• October 2020
  • Vol. 21, No. 7

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Moving Upstream: The Urgency of Transforming Systems

Written by Michael D. Warren, M.D., M.P.H., F.A.A.P., associate administrator, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services

A public health fable: Imagine that you are walking alongside a peaceful river on a beautiful fall afternoon. As you continue your walk, the tranquility is interrupted by the sounds of splashing and cries for help. You look out and notice that someone is drowning in the river. So you immediately jump in, swim to them, and help them to shore. As you are helping them up on the bank to safety, you hear more screaming and splashing. You turn around and see someone else struggling in the river. So, you swim back out, grab them, and bring them back to the riverbank. By this point, as you're feeling a bit weary, you hear more splashing and cries for help. And—you've guessed it—there's another person struggling in the river that needs your help. About this same time, you see someone jogging along the riverbank. You call out to them, "Can you help me?" The jogger keeps going along. You call out again, "Hey, why won't you stop and help me?" The jogger looks at you and says, "I'm going upstream to find out why these people are falling into the river in the first place."

For those of us who work with children and families—whether it be in the context of child welfare, public health, pediatric primary care, or early childhood education—we can often feel like we spend the bulk of our days pulling people out of the river. We see the impact of adverse childhood experiences, acute and chronic stressors on families, and longstanding community inequities manifest in myriad ways: inattention or acting-out behaviors, chronic physical and behavioral health problems, and child abuse and maltreatment. So, we've built our system to respond to this—to diagnose and treat those maladies. And that's okay, if we want to spend our days pulling people from the river when it's nearly too late. But it doesn't have to be that way. A focus on primary prevention helps to prevent disease and harm before it ever happens, to move upstream to prevent people from falling into the river in the first place.

At the Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB), we have incorporated this primary prevention approach into many of our programs. We are thrilled that our partners at the Children's Bureau are now embarking on the exciting new Thriving Families, Safer Children: A National Commitment to Well-Being initiative. This effort will radically transform the child welfare system as we know it—from one that is largely reactive, responding when someone makes a report of suspected abuse or neglect, to one that is focused more upstream on supporting communities and families to thrive and achieve their fullest potential.

Fortunately, we already know many of the key ingredients needed to support healthy child development and prevent child maltreatment. Children develop best in the context of safe and nurturing relationships, in which they are engaged and supported through "serve-and-return" interactions. Families thrive when they are surrounded by a range of "protective factors" that can reduce sources of stress, build resilience, connect them to social supports and needed resources, and enhance their skills to guide their children's development. There are already many parenting programs, evidence-based home visiting models, and behavioral health supports that have proven effective in promoting healthy development and preventing child maltreatment. Despite their effectiveness, these programs are often not available to families or, contrary to a preventive approach, are available or accessed only after problems emerge.

HRSA's MCHB is committed to partnering with the Children's Bureau and community partners in implementing this new initiative by taking all that we know and translating it into priorities and programs that create a unified primary prevention system that reduces child maltreatment by promoting well-being from the start. One way MCHB can support this initiative is through our Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, which supports pregnant women and families to develop necessary resources and skills to raise children who are physically, socially, and emotionally healthy and ready to learn. The program builds upon decades of scientific research showing that home visits by a trained professional during pregnancy and early childhood help to prevent child abuse and neglect, support positive parenting, improve maternal and child health, and promote child development and school readiness.

Another way MCHB will advance the Children's Bureau's initiative is through our Infant-Toddler Court Program. Using a cross-sector approach, this program not only provides intensive individualized support to court-involved families with infants and toddlers but also brings together service providers, family members, community representatives, and other experts to make systems work better for families. The program seeks to change the knowledge, culture, and practices of the court system and community partners to advance two-generation, trauma-informed approaches to strengthen families and prevent future maltreatment. We must continue to look even further upstream. Ideally, we shouldn't wait until a family interacts with the child welfare or judicial systems to marshal the necessary resources and support to keep them well.

Further, MCHB's Early Childhood Comprehensive Systems (ECCS) build comprehensive systems of care at state and community levels to effectively support young children and their families to reach their full potential. ECCS ensures families can access resources for basic needs, such as food and diapers; improves connections to quality child care or mental health services; and identifies and addresses parental depression early. No matter which "door" a family enters for help, ECCS puts families at the center to build bright futures. 

Working together and reenvisioning our systems in these ways is not always easy, but the urgency and complexity of the current moment requires that we do so. It will take all of us. MCHB is excited to partner with the Children's Bureau, and we stand ready to expand our reach and advance a public health approach to accelerate our pace of change, move upstream, and together realize a transformed child welfare system for the benefit of all children and families.


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