The First Steps Report

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The First Steps Report by Melanie Morris,
Esperanza Torres, Najja Webster, Amanda Zangara
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What Is The Report?
A data report on the status of San Franciscos
children, 0-5 years, headed by the San Francisco
Starting Points Initiative to assess the need for
services
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Why ?
National Educational Goals Panel Issued a report
in 1993 stating that nearly half of American
infants and toddlers start life at a
disadvantage and do not have the supports
necessary to grow and thrive.
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Who ?
A significant number of children under three
confront one or more major risk factors
Inadequate prenatal care Isolated
parents Substandard child care Poverty
The Carnegie Corporation, devoted to promote the
advancement and diffusion of knowledge and
understanding, expanded their efforts to
stimulate reform in policies and programs and to
mobilize community action based on the
recommendations of each Starting Points Task
Force
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The Carnegie Corporation, funded 14 national
sites for Starting Points Initiatives to inform
their policy recommendations San Francisco
Starting Points Initiative (SFSPI) began in 1996
SFSPI envisions retaining families in San
Francisco by improving the health and well-being
of young children and their families by
improving quality, availability, and
accessibility for local services
SFSPI provides data and evaluation services to
other agencies
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First Steps
In 2000, the San Francisco Children and Families
Commission contracted SFSPI to create a report
that provides hard data to assess the needs of
children years 0-5, and their families, in San
Francisco.
Rep rt 2000
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First Steps
The report is separated into five sections
General Landscape Child And Family
Health Early Care and Education Family Support
and Education Children and Families Needing
Enhanced Services Each section has five to
ten indicators
Rep rt 2003
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First Steps
The 2003 report includes indicators that had
not been in the 2000 report, these
include Immunization and Hospitalization Nutri
tion and Dental Developmentally Delayed Children
and Children with Handicaps Children with
Learning/Language Handicaps and Children with
Emotional/Mental Handicaps
It also includes a policy analysis section with
trends and quotes from community stakeholders
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Immunization
Child and Family Health

• Definition
• The immunization rate is the percentage of
  kindergarten children whose school records
  indicate that they were fully immunized by age
  two.

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Immunization
Child and Family Health

• Significance
• Protects children and their communities from
  communicable disease outbreaks and substantial
  health-care costs.
• For every dollar spent on immunizations, up to
  16 is saved in medical costs.

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Immunization
Child and Family Health
Where Do We Stand

• The San Francisco childhood immunization rate is
  improving
• In 1996, 60 of San Francisco children were fully
  immunized
• In 1999, 70 of San Francisco children were fully
  immunized
• And finally in 2002, 81.5 of San Francisco
  children were fully immunized

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Immunization
Child and Family Health

• Where Do We Stand
• San Franciscos immunization rate is consistently
  better than the States.
• In 2002, the States immunization rate was 70
  while San Franciscos rate was 81.5.

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First Steps
Child and Family Health

• Immunization rates vary by race
• Why do African Americans have the lowest
  immunization rate?
• Poor number of providers in predominantly African
  American neighborhoods
• Lack of racial diversity in health care providers
• Only 1 African American doctor in Bayview
  Hunters Point

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Child and Family Health

• Where Do We Stand
• Currently, there is no standard method of
  immunization data management
• Current methods range from computerized databases
  to written medical charts.

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Child and Family Health

• Where Do We Stand
• The combination of a reminder and recall system
  is most effective in tracking patients in need of
  immunizations.
• What are the reminder and recall systems?
• The reminder system uses post card or recorded
  phone messages to remind patients that they have
  an upcoming immunization appointment
• The recall system alerts medical staff to
  patients that missed immunization appointments.

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First Steps
Child and Family Health

• Recommendations
• The increased use of the combination
  reminder/recall system
• 1998 study by Kaiser Permanente proved that a
  letter followed by recorded message is the most
  effective reminder for under immunized
• Implementation of computerized immunization
  databases a.k.a immunization registries
• Computerized databases make the reminder/recall
  effort less labor intensive

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Child and Family Health

• Examples
• MMR- Measles, Mumps, and Rubella
• New combination vaccine for Diptheria, Tetanus,
  Whooping Cough, Hepatitis B, and Polio -
  eliminates 6 of the 20 injections in a childs
  first 2 years

• Recommendations
• New Developments in Combination Vaccines
• They decrease the number of needle pricks a
  patient requires, thus the vaccine administration
  is easier for the provider and patient

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Child and Family Health

• Definition
• Hospitalization is defined as the rate of
  children aged zero through five that are
  hospitalized per year. Causes of hospitalization
  include
• Falls
• Burns or Scalds
• Motor Vehicle Accidents
• Asthma
• Poisoning
• Suffocation

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Child and Family Health

• Significance
• Analyzing San Franciscos child hospitalizations
  points to the failures of systems such as access
  to regular health care, building inspection,
  public education measures, and air quality
  management.
• The hospitalization of a child burdens the family
  emotionally and financially. The economic burden
  is often times passed on to the provider if the
  child is uninsured.

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Child and Family Health

• Where Do We Stand
• In 2000, 125 children under five years of age
  were hospitalized due to non-fatal injury.
• Falls were the leading cause of non-fatal injury
  hospitalizations in both 1999 and 2000.

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Child and Family Health

• Where Do We Stand
• San Francisco has the 4th highest asthma
  hospitalization rate for children under 14 in the
  state.

• One in six Bayview-Hunters Point children have
  asthma while the national average is one in
  twelve.

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Child and Family Health

• Where Do We Stand
• Current efforts in addressing hospitalized
  children
• Home visits for children hospitalized due to
  injury
• Looks for possibilities for poisoning, falls, or
  other types of injury
• 2) Very limited one hospital and one nurse to
  refer all patients in need of home visit

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Child and Family Health

• Recommendations
• Preventative Measures
• Public education and outreach
• Increased funding and use of home visits of
  hospitalized children. Currently only San
  Francisco General Hospital refers patients to
  health worker for home visitor

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Child and Family Health
Nutrition

• Definition
• The intake of fruit, vegetables, and grains are
  necessary for the healthy development of human
  beings
• Since significant neurological and physiological
  development occurs between the ages of 0-5, it is
  important for infants and toddlers to have a
  healthy diet
• 0-5 is also an important stage for establishing
  healthy exercise habits

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First Steps
Child and Family Health
Nutrition

• Significance
• Establishing healthy eating and exercise patterns
  during the ages of 0-5 can provide proper growth
  and development, and prevent future nutrition
  related diseases
• If children do not intake adequate nutrients and
  engage in physical activities during these years,
  they may show signs of cognitive impairment by
  the time they enter elementary school.
• Children who are overweight may face
  discrimination, low self-esteem, and poor body
  image.

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Child and Family Health
Nutrition
Where Do We Stand The WIC Program The Women,
Infants, and Children Program aims to help
pregnant women, mothers, and children eat well
and stay healthy. Per month, WIC serves an
average of 16,000 pregnant women, breastfeeding
women, and children. The program provides
supplemental foods (such as milk, cheese, cereal,
eggs, beans, peanut butter, and juice),
nutrition education, and referral to health care.

Approximately 50 of WIC clients are ages 1-4,
and 24 are infants.
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First Steps
Child and Family Health
Nutrition

• Where Do We Stand Overweight Children
• According to data from the Pediatric Nutrition
  Surveillance System, San Franciscos percentage
  of overweight status for children 3-4 is 14.2,
  which is slightly higher than the statewide
  average of 12.9.
• 70 of all Child Health and Disability Prevention
  Program Health Exams in San Francisco were
  provided to Asian and Hispanic children in 1999,
  revealing that Hispanic children have the highest
  percentage of overweight status at 17.1 for ages
  3-4.
• Sufficient research on the numbers of overweight
  children in San Francisco has not been collected,
  although it has been identified by the Department
  of Public Health and health professionals as an
  issue that needs attention

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First Steps
Child and Family Health
Nutrition

• Recommendations
• More data must be collected on the nutritional
  status of children 0-5 in San Francisco
• Families citywide must be provided with more
  information about nutrition guidelines and the
  importance of proper nutrition for children.
• Implement comprehensive health education programs
  in preschools and child care programs
• Provide support for communities to help children
  be more physically active and create
  neighborhoods safe for play

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First Steps
Child and Family Health
Nutrition
Whos Working on This
The Childrens Council of San Francisco currently
sponsors the USDA Child Care Food Program, which
reimburses childcare providers for two meals and
one snack, per child per day. Meals and snacks
must meet USDA meal program requirements.
Although providers are educated about the meal
pattern, parents are not. Information and
resources should be extended to families. The
providers are the conduits to working with
parents the good message should be
shared -Cheryl Magid, Child Care Food Program
Director
The Childrens Council also provides workshops
for Eating Right is Basic, a preschool
nutrition education curriculum that child care
providers and centers can use to introduce the
importance of nutrition to children.
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Child and Family Health
Dental Care
Definition Tooth decay, also known as caries or
cavities, is the destruction of the tooth enamel.
It occurs when foods containing carbohydrates are
frequently left on the teeth. Bacteria that live
in the mouth thrive on these foods, producing
acid as a result. Over a period of time, these
acids destroy tooth enamel, resulting in tooth
decay.
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First Steps
Child and Family Health
Dental Care

• Significance
• Early Childhood Caries (ECC) is a form of dental
  decay in very young children.
• ECC may result in missed school hours, and if
  left untreated, can result in problems with
  eating, speaking, and concentration in school
• Problems caused by tooth decay can cause extreme
  shyness, withdrawal,
• and low self-esteem
• Poor oral health in children can negatively
  affect adult oral health

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Child and Family Health
Dental Care

• Where do We Stand
• San Francisco is the only 100 fluoridated city
  and county in California
• In April 2002, San Francisco became the 2nd
  county in the United States to adopt universal
  health care for children through the Healthy Kids
  program
• 66 of public school children in San Francisco
  have cavities, including half that are untreated
• Oral screenings conducted by the Department of
  Public Health in the 1999-2000 school year showed
  that 20 of 544 preschool children had untreated
  decay
• Only 23.3 of children 0-5 eligible for Denti-Cal
  saw a dentist in 2002
• Only 9 of dentists in San Francisco will accept
  new Denti-Cal clients

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First Steps
Child and Family Health
Dental Care

• Recommendations
• Outreach efforts by dentists
• Inclusion of dental records in required health
  records for public schools
• Update list of dentists who accept Denti-Cal
  patients and make available to Denti-Cal
  recipients in order to increase accessibility
• Address cultural barriers to accessing care,
  which include language and a lack of education
  regarding preventative dental care

There will never be enough dentiststhe medical
profession must get involved. Just a little more
involvement would help -Samantha Stephen,
Coordinator of the DPH Dental Prevention Program
We need to create an infrastructure to maximize
resources and triage them depending on the degree
of disease -Francisco Ramos-Gomez, DDS, UCSF
School of Dentistry
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Children and Families Needing Enhanced Services
Special Healthcare Needs
Federal Maternal and Child Health Bureau One
who has or is at increased risk for chronic
physical, developmental, behavioral, or emotional
conditions beyond that required by children
generally.
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Children and Families Needing Enhanced Services
Special Healthcare Needs

• Four major agencies providing services
• Golden Gate Regional Center (GGRC)
• San Francisco Unified School District (SFUSD)
• California Childrens Services (CCS)
• Community Mental Health Services (SFMHS)
• Other Agencies providing services
• San Francisco Head Start
• High Risk Infant Interagency Council (HRIIC)
• California Children and Families Commission

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Children and Families Needing Enhanced Services
Special Healthcare Needs

• Stein, R.E., Silver, E.J. estimate 13.7 of
  children have special healthcare needs
• Maternal Child Health Policy Research Center
  estimate 16.9 of children have special
  healthcare needs
• California Children and Families Commission
  estimates 18 of children have special healthcare
  needs

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Children and Families Needing Enhanced Services
Special Healthcare Needs

• Estimated 5,637 to 7,406 children 0-5 with
  special healthcare needs
• 1,559 served by the four agencies
• Estimated 4,078 to 5,847 children unserved

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Children and Families Needing Enhanced Services
Special Healthcare Needs
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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities

• Developmentally delayed delayed achievement of
  one or more of the normal milestones of growth
  affect speech, language, social or motor skills
• Developmentally disabled a substantial handicap
  in mental or physical functioning, and of
  indefinite duration examples- autism, cerebral
  palsy and mental retardation

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• 0-5 is when the brain develops the most
• Developmental delays can be modified with proper
  intervention
• Intervention is determined by assessment and an
  Individual Education Plan (IEP)

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AssessmentProcess of identifying risk,
describing behavior and estimating the prognosis
for future development
First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities

• resulting in a cumulation of programatic plans
  and implementation (IEP)
• no national or regional standards for conducting
  or reporting results

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities

• There can be other problems caused by the
  underlying disease
• developmental delays may be caused by or a sign
  of a disability
• early intervention can maximize a child with
  disabilities capacity to live an independent
  lifestyle

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Risk Factors

• Developmental delays
• - premature birth
• mother over 35
• prenatal brain trauma
• lack of prenatal care
• - fetal alcohol syndrome

• Developmental disabilities
• chromosomal disorders
• gene defects
• prenatal exposure to toxins or infections
• premature birth
• postnatal infections

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Where Do We Stand?

• Most common developmental delays are speech and
  language delays
• estimated 5 to 10 affected nationwide
• San Francisco, estimated 1,082 0-5 year-olds who
  have or at-risk of forming developmental delays

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Problems With Counting

• No standard assessment or IEP process
• Classification differs among agencies children
  don't meet eligibility requirements
• No reporting system for number served or
  demographics

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Problems With Counting

• Duplication of Services
• 246 children served by two of four major agencies
• 28 of these 246 children served by three of the
  four agencies (2001)
• Unserved children are uncounted
• estimates used to count unserved population

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Whats Next?

• Increase interagency interaction
• standardize reporting and data collection
• definitions and eligibility- catch ineligibles
• assessment and IEP formation
• The High Risk Infant Interagency Council provide
  coordinated services in a timely and coordinated
  manner"
• coordinating referral services
• investigating risk factors and causes

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Whats Next?

• Infrastructure Expansion
• seek out children not being served (ChildFind)
• communication with primary pediatricians
• Leveraging Funds
• cuts to programs and research groups
• prop 10 funds may help

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First Steps
Children and Families Needing Enhanced Services
Developmental Delays Disabilities
Whats Next?

• Education and Outreach
• Parents
• rights
• availability of services
• Caregiver
• knowledge of a greater range of disabilities
• Dialog between parents and caregivers

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Children and Families Needing Enhanced Services
Physical Disabilities
Significance

• Assessment
• finds individual needs
• services aid development and to perform at
  optimal ability
• Many physical disabilities are incurable without
  surgery but can be mitigated
• IEP and proper educational placement
• abnormal positioning of the joints and disease
  progression at times mitigated with medicine and
  special exercises

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Children and Families Needing Enhanced Services
Physical Disabilities
Significance

• Family support programs
• parent reactions and interactions
• knowledge of programs and services
• medical and placement assistance
• About a third of children limited in major
  activity (school or play) are poor
• a quarter of them are uninsured

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Children and Families Needing Enhanced Services
Physical Disabilities
Where Do We Stand?

• Specific number of children difficult to
  determine
• lack of a standard reporting system for data and
  demographics
• uncounted population must be estimated
• categorization and terminology varies by
• different disabilities aggregated under different
  titles determined by the individual agency

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Children and Families Needing Enhanced Services
Physical Disabilities
Where Do We Stand?

• 12 children age 0-5 with orthopedic impairments
  San Francisco Unified School District (SFUSD)
• San Francisco Head Start is now serving 5
  children with motor impairments

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Children and Families Needing Enhanced Services
Physical Disabilities
Current Strategy

• High Risk Infant Interagency Council (HRIIC)
• standardize the assessment process and Individual
  Education Program
• lower the duplicated count
• better coordinate referrals and transitions
• Agencies provide family support services
• California Childrens Services
• financial assistance to families earning less
  than 40,000/yr or spend more than 20 on medical
  services

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Children and Families Needing Enhanced Services
Physical Disabilities
Whats Next?

• expand parent education and family support
• improve teacher preparation and in-service
  opportunities
• research and technical assistance on diversity in
  the classroom
• collect and share useful data
• examine relationship to prisons, after school
  programs, dropout rates

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Summary

• Research
• Dental Health
• Special Needs
• Child Abuse
• Racial Disparities
• Family Violence

• Systems Level
• Coordination and Collaboration of Services
  Providers
• Targeted Funding
• Information Systems
• Service Delivery
• Need for more trained staff
• Need for culturally and linguistically competent
  staff
• Increase quality of service delivery
• Improve client/staff relationship using
  family-focused approach