Administration for Children and Families

Three studies examined associations between early child care and child outcomes among families different from those in the National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network study. Results suggest that quality is an important influence on children's development and may be an important moderator of the amount of time in care. Thus, the generalizability of the NICHD findings may hinge on the context in which those results were obtained. These studies, conducted in three national contexts, with different regulatory climates, ranges of child care quality, and a diversity of family characteristics, suggest a need for more complete estimates of how both quality and quantity of child care may influence a range of young children's developmental outcomes.

OBJECTIVE: This was a prospective longitudinal multisite study of the effects of prenatal cocaine and/or opiate exposure on neurodevelopmental outcome in term and preterm infants at 1 month of age. METHODS: The sample included 658 exposed and 730 comparison infants matched on race, gender, and gestational age (11.7% born <33 weeks' gestational age). Mothers were recruited at 4 urban university-based centers and were mostly black and on public assistance. Exposure was determined by meconium assay and self-report with alcohol, marijuana, and tobacco present in both groups. At 1 month corrected age, infants were tested by masked examiners with the NICU Network Neurobehavioral Scale and acoustical cry analysis. Exposed and comparison groups were compared adjusting for covariates (alcohol, marijuana, tobacco, birth weight, social class, and site). Separate analyses were conducted for level of cocaine exposure. RESULTS: On the NICU Network Neurobehavioral Scale, cocaine exposure was related to lower arousal, poorer quality of movement and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes with most effects maintained after adjustment for covariates. Some effects were associated with heavy cocaine exposure, and effects were also found for opiates, alcohol, marijuana, and birth weight. Acoustic cry characteristics that reflect reactivity, respiratory, and neural control of the cry sound were also compromised by prenatal drug exposure, including cocaine, opiates, alcohol, and marijuana and by birth weight. Fewer cry effects remained after adjustment for covariates. CONCLUSIONS: Cocaine effects are subtle and can be detected when studied in the context of polydrug use and level of cocaine exposure. Effects of other drugs even at low thresholds can also be observed in the context of a polydrug model. The ability to detect these drug effects requires a large sample and neurobehavioral tests that are differentially sensitive to drug effects. Long-term follow-up is necessary to determine whether these differences develop into clinically significant deficits.

OBJECTIVE: The objective of this study was to describe drug use by pregnant women participating in the 4-site Maternal Lifestyle Study of in utero cocaine and/or opiate exposure. METHODS: Meconium specimens of 8527 newborns were analyzed by immunoassay with GC/MS confirmation for metabolites of cocaine, opiates, cannabinoids, amphetamines, and phencyclidine. Maternal self-report of drug use was determined by hospital interview. RESULTS: The prevalence of cocaine/opiate exposure in the 4 sites was 10.7% with the majority (9.5%) exposed to cocaine based on the combination of meconium analysis and maternal self-report. However, exposure status varied by site and was higher in low birth weight infants (18.6% for very low birth weight and 21.1% for low birth weight). Gas chromatography/mass spectrometry (GC/MS) confirmation of presumptive positive cocaine screens was 75.5%. In the cocaine/opiate-exposed group, 38% were cases in which the mother denied use but the meconium was positive. There was 66% agreement between positive meconium results and positive maternal report. Only 2% of mothers reported that they used only cocaine during pregnancy and mothers were 49 times more likely to use another drug if they used cocaine. CONCLUSION: Accurate identification of prenatal drug exposure is improved with GC/MS confirmation and when the meconium assay is coupled with a maternal hospital interview. However, the use of GC/MS may have different implications for research than for public policy. We caution against the use of quantitative analysis of drugs in meconium to estimate the degree of exposure. Our study also highlights the polydrug nature of what used to be thought of as a cocaine problem.

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

OBJECTIVE: To determine the level of developmental and behavioral need in young children entering child welfare (CW), estimate early intervention services use, and examine variation in need and service use based on age and level of involvement with CW by using a national probability sample in the United States. METHODS: As part of the National Survey of Child and Adolescent Well-Being, data were collected on 2813 children <6 years old for whom possible abuse or neglect was investigated by CW agencies. Analyses used descriptive statistics to determine developmental and behavioral needs across 5 domains (cognition, behavior, communication, social, and adaptive functioning) and service use. Logistic regression was used to examine the relationship between independent variables (age, gender, race-ethnicity, maltreatment history, level of CW involvement, and developmental or behavior problems) and service use. RESULTS: Results indicate that age and level of CW involvement predict service use when controlling for need. Both toddlers (41.8%) and preschoolers (68.1%) in CW have high developmental and behavioral needs; however, few children are receiving services for these issues (22.7% overall). Children that remain with their biological parents have similar needs to those in out-of-home care but are less likely to use services. Children <3 years of age are least likely to use services. CONCLUSIONS: Children referred to CW have high developmental and behavioral need regardless of the level of CW involvement. Both age and level of involvement influence service use when controlling for need. Mechanisms need to be developed to address disparities in access to intervention.

BACKGROUND AND OBJECTIVE: The Patient Protection and Affordable Care Act established the Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion to states over 5 years for home visiting program models serving at-risk pregnant women and children from birth to age 5. The act stipulates that 75% of the funds must be used for programs with evidence of effectiveness based on rigorous evaluation research. Home Visiting Evidence of Effectiveness reviewed the home visiting research literature and provided an assessment of the evidence of effectiveness for program models that serve families with pregnant women and children from birth to age 5. METHODS: Home Visiting Evidence of Effectiveness included a systematic search and screening process, a review of the research quality, and an assessment of program effectiveness. Reviewers rated studies' capacity to provide unbiased estimates of program impacts and determined whether a program met the Department of Health and Human Services' criteria for an evidence-based model. RESULTS: As of July 2012, 32 models were reviewed, of which 12 met the Department of Health and Human Services criteria. Most of these models were shown to have favorable effects on child development. Other common favorable effects included health care usage and reductions in child maltreatment. Less common were favorable effects on birth outcomes. CONCLUSIONS: Home visiting is a promising way to serve families who may be difficult to engage in supportive services. Existing rigorous research indicates that home visiting has the potential for positive results among high-risk families, particularly on health care usage and child development.

OBJECTIVE: To identify associations between cocaine exposure during pregnancy and medical conditions in newborn infants from birth through hospital discharge. DESIGN: Multisite, prospective, randomized study. SETTING: Brown University, University of Miami, University of Tennessee (Memphis), and Wayne State University. Subjects A total of 717 cocaine-exposed infants and 7442 nonexposed infants. MAIN OUTCOME MEASURES: Results of physical examination and conditions observed during hospitalization. RESULTS: Cocaine-exposed infants were about 1.2 weeks younger, weighed 536 g less, measured 2.6 cm shorter, and had head circumference 1.5 cm smaller than nonexposed infants (all P<.001). Results did not confirm previously reported abnormalities. Central and autonomic nervous system symptoms were more frequent in the exposed group: jittery/tremors (adjusted odds ratio, 2.17; 99% confidence interval, 1.44-3.29), high-pitched cry (2.44; 1.06-5.66), irritability (1.81; 1.18-2.80), excessive suck (3.58; 1.63-7.88), hyperalertness (7.78; 1.72-35.06), and autonomic instability (2.64; 1.17-5.95). No differences were detected in organ systems by ultrasound examination. Exposed infants had more infections (3.09; 1.76-5.45), including hepatitis (13.46; 7.46-24.29), syphilis (8.84; 3.74-20.88), and human immunodeficiency virus exposure (12.37; 2.20-69.51); were less often breastfed (0.26; 0.15-0.44); had more child protective services referrals (48.92; 28.77-83.20); and were more often not living with their biological mother (18.70; 10.53-33.20). CONCLUSIONS: Central and autonomic nervous system symptoms were more frequent in the exposed cohort and persisted in an adjusted analysis. They were usually transient and may be a true cocaine effect. Abnormal anatomic outcomes previously reported were not confirmed. Increased infections, particularly sexually transmitted diseases, pose a serious public health challenge. Exposure increased involvement of child protective services and out-of-home placement.

Parental substance abuse is a significant factor in many of the families served in the child welfare system. This article examines: (1) the prevalence of substance abuse among families involved with the child welfare system; (2) the impact of substance abuse on child welfare practice; (3) how both the Adoption and Safe Families Act of 1997 and welfare reform legislation intensify the need to address parental substance abuse effectively; and (4) promising strategies for addressing these families' needs.

In this article, we use data on biological fathers (n = 597) and mothers (N = 1,550) from 12 sites of the Early Head Start Research and Evaluation Project (EHS study) to examine the type and frequency of father involvement. We use a three-part model of father involvement to examine whether fathers participating in the EHS study are accessible to, engaged with, and show responsibility for their two-year-old children. We also examine patterns of reported father involvement by relationship status and residency. We find that more than 80% of all two-year-old children in the EHS study have accessible biological fathers, with the majority of nonresident boyfriends and nonresident friends and more than a third of fathers in no relationship with the mother seeing their children at least once in three months. These accessible fathers are engaged in a range of activities and show responsibility for their children, although patterns vary by the father-mother relationship status and father residency. More specifically, fathers who had at least a romantic relationship with the mother were more involved with their children across types of involvement than those in no relationship. Associations between relationship status and father engagement and responsibility remained after controlling for demographic variation among fathers in different relationship groups. A significant proportion of fathers who had no relationship with the mother of their child had some contact with the child, suggesting that the relationship between mother and father is not the only factor helping fathers stay involved in their children’s lives. Finally, fathers report doing a lot more caregiving than has been suggested by other studies.

The purposes of the current study were: (1) to examine the roles of early maternal attachment relationships and teacher-child relationships during childhood for externalizing and internalizing behaviors in late childhood, and (2) to investigate teacher-child relationships, as well as externalizing and internalizing behaviors in early childhood as possible mechanisms linking early maternal attachment relationships to behavior problems in late childhood. Longitudinal data from the National Institute of Child Health and Human Development Early Child Care Research Network Study of Early Child Care and Youth Development (N = 1140 mothers and children) were used in this investigation. There were three main findings. First, insecure/other maternal attachment relationships in early childhood (i.e., 36 months) were associated with externalizing and internalizing behaviors in late childhood (Grade 5). Second, elevated levels of teacher-child conflict during childhood were associated with externalizing behaviors in late childhood whereas low levels of teacher-child closeness were associated with internalizing behaviors. Third, the effects of insecure/other attachment on externalizing and internalizing behaviors in late childhood were mediated through teacher-child relationships during childhood and early externalizing and internalizing behaviors. Implications for attachment theory are discussed.

Study 1 investigated whether differences in the lexical explicitness with which languages express false belief influence children's performance on standard false belief tasks. Preschoolers speaking languages with explicit terms (Turkish and Puerto Rican Spanish) were compared with preschoolers speaking languages without explicit terms (Brazilian Portuguese and English) on questions assessing false belief understanding either specifically (the think question) or more generally (the look for question). Lexical explicitness influenced responses to the think question only. Study 2 replicated Study 1 with groups of both speakers differing in socioeconomic status (SES). A local effect of explicitness was found again as well as a more general influence of SES. The findings are discussed with regard to possible relations among language, SES, and understanding of mind.

A critical component of community-based disaster preparedness (CBDP) is a local resource database of suppliers providing physical, information and human resources for use in disaster response. Maintenance of such a database can become a collaborative responsibility among community-based non-governmental organisations (NGOs) and public and private community organisations. In addition to mobilising resources, this process raises awareness within the community and aids in assessing local knowledge and resources. This paper presents the results of a pilot study on implementing a community-based resource database through collaboration with local American Red Cross chapters and public and private community organisations. The design of the resource database is described. The resource database is accessible via the internet and offline using laptops and handheld Personal Digital Assistants. The study concludes that CBDP is strengthened through a combination of appropriate information technology and collaborative relationships between NGOs and community-based organisations.

This school-based randomized controlled trial tested the efficacy of 2 expressive writing interventions among youth living in high-violence urban neighborhoods. Seventeen classrooms (n = 258 seventh graders; 55% female; 91% African American/Black) from 3 public schools were randomized to 3 conditions in which they wrote 8 times about a nonemotional topic (control condition) or about experiencing and witnessing violence following either a standard or an enhanced expressive writing protocol. Outcomes were assessed 1 month prior and 2 and 6 months postintervention and included teacher-rated emotional lability and aggressive behavior and child-rated physical aggression. Intent-to-treat, mixed-model analyses controlled for preintervention measures of outcomes, sex, race, and family structure. At 2 months postintervention, relative to controls, students in the standard expressive writing condition had lower levels of teacher-rated aggression and lability (d = -.48). The beneficial effects of the writing interventions on aggression and lability were stronger at higher levels of community violence exposure.

The U.S. Department of Health and Human Services (HHS) is committed to advancing the oral health and general well-being of all populations across the lifespan.The HHS Oral Health Strategic Framework 2014-2017 (hereinafter, the Framework) reflects the collective deliberations and next steps proposed by HHS and other federal partners to realize the department's oral health vision and eliminate oral health disparities.The Framework builds upon and outlines a strategic alignment of HHS operating and staff divisions' resources, programs, and leadership commitments to improve oral health with activities of other federal partners.The U.S. Public Health Service Oral Health Coordinating Committee authored the Framework to provide the context for leveraging current and planned oral health priorities and actions across HHS and partner agencies.The Framework aligns key activities with five major goals and associated strategies in response to recommendations from two 2011 Institute of Medicine reports, Advancing Oral Health in America and Improving Access to Oral Health Care for Vulnerable and Underserved Populations, 1,2 and reflects discussions with external stakeholders.Although the Framework does not attempt to inventory all oral health initiatives supported by HHS and other federal partners, it provides a roadmap to prevent oral disease, increase access to services, develop and disseminate oral health information, advance public policy and research and translate it into practice, strengthen the oral health workforce, and eliminate oral health disparities.The Framework is written primarily for oral health, behavioral health, and primary care health professionals and program administrators within and outside of the federal government and other external stakeholder groups interested in oral health.It serves as an essential resource to ( 1) optimize the implementation of activities that are planned and underway, (2) strengthen existing cross-agency collaboration, and (3) identify new avenues for privatepublic partnerships by creating maximum synergy with other current federal and nonfederal oral health initiatives. THE CHALLENGEA stated health objective of our nation is to place a greater focus on health and not just health care.3 Total health and wellness cannot exist without oral health, and the two are closely linked.Oral disease can have an impact on physical, psychological, social, and economic health and well-being through pain, diminished function, and reduced quality of life.These impacts were underscored in the Office of the Secretary/OMH.The Office of the Secretary/ OMH works to improve awareness of the benefits of electronic health records for providers serving underserved and at-risk communities, and use websites and trainings to fully promote functional and exchangeable

On March 23, 2010, the President signed into law the Affordable Care Act (Public Law 111-148), which included an amendment of Title V of the Social Security Act authorizing the creation of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Authorized and funded at $1.5 billion for 5 years, the MIECHV represents a large investment in health and development outcomes for at-risk children through evidence-based home visiting programs. The MIECHV presents unprecedented opportunities to integrate early childhood services systems, not only on the federal level but also within states and local communities. The MIECHV is funded in escalating amounts over 5-year period authorized, as follows: $100 million in fiscal year (FY) 2010, $250 million in FY 2011, $350 million in FY 2012, $400 million in FY 2013, and $400 million in FY 2014. Most of the funding is being provided to states and territories to provide home visiting services in their at-risk communities. In addition, the legislation included a 3% set-aside for tribes, tribal organizations, and urban Indian organizations and a 3% set-aside for research and evaluation. This investment has spurred the creation of more comprehensive and coordinated early childhood service systems across the United States. This article provides an overview of the MIECHV program, including descriptions of the various requirements under the Affordable Care Act. These include partnering with states to provide evidence-based home visiting services to at-risk families, working with tribal communities to implement culturally competent home visiting programs, and developing a mechanism to systematically review the evidence of effectiveness for home visiting program models and to conduct a national evaluation of the MIECHV program.

This study examined the successes and challenges of refugee entrepreneurs by interviewing 50 refugees, service providers, and technical assistance providers. Qualitative data analyses revealed that successes and challenges occurred both at the individual and family levels as well as at the community and agency levels. The findings underscore the need to acknowledge the importance of the personal characteristics of the individual entrepreneurs, to deal with the competing factors revolved around family commitments, to encourage agencies to provide sufficient literacy and financial training, and to have community collaborations for capacity-building.

OBJECTIVE: To evaluate feeding difficulties and maternal behaviour during a feeding session with 1 month old infants prenatally exposed to cocaine and/or opiates. METHODS: The study is part of the maternal lifestyle study, which recruited 11 811 subjects at four urban hospitals, then followed 1388 from 1 to 36 months of age. Exposure to cocaine and opiates was determined by maternal interview and meconium assay. At the 1 month clinic visit, biological mothers were videotaped while bottle feeding their infants. This sample included 364 exposed to cocaine, 45 exposed to opiates, 31 exposed to both drugs, and 588 matched comparison infants. Mothers were mostly black, high school educated, and on public assistance. Videotapes were coded without knowledge of exposure status for frequency, duration and quality of infant sucking, arousal, feeding problems, and maternal feeding activity and interaction. RESULTS: No cocaine effects were found on infant feeding measures, but cocaine-using mothers were less flexible (6.29 v 6.50), less engaged (5.77 v 6.22), and had shorter feeding sessions (638 v 683 seconds). Opiate exposed infants showed prolonged sucking bursts (29 v 20 seconds), fewer pauses (1.6 v 2.2 per minute), more feeding problems (0.55 v 0.38), and increased arousal (2.59 v 2.39). Their mothers showed increased activity (30 v 22), independent of their infants' feeding problems. CONCLUSIONS: Previous concerns about feeding behaviour in cocaine exposed infants may reflect the quality of the feeding interaction rather than infant feeding problems related to prenatal exposure. However, opiate exposed infants and their mothers both contributed to increased arousal and heightened feeding behaviour.

This monograph addresses the hypotheses that preschool children benefit most strongly when early care and education (ECE) is at or above a threshold of quality, has specific quality features, and/or is of longer duration. These issues are pivotal in recent policies designed to improve the quality of ECE, especially for children from low-income families. Evidence of quality thresholds in which ECE quality has stronger impacts in settings with moderate to high levels of quality than in settings with low quality would inform policy initiatives in which monetary incentives or consequences are allocated to ECE settings based on their level of quality. Evidence that specific features of quality, such as quality of teacher-child interactions and of literacy and mathematics instruction, are predictors of gains in child outcomes could help inform quality improvement efforts. Evidence that more time spent in center-based ECE or in instruction in specific content areas predict larger gains among preschoolers could be useful in designing public preschool programs such as Head Start or prekindergarten. Secondary data analyses of eight large studies of preschool children in center-based ECE were conducted. Analyses focused on quality thresholds and quality features examined the extent to which three types of quality measures predicted gains in children's language, literacy, mathematics, and social skills. The measures comprised (1) global quality measures that provide an overall or global rating of quality, focusing on interactions as well as on physical features of the environment, activities, and routines; (2) interaction-specific measures that focus in depth on the quality of interactions between teachers and children with respect to instructional and emotional support; and (3) domain-specific measures that focus on the quality of instruction and stimulation in specific content areas such as early language and literacy. The goal was to provide replicated analyses with data from several projects in order to address each question. Multilevel analyses that controlled for entry skills were conducted, and results were combined by using meta-analysis, nonlinear and nonparametric analyses, and propensity score analyses. With respect to thresholds, the analyses suggest that increases in the quality of instruction are related to larger gains in language and literacy outcomes, but only in higher quality classrooms. Results point to stronger associations between quality and child outcomes in higher versus lower quality classrooms for measures of the instructional quality of teacher-child interactions and of the quality of specific activities thought to promote early literacy, such as teaching phonemic skills and book reading. In addition, the items focusing on quality of interactions on the global measure also predicted acquisition of language and social skills in higher but not in lower quality classrooms. With respect to quality features, interaction-specific and especially domain-specific measures of quality remained significant predictors of child outcomes, whereas global measures of quality were never significant positive predictors, when both global and more specific measures of quality were included simultaneously in analyses. There is thus consistent evidence that more specific measures of quality are better predictors of child outcomes. With respect to dosage, several approaches were used in operationalizing both the cumulative and current dosage of children's exposure to ECE. Propensity score analyses that included baseline scores on outcomes to control for selection into larger dosages suggested that children with two as opposed to one year of Head Start had stronger vocabulary and literacy skills both immediately upon exit from Head Start and at the end of kindergarten. Fewer absences and more observed time spent on instruction were associated with stronger gains in literacy and mathematics skills. Finally, findings revealed that more time spent on instruction in classrooms with higher overall quality was particularly important to the development of mathematics skills. No other replicated evidence of quality by quantity interactions emerged.

Child protection systems that implement differential response (DR) systems screen to route referrals to an investigation response (IR) or alternative response (AR). AR responses emphasize family engagement, assessment of family needs, and service linkage. Usually, AR state-level policy does not require child welfare staff to make a maltreatment determination. Jurisdictions implement DR systems differently, leading to variations in the proportion of AR cases, risk levels of cases served, and the ways families access and use services. County data from the National Child Abuse and Neglect Data System were analyzed for six states from 2004 to 2013 that implemented DR. Variation in county-level AR rates were associated with county-level re-report rates using regression models with risk adjustments for socioeconomic and other county characteristics. Counties had 3% fewer re-reports overall for each percentage increase in AR use; higher levels of AR use are related to lower levels of re-reporting. When county AR and IR cases were analyzed separately, increasing rates of AR were associated with lower re-report rates for IR cases, but higher re-report rates for AR cases. Findings for the AR and IR subgroup must be interpreted with caution as a number of technical factors may be driving these results.

In recent years, researchers, policymakers, and practitioners have expressed a growing interest in the use of interventions with scientific evidence of effectiveness. Reproducing positive effects shown in research, however, requires more than simply adopting an evidence-based program. There is growing recognition across disciplines of the importance of implementation research to guide adoption, replication, and scale-up of evidence-based interventions. We evaluate the state of the knowledge base supporting replication and scale-up of evidence-based programs by reviewing information on implementation included in the research literature on 22 home visiting programs that have or are building an evidence base. We used the Interactive Systems Framework for Dissemination and Implementation to assess programs.