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January 31, 2022

ABC Program Background and Pilot Outcomes

Testimony presented by Health Fund President David Jordan to the House Children and Seniors Committee on Wednesday, January 26, 2022.

To:          Chairwoman Concannon and members of the House Children and Seniors Committee

From:    David Jordan, President & CEO, United Methodist Health Ministry Fund

Date:     January 26, 2022

RE:          ABC Program Background and Pilot Outcomes

Chairwoman Concannon and members of the House Children and Seniors Committee:

Thank you for the opportunity to provide background information to the committee on the Attachment and Bio-Behavioral Catch-up (ABC) Program and the Kansas pilot program. ABC is a ten-week targeted, manualized program delivered in the home for parents of children birth to four years old who have experienced adversity.

During each of the ten visits, the staff engage the parents and review very specific information with them focused on four target areas, outlined below. The goal is NOT to “cover the required materials” but to engage the parents and to frequently reinforce their positive behaviors consistent with the main targets of the ABC program: 

  1. Nurturance – attending to a child who has expressed a need;
  2. Synchrony/Following the Lead – interactions follow the child’s lead in play, neither passive nor intrusive;
  3. Delight – words or expressions from the parent to the child expressing positive emotion; and
  4. Avoiding frightening behavior – rough handling, menacing or throwing, threatening behaviors.

ABC was initially developed by the University of Delaware more than 25 years ago through several randomized, controlled trials to address toxic stress in young children living in adverse environments. The program has become one of the highest-rated interventions (and one of the only truly preventative programs) on the California Clearinghouse for Child Welfare. More information can be found online at: http://www.cebc4cw.org/program/attachment-and-biobehavioral-catch-up/.

ABC:  Evidence-based intervention that reduces toxic stress, improves school readiness and student success, reduces interaction with the child welfare system, and improves health

Research shows that the toxic stress caused by Adverse Childhood Experiences (ACEs) in early childhood has a major impact on the child’s overall development—on school readiness and the ability to learn, on physical and mental health, and on other factors including the ability to exercise self-control. These deficits negatively affect a child’s success both in the school setting and throughout adult life.

As an intervention to address adverse childhood experiences (ACEs), ABC has been shown to lead to increased parental sensitivity and responsiveness to child needs. Children who participated in ABC as toddlers were shown to have better receptive vocabulary than comparison children who did not participate. Furthermore, children who received ABC showed more normal levels of cortisol and improved executive function, meaning they have improved their ability to regulate behavior and emotion, by the preschool years. Science indicates that vulnerable children who have well-developed executive functioning and emotional regulation are able to do well in school despite experiences of adversity. Executive functioning predicts literacy and math scores, and many teachers contend that competence in terms of executive functioning “is more important at school entry than knowledge of letters and numbers.” 

ABC can also reduce interaction with the child welfare system by building secure attachment between parents and children. ABC strengthens parents’ relationships with their children, while helping children learn to regulate behaviors and emotions. Research has shown that immediately after receiving ABC, children whose parents received ABC were more likely to be classified as having a secure attachment compared to children whose parents received a control intervention. This finding sustained through middle childhood, with 9-year-olds whose parents received ABC reporting attachments to their parents that were significantly more secure than children whose parents received the control intervention. In national research, immediately following the intervention and three years’ post-intervention, ABC parents showed higher sensitivity (followed their children’s lead more), showed more positive affect (delight), were less detached, and were less intrusive than control intervention parents. ABC parents looked nearly indistinguishable from a low-risk comparison group of parents.

The more ACEs that a child experiences, the more likely that child will be to suffer from issues such as heart disease, poor academic achievement, and substance abuse later in life. According to the Centers for Disease Control, at least five of the top ten leading causes of death are associates with ACEs. The ABC intervention can improve the health of children by mitigating the effects of ACEs. The ABC intervention can buffer the biological and behavioral effects of early adversity and strengthen interpersonal relationships with caregivers, both of which influence long-term health, learning and behavior.

Kansas ABC Project Current Pilot

While ABC is typically completed over just ten weeks, research to date has shown measurable, long-term positive impacts lasting at least into middle childhood. 

Given ABC’s success in improving school readiness and student success, reducing family interaction with the child welfare system, and improving long-term health, five philanthropic organizations funded a pilot program to support the implementation of ABC in Kansas: United Methodist Health Ministry Fund, Hutchinson Community Foundation, Kansas Health Foundation, REACH Healthcare Foundation and Wyandotte Health Foundation.

From May 2017 through April 2020, they funded the Kansas ABC Early Childhood Initiative to determine if the ABC program would deliver the same results in a variety of service settings and in five geographic regions throughout the state.

Additionally, the Kansas ABC Early Childhood Initiative was funded to expand early childhood service capacity in Kansas by promoting widespread screening for toxic stress, training more providers in the ABC intervention, and evaluating the effectiveness of integrating an evidence-based intervention into the array of early childhood programs through five sites across the state.

Evaluating the Impact of the Kansas ABC Project

To understand the impact of the ABC project on Kansas families and the system, the project partnered with the University of Kansas School of Social Work to evaluate the project. The review of the project included an implementation evaluation as well as an impact study focused specifically on how the ABC intervention impacted children, caregivers, and their families. The in-depth evaluation also conducted pre and post intervention cortisol levels to understand the impact of the intervention in mitigating the impacts of toxic stress.

Over the course of three years, the Kansas ABC Early Childhood Initiative impacted the lives of Kansas families across 36 counties. 536 families were screened for toxic stress, 402 families were enrolled to receive the ABC intervention, and 682 caregivers and 907 children were impacted.

The evaluation found that the initiative resulted in more comprehensive early childhood services across Kansas and that families who participated in ABC demonstrated more positive outcomes, including healthier children, more confident parents, and stronger families.

After completing the ABC program, the evaluation found that:

  • Caregiver concerns regarding child social-emotional functioning decreased.
  • Children’s cortisol levels, an indicator of stress, became more normalized, especially for the children with the highest cortisol levels (though the change was not statistically significant for the entire sample).
  • Parent coaches rated children’s overall wellbeing as more positive.
  • Caregivers’ knowledge and beliefs in their caregiving abilities increased.
  • In interactions with their children, caregiver intrusiveness went down, while sensitivity and delight went up.
  • Caregiver capabilities significantly improved.

ABC was primarily delivered in English. To test its use in other languages and cultures, Hispanic populations were targeted for enrollment at three sites. In all, 41% of caregivers were Hispanic and 22% of caregivers spoke Spanish in the home. The family-focus of ABC appeared to be a good fit among Spanish-speaking populations, particularly when delivered by a parent coach with a similar identity. The same positive outcomes were seen in Spanish-speaking families as in English-speaking families.

In addition to demonstrating positive outcomes in the lives of children and caregivers, the initiative resulted in expanded capacity for early childhood services across the state. Kansas has provided Family First dollars to support ABC projects as part of child welfare prevention strategies deployed under Family First. Likewise, the Kansas Department of Education has recognized ABC as an approved program for equity funds at the state level, and Medicaid is reimbursing mental health providers using ABC for eligible children.

Considerations for policymakers

As policymakers explore evidence-based strategies to:

  • prevent utilization of the child welfare system,
  • keep children with their parents in their homes,
  • improve health,
  • build parenting skills, and
  • address equitable attainment of education,

The Kansas experience with ABC highlights its potential as a worthy, evidence-based investment. Kansas has already moved in this direction by providing Family First dollars to support ABC projects as part of child welfare prevention strategies deployed under Family First. Likewise, the Kansas Department of Education has recognized ABC as an approved program for equity funds at the state level, and Medicaid is reimbursing mental health providers using ABC for eligible children.

Given the success of ABC in normalizing cortisol levels and lessons learned from other states – like New York, which utilized ABC to sustainably reduce child welfare caseloads and aid reunification efforts – there is great potential for policymakers to further support evidence-based programs like ABC to advance child health and child welfare goals as well as improve educational attainment.

Continued investment from state government, foundations and early childhood stakeholders in ABC and other evidence-based programs will offer important opportunities to test, pilot, and evaluate programs to inform and maximize the return on future investments affecting generations to come. Ultimately, these lessons will offer policymakers the opportunity to fund evidence-based interventions like ABC that can improve health, educational outcomes, keep families together and save the state money.

Thank you for the opportunity to provide comments to you today regarding the ABC program.  Please be in touch with questions or if I can be helpful.

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