National Collaborative for Infants & Toddlers

Developmental screenings identify early developmental delays in infants and toddlers and provide the opportunity to intervene with the necessary supports that a child may need to be on track for healthy development. Children who receive screenings are more likely to be identified with developmental delays (which may signal serious physical or psycho-social problems), referred for early intervention, and determined eligible for early intervention services to get them on track for success. Early intervention can not only enhance the development of infants and toddlers with disabilities, but can help families better meet their child's needs, reducing later educational costs or the likelihood of institutionalization

In Tarrant County, Texas—an urban county of approximately 2 million people containing Fort Worth and bordering Dallas County—complications often go undetected for infants and toddlers because many young children do not receive developmental screenings. In a county with more than 83,000 infants and toddlers, of which an estimated 23 percent live in poverty (2016 estimate), even those who are screened may not get the proper referrals for care or the right services to address their needs. 

There is a real cost for communities that lack a robust developmental screening and referral system. Michelle Larva, a Pritzker fellow at Tarrant County Public Health, explains, “What we’re seeing now is that some of these children who went without the necessary screening and intervention in their infant and toddler years are enrolling in early childhood interventions late, past the age of three and sometimes well into school-age—a much costlier and more challenging process. It is easier and less costly to form strong brain circuits during the early years than it is to intervene later.”

Recognizing the need for a coordinated screening and referral system in Tarrant County to better support infants, toddlers, and their families, the Early Learning Alliance (ELA) brought a diverse group of early childhood stakeholders together in 2017 to create the Infant Toddler Developmental Screening Initiative (ITDSI). In an effort to better understand the county’s current landscape, ITDSI is working to collect and share the number of developmental screenings and referrals—data that will then be used to enhance the support systems available for infants, toddlers, and their families. Access to this information will allow young children with developmental delays to be identified earlier and be provided with the right resources and support sooner. 

Ann Salyer-Caldwell, deputy director of Tarrant County Public Health, says the goal of the program is for kids to learn better in school and get out of poverty—with the hope of providing them a better start. 

From the beginning, Tarrant County recognized that driving systems-level change to support infants, toddlers, and their families demands a holistic approach with buy-in and collaboration from a wide group of stakeholders. Supported by the National Association of Counties (NaCo) through a grant from the Pritzker Children’s Initiative, the Infant Toddler Developmental Screening Initiative (ITDSI) brings together members from the ELA, Tarrant County Public Health, and the Infant Health Network to work toward a common goal. 

Each organization in ITDSI brings an important voice to the table and plays a unique role in the initiative:

• Tarrant County Public Health manages reporting and administrative support and connects the community’s public health system to early childhood education and services. Salyer-Caldwell summarized the health department’s role as “making sure we’re all on the same page, the same track, and keeping the bigger end-goal in mind. What we’re trying to end up with is children that are healthier because they have been screened and have received the services they need.”  
• Early Learning Alliance (ELA) is a group of over 50 organizations and individuals representing government, community-based early child care providers, faith-based organizations, educators, school district administrators, training organizations, nonprofit service providers, health and mental health providers, parents, and private foundations. ELA’s role in ITDSI is to collect and share information about the number of developmental screenings and referrals in Tarrant County in order to understand what types of services and supports are needed to prepare children for school. Michelle Buckley, director of ELA, says that “our vision is a community united to provide a strong start for all children; a coordinated system for developmental screenings will help us provide that strong start.”
• Infant Health Network is a collaborative with over 20 members focused on improving pregnancy outcomes and reducing infant mortality in Tarrant County through home visiting programs. The Network’s role in the developmental screening project is to support maternal health, families, and prenatal care efforts. “We are a connector and resource-sharing organization,” explains Misty Wilder, chair of the Network. 

Within ITDSI, a subset of members has been designated as the working group for action. Participants in this smaller group include:

• My Health My Resources (MHMR)
• University of North Texas Health Science Center’s Healthy Start initiative
• Cook Children’s Hospital
• Head Start/Early Head Start
• Workforce Solutions for Tarrant County
• Fort Worth Independent School District
• Lena Pope
• Camp Fire First Texas
• Educational First Steps

To date, the working group has been meeting and coming up with ideas around how to work best together. According to Wilder, instead of meeting in silos, they are meeting and learning from each other. The group has many voices and moving parts, and as Wilder describes, “it’s a lot easier than starting from scratch.”

To understand where children are being referred after they receive a screening and which services they receive, the working group’s first priority is to collect and share information on the number of developmental screenings and referrals in Tarrant County. For birth-to-age-three, the group is focused on using the ASQ assessment tool, specifically the ASQ-3 and ASQ-SE. For maternal health and prenatal care, the initiative plans to incorporate other screening tools for maternal depression and social determinants of health. 

Early data show evidence of an uncoordinated screening and referral process. For example, the group found that approximately one-third of referrals were to MHMR and one-third were to health systems. Michelle Buckley, director of ELA, wonders if in some cases doctors even knew a referral took place. She explains that “there are many layers and no coordinated system yet. We’re trying to create one place where screenings are collected and use that as a starting point to collect solid data for referrals and services.”

The hope is that the data will help them understand what types of services they need for infants and toddlers and could help target specific areas of the county that may have higher instances of developmental delays.

The working group’s next step is to use data to determine why developmental delays are occurring and which interventions are working. 

In financial terms, Tarrant County secured initial funding from the NaCo to support the ITDSI. The ITDSI is also pursuing additional funding opportunities through ELA funders.

Early budget estimates identify several areas that will need to be funded to support the success of ITDSI. These estimates include the following:

• Providing ASQ kits to new providers of ASQ developmental screenings
• Funding additional screenings that will be coming through Tarrant County MHMR’s ASQ Enterprise platform
• Expanding the data system and the personnel required to maintain it 
• Supporting the need for increased capacity for early childhood intervention programs as more children are screened and more needs for intervention are identified

While the effort in Tarrant County is still in the early stages, county leadership is expecting promising results because of the strong coordination across a broad group of stakeholders representing diverse early childhood services. Collaboration among stakeholders has allowed many groups to work together toward a common goal, and moving forward, it will allow organizations across the county to pool and cross examine data from multiple sources to provide the right services at the right times for infants, toddlers, and their families. 

For other communities trying to move the needle on early childhood developmental screenings, Wilder recommends, “Don’t try to start something fresh. Look at the relationships already established in your community and try to make them stronger.”

Salyer-Caldwell points out, “We’re fortunate to have lots of passionate people here; we just need to make sure we’re all pointed in the same direction and not taking too long to make decisions.” 

Buckley underscores the need to build community infrastructures to meet identified goals. She said that communities should ask themselves, “What’s missing? Who do we need at the table? And how much will that cost?” For Tarrant County, the team realized that “developing a coordinated system will not happen overnight, so as a first step, we needed short-, mid-, and long-term budgets with realistic costs and a sustainability plan to support the work.” 

Like Tarrant County, many communities have a real need to build data systems that inform programs and policies. Some communities may already have a coordinated data system, but based on this group’s research, many do not. 

For communities kicking off this work, Buckley recommends contacting the state’s child care licensing authority to piece together the landscape of child care centers that are working with parents on developmental screenings in the area. She also advises looking to the state for blended funding opportunities. “In Texas right now, the state is figuring out what we have here for [birth-to-three] children, what we should advocate for, and how can we be better coordinated.”