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A SpeciAl RepoRt by h task F r on S ra g p ann ngf r infan and t dd r D v m nMAYoRS ADViSoRY coMMittee oN eARlY cHilDHooD DeVe opMeNt

N t m Waensur ng a G d S ar f r infan s and t dd rsn h D s r f c umb a


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CHAIR Joan Lombardi The Childrens Project

TASK FORCE MEMBERSAlice Galper Educational ConsultantLindsey Allard DC Head Start State Collaboration Of ceGeorge Askew Docs for Tots Jennifer Boss ZERO TO THREEMarsha Boveja Rosemount Center

Joyce Brooks Maternal and Family Health AdministrationMichelle Crowder-Sermon D.C. Dept. of Health, Maternal and Family Health Administration Joe Collier Jubilee JumpStartBarbara CurtisKendra Dunn D.C. Childrens Trust Fund Jaimie Caleb D.C. Dept. of Health, Maternal and Family Health AdministrationWalter Faggett D.C. Dept. of Health, Maternal and Family Health AdministrationMarta Gonzalez D.C. Dept. of Human Services, Early Care and Education AdministrationDebbi Hall Big Mamas Children CenterTravis Hardmon NCCFDMarilyn Hamilton Univ. of the District of ColumbiaBill Hughey UPO Of ce of Pre-school & Day CareSuzanne Humpstone Parent-Child Home Program

Beverly Jackson U.S. Dept. of Health and Human Services, Admin. for Children and FamiliesBarbara Ferguson Kamara D.C. Dept. of Human Services, Early Care and Education AdministrationGeraldine Law Kids Are Us Learning CenterTanetta Merritt Southeast Childrens Fund Infant/Toddler CenterGloria Otero D.C. Dept. of Human Services, Early Care and Education AdministrationPeter Pizzolongo NAEYCCrystal Powell UPO Of ce of Pre-school & Day CareNiccola Reed The New Family Child Care Providers AssociationTracey Rush Docs for TotsBadiyah Sharif D.C. Dept. of Human Services, Early Care and Education AdministrationDonna Shelly Georgetown University Center for Child and Human DevelopmentPam Simon Just Us KidsPeter Tatian Urban InstituteCarolyn Taylor D.C. Dept. of Human Services, Early Care and Education AdministrationBarbara Tayman National Child Care Information CenterRuth Uhlmann Early Head Start SpecialistRobin Wallace D.C. Dept. of Human Services, Early Care and Education Administration Jean Wilks D.C. Dept. of Health, Maternal and Family Health AdministrationLettie Williams UPO Of ce of Pre-school & Day Care Joan Yengo Mary CenterDiana Zurer Early Childhood Leadership Institute

TASK FORCE STAFF Julie Cohen ZERO TO THREEHelene Stebbins HMS Policy Research


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ACKnOwlEdgMEnTSThe members of the task force are grateful for the nancial support provided by theEarly Care and Education Administration, and the staff support provided by ZEROTO THREE in producing this report. Special thanks to Barbara Ferguson Kamara,Administrator of the Early Care and Education Administration, for her vision to create ttask force and her dedication to the process. The behind-the-scenes work of the staffmade the report possible, especially Helene Stebbins from HMS Policy Research whogathered the data for the report, and Julie Cohen from ZERO TO THREE who groundein the research. There were dozens of others who provided data, answered questions,helped clarify the recommendations, and provided administrative support. They includebut are not limited to: Erica Lurie-Hurvitz, Yolanda Norton, Barbara Gebhard, KimberlyLagomarsino, Denise McCoy, Jacob Andoh, Nancy Blackwell, Ellen Yung-Fatah, LarSiClaiborne, Aman Sandhu, Tracey Rush, Kimberly Johnson, Jacqueline McMorris, JoanChristopher, Tracie Dickson, Edna Ranck, Robert Maruca, Linda Randolph, Rhonda WellsWilbon, BJ Wolf, Nathaniel Beers, Vince Schulyer, Mark Weissman, Jim Thompson, KadAsh, Richard Flintrop, Heather Koball, Olivia Golden, Orlene Grant, Jennifer Comey andthe Annie E. Casey Foundation for their support of the NeighborhoodInfo DC project.Thank you for your time, your knowledge, and your willingness to help infants andtoddlers thrive in the District of Columbia.


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The early years are a period of unparalleledgrowth. From the time of conception tothe rst day of kindergarten, developmentproceeds at a pace exceeding that of anysubsequent stage in life. Although the early yearsare a time of great opportunity for young children,they are also a time of great vulnerability. Babiesand toddlers need caregivers and parents to bewarm and nurturing, as well as to protect them fromenvironmental toxins, extreme poverty, malnutrition,substance abuse, homelessness, child abuse andneglect, community or family violence, and poorquality child care. Early and sustained exposure tosuch risks can in uence the physical architectureof the developing brain, preventing babies andtoddlers from fully developing the neural pathwaysand connections that facilitate later learning.

Every year, close to 8,0001 new residents are borninto the nations capital, and there are 19,0712children younger than age three. They live in a citywhere the trends on a variety of indicators of well-being for young children are improving.

The number of children in foster care declinedfrom 3,466 in 1999 to 2,554 in 2005.3

In 2005, the number of families applying foremergency shelter declined for the rst time insix years.4

The District of Columbia has one of the highestaccess rates for children eligible for child caresubsidies in the nation. Sixty-eight percent ofeligible children received subsidies in 2005,while the national average is estimated to bebetween 15 percent and 20 percent.5

But in one of the most powerful cities in the world,e are fai i our you est citize s i key areas

that i affect their success o ce they e ter schoo .

Close to one-half of the infants and toddlersin the District live in low-income families, analmost one-quarter live in extreme poverty(below 50 percent of the federal poverty level$8,300 for a family of three).6

Twenty-two percent of children younger than athree in the District are exposed to three orrisk factors twice the national average.7

More than one-third of all mothers, and morethan one-half of Hispanic mothers, did nothave adequate prenatal care, which includesbeginning prenatal care in their rst trimesterand making at least nine subsequent visits.8

Fifty-six percent of all births in the District wto single mothers, and in Wards 7 and 8 theis 80 percent or more.9

There are an estimated 2,000 at-risk families ithe District who could bene t from home visiservices, and less than 30 percent of that groreceives them.10

Medicaid reimbursement rates in the District aamong the lowest in the country. NationallyMedicaid reimburses primary care physiciansan average of 62 percent of Medicare fees. AMedicaid primary care physician in the DistricColumbia receives 35 percent of the Medicarefor the same service.11

According to the IDEA Infant and ToddlerCoordinators Association, the District ofColumbia is one of only a few states that donot dedicate any state or local funds for earlyintervention (IDEA Part C) services.12

Only 4 percent of eligible children (from birthage three) receive Early Head Start services.13

Of the 348 licensed child care centers in thDistrict, only 149 offer infant care. These cehave the capacity to serve 3,893 childrenyounger than age two, yet there are an estim13,000 children younger than age two in the

ex u v Summary

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District. By comparison, 325 of the 348 centersserve children from age three to age ve.14

Child care data gathered over a four-yearperiod indicate the quality of child care in manyinfant/toddler classrooms in the District isinadequate. 15 The Quality Training AssessmentProject found that out of twenty-four indicators,almost half were rated minimal or belowminimal for all four years.16

To identify ways to help infants and toddlersgrow and thrive, the District of ColumbiasMayors Advisory Committee on Early ChildhoodDevelopment created the Task Force on StrategicPlanning for Infant and Toddler Development. Taskforce members representing local home- andcenter-based child care programs, health clinics,social service agencies, universities, and relevantlocal government agencies met twice, andprepared a set of eleven recommendations for thecitys leaders framed by the cornerstones of goodhealth, strong families, and positive early learningexperiences. Although the depth and breadthof the recommendations reaf rm there is nosingle or simple solution, three principles shouldguide future decisions about prioritizing andimplementing the task forces recommendations.

Su r h d v m n f s r ng fam s andnur ur ng ar g v rs.The healthy development of young childrendepends on the healthy development of theadults in their lives. Families that face economicinsecurity, parents who struggle with substanceabuse or mental illness, and child care providerswho do not have adequate skills or resourcescannot provide the nurturing environments thatbabies and toddlers need to thrive.

pr v d m r h ns v su r s.Families with babies and toddlers need accessto a medical and dental home, high-qualitycomprehensive child care, home visiting services,and mental health, substance abuse, and otherfamily support services. These families need

coordinated access to all these supports, nota piecemeal approach, to protect them fromthe multiple risks threatening their healthydevelopment.

targ ar as f x r m n d.There are concentrated areas of extreme poverty arisk in the District of Columbia. Babies, toddlerstheir caregivers who live in these areas have theto lose from inaction, and the most to gain fromcoordinated, comprehensive response.

With the dramatic growth and development thattakes place in the early years, infants and toddneed the attention of policymakers now.The task forces recommendations provide aroadmap to guide policymakers in enactingpolicies supporting good health, strong families,and positive early learning experiences for infantand toddlers in the District of Columbia. Districleaders must act now to support familiesand the developmental needs of their youngchildren before it is too late.

There is no time to wait.

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GoAl i: iMpRoVe AcceSS to HeAltH AND MeNtAl HeAltH SeRViceS

1. I crease pre ata care, ith a focus o Hea th

Professio a Shorta e Areas.A. Identify and address barriers to prenatal care.

B. Improve the quality and number of prenatalcare facilities in Health ProfessionalShortage Areas.

2. Support curre t efforts to improve theeve opme ta scree i of chi re , a i crease

efforts to e sure chi re receive the fo o upeva uatio s a services they ee .

A. Provide core funding for the DC Partnershipto Improve Childrens Healthcare Qualityto continue implementing, validating, andcontinuously improving the standardizedmedical record forms.

B. Increase Medicaid reimbursement rates sochildren receive the followup evaluations andservices they need.

3. He p pare ts bri e the ap bet ee their chi re s hea th care ee s a the hea th caresystem.

A. Examine how Medicaid managed careorganizations are conducting outreach toparents.

B. Support the recommendation of the Districtof Columbias Children with Special HealthCare Needs Advisory Board to create a centralservice delivery system to provide early

identi cation, diagnosis, and treatment.C.Raise awareness about the importance of a

dental home.

4. E sure access to me ta hea th services byi creasi the or a izatio a commitme t aresources of the departme t of Me ta Hea th ire ar to ear y chi hoo eve opme t.

A. Appoint an individual in the DistrictsDepartment of Mental Health to focus solely

on early childhood mental health, particularlworking to address the mental health needsvery young children.

B. Garner funding to reinstate access to mentahealth consultation for all early childhoodprograms.

GoAl ii: SUppoRt FAMilieSoF VeRY YoUNG cHilDReN

5. I te sify efforts to provi e pare ti i formatio a support to pare ts of e bor s,i fa ts, a to ers.

A. Ensure help lines provide responsiveassistance and accurate referral information.

Convene administrators of the Districtsprimary help lines for parents of very younchildren to establish a schedule for regularlupdating information.

Improve training for staff who answer thesehelp lines to ensure appropriate

and responsive assistance.

B. Launch an outreach campaign for parents,particularly fathers, to raise awareness of thimportance of the rst three years of childdevelopment and to connect them to existininformation and referral resources.

6. Expa a better coor i ate home visiti services to fami ies.

A. Provide core funding for the Home VisitingCouncil to coordinate existing home visitingprograms, provide training and evaluationso programs meet high standards of quality,

and ensure families receive appropriate homvisiting services.

B. Increase funding for home visiting service

C. Establish a universal screening and referralprocess for all District residents who areparents of newborns.

7. de icate oca fu s to provi e ear yi terve tio services to more i fa ts a to ers.

p y R mm nda ns n Br f

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GoAl iii: pRoMote poSitiVe eARlY leARNiNG eXpeRieNceS

8. Create a et ork of ear y

eve opme t pro rams, a at eastt o comprehe sive service ce ters,particu ar y i ei hborhoo s ithpoor performi schoo s a hi hco ce tratio s of poverty.

A. Develop a network of EarlyDevelopment Programs building onexisting child care providers.

B. Create at least two comprehensiveservice centers in areas of the citywith high concentrations of poverty.

9. Support the professio a eve opme tof i fa t a to er chi care provi ers.

A.Support a career pathway that leadsto degrees and/or credentials forinfant and toddler caregivers.

Establish an Associate of Arts (A.A.)degree in Child Development with aconcentration in infant and toddlercare at a local institution of highereducation.

Increase child care subsidyreimbursement rates to supportbase pay at the living wage level forcaregivers in subsidized programs.

Increase scholarships for infantand toddler caregivers to earncredentials.

Promote increased staffcompensation linked to professionaldevelopment and education.

B. Provide training on the birth-to-threeearly learning guidelines through theEarly Childhood Leadership Institute.

C.Develop a network of infant/toddlerspecialists who provide onsiteguidance and support to infant andtoddler caregivers on issues relatedto early development, health, mental

health, family support, and programquality.

D. Increase the capacity of child care

settings to provide care to familiesthat re ect their culture andlanguage.

GoAl iV: pRoViDe tHe ReSoURceS ANDSUppoRt NeceSSARY to eNSURe tHAtcHilDReN Get oFF to A GooD StARt

10. E sure that fu i is avai ab e toimp eme t these recomme atio s.

A.Establish a set-aside of at least 20percent of any preschool expansionfunds to improve infant and toddlercare.

B. Increase child care funds targeted aimproving infant and toddler care.

C.Expand Early Head Start funds orencourage Congress to permit HeadStart funds to be used for childrenfrom birth to age ve in the DistrColumbia.

D. Create a public-private partnershipdedicated to funding services forinfants and toddlers.

11. E sure a equate perso e i cityover me t to support pro rams a

services for chi re a fami ies.

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A growing body of research highlights the tremendous and uniquewindow of opportunity to optimize future child developmentduring the rst three years of life. These early years are a periodof unparalleled growth. From the time of conception tothe rst day of kindergarten, development proceedsat a pace exceeding that of any subsequent stagein life.1 It begins during pregnancy, when themothers nutrition and physical and emotionalhealth begin to shape her babys future.Early experiences in uence the physicalarchitecture of the brain, literallyshaping the neural connections inan infants developing mind.2 Young children who do nothave the opportunityto participate inquality early learningexperiences, those whoare rarely spoken to, or thosewho have little opportunity toexplore and experiment with theirenvironment may fail to fully developthe neural connections and pathwaysthat facilitate later learning.3 Althougha childs brain takes years to developcompletely, never again will it develop with

the speed and capacity re ected in the prenatalmonths and rst three years of life.

Although the early years are a time of greatopportunity for young children, they are alsoa time of great vulnerability. A childs earlydevelopment can be compromised by in uencessuch as environmental toxins, extreme poverty,malnutrition, substance abuse, homelessness,child abuse and neglect, community or familyviolence, and poor quality child care. Many babies

N t m Waensur ng a G d S ar f r infan s and t dd rs

n h D s r f c umb ain r du n

p u a n f ch dr n Y ung r han Ag thrn h D s r f c umb

19,071 children younger than age threein the District of Columbia (2005).4

7,937 annual births (2004)5

1 Dot = 15 children younger than age 3

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face signi cant challenges long before they even learn totalk. Access to comprehensive, high-quality, developmentallyappropriate programs and services whether child care, EarlyHead Start, early intervention, or home visiting can serve asa protective factor for infants and toddlers.

In the District of Columbia, the trends on a variety of

indicators of well being for young children are improving. Butthe nations capital is still falling short in key areas that willaffect thesuccess of you chi re o ce they e ter schoo .It is clear there are concentrated, extreme areas of povertyand risk for infants and toddlers in the District, and we mustact now to support families and the developmental needs oftheir young children.

On March 15, 2006, the District of Columbias MayorsAdvisory Committee on Early Childhood Development createdthe Task Force on Strategic Planning for Infant and Toddler

Development to identify policy recommendations that wouldimprove services and supports for infants and toddlers. Joan Lombardi chaired the task force with staff supportfrom Barbara Ferguson Kamara and ZERO TO THREE. Taskforce members representing local home- and center-basedchild care programs, health clinics, social service agencies,universities, and relevant local government agencies mettwice, and reviewed two drafts of this report.No Time to Wait:Ensuring a Good Start for Infants and Toddlers in the District of Columbia is the culmination of the task forces work. Itoffers eleven policy recommendations organized by four

goals:

improve access to health and mental health services; support families of very young children; promote positive early learning experiences; and provide the resources and support necessary to ensure

that children get off to a good start.

We know, from the data and from experience, that babiescannot wait. With the tremendous growth and developmenttaking place in the early years, infants and toddlers need

the attention of policymakers now. We must work to ensurethat policies and programs help infants and toddlers get offto the best possible start in life. We have a responsibility totake action now to guide policymakers in enacting policiesthat support good health, strong families, and positive earlylearning experiences for all infants and toddlers in the Districtof Columbia.

There is no time to wait.

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B r h Da a, by Ward

Source: Every KID COUNTS in the District of Columbia; 13th Annual Fact Book 2006 (data year 2004)

59% Black

24% White

13% Hispanic

4% Other

B r hs, by Ra

Source: Every KID COUNTS in the District of Columbia, 13th Annual Fact Book, 2006 (data year 2004)

19,071 children younger than age three in the District of Columbia (24 7,937 annual births (2004)5

p r ra f infan s and t dd rs n h D8


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infan s and t dd rs , by in m l v

Source: National Center for Children in Poverty using the March supplement of the Current Population Survey for 2003-2005

Note: FPL means federal poverty level

ch dr n Y ung r than Ag thr ex r n ng Mu R sk Fa rsResearch demonstrates that circumstancescharacterized by multiple, interrelated risk factorsimpose particularly serious developmental burdensduring the early childhood years and are the most likelyto incur substantial costs in the future.6

Source: National Center for Children in Poverty, using the American Community Survey, 2005

Risk factors include any combination of the following:(1) single parent, (2) living in poverty, (3) parents donot speak English well, (4) parents have less than ahigh school education, or (5) parents have no paidemployment.

D m gra h Da a

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The District has one of the highest rates forEarly and Periodic Screening, Diagnostic, andTreatment (EPSDT) health screens in the coun-try, and exceeds the federal benchmark of 80percent. In 2005, 86 percent of children ages 1-2

on Medicaid received at least one EPSDT healthscreening or well-check.7

In 2004-05, 13 percent of children younger thanage 18 were uninsured and 45 percent were onMedicaid. Nationally, 20 percent are uninsuredand 26 percent are on Medicaid. Pregnantwomen, children, and parents earning up to 200percent of the federal poverty level are eligiblefor Medicaid.

According to the D.C. Behavioral Risk Factveillance System for 2002, less than 10 percof adult women in the District lack health isurance, yet more than one-third (36 percent)reported they did not seek preventative care.9

More than one-third of mothers in the Distrido not begin prenatal care in their rst trimand do not have at least nine subsequent visThe rate increases to almost half of all pregwomen in Wards 7 and 8.10

In 2002, Medicaid paid for 64 percent of bito District residents.11

Eleven percent of infants born in the District

Children develop best when they are healthy. Hunger, a vision or hearingimpairment, or maternal depression can inhibit early childhood development,but each of these crises can be resolved with early identi cation and access to

appropriate services. The American Academy of Pediatrics recommends healthy childrenvisit the doctor ten times before their second birthday. In the District of Columbia, thehealth care system is a vital point of contact between child development professionalsand parents with young children. These encounters are essential opportunities toidentify and address developmental delays when they rst begin.

Po icy Recomme atio s

1. I crease pre ata care, ith a focus o Hea th Professio a Shorta e Areas.Healthy development begins long before a baby is born. Prenatal care canimprove birth outcomes, and District women continue to enter prenatal care in therst trimester at a rate lower than the national average.

A. Identify and address barriers to prenatal care. Barriers to prenatal care arecomplex, but worthy of additional resources and attention because of thesigni cant impact prenatal care has on birth outcomes and the subsequentdevelopment of the child. In general, the leading causes of death for infants arebirth defects, premature birth disorders, and sudden infant death syndrome.However, in the District, most infant deaths are due to maternal complications

in pregnancy and delivery, which can be prevented with adequate and qualityprenatal care.18 The D.C. Department of Health Title V Block Grant Five-Year

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K E Y F A C T S

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are low birthweight (weighing in at less than 5.5pounds). Seventy- ve percent of these babies arenon-Hispanic Black.12

The infant mortality rate in the District increasedto 11.8 deaths per 1,000 births in 2004. This is thehighest rate since 2000.13

Immunization rates in the District have increasedsteadily between 2000 and 2004, exceeding the na-tional average since 2002. However, rates declinedin 2005 from 98 percent to 94.4 percent of childrenvaccinated against the major childhood diseases.14

The American Academy of Pediatric Dentistry en-courages parents and other care providers to help

every child establish a dental home by age one.Only 6 percent of children ages 1 and 2 who arMedicaid received any dental services in 2005.15

Between 1998 and 2003, the Districts Medicaidfees remained the same for primary care and ob-stetric physicians, and declined by 2.4 percent overall. This was the largest decline among the stateswhere, on average, fees increased by 27 percent.16

Medicaid reimbursement rates in the District areamong the lowest in the country. Nationally, Medic-aid reimburses primary care physicians an averageof 62 percent of Medicare fees. A Medicaid primarcare physician in the District of Columbia receivespercent of the Medicare fee for the same service.17

Needs Assessment (1998-2003) indicates women do not seek earlier carebecause they do not know they are pregnant, are unable to get a prenatalappointment early in their pregnancy, or do not have enough money orinsurance to pay for prenatal care. Task force members heard stories of womenbecoming impatient with long visits inwaiting rooms to spend ve minutes with adoctor, and stories of health facilities thatare poor quality. More time, attention, andfunding are necessary to understand andremove the barriers to prenatal care. TheDistrict can look to the D.C. DevelopingFamilies Center as a model for providingprenatal care. Approximately 30 percentof its clients travel from Wards 7 and 8 toreceive care at its Birthing Center in Ward 5.

B. Improve the quality and number of prenatalcare facilities in Health Professional Shortage Areas. Making high-qualityprenatal care easily accessible is one wayto improve access to prenatal care. Forty-seven percent of women of childbearingage, infants, and children live in federallydesignated primary medical care healthprofessional shortage areas (HPSA),

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Provi i pre ata care:The Birthi Ce ter (district of Co umbia)

According to Linda Randolph, executive director of theD.C. Developing Families Center, health care professionalsmust recognize that prenatal visits require time to

build supportive relationships with the patient, andhealth insurance companies must provide adequatereimbursement for longer visits. The Birthing Center isimplementing the CenteringPregnancy Program, anevidence-based model where women are invited to joina support group that meets after they receive their usualobstetric care. The same group meets every month andthrough the initial postpartum period, forming a supportnetwork for the expectant parents and allowing a skilledfacilitator/practitioner to observe and interact with theindividuals in the group. For more information, www.

centeringpregnancy.com.


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p y R mm nda ns M G a i

12

and 30 percent live in medically underserved areas.19 The census tracts thatexperience the highest numbers of adverse health indicators (i.e. infant mortality,low birthweight babies, and prenatal care) are highly correlated with health

professional shortage areas. 20 There are at least two funding opportunities toexpand prenatal care facilities in the District.

The new mayor will have to act on the recommendations of the Health CareTask Force report delivered on August 1, 2006. That report recommends thata minimum of $212 million be invested in building health care facilities inthe eastern part of the District of Columbia in the next few years. Access toprenatal care can be improved if these new facilities include prenatal careclinics and/or birthing centers.

The D.C. Primary Care Association is distributing grants to build health care

facilities that provide a medical home for District residents, with prioritygoing to Wards 7 and 8. Access to prenatal care can be improved if child carecenters, or other places women may go on a daily basis, partner with healthcare providers to submit applications to build facilities that are convenientand inviting.

2. Support curre t efforts to improve the eve opme ta scree i of chi re ,a i crease efforts to e sure chi re receive the fo o up eva uatio sa services they ee . Childrens developmental needs change as they grow.Risks and delays are identi ed earlier when children have regular access to aprimary care medical home. The DC Partnership to Improve Childrens HealthcareQuality (DC PICHQ) is a collaboration between local pediatric providers and theD.C. Medical Assistance Administration to improve well-child health care deliveryand documentation. The result is the implementation of standardized medicalrecord forms (SMRFs), which will increase the likelihood that children receivecomprehensive health exams, at regular intervals, using the best guidance abouthow to promote their physical, emotional, and behavioral health. The forms re ectthe best practice standards of care recommended in the American Academy ofPediatrics and Bright Futures guidelines. Data from visits to the primary healthcare provider will be captured in a new Child Health Data Registry. Although thedata will provide a more accurate picture of the health and developmental needs ofD.C.s children, they will not guarantee that individual children receive appropriatefollowup evaluations and/or interventions in a timely fashion.

A. Provide core funding for the DC Partnership to Improve Childrens HealthcareQuality to continue implementing, validating, and continuously improvingthe standardized medical record forms. Currently, the DC PICHQ relies on asmall grant from the Commonwealth Fund and a subcontract with the Medicaidmanaged care plans to implement the SMRF utilization citywide. This funding isinsuf cient to further validate and re ne this valuable tool to improve providereffectiveness in identifying medically- and developmentally-at-risk children.Additional funding would allow DC PICHQ to revise the standardized form to

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enhance its effectiveness in identifying at-risk children, and provide ongoingfeedback and training for pediatricians to improve their screening. Morefunding would also allow DC PICHQ to conduct a pilot survey to see how many

children identi ed through the standardized reporting process actually receivedcomprehensive developmental evaluations and recommended services.

B. Increase Medicaid reimbursement rates so children receive the followupevaluations and services they need. Improved screening is just the rst step.The DC PICHQs initiative will provide data about the need, but will not ll theneed. Better identi cation of at-risk children will necessarily generate additionaldemand for developmental specialists for comprehensive evaluation andappropriate treatment, and developmental specialists are already in short supply.Increasing the Medicaid reimbursement rates for both primary care screening anddevelopmental specialty evaluation is critical to ensuring that children get theservices they need.

3. He p pare ts bri e the ap bet ee their chi re s hea th care ee sa the hea th care system. Taskforce members heard story after story ofparents who could not get appointments fortheir children and ended up in emergencyrooms. Child care providers spoke of parentswho did not know when to seek the adviceof health care professionals, and parentswho did not know how to advocate for theirchildren when seeking advice. Doctors spokeof children aging out of the early intervention(birth through age two) program beforethey received needed services. Infants andtoddlers cannot get to the doctor withoutthe help of their parents, and the anecdotalevidence suggests that these adults needmore help in knowing when and how to accesshealth care.

A. Examine how Medicaid managed careorganizations are conducting outreachto parents. A portion of the administrativecosts that Medicaid managed care plansreceive is speci cally designated foroutreach to parents, with the goal ofgetting those parents to bring their childrento the doctor for regular check-ups. Thetask force recommends the MedicalAssistance Administration review theguidance on the use of these funds and

I e tifyi socia a emotio ae ays: Assuri Better Chi Hea th a

deve opme t II

The Commonwealth Fund and the National Academyfor State Health Policy launched the second phase oftheir Assuring Better Child Health and Development(ABCD II) initiative in 2004. Although the nalevaluation results will not be available until 2007,preliminary data suggest the ve grantee states havesuccessfully improved the care of young childrenwith, or at-risk of, social or emotional developmentaldelays. Although grantee states chose various meansby which to achieve the same goals, all ve statesrelied upon developing standardized screeningguidelines, increasing the use of screening to identifydelays, educating physicians on integrating screeningguidelines into their practices, and improving referralsto necessary services. By creating such guidelines, aswell as a database of local and state resources, the

ve states improved the ability of clinicians to identifyproblems early and direct those patients to availableservices, thereby lling service gaps that preventchildren from receiving supports they need. For moreinformation, http://www.cmwf.org.

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evaluate the effectiveness of the outreach efforts. A more targeted, coordinatedapproach to parent education and outreach could help parents be betteradvocates not only for the health of their children, but for their own health as well.This effort can be coordinated with the recommendations in the next section tosupport families of very young children.

B. Support the recommendation of the District of Columbias Children with SpecialHealth Care Needs Advisory Board to create a central service delivery systemto provide early identi cation, diagnosis, and treatment. This system wouldbe central, interdisciplinary, comprehensive, culturally competent, coordinated,family-centered, and modeled after the former Children with Special Health CareNeeds Clinic located on the grounds of D.C. General before it was closed in 2001.

C. Raise awareness about the importance of a dental home. Oral health is justas important as general health, and encompasses more than just healthyteeth. The American Academy of Pediatric Dentistry (AAPD) recognizes thatearly prevention practices reduce the risk of preventable oral disease that cansigni cantly impact learning. In 2006, AAPD recommended all parents establisha dental home for their children by age one. In 2005 in the District of Columbia,only 6 percent of all children ages one or two who receive Medicaid receivedany dental services.21 By raising oral health awareness, the prevention, earlydetection, and treatment of dental disease can be integrated into health carepolicies to ensure young children are physically healthy and ready to learn.Collaboration between early intervention programs, early care and educationprograms, physicians, and dentists will help ensure public awareness of age-speci c oral health issues and the impact on learning.

4.E sure access to me ta hea th services by i creasi the or a izatio acommitme t a resources of the departme t of Me ta Hea th i re ar toear y chi hoo eve opme t. Infants develop in the context of relationships andare highly sensitive to the quality of care they receive from their primary caregivers.Because the parent-child relationship is so important for early development, themental wellness of adults plays a critical role in how young children develop.22Parental depression can negatively affect children if parents are not capable ofproviding consistent, sensitive care, emotional nurturance, protection, and thestimulation that young children need.23 Parental mental health problems can also

have a biological impact on the development of a child by raising the level of cortisolin the brain, which has been linked with internalizing problems, extreme behavioralinhibition, social wariness, withdrawal, and increased anxiety disorders.24 Becausethe incidence of maternal depression is high (and even higher for families inpoverty), 25 too many young children are at risk for developing mental healthand behavioral problems such as infant depression, attachment disorders, andaggression. As a result, intensive and targeted mental health services for youngchildren and their families are necessary.

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A. Appoint an individual in the Districts Department of Mental Health to focus solely on early childhood mental health, particularly working to addressthe mental health needs of very young children. The District of ColumbiaDepartment of Mental Health has a Director of Childrens Services, but no onewho focuses speci cally on the mental health needs of young children. Thisrecommendation would assign a separate individual to develop a plan for howto address the mental health needs of very young children in the District byaddressing three strategies representing a continuum of services: 1) promotionservices aimed at maintaining the social and emotional well-being for all youngchildren; 2) prevention services targeted toward children who are at risk ofmental health disorders; and 3) treatment services that provide individualizedattention to young children and families already exhibiting symptoms of mentalhealth disturbances. 26 This plan could be informed by the District of ColumbiaEarly Childhood Mental Health Planning Committee, and the success of statesparticipating in The Commonwealth Funds Assuring Better Child Health andDevelopment II initiative (see sidebar).

B. Garner funding to reinstate accessto mental health consultation for allearly childhood programs. Infants andtoddlers are spending more time innonfamilial care, so child care providers,home visitors, and Early Head Start staffmust have appropriate skills to promotethe childrens social and emotionaldevelopment. Mental health consultationin child care is a proven and effectivemodel for preventing behavioral problemsand reducing expulsion in child care,supporting relationships with families, andidentifying early warning signs of mentalhealth disorders. The District had anearly childhood mental health consultantproject, but funding ended in 2006. Thisproject placed graduate psychologystudents in early childhood classrooms,

supervised by a licensed mental healthprofessional. These consultants providedsupport to teachers when childrendisplayed challenging behaviors andother social-emotional issues. They alsoprovided occasional direct services tochildren and their parents. San Franciscopioneered a promising model for mentalhealth consultation in child care that is areplicable best practice.

Provi i me ta hea th co su tatio i chicare: Ear y Chi hoo Me ta Hea th Pro ram(Sa Fra cisco, Ca ifor ia)The Early Childhood Mental Health Program is acollaboration of the Jewish Family and Childrens ServicesDay Care Consultants of the University of Californiaat San Francisco, and several county and communitymental health agencies. With an end goal of improvingthe overall quality of child care and healthy childhooddevelopment, the project relies upon skilled consultantsto provide onsite support to 65 child care centers servinglow-income, at-risk children (from birth to age ve) in thBay Area. Each consultant works directly with child careprofessionals in a particular facility to improve the overallquality of the program. In addition, they provide caseconsultation for individual children by assessing a childs

needs; developing guidance, training, and mentoringfor teachers; and suggesting appropriate interventionsand support to the staff. Consultants also help designparent support and education activities. Funding of the$1.5 million program comes from TANF and the Child CDevelopment Fund. Those children requiring additionalservices receive assistance through Medicaid. For moreinformation, www.jfcs.org/Services/Children,_Youth,_and_Families/Parents_Place/Early_Childhood_Mental_Health_Consultation/default.asp

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Young children thrive in stable, nurturing families. They learn and developcontext of family, and their early development depends on the health andbeing of their parents.27 Parents must be able to successfully face the cha

of caring for their children while, at the same time, meeting their work and oresponsibilities. Children and families living in poverty face even greater challenand are more likely to experience school failure, learning disabilities, behavioralproblems, mental retardation, developmental delays, and health impairments.28Research indicates that the risks posed by poverty are greatest among childrenwho experience poverty when they are young, and among children who experiepersistent and deep poverty.29 With close to one-half of the infants and toddlerDistrict living in low-income families, and almost one-quarter living in extreme(below 50 percent of the federal poverty level or $8,300 for a family of three30 the

need to provide additional supports to families is obvious.At one time or another, most families turn to early childhood developmentprofessionals for support and guidance. For some families, a conversation withnurse or a child care provider will be the support they need. For others, moreand specialized services are necessary, such as mental health or child welfareservices. The District of Columbia can support parents of very young childrenensuring easy access to information about the importance of their job as a pareclearly identifying where they can turn for help.

Po icy Recomme atio s5. I te sify efforts to provi e pare ti i formatio a support to pare ts of e bor s, i fa ts, a to ers. Parents need adequate time and resourcesto carry out their parenting responsibilities, and they need to know how and wto seek professional help when necessary. Public media campaigns and telephoninformation/referral services have the potential to provide reliable assistance andadvice for families with young children,38 but the quality and availability of theseservices in the District is inadequate.

A. Ensure help lines provide responsive assistance and accurate referral information.

The District of Columbia has multiple telephone information and referral servicesthey are not well advertised and the information they have available is often oudate. Improving both the quality of the information and the training of the indivwho answer the phone is the rst step in providing responsive and accurate ass

Convene administrators of the Districts primary help lines for parents of very young children to establish a schedule for regularly updating information. Thosinclude the Parent Directory, Access HelpLine, 1-800-MOM-BABY, the MayCenter, and 211 Answers, Please! Many of the parenting information servithe District rely on theParenting Education Directory , which was last updatedin 2002. Data available at the online information centers at www.dc.gov c

The task forcerecognizes theimportance ofalleviating poverty forthe overall well-beingof children. Althoughthis report doesnot provide speci crecommendations toimprove the economicsecurity families needto adequately care for

their young children,the task force stronglyrecommends that theDistricts new mayormakes this issue apriority for familieswith children of allages, but particularlyfor those with infantsand toddlers.

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Seven Healthy Families Thriving CommunitiesCollaboratives work to provide a seamlessnetwork of community partners focusedon building strong families and supportivecommunities in which children, youth, and adultscan thrive. Although local needs drive the focusof the collaboratives, their work includes primaryprevention efforts to keep children out of thefoster care system. Between 1999 and 2005, thenumber of children in foster care declined from3,466 to 2,554.31

Since 2004, the District of Columbia FatherhoodInitiative (DCFI) has helped 3,000 low-incomefathers overcome barriers to providing emotionaland nancial support to their children. InOctober 2006, the District received a $10 millionResponsible Fatherhood Program federal grantto expand the work of the DCFI over the next veyears. The District is one of only two jurisdictions inthe nation to be awarded this grant, which requiresfunding activities to promote healthy marriage,responsible parenting, and economic stability.32

The overall number of families applying foremergency shelter in the District decreased for

the rst time in six years, but the proportionof families with children younger than age vincreased. In 2005, 2,936 families applied foremergency shelter down from 3,326 in 20037 percent of the families with children incluchild who was ve years old or younger. Thincrease from 35 percent in 2004.33 Funding forHousing Production Trust Fund, which supporthe construction and renovation of affordablehousing in the District, has doubled from $68million in 2006 to $132 million in 2007.34

Fifty-six percent of all births in the Districtsingle mothers, and in Wards 7 and 8 the rapercent or more.35

More than half (52 percent) of all grandparethe District are directly responsible for the catheir grandchildren approximately one-thirdthem live below the poverty level.36

There are an estimated 2,000 at-risk familiesthe District who could bene t from home visservices, and less than 30 percent receive the3

three and four years old. Information and referral services are only as good asthe information they provide. Establishing a regularly scheduled meeting for theadministrators of the various referral lines in the District will enable staff to keepcurrent on services and be accountable for regularly updating information.

Improve training for staff who answer these help lines to ensure appropriateand responsive assistance. In a national study of help lines, most states reportthey provide at least some training to staff answering calls. However, only21 percent of states require training that can certify staffers as informationand referral specialists, and fewer than 10 percent of referral lines havea child development specialist answering calls.39 Training might includebasic information on early childhood development and information on newcommunity resources and services for young children and their parents.

B. Launch an outreach campaign for parents, particularly fathers, to raiseawareness of the importance of the rst three years of child development and to

K E Y F A C T S

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connect them to existing information and referral resources . Once the infrastructureis in place to provide parents with accurate and responsive assistance, an outreachcampaign can inform parents about these resources. In addition to raising awareness

about available resources and help lines, such an outreach campaign can promoteeffective parenting practices. For example, radio, television, and print ads can explainthe importance of prenatal care or having a medical and dental home, and thenrefer parents to a help line for more information. Given the high percentage of singlemothers in the District, a special effort can be made to reach fathers. The outreachcampaign should re ect the latest research on social marketing to ensure messagesare culturally appropriate for the diverse populations in the District, and effectivewith the target audience parents. Public outreach campaigns can be expensive, butthere are several existing campaigns that the District can modify, such as the BornLearning campaign.

6.Expa a better coor i ate home visiti services to fami ies . Home visit-ing can be an effective way to reach vulnerable infants and toddlers beforedelays occur, thereby preventing more long-term costs associated with remediationlater on. Home visiting is a unique approach as it reaches families where they live,eliminating many of the scheduling, employment, and transportation barriers thatmight otherwise prevent them from accessing community services.40 Generally, pro-grams combine health care, parenting education, child abuse prevention, and earlyintervention services. Although the research has shown mixed results, evaluationsof some home visiting programs demonstratethat they can improve parenting skills, fosterincreased parental self-con dence, and help

lay the foundation for childrens later successin school.41 The bene ts of home visitationvary across families and programs.

A. Provide core funding for the HomeVisiting Council to coordinate existinghome visiting programs, provide trainingand evaluation so programs meet high standards of quality, and ensure familiesreceive appropriate home visiting services. Like most cities, the District of Columbia

has multiple home visiting programs, andthe list is still growing. The replication ofthe Parent Child Home program will joinDC Healthy Families, Healthy Start, HIPPY,Early Head Start, Parents as Teachers, andseveral other programs that can potentiallytarget the same families. The Home VisitingCouncil was created in 2000 to strengthenthe quality and improve the coordinationof home visiting programs throughout theDistrict. The Council effectively convened

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Creati a effective pub ic outreach campai :Bor lear i Born Learning is a $37 million national campaign builtpartnership with the United Way, Civitas, the Families aWork Institute, and the Ad Council. With 350 local andstate Born Learning campaigns around the nation, thefocus is on helping parents, grandparents, caregivers, andcommunities create positive early learning opportunitiesfor young children. Utilizing public service announcemenand advertisements as well as educational resources on

its website, the Born Learning campaign provides tips tocaregivers on ways in which to encourage learning, factsheets on a childs ages and stages, and helpful parentinchecklists. In addition, the campaign offers strategiesfor community action and public policy advocacy. Stateand local Born Learning campaigns vary from increasingparent outreach and education to engaging hospitals,pediatricians, state agencies, and the business communityto encourage these groups to be part of its program. Fomore information, www.bornlearning.org.

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local home visiting programs who then jointly established standards for bestpractices in home visiting and then developed training to support programs inmeeting those standards. The small grants and in-kind contributions that Council

members relied on in the startup phase cannot sustain the work of the Council overtime. With core funding of $50,000 per year, the Council can coordinate high-qualityhome visiting programs and maximize the number of families who receive services.

B. Increase funding for home visiting services. A high-quality home visiting programcosts a fraction of the cost of foster care and other expensive services availableto families only after they fail. An estimated 2,000 at-risk families in the Districtcould bene t from home visiting services, but less than 30 percent of these familiesparticipate. 42 Targeted, high-quality home visiting programs can be a cost-effectivestrategy to improve health outcomes, parenting skills, and educational outcomesfor families.

C. Establish a universal screening and referral process for all District residentswho are parents of newborns. A universal assessment and referral processin the District will ensure that the families who receive home visiting servicesare those who most need support, and that families are referred to the homevisiting program that best meets their needs. The D.C. Department of Health iscurrently piloting universal screening for home visits at Providence, Howard, andWashington Hospital Center. Data from this pilot can inform the expansion of auniversal screening process until it is available to all District residents.

7. de icate oca fu s to provi e ear y i terve tio services to more i fa ts

a to ers. Part C of the Individuals with Disabilities Education Act(IDEA) requires all states to de ne who is eligible for interventions that addressdevelopmental delays of children from birth to age three, screen children in order toidentify who should receive services, and provide appropriate services to those whoare eligible. The federal law allows states to de ne eligibility, but sets a benchmarkof serving a minimum of 2 percent of all children younger than age three. Federalfunds are capped, so most states must supplement Part C funds to meet the needs ofchildren identi ed as eligible for early intervention services.

According to the IDEA Infant and Toddler Coordinators Association, the District ofColumbia is one of only a few states that do not dedicate any state or local funds for

early intervention (IDEA Part C) services. The percentage of children served in the Districtis also among the lowest in the country, although it is improving. In 2004, the Districtserved 1.3 percent of all children younger than age three, and in 2005 the percentagerose to 1.68 percent.43 The District may not meet the federal 2 percent benchmarkbecause it has one of the most restrictive eligibility de nitions. The District requires atleast a 50 percent delay in one or more aspects of development, while other states aremuch more inclusive. In fact, six states include children who are not yet developmentallydelayed but who have biological or environmental factors that are predictive of delay.44By dedicating local funds for early intervention services, the District can expand itsde nition of eligibility to include more children who are experiencing developmentaldelays and who can bene t from services that will minimize those delays.

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Babies are born learning. Learning happens through play, the active explorationof their environment, and, most importantly, through interactions with thesigni cant adults in their lives. Babies learn in the context of relationships,

through everyday routines and experiences. The quality of these early experiencesmatters. High-quality early learning experiences are associated with outcomesindicative of later school success, like early competence in language and cognitivedevelopment, cooperation with adults, and the ability to initiate and sustain positiveexchanges with peers.

Research indicates that high-quality early care experiences make a difference forvery young children; however, access to quality programs is uneven and inadequatein the District, especially for infants and toddlers. The following recommendationsaim to improve the overall quality of care, and to coordinate high-quality services tomeet the comprehensive needs of families with infants and toddlers.

Po icy Recomme atio s

8. Create a et ork of ear y eve opme t pro rams, a at east t ocomprehe sive service ce ters, particu ar y i ei hborhoo s ith poor performi schoo s a hi h co ce tratio s of poverty. Three decades of researchshows that when early childhood programs focus on both child developmentand family development, opportunities for optimal child and family developmentcan be realized even for the most vulnerable.56 Comprehensive early childhoodprograms such as Early Head Start mitigate the effects of poverty by providingbasic supports through early, high-quality, comprehensive, continuous services.The National Evaluation of Early Head Start showed that comprehensive servicessuch as nutritional meals and health care, education and job training for parents,and child development and parenting classes have a positive impact on families.When compared to families who did not receive Early Head Start, children hadmore positive interactions with their parents and made great advances in cognitiveand language development. Parents also showed they were more emotionallysupportive and provided signi cantly more support for language and learning.57 Anetwork of Early Development Programs like Early Head Start would help improvequality and bring comprehensive services to child care settings serving infants andtoddlers in the District.

A. Develop a network of Early Development Programs building on existing child care providers. The District needs more high-quality child care programs thataddress the comprehensive needs of families. Child care centers are the newneighborhood where families interact on a daily basis with others who care fortheir children. As the model of the DC Developing Families Center demonstrates,child care centers can be the hub for the comprehensive services that familiesneed from child care to health care to other family supports. The District can

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Source: DHS/Of ce of Information SystemsOnline OECD Childcare System - Provider information database, 2006.

K E Y F A C T S

The District has one of the highest access ratesfor children eligible for child care subsidies.Sixty-eight percent of eligible children receivedsubsidies in 2005-06, while the national averageis estimated to be between 15 percent and 20percent. 45

The District has the highest percentage ofaccredited family child care homes in the nationand the third highest percentage of licensedchild care centers with national accreditation.46However, access to accredited child care isuneven, especially for children who dependon child care subsidies. Overall, 45 percent ofpreschool children are in accredited child carecenters that accept child care subsidies, butonly 38 percent of infants and toddlers are inaccredited centers. In Ward 8, 30 percent ofinfants and toddlers and 47 percent of preschoolchildren are in accredited centers.47

Of the 1,243 providers with Child DevelopmentAssociate (CDA) credentials that work in the

District, 589 have an Infant/Toddler specialization.48

Seventy percent ofall four-year-olds in the District areenrolled in a Head Start orprekindergarten program. 49

Only 4 percent of infants atoddlers (from birth to agethree) in families earning ator below the federal povertylevel receive Early Head Staservices, compared with 66percent of eligible three- anfour-year-olds who receiveHead Start services.50

Of the 348 licensed child care centers in theDistrict, only 149 offer infant care. These cenhave the capacity to serve 3,893 childrenyounger than age two, yet there are an estim14,000 children younger than age two in theDistrict. By comparison, 325 of the 348 centeserve children from age three to age ve,51 witha capacity to serve more than 15,000 preschochildren. 52

The percentage of infants and toddlers inhigh-quality child care centers varies greatlyby Ward, from only 16 percent in accreditedcenters in Ward 5 to 100 percent in accredicenters in Ward 3.53

Child care data gathered over a four-yearperiod indicate the quality of child care in minfant/toddler classrooms in the District isinadequate. 54 The Quality Training AssessmProject (QTAP) found that out of twenty-fouindicators, almost half were rated minimalbelow minimal for all four years.55

Total Child Care Capacityby Ward and Age Group

C a p a c

i t y

Ward

InfantPreschoolSchool-Age

1 2 3 4 5 6 7 8

3500

3000

2500

2000

1500

1000500

01

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raise the level of quality in existing child care settings by funding access tothe comprehensive supports and services that families need (see sidebar onCharacteristics of High-Quality Early Development Programs). The District canlook to Rhode Island and Oklahoma as examples of how to promote a network ofhigh-quality early development programs.

B. Create at least two comprehensive service centers in areas of the city withhigh concentrations of poverty. In areas of the Distrct where services are scarce(i.e., Wards 7 and 8), facilities should be built that will provide services underone roof. These comprehensive service centers, modeled after DC DevelopingFamilies Center or Educare (see sidebars), would provide direct services tochildren and families. These centers would also serve as a focal point for health,mental health, and family support outreach to family child care providers andfamily, friend, and neighbor (FFN) caregivers. The District should seek privatefunds to help build the facilities. In addition, there are at least two otherpotential funding opportunities:

The CareBuilders Recoverable Grant Program offers nancing and freetechnical assistance to new and existing child care providers seeking tocreate, expand, or improve child care services for infants and toddlers. Thegrants can be used to cover costs associated with making physical changes tonew or existing child care sites that will result in the creation, expansion, orimprovement of child care services for infants and toddlers.

The D.C. Primary Care Association distributes grants to build health care facilitiesthat provide a medical home for District residents. Wards 7 and 8 are given

priority.

9. Support the professio a eve opme t of i fa t a to er chi careprovi ers. Research con rms that quality child care is contingent upon thespecial training that caregivers receive in early childhood development.59 Both formaleducation levels and recent specialized training in child development have beenconsistently associated with high-quality interactions and childrens development.60In the District of Columbia, infant and toddler caregivers need more education andtraining focused speci cally on the unique needs of children younger than age three.These caregivers need credit-bearing opportunities and training, as well as on-the-jobmentoring and support.

A. Support a career pathway that leads to degrees and/or credentials for infant and toddler caregivers.

Establish an Associate of Arts (A.A.) degree in Child Development witha concentration in infant and toddler care at a local institution of higher education. Across the country, states are developing specialized degreeprograms and training opportunities speci cally for infant and toddlercaregivers. Seventeen states now either have, or are in the process ofestablishing, an infant/toddler credential that recognizes training, coursework,

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$

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and experience in working with infants and toddlers in child care programs.These states are increasing the availability of coursework and training, andformally recognizing the completion of this education with a credential,certi cation, or endorsement. At the University of the District of Columbia,past proposals to establish an associates degree in child development witha concentration in infant and toddler care have failed. The new mayor cansupport a future proposal to the Department of Education and the Collegeof Arts and Sciences with the University of the District of Columbia, as wellas encourage other District institutions of higher education to offer a similardegree.

Increase child care subsidy reimbursement rates to support base pay at the living wage level for caregivers in subsidized programs. Like parents,caregivers cannot give focused attention to the children they care for ifthey are distracted by nancial insecurity. The D.C. Living Wage Act of 2006requires recipients of new contracts or government assistance to pay af liatedemployees and subcontractors who perform services under the contracts noless than the current living wage of $11.75 per hour.61 The law exempts mostchild care workers, who earn an average wage of $8.96.62 Including subsidizedchild care providers under the Living Wage Act will help programs attract andretain quali ed providers.

Increase scholarships for infant and toddler caregivers to earn credentials.A signi cant body of research in child care settings links well-trained,quali ed teachers and staff to better child outcomes, particularly for low-income children who are at-risk for early developmental problems and latereducational underachievement. 63 With the help of additional scholarships thatcover costs associated with higher education (e.g. tuition, books, travel), moreinfant and toddler caregivers in the District can have the opportunity to takecollege courses leading to two- or four-year degrees in child development orearly childhood education.

Promote increased staff compensation linked to professional development and education. Child care programs have dif culty attracting and retainingwell-trained individuals to work with young children, in part, because theydo not pay a living wage. In the District of Columbia, the average child careworker earns $8.96 per hour, and the average preschool teacher earns $11.96.65Adequate compensation is critical to ensuring the stability of a well-trained,quali ed early childhood workforce. Compensation or retention initiatives forchild care providers often link increases in a child care professionals compen-sation to increases in his or her quali cations.66 By compensating child careproviders for receiving additional training and education, the District can retainchild care providers and work to improve the quality of the child care workforce.North Carolina employed such a strategy and saw a reduction in the turnover ofchild care providers.64

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Comprehensive Chil Care Services Program(Rho e Islan )Rhode Island has been at the forefront of early careand education services, becoming the only state with

an entitlement to child care assistance for low-incomefamilies as well as access to health care coverage forchild care staff. Under the umbrella of its Starting RIghtinitiative, the state has also taken a unique approachto expanding Head Start services to low-incomepreschoolers through the Comprehensive Child CareServices Program (CCCSP). CCCSP funds networks ofchild care providers in the provision of comprehensiveservices based on those offered under the federal HeadStart program (early education and child developmentservices; social services; health, mental health, and

nutrition services; parental involvement activities; andschool readiness services). Not only do the networks ofproviders need to meet essentially the same standards asthe Head Start Program Performance Standards, but theyalso must establish a policy council that determines howto spend funds. In addition, the networks must supporthome visiting for all participants. The CCCSP networksspent $1.3 million in 2004, providing services to nearly300 low-income preschoolers. For more information,www.dhs.state.ri.us/dhs/famchild/CCCSP.pdf.

Pilot Early Chil hoo Program (Oklahoma)

The Oklahoma state legislature appropriatedfunds to the state Department of Education to

fund a pilot early childhood program. Applicantsmust serve infants and toddlers from families wiincomes at 100 percent of the federal poverty leor less. To ensure that programs receiving fundinprovide high-quality early learning experiencesthat are developmentally appropriate for youngchildren, grantees who participate in the pilot hato meet Early Head Start standards, and have tobegin the process for accreditation by the NationAssociation for the Education of Young Children(NAEYC). Furthermore, there must be one teach

with a bachelors degree in every two classroomall assistant teachers must have an associatesdegree; and all teachers aides must have a CDAMost of the programs that will receive fundsinitially are Early Head Start programs, becausethey are already in compliance with the majorityof the standards, but of cials are reaching out tthe child care and early learning community toparticipate in this pilot.

The program is accredited or has received thehighest quality rating

Master teachers have a B.A. degree (or equivalent)with a focus on infant development

Teachers have a Child Development Associate(CDA) with infant and toddler specialization, andare working toward an A.A. degree (or equivalent)

Teachers assistants/aides have, or are workingtoward, a CDA

Teachers receive training in early learning anddevelopment guidelines for children from birththrough age three

Children receive continuity of care The program takes a family strengthening

approach The program supports developmental screening

and followup The program has connections to a school or

preschool in the neighborhood There are linkages to health and mental health

supports There is a hub of support for parents, family,

friends, and neighbors

ear y D v m n pr grams

pr m ng a n w rk f h gh-qua y ar y d v m n r grams:

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developing Families Center (district of Columbia)Funded through the private, public, and business communities, the DCDeveloping Families Center is a unique model of collaboration that offersuninterrupted care for women and their families during the childbearingand early child-rearing years. All services are provided under one roof ina center that is easily accessible to low-income communities of CarverTerrace and Trinidad/Ivy City in northeast Washington. Services include:health checkups for women, children, and teens; pregnancy testing;

early childhood development services; immunizations; prenatal care andeducation; a free-standing, homelike birth center; job training; socialservice assistance; and continuing education. For more information,http://www.developingfamilies.org/FAQs.html.

Educare (Omaha, nE)

Modeled on the Educare program originally established by the Ounceof Prevention Fund in Chicago, Educare of Omaha provides full-day,year-round education and care to 239 low-income infants, toddlers,and preschool-aged children. Included in this group are children withspecial needs, English language learners, and children whose parentsare enrolled in school, job training, or work at least part-time.

Funded through a public-private partnership with state agencies,Omaha public schools, Head Start, Early Head Start, and sliding scaleparticipant fees, the program is built around promoting kindergartenreadiness. By working closely with the Omaha school district sinceit began in 2002, Educares teachers regularly attend trainings withdistrict teachers and collaborate on curriculum standards. In addition,the program emphasizes low child-staff ratios, parent volunteers,monthly parent informational meetings, and family partnershipagreements to identify goals for a childs success. As part of itsdaily program, Educare focuses on language and literacy, social skilldevelopment, music, and art. It also provides a nutrition and healthprogram, offering regular physical and dental exams as well as periodichealth screenings. For more information, www.educareomaha.com/index.asp.

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B. Provide training on the birth-to-three early learning guidelines through the Ear-ly Childhood Leadership Institute. Early learning guidelines are research-based,measurable expectations about what children should know (understand) anddo (competencies and skills) in different domains of learning.67 Currently, eigh-teen states have adopted early learning guidelines for children from birth to agethree. The Early Childhood Leadership Institute at the University of the District ofColumbia is in the process of developing similar guidelines for the District, which

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Supporti cu tura iffere ces:Fami y, Frie , a nei hbor Best PracticesProject (Mi esota)

With nearly one-half of all families relying on family,friend, and neighbor (FFN) child care, Minnesota haslaunched a new initiative to meet the needs of thestates increasingly diverse population. By studyingthe best practices of families from among the Hmong,Latino, African-American, and Native American com-munities, the FFN Best Practices Project works toensure all children are fully ready for kindergartenregardless of cultural differences. The results of thesestudies provide resources to FFN caregivers and in-crease the ability of early education professionalsand caregivers to implement the most culturally ap-propriate strategies for entry into formal schooling.For more information, http://www.ready4k.org/index.asp?Type=B_BASIC&SEC=%7BC2C1E3F7-E149-484C-AE5E-

should be completed by the end of 2006. In order for the guidelines to be effec-tive, infant and toddler caregivers must be trained on both what the guidelinessay and how to integrate them into their daily work. An effective implementa-

tion plan will include onsite observation and instruction to ensure that providersintegrate the guidelines into the care setting.

C. Develop a network of infant/toddler specialists who provide onsite guidanceand support to infant and toddler caregivers on issues related to early devel-opment, health, mental health, family support, and program quality. In addi-tion to education and training opportunities, providers need experts to comeinto their child care centers or homes, effectively providing on-the-job supportand training to improve the quality of care. Training would be speci c to issuesaffecting infants and toddlers, including integrating the Districts soon-to-be-released birth-to-three early learning guidelines (recommendation 9-B) and im-

proving infant mental health (recommendation 4-B). Infant/toddler specialiststypically include health, mental health, and family support professionals. Spe-cialists work with providers using a variety of approaches, including mentoring,coaching, consultation, training, technical assistance, and referral. Seventeenstates have developed networks of infant/toddler specialists most are fundedthrough the federal Child Care and Development Fund. In the District, the net-work could also include curriculum and assessment professionals to ensurethe content of the programs meets the forthcoming early learning standards forchildren from birth to age three.

D. Increase the capacity of child care

settings to provide care to familiesthat re ects their culture and language. As states and communitiesbecome more diverse, child careproviders face the challenge of ensur-ing that care is culturally appropriate.Research indicates that all early child-hood policies and programs shouldbe designed and implemented withina culturally sensitive context and in amanner that respects the importanceof individual differences among chil-dren and families.68 Early childhoodcaregivers need to understand the rolethat culture plays in a childs develop-ment and respect families culturalbeliefs and traditions. The District canlook to Minnesota as a model of howto increase the capacity of child careproviders to implement culturally ap-propriate best practices.


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To help ensure that all infants and toddlers have access to quality earlychildhood programs, states need to be strategic and creative in how they

nance services and supports for very young children and their families. Intight scal climates, federal, state, and community policymakers are challenged to

nd, allocate, and effectively use funds for early childhood programs.69 Fundingneeds to come from private and public sources parents, employers, civic groups,government (federal and state), and foundations.70 States are using a variety ofapproaches to help nance services for infants and toddlers, from creating public-private partnership funds to establishing a set-aside for babies in their preschoolprograms.

Po icy Recomme atio s10. E sure that fu i is avai ab e toimp eme t these recomme atio s. A. Establish a set-aside of at least 20 percent

of any preschool expansion funds to improveinfant and toddler care. Access to high-quality prekindergarten programs lays thefoundation for later school success. However,learning begins even before birth, with ahealthy pregnancy, and continues past the

rst day of kindergarten. Formally linkingthe growth of funding for the Districtsprekindergarten and infant/toddler programsrecognizes that important and lastingdevelopment takes place during the rstthree years of life. The federal governmentestablished this linkage with a 10 percentset-aside of Head Start funds for Early HeadStart. Illinois replicated this model andcreated the infant-toddler set-aside of theIllinois Early Childhood Block Grant.

B. Increase child care funds targeted at improving infant and toddler care. Access toquality programs in the District of Columbiais uneven, especially for infants and toddlers.According to the Quality Training AssessmentProject, the quality of child care in manyinfant/toddler classrooms in the District isinadequate. 71 Between October 2002 andAugust 2006, classroom assessments were

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Illinois has set an example for other states andcommunities by taking steps to bridge the gap betweeninfant-toddler initiatives and other preschool initiativesthrough the creation of the Early Childhood Block Graand the Infant-Toddler Set-Aside. In the mid-1990s, apush occurred to consolidate programs and fundingfor early childhood. Advocates used this effort as anopportunity to link prekindergarten to infants andtoddlers borrowing the precedent established by thefederal government with Early Head Start, which is futhrough a set-aside in the Head Start appropriation. In1997, the Illinois Early Childhood Block Grant becamelaw, and funding for infants and toddlers was de ned

as 8 percent of the block grant. The rapid increase infunding for child care and prekindergarten since 1997led to funding increases from $3 million to $30 milliofor infants and toddlers. The set-aside for infants andtoddlers is now 11 percent of the Early Childhood BloGrant. The Illinois General Assembly recently passedlegislation that requires all Block Grant programs serviinfants and toddlers to use a research-based programmodel. For more information,www.ounceofprevention.org/downloads/publications/Infant_Toddler_setaside.pdf.

Estab ishi a set-asi e:Ear y Chi hoo B ock gra t (I i ois)


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conducted in 119 child care centers (325 total classroom observations, including123 infant and toddler classroom assessments). The evaluation found that out of24 indicators, almost half were rated minimal or below minimal for all fouryears. 72 Many of the areas where the Districts infant and toddler classroomsperformed the worst were health-related factors that predict overall child carequality such as meals andsnacks, nap, and diapering andtoileting. The ndings are based onaverage scores across classrooms.

The percentage of infants andtoddlers in accredited centersvaries greatly by Ward; fromonly 16 percent in accreditedcenters in Ward 5 to 100 percentin accredited centers in Ward 3.In addition, the demand for infantcare in the District far exceedsthe supply. There are 7,500children born annually in theDistrict but only 4,210 licensedslots (including center-based andin-home child care providers)for children younger than agetwo. Additional funds for infantand toddler care can addressthe issues of poor quality andinadequate supply documentedin the aforementionedrecommendations.

C. Expand Early Head Start fundsor encourage Congress to permit Head Start funds to be used for children from birth to age ve in the District of Columbia .Although Early Head Start isa federal-to-local program, inrecent years, states have joinedwith Early Head Start to expandand enhance services for infants,toddlers and their families. Statesmay use state funds to expandprograms (as with the Kansas EarlyHead Start program highlighted

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Beginning in 1998, the governor of Kansas and the state legislaturauthorized the rst-ever state expansion of the federal Early HeadStart (EHS) program, using funds transferred from the statesTemporary Assistance for Needy Families (TANF) block grant andthe Child Care and Development Block Grant (CCDBG). Under thexpansion, the Kansas Early Head Start model provides the samecomprehensive services as the federal program, utilizing weeklyhome visits as well as visits to center-based and family-based childcare facilities.

Three aspects of the Kansas program make it unique. First, it requ

its sites to partner with existing child care providers rather thanprovide child care services directly. Secondly, it seeks to expand thavailability of its full-day, year-round care by covering three-year-olwho fall through the gaps between qualifying for EHS and HeadLastly, it allocates funds to provide professional development traininand technical assistance through a partnership with the federalDepartment of Health and Human Services and the Administrationfor Children and Families for Region VII. Because the Kansas EHprogram must follow federal Head Start Performance Standards,these funds are particularly useful, as Kansas EHS staff and childcare providers must obtain a Child Development Associate credenti

within one year of hire.

From its inception in 1998 with just four sites, the Kansas EHSprogram has expanded to 13 sites in 32 counties, directly serving825 children, including approximately 300 three-year-olds. Inaddition, approximately 150 child care providers in those countiesserve an additional 2,000 children who bene t from receivingservices from a child care setting that is required to meet the feHead Start Performance Standards. For more information,www.srskansas.org/ISD/ees/childcare_ehshs.htm.

Expa i access ith state fu s:Ear y Hea Start (Ka sas)


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in the sidebar) to serve more infantsand toddlers. States and communitiesare increasingly providing services to

preschoolers, providing more optionsfor children eligible for Head Start toparticipate in other preschool programs.In the District of Columbia, approximately70 percent of all four-year-olds are inHead Start or public prekindergarten, yetonly 4 percent of eligible children (frombirth to age three) receive Early HeadStart services. The District can encourageCongress to allow Head Start granteesin every state to reallocate resources to

services for infants and toddlers throughthe reauthorization of Head Start. Inthe meantime, the new mayor can seekpermission from the federal governmentto pilot the conversion of Head Start fundsto Early Head Start services. The District isin a unique situation, as it does not havethe same geographic exibility as states tomove Head Start funds from low-need to high-need areas. The District should notbe penalized for increasing local funding for three- and four-year-olds by losingHead Start funds.

D. Create a public-private partnership dedicated to funding services for infantsand toddlers. Public-private partnerships help engage stakeholders to supportand help fund early childhood programs. Several states have created newtypes of funding mechanisms, called public-private partnership funds, tosupport early childhood programs. A public-private partnership fund could beestablished as an endowment fund that distributes the interest or a limitedpercentage of the funds value to programs that serve children younger thanage three. To avoid duplication and competition, the establishment of thepublic-private partnership should be coordinated with the existing District ofColumbia Early Childhood Collaborative at the Community Foundation for the

National Capital Region. The District can look to Nebraska as a model.

11.E sure a equate perso e i city over me t to support pro rams aservices for chi re a fami ies. Severe staf ng shortages due to vacantpositions make it dif cult for local government agencies to manage programsthat serve young children. Currently, it can take more than two years to ll vacantpositions. Although this problem is far from unique to human services agencies,it is extensive. Programs cannot provide needed services with chronic staf ngshortages.

p y R mm nda ns M G a iV

Bui i pub ic-private part erships:

Ear y Chi hoo E ucatio E o me t (nebraska)In 2006, Nebraska created an Early Childhood EducationEndowment to fund quality services for at-risk childrenfrom birth to age three statewide. The endowment is apublic-private partnership that will annually generate $2million in interest from the $40 million public EducationaLands and Trust Funds, and $1 million in interest from a$20 million endowment funded by private entities. Grants will be awarded to school districts and educational serviceunits to partner with local agencies or programs in their

communities for services for these children. Grants will bcompetitive and will require a match of at least 50 perceof the total program costs. For more information,www.nde.state.ne.us/ECH/RFP%20Endowment/Overview.pdf

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The rst three years of life are crucial in a childs social, emotional, and cognidevelopment. At no other time in a childs life will he or she experience such

unparalleled growth. As such, the District of Columbia has a critical responsibilitytake action to support early childhood development now.

Although the depth and breadth of the recommendations reaf rm there is no singlor simple solution, three principles should guide future decisions about prioritizingand implementing these recommendations.

Support the eve opme t of stro fami ies a urturi care ivers. Thehealthy development of young children depends on the healthy developmentof the adults in their lives. Families that face economic insecurity, parents whstruggle with substance abuse or mental illness, and child care providers whonot have adequate skills or resources cannot provide the nurturing environmentthat babies and toddlers need to thrive.

Provi e comprehe sive supports. Families with babies and toddlers need accessto a medical and dental home, high-quality comprehensive child care, homevisiting services, and mental health, substance abuse, and other family supportservices. These families need coordinated access to all of these supports, not apiecemeal approach, to protect them from the multiple risks threatening theirhealthy development.

Tar et areas of extreme ee . There are concentrated areas of extreme povertyand risk in the District of Columbia. Babies, toddlers, and their caregivers whlive in these areas have the most to lose from our inaction, and the most tofrom a coordinated, comprehensive response.

Encouraging the new mayor and city leaders to enact policies that support goodhealth, strong fa

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