Changing lives from the very start: Report identifies best measures to help at-risk kids

Birth to 3 Special Report
The 3-year-olds attending The Children's Center's Head Start preschool program in Detroit are all giggles and smiles, exploring their surroundings with that special brand of bright eyes, innocence and curiosity that only toddlers possess.
These chubby-cheeked kids face big hurdles, though: poverty, parents with low educational attainment, parents who don't speak English, developmental delays, disabilities or having a history of "toxic stress" from witnessing violence and trauma.
Statistically, kids with these problems are shown to be less likely to graduate high school and college, will earn less money as adults and are more likely to be incarcerated than kids from the general population.
But by their very presence in this Head Start program, these kids are receiving one of the interventions shown to reduce the risk of those outcomes.
That's why funding for Head Start was boosted in 2013, with a $65 million funding infusion for the Great Start Readiness Program by the State of Michigan.
The boost focused on kids one year older than these ones, affording preschool to an additional 10,000 4-year-olds in the state. It represented the largest public preschool expansion in the nation but still left approximately 20,000 Michigan 4-year-olds unenrolled, according to an analysis by Bridge Magazine.
Early childhood advocates know birth to age 3 is a critical period for brain development, so they are increasingly turning their attention to that window of opportunity.
To be effective, they need to know two things. First, how many kids in Michigan are at risk? And second, which interventions have the best evidence of producing results?
"In public policy, we often invest in programs where we think the program works, but we don’t necessarily have a high-quality research study to know for sure," says Jeff Guilfoyle, vice president at Public Sector Consultants, a Lansing-based public policy consultancy. "There's a little bit of doing stuff on faith, and we need to have good, solid data to be able to help any population. There was a real knowledge gap on the number of at-risk children in Michigan and where Michigan should turn to next."
To address this knowledge gap, PSC joined forces with Citizens Research Council of Michigan, a nonprofit public policy think tank, to answer these questions. Their report, Policy Options to Support Children from Birth to Age 3, was released late last year. The report was funded by a number of philanthropic organizations with an interest in early childhood education.
"We have significantly better evidence for early childhood programs than we do for the typical public program," says Guilfoyle. “In this report, we use that evidence to outline the things policymakers should be considering if they want to tackle this issue. Compared to other things we frequently do in public policy, the evidence for early childhood investment is much more solid.”
What does the report tell us?
Childhood poverty in Michigan exceeds national average
Michigan's poverty rate for kids in the age category birth to 5 exceeds the national average, according to 2013 American Community Survey data.
The PSC/CRC report found 56 percent of Michigan children from birth to age 3 --
260,000 kids -- are considered to be at-risk for showing up to kindergarten unprepared for success, based on a family income threshold of 185 percent of the poverty line. This is the same threshold used to qualify families for reduced-price school lunches and Medicaid.
Making a difference through interventions
The PSC/CRC report identifies four interventions that have solid, research-based evidence of effectiveness and return on investment: home visiting programs, access to medical homes, high-quality child care and preschool for 3-year-olds.
"The programs we describe in this report have enough evidence behind them to warrant serious consideration by policy makers," says Guilfoyle. "We looked at programs that were evidence-based, and paid a return on the investment. These would be a logical place for Michigan to go to next."
Home visiting leads interventions
Of the four areas, evidence for home visiting programs is strongest, according to Guilfoyle.
"The evidence is fairly overwhelming," he says. "We're clearly not the only people who recognize this; the federal government is investing in these programs. They have some of the best evidence I've ever seen looking at any public policy programs in the course of my career."
A home visiting program is a voluntary program that connects parents with service providers, like nurses or social workers, who help address challenges. In August, the United States Department of Health and Human Services issued $106 million in grants to support the Maternal, Infant, and Early Childhood Home Visiting Program established by the Affordable Care Act. As of November, Michigan has been awarded $34.4 million in federal funding for this program.
The Michigan Council for Maternal and Child Health is working to help build a systematic approach to Michigan's home visiting program, making sure a variety of models with quality professional resources are available to meet families' needs.
"We're very involved in trying to make sure that home visiting has the support it needs in Michigan," says Amy Zaagman, executive director. "If we don't build a system of home visiting in Michigan with a number of models available to families, we don't think that we'll ever see the full benefit. That will require additional investment."
The report recommends a suite of policy options to improve access to home visiting, including providing grants, technical assistance, serving the neediest children first and assisting in community outreach programs.
Medical homes show promise for investment
Access to medical homes is another promising area for investment, according to the report. The American Academy of Pediatrics defines a medical home as a home base for a child's medical care that provides better outcomes than sporadic, disjointed care in emergency departments, walk-in clinics and urgent care facilities.
Maureen Kirkwood, president and executive of Health Net of West Michigan, helped launch and oversee the Children's Healthcare Access Program (CHAP) in Kent County.
"We knew the data showed a disparity between health outcomes for children on Medicaid versus kids with private insurance in Michigan," says Kirkwood. "CHAP was formed in 2009 as a demonstration project in Kent County, under the theory that if we could work to provide access to high-quality primary care to children on Medicaid, we would decrease their hospitalization rates and their use of the emergency room, and see better health outcomes."
The pilot succeeded in these goals, according to Kirkwood.
"We showed positive outcomes in cost reduction, quality of care, and health," she says. "We were able, over the course of a two-year period, to show $1.53 in savings for every $1 invested."
The CHAP program works as an intermediary, connecting families with medical homes in the area and with other services as needed. It functions as a shared resource for private medical practices in the area.
"We provide something that a lot of communities still do not have --a centralized, neutral resource that family practices can refer families to," she says. "We function as a parent education and engagement arm of the private practices. We contact the family and give feedback to the practice to let them know what we did. It saves busy practices from having to dial a bunch of different phone numbers to find an agency that might be able to help."
The report recommends providing matching grants to communities to develop CHAP programs, funding technical assistance and long-term evaluation.

High-quality child care and preschool for 3-year-olds are the final two areas recommended for investment.  According to the report, the cost of child care is high and rising, and the benefits of early preschool and high-quality child care are well documented. It recommends increasing reimbursement rates for high-quality child care, evaluating Great Start to Quality, the system used by the state to rate child care, and raising awareness of Great Start Connect, the Michigan Department of Education's web resource to access child care ratings. The report also recommends the state conducts a pilot to study the effectiveness of preschool for 3-year-olds, such as the studies at The Children's Center.
Report serves as a good start
"This report is not an exhaustive list of what we need to do, but it includes the four strategies that have the most research to support investment," says Susan Broman, director of Michigan's Office of Great Start, which oversees early childhood efforts in the state government.
"There are other strategies and other things we would support, but these are the four that emerged as the strongest," she says.
Broman points out transportation as another need that must be addressed to allow all four of these measures to be effective.
"We need to increase access to transportation, and that cuts across all of the services," she says. 
Erica Hill, education specialist with The Children's Center, agrees.
"Our families struggle with transportation issues," she says. "Especially when we had issues like the weather -- they can't stand out at the bus stops or get out of their driveways because the streets haven't been plowed."
Integrating these services is also important, according to Hill.
"That's something that we do really well because we are part of a center with an array of services to support children," she says. "We don't have to go through a lot of red tape to get families the services that they need if children are experiencing trauma or have some cognitive issues."

This piece was made possible through a partnership with Public Sector Consultants.

Photos by Amy Sacka at The Children's Center.
Q&A: Jeff Guilfoyle
Q&A: Jeff Guilfoyle
Vice President
Public Sector Consultants

IMG: Describe the need for a report on Policy Options to Support Children from Birth to Age 3. What information gap does it fill?
Jeff Guilfoyle: Based on our conversations with advocates in the early childhood space, we knew there was an interest in trying to come up with good estimates of the number of at-risk children in Michigan and the unmet need for programs to serve them, as well as to identify evidence-based early childhood programs that support young children in Michigan.
Public Sector Consultants partnered with the Citizen’s Research Council to produce this report because we were both interested in the topic and had expertise. (Ed. note: Guilfoyle was at CRC when the project started and has since moved to PSC).
We approached a number of philanthropic organizations we knew had an interest in early childhood issues and explained to them what we were trying to do. They were very interested in the research and saw the value in having this report out there.
IMG: How exactly is "at-risk" defined? Who are these kids?
Guilfoyle: When we say children are at-risk, what we really mean is they're at risk of arriving to kindergarten not ready to succeed.
We identified a number of risk factors that statistically show that you're at a much higher risk of not being ready for kindergarten, based on the academic research.
The most important risk factor is being from a low-income family. One of the tricky issues is, what is the definition of low income? It's a continuum; the lower your income is, the higher your risk. The number we used was 185 percent of the Federal poverty line, which is also the income threshold used to determine Medicaid eligibility and reduced-price school lunches.
Other risk factors include having a development delay or disability, coming from a household in which your parents or caregivers had low education attainment, defined as, “not at least having a high school degree,” and having parents or caregivers who were not strong English speakers.
Also, we included children who have experienced three or more of what we call “adverse situations or toxic stress.” Basically, children who have been exposed to very high stress.
IMG: What is the cost to society of poor outcomes in this population and conversely, the economic benefit of early childhood intervention?
Guilfoyle: The research shows if you make an investment in a child in the period from birth to age 3, you can actually see the return on that investment, all the way into adulthood.
That's pretty remarkable. Investing in an early childhood program can potentially affect the probability of a child graduating from high school, their expected earnings as an adult and the probability that they might be incarcerated.
Not only do you get your initial investment back, but you actually end up with long-term savings.
The evidence is particularly strong for home visiting programs. Random control trials that followed at-risk children into adulthood showed a measurable difference in outcomes between kids that were selected for the program and kids who were randomly selected not to participate in the program.
You see that return on investment in two different places. First, there's a return to the child you invest in. They're less likely to be incarcerated, they're more likely to graduate from high school, and they have higher earnings. And then there's also a return to taxpayers because they end up spending less money on things like special education, repeating grades and incarceration costs. Taxpayers get more tax money back when these children as adults earn more money.
As an example, one of the studies looked at the Nurse Family Partnership, a home visiting program. It concluded was $3.50 return in public sector savings for every dollar spent on the program. And that's just the return that the taxpayers got, it doesn’t even factor in the benefit the child received from the program to his or her own personal life and well-being.
If you can invest early and prevent problems from happening in these children’s lives, it's much cheaper than trying to fix the problems once they've already occurred. There is a huge benefit to society, to taxpayers, and to the children from investing in that birth to age 3 time period.