Implementing Child First Meets HHS Criteria

Model implementation profile last updated: 2020

Model overview

Theoretical approach

Child First intervenes with vulnerable young children and families at the earliest possible time to prevent and heal the effects of trauma and adversity. The goal is to decrease the incidence of emotional and behavioral disturbance, developmental and learning problems, and abuse and neglect among high-risk young children and their families. The Child First model is based on brain development research, which shows that extremely high-stress environments (including poverty, maternal depression, domestic violence, abuse and neglect, substance abuse, and homelessness) are toxic to the developing brain of the young child. Child First aims to build a nurturing, consistent, and responsive parent-child relationship, which buffers and protects the child’s brain from these stressors. In addition, the model is designed to stabilize and decrease the multiple concrete challenges in the family’s life.

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Implementation support availability

Child First, Inc. is a nonprofit organization based in Connecticut that supports model implementation throughout the Child First network, composed of local providers known as Child First affiliate agencies. The Child First National Program Office (NPO) provides these affiliate agencies with 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 in which Child First is replicated has a state clinical director who is a member of the NPO Clinical Department. The state clinical director (1) provides affiliate agencies in the state with clinical and administrative oversight, technical assistance, and biweekly clinical consultation; (2) coordinates monthly meetings with the Child First network and calls or meetings with senior leadership; and (3) supports integration of the Child First model into local and state early childhood systems of care.

Affiliate agencies can request technical assistance from the NPO for any reason at any time. Child First NPO leadership conducts quarterly group meetings and/or conference calls with Child First network senior leaders in each state or region.

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Intended population

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

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Targeted outcomes

Child First works to heal and protect young children from trauma and adversity by supporting the development of a nurturing and responsive parent-child relationship. The targeted child outcomes include decreased child abuse and neglect and improved social-emotional development (mental and behavioral health), language and cognitive development, and executive functioning. Targeted parent outcomes include reduced depression, post-traumatic stress disorder, and other mental health problems; decreased parenting stress; improved executive functioning; and increased parental education and employment. The model also aims to decrease the family’s psychosocial and environmental stress (the social determinants of health) and increase their connection to comprehensive, growth-promoting, community-based services and supports.

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Model services

Child First affiliate sites assign each family a team consisting of a licensed master’s-level mental health/developmental clinician responsible for assessment and therapeutic intervention and a care coordinator responsible for connecting families to community services and supports. The Child First model involves the following:

  • Engagement and assessment of child and family needs. The clinician and care coordinator work as a team to engage and build a trusting relationship with the family. To understand the family’s strengths and challenges, the team, in collaboration with the family, uses an ecological approach to assess the child’s health and development, important relationships, and the family’s culture and priorities. The assessment includes a protocol of standardized and informal measures; discussions with parents; observations in the home and early care and education settings (see details below); information from the child’s health provider, teacher, and others who regularly interact with the child and family; and reviews of records.  
  • Observation and consultation in early care and education setting. The mental health/developmental clinician gathers information within any early care setting attended by the child receiving home visiting services. These settings may include family, friend, and neighbor care; early care and education programs; and schools. The clinician gathers information through observations; conversations with the teacher and school administration; and review of any records. The clinician works with the teacher to understand the meaning of the child’s behavior, develop classroom strategies to decrease challenging behaviors and enhance the child’s social-emotional development, and coordinate efforts between the child’s early care and education setting and the home.  
  • Development of a child and family plan of care. The plan of care outlines the therapeutic intervention; parenting supports; and community-based services for the child, parents, and other family members. The Child First team develops the plan with the family during home visits; it reflects the parents’ goals, priorities, strengths, culture, and needs. The initial plan is revised as the family accomplishes goals and subsequently focuses on new challenges. The plan is reviewed at least every three months.  
  • Parent-child mental health intervention. The home-based intervention incorporates both Child-Parent Psychotherapy (CPP) and parenting support and guidance. It is a two-generation approach, designed to strengthen the parent-child relationship and promote secure attachment so the relationship both serves as a protective buffer from unavoidable stress and directly facilitates emotional, language, and cognitive growth. It addresses the experience of trauma and adversity in the child’s life, with the goal of helping the child heal and resolving behavioral problems. The model aims to promote parents’ understanding of normal and atypical developmental challenges and expectations; safety and joy in the relationship; parental reflection on the meaning and feelings motivating a child’s behavior; problem solving and the development of new strategies; and reflection on the psychodynamic relationship between parental history, feelings, and the parental response to the child.  
  • Promotion of executive functioning. The clinician works with the parent on emotional regulation. The care coordinator scaffolds and supports the parent in the development of other executive functioning capacities, such as goal planning. The care coordinator works with the parent to develop individual and family goals, prioritize those goals, create plans to accomplish them, monitor progress, and revise those plans. In addition, the care coordinator provides the parent with relationship-based activities and routines, based on the Abecedarian Approach, that help the parent scaffold executive functioning skills with the child.  
  • Care coordination. The care coordinator’s priority is to help stabilize the family, especially in the face of acute challenges, such as threats to the child’s safety, possible eviction, or lack of adequate food. To help decrease stress and enhance the child’s and family’s development, the care coordinator helps connect the family to comprehensive community-based services and supports, and directly addresses barriers to service access.

The Child First curriculum includes topics, concepts, and implementation methods delivered based on the unique needs of the child and family. Child First is a flexible, relationship-based, psychotherapeutic intervention. The curriculum does not designate what content should be covered for specified visits. However, it does specify what constitutes fidelity to the Child First model.

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Model intensity and length

The intensity and length of Child First services vary based on the child’s and family’s needs.

  • Engagement/assessment phase (first month): Home visits are scheduled twice per week for 60 to 90 minutes, and clinicians and care coordinators visit families together. Thereafter, the individual needs of the child and family determine when visits are made, either together or separately.  
  • Intervention phase: Each family is visited weekly, at a minimum. Visits can be more frequent if there is high need, with their intensity determined by the unique needs and goals of the family.

The child’s and family’s needs determine the length of service, which is usually from 6 to 12 months. However, the intervention can be longer if significant challenges exist.

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Adaptations and enhancements

The NPO has not approved any adaptations or enhancements to the model. No information is available on the process, if any, for considering modifications to the model.

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Organizational requirements

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

  • Not-for-profit, 501(c)(3) status or public agency;
  • A respected relationship 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;
  • A Child First Advisory Board that includes the major community providers for young children and families. (Another existing early childhood collaborative may be designated for this purpose.)
  • A social justice commitment, including hiring staff who represent the diverse languages and culture of the communities being served;
  • Early childhood expertise, including experience in serving children from infancy through age 5 years;
  • A provider of mental health services, including early childhood mental health and/or prevention services for low-income, high-risk families;
  • Experience in providing home-based services;
  • Experience in or willingness to apply for Medicaid reimbursement for child mental health services, or have another consistent public funding stream to sustain services;
  • Experience in serving the child welfare population and willingness to work closely with the child welfare agency to serve the most vulnerable families;
  • Staff that meet Child First education, standards, and licensing requirements, including master’s-level, licensed, mental health clinicians and supervisors; and bachelor’s-level care coordinators;
  • 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/supervisor participate in reflective, clinical consultation; and
  • 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.

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Staffing requirements

A team consisting of a mental health/developmental clinician and a care coordinator working together deliver the intervention. A Child First trained clinical director or supervisor provides reflective clinical and administrative supervision for the team. An affiliate agency must have a senior clinician to provide reflective, clinical supervision and implementation support to the affiliate site Child First clinical director/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/developmental clinicians must have a master’s-level or higher degree, be licensed or license-eligible (with approval) in a mental health specialty, and have three to five years of experience in providing relationship-based psychotherapy with very young children.
  • Care coordinators must have a bachelor’s degree, knowledge about community resources, and experience in working with ethnically diverse young children and families.
  • Clinical directors/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 years), including at least five years of experience in providing relationship-based psychotherapy for young children and their families; experience with dyadic, parent-child psychotherapy and knowledge of adult psychopathology; (3) experience in providing reflective, clinical supervision; and (4) experience in working with ethnically diverse, low-income, high-risk families.

The Child First clinical director/supervisor provides each clinician and care coordinator with a total of 3.5 hours of clinical, reflective supervision per week: one hour of individual supervision, one hour of clinical team (clinician and care coordinator together) supervision, and 1.5 to 2.0 hours of group supervision with all clinical teams together. All staff receive programmatic or administrative supervision as a group for at least one hour per month. Clinical directors/supervisors must also maintain an open-door policy to respond to acute clinical needs. The clinical director/supervisor must participate in (1) biweekly, individual, clinical, and reflective consultation with the Child First state clinical director and (2) weekly individual clinical supervision from a senior clinician at the affiliate agency with experience in psychodynamic work with young children.

This model requires staff to participate in pre-service training. All staff participate in distance learning modules, which explain the fundamentals of the Child First model through webinars, videos, teleconferencing, discussion questions, and activities. The modules are accompanied by prescribed reading and community-based child observations. Staff participate in selected distance learning modules before serving families; other modules are interspersed throughout the service delivery process. 

All new Child First affiliates within a state participate in an in-person, on-site Child First Learning Collaborative. The collaborative lasts about eight months and is divided into four learning sessions of two to three days each that extend from pre-service through in-service training. Learning Sessions 1 and 2 occur before staff begin working with families and last about five to six weeks.

The Child First NPO provides all new clinical directors/supervisors with an intensive four-day training on the Child First model, emphasizing supervision. The state clinical director provides weekly Child First reflective clinical consultation with new affiliates for three hours per week (one hour individually with the affiliate site clinical director/supervisor and two hours with all teams) to enhance learning and respond to questions about clinical work and the implementation process. Please contact the model developer for additional information about the pre-service training requirement.

This model also requires staff to participate in ongoing professional development. After beginning to work with families, staff participate in two more Child First Learning Collaborative learning sessions over about six months. Each learning session is two to three days long. Staff continue to participate in distance learning modules between each learning session. Specialty conferences are provided based on identified training needs for the population served. Staff also participate in a CPP learning collaborative conducted by CPP national trainers; it consists of three learning sessions over 12 months and 18 months of biweekly consultation calls.

The state clinical director continues to provide the affiliates with on-site reflective clinical consultation for three hours weekly for six months, and then three hours biweekly for six months. Each session includes two hours of group consultation with all clinical teams and one hour of individual consultation with the affiliate site clinical director/supervisor. After 12 months, the state clinical director provides the affiliate site clinical director/supervisor with individual consultation biweekly. The affiliate site clinical directors/supervisors also participate in Child First Clinical Director Network Meetings, which occur monthly for two hours. Please contact the model developer for additional information about the ongoing professional development requirement.

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