How has San Diego County prioritized developmental screening, assessment, and treatment for young children?

Thanks to advances in brain science and research, we now know that a child’s earliest years are most critical to development and that what happens during these years lays the groundwork for the rest of a child’s life. This understanding led partners within the County of San Diego to form DSEP (Developmental Screening & Enhancement Program) and KidSTART (Screening, Triage, Assessment, Referral, and Treatment), two programs aimed at ensuring that children in foster care 5 years old or younger receive needed services to maintain placement stability, achieve timely permanency, and reach their full potential.1

Both programs operate under Rady Children’s Hospital San Diego. DSEP provides developmental and behavior screening and service linkages for all young children involved with the County of San Diego’s Child Welfare Services (CWS), while KidSTART provides comprehensive services to young children with complex needs, regardless of system involvement.

DSEP and KidSTART may be distinct, but the programs are integrated in that they share many common goals, a common population, and specially trained staff that coordinates as a team — often delivering clinical and other treatment interventions within the same location or during the same session with a child or family. DSEP screens all young children in foster care (ages birth to 5 years old) and connects them to appropriate services. For children with more complex needs,2 KidSTART is the next step after DSEP. KidSTART delivers the more intensive services identified by DSEP, including: speech, occupational, and physical therapy; mental health therapy; and behavioral interventions, in an integrated and coordinated approach.

Data indicate that investments in these programs have been paying off: 91% of the children receiving DSEP case management were linked successfully to at least one service, and more than 90% of children in out-of-home care maintained their placement for the duration of KidSTART services.

Sometimes children have subtle needs that aren’t seen by an individual community provider — but they will grow into big needs if they aren’t identified early and addressed from a transdisciplinary perspective. If you can get in there early and serve the child and family across multiple disciplines, the possibilities are so much greater than if you wait to intervene until children are 5 or 6.

– Staff at DSEP/KidSTART

What make DSEP and KidSTART unique?

  • Specialized services. The focus on young children involved with CWS and/or with complex needs, whom we know to be at the highest risk for child abuse and neglect, and even child maltreatment-related death, make these two programs an essential part of an effective service continuum.
  • Transdisciplinary partnership. DSEP and KidSTART emphasize an approach where providers offer training and support to one another in their relentless efforts to engage families and find solutions to a child or family’s unmet needs. Both programs rely heavily on integration and collaboration, within and between their individual professional areas of expertise, as well as with: caregivers and families, county agencies (such as child welfare, behavioral health, and education), and community providers (such as health care, child care, and early education). “One challenge for caregivers of children with complex needs is the siloes that they have to navigate,” said Michael Miller, KidSTART’s contract monitor at San Diego County’s Health and Human Services Agency’s Behavioral Health Services. “The transdisciplinary approach crosses over, and KidSTART’s work with caregivers to get them better connected bears fruit.”
  • Whole child, whole family. Birth parents, relatives, and/or foster parents are included in services from the start. The family’s input regarding priorities, comfort level, and hopes for the future guide the creation of a child’s care plan. Through joint participation in services, both parents and caregivers learn how to support a child’s development and functioning. Further, by providing service referrals and linkage to address other family needs, such as parental mental health, housing, or food insecurity, parents can be more engaged in the child’s care plan.
  • Accessibility. DSEP and KidSTART staff realize that families may be receiving multiple services, and therefore seek to weave together different clinical services either within a single or group session, or schedule them back-to-back so that families do not have to contend with appointments on multiple days. Staff also make home visits when possible, and connect with families as often as needed.
  • Follow-through. Both the DSEP Individual Care Plan and the KidSTART Care Plan include details on what services are recommended and who will be providing them or making the referral. That way, it is clear how the plan will move forward. Updates to the plans also are made throughout so that any barriers to completion can be identified and addressed.
  • Organizational leadership. Ensuring that potential job applicants are committed to the program goals of breaking down siloes and addressing barriers is critical for hiring the right staff. Providing strong clinical supervision and support, along with training and a positive work culture, are necessary for retaining staff.

DSEP: Case management and service linkage

San Diego County’s Health and Human Services Agency’s Child Welfare Services funds DSEP. DSEP was created in response to the concern that many young children in out-of-home care had developmental and social-emotional needs that were not being identified, and therefore they were not receiving necessary early intervention services. 

Development and implementation

Over the last 20 years, the program has grown and adapted to support universal referrals for screening children age 5 and younger. Today, CWS has an automated process that triggers a referral to DSEP when a case is opened for any child under 6 years old. DSEP also accepts referrals from CWS when a child changes placement or if any developmental or behavioral concerns are observed after the initial screening. Caregivers also can refer a child directly to DSEP at the time of placement if any concerns are noted.

DSEP staff deliver services in the home or at accessible locations within the community. Services include:

  • Developmental and social-emotional screenings.
  • Referrals to other programs for further evaluations if deemed necessary after the initial screening (such as comprehensive developmental evaluation by a psychologist; and physical and/or occupational therapy, speech, and/or audiology evaluations).
  • Referrals to recommended early intervention programs and treatment services.
  • Case management to help children and families connect to recommended services.
  • Education and training for caregivers, parents, and social workers.
  • Consultation and training for service providers within the community.

DSEP provides direct training to all new CWS social workers to ensure an understanding of the program and annual training to CWS social workers on relevant topics. DSEP staff maintain regular office hours at CWS locations across the county so they can build relationships with agency staff, discuss cases, and collaborate as necessary. 

Current approach and elements

Initial screenings are completed within 30 days of referral, using the Ages and Stages Questionnaire-3 for children over 1 month old, and the Ages and Stages Questionnaire: Social Emotional 2 for children 1 month to 6 years old. For children between 18 months and 6 years old, caregivers also are provided a Child Behavior Checklist to help them detect any potential emotional or behavioral concerns that might not be age appropriate.

Once the screening process is complete, the team creates an Individual Care Plan (ICP), which includes the screening results, practical activities that the caregiver can do with the child, and recommended services. The ICP includes an action plan that identifies what is being recommended and who will be making the referral, and is updated every 30 days with the progress made toward connecting the child to the recommended services.

When CWS initiates a Child and Family Team meeting (CFT) for a child 5 years old or younger with an open CWS case, DSEP staff typically will attend. The CFT meetings usually include the child’s birth parents, relatives, social worker, caregiver, and any other identified providers or supportive adults. The CFT meetings create a space where the child’s team can come together to discuss strengths and concerns, and make decisions as a group. At the initial CFT meeting, the team reviews the Child and Adolescent Needs and Strengths assessment and DSEP shares information about its screening and potential services and supports. CWS invites DSEP to attend all subsequent CFT meetings. DSEP’s role at those ongoing meetings can be to provide updates on previously recommended developmental and behavioral services, as well as provide education on early intervention, attachment, trauma, and/or exposure to alcohol/drugs.  

On average, DSEP staff work with families for six months, providing case management until the child and family are connected successfully to all recommended services identified in the ICP. DSEP also provides short-term, home-based services, including: 

  • DSEP staff teach infant massage to parents and/or caregivers with children under 6 months old to support positive touch and promote bonding and attachment.
  • DSEP staff provide activities that support healthy child development to parents and/or caregivers with children older than 6 months.
  • DSEP staff teach parents and/or caregivers a variety of evidence-informed techniques that support successful parenting and successful relationships with their children, and monitor for higher level of service need.

KidSTART: Delivering services for children with complex needs

KidSTART was developed specifically to deliver services to young children with complex socio-emotional, behavioral health, and developmental needs who might also have complex medical and family situations. KidSTART integrates mental health and developmental specialists who assess needs develop collaborative treatment plans, provide tailored interventions, and facilitate long-term care coordination for children and their families. 

Development and implementation

In 2010, San Diego County’s Juvenile Courts, Behavioral Health Services, and Child Welfare Services conducted an analysis of system-involved adolescents, particularly those with the most intense needs, in order to identify common denominators. It found that these youth had experienced a disrupted parent/child attachment relationship before the age of 6. The majority also had been involved with CWS to some degree, even if they were not removed from their homes. Taking these factors into account, the county adapted Ira Chasnoff’s SART (Screening, Assessment, Referral, & Treatment) early intervention model in creating KidSTART. 

KidSTART began serving children only with active CWS cases, but after the first year, expanded to serve children in the local community with complex needs. Currently, 48% of children served by KidSTART are involved with CWS.

KidSTART is supported through two separate contracts, both with Rady Children’s Hospital in San Diego: 

  • KidSTART Center delivers developmental assessment and treatment, and intensive family support, and is funded through First 5 San Diego. 
  • KidSTART Clinic provides mental health treatment and support for caregiver well-being, and is funded by the County’s Behavioral Health Services, using Early and Periodic Screening, Diagnostic, and Treatment dollars and funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services.

Current approach and elements

Children eligible for KidSTART often have multiple diagnoses, and several assessments may be needed by multiple disciplines to better understand the child’s functioning and needs, including occupational therapy, speech language pathology, developmental behavior pediatrics, psychiatry, and mental health.  

KidSTART uses an intensive mental health evaluation based on the Trauma Assessment Pathway, an intervention model that uses standardized measures and includes clinical observation of the child in at least two settings, and a structured parent/child relationship assessment with all significant caregivers who will be involved in the child’s treatment. As KidSTART staff pointed out, “a young child can’t be properly assessed outside of their relationship with their caregivers.”

Through this process, KidSTART is able to assess the child and family’s strengths and areas of need, and identify the best course of treatment. KidSTART uses evidence-based or evidence-informed treatments such as Child-Parent Psychotherapy, Trauma Assessment Pathway,3 and Parent-Child Interaction Therapy, along with integrated elements from other interventions. KidSTART’s mental health clinicians work closely with clinical supervisors, family experts (those with lived experience as the parent of a child with complex needs), and a psychiatrist, to continually assess the child and family’s situation and adjust interventions as needed. This mental health team also works closely with the developmental treatment team, which offers speech, occupational, physical, and behavioral therapies. 

KidSTART team members partner with the family of the child to develop a care plan, which includes services offered directly through the program as well as any community-based short- and long-term services that might be needed, often through an early intervention agency, early care and education provider, and/or the school district. Led by the care coordinator, the team works together to ensure that children and families are connected to needed services and that these services are coordinated, with a focus on shared goals. 

A child’s treatment plan begins with the Integrated Clinical Team (ICT) meeting, which is a two-part process. The team can include a number of KidSTART staff as well as community providers, such as the child’s primary care physician, medical specialists, CWS social worker, Court Appointed Special Advocate (CASA), or school district liaison. The first ICT meeting is designed for providers to begin developing the teamwork structure crucial to child and family success. The provider ICT meeting is not for making decisions or developing a plan (since the family is not present), but rather to agree on the various diagnoses being considered and options to be offered to the family. Coming to a consensus is essential so that by the time providers approach the family, they are on the same page regarding diagnoses and treatment options. At the second ICT meeting, the family shares its priorities, which are used to shape the creation of the treatment plan. If the child is in out-of-home placement, the family ICT meeting includes the parents as well as the current caregiver. Over time, additional ICT meetings are held as necessary, based on the needs of the child, the family, and the providers.

A hallmark of KidSTART is the transdisciplinary nature of services. Although KidSTART’s clinicians each have their own areas of expertise, the team approach allows them to learn from their colleagues and incorporate goals from each other’s work into their own. For example, by collaborating with an occupational therapist, a speech pathologist might integrate some occupational therapy goals into a speech therapy session.

While KidSTART does not provide clinical recommendations regarding family reunification for children in out-of-home care, the program supports timely and successful reunification once that process has begun. If parents have not already been involved in treatment sessions, KidSTART will begin including them along with the foster or kinship caregivers. Doing so demonstrates support of that transition while in the child’s presence, and keeps everyone’s focus where it should be — on the child. Above all, KidSTART’s priority is child well-being, and the team works hard to support placement stability and permanent placements.

In 2015, the KidSTART Clinic received grant funding through the federal Mental Health Services Act4 to design a program to support caregivers. “It’s important to understand that the caregivers of these children are also facing multiple challenges due to the nature of their children’s challenges,” says Michael Miller, San Diego County Behavioral Health Services contract monitor. KidSTART’s Caregiver Wellness Program provides screening, needs assessments (inclusive of needs specific to the caregiver), linkage to services, individual therapy, and therapeutic, educational, and support groups for caregivers, including parents, relatives, foster and adoptive parents, and anyone considered a significant attachment figure for the child. Initially, separate groups were held for parents, relative caregivers, and foster parents, but feedback from participants indicated that they wanted to learn from one other so the model was adapted to support all caregivers attending the same groups. 

COVID-19 Adaptations

When the COVID-19 pandemic disrupted in-person services, DSEP and KidSTART sought to meet the needs of the children they serve through telehealth services. Both programs found that the use of telehealth sparked creative thinking internally about how to provide services moving forward. This was especially true for serving families that live farther away. By scheduling virtual visits and eliminating travel time, the programs have been able to provide services to more families. 

In fact, the percentage of children screened by DSEP within 30 days increased significantly, from around 18% to 20% in the first half of FY2019-20, to more than 60% in FY2020-21. In addition to developmental and behavioral screenings by phone and video, DSEP also was able to provide behavior coaching sessions, infant massage instruction, and child enrichment education through telehealth.

DSEP enlisted feedback from staff regarding the benefits and challenges of doing their work virtually: 

  • They were able to provide more comprehensive services.
  • Flexibility made it easier to engage families in some circumstances.
  • Their relationships with families were about the same or better via telehealth, although building relationships could be more difficult, especially at first.
  • Half of the families were more engaged while the other half was less engaged.
  • They expressed confidence in their ability to deliver services virtually.
  • Telehealth services should remain an option post-pandemic.

KidSTART also was able to quickly adapt, rapidly delivering all services to children and families via telehealth while also training staff on delivering treatment virtually.

KidSTART eventually brought back in-person services and set parameters for staff to meet with families in community-based settings. The program continued to work creatively to meet the needs of families, including increasing the number of groups provided, pairing children in telehealth groups to support peer interactions and social connectedness, and providing families with access to resources such as educational materials, food, clothing, and enrichment activities. Through these efforts, KidSTART leadership reported a high participation rate throughout the pandemic. In addition, caregivers reported high levels of satisfaction, as evidenced by their feedback:

  • “I love that group is a place of no judgment and it helps me not feel alone.”
  • “KidSTART seemed to care what I think even though I am a dad.  It’s tough out there right now. I never got that before.”

1 Information for this brief provided through personal communication on Feb. 21, 2018, and April 27, 2018, with DSEP leadership and staff: Jeanne Gordon, Julie McCormack, Veronica Miller, Chelsea Tortona, and Katie Olson; and KidSTART leadership and staff: Virginia (Ginger) Bial, Jeanne Gordon, Natalie Elms, Leilani Parlin, Meghan Lukasik, and Joy Brewster; through personal communication on Aug. 1, 2019, with Alethea Arguilez, Executive Director, First 5 San Diego; and through personal communication on Sept. 26, 2019, with San Diego County Behavioral Health Services: Yael Koenig, Deputy Director, and Michael Miller, Contract Monitor.
Information regarding the COVID-19 adaptations was provided through personal communication on June 4, 2021, Virginia (Ginger) Bial, KidSTART Clinic Program Manager, Joy Brewster, KidSTART Speech Pathologist, and Julie McCormack, DSEP Manager; and through an internal DSEP report: Developmental Screening & Enhancement Program (DSEP): Success in service delivery amidst the COVID-19 pandemic (2021).
2 Children with complex needs are those who have developmental, behavioral, and/or mental health needs, as well as medical and psycho-social or family complexities, who are not making gains with their current services and could benefit from integrated, coordinated, and transdisciplinary care.
3 Trauma Assessment Pathway is both an assessment model and a treatment model.
4 After the grant ended, the caregiver wellness program has been funded through SAMHSA.