Innovation Ecosystem

Nurturing the future

Issue brief targets need for better supports in being a parent in Rhode Island, with recommendations about how to cross policy divides

Courtesy of Rhode Island Kids Count

The recommended policy priorities for Rhode Island to address the health and well-being of infants, toddlers and families were presented on June 3 at a gathering of advocates convened by Rhode Island Kids Count.

Courtesy of the R.I. Department of Health

The new array of Family Visitation programs coordinated by the R.I. Department of Health has branded with the name, "Love That Baby."

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By Richard Asinof
Posted 6/8/15
The future of Rhode Island is its children, and the infrastructure that needs to be the soundest is the one that underpins and creates supports for infants, toddlers and families. The new issue brief prepared by Rhode Island Kids Count and the recommendations for turning policy priorities into action in a coordinated, collaborative fashion are hopeful signs. But, how such recommendations are then translated by the legislature into actual spending priorities, as a key to economic development, is another question altogether.
Why is there a disconnect between green and healthy homes and the health of infants and toddlers and their families? How does the model of community-based health equity zones become fully integrated as an important part of the health care delivery system? When will the conversation around toxic stress become more inclusive and shared? When will the comparisons of “saving money” compared to our neighboring states – such as the dismal results of poor quality diapers under Medicaid – be changed to reflect the value and highest quality of outcomes?
Another important nuance of Rhode Island’s coordination of resources to translate policy priorities into action is a research consortium on early childhood, organizing last fall by Stephen Buka at Brown University, focused on developing benchmarks to measure best practices for interventions and initiatives.
The research consortium, an outgrowth of early work done by Ready, Rhode Island, has the potential to position Rhode Island’s efforts in a broader national context as a leader in health innovation. Knowing what works, and what works best, and then developing programs around such evidence-based research – what has happened with the Family Visiting RI and its “Love That Baby” outreach – is an example. More than just recording the cortisol levels of stress in young infants and toddlers, there is a need to put that work in context, to provide answers to what kinds of emotional support and interventions will reduce stress levels.

PROVIDENCE – It took about two hours to go through some 86 slides, documenting the state of infants’ and toddlers’ health and well-being in Rhode Island, in the kind of fact-based analysis of which Rhode Island Kids Count has become the undisputed champion.

Some 65 advocates were gathered around the table at Save The Bay headquarters on June 4 – about 55 women and 10 men, if anyone was counting. They represented one of Rhode Island’s most important if unheralded resources: the protectors of the first 1,000 days of life for children, a time of great opportunity and great vulnerability.

As the issue brief said, unambiguously: “By age three, a child’s brain has grown to 90 percent of its adult size and the foundation of many cognitive structures and systems are in place. Early experiences lay the foundation for future learning, and strong, positive relationships with parents and other caregivers are the building blocks of healthy development.”

The advocates all displayed the kind of patience that perhaps often only a parent can fully know and appreciate, as Leanne Barrett, senior policy analyst at Rhode Island Kids Count, rattled through a detailed issue brief and policy recommendations.

There were an impressive group of listeners at the table, including: Dr. Nicole Alexander-Scott, the new director of the R.I Department of Health; Elizabeth Roberts, the secretary of the R.I. Executive Office of Health and Human Services; Rep. Joseph McNamara, chair of the R.I. House Committee of Health Education and Welfare; Jamia McDonald from the R.I. Department of Children, Youth and Families; Sen. Gayle Goldin, who championed the passage of a new paid state leave law; Kristine Campagna, who directs the Family Visiting RI programs at the R.I. Department of Health, Dr. William Hollinshead; Dr. Patrick Vivier, a pediatrician at Hasbro Children’s Hospital; Anna Aizer, an economist from Brown University, and Lauren Schumer, program officer from the Pew Charitable Trusts.

The issue brief, presented in tandem with the recommended next steps in policy priorities, was a case of the glass being both half-empty and half-full: the fact that 26 percent of Rhode Island’s children from birth to 4 years between 2011 and 2013 were living in poverty is a disgrace; the expansion of “Love That Baby,” a free family visiting program run by the R.I. Department of Health to support moms-to-be, parents and babies, testified to the kind of thoughtful, successful intervention that sets Rhode Island apart.

Across the great divide
It was a ton of information to digest, no matter how well developed the adult brains in the room were.

The key take-away message, however, was not about the content; it was about the process moving forward.

“What babies really need is for all of us to work together with the grown-ups who care for them,” said Susan Dickstein, president of the R.I. Association for Infant Mental Health, cutting to the chase at the end of the two-hour session.

Dickstein served as one of the co-chairs of the Infant & Toddler Policy Priorities Steering Committee, which produced “Next Steps: For infants, toddlers and their families,” a prescription for recommended state policy priorities for Rhode Island.

Dickstein also touted the integration of the database, KidsNet, at the R.I. Department of Health, as an important research tool to translate fact-based evidence into policy actions.

Dickstein’s diagnosis had been supported by an earlier comment by Roberts, the former Lt. Governor, about the need to look beyond being advocates for specific programs.

“This is about the future of Rhode Island,” said Roberts, referencing the obvious fact that how children grow up will determine the state’s future. Roberts also pithily pinpointed the divide between looking at the needs of programs vs. the needs of families. “My role is to coordinate across agencies that really haven’t focused on families but on programs [in the past],” she said. “We really have an opportunity here to coordinate across some of these divides.”

Saying that she was channeling Gov. Gina Raimondo, Roberts said that the most important thing we can do to change a lot of these situations “is to create good jobs and stable homes.”

The new director of the R.I. Department of Health, Dr. Nicole Alexander-Scott, a pediatrician and an internist, spoke about the need to create a common message around health disparities and health equity.

“One of my main priorities is to eliminate the disparities of health in our state,” she said. To do that, Alexander-Scott continued, “We must promote health equity. There is nothing more or nothing less than full life chances that we all want to have – and certainly, we want for our children.”

Alexander-Scott talked about the importance of the newly created 11 Health Equity Zones in Rhode Island. “It’s our new investment in innovative, community-based projects to prevent chronic disease, improve outcomes, and improve the social and environmental conditions of our neighborhoods,” she said.

Alexander-Scott also praised Family Visitation programs, and her agency’s immunization program that “protects our children and our families from vaccine-preventable diseases,” proudly noting that Rhode Island was the “best state in the country.”

Alexander-Scott also alluded to a new program looking at toxic stress, now under development through the agency, to create a working definition of toxic stress that can be used by pediatricians as a diagnostic and treatment tool. [More on that below.]

Policy vs. budget priorities
Kids don’t vote, of course, and crossing the chasm between policy and budget priorities is often a difficult leap for politicians to make.

So, it was remarkable to hear McNamara say: “In God we trust, but everyone else has to provide the fact-based research that Rhode Island Kids Count does.”

Of course, how exactly McNamara’s sentiment translates into the final budget item for minimum wage remains to be seen, even if the issue brief made clear the dismal facts about low pay for the infant and toddlers childcare workforce:

• The staff caring for and educating infants and toddlers in licensed child care centers make very low wages, with an average hourly wage of some $10.50, and $13 for a preschool teacher.

• Infant and toddler teachers in Rhode Island tend to have lower educational levels, with 24 percent having a high school diploma or less, 44 percent some college but no degree, 17 percent with an associate’s degree, and 15 percent have a bachelor’s degree or higher.

• Experts recommend that all educators of children from birth to age eight have a minimum of a bachelor’s degree with specialized coursework in child development and early learning.

Roberts praised the recent news that RIte Care, the state’s managed Medicaid program for children and families, had been recognized as the top such program in the nation, to a round of applause.

What wasn’t mentioned was the fact that there is still a gap in health insurance coverage for children, despite the success of RIte Care.

In 2013, the rate of uninsured children had climbed to 5.4 percent, or about 12,000 children, the same number as in 2009. On Nov. 24, 2014, at the 20th annual celebration of children’s health, R.I. House Speaker Nicholas Mattiello had pledged, in addition to his focus on creating jobs and growing the economy, to help Rhode Island Kids Count achieve its goal to have 100 percent of all children living in Rhode Island covered by affordable, comprehensive, high-quality health insurance.

The question is: will Mattiello and McNamara follow through, and in street vernacular, put their money where their mouths are?

Just the facts
The compilation of evidence-based data in the latest issue brief by Rhode Island Kids Count reveal some disturbing trends in perhaps the most important infrastructure in Rhode Island: healthy infants, toddlers and families.

•  There is a declining birth rate in Rhode Island, at 10,788 in 2013, a decline of 18 percent since 2003.

•  In 2014, 47 percent of babies were born to single mothers; children in single-parent families in Rhode Island are five times more likely to be living in poverty.

•  26 percent of children four or younger in Rhode Island live below the poverty threshold; research indicates that economic insecurity in early childhood may compromise the child’s lifetime achievement and employment opportunities.

•  Housing is the biggest expense for families with young infants and toddlers, with the average monthly rent for a two-bedroom apartment in Rhode Island in 2014 being $1,172.

•  Childcare is the second largest expense, behind housing. The average infant care at a childcare center in 2013 was $12,097 per child; the average toddler care at a childcare center in 2013 was $11,121.

•  In 2014, there were 831 infants and toddlers under age three who were maltreated.

•  Infant mortality, at 6.5 deaths per 1,000 live births, ranks Rhode Island in the bottom-half of states.

•  In 2013, there were 76 babies diagnosed with neonatal abstinence syndrome [withdrawal] from opioids.

The nuances
For Elizabeth Burke Bryant, the tireless optimist who serves as executive director of Rhode Island Kids, the take-away from the session was that Rhode Island, because of its size and its leadership, and its “terrific” community partners, was positioned to move forward to address the challenges enumerated.

“We have a lot of strengths to build upon to give children, infants and toddlers the best possible start in life,” she told ConvergenceRI.

“RIte Care is now the number-one children’s health insurance program in the country,” she said. “It did not happen over night. It’s an example of the kind of foundation we have. We know the numbers; there was a lot of data presented today. But we know that [evidence-based] data informs policy and practice.”

Burke-Bryant thought that Dickstein’s comments at the session’s end had correctly framed the message moving forward.

“She reminded us that we are all adults, and whatever the role is we can play, there is so much more that we can do [by working together] to make sure that children have what they need to thrive.”

Toxic stress
Throughout the session, there were well-placed hints that Rhode Island Kids Count and the coalition of advocates were beginning to look at the role that diagnosis and treatment of toxic stress in early childhood can play – defined as “early exposure to adverse experiences, such as child abuse, or neglect, poverty, neighborhood and domestic violence, and parental mental illness causes enduring trauma to a child’s developing brain,” according to the brief.

The fact that Rhode Island Kids Count is adding toxic stress as one of the benchmarks of health and well-being is a positive step in measuring its impact. On the ground, there are some programs under development.

Through a grant administered by the R.I. Department of Health, the R.I. chapter of the American Academy of Pediatrics has developed a working definition of toxic stress to be used as a diagnostic tool for treatment and referral. That working definition is now being “tested” before select groups of pediatricians and therapists, to gather feedback to develop a final definition. Indeed, that every evening of the issue brief discussion, a session was held with pediatricians in Warwick.

[To date, the conversation around toxic stress had tended to be somewhat insular. ConvergenceRI has proposed creating a broader, community-wide conversation around toxic stress this fall, bringing in many disciplines, including nurses, clinical researchers, environmentalists, health homes advocates, mental health practitioners and social workers. In addition, ConvergenceRI has suggested that a mapping of resources and research around toxic stress become one of the first mapping exercises for health innovation in Rhode Island.]

Green and healthy homes
As much as the discussions at the issue brief session began to address some of the root causes and social determinants of disparities in health care for infants, toddlers and families, healthy housing – beyond access to affordable homes – has not fully entered the conversation.

The gap is that much more surprising, given that the R.I. Alliance for Healthy Homes held its first annual celebration on June 3, the day before the issue brief discussion. The group has braided together more than 80 organizations and created its own wiki for housing resources in Rhode Island, exactly the kind of evidence-based data resource that Rhode Island Kids Count promotes.

The lack of connection speaks more to a tendency, as identified by Roberts, to look at interventions as coordination of existing programs, rather than a focus on the social and environmental determinants of health, and what families need, rather than what programs need, in order to thrive.

The programs championed by the Green & Healthy Homes Initiative, working in conjunction with the Johns Hopkins Medical Center, have achieved phenomenal returns on investment – 220-to-1 for every dollar invested in lead removal and renovation, and 14-to-1 for every dollar invested in asthma remediation in the home.

Beyond promoting more lead screenings, programs that remove lead from the homes of Rhode Island’s infants and toddlers can go a long way to address the health and educational disparities.

Burke-Bryant, when asked about the apparent need to connect with healthy housing, promised that she would follow up.

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