Child First

Child First is a relationship-focused, two-generation infant/early childhood home-based psychotherapeutic intervention that partners with pregnant people and families with infants and young children from birth through age 5. Using a two-pronged approach that provides a system of care and relationship-based psychotherapy, a mental health clinician and care coordinator work as a team to help families access needed services and supports in the community and promote responsive and nurturing caregiving. Child First seeks to prevent and decrease a family’s involvement with child protective services and improve a child’s behavior, social skills, and communication. Child First also seeks to prevent and reduce depressive and post-traumatic stress disorder symptoms and decrease parenting stress for caregivers. Services typically last 6 to 12 months, depending on a family’s needs. During the assessment phase (first four to eight weeks of the intervention), the clinician and care coordinator conduct joint home visits twice per week. Thereafter, visits occur either separately or jointly at least weekly.

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Child First partners with pregnant people and families with infants and young children to enhance strong, loving relationships. The program uses a relationship-focused, two-generation infant/early childhood mental health model. The model intentionally considers structural inequities experienced by families as well as the impact of past and present trauma, such as historical trauma, oppression, and structural racism. Child First aims to support caregivers and their children by helping them process the stresses and trauma in their lives and enhancing healthy patterns of interactions between a caregiver and a child. Child First strives to intervene with families as early as possible and to connect them to services and supports within their communities to help ease their stress.

The Child First intervention was developed as a two-pronged approach:

1. A “system of care” approach that connects families to comprehensive, integrated services and supports to decrease environmental stressors and promote positive child and family development. 
2. A relationship-based psychotherapeutic approach that promotes responsive and nurturing caregiving to protect the child’s developing brain from stress and to facilitate cognitive and social-emotional development.

Child First uses a team-based approach to home visiting involving a mental health clinician and a care coordinator. This team approach offers (1) two independent observations, especially during the assessment phase (first 4 to 8 weeks of the intervention); (2) multiple perspectives, which can aid in understanding the family; (3) a model for families on how two adults communicate and cooperate; (4) peer support for the home visitors to help lessen any vicarious trauma they may experience; and (5) continuation and consistency of work with the family (within their own roles) when one team member is unavailable.

Child First is supported by the National Service Office (NSO) for Nurse-Family Partnership and Child First. The NSO is a nonprofit organization based in Colorado that supports model implementation throughout the Child First network, which is composed of local providers known as Child First affiliate agencies. The NSO provides these affiliate agencies with implementation guidance, ongoing training, clinical consultation, and technical assistance. It also provides data support, analysis, and access to reports on process and outcome data to support implementation fidelity and quality improvement.

Each state or region with affiliate agencies is supported by a clinical lead who is a member of the Child First team at the NSO. This individual (1) provides affiliate agencies in the state or region with clinical and administrative oversight, technical assistance, and biweekly clinical consultation; (2) coordinates with Child First network development and government affairs staff to support affiliate agency leadership; and (3) supports integrating the Child First model into local and state early childhood systems of care.

Affiliate agencies can request technical assistance from the NSO to support model implementation throughout the course of their active contract period.

Child First serves pregnant people and families with children from birth through age 5 in which (1) children have emotional, behavioral, or developmental difficulties or (2) the family faces multiple environmental and psychosocial challenges, such as caregiver depression, domestic violence, substance use, insecure housing, or abuse and neglect, that could contribute to negative parent and child outcomes. Child First views these environmental and psychosocial challenges as social determinants of health. Families are served without regard for their legal status or the number of children in the family.

Child First seeks to prevent and decrease a family’s involvement with child protective services and improve a child’s behavior, social skills, and communication. Child First also seeks to prevent and reduce depressive and post-traumatic stress disorder symptoms and decrease parenting stress for caregivers. The model also aims to improve the child-caregiver relationship and increase the family’s connection to community-based services.

Child First is a home-based psychotherapeutic intervention. Child First services are provided by a team consisting of a mental health clinician and a care coordinator. The team comprehensively assesses a child’s and family’s needs and supports the family through both joint and individual sessions depending on identified needs. The major intervention components include the following:

Various therapeutic intervention strategies to best fit the family’s needs. Staff are trained in a range of early childhood psychotherapeutic approaches that can be integrated into sessions depending on family dynamics. The team works to support and strengthen the relationship between the caregiver and child to optimize early relational health for young children and families who have experienced trauma and adversity.

Comprehensive, reflective care coordination to address primary needs. The care coordinator addresses (1) acute family stressors, such as insecure housing, lack of heat or food, expulsion from child care, or imminent removal of the child from the home; (2) a broad range of chronic challenges related to the social determinants of health, such as caregiver depression, domestic violence, substance use, insecure housing, or abuse and neglect; and (3) connection to growth-promoting, community-based services and supports.

Metacognitive strategies to support executive functioning skills in both caregiver and child. Executive functioning encompasses the capacity to organize, plan, and prepare for activities as well as to regulate one’s emotions while engaged in tasks. Emotional regulation is a core component of executive functioning that is modeled and supported by both team members. The care coordinator uses scaffolding as they support the caregiver in the development of other executive functioning capacities. As part of this, the care coordinator works with the caregiver to develop individual and family goals, prioritize needs and goals, create step-by-step plans to accomplish them, monitor and reflect on progress, and revise those plans as needed. The care coordinator also shares with the family an interactive, relationship-based approach (based on the Abecedarian Approach) to games and activities, language and reading, and routines and caregiving. This approach is designed to promote the caregiver-child relationship and child self-regulation and cognitive ability.

Mental health consultation in early care settings. When consent is provided, a clinician or clinical team observes the child within their early care setting, such as a formal early care and education center or home-based child care. As part of the assessment process, the team gathers information about the child’s strengths and any behavioral or emotional concerns from the teachers or child care providers. Child First then works with the teacher or child care provider depending on the child’s need and the availability of other mental health consultants working in that setting. Child First fully collaborates with other mental health providers so as not to duplicate services.

The NSO expects the team to provide a majority of services within the home or a mutually agreed upon community setting. The team may provide virtual visits when deemed appropriate and permissible by state or other funding regulations, particularly as visits relate to individual therapeutic sessions with caregivers or assisting families to meet their basic needs through care coordination or both.

During the assessment phase (first four to eight weeks of the intervention), the Child First team strives to visit families together twice per week. The clinician also visits the families alone to inquire about child and adult trauma.

After that phase, the clinician and care coordinator may visit the family together or separately, depending on the unique needs of the child and family. Visits are a minimum of once per week but could happen several times per week, if needed. They typically last 60 to 90 minutes, depending on circumstances. Services are provided from 6 to 12 months but could be longer, depending on family needs.

Because of the flexible nature of its delivery, Child First has not yet developed allowable deviations from the model. However, doing so may be necessary depending on new settings and new populations, such as Tribal communities. Child First is willing to explore adaptations and enhancements through an intentional process grounded in understanding population needs, planning implementation accordingly, and conducting pilot projects to assess needed modifications.

The NSO works with state and community stakeholders to select Child First affiliate agencies in a region. Affiliate agencies must be or have the following qualifications:

• Respected relationships within the community, including being (1) known as a reliable, trusted, collaborative partner and community leader, and (2) committed to a family-centered system-of-care approach to providing comprehensive, coordinated services to children and families
• Engagement with an Infant and Early Childhood Community Collaborative that includes the major community providers for young children and families
• A social justice commitment, including hiring staff who represent the diverse languages and cultures of the communities being served
• Early childhood expertise, including experience serving children from infancy through age 5
• A provider of mental health services, including early childhood mental health or prevention services for families affected by multiple stressors or both
• Experience in providing home-based services
• Experience in or willingness to apply for Medicaid reimbursement for child mental health services or another consistent public funding stream to sustain services
• Experience in serving the child welfare population and willingness to work closely with regional child welfare agencies
• Staff that meet Child First education, standards, and licensing requirements, including master’s level, licensed (or license eligible) mental health clinicians and licensed mental health supervisors
• Willingness to commit to all Child First fidelity requirements, including comprehensive training, implementation standards, benchmarks, assessment protocols, continuous quality improvement, and evaluation of model effectiveness
• Willingness to dedicate staff time for weekly individual, clinical team, and group reflective supervision, and have the clinical director or supervisor participate in reflective, clinical consultation
• Willingness to participate in the Child First accreditation process

This model requires affiliate agencies and staff to meet a set of ongoing fidelity guidelines. Please contact the model developer for additional information about these guidelines.

A team consisting of a mental health clinician and a care coordinator work together to deliver the intervention. A Child First–trained clinical director or supervisor provides reflective clinical and administrative supervision for each team. An affiliate agency must have a senior clinician to provide reflective, clinical supervision and implementation support to the affiliate site’s Child First clinical director or supervisor.

Child First teams must be culturally informed and sensitive and meet the language needs of the communities served. Child First requires staff to have the following education and experience:

• Mental health clinicians must have a master’s degree or higher and be licensed or license eligible in a mental health specialty.
• Care coordinators must know about community resources and have experience in working with ethnically diverse young children and families. Although a bachelor’s degree is preferred, lived experience as a provider in the community is strongly considered. These expectations are also subject to regional or statewide mandate for commensurate service provision.
• Clinical directors and supervisors must have (1) a master’s level or higher degree in a mental health field; (2) training and experience in mental health and child development (prenatal through age 5), including experience in providing relationship-based psychotherapy for young children and their families; (3) experience with dyadic parent-child psychotherapy, and knowledge of adult psychopathology; (4) experience in providing reflective, clinical supervision; and (5) experience in working with diverse families who have experienced multiple stressors.

The Child First clinical director or supervisor provides each clinician and care coordinator with a total of 3.5 hours of clinical, reflective supervision per week: 1 hour of individual supervision, 1 hour of clinical team (clinician and care coordinator together) supervision, and 1.5 to 2.0 hours of group supervision with all teams together. All staff receive programmatic or administrative supervision as a group for at least one hour per month. Clinical directors or supervisors must also maintain an open-door policy to respond to acute clinical needs. 

During the first year of implementation, the state or regional clinical lead provides on-site weekly reflective clinical consultation with new affiliates, including individual consultation with the affiliate site clinical director or supervisor and group consultation with all Child First teams. After 12 months, the state or regional clinical lead provides the affiliate site clinical director or supervisor with individual consultation biweekly for another year, after which time consultation support varies depending on need. The affiliate site clinical directors or supervisors also participate in Child First Clinical Director Network Meetings, which occur monthly.

The model requires staff to participate in foundational training delivered through distance learning modules and an in-person, on-site Child First Learning Collaborative. Child First provides foundational training in infant and early childhood mental health, including topics such as development, attachment, trauma, adversity, social determinants of health, physical health, adult mental health and substance use, early diagnosis, executive functioning, reflective process, and the Abecedarian Approach. The Child First NSO provides all new clinical directors or supervisors with an intensive preservice training centered around the principles of diversity-informed reflective supervision as it relates to the Child First model. Please contact the model developer for additional information about the preservice training requirement and any ongoing professional development requirements.

National Service Office for Nurse-Family Partnership and Child First
1900 Grant St.
Denver, CO 80203
Website: www.childfirst.org/

Rebecca Parilla, PhD.
Child First Interim Program Lead
Phone: (860) 484-1168
Email: rparillal@childfirst.org

Serena Curry, M.S.
Child First Network Development Director
Phone: (860) 841-8318
Email: scurry@childfirst.org