STARTING EARLY STARTING SMART:
SUMMARY OF EARLY FINDINGS

The Starting Early Starting Smart Steering Committee

December 2001

This report was supported by Grant 6 UD1 SP08255 from the U.S. Department of Health and Human Services (DHHS), the Substance Abuse and Mental Health Services Administration (SAMHSA) and its three centers—the Center for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT)—and Casey Family Programs. This report would not have been possible without the contributions of staff from DHHS, the SAMHSA Office on Early Childhood, Casey Family Programs, the Starting Early Starting Smart (SESS) principal investigators, project directors and researchers, and the parent representatives, who helped design and supervise the data collection. The content of this publication does not necessarily reflect the views or policies of DHHS or Casey Family Programs, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Responsibility for the content of this report, however, rests solely with the named authors.

Suggested citation:
Casey Family Programs and the U.S. Department of Health and Human Services (2001). Starting Early Starting Smart: Summary of Early Findings. Washington, DC: Casey Family Programs and the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

STARTING EARLY STARTING SMART: SUMMARY OF EARLY FINDINGS

The Starting Early Starting Smart Steering Committee

Starting Early Starting Smart (SESS) provides an integrated system of child-centered, familyfocused, and community-based services targeted to at-risk children from birth to age 7 at twelve sites across the country. This 4-year program and evaluation study is sponsored by an innovative public-private collaboration between the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) and Casey Family Programs. The SESS collaboration also includes service providers and researchers in the local sites, and families who participate in the program, rather than simply attend it. Families are represented in local collaborations, on the national Steering Committee, and in the SESS Family Institute.

To access families that are often not in the mainstream of service access and use, SESS programs partner with primary care institutions and early childhood education institutions. These settings are thought to be windows of opportunity in which caregivers are particularly open to helping services that may benefit their children. Five of our programs are in primary care settings; seven are in early childhood education settings—five of these are in Head Start programs, and two are in child care settings.

Rigorous evaluation of the project has produced early findings demonstrating that SESS programs have succeeded in:

• Increasing access to needed services for participating families
• Helping participating families strengthen the ways in which they positively guide and support the development of their young children
• Decreasing drug use among caregivers when programs targeted caregivers in need of substance use treatment
• Strengthening positive interaction between participating caregivers and infants in the early months of life
• Strengthening the development of young children in the program in ways that are crucial for future school success

The SESS multisite methodology imparts lessons regarding where and how programs best engage families in behavioral health services. This summary will elaborate and explain findings of positive program effects across the broad scope of intended outcomes. As such, certain outcomes pertain only to families or sites with certain characteristics. For example, some measures are only meaningful for monolingual English speakers or for parents who show warning signs of substance use. In addition, two of the original programs could not be implemented due to legal and administrative difficulties. The findings therefore represent the families and sites for whom the particular measures were deemed most valid.

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Program Purposes
SESS purposes are embedded in growing public awareness and scientific understanding of the importance of the earliest years of life in setting the essential foundation for social-emotional development, cognitive development, and the caregiver nurturing and support that is important to later success in school and life. These purposes are also grounded in the growing knowledge and awareness that many families fall through the cracks in our service system because of fragmentation, poor infrastructure, lack of appropriate service, or cultural or individual barriers to service access.

Accordingly, SESS can be understood in the context of four sequential sets of purposes.

1. Creating integrated service collaboratives in each local community. While programs respond to the needs and opportunities in the local community, there are similarities in approach and procedure across the SESS collaboratives.

2. Improving access to and utilization of services needed by caregivers, families, and children. Strengthened access includes direct SESS services to families, but also includes services to systems that support these families. For preschool children, this includes strengthening the capacity of the preschool classroom to identify and respond to their developmental needs.

3. Improving parenting skills and overall family well-being in recognition that a strong and nurturing family environment is consistently documented as one of the most important assets a child can have for prevention of problem behaviors and support of positive outcomes. Family well-being includes the behavioral health of caregivers, parenting skills, and the establishment of a safe, nurturing, educational, and supportive home environment.

4. Ultimately, the accumulation of accomplishment in the above areas will strengthen early childhood development in ways that are known to support success in school and the social environment. The importance of these achievements cannot be minimized. All families want a better future for their children, and we know from longitudinal studies that the path established early in life is critical. In addition to these research purposes, the SESS initiative promotes two long-range systemic goals through program, DCC, SAMHSA and Casey Family Program, and other activities:

In addition to these research purposes, the SESS initiative promotes two long-range systemic goals through program, DCC, SAMHSA and Casey Family Program, and other activities:

• Improve Federal/State policy, promote blended funding, and reduce administrative barriers to integrated services for families and young children in need.

• Encourage Federal grant funding approaches to enable more partnerships, longer-term projects, and benefit-cost studies.

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Who Are the SESS Participants?
The idea that “if we build it, they will come” is not a reasonable expectation for behavioral health or other services important to multiple need families. The categorical approach to service delivery, a model that is characterized by centralized locations, highly defined diagnoses, and limited perspective services, has serious service access and delivery deficiencies. Multiple and related family needs are often not adequately addressed; the lack of a preventive orientation means that crises frequently trigger services, with more expensive prescriptions and consequences; and many barriers to service mean that families often do not access them voluntarily. The SESS programs have enrolled families and maintained them in multiple services.

The primary care and early childhood education settings provide opportunity to engage families of index children at very different ages. The great majority of children in the primary care sites are under 2 years old when their family enters the program. For some programs, children are newborns because many families are recruited from hospital delivery wards and pediatric departments. Children in early childhood education sites are almost always between 3 and 5 years old when a SESS program is initiated for their education center.

SESS families are of diverse ethnic and racial membership, and represent a variety of personal circumstances. Approximately 40 percent have less than 12 years of schoolroom education (compared to 16 percent nationally). Just over half are single parents (compared to 25 percent nationally). Neither parent is employed in 13.9 percent of families (compared to the 3-5 percent national unemployment rate).

As a group, they are in a disadvantaged circumstance with respect to service access. For example, over 29 percent of the SESS caregivers had no health insurance, compared to 18 percent of the American adult population. Other barriers to service access apply differentially across sites, including poor transportation resources, language barriers, uncertainty about legal status, and pressures from multiple jobs and coping with very low-income status, as well as many others. While these families often face multiple needs and challenges, they also bring caring and strengths. By keeping assets in perspective, SESS programs seek to more successfully engage and empower these families in their efforts to provide the best possible futures for their children. As a result, many lessons have been learned from each site’s unique approach to working with families in their particular community and cultural setting.

In summary, the information collected on study participants confirms that SESS programs engage and serve:

• Families and their children in the early years of life

• Families in a variety of community contexts and cultural backgrounds

• Families in a variety of multiple need situations, with a variety of unique assets to use in meeting these challenges

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SESS Service Principles and Program Components
With respect to the first of the SESS purposes, local programs have built collaborations designed to meet the particular constellation of priority needs within the population they serve, and to flexibly respond to the particular needs of each family.

Across these local collaborations, SESS has developed a common set of service concerns and a generally shared strategy for integrated service delivery. At a broad level, SESS programs share service principles.

• First, SESS programs strive to be Family-Centered, meaning that they engage and involve families in the mutual identification and resolution of their unique needs. From a service perspective, the dignity of the family is respected in the most fundamental way by fashioning a collegial and trusting relationship.

• Second, SESS programs strive to be Strengths-Based, meaning that SESS programs identify and support the many personal and cultural strengths that caregivers bring to their families, and not simply the inferred needs that may require participation in treatment services.

• Third, SESS programs adopt a Holistic Perspective. This means that families, caregivers, and children are engaged in their fullness and complexity. Often, single service solutions will not be effective. For example, it is recognized that a caregiver consumed with concern about meeting basic survival needs such as housing or transportation for her or his family must be given help and hope in this area before other needs can be met.

To put these principles into practice, SESS programs also share a common portfolio of service components. Engagement with the family—providing family support, advocacy, and care coordination—lies at the center of SESS service components. A typical SESS site provides or supports access to a range of family and parenting services, child development and child mental health services, and caregiver mental health and substance abuse services.

SESS programs address indicated needs for treatment services, and also represent prevention in its most fundamental sense. For children, numerous studies have clearly demonstrated the importance of family as a protective factor as youth mature. Our increasing understanding of the earliest years of life makes it clear that prevention must begin in the early years when so much foundational development takes place.

In summary, SESS programs share important program principles and components while maintaining flexibility in responding to individual families through care coordination. They:

• Establish and maintain collaborative relationships with other agencies and providers

• Work cooperatively with their host setting to increase capacity for family-centered, strengths-based, and holistic service provision

• Engage families in the home or on site

• Coordinate needed services with external agencies

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Service Access and Utilization
The portfolio of SESS services is designed to produce a sequence of outcomes that culminate in strengthened child development outcomes for SESS children. The sequence of intended outcomes begins with efforts to improve access to and use of needed services by SESS families.

Thorough and rigorous evaluation research ¹ has demonstrated that, over two follow-up measures, approximately 6 and 12 months after program entry:

SESS programs increase access to and use of needed services by participating families.

More specifically, SESS programs increased caregiver participation in educational and therapeutic services concerning parenting behaviors. The bars in the graphs of service access outcomes indicate the percentages of SESS participants who received parenting services across the two follow-up time points as compared to study participants receiving the usual standard of care in their sites. SESS parenting services are a comprehensive package tailored to the service environment of each site, commonly including:

• Site-based parenting classes

• Home-based parenting skills development

• Mom-and-baby classes

• Social support groups

• Information sessions (cooking, budgeting, etc.)

• Support services for basic family needs (e.g., housing, transportation)

Primary care sites had the opportunity for more focused selection of caregivers with behavioral health needs, including both substance use and mental health. Approximately half of the caregivers at these sites (423) showed substance use warning signs at baseline, including: a history of use, other users in the family, and symptoms of use noted by the family worker. A greater number of SESS caregivers with warning signs had entered substance treatment by the first follow-up than had standard of care comparisons.

Similarly, 337 caregivers at primary care sites (approximately 40 percent) showed mental health warning signs at baseline, including: scoring in the “risk” zone on a mental health screen, recent mental health treatment, or an unmet need for mental health treatment. A greater number of SESS caregivers with warning signs had entered mental health treatment by the first follow-up than had standard of care comparisons.

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Improved Family Well-Being
Increased access to needed services combined with family strengthening, advocacy, and support provided by SESS staff working with families are expected to facilitate improvements in family well-being. Improved well-being is reflected in several areas of impact on caregivers and families. Caregivers are supported in improving methods of resolving family conflict, improving their parenting skills, and strengthening their family environment, as well as in meeting their personal behavioral health needs.

Parenting and family services are a central component of SESS prevention. Most of these services are provided by SESS staff themselves, or by collaborators who have a central, often contractual, role in providing services to SESS families. Parenting and family services in different programs include: group educational sessions on infant and toddler development, nurturing and care, and preschool child development and parenting skills. Primary care sites also offer dyadic mother-child groups. Other parenting and family support services include a variety of informational and social support meetings, regular parenting support groups, and situational informational and educational activities in the home or in other situations of teaching opportunity. Early evaluation findings indicate that:

SESS programs help participating families strengthen the ways in which they positively guide and support the development of their young children.

Statistical findings specify the areas in which this strengthening occurs.

• SESS caregivers made gains in appropriate discipline and positive reinforcement for their children compared to declines in both of these positive parenting behaviors in comparison families. These positive gains were strongest in early childhood programs that emphasize education with respect to parenting.

• The SESS research included observations or reports on the home environment of participant and comparison families. There was an increased presence of learning stimulation in the homes of SESS families while indicators of learning stimulation declined in comparison homes. This finding refers only to families for whom the home measure was age- and culture-appropriate (omitted by Native American site).

• In another important area, SESS caregivers report a decrease in verbal aggression in the home, while comparison homes experienced an increase in this form of conflict. This finding refers only to those caregivers for whom the conflict measure was culturally appropriate (omitted by a primarily Asian American program), and who had a relationship partner at both baseline and the first follow-up interview.

Together, the pattern of statistically significant positive change in these indicators is evidence of positive program impacts on the well-being of the SESS families.

Primary care sites in particular have targeted caregivers with substance use issues, and increased their access to treatment services. Early research findings confirm the effectiveness of improving access to substance use treatment.

SESS programs that target services for caregivers in need of substance use treatment decrease use rates among caregivers in need.

More specifically, 211 caregivers at primary care sites reported having an acute need for substance use treatment at baseline. Among these, SESS participants demonstrated a greater decline in drug use between program entry and the first follow-up interview than comparison caregivers. While use dropped for both groups, SESS caregivers were using more heavily at baseline and dropped their use more sharply during the program. Programs that targeted caregivers with need for substance use services have had early success in achieving this major behavioral health objective.

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Outcomes for Child Development
The ultimate intended outcomes of the SESS interventions are to lay a more positive foundation of social-emotional, physical, and cognitive development for children. The intervention is a focused attempt to improve the futures of children at a point when they are most vulnerable—in the earliest years of life.

Early evaluation findings indicated strengthened outcomes for both major age groups of SESS children. In the primary care sites that serve newborns and infants:

SESS programs strengthen positive interaction between participating caregivers and infants in the early months of life.

More specifically, videotaped feeding and playtime interactions between mothers and infants were found to be more positive and responsive for SESS families than for comparison families at the first follow-up interview. These findings represent important strengthening of the caregiver- child interaction that is crucial to positive child development in the first years of life.

For older preschool children, largely in the early childhood education sites, early evaluation findings support a conclusion that:

SESS programs strengthen the development of young children in ways that are crucial for future success.

Appropriate social-emotional development is an important foundation for school readiness and the ability to successfully adapt to the school-learning environment. SESS staff helped children through:

• In-class behavioral observation

• In-class social skills curriculum

• Early assessment of behavioral issues

• Therapeutic individual and group sessions

• Behavioral management techniques

In teacher ratings of preschool classroom behavior, SESS children demonstrated a decreased incidence of external and internal problem behaviors, while comparison children were observed to have increasingly problematic behaviors in these areas. The reduction in externalizing problems is particularly important because these behaviors are disruptive in the classroom, and interfere with the ability of a child to benefit from the classroom experience.

Reports by caregivers confirm the classroom teacher reports in the area of internalizing problems. Externalizing behaviors may manifest quite differently in home and classroom environments.

Finally, SESS children also experienced a much steeper rise in the mastery of linguistic concepts than did comparison youth who did not benefit from the augmentation of their preschool environment through SESS. This outcome is based upon a psychological assessment in which a trained clinician conducts speaking, comprehension, and verbal recognition exercises with the child (rather than parent observation or self-report). It is appropriate only for monolingual,English-speaking children as one measure of school readiness. This positive finding for SESS families demonstrates the benefit of SESS services, including increasing the staff-to-child ratio in educational settings and providing staff with the resources to make learning fun and interactive. Solid language skills are critical tools for academic success as they lay a foundation for reading ability.

Taken together, the findings on social-emotional and linguistic development in preschool SESS children form a promising result with respect to school and reading readiness.

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Summary
In summary, the SESS demonstration has demonstrated scientifically validated successes with respect to the major sequential stages of positive outcomes that represent the intent of the programs. Access to crucial areas of family and needed behavioral health services has been increased. The well-being of families, and therefore their nurturing and supportive influences on their youngest members, has grown stronger in important ways. And the infants, toddlers, and children nurtured by these strengthened families, strengthened classrooms, and the SESS programs have benefited in their early development.

As the study continues, SESS will report findings from many more analyses to examine site variation and similarity, combinations of program characteristics or services that are linked with specific outcomes, and longitudinal outcome findings.

In short, SESS is showing that we can achieve what we know must be done. We can engage families of young children on the borders of the service system, build their strengths, support their victory over challenges, and help build stronger environments for their children. Most important, these accomplishments can produce gains in attachment for infants, and in socialemotional and behavioral development of preschool children that are measurable even shortly after initiation of the intervention. We can create a more solid foundation for the positive growth of these young children.

Our growing knowledge of children’s social-emotional development tells us that these early gains will reap later rewards in positive youth development and resiliency. The experience and research findings from the SESS collaboration highlight the crucial tasks before us. As a society, we must mobilize the collective will, disseminate the knowledge, and make the policy choices necessary to bringing these services to every young child in need.

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APPENDICES
A. About Starting Early Starting Smart
B. SESS Program Acknowledgments
C. Starting Early Starting Smart Grant Sites

Appendix A: About Starting Early Starting Smart

Starting Early Starting Smart (SESS) is a knowledge development initiative designed to:

• Create and test a new model for providing integrated behavioral health services (mental health and substance abuse prevention and treatment) for young children (birth to 7 years) and their families; and to
• Inform practitioners and policymakers of successful interventions and promising practices from the multi-year study, which lay a critical foundation for the positive growth and development of very young children.

The SESS approach informs policymaking for:

Service system redesign	Service access and utilization strategies
Strengthening the home environment	Targeting benefits for children
Using culture as a resource in planning services with families	Working with families from a strengths- based perspective

In October 1997, with initial funding of $30 million, the Substance Abuse and Mental Health Services Administration (SAMHSA) and Casey Family Programs embarked on a precedentsetting public/private collaboration. Twelve culturally diverse grantee organizations were selected. Each provides integrated behavioral health services in community-based early childhood settings—such as child care, Head Start, and primary care clinics—where young families customarily receive services for children. Critical to this project is the required collaboration among funders, grantees, consumers, and local site service providers. Implicit in the design of this project is sustainability planning for secured longevity of the programs.

The Research Design
The 12 grantees, working collaboratively, designed a study whereby integrated behavioral health services are delivered in typical early childhood settings. Each site has an intervention and comparison group, and each site delivers similar targeted, culturally relevant, interventions for young children and their families. A collaboratively determined set of outcomes has been established to evaluate project effectiveness:

Access to and use of services	Caregiver-child interaction outcomes
Social, emotional, and cognitive outcomes for children	Family functioning

The goal of the SESS research is to provide rigorous scientific evidence concerning whether children and families participating in SESS programs achieve better access to needed services and better social, emotional, cognitive, and behavioral health outcomes than do the children and families not receiving these services. SESS programs may also generate information about opportunities, practices, and barriers to sought-after outcomes. This information is critical to achieving effective public policies.

SESS Extended
It was clear from the early days of SESS that whatever effects were uncovered, longitudinal extension of the study would be valuable. In 2001, SAMHSA and Casey Family Programs embarked upon an extension phase, which will increase understanding of the impact of early intervention as young children enter preschool and school years, when babies or toddlers are asked to meet escalating emotional and cognitive demands. This longitudinal extension can validate early methods and findings and assess their durability. It is anticipated that this work will include additional data points of a refined instrument set and intervention package with the addition of study questions related to cost and value, and other special studies. Additional future plans include applying and validating early SESS lessons learned, key concepts, components, and principles to new settings that serve families with young children.

Summation
In sum, SESS reflects the growing acknowledgement that it is important to target positive interventions to very young children. The infant and preschool years lay a critical foundation for later growth and development. Second, successful interventions for very young children must meet the multiple behavioral health, physical health, and educational needs of families. Third, integrated behavioral health services must be made more accessible to families with multiple needs, which are difficult to meet in a fragmented service system.

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Appendix B: SESS Program Acknowledgments

The Families and Grantees of Starting Early Starting Smart (SESS) would like to acknowledge:

along with the Casey Board of Trustees and the three SAMHSA Centers—Center for Substance Abuse Prevention, Center for Substance Abuse Treatment, and Center for Mental Health Services—for their vision and commitment to reaching families with very young children who are affected by environments of substance abuse and mental disorders. Without their innovative public-private partnership and unprecedented support, this initiative would not have been possible.

We further acknowledge the early guidance and program development from Stephania O’Neill, M.S.W.; Rose Kittrell, M.S.W.; Hildy (Hjermstad) Ayers, M.S.W.; Karol Kumpfer, Ph.D.; Sue Martone, M.P.A.; and Jeanne DiLoreto, M.S. In addition, the advisement and investment of the U.S. Department of Education, the Health Resources and Services Administration and the Administration for Children and Families of the U.S. Department of Health and Human Services were critical in this collaboration effort.

Many thanks to the SAMHSA-Casey Team for their tenacious efforts and unprecedented collaboration:

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Appendix C: Starting Early Staring Smart Grant Sites

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¹ The SESS cross-site research used a carefully designed instrument package, control or comparison group designs to distinguish SESS program effects from the gains made through the usual standard of care in each site, and several repeated measurement points to establish the longer-term pattern of program effects. These early findings are based upon two follow-up measures for service access data (at about 4 months and 8 months after program entry), and one follow-up for family and child outcome data (at about 8 months after program entry). All statistical contrasts presented here are statistically significant (1-tailed test, p < .05 for univariate tests, < .10 for multivariate), unless labeled as a trend. The continued analysis of follow-up information will allow us to confirm and elaborate the early findings reported here on the first year of service to families.

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