Child FIRST

About the program

Child FIRST (Child and Family Interagency, Resource, Support and Training) is a home-based program. It is a therapeutic intervention for multi-risk families with young children. It also seeks to ensure families diverse needs are met through a coordinated ‘system of care’. 

The program aims to:

• prevent or diminish serious emotional disturbance, developmental and learning disabilities, and abuse and neglect. 
• Strengthen parent-child relationships
• Build a network of supportive relationships that could continue to sustain the primary parent over the long term.

Child FIRST has two core components: 

• a system of care approach to provide comprehensive, integrated services and supports (e.g., early education, housing, substance abuse treatment) to the child and family
• a relationship-based approach to enhance nurturing, responsive parent–child interactions and promote positive social-emotional and cognitive development.

The program was developed by Darcy Lowell, MD, a Developmental and Behavioural Pediatrician in Connecticut, USA.

Who does it work for?

The Child FIRST program was designed for:

• families with children, prenatal to 6 years of age, demonstrating emotional/behavioural or developmental/learning problems
• families experiencing significant psychosocial risk

The Child FIRST program has only been evaluated in the USA (Lowell et al. 2011).

A randomised control trial was conducted with 117 people (58 in the intervention group and 59 in the control group). It has only been evaluated with mothers. On average, the mothers were 27 years old and the children were 19 months old. Most of the mothers were Latino/Hispanic (60%) and African American (27%). 

The program has not been evaluated in Australia or with Aboriginal Australians.

What outcomes does it contribute to?

Positive outcomes:

• Involvement with child protection: families who participated in Child FIRST has less child protective services involvement 3 years after the program finished, compared to families who did not participate in the program.
• Parenting stress: mothers who participated in Child FIRST reported lower clinical levels of parenting stress at six-month follow up, compared to mothers who did not participate in the program.
• Parent’s mental health: mothers who participated in Child FIRST were less likely to self-report psychiatric symptoms and symptoms of maternal depression at 12-month follow up, compared to mothers who did not participate in the program. 
• Parent’s use of services: families who participated in Child FIRST were more likely to receive services they wanted, compared to families who did not participate in the program. 

No effect:

• No non-significant effects were found.

Negative outcomes:

• No negative effects were found.

How effective is it?

Overall, the program had a positive effect on client outcomes.

How strong is the evidence?

Promising research evidence:

• At least one high-quality randomised controlled trial (RCT)/quasi-experimental design (QED) study reports statistically significant positive effects for at least one outcome, AND
• Fewer RCT/QED studies of similar size and quality show no observed effects than show statistically significant positive effects, AND
• No RCT/QED studies show statistically significant adverse effects.

How is it implemented?

Child FIRST is a home visitation program. Families have weekly visits from a case manager and mental health clinician. Visits typically last 45-90 minutes. On average, families participate in the Child FIRST program for 22 weeks. 

The weekly sessions are conducted with all relevant family members, including siblings, grandparents, father (even if he does not live with the child), and the primary parent’s partner.

Engagement and building trust are fundamental goals of the intervention. Staff are trained to approach families with warmth, empathy, and respect and to demonstrate they are there as partners and advocates. Outreach continued even in the face of multiple missed appointments. Assigned case managers reflect the ethnicity and culture of families and speak the language of the families choosing. 

The clinician and care manager partner with parents to conduct a comprehensive assessment of the child and family. This assessment identifies and, when appropriate, involves other service providers. This results in a family driven plan of broad, integrated supports and services for all family members, which reflects family priorities, strengths, culture, and needs. 

The mental health clinician takes primary responsibility for therapeutic assessment and intervention with child and parent. The case manager, with expertise in community resources, facilitated family engagement in community services. They also had role flexibility to respond to individual family needs. For example, the case manager could play with and observe the target child and siblings, while the clinician discussed sensitive topics with the parent(s).

A highly individualised, multilevel, parent–child psychotherapeutic and psychoeducational approach was used. This was guided by the issues that were most important to the family, as well as the strengths, needs and psychological availability of the child and family. There was no set curriculum; however, child development materials were often shared. 

A key goal of the therapeutic relationship is to help parent(s) reflect on their child’s experiences and the motivations and feelings underlying their child’s behaviour. In turn, they also reflect on their own feelings and responses to the behaviour. This often involves exploring connections between the parent’s past and current relationships and feelings toward the child. Together, the parent and clinician explore alternate interpretations of the meaning of the child’s behaviour and developed more effective responses. The goal is to help parents internalise a process for future responses to child communications rather than teaching specific strategies for specific problem behaviours.

Clinicians are also trained to reinforce positive maternal behaviours directed to the child and child behaviours indicative of the importance of the mother to the child. A central goal was to facilitate positive interactions through reciprocal parent–child play, reading, play, and family routines. Play also was used to help the child master and rework difficult challenges and to promote language development.

How much does it cost?

Less than $4,000 USD per family.

What else should I consider?

Materials were written at sixth grade reading level and are available in English and Spanish. 

The Child FIRST Assessment and Intervention Manual was used to teach and guide the intervention. 

The Assessment and Intervention Fidelity Checklist focused on the core elements of the intervention and included: 

• observation of the child’s emotional, cognitive, and physical development
• observation of parent–child interaction and play
• psychoeducation including developmental stages, expectations, and meaning of typical behaviours
• reflective functioning to understand the child’s feelings and meaning of child’s unique and challenging behaviours
• psychodynamic understanding of mother’s history, feelings, and experience of the child; alternate perspectives of child behaviour and new parental responses
• positive reinforcement of both parents’ and child’s strengths to promote parental self-esteem. 

Where does the evidence come from?

1 RCT conducted in the USA with a sample of 131 people at 6-month follow up and 117 people at 12-month follow up (Lowell et al. 2011). 

Further resources

For more information and resources about the Child FIRST Program see: https://www.childfirst.org/

Lowell, DI, Carter, AS, Godoy, L, Paulicin, B, & Briggs-Gowan, MJ, (2011), ‘A randomized controlled trial of Child FIRST: A Comprehensive Home-Based Intervention Translating Research into Early Childhood Practice’, Child Development, vol. 182, no. 1, pp. 193-208.