Comprehensive Screening and Referral Programs

The perinatal period and early years of a child’s life lay the foundation for healthy development and family functioning, providing a crucial window of opportunity for infants, toddlers, and their families.⁶ Periodic screenings of families prenatally, postpartum, and throughout the first years can help identify needs early, and referrals to community resources can help families access services and supports they need during this sensitive period of growth and development. The term comprehensive refers to the types of risk factors for which children and families are screened. In addition to physical health screenings, families can also benefit from screenings for other important factors that contribute to overall wellbeing, such as developmental delays, maternal depression, and the social determinants of health – which include exposure to violence, food insecurity, housing insecurity, financial resource strain, and substance use.¹ Comprehensive screening and referral programs are often also universal, a term denoting the scope of who gets screened and referred to needed services. Universality is intended to destigmatize professional intervention and to reach families who may not otherwise get connected to local resources.

Although many models of comprehensive screenings and referrals exist, including home visiting programs, this review focuses on two comprehensive, universal approaches that have been rigorously studied with randomized control trials: Family Connects and Healthy Steps. Family Connects is designed to connect new parents and infants to resources following birth. Soon after delivery, all mothers in participating hospitals are offered the opportunity to participate in the program, and those who choose to participate receive a home visit from a nurse who completes an assessment questionnaire. Based on the results of the assessment, families are offered services tailored to their specific needs and level of risk, including referrals to available community resources. Healthy Steps is another approach to comprehensive screening that connects with parents in the pediatric setting. By incorporating child developmental specialists and services into routine pediatric care, Healthy Steps aims to improve parenting knowledge and behaviors to promote optimal growth and development during a child’s earliest years. Different tiers of short-term and ongoing supports are available to participating families, depending on their identified needs.

Who Is Affected by Comprehensive Screening and Referral Programs?

Comprehensive screening and referral programs have been implemented in local settings nationwide, and Oregon has recently passed legislation to implement Family Connects statewide to serve all families in the state. Because Family Connects and Healthy Steps are both considered universal, all children and families in participating settings are eligible for the initial screening assessment, though the number and location of participating settings limit how many and which types of families can participate in these programs. Families with identified risks or needs are eligible to receive educational materials, referrals to existing community resources, and additional screenings.

What Are the Funding Options for Comprehensive Screening and Referral Programs?

Comprehensive screening and referral programs are funded through both public and private support. Local Family Connects and Healthy Steps programs are typically funded through a combination of local government resources, foundation support, and reimbursement from health care payers.^2,3 For example, Durham Connects, the pilot for Family Connects, was funded primarily through the Duke Endowment and the Durham County Government, with additional support from other grants.² States can also use federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) dollars to fund comprehensive screening and referral programs. Oregon has the only statewide Family Connects program, which was established through legislation in 2019 and began implementation in 2020. The statewide Family Connects program will be funded through state general funds and a combination of private foundations and insurers.⁴

The goal of comprehensive screening and referral programs is to identify a wide range of potential risks and needs early to promote long-term optimal child development and family wellbeing, and addressing needs early is key to laying a strong foundation for child development.⁶ Comprehensively screening for indicators of health beyond behavioral and biological issues encourages providers to take a more holistic approach to the many factors affecting a child’s health and wellbeing.⁵ Importantly, these programs identify the needs of parents as well as children to recognize factors such as maternal mental health that can greatly impact parent-child interactions. Comprehensive screening and referral programs may also help to increase parent knowledge of child development, create support networks for parents, and improve parenting behaviors to promote better parent-child interactions, all of which can contribute to optimal child health and development. Identifying needs through screenings alone is not enough to move the mark on child outcomes; referrals to, and initiation of, effective services are key aspects of these approaches to address identified areas of need.

The review of the evidence below is limited to randomized control trials (RCTs) of Family Connects and Healthy Steps in local settings. Comprehensive screening and referral programs have not yet been studied as a statewide policy. Additional quasi-experimental studies of Healthy Steps have been conducted but are not included in this review. RCTs are the most methodologically rigorous study designs and allow for the strongest causal conclusions of the impact of a program on child and family outcomes, so these studies alone are considered in our assessment of the overall effectiveness of comprehensive screening and referral programs. Subgroup analyses and long-term findings from follow-up interviews with the original RCT families led to multiple publications from the same intervention. For the purposes of our assessment, studies that measure the impact of the same intervention on the same sample are treated as a single example of effectiveness, regardless of the number of distinct publications.

The research discussed here meets our standards of evidence for being methodologically strong and allowing for causal inference, unless otherwise noted. Each strong causal study reviewed has been assigned a letter, and a complete list of causal studies can be found at the end of this review, along with more details about our standards of evidence and review method. The findings from each strong causal study reviewed align with one of our eight policy goals from Table 1. The Evidence of Effectiveness table below displays the findings associated with comprehensive screening and referral programs (beneficial, null,ⁱ or detrimental) for each of the strong studies (A through I) in the causal studies reference list, as well as our conclusions about the overall impact on each studied policy goal. The assessment of the overall impact for each studied policy goal weighs the timing of publication and relative strength of each study, as well as the size and direction of all measured indicators.

Table 2: Evidence of Effectiveness for Comprehensive Screening and Referral Programs by Policy Goal

^{^}Impacts on discipline were not consistent across assessment points.
⁺Among the small sample of those who did use nonparental care, quality of care was higher.
*Larger effects among “nonminority” and Medicaid insured families
**Treatment effect significant for “nonminority” families only
^–Significant impact on safe sleep practices only

Access to Needed Services

Findings from three RCTs show that comprehensive screening and referral programs have a positive impact on connecting families to needed community resources, though the effect sizes are relatively small. The original RCT of Family Connects found that six months after the intervention, treatment families had accessed 0.9 more community resources,^B and a recently published second RCT similarly found 0.7 more total community connections at six months among treatment families.^D Healthy Steps has also been shown to positively impact referrals to needed services, with 3.5 higher odds of being informed about community resources among families who received the intervention programming.^F

Parental Health and Emotional Wellbeing

Family Connects has been shown to have mixed impacts on maternal mental and physical health. Participating mothers had lower odds (0.65 OR) of reporting clinical anxiety, but statistically insignificant differences in the odds of depression or substance use.^B More recent RCT findings similarly showed a null impact on maternal depression and completion of recommended postpartum visits, as well as a small but significant increase of 0.21 more emergency department visits among Family Connects mothers.^D

Nurturing and Responsive Child-Parent Relationships

Overall, comprehensive screening and referral programs have not been shown to have a significant impact on parenting behaviors or child-parent relationships. Each of the three main RCT evaluations found a null impact of program participation on positive parenting behaviors, such as following routines or regularly reading to one’s child. Follow-up studies of Healthy Steps participant families at child ages 3 and 5.5 years showed no significant impact on parent responses to child misbehavior.^F,G Additional observations of a subsample of Healthy Steps families concluded that participants had higher scores on inductive (positive) discipline techniques at child age 16 to 18 months, but the effect diminished by child age 34 to 37 months; no significant differences in punitive discipline techniques were found.^H Subgroup analyses showed that these beneficial impacts on inductive discipline were only significant among White mothers and mothers with incomes under 200 percent of the federal poverty level, relative to their respective control counterparts.^H Maternal warmth and nurturance was no different at child age 16 to 18 months, though NCASTⁱⁱ scores were 1.53 points higher on a scale of 73 possible points among treatment families at child age 34 to 37 months, likely due in part to skewed sample attrition issues.^I Contrary to these null findings, the six month follow-up study of Family Connects did find a small but statistically significant increase of 0.21 points on an 18-point home environment quality scaleⁱⁱⁱ among treatment families.^B

Nurturing and Responsive Child Care in Safe Settings

Both the original and more recent RCT of Family Connects found no statistically significant impact of program participation on use of nonparental care.^B,D However, among those parents that did use nonparental care, out-of-home care quality was rated 0.66 points higher on a 5-point rating scale compared to control families.^B

Optimal Child Health and Development

Comprehensive screening and referral programs have been shown to have mixed impacts on optimal child health and development measures. One major outcome assessed in evaluations of Family Connects was total infant emergency care use, which included overnight hospital stays and emergency department visits (less infant emergency care use suggests that families are using primary care instead of emergency department care for nonemergency needs). An initial report of findings 12 months after the intervention found 50 percent less total emergency care use among treatment families, with effects being larger among infants with more birth risks, infants with Medicaid or no insurance coverage compared to private insurance, and “nonminority”^iv families.^A An additional report of findings at child ages 6 months and 24 months found 0.91 fewer overall emergency episodes and 37 percent less total infant emergency care use, respectively, but the beneficial treatment effects were only significant among “nonminority” infants at 24 months.^C The second RCT of Family Connects and the evaluation of Healthy Steps both found no significant impact on emergency care use.^D,F,G

Additional measures of child safety, physical health, and behavior similarly showed mixed results. Family Connects was not found to have a statistically significant impact on accident- or maltreatment-related emergency department visits^C or Child Protective Services investigations.^DHealthy Steps was significantly associated with lower odds (0.76 OR) of using incorrect sleep positioning for infants but had no significant impact on any other safety or feeding practices, including odds of breastfeeding.^E Odds of timely vaccinations and pediatric appointments were 1.3 and 2.3 times higher, respectively, among Healthy Steps treatment families at child age 30 to 33 months,^F but Family Connects had a null impact on timing of pediatric appointments.^D Further, Healthy Steps was found to have no significant effect on mother-reported child behavioral problems at child ages 16 to 18 months, 34 to 37 months,^I and 5.5 years,^G though reporting of aggressive behavior was significantly higher among treatment families at child age 30 to 33 months.^F

1. An impact is considered statistically significant if p<0.05.
2. The Nursing Child Assessment by Satellite Training (NCAST) assessment measures sensitive interactions and communication patterns between mothers and children.
3. This study used the Responsivity and Acceptance subscales of the Home Observation for Measurement of the Environment (HOME) assessment.
4. “Nonminority” reflects the authors’ language; this term is not defined in the study.

Randomized control trials of comprehensive screening and referral programs do not find evidence of reductions in racial disparities. Evidence from 12 months after receipt of Family Connects showed that the program had larger positive effects on infant emergency care use for “nonminority” families and families who were on Medicaid or uninsured compared to privately insured families.^A Further, a follow-up study at 24 months after program receipt found positive treatment effects were only significant among “nonminority” families.^C Healthy Steps has also been shown to have larger positive impacts on parental discipline among White mothers, but these findings may have been influenced by skewed attrition rates.^H,I

5. Disparities are defined here as differential outcomes by race, ethnicity, or socioeconomic status (SES).

The six month findings from the RCT of Family Connects estimated $3.02 in savings from emergency health care costs for every $1 invested in the program,^A and this estimated benefit-cost ratio increased to $3.17 in the 24 month findings.^C A cost-benefit analysis was not included in the multisite experimental study of Healthy Steps. A more comprehensive analysis of the return on investment is forthcoming.

A review of the experimental evidence on Family Connects and Healthy Steps shows that comprehensive screening and referral programs, either postpartum or in the pediatric setting, connect families to needed services and have the potential to promote optimal child health and development, especially as it relates to timely vaccinations and pediatric appointments. However, impacts on other goals are null or mixed. Experimental findings suggest that Healthy Steps largely does not meet its goal of improving child outcomes through the pathway of changing parenting behaviors, and future research should explore other potential mechanisms for promoting optimal child health. Randomized control trials of Family Connects have shown increased connections to community resources, but impacts on parental and child outcomes are mixed.

The evidence base for comprehensive screening and referral programs suffers from a number of notable limitations. In the case of Family Connects, the two randomized control trials were set in the same geographic location in North Carolina, which limits the generalizability of their findings. The upcoming statewide implementation of Family Connects in Oregon will provide an opportunity to study the program in a different setting and at scale, which will strengthen the conclusions about its effectiveness. The RCTs of Healthy Steps were multisite and spread across the country, but the original intervention took place more than 20 years ago, and the evidence base would benefit from updated findings.

Additionally, the impacts of comprehensive screening and referral programs were largely focused on mothers, who constituted the vast majority of the study samples. The recent RCT of Family Connects did examine father-infant relationship quality, though no significant association was found. Further experimental research should explore the impacts on fathers as well as mothers.

All current and future comprehensive screening and referral programs are limited in how many and which types of families can be served based on the geographic location of the participating setting, even if all families in a particular clinic are universally screened. Current evidence does not demonstrate the potential for comprehensive screening and referral programs to reduce disparities, and future research should consider under which circumstances such programs can have the largest positive impact on reducing racial and socioeconomic disparities.

Comprehensive screening and referral programs are an effective strategy to increase families’ connections to needed services and may promote optimal child health and development, though evidence is mixed. Because these programs have been rigorously studied only as local interventions, the evidence does not provide clear guidance for states on the most effective way to implement comprehensive screening and referral programs as a statewide policy.

Table 3 below summarizes state-level variation related to comprehensive screening and referral programs. Oregon passed legislation in 2019 to fund Family Connects, a statewide comprehensive postpartum screenings program, but the program has not yet been implemented statewide. Family Connects was first piloted in 2008 and has since been funded and universally offered in various other hospitals, cities, and counties throughout the nation. Healthy Steps, which began in 1996, has expanded to locations nationwide but has not yet been funded statewide.

Table 3: State Variation in Comprehensive Screening and Referral Programs

Data as of June 12, 2020. Healthy Steps and Family Connects national websites. State statutes and legislation on comprehensive screenings. State department website information on available screening programs.
For additional source and calculation information, please go to Methods and Sources.

Method of Review

This evidence review began with a broad search of all literature related to the policy and its impacts on child and family wellbeing during the prenatal-to-3 period. First, we identified and collected relevant peer-reviewed academic studies as well as research briefs, government reports, and working papers, using predefined search parameters, keywords, and trusted search engines. From this large body of work, we then singled out for more careful review those studies that endeavored to identify causal links between the policy and our outcomes of interest, taking into consideration characteristics such as the research designs put in place, the analytic methods used, and the relevance of the populations and outcomes studied. We then subjected this literature to an in-depth critique and chose only the most methodologically rigorous research to inform our conclusions about policy effectiveness. All studies considered to date for this review were released on or before March 31, 2020.

Standards of Strong Causal Evidence

When conducting a policy review, we consider only the strongest studies to be part of the evidence base for accurately assessing policy effectiveness. A strong study has a sufficiently large, representative sample, has been subjected to methodologically rigorous analyses, and has a well-executed research design allowing for causal inference – in other words, it demonstrates that changes in the outcome of interest were likely caused by the policy being studied.

The study design considered most reliable for establishing causality is a randomized control trial (RCT), an approach in which an intervention is applied to a randomly assigned subset of people. This approach is rare in policy evaluation because policies typically affect entire populations; application of a policy only to a subset of people is ethically and logistically prohibitive under most circumstances. However, when available, randomized control trials are an integral part of a policy’s evidence base and an invaluable resource for understanding policy effectiveness.

The strongest designs typically used for studying policy impacts are quasi-experimental designs (QEDs) and longitudinal studies with adequate controls for internal validity (for example, using statistical methods to ensure that the policy, rather than some other variable, is the most likely cause of any changes in the outcomes of interest). Our conclusions are informed largely by these types of studies, which employ sophisticated techniques to identify causal relationships between policies and outcomes. Rigorous meta-analyses with sufficient numbers of studies, when available, also inform our conclusions.

Studies That Meet Standards of Strong Causal Evidence

1. Dodge, K. A., Goodman, W. B., Murphy, R. A., O’Donnell, K., & Sato, J. (2013). Randomized controlled trial of universal postnatal nurse home visiting: Impact on emergency care. Pediatrics, 132(Supplement 2), S140–S146. https://doi.org/10.1542/peds.2013-1021M
2. Dodge, K. A., Goodman, W. B., Murphy, R. A., O’Donnell, K., Sato, J., & Guptill, S. (2014). Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. American Journal of Public Health, 104 Suppl 1, S136-143. https://doi.org/10.2105/AJPH.2013.301361
3. Goodman, W. B., Dodge, K. A., Bai, Y., O’Donnell, K. J., & Murphy, R. A. (2019). Randomized controlled trial of Family Connects: Effects on child emergency medical care from birth to 24 months. Development and Psychopathology, 31(5), 1863–1872. https://doi.org/10.1017/S0954579419000889
4. Dodge, K. A., Goodman, W. B., Bai, Y., O’Donnell, K., & Murphy, R. A. (2019). Effect of a community agency–administered nurse home visitation program on program use and maternal and infant health outcomes: A randomized clinical trial. JAMA Network Open, 2(11), e1914522. https://doi.org/10.1001/jamanetworkopen.2019.14522
5. Minkovitz, C. (2001). Early effects of the Healthy Steps for Young Children program. Archives of Pediatrics & Adolescent Medicine, 155(4), 470. https://doi.org/10.1001/archpedi.155.4.470
6. Minkovitz, C. S., Hughart, N., Strobino, D., Scharfstein, D., Grason, H., Hou, W., Miller, T., Bishai, D., Augustyn, M., McLearn, K. T., & Guyer, B. (2003). A practice-based intervention to enhance quality of care in the first 3 years of life: The Healthy Steps for Young Children Program. JAMA, 290(23), 3081. https://doi.org/10.1001/jama.290.23.3081
7. Minkovitz, C. S., Strobino, D., Mistry, K. B., Scharfstein, D. O., Grason, H., Hou, W., Ialongo, N., & Guyer, B. (2007). Healthy Steps for Young Children: Sustained results at 5.5 Years. Pediatrics, 120(3), e658–e668. https://doi.org/10.1542/peds.2006-1205
8. Caughy, M. O., Miller, T. L., Genevro, J. L., Huang, K.-Y., & Nautiyal, C. (2003). The effects of Healthy Steps on discipline strategies of parents of young children. Journal of Applied Developmental Psychology, 24(5), 517–534. https://doi.org/10.1016/j.appdev.2003.08.004
9. Caughy, M. O., Huang, K.-Y., Miller, T., & Genevro, J. L. (2004). The effects of the Healthy Steps for Young Children Program: Results from observations of parenting and child development. Early Childhood Research Quarterly, 19(4), 611–630. https://doi.org/10.1016/j.ecresq.2004.10.004

Other References

1. American Academy of Pediatrics. Recommendations for Preventative Pediatric Health Care. (2019). https://www.aap.org/en-us/documents/periodicity_schedule.pdf
2. Family Connects International. Family Connects: Frequently Asked Questions. (2019). http://www.familyconnects.org/faq
3. Zero to Three. Healthy Steps: Frequently Asked Questions. (2019). https://www.healthysteps.org/article/preview/5118ad75-b1d0-4755-a66e-c08234054188#13
4. Office of Senator Steiner Hayward. (2019). SB 526: Universal Home Visiting. https://olis.leg.state.or.us/liz/2019R1/Downloads/CommitteeMeetingDocument/154725
5. Hagan, J.F., Shaw, J.S. & Duncan, P.M. (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. American Academy of Pediatrics. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx
6. Shonkoff, J. (2017). Breakthrough impacts: What science teaches us about supporting early
   childhood development. Young Children, 72(2), 8–16. https://www.jstor.org/stable/90004117?seq=1
7. Shonkoff, J., & Phillips, D. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: The National Academies Press. https://doi.org/10.17226/9824.