Program Evaluation on Early Head Start

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INFANT MENTAL HEALTH JOURNAL, Vol. 23(1 – 2), 231 – 249 (2002) � 2002 Michigan Association for Infant Mental Health

A R T I C L E

EARLY HEAD START MAP: MANUALIZED

ASSESSMENT OF PROGRESS

SUSAN DICKSTEIN RONALD SEIFER

MARIA EGUIA REGINA KUERSTEN-HOGAN

KARIN DODGE MAGEE Brown University School of Medicine, E. P. Bradley Hospital

ABSTRACT: We present the Early Head Start MAP (Manualized Assessment of Progress) system, a newly developed program evaluation protocol for Early Head Start (EHS). Briefly, EHS is a prevention program for low-income families with infants, toddlers, and pregnant women. The EHS MAP protocol was de- signed to be incorporated into the fabric of the EHS program, utilized by all EHS staff members with input from EHS families. As such, it serves to document ongoing progress of children and families while enrolled in the program, as well as the fidelity of services provided. Preliminary empirical results are presented to exemplify the nature of efficacy and fidelity data that can be obtained with this EHS MAP system. Implications of conducting program evaluation are discussed as related to Early Head Startservice delivery.

RESUMEN: En este estudio se presenta el sistema MAP (Evaluacio´n manualizada del progreso) de “Early Head Start,” un protocolo para la evaluacio´n de programas recientemente desarrollado para “Early Head Start.” En breve, EHS es un programa de prevencio´n para familias de bajos recursos econo´micos con infantes, nin˜os que empiezan a dar pinitos, y mujeres embarazadas. El protocolo MAP fue disen˜ado para ser incorporado dentro de la estructura del programa EHS, utilizado por todo el personal de EHS con sugerencias de las familias de EHS. Como tal, el protocolo sirve para documentar el constante progreso de los niños y familias que participan en el programa, ası´ como tambie´n la fidelidad de los servicios que se prestan. Los preliminares resultados empı´ricos son presentados para ejemplificar la naturaleza de la eficaz y fiel informacio´n que se puede obtener con este sistema MAP. Las implicaciones de llevar a cabo una evaluacio´n del programa se discuten tal como se relacionan con el servicio de prestaciones de “Early Head Start.”

RÉSUMÉ: Nous présentons le syste`me Early Head Start MAP. Le Early Head Start est un programme de prévention et d’aide gouvernementale a` la petite enfance de´favorisée aux Etats-Unis d’Ame´rique. Le MAP (Evaluation Manuelle de Programme, abre´gé MAP en anglais) est un protocole d’e´valuation de programme tout nouvellement de´veloppépour le programme Early Head Start. Brie`vement, et plus spe´- cifiquement, le EHS est un programme de pre´vention pour les familles a` bas revenus ayant des be´bés,

The authors wish to acknowledge collaboration with New Visions for Newport County, Inc., Early Head Start, and Self Help, Early Head Start, in the development and implementation of this work. The authors are supported in part by the National Institute of Mental Health. Direct correspondence to: Susan Dickstein, Bradley Hospital, Brown University, 1011 Veterans Memorial Parkway, East Providence, RI 02806; phone: 401-751-8040; fax: 401-331-2768; e-mail: Susan�[email protected].

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cap height base of textdes petits enfants, et pour les femmes enceintes. Le protocole EHS MAP a e´téconçu pour être incorpore´

dans le tissu du programme EHS, utilise´ par tous les employe´s de EHS avec le concours des familles participant au programme. En tant que tel, il sert a` documenter le progre`s en cours des enfants et des familles pendant qu’elles sont inscrites au programme, ainsi que la fide´lité des services qui sont offerts. Des résultats empiriques pre´liminaires sont pre´sentés afin d’exemplifier la nature de l’efficacite´ et la fidélité des donne´es qui peuvent eˆtre obtenues avec ce syste`me EHS MAP. Les implications pour effectuer une évaluation de programme sont discute´es comme e´tant liées au service qu’offre le EHS.

ZUSAMMENFASSUNG: Wir präsentieren das Early Head Start (EHS� Frühförderungsprogramm in den USA) MAP (ein Manual zur Bestimmung der Fortschritte) – ein neuerdings entwickeltes Manual zur Evaluation des Fru¨hförderungsprogramms EHS. In aller Ku¨rze gesagt ist EHS ein Vorsorgeprogramm für einkommensschwache Familien mit Sa¨uglingen, Kleinkindern und fu¨r schwangere Frauen. Das EHS MAP wurde so hergestellt, dass es in das Netzwerk des EHS passt und von allen MitarbeiterInnen und Familien, die das EHS gestalten, verwendet werden kann. So dient es als eine Dokumentation der Ver- laufsbeobachtung der Kinder und ihrer Familien, die am EHS teilnehmen und dokumentiert die Sicherheit der Leistungserbringung. Vorla¨ufige empirische Daten werden pra¨sentiert, um die Art der Leistungsmes- sung und deren Sicherheit zu zeigen, die mit dem EHS MAP System erhoben werden ko¨nnen. Die Bedeutung einer Evaluation eines solchen Programms wird im Zusammenhang mit der Leistungserbrin- gung des EHS diskutiert.

* * *

Children develop in context. Their outcomes reflect the risk and protective circumstances of their early environments. Early Head Start (EHS), a federally funded prevention program, was designed to promote the well-being of at-risk children by providing a healthy context in which young children and their families can develop. The mission of EHS is to enhance chil- dren’s physical, social, emotional, and cognitive development; to enable parents to promote their child’s development, enhance parenting competence, and meet their own goals including economic independence; to provide individualized child development, parent education, and family-focused services; to use a plan developed by parents and staff that is supportive and nurturing of families; to recognize child care needs of working families; to help them connect with other community services; and to involve parents in policy and decision making at all levels of the program. Further, this mission not only involves implementing the EHS program, but also includes monitoring its effectiveness at both local and national levels.

Effective monitoring of EHS needs to incorporate all aspects of its impressive mission and be flexible to meet the needs of the children, families, and staff associated with the program. We designed the EHS Manualized Assessment of Progress (MAP) system as a program eval-

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members with input from EHS families. As such, it serves to document on-going progress of children and families while enrolled in the program, as well as the fidelity of services provided.

WHAT IS MONITORED?

The EHS MAP system can be used to monitor efficacy and fidelity of program implementation. It can be used to assess and track individual child and family progress in five domains that are related to the EHS mission. The five goal domains include: (1) Parent Self-Sufficiency; (2) Child Developmental Readiness; (3) Parent Promotion of Child’s Development; (4) Health, Nutrition, and Mental Health; and (5) Program–Community Integration. Three major factors influenced the selection of goals within these five domains. First, they reflect the U.S. Depart- ment of Health and Human Services, Administration on Children, Youth, and Families(ACYF), Head Start Bureau’s “Head Start Program Performance Standards and Other Regulations,” intended as a guide for EHS service implementation. Second, the goal domains reflect the principal means by which the broad EHS mission, described at the outset, has been operation- alized. Third, they highlight the empirical research findings on predicting child competence in poverty samples. The specific goals that are chosen within each domain are detailed in Table 1. The selection of these specific goals was guided by empirical literature, and integrated the collective years of experience and wisdom of the EHS staff with whom we collaborated in the development of this system. It is important to note that additional specific goals of interest to EHS programs that are not listed in the table can be easily incorporated into the current system.

Parent Self-Sufficiency

This goal domain focuses on the pragmatic aspects of family functioning. Each child’s partic- ipation in EHS is embedded in his or her relationships with primary caregivers, which in turn, are embedded in a family context, and further within neighborhood, economic, and cultural circumstances (Sameroff, 1983; Chase-Lansdale et al., 1997). Recent research on poverty has highlighted the complex interplay among family and environmental factors that are most related to child outcomes (McLoyd, 1998), including the pragmatic aspects of family life. For EHS to be most effective in addressing principles of development and adaptation, it is necessary for the program to be maximally sensitive to this level of the child’s developmental context. EHS MAP goals in this domain would be selected if the family indicates a particular need or desire for improvement in areas such as income or finances, employment, obtaining basic resources, credit history, child care, and/or education.

Child Developmental Readiness

The negative effects of poverty on child development are well documented and pervasive (Halpern, 1993; Huston, McLoyd, Garcia Coll, 1994; McLoyd, 1998). This is even more con- cerning given the recent trend for a gradual yet steady increase in poverty rates for children, particularly preschoolers (McLoyd, 1998). Research has shown that poverty negatively affects children’s cognitive development, academic achievement, and socio-emotional development (McLoyd, 1988; McLoyd, Ceballo, & Mangelsdorf, 1996; Stipek & Ryan, 1997). The EHS program is intended to promote optimal child outcomes, not only by facilitating pragmatic family functioning (see above), but by providing services that directly improve or enhance the child’s development. EHS MAP goals in this domain would be selected to facilitate the ac- quisition, maintenance, and/or generalization of development in areas of language, fine motor,

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cap height base of textTABLE 1. MAP Domains: Early Head Start Goals

(01). Parent Self- Sufficiency

(02). Developmental Readiness

(03). Parent Promotion of Child Development

(04). Health, Nutrition, and Mental Health

Wellness

01. Income 02. Employment 03. Basic resources:

Food Housing Clothing Utilities Health insurance Transportation

04. Credit history 05. Child care 06. Registration

Birth certificates Social security Voting

07. Education 08 Other self-sufficiency

01. Developmental milestones Language Gross motor Fine motor Adaptive Cognitive Specific milestone

02. Socialization Classroom adjust- ment Behavior/emotions Relationship with Peers/caregivers

03. Transition plan 04. Developmental as-

sessment 05. Other readiness

01. Parenting skill 02. Family violence pre-

vention and interven- tion

03. Family relationships Adult relationships Parent–child bond

04. Neighborhood safety 05. Home environment 06. Parent involvement 07. Other parent promo-

tion

01. Routine health care Nutrition Prenatal health Family planning Well-baby/child checks Health screens Immunizations

02. Chronic/acute illness 03. Preventive mental

health care 04. Mental health treat-

ment 05. Behavioral health

care (e.g., addictions) 06. Social support 07. Other wellness

(05). Program– Community Integration

01. Coordination among service providers

02. Collaboration with community services

03. Assessment/develop- ment of community resources

04. Other community

gross motor, cognitive and adaptive functioning. In addition, this domain includes tracking of the child’s socialization capacities and behavioral adjustment.

Parent Promotion of Child Development

The EHS program emphasizes partnerships with families that is critically important for the enhancement of child competence. The Early Head Start program is designed to serve families in poverty, a context often associated with additional risks such as neighborhood violence, teen- and single-parenthood, and nonoptimal parenting practices. Researchershavedocumented that parents in impoverished contexts are more likely to use harsh, inconsistent, and coercive parenting practices compared to parents with greater economic means (Lyons-Ruth, Zoll, Con- nell, & Grunebaum, 1986; Sampson & Laud, 1994; Smith, Brooks-Gunn, & Klebanov, 1997). Further, father absence is a critical variable for predicting child outcome in this context (Osof- sky, Hann, & Peebles, 1993). Research findings are often contradictory regarding the degree to which young fathers indicate desire to be involved in the parenting of their children (Chase- Landsdale & Vinovskis, 1987; Furstenberg & Harris, 1993) and the degree to which nonresi- dential fathers actually are involved in their children’s lives (Anderson, 1989; Sullivan, 1989).

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of at-risk children is associated with better educational and behavioral child outcomes (Cook, Church, Ajanaku, Shadish, Kim, & Cohen, 1996; Furstenberg & Harris, 1993).

Finally, it is crucial to recognize that family systems are not limited to the (so-called) traditional nuclear family especially when working with at-risk populations. Impoverished and minority populations are more likely to live in larger extended family networks or to utilize extended family members to provide child care and basic necessities such as food, shelter, and financial assistance (Garcia Coll, 1990; Halpern, 1993; Hunter, 1997; MacPhee, Fritz, & Miller- Heyl, 1996; Pearson, Hunter, Cook, Ialongo, & Kellam, 1997; Pearson, Hunter, Ensminger, & Kellam, 1990). Teenage parents, compared to older mothers, are also more likely to reside with their own mothers (Burton, 1990; Osofsky et al., 1993; Wakschlag, Chase-Lansdale, & Brooks- Gunn, 1996). Recent research has pointed to a complex interplay of the quality of the mother– grandmother relationship, age of the mother, and mother and child characteristics in the effects of mother–grandmother coresidence on child developmental outcomes. For example, having a grandmother living in residence with teen and minority mothers is related to improvements in parenting skills and child developmental outcomes (Apfel & Seitz, 1997; Kellam,Ensminger, & Tuner, 1977; Osofsky et al., 1993). More specifically, grandmother co-residence is most beneficial for children and teen mothers when the teen is younger (Chase-Lansdale, Brooks- Gunn, & Zamsky, 1994; Wakschlag et al., 1996). Alternatively, older mothers who maintain positive, supportive, and independent relationships with their own mothers demonstrate more effective parenting skills when living apart from grandmothers (Wakschlag et al., 1996). The grandparent–child relationship in and of itself may provide a protective function for young at- risk children (Chase-Lansdale et al., 1994; Halpern, 1993) and certainly needs to be examined when developing EHS goals for children and families.

Given the importance of parenting and family relationships for predicting childcompetence in poverty samples, the EHS MAP system emphasizes this domain. EHS MAP goals related to Parental Involvement in the Child’s Development include facilitating and/or enhancing par- enting skills and family relationships (including parent–parent and parent–child bonds), as- sessing the need for family violence prevention and/or intervention, and addressing issues related to neighborhood safety and healthy home environments.

Health, Nutrition, and Mental Health Wellness

Children born in the context of poverty are more likely to have health problems including prematurity; poor nutrition; increased rates of lead exposure; more frequent and longer hospital stays; and prenatal exposure to alcohol, tobacco, and other drugs (Bradley, Whiteside, Mund- from, Casey, Kelleher, & Pope, 1994; Halpern, 1993; McLoyd, 1998; Needleman, Schell, Bellinger, Leviton, & Allred, 1990; Pollitt, 1994; Siegel, 1982). Further, mental health needs of this population are rarely addressed. It is crucial that, given the needs of the vulnerable children and families it serves, Early Head Start programs must attend to and fully integrate mental health services to improve overall quality of relationships between EHS staff and fam- ilies, as well as the larger childcare community (Mann, 1997).

In addition, the parents of these children are more likely to have health and mental health difficulties that also affect child outcomes. For example, much research targeting the influence of maternal depression on infant and child outcomes supports the notion that depressed mothers display disruptions in parenting behavior, and that their children exhibit a variety of impair- ments in social, psychological, and affective functioning (Dickstein et al., 1998; Lyons-Ruth et al., 1990; Seifer & Dickstein, 2000; Weissman et al., 1987). EHS families are at high risk for health and mental health problems given the burden of accumulated contextual risks. Teen-

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and depression (Garrison, Schuluchter, Schoenback, & Kaplan, 1989; Kessler, Berglund, Fos- ter, Saunders, Stang, & Walters, 1997; Osofsky & Eberhart-Wright, 1988; Osofsky et al., 1993). Further, depression is more common in women without partners (as is frequently the case with young mothers), and in the context of poverty (Bradley et al., 1994; Duncan, Brooks-Gunn, & Klebanov, 1994; Planos, Zayas, Busch-Rossnagel, 1997; Sameroff, Seifer, & Bartko, 1997).

In sum, the health and mental health needs of families enrolled in EHS require attention and documentation. Therefore, EHS MAP goals in this domain include routine health care, health care for chronic or acute illness issues, mental health care (treatment)and/orconsultation, behavioral health care, and/or social support.

Program– Community Integration

This goal domain focuses on two main issues related to establishing a coordinated system of care for EHS families. Often times, and with all good intentions, families with multiple needs are helped to access the variety of services they might require. However, they often are left overwhelmed and befuddled by the numerous appointments, agencies, and care providers of- fering assistance, yet operating independently of each other. Ultimately, this leads to families withdrawing from obtaining the “help” they might need. One role of the EHS Family Advocate is to serve as a coordinator of services. Thus, EHS MAP goals in this domain include the coordination of services among multiple services, service providers, and/or agencies withwhich the family is involved, linking families with community services, and facilitatingtheassessment or development of community resources that might not be readily available.

Summary

The EHS MAP system can be used to track and monitor progress of individual children and families during their enrollment in EHS. It guides the selection of goals that are relevant to the EHS mission, and guides staff in their work with families. The EHS MAP system is embedded in the day-to-day functioning of the EHS program. That is, all staff members working with children and families enrolled in the program contribute to the documentation of progress. A basic principle in designing the EHS MAP system was to employ activities that program staff were already completing, and toorganize(developmentally and sequentially),systematize, and track these activities in a data-based manner.

METHOD AND CASE VIGNETTE

As part of the routine EHS enrollment procedures, all members of the EHS team (including a teacher, family advocate, mental health consultant, nurse, and nutritionist) met with Jimmy Z. and his family to obtain basic information about child and family functioning (through inter- view, testing, and observation of family interaction). During these meetings, EHS staff, in partnership with the family, identified areas of strength as well as areas of nonoptimal func- tioning, which are recorded using EHS MAP reviews.

Below, we briefly describe the main components of the MAP system, and use the case of Jimmy Z. and his family to illustrate the dynamics of the system. These system components include MAP reviews and goal plans. We then discuss the conversion of the MAP paperwork into data used to provide feedback regarding program efficacy at the level of average child and family progress.

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cap height base of textMAP Reviews

The EHS MAP system is based on partnership efforts between EHS staff and families, as well as coordinated efforts among EHS staff. To document results of these collaborations, three reviews are completed. TheFamily Development Reviewis completed by the Family Advocate (or Home Visitor) in conjunction with the family upon enrollment in the program. It documents the family’s level on all EHS social service goals in domains of Parent Self Sufficiency, Parent Promotion of Child Development, Health/Mental Health Wellness, and Program–Community Integration. Although it is initially conducted as part of the family’s enrollment in the program, it is updated quarterly during the time the family is enrolled in the program. Areas of nonoptimal functioning and/or strong needs are identified as goals that comprise the Family Development Plan (see below).

Also upon enrollment to the program, aDevelopmental Readiness Reviewis completed by the primary care provider (teacher) to document the child’s level on all Child Developmental Readiness goals. Ratings in all areas of child developmental readiness are guided by results of a formal developmental assessment (conducted as a routine enrollment procedure). The De- velopmental Readiness Review is updated and discussed with the family at least three times per year. Goals for the Developmental Lesson Plan (see below) are chosen based on these reviews, which reflect areas of nonoptimal development and/or strong needs.

The following vignette summarizes information obtained from EHS staff regarding Jimmy Z. and his family shared at the initial Care Coordination meeting, based on EHS MAP review information. Jimmy Z. was being considered for placement in a center-based full-day class- room.

“Jimmy Z. is a nearly two-year-old boy who lives with his unmarried father and five-year- old brother. Jimmy was placed in the care of his father (Mr. Z) two weeks prior to EHS enrollment, after having resided in foster care since birth. Mr. Z reported that Jimmy was removed from his mother’s custody at birth due to a positive toxicology screen, following which she apparently made no attempt to regain custody of Jimmy, or reestablish a relationship with Mr. Z. Jimmy’s brother had a similar early history, and had been in the sole custody and care of his father for the past six months. Mr. Z had liberal visitation with Jimmy since birth, and increased lengths of stay recently in preparation for the current placement. Mr. Z was positive about his reunification with his son, and expressed realistic concerns about the chal- lenges facing him as a single father of 2 young boys.

Mr. Z described his own history of drug and alcohol abuse, although indicated that he has maintained sobriety for the past year. He also reported a sometimes-volatile relationshiphistory with one adult partner. Mr. Z is employed fulltime, and has minimal social supports. He identified a desire for general assistance with parenting.

Jimmy has a well-documented history of language delays, for which he was evaluated and in treatment with the local Early Intervention agency. Mr. Z indicated that he was concerned about Jimmy’s limited use of words. He otherwise described Jimmy as a robust child, with minimal medical or nutrition difficulties.

Jimmy was observed to be a happy and sociable toddler. He engaged in exploratory be- havior during most of the interview, examining just about every object in the room, and sharing particularly fascinating discoveries with his father. In addition to abundant curiosity, Jimmy was quite physically active, and was observed to nearly run into doors or walls on several occasions. Mr. Z was appropriately vigilant to Jimmy’s activities, although demonstrated less than effective limit setting abilities. The dyad engaged in warm and affectionate behavior.”

At the initial care coordination meeting, aCare Coordination Reviewwas completed by the Care Coordination team leader to document family and child levels for all current (in

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from the initial Developmental Readiness Review and initial Family Development Review, so that the EHS team was aware of the initial goals to be addressed. Subsequent to this initial meeting, care coordination meetings are held to review each child’s and family’s progress at least on a monthly basis, with input provided by all EHS staff involved with the family. The team meeting serves to coordinate efforts among EHS staff in their work with a particular child and family. During this time, staff members participate in a discussion and planning session regarding all in-progress goals as well as other issues that require attention.

In the case of Jimmy Z., the team reviewed information about the child’s developmental status, as well as family functioning. The team (with input from Mr. Z during the enrollment process) identified the following initial goals. The EHS teacher selected a “Language” goal for Jimmy, and the Family Advocate selected a “Parenting Skill” goal. The selection of these goals was consistent with the parent’s input. It should be noted, however, that other goals may have been equally appropriate for this family (such as Parental Social Support, Adult Relationships, and/or Coordination of Community resources), and which may flexibly be selected at any time while the child is enrolled in the program.

Developmental Lesson Plan (DLP)

Using the MAP system to monitor the child’s developmental progress, the child’s teacher rates selected Child Developmental Readiness goals using the Developmental Lesson Plan. This includes a series of goal sheets, one for each of the Child Developmental Readiness goals. Goals are chosen for an individual child based on information obtained from developmental screening assessments, classroom observations, and family reports of the child’s strengths and needs. When relevant, the DLP incorporates goals originated in other service agencies (such as Early Intervention). Note that we use the language of the center-based program component (e.g., teacher developed plans), but there are equivalent functions performed by home visitors in the home-based portion of the program.

The DLP is reviewed on a weekly basis by the teacher to plan and track the child’s activities and progress in the particular goal area—it is a continual “work in progress” as the child grows and develops. The steps to achieve each goal (termed “accomplishments”) are listed, by chron- ological age, to facilitate the planning and monitoring process. An example of a DLP goal sheet (targetingLanguagedevelopment) and the accompanying Accomplishment Manual page (for Languagedevelopment) are presented in Tables 2 and 3, respectively.

Family Development Plan (FDP)

Using the MAP system to monitor family progress, the Family Advocate together with the family selects at least one goal to be rated using the Family Development Plan goal sheet. This document is family-focused, addresses family needs and desired goals, and like the child- focused DLP is a continual work in progress. Following an initial family needs assessment target goals are chosen in at least one of the four family-based domains consistent with the EHS mission (described in the Introduction). The FDP is reviewed on a regular basis to plan and track the family’s progress on selected goals. Akin to the DLP, the accomplishments that may be chosen en route to achieving goal progress are provided in list form to facilitate the planning and monitoring process. An example of an FDP goal sheet (targetingParenting Skill) and the accompanying Accomplishment Manual page are presented in Tables 4 and 5, respec- tively.

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cap height base of textTABLE 2. Example of Developmental Lesson Plan (DLP) Goal Sheet for Language Development

DEVELOPMENTAL LESSON PLAN (Week of )

Child Name: Staff: Reviewed with Family□

0201 (Development—Language) Date Initiated: Initial Goal Level: Desired Goal Level:

(Circle Current Goal Level) 0. On Hold 1. Nonoptimal development; evidence of impairment 2. Nonoptimal development; no impairment 3. Development generally on track; some inconsistencies 4. Development on track; solidly within normal limits 5. Maintenance/consolidation of gains 6. Generalization/enhancement of gains

Accomplishments End of Week Review Date

Completed

1. # Incomplete—No Progress Incomplete—Progress Completed

2. # Incomplete—No Progress Incomplete—Progress Completed

3. # Incomplete—No Progress Incomplete—Progress Completed

4. # Incomplete—No Progress Incomplete—Progress Completed

5. # Incomplete—No Progress Incomplete—Progress Completed

6. # Incomplete—No Progress Incomplete—Progress Completed

Activities:

Codifying Progress in Goal Domains

Each child and family enrolled in EHS works with a multidisciplinary team on at least one child and one family goal. For each goal, objective and measurableGoal Levels(from absent to sufficient) are established, rated when the goal is initially identified, and updated regularly. SpecificAccomplishmentsare determined to help promote progress toward each goal in smaller chunks. Accomplishments are reviewed and rated regularly (as “incomplete- no progress,”

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cap height base of textTABLE 3. Example of Accomplishment Manual for Language Development

Language Age Range

01. Child smiles 0–3 months 02. Child coos 03. Child orients to voice

04. Child vocalizes pleasure, displeasure, eagerness, satisfaction 4–9 months 05. Child babbles (vowels, consonants, multisyllables) 06. Child produces at least three different sounds 07. Child listens selectively to familiar words (bath, name for bottle, going

out) 08. Child spontaneously uses gestures

09. Child plays gesture/language games (pat a cake, so big) 10–15 months 10. Child uses dada and mama specifically 11. Child understands and responds to “no” 12. Child uses one word 13. Child imitates sounds 14. Child follows one step command with adult’s gesture (“Come to

mommy”) 15. Child imitates words 16. Child speaks two to six words 17. Child uses jargon (babbles with inflection) 18. Child uses exclamatory expressions 19. Child uses pointing and reaching to communicate needs 20. Child can identify familiar objects/people 21. Child labels/says animal sounds

22. Child speaks 7 to 20 words 16–24 months 23. Child uses words to make needs/wishes known 24. Child uses two-word combinations 25. Child can name up to 30 pictures 26. Child speaks 50 words 27. Child labels body parts 28. Child uses words to describe actions

29. Child uses two- to three-words sentences 25–36 months 30. Child uses pronouns 31. Child understands prepositions 32. Child uses descriptives 33. Child uses 50–100 words 34. Child can name 31–100 pictures

“incomplete-some progress,” or “completed”). This is a unique aspect of the MAP system in that specific goals are broken down into manageable steps that are easily tailored to individual needs and strengths, that are developmentally appropriate, and simultaneously keep both the big picture and the little pictures in sharp focus. A Manual of Accomplishments is provided (and updated at regular intervals) to effectively guide staff to develop systematic, coherent plans with families to facilitate progress on goals.

Computer Data Entry

On a weekly basis, MAP goal levels and accomplishment ratings are entered into the computer for data analysis. The data are organized such that each record represents a specific goal,

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cap height base of textTABLE 4. Example of Family Developmental Plan (FDP) Goal Sheet for Parenting Skill

FAMILY DEVELOPMENT PLAN—CONTACT NOTE

Name: Date: Reviewed with family□

0301 (Parenting Skill) Date Initiated: Initial Goal Level: Desired Goal Level:

(Circle Current Goal Level) 0. On Hold 1. Nonoptimal evidence of impairment 2. Nonoptimal no evidence of impairment 3. Adequate but inconsistent or undesirable 4. Adequate and consistent or desired 5. Better than adequate; maintain/enhance gains

Accomplishments Visit Review Date

Completed

1. # Incomplete—No Progress Incomplete—Progress Completed

2. # Incomplete—No Progress Incomplete—Progress Completed

3. # Incomplete—No Progress Incomplete—Progress Completed

4. # Incomplete—No Progress Incomplete—Progress Completed

5. # Incomplete—No Progress Incomplete—Progress Completed

6. # Incomplete—No Progress Incomplete—Progress Completed

Notes:

recording overall goal level, specific accomplishments, and whether progress was made in the last time period. Also, the type of staff member implementing this part of the individualized plan is recorded. Goals are coded in such a way that specific domains and developmental level are easily determined. The result is a database that is time-based relative to each goal identified in the child/family’s individual plan, and data can be flexibly organized depending on the type of report required.

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cap height base of textTABLE 5. Example of Accomplishment Manual for Parenting Skill

Goal 03. Parent promotion of child development

Goal 0301. Parenting skill

General parenting issues 01. Obtain information regarding normative child development 02. Expand repertoire of behavior management techniques 03. Establish consistency in parenting between adult caretakers 04. Coordinate behavior plans between home and EHS 05. Enhance ability/amount of time to play with child 06. Use proper child safety restraints/learn about child-proofing home 07. Balance work/family issues 08. Attend parenting groups/workshops/training/socialization 09. Attend individual parenting meetings 10. Obtain information about specific developmental milestone(s) 11. Obtain information about specific child difficulty (e.g., night terrors) 12. Coordinate across agencies regarding parenting issues 13. Access/attend community resource related to child development (like library, playground, etc.)

Language 51. Repeat infant’s vocalizations 52. Talk to infant/toddler during diaper change, feeding, dressing, and other caretaking tasks 53. Read books to the child at least once per day 54. Label objects and people child points to 55. Sing songs to the child 56. Encourage child to use language to express needs 57. Obtain information about developmentally appropriate language skills

Gross motor 101. Provide child with push and pull toys to strengthen muscles 102. Encourage child to move his/her body by gently turning child side to side or stomach to back to strengthen

muscles 103. Hold child’s hands and pull child to stand to practice leg muscles 104. Provide child with safe environment to practice crawling/walking 105. Hold child’s hands and let child walk 106. Take child to outdoor/indoor playground to provide opportunity for gross motor activity 107. Lay child on stomach during waking hours to strengthen back muscles 108. Practice walking up and down the stairs 109. Encourage child to roll and catch ball on the floor 110. Encourage child to throw ball 111. Encourage child to hop 112. Encourage child to run 113. Play dancing games with the child in which the child has to copy the leader’s moves

RESULTS

To use the MAP system to assess efficacy within the program, program functions need to be specified from which progress and adherence can be determined. An example is provided below with respect to child and family outcomes in a local EHS program based on a four-month period of time. Data is based on enrollment of 108 children and their families; 40 children were in a home-based program and 68 were in a center-based program. (More specifically, we will report on information obtained from families whose children were enrolled in the program for at least seven weeks. This is a relatively arbitrary cut-off, but one that likely yields data that reflect progress made by children and families who were fully engaged with the program). Using this system, we report on a total of 69 center-based and 23 home-based families.

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cap height base of textTABLE 6. Average Progress Made in EHS Center-Based Program on Child-Focused Goals (n � 69)

Goal Domain Initial Goal

Levela Current

Goal Level

Average Change in Goal Level

Number of Completed Accomplishments per

Goal Number of Children

Developmental readi- ness

2.9 4.1 1.2 5.7 69

Health, nutrition, mental health wellness

2.4 4.2 1.8 8.1 46

aGoal level: 1–2� Nonoptimal; 3� adequate but inconsistent; 4–6� on track.

Although the main purpose of this article is to describe the program evaluation system, we provide preliminary results to exemplify the type of data that can be obtained. We list only a small subset of the questions that can be asked of the MAP system data to illustrate its functionality. These include:

1. What is the average initial goal level of all center-based children in the EHS program in the domain of developmental readiness?

2. What is average amount of progress in the domain of developmental readiness during the quarter?

3. What is the average number of accomplishments that are completed related to goal progress?

4. What are the results of questions 1–3 (above) with respect to the children and families enrolled in the home-based program?

Center-Based Child Outcomes

Table 6 indicates that all (100%) children had individual developmental readiness goals se- lected, worked on, and monitored during the quarter. This is consistent with Program Require- ments. Most (67%) of children had health, nutrition, and/or mental health wellness goals se- lected during the quarter. This reflects the relatively high number of children for whom medical, nutritional, and/or mental health issues necessitated attention by EHS. On average, substantial progress was made on goals selected in both domains for the quarter. In both domains, children were functioning at nonoptimal levels at the time the specific goals were selected. By the end of the quarter, children were rated as solidly on track. Goal level progress was associated with completion of accomplishments. On average, children completed six to eight accomplishments in each goal domain.

Center-Based Family Outcomes

Table 7 indicates that Parent Self-Sufficiency goals were selected by 57% of families. Parent Promotion of Child Development goals were selected by 77% of families. On average, in both goal domains, some progress was made during the quarter. In the Parent Self-Sufficiency domain, families were initially rated as functioning at nonoptimal levels. By the end of the quarter they progressed to adequate but inconsistent levels of functioning. Families made sim- ilar progress in the Parent Promotion of Child Development domain, although level of func-

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Goal Domain Initial Goal

Levela Current

Goal Level

Average Change in Goal Level

Number of Completed Accomplishments per

Goal Number of Children

Parent self-sufficiency 2.6 3.1 0.5 2.1 39 Parent promotion of child development

3.2 3.6 0.4 2.6 53

Average across parent- focused goal domains

2.9 3.4 0.5 2.4

aGoal levels: 1–2� Nonoptimal; 3� adequate but inconsistent; 4–6� on track.

TABLE 8. Average Progress Made in EHS Home-Based Program on Child-Focused Goals (n � 18)

Goal Domain Initial Goal

Levela Current

Goal Level

Average Change in Goal Level

Number of Completed Accomplishments per

Goal Number of Children

Developmental readi- ness

2.7 3.6 0.9 2.4 18b

Health, nutrition, mental health wellness

3.0 3.9 0.9 4.2 13

aGoal levels: 1–2� Nonoptimal; 3� adequate but inconsistent; 4–6� on track. b Note that 5 of the 23 participants enrolled were pregnant women; 18 were children.

tioning did not change by the end of the quarter. This may reflect that goals were initiated when families demonstrated adequate (although inconsistent) levels of functioning.

Home-Based Child Outcomes

Table 8 indicates that all (100%) children had individual developmental readiness goals se- lected, worked on, and monitored during the quarter. This is consistent with Program Require- ments. Most (57%) of children had health, nutrition, and/or mental health wellness goals se- lected during the quarter. This reflects the relatively high number of children for whom medical, nutritional, and/or mental health issues necessitated attention by EHS. On average, substantial progress was made on goals selected in both domains for the quarter. In the Developmental Readiness domain, children were functioning at nonoptimal levels at the time the specific goals were selected. By the end of the quarter, children were rated as adequate. In the Health domain, children were functioning at adequate levels at the time the specific goals were selected. By the end of the quarter, children were rated as nearly on-track with respect to these issues.

Home-Based Family Outcomes

Table 9 indicates that Parent Self-Sufficiency goals were selected by 61% of families. Parent Promotion of Child Development goals were selected by 48% of families. In the Parent Self- Sufficiency domain, families were initially rated as functioning at nonoptimal levels. Although some progress was made, on average, families continued to function at this level at the end of

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Goal Domain Initial Goal

Levela Current

Goal Level

Average Change in Goal Level

Number of Completed Accomplishments per

Goal Number of Children

Parent self-sufficiency 1.6 2.0 0.4 1.6 14 Parent promotion of child development

2.2 3.3 1.1 2.3 11

Average across parent- focused goal domains

1.9 2.7 0.8 2.0

aGoal levels: 1–2� Nonoptimal Functioning; 3� adequate but inconsistent; 4–6� on track. b Note that 5 of the 23 participants enrolled were pregnant women; 18 were children.

the quarter. Families made solid progress in the Parent Promotion of Child Development do- main, and level of functioning improved from nonoptimal to adequate by the end of the quarter.

Summary

It seems likely that in this EHS program, home-based families, on average, are the most vul- nerable or fragile. Even with substantial progress made on selected goals, functioning continues to be in the nonoptimal range. Also, working on accomplishments made a difference for goal levels—on average, the more accomplishments completed, the greater the change in goal level. On average, goal levels changed more dramatically for child-focused goals than for parent- focused goals, possibly because (especially center-based) children are in more frequent contact with EHS professionals compared with their home-based counterparts.

DISCUSSION

The Early Head Start Manualized Assessment of Progress was designed to be embedded within the fabric of daily operations of the program. This reflects our belief that evaluation is most efficient and accurate when the evaluation data are created as part of everyday activities per- formed by program staff. Furthermore, the organization imposed by structured evaluation ac- tivities is more likely to have positive effects on quality of intervention when the activities are closely tied to program functions. The system we have described here documents continuous improvement and growth in the context of ongoing social, developmental, and/or familial challenges. Further, it provides opportunity for families and staff to receive regular feedback about progress.

Understanding Outcomes

The data we presented suggested that progress was made in child development and family goal domains. It is important to clarify that the MAP system is not a developmental assessment, per se. Rather, it is a system that facilitates the selection and attention to particular child and family areas identified either as a strong need. Once a goal has been adequately achieved, new goals are selected. Further, the same goal may be selected on different occasions, as circumstances change for the family. For example, a parent may identify to her Family Advocate that she requires a car without which she is unable to work. Together, they agree to select a “transpor- tation” goal in the Parent Self-Sufficiency” domain; the initial goal level would be rated

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cap height base of textin the nonoptimal range. After working together for 3 months to save money and locate an

appropriate car, the family advocate and parent agree that the goal has been adequatelyachieved (the goal rating would then be changed to reflect this improvement, and the goal is no longer targeted). However, six months later, the car breaks down, again leaving the family with no means of transportation (at which point the goal is reselected, and the goal level is againinitiated in the nonoptimal range).

Thus, the MAP system is used to characterize and monitor the progress made on salient child and family goals. Snapshot assessments (e.g., quarterly reports) of the data are taken to give the program feedback about the nature of their work with the families they serve. We have presented data aggregated for the program as a whole (to describe program efficacy), although data can be analyzed at the level of individuals, as well.

Implications of Program Evaluation for Early Head Start Service Delivery

Implementation of the EHS-MAP involved intensive training of all EHS staff in assessment of normativechild development. Such basic training is consistent with the tenets of thedevel- opmental psychopathologyagenda that has been well articulated by Ciccetti, Rutter, Emde, Sameroff, and others (e.g., Sameroff & Emde, 1989). Not only is it important that EHS staff have good understanding of the interplay of normative and maladaptive processes, but also that they focus on thecontext in which behavior occurs. That is, while the individual psycho- logical existence of infants and toddlers is one important framework, it is crucial to place developmental understanding in context of the child’s family/caregiving environment. EHS can be a unique resource for helping young families maintain and capitalize on their strengths in the service of making strides toward optimal growth and development.

First and foremost, good program evaluation can help guide programs to most effectively provide services to optimize chances for positive development for children and families. But, evaluation can serve other important functions as well. One of these functions is to improve the quality of services delivered in the program. At this time we have anecdotal information to suggest that implementation of the EHS-MAP system has served to enhance the quality of service by fostering cooperation among EHS team members; facilitated staff-family partner- ships; challenged staff to flexibly address child and family needs; and required staff to regularly monitor and evaluate service provision and utilization. Thus, if the specific programming used is better matched with individual families’ needsand the programming itself is of higher quality, then children’s development may be doubly enhanced.

A related issue is the function of staff supervision within a complex program such as EHS. The implementation of the EHS-MAP system underscored the importance of this supervision, both at the level of individual staff members interacting with professionals with different areas of specialization, as well as in the domain of collaborative peer supervision. As staff members better understood the boundaries of their expertise, the most effective ways of delivering spe- cific interventions, and methods for maximizing collaboration between professionals with di- verse expertise, they became more effective change agents for the EHS children and families. In addition, the structure of the evaluation process also served to maintain the focus of EHS providers on proactive strength-based case management, as opposed to “putting out the fires” identified in a crisis intervention mode. In sum, there are many potential ways to use this system in supervision. First, the process of goal selection is an opportune time for individual supervision to focus on child and family developmental agendas and trajectories. Second, data can be analyzed on various levels (program, classroom, individual staff member, individual

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cap height base of textchild or family, etc.); this flexibility allows for exploration of patterns of progress, both for

EHS clients and staff. Third, program level feedback can be used to inform issues such as future program planning, allocation of resources, and qualifications of staff that best match client needs.

FUTURE DIRECTIONS

The EHS MAP system shows initial promise, but future work should be directed toward further establishing its utility in evaluating EHS program goals. Furthermore, it would be useful to determine whether the evaluation structure also provides feedback to programs resulting in improved quality. We emphasize that it is important not only to evaluate program effectiveness in EHS, but to do so in the best possible manner. The purpose of this article was to introduce the system, and to describe our initial impressions of its utility within the EHS program. We believe that the next step clearly needs to be an empirically based validation study to fully understand its scope and limitations.

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