Leigh: Policymakers talk about solutions, but which ones really work? Welcome to Evidence First, a podcast from MDRC that explores the best evidence available on what works to improve the lives of people in poverty. I'm your host, Leigh Parise.

Early childhood experiences of trauma and toxic stress can affect how young children develop and are associated with learning and behavior problems. We also know that a stable, nurturing environment stimulates children's brains in positive ways, priming them for better outcomes in life.

Today, we'll talk about Child First, a promising program that aims to mitigate or prevent these negative experiences for families to promote healthy development for kids. At Child First, clinicians and care coordinators work with vulnerable young children and caregivers by providing intensive home-based services like child-parent psychotherapy and role-playing activities to discuss approaches to challenging situations and help caregivers respond to a child's needs in a sensitive and emotionally supportive way. The care coordinator also works with families to assess their needs and connects them to resources in their community.

An initial study of Child First found that the program improved children's social-emotional skills and language development, reduced mother's depression and improve their psychological functioning, reduced family involvement with child protective services, and increased families’ connections to services and support.

Right before the pandemic, MDRC was in the process of recruiting families for a replication study of Child First, and today we'll discuss how Child First staff adapted their services in light of the pandemic and what that meant for MDRC's study.

Joining me is Mervett Hefyan, a research analyst at MDRC studying family well-being and children's development; Massiel Abramson, a clinician with Child First in Connecticut; and Jessica Canavan, a licensed clinical social worker and assistant director of community-based services at her organization in North Carolina, which houses a Child First program. Thanks so much for joining me today. I'd love to start just by having you describe what the Child First model is for people.

Massiel: Child First is an evidence-based model of child and parent therapy, and it's focused on building attachments between the parent and the child with a perspective of understanding the trauma they have experienced together and working through that. So we work with from prenatal to about age six, and it's that family therapy between the parent and child.

Leigh: Great, thank you. And how has the pandemic affected implementation of the Child First model?

Jessica: Child First, pre-pandemic, I guess I would say, it is a home visiting model. You have a team of two professionals who are coming to a family's home to work with that parent and the child together. In sessions, it sort of depends on what the clinical need is. There are times where our teams visit jointly and both of our staff are present, there are times when just our clinician is in attendance—or just what we call a family resource partner here in North Carolina, but I think there are called care coordinators in the Connecticut area­—and so there are times where just our family resource partner would be there, based on what the family is needing.

In this pandemic, it's definitely more challenging, because I think the mood in the room changes a little bit, because you're engaging with a video screen. Initially, I think what changed the most about the service is that we had a lot of parents and caregivers who just needed time and space to process what was happening for them, as they were home with their children and supporting their young children and supporting—in particular, our client or the identified child, so to speak—not only through their experiences and history, but what was presently happening. There were a lot of increased stressors.

I think initially we saw our home visits or our telehealth visits, changed—in that the parent did a little bit more leading than I think normally they would have, but it was necessary. They needed that support. They needed someone to come to with their challenges. And we found that by providing them with that space, we then had a parent who was better able to engage their child. It helped us talk with parents about what they needed to regulate their own affect and kind of manage their own experiences as then they're responding to the emotional needs and those social-emotional cues and bids from their small child.

Over time, I think as families adjusted to telehealth, we were able to really return much more to what a traditional session would look like, where we can open up the screen, and the kiddo and the caregiver are set up with their toys, their activity, whatever it is that they're going to do for the day.

Our staff have gotten really creative with coming up with toys or helping families to use toys that they have at home for play therapy purposes. Before, we were always bringing things into the home, and we would supply what the family needed or what the child could use, and so now the family has to have these things.

We're getting creative by creating play kitchens out of boxes, because not everybody has a play kitchen at home, not everybody has the toys or food sets that go with it. Not everybody has the fire trucks or the police cars at home. So how can we create these things?

Leigh: Has the number of families that you've been able to reach been affected by the pandemic?

Massiel: The pandemic has really changed things for us, and the biggest difference is that now we're able to give our services virtually, which in some ways has allowed for more access to us. I'll give an example. I had a family who was struggling with housing and every week she was kind of somewhere else in limbo. She was always in the town, but often at a friend's house, having trouble with the residents in her home or on the road. And in other circumstances, if it were in-home, we wouldn't have been able to keep the appointments, but because it was virtual, we were able to set up some kind of nice private space for the therapy between her and her daughter. Treatment was able to continue through really, really difficult times.

We wouldn't have had that ability to kind of follow her through all these different arrangements that she was going through.

Leigh: Jessica, anything that you want to add to that?

Jessica: One of the challenges that I've noted is that more of the referrals who have come to us in the last five or six months really have been more acute referrals. When families have surfaced, or when they were surfacing through this, we were seeing heavier trauma cases, families that have had experienced more significant abuse or had experienced greater domestic violence because everybody had been cooped up together for a long period of time. At that point, we started to see an increase in referrals.

We've been really fortunate, though, that we've been able to engage a lot of those families because telehealth has broken down those barriers. And so I feel like we have a bigger impact, and we're able to better partner with our community partners, help make sure that our child protective services are able to do their jobs and keep kids safe, and we're able to help support families through a lot of these big transitions and experiences.

Leigh: Thank you. Massiel, is there anything that you want to add from your experience? I don't know if things look similar across families or across locations, but I’m happy to have you add or share anything from your pandemic experience.

Massiel: Actually, with this setup—the structure of the video and the sitting down for the play therapy sessions and keeping it so organized and weekly—has really benefited some of the people that felt really, really scattered. This was the one time that the child was able to sit down in the computer and practice for when they have to actually engage with their teacher and the teacher might have less attention than Ms. Massiel has here with all my toys and all my patients with a lot of the behaviors. So, it has really benefited people, this type of structure.

Jessica: Massiel, as you mention, it brings to mind conversations that I've had with parents and caregivers as well, where they're trying to say, "I don't think I can do telehealth with my two- or three-year-old. What are they going to be doing?" And it's been really great, too, because we've been able to help our community and our parents really better understand that Child First is not necessarily about the therapist being the expert. It's really about those relational interactions that are on the other side of the screen, and how we're helping to engage them, and how we're helping to really instill that hope into the parent who is doing a lot of really hard work right now. Not only because many of their life circumstances, but just because of the world in a pandemic. As Massiel was telling her story, I was thinking very much about how I could very much relate to that in our area as well.

Leigh: It sounds really like you're being responsive to so many different shifts that are happening in the public world and environment, but also personally for your families that you're working with. So thank you for sharing all that.

With all of the changes that have been made to the typical Child First model, do you find that families are still as engaged in the services?

Jessica: Engagement was fairly good. Of course, we lost contact with families, but if I look at it program-wide, I don't think that we lost contact with any more families than we otherwise would have non-pandemic.

In this time, families have needed a lot more hands-on or tangible support than our family resource partners are able to provide. One thing that we saw a lot of as everything closed down and then as many people lost their jobs was food insecurity. And so helping families to manage stress by helping connect them to community resources for food or meals or tangible supports or financial supports for housing costs or just basic needs was very helpful, I think. It helped to keep families engaged because we were meeting a lot of those basic needs. And when we think about Maslow's hierarchy of needs, and we think about the work that we do, we want to help families meet basic needs so that they have then the emotional availability to engage in that therapeutic or processing work.

Not only were we meeting basic, tangible needs, [but] we were engaging parents and helping them manage their emotional needs and their emotional stress during this time. We saw that we were meeting some really important needs.

Massiel: One of the biggest changes that I see that could be influencing people to stay engaged is that because you're on the computer, you are looking at the case with a little bit more access to the family's chart, and a little bit more access to the rest of the world that operates around them. I find that I've been able to do more care coordination when it comes to early childhood development treatments and programs and schooling.

It's been easier for me to set up times to meet with their teachers on the phone, to set up times to meet with their early intervention specialists. So that communication has allowed us to wrap around the families so much better. And I think people are staying because they're seeing that this is a way to help my child—and also manage these strong feelings and difficulties in the moment.

That's so important because when you've had trauma and you've had difficult times, and when you have a baby, it's so isolating. I have a 16-month-old baby, so I feel like it's just me and him a lot of the times. So feeling like somebody is coming in and checking in and telling you, "This is the early intervention thing. He's 16 months old? These are the type of games that they like to play." It's like, "Oh, okay. Yes." So people will feel a lot less isolated when we're able to come in there and take a look at what are the other resources that are coming into play in the household.

Leigh: Let's be forward-looking now. When in-person activities eventually do begin again, how would you say that your experiences during the pandemic will affect how you implement Child First in the future?

Massiel: I want to say that the biggest thing that I will take from this experience is remembering the importance of celebrating milestones and celebrating markers of change. So in the pandemic, what we've lost is time for celebration, time to honor some big change that has happened or even a birthday or some other milestone.

While I always made a big deal about my discharges and how to end with families in a way that honors what they did and with a token of a memory of our time together, I feel like now I really miss that more than ever. Just to take a little bit of time to sit back and acknowledge—wow, look at the progress we've made. Look at how much the baby has grown. Look at how before one of my clients who would sit far away and just go out of the shot and stand there and cry for a snack. It was just that every day, that 4:00 snack, I was always interrupting it. And now he sits there, he's fixing the camera angles, telling mom to make sure that she's sitting down, because she's taken off doing something else in the house. So it’s important to just to be able to sit down and really look at the progress and how our coping skills have got you through these difficult times. I really want to make sure we emphasize that when we go back.

Leigh: Great, Jessica, anything that you want to add?

Jessica: I sort of think the way everyone works and the way everyone does things is going to be forever changed. I would love to see us, as in-person activities eventually begin again and we're able to do that safely, take the creativity that we learned, and the flexibility and resilience, with us into future interactions. There are always challenges for home visiting, which are unique to home visiting, which is why many of us do it. We love this field, and we love doing this work. Being able to take this way of thinking and being forward will be really helpful.

Leigh: Thanks so much, Massiel and Jessica. It sounds like Child First is a really promising model, and I'm so glad you're able to continue helping families during this difficult time. I also spoke with Mervett Hefyan, a researcher at MDRC about the replication study of Child First and how the research team had to adapt since the pandemic. Here is that conversation now.

Leigh: Mervett, I'd love for you to tell us about why MDRC is conducting a study of Child First.

Mervett: We are trying to replicate and extend findings from an earlier study of Child First that was done in 2011.

That first study was done with just one of the Child First sites with a smaller sample size.  For this study that we're doing now, we are working with a larger sample size. We are working with sites in North Carolina and Connecticut, and we're also looking at longer-term outcomes. And all of this is really set up for us to help Child First build a stronger evidence base for their program, to allow Child First to grow and eventually serve more families in the long run.

Leigh: Great. So you talked about how this study is a replication, or kind of doing it again. Can you talk a little bit about what the earlier study of Child First found that made us think, “Hey, this is something that we really need to test again and see if the impacts hold up?”

Mervett: The first study found that Child First was improving children's social-emotional and language skills; it was reducing caregivers' depression and decreased family's involvement with child welfare services.

For the study that we're doing now, we are looking at similar outcomes. We will be looking at how the program impacts caregivers' psychological well-being a year after they enroll in this study. And we'll also be looking at family's involvement with child welfare services one year and three years after enrollment into the study, really looking at the longer-term impacts of the program.

We'll also be looking at how Child First impacts different types of families. And that's really important for Child First to understand whether some families have different experiences from their service. Maybe some families benefit a little bit more from their services, and we'll want to understand who those families are and what those benefits look like.

I think that that's something that Child First is exploring because they really care about their families, and they really want to know how to better serve those families. And this is important for Child First and improving its program to really make sure it's serving families in the best way that it can. It's also great for the home visiting field in general, since lots of home visiting practitioners could really benefit from knowing the approaches that work best for families and trying to foster these positive caregiver-child relationships, and really helping children succeed.

Leigh: Mervett, I know that the study team was supposed to be enrolling families on a rolling basis over about 18 months, was going to do in-person data collection and visits, and that you've had to pause study enrollment for the moment because that was just what felt like it made the most sense, given the pandemic.

This is a challenge that research teams, certainly at MDRC and more broadly, are wrestling with. They really need to figure out how to be responsive and do what makes sense for each study, and do this in close partnership with the programs that we're working with. Can you say a little bit about the ways that the MDRC team has worked with Child First to shift plans for this study?

Mervett: In March, when things with the pandemic where were becoming really bad in the US, we connected with our Child First partner sites and we were trying to get a sense from them of whether they were going to still continue home visiting. And we said, ”You know what, we are going to follow your lead. If your site says that this is something that you're not comfortable with, that is entirely fine, we can pause enrollment if your teams are no longer going into the home; if it's no longer safe for you and the families to be in the home, we completely understand that.”

At about mid-March, it became clear that that was the case for most of our sites, and so we decided to pause enrollment into the study at that point. And pausing enrollment meant that Child First teams could still serve families that they had on their caseloads and could still serve new families coming in as well, but they didn't have to go through the process of the study. So any new families were continuing to receive services without participating in the study.

We, of course, still had those families that had been [enrolled] into the study right up to March 2020, and we decided that we still wanted to understand what families were going through during this time. I mean, this is a pandemic. We want to know how families are doing. And so instead of continuing with the follow-up survey like we had intended—this was supposed to be an in-person follow-up survey—we decided that we were just going to keep it much simpler. We were going to send families a short online survey just to understand how they were doing during this time of the pandemic and how things have changed for them. And, of course, we wanted to keep it shorter because we didn’t want to ask too much of families during this time. There's just a lot happening right now.

But it is helpful to get this type of information from families during this time, because it could point to how Child First could be making a difference for families during this period. This is such an unprecedented time for everybody, and just having this information on how Child First could be supporting families during this time is helpful for the program to know.

That's something that we work towards—just being responsive to how sites are operating, being responsive to what families are dealing with at this time. As we think about restarting the RCT sometime, hopefully in 2021. We're still talking to our partner sites about what works best for them and their teams and their families that they serve.

Leigh: Sounds like the research team is being very thoughtful and making sure the study can continue while keeping everyone safe.

Thanks so much for joining me today, Mervett, Massiel, and Jessica, and for sharing these lessons and examples from working with families during such a challenging time. To learn more about our work, visit mdrc.org.

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