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Helping the Most Vulnerable Infants, Toddlers, and Their Families

Authors: Jane Knitzer and Jill Lefkowitz
Publication Date: January 2006

Executive Summary

Compelling evidence from neuroscience about how early relationships and experience influence the architecture of the brain, 1 and in turn early school success, has led to increasing policy and practice attention to implementing child development and family support programs like Early Head Start for infants and toddlers.

But, there is also a group of babies, toddlers, and parents who face so many risks that programs like these alone may not be enough. This issue brief focuses on the special challenges of helping babies and toddlers whose earliest experiences, environments, and especially relationships create not a warm and nurturing atmosphere, but what scientists have called “toxic stress”—exposing them to such high and consistent levels of stress that their growing brains cannot integrate their experiences in ways that promote growth and learning. It describes 10 strategies that programs and communities can implement to ensure these babies, toddlers, and families are connected to sufficiently intensive supports that can get them on a path to early school success.

Defining Vulnerability: Empirically-based Approaches

Given the challenge of using scarce resources for these infants and toddlers in the most effective way, it is important to define the parameters for vulnerability with even more specificity. Currently, there are three approaches to identifying levels of risk in young children, all based in some way on empirical and theoretical developmental science:

  • Risk indices that reflect some combination of demographic, child, family, and environmental risks, for example, being a single parent, receiving public assistance, being neither employed nor in school or in job training, being a teenage parent, and lacking a high school diploma or GED. Twenty-six percent of the families enrolled in Early Head Start experienced four or more of these risk factors. That sub-sample of Early Head Start families did not benefit from the program in the same way that other families did. 2
  • Identifying young children in circumstances known to place them at risk by virtue of their exposure to ineffective parenting or parental absence. These include:
  • –The more than 150,000 young children under age 6 in foster care in 2003, including 25,000 infants. 3

    – Over 300,000 young children with incarcerated parents (half of whom are infants and toddlers). 4

    – An estimated 550,000 young children in homeless families. 5 (There are no separate figures for infants and toddlers.)

    – The just over 175,000 infants and toddlers who were victims of substantiated abuse and neglect in 2003. (Infants and toddlers have the highest rate of victim investigations—16.4 per 1,000—and are most likely to suffer a recurrence.) 6

  • Using prevalence data based on parental risk factors known to impair effective parenting. Impaired parenting—defined as harsh, inconsistent, or indifferent parenting—is known to be related to poor developmental and emotional outcomes in young children. 7 Factors that place young children at serious risk for such parenting include maternal depression, substance abuse, domestic violence, and—although we lack even estimates of national prevalence rates—the parents’ own unaddressed childhood or current trauma. A prevalence-based parental risk perspective includes:
  • – The estimated 10 percent of all young children who live with parental substance abuse/dependence. 8

    –  The estimated 1.4 million to 4.2 million young children who experience domestic violence. 9

    – Young children whose parents have either clinically diagnosed or clinically significant symptoms of depression, often with other risks as well. For example, in a recent study of Early Head Start parents, a stunning 48 percent of the parents had depressive symptoms. 10

Appropriate Goals for Interventions Targeted to the More Vulnerable Infants, Toddlers, and Families

Even in the most high-risk families, unless a child’s safety is at stake, the best way to promote healthy development and reduce risks is to help the baby’s parents and other caregivers. In general, research supports an integrated four-pronged approach:

  • Promote healthy, effective parenting responsive to complex parental risks.
  • Provide interventions that explicitly address parental risk factors.
  • Connect babies and toddlers with necessary health and related services.
  • Address the concrete needs of the family.

Ten Strategies to Help Infants, Toddlers, and Families at Higher Risk for Poor Outcomes

Strategy 1: Ensure that ALL low-income families have access to infant and toddler child development and family support programs.

Strategy 2: Embed research-informed intensive interventions, such as parent therapies, into Early Head Start and home visiting infant and toddler child development and family support programs.

Strategy 3: Embed intensive interventions for infants and toddlers and their families in settings serving only high-risk families.

Strategy 4: Organize services by level of family risk.

Strategy 5: Use basic support programs for families to provide more intensive services.

Strategy 6: Build partnerships with early intervention and child welfare systems.

Strategy 7: Screen for and address maternal depression and other risks in health care settings serving women and young children.

Strategy 8: Implement parenting curricula and informal support groups designed for higher-risk families.

Strategy 9: Build a community approach to prevention and early intervention for groups of babies, toddlers, and families facing special risks.

Strategy 10: Include more vulnerable families in broader infant, toddler, and early childhood advocacy strategies.

Moving Forward

Even in the face of continuing budget cuts, high staff turnover rates, and often times greater demands on those who work directly with the most vulnerable babies and toddlers and their families, programs and communities have been able to:

  • Develop effective outreach and engagement strategies to provide earlier interventions to those at greatest risk.
  • Provide services at critical times of need, such as police involvement and domestic violence support services.
  • Enhance collaboration across systems and service providers, such as child welfare services and early intervention services.
  • Mobilize the needed range of skills and staff to address the range of family needs, such as drug and alcohol treatment, early childhood development services, early intervention, psychologists, health practitioners, and social workers.
  • Provide mental health support and reflective supervision practices for staff working with the highest-risk families.

Important challenges both from a resource as well as a clinical perspective also face the field. These include the need to:

  • Develop culturally appropriate and effective treatments for both parent and child depression and mental illness, particularly for immigrant and refugee families.
  • Find and retain high-quality and appropriately skilled staff and provide resources to address staff depression and job stress among those working directly with infants and toddlers.
  • Build “healthier” partnerships among child protective services, early intervention, mental health, substance abuse treatment, and domestic violence services in the context of the broader early childhood agenda.
  • Promote a research agenda among local programs that includes not only outcome data, but also information on how well programs are actually implemented. Lessons from Early Head Start evaluations suggest that this is key to moving to a new level of program effectiveness.

Ten Principles to Guide Policy, Practice, and Advocacy

  1. Start with the parents, but connect with the whole family—not just the mother and the young child—and don’t forget the fathers, wherever they are.
  2. Work in partnership with community leaders (promoters, mentors, resource moms, and others).
  3. Target important moments and transitions in families’ lives (such as pregnancy, birth, entrance into early childhood programs, probation/incarceration).
  4. Connect with families as early as possible (starting during prenatal care is best).
  5. Connect with families across as many settings as possible (such as churches, other faith-based organizations, informal child care providers, and resource and referral agencies).
  6. Use multiple entry points for access to family-focused screening, assessment, prevention, and more intensive treatment (such as community health clinics, family court, juvenile justice system, substance abuse programs, and shelters).
  7. Make sure that parenting programs are responsive to the special needs of more vulnerable families.
  8. Nurture the staff. Make sure there are supports for child care staff that are depressed, stressed, and burnt out (such as access to early childhood mental health consultation).
  9. Find ways to use existing funding more efficiently, and then seek new funding for specific purposes. 11
  10. Train the next generation of professionals with real families as their teachers, especially families who have overcome burdens. For example, assign medical and other graduate students for a year to a family with a new baby to understand the context of stressed families’ daily lives, their celebrations, and hardships.


Each year, over 4 million young children are born, many of them into loving, nurturing homes regardless of family income. For those less fortunate, it is in the public interest to invest in interventions that can help change a negative development course to a positive one. The strategies highlighted in this document provide a framework with which to start. Helping the most vulnerable infants, toddlers, and parents is not easy, but if we fail to do so, the consequences will most surely spill over into the next generation.


1. Institute of Medicine; Shonkoff, J. P. & Phillips, D. A. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.

2. Love, J. M.; Kisker, E. E.; Ross, C. M.; Schochet, P. Z.; Brooks-Gunn, J.; Paulsell, D.; Boller, K.; Constantine, J.; Vogel, C.; Fuligni, A. S.; & Brady-Smith, C. (2002). Making a difference in the lives of infants and toddlers and their families: The impacts of Early Head Start, Vol. I: Final Technical Report. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families, Office of Planning, Research, and Evaluation, Child Outcomes Research and Evaluation and Administration on Children, Youth and Families, Head Start Bureau. Prepared by Mathematica Policy Research under Contract DHHS-105-95-1936.

3. Adoption and Foster Care Analysis and Reporting System (AFCARS) data submitted for FY 2003 (October 1, 2002 through September 30, 2003.

4. Johnson, E. I. & Waldfogel, J. (2002). Children of incarcerated parents: Cumulative risk and children’s living arrangements (JCPR Working Paper 306). Chicago, IL: Joint Center for Poverty Research, Northwestern University and University of Chicago.

5. National Center on Family Homelessness. (2003). America’s homeless children. Newton, MA: National Center on Family Homelessness; Homeless Children’s Mental Health Initiative (2004). Evaluation report. San Francisco, CA: San Francisco Department of Public Health.

6. Gaudiosi, J. A. (2003). Child maltreatment, 2003. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children’s Bureau, Table 3-8: Victimization Rates by Age Group, 2003 and Table 3-9: Percentage of Victims by Single Year of Age, 2003.

7. Hay, D. F.; Pawlby, A.; Angold, A.; Harold, G. T.; & Sharp, D. (2003). Pathways to violence in the children of mothers who were depressed postpartum. Developmental Psychology, 39(6), pp. 1083-1094.

8. National Household Survey on Drug Abuse. (2003). Children living with substance-abusing or substance-dependent parents. The NHSDA Report, June 2, pp. 1-3.

9. Edleson, J. J. (1999). Children’s witnessing of adult domestic violence. Journal of Interpersonal Violence, 14(8), pp. 839-870.

10. Early Head Start Research and Evaluation Project. (2003). Research to practice: Depression in the lives of Early Head Start families (Research Brief). Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families.

11. For more information on using federal funding programs see: Knitzer, J. & Johnson, K. (2005). Spending smarter: A funding guide for policymakers to promote social and emotional health and school readiness. New York, NY: National Center for Children in Poverty, Columbia University Mailman School of Public Health.