By Nurture Connection
The first chapter of Dr. Darcy Lowell’s remarkable story of practice transformation is about recognizing the problem. In the 1990s, in Bridgeport, Connecticut, where Dr. Lowell worked as a developmental and behavioral pediatrician at Bridgeport Hospital, she noticed that young children and families were not receiving critically needed mental and relational health services. This was impacting their health and well-being. What could be done?
She convened a task force of like-minded health, education, and social services providers, and out of those many cross-sector meetings came the impetus for Child First, an intensive, two-generation intervention helping the most vulnerable young children and their families that Dr. Lowell founded as a home-visiting program in 2001.
Since then, Child First has been recognized by the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program of the Department of Health and Human Services (HHS); the National Registry for Effective Programs and Practices (NREPP) of the Substance Abuse and Mental Health Services Administration (SAMHSA); and the Coalition for Evidence-Based Policy as one of only a handful of organizations that provide evidence-based mental health interventions for young children and their families.
Child First works with families with young children experiencing adversities like poverty, homelessness, and domestic violence, and factors like maternal depression and substance abuse to build strong, nurturing relationships that heal and protect young children from trauma and chronic stress. Most families are eligible for Medicaid and have children younger than six years with emotional/behavioral or developmental/learning challenges, as well as histories of trauma.
The original Child First program has expanded to 31 affiliate sites in seven states (with exploration for possible replication in four others) through its development of a reproducible model for mental health providers, hospitals, and other agencies that provide home-visiting services. In addition, it has merged infrastructure with Nurse-Family Partnership®, a national program serving first-time moms and their children living in poverty.
Child First Is Rooted in Relational Health
The Child First model is built on recognizing and embracing the importance of relationships, which influences everything from its interventions with families and its organizational structure to how it engages with the communities it serves. This is intentional, as Dr. Lowell explains: “When we’re working with children and families, it’s all about facilitating safe, nurturing, responsive relationships. This is fundamental to buffering stress and adversity, and promoting resilience. Listening closely and building trust are key to work at all levels. This is called ‘parallel process.’”
The model takes a two-pronged approach to intervention: It addresses family stressors/social drivers of health, as well as the mental health of both the parent/caregiver and the child. This dual focus is important because, as Dr. Lowell clarifies, “the stressors on the parents directly impact the child. I knew we needed a way to address these challenges and to do it in a relational way. For me, Early Relational Health was so fundamental. We needed to look at the dyad as well as the parent’s experience, both past and present.”
In addition, the organizational structure of Child First is founded on relationships. Staff in the field work as long-term partners: Each home-visiting team consists of a mental health/developmental clinician and a care coordinator. Also, Child First leans into reflective supervision, which nurtures strong, supportive relationships between teams and supervisors. Considered an essential factor in mitigating employee burnout from secondary trauma, Child First allocates three hours per week for reflective supervision at the individual, team, and group (all teams) levels.
From an implementation standpoint, community relationships are essential for Child First. The model depends on partnership with multiple community agencies and stakeholders (e.g., various commissions, state agencies, providers, parents) to be able to effectively integrate within a community’s system of care. In addition, implementation and decision-making are community-led and collaborative.
“The Child First model is built on recognizing and embracing the importance of relationships, which influences everything from its interventions with families and its organizational structure to how it engages with the communities it serves.”
How Child First Actuates Practice Transformation
The second chapter of Dr. Lowell’s practice transformation is about creating growth and sustainability for Child First. As Child First’s home-visiting intervention model has been implemented in more communities, there has been subsequent transformation at the system level in the way care is delivered — with relational health at the core.
How did Child First become an instrument of practice transformation? Dr. Lowell shares some valuable insights on what she feels is required for achieving practice transformation, based on her experience founding and leading Child First from 2001 to 2023:
Articulate a clear vision
Practice transformation is hard work, and it can be frustrating when leaders are told their ideas for change are impossible. To stay focused, leaders need a clear vision for what they want to accomplish and why. “For practice transformation, you have to understand the big picture,” says Dr. Lowell. “You have to feel what you’re doing is something that’s really important and is going to fill a gap or unmet need.”
Establish strong partnerships
Partnerships are critical for collaboration and support and also for perspective and learning. “Community involvement is essential. You need to involve the stakeholders that you will be serving from the beginning. Listen closely to what they need and want. You can’t do it alone; you need people who are in it with you,” says Dr. Lowell. “Also, you have to be looking at systems of care as you develop a practice to see most clearly how to move forward. You need different partners at different levels. Again, this is all about connection and relationships.”
Embrace continuous learning
There is always a lot to learn from others and opportunity to leverage what exists and build on it. As Dr. Lowell explains, “I would say, learn from everyone, read deeply, and listen closely. So that you really understand, in terms of practice transformation, where what you’re working on fits in the big picture.” Also, don’t hesitate to incorporate existing models into your work (and of course, give them credit). Dr. Lowell says they train staff on other models in addition to Child First, as some have “wonderful ways of communicating with parents about attachment and relationships.”
Be thoughtful about data collection
Using data to measure impact and fidelity to the model is a key part of practice transformation. But Dr. Lowell warns leaders not to collect data for data’s sake. Instead, make sure the data you collect is actually what you want to measure. “You don’t want to overload staff and families with collecting data you won’t use,” says Dr. Lowell. “Also, really look at the data and think about it. What is this telling us and why? How can we improve our services?”
Start early on sustainability
Once you have a model, the issues of funding and sustainability are critical. Dr. Lowell recommends working on establishing funding streams, including public funding,* from the very beginning: “What is the public funding stream or streams that we’re going to need? Start working on actually making those happen. Don’t rely on grants or philanthropy alone; this will leave you really vulnerable.”
Research can be a powerful tool for acquiring and sustaining funding. Child First published results from a randomized controlled clinical trial in 2011, which showed strong improvement in child mental health, child language development, maternal depression, and child welfare involvement. Continued ongoing data collection from August 2010 to the present also shows improved child social skills, parent-child relationships, parental stress, and PTSD.
*Public funding has played a key role in sustaining the success of Child First, making it one of many examples that show why it is so important. Nurture Connection closely follows the latest funding shifts in social services and health programs and supports.
Focus on communication and reflection
Child First is intentional about creating space for listening and incorporating learnings along the way. For example, in each community/region, Child First facilitates monthly Child First Network meetings of all the agencies involved. “We really promoted those relationships so the Child First programs at different agencies would learn from and support each other,” says Dr. Lowell. “There was a lot of peer interaction. Also, if the network felt like they needed more learning in a certain area, we would have an expert come in and present.”
In addition, reflective supervision is a key factor in helping teams feel supported, communicate, and build their therapeutic skills. As Dr. Lowell explains, “They had a safe space to think deeply about their families and themselves, and knew there was an open-door policy with their supervisor, who was there to support them in the emotionally difficult work.”
Early Relational Health (ERH) Is the Foundation for Everything
“I really believe that Early Relational Health is the most important work we can do,” says Dr. Lowell. This belief — this vision — is what sustains Child First in its practice transformation efforts.
In addition to a clear vision, practice transformation requires partnership and continuous learning — which is Nurture Connection’s focus as an early childhood field catalyst promoting ERH. “Nurture Connection is so critical because it brings together like-minded people who understand the importance of early relationships,” says Dr. Lowell. “It promotes community and magnifies our voice and our message. And it’s an opportunity to hear about new programs and ideas, and find out about other people who are doing work that might intersect with my own and who I might want to collaborate with to move this essential work forward.”
This blog post is part of Nurture Connection’s “ERH in Action” series of listening and learning sessions. Our network is full of meaningful examples of people and organizations promoting ERH in their daily lives and work. Our “ERH in Action” series highlights and uplifts stories from various fields to share learnings, challenges, and bright spots in the movement.