Michael Salter and Heather Hall’s article, “Reducing Shame, Promoting Dignity: A Model for The Prevention of Complex Post Traumatic Stress Disorder” (Salter & Hall, 2022) was such a refreshing reminder for me about the important role of primary prevention for the promotion of child and family health and well-being. So much important work focuses on advancing effective services and supports for the treatment of children and adults who have experienced childhood abuse and trauma.
What if it is possible to design systems-level programs to prevent child abuse and maltreatment?
“Hello Baby” in Allegheny County is just such an initiative – a comprehensive primary prevention model designed to promote the well-being of children and families, with the aim of reducing child maltreatment and the need for Child Protective Service (CPS) involvement. In an effort to reduce stigma and normalize engagement in prevention services, “Hello Baby” offers an array of services to every family with a newborn (universal component) as well as evidence-based targeted services for families with greater risk for child abuse and neglect (priority component).
Every parent giving birth in one of our county hospitals receives a “Hello Baby” bag with an assortment of materials and information about the Hello Baby Website , which hosts reliable information about resources, infant and child development, health, and much more. Each bag also includes a children’s board book for their new baby. Families with higher risk for child maltreatment are offered a greater range of community supports and services as early as two weeks after the birth of their child.
“Hello Baby’s” overarching goal is to create an environment in which all families feel supported after having a baby. Families with moderate needs are linked to community-level supports that promote family strengths. Families with the greatest needs are offered a service that includes a careful assessment of family needs to identify their priorities and then follow-up services or warm connections to community partners according to family priorities and preferences. This approach to best support families with the greatest needs is based on the Camden Coalition, which works to advance the field of complex care by implementing person-centered programs and piloting new models that address chronic illness and social barriers to health and well-being.
“Hello Baby” was created due to startling county statistics indicating that in over half of cases where a child died or nearly died due to abuse or neglect, there had been no contact with county CPS services (Vaithianathan et al., 2020). These shocking statistics underscored the imperative to find ways to improve supports for families to reduce the likelihood of child abuse and neglect. Allegheny County’s Department of Human Services (DHS) considered this data in combination with other county-wide data on service utilization and discovered that very few families (only 15%) engaged in prevention services. Additionally, families living in poverty, with legacies of multi-generational trauma and abuse were even less likely to engage in supportive or prevention services.
We know from decades of research that early supportive relationships with caregivers are critical for child well-being, attachment, and development (Bowlby, 2008; Fisher et al., 2016; Mendelsohn et al., 2013). We also know that when caregivers feel supported and emotionally healthy, they are better able to be responsive, attuned, and engaged parents. Early in life, when parents feel supported, they are more able to attend and respond to their infant’s needs. Being responsive and attentive is difficult if you’re facing imminent homelessness, experiencing post-partum depression, or intimate partner violence. Providing optimal care for your newborn and their siblings is also difficult when one has not had nurturing relationships or positive models for how to be a parent. When parents have histories of childhood trauma, this generates a range of challenges as they welcome their newborn into the family and step into the parenting role.
“Hello Baby” represents Allegheny County’s commitment to children by way of increasing the ecological supports around each family. “Hello Baby” is not a program, but rather a system of supports for families with newborns in Allegheny County. It represents a system-wide change in service delivery, encompassing strong outreach to families to better understand their needs, the provision of concrete support for basic needs (including diapers, formula, cribettes, car seats), financial support during times of crisis (unpaid rent or utility bills) and prevention of homelessness. In addition, each “Hello Baby” family in the higher risk tier is offered a home visiting service at no cost to the family. Home visiting models that promote positive parenting are designed to overcome many of the barriers to service engagement, barriers such as transportation, childcare, and the stigma of seeking a “mental health” service. “Hello Baby” providers meet families where they are most comfortable; historically this has been in the family’s home, however, due to the pandemic, many of these services are offered virtually as well, further enhancing the flexibility of service provision for families who need a lot of flexibility in order to sustain engagement.
The “Hello Baby” system offers relationship-based support to mothers of newborns through baby’s third year. Some families will receive relationship-based support and case management services through Healthy Start, which has developed a service arm devoted to “Hello Baby” families. Healthy Start, an organization dedicated to the reduction of maternal and infant mortality, offers each “Hello Baby” parent a team of providers. This team includes a social worker, who facilitates supports and resources, as well as a peer-support worker, to connect with and support parents through the normative stressors of adjusting to parenthood.
Another group of families are offered the evidence-based model, Family Check-Up, which has a long history of promoting positive outcomes for families and children, including improvements in positive parenting, the parent-child relationship, as well as reductions in child neglect, and reductions in maternal depression (Chang et al., 2014; Dishion et al, 2008; Gill et al., 2014). Family Check-Up is a strengths-based home visitation model which considers the broad ecology around each child and family, and, in the spirit of true collaboration invites parents to reflect on the kind of parent they wish to be, and to see clearly the strengths and challenges they are experiencing. Family Check-Up is a trauma-informed prevention service, with many unique components, including careful use of non-stigmatizing language, strength-based assessment, inclusion of video-based feedback of parent-child interactions to highlight parent and child strengths, and a collaborative relationship with their service provider (Gill & Shaw, 2020). Family Check-Up incorporates motivational enhancement strategies at each session to instill hope and to support parents with making the changes they value most.
Family Check-Up has been supporting parents in Allegheny County for decades through various federally funded grants, and more recently, state funding. The new partnership with “Hello Baby,” funded at the county-level, has greatly enhanced the efficient linkage of families with Family Check-Up, as well as linkages to community resources and supports for families, especially financial support for basic needs and crisis situations. A DHS colleague made this powerful statement to me in a meeting, “No baby should be homeless in Allegheny County.” And, true to this spirit, DHS has opened doors and adopted a “do whatever it takes” attitude to support families with children in the first years of life. Together, we are breaking down silos, opening doors, and leveraging cross-county and cross-organizational relationships in service to families in ways I have never seen before.
A few examples can best illustrate the beautiful synergy that is emerging with the “Hello Baby” service system (while examples reflect real experiences, all identifying information has been removed). In one example, a parent engaged in the Family Check-Up service commented that, “this is the best parenting program I ever received – seeing myself on video really helped me – much more than receiving a flyer or having someone tell me what to do.” In another situation, a parent active in Family Check-Up was pulled over for a routine traffic stop. In the course of this traffic stop, the officer noticed she did not have adequate car seats for her two children. The officer immediately called CPS, despite the fact that the county offers free car seats through its Emergency Services Department and she could have been referred there. This parent called her Family Check-Up provider in a panic upon learning that in two days, a CPS worker would present at her house to assess if she had adequate car seats for her children. If she did not have them in two days’ time, a CPS case would be opened on her family. This parent lives well below the poverty line, and car seats that meet legal standards are expensive. Thanks to “Hello Baby,” this Family Check-Up provider was able to get the needed car seats to the parent within 48 hours. It took some teamwork and strategic outreach, but ultimately, the presence of “Hello Baby” supports and services for this family prevented an unnecessary CPS case being opened. This parent remains engaged with her Family Check-Up provider and is working on goals related to supporting her baby’s development and spending quality time with all of her children.
Beginning in 2003, I met with families in their homes, using the Family Check-Up model to support our work together. Twenty-years later, in my role as clinical supervisor for the “Hello Baby Family Check-Up” service, it is inspiring to be part of this system-level change. In many ways, this is a dream come true: local partnerships and collaborations are working together to make an array of community supports and effective home visitation programs available to families. As a professional trained in family systems, I appreciate the value of second-order change for the promotion of enduring and sustainable change.
With “Hello Baby,” I see value placed on healing relationships, accessible positive parenting programs, financial assistance, and community and institution-level partnership. Ultimately, I see “Hello Baby” as a system that is restoring dignity to families. When we can change the way systems operate around families, to increase both formal and informal supports and to enhance networks of care, children and families have more opportunities to heal, to parent well, and even to thrive.
Bowlby, J. (2008). Attachment. Basic books.
Chang, H., Shaw, D. S., Dishion, T. J., Gardner, F., & Wilson, M. N. (2014). Direct and indirect effects of the family check-up on self-regulation from toddlerhood to early school-age. Journal of Abnormal Child Psychology, 42, 1117-1128.
Dishion, T. J., Shaw, D., Connell, A., Gardner, F., Weaver, C., & Wilson, M. (2008). The family check‐up with high‐risk indigent families: Preventing problem behavior by increasing parents’ positive behavior support in early childhood. Child Development, 79(5), 1395-1414.
Fisher, P. A., Frenkel, T. I., Noll, L. K., Berry, M., & Yockelson, M. (2016). Promoting healthy child development via a two‐generation translational neuroscience framework: the Filming Interactions to Nurture Development video coaching program. Child Development Perspectives, 10(4), 251-256.
Gill, A. M., Dishion, T. J., & Shaw, D. S. (2014). The family check-up: A tailored approach to intervention with high-risk families. In S. H. Landry & C. L. Cooper (Eds.), Wellbeing in Children and Families (pp. 385–405). Wiley Blackwell.
Gill, A. M., & Shaw, D. S. (2020). The family check-up: Building on family strengths to promote child wellbeing. In Handbook of Research on Emotional and Behavioral Disorders (pp. 111-124). Routledge.
Mendelsohn, A. L., Cates, C. B., Weisleder, A., Berkule, S. B., & Dreyer, B. P. (2013). Promotion of early school readiness using pediatric primary care as an innovative platform. Zero to Three, 34(1), 29-40.
Salter, M., & Hall, H. (2022). Reducing shame, promoting dignity: A model for the primary prevention of complex post-traumatic stress disorder. Trauma, Violence, & Abuse, 23(3), 906-919.
Vaithianathan, Rhema; Diana Benavides-Prado and Emily Putnam-Hornstein. Implementing the Hello Baby Prevention Program in Allegheny County [PDF, 1.0 MB]. Centre for Social Data Analytics. Auckland, New Zealand. September 2020.