufficient evidence of success in a sufficient number of places that there is pressure to expand that success statewide. Importantly, as Arizona continues to work on health reform overall and, in particular, to promote reduced use of high cost services through more effective management of existing health conditions (including accountable care organizations and other financing strategies), some of any shared savings from successful efforts could be directed to more long-term efforts to improve child health and contain long-term costs. 7

8 Overall Recommendations and Incremental Steps BUILD can play a valuable role both in presenting a systemic focus and a broad vision for success in intervening early and in identifying tangible steps and advocating for investments in specific drivers which can help to move Arizona forward in developing that system. Where there already are multiple efforts across the state which promote intervening early with a similar focus or to address a similar need, BUILD can work to coordinate those efforts and show how they jointly can contribute to improving child outcomes and promote a learning community approach that presses for collective advocacy and continuing improvement. From the perspective of BUILD AZ, the following strategic recommendations and incremental steps can serve as drivers for further reform efforts: Inventory and map the array of early intervention services currently available to children 0-5 who are at risk of developmental delay. Develop a data system with the ability to share information and track child progress and outcomes on relevant developmental indicators. Identify financing mechanisms for early intervention services and maximize opportunities for coordination and leverage. Support efforts to increase access to and use of developmental screenings, with particular attention to and building on opportunities available within the Affordable Health Care Act. Identify, support and diffuse exemplary practices in care coordination and service provision. Educate the broader community around impacts and long term outcomes of intervening early. Support efforts to sustain and integrate home visiting programs as a core component of an statewide early intervention system. What Other States Have Done There are many examples within states of exemplary programs and initiatives around intervening early, including advances across the five elements described as interconnecting parts of a successful system. As described earlier, There are no from a systems perspective, success would states which have fully involve, for children living throughout developed a system for the state, the following five general components: (1) early identification intervening early with all (through screening and surveillance), children and families (2) professional, evidenced-based who can benefit. service responses to identified child needs (through medical and other treatment services, including but not limited to Part C and B); (3) professional, evidencedbased responses to identified family vulnerabilities (through treating parental depression and stress and adversity, providing individual/parent-child dyadic and group counseling and therapeutic interventions, and stabilizing families); (4) community responses to strengthen protective factors (through home visiting, parenting education, and peer support available), and (5) ongoing engagement (through care coordination, targeted case management, and family advocacy). 8 Intervening Early in Arizona BUILD Arizona Initiative

9 There are no states which have fully developed a system for intervening early with all children and families who can benefit, but there are exemplars within and across the components and for different specific child health conditions which can be drawn upon in developing Arizona-specific plans. Moreover, some (but not all) of these also have significant research and evidence of achieving strong and positive outcomes for children, which can be employed in Arizona in developing its system for intervening early. Conclusion Ultimately, the greatest impact upon an individual s health and development occurs in the first five years of life (not the last five, where the majority of health expenditures are made). Moreover, there are many opportunities in these first five years to prevent early childhood adversity which can produce toxic stress and its profound lifelong impacts across health, education, and social and emotional well-being and consequent human services and corrections system involvement. Advances in medical, child development, education, and family research also have identified effective strategies to better identify and intervene early to respond to developmental, mental, and behavioral conditions in young children to address those conditions and improve their overall development. This knowledge of both the need for and the effectiveness of responses to young children experiencing or at risk for developmental delays intervening early needs to be recognized and be the basis for systemic action. Ultimately, for its own prosperity as well as the prosperity of its children, Arizona needs to build an early childhood system which ensures that needed services and supports are available to all children. Intervening early is essential to equipping children with the early development they need to be ready for success in school and to ensure they can achieve proficiency in reading by the end of third grade. Acknowledgments BUILD AZ is grateful for the contributions and support from the many individuals and organizations that contributed to this report. BUILD AZ is supported through general financial contributions and/or in-kind support from the following foundations: The Virginia G. Piper Charitable Trust Helios Education Foundation The Steele Family Foundation Valley of the Sun United Way We are also grateful for the leadership and expertise of Charlie Bruner, Ph.D., who served as the author and writer of the brief. Charlie is the executive director of the Child and Family Policy Center in Iowa and lead evaluator for the BUILD National Initiative. Finally, BUILD AZ is grateful to all of the Children s Health Work Group members that provided data for the publication, along with insight, expertise and time in developing the recommendations and reviewing the brief. BUILD Arizona is part of the BUILD Initiative, a national project that helps state leaders better prepare young children to thrive and succeed through a comprehensive early childhood system tailored to the needs of the state s unique young child population. 9