The Preview: Early Childhood Edition

Infusing mental health care into services for young children


	*How well integrated are the services and supports to young children in your* state or community? Answer the questions in this Self-Assessment Guide to pinpoint areas in need of attention**

Finally—states are beginning to understand how critical the social-emotional health of young children is to positive child outcomes and school readiness.

To realize better outcomes for children, states must face the tall task of building an infrastructure that will enable the delivery of a full array of mental heath services and supports into early childhood programs and environments. Deborah Perry, Roxanne Kaufmann, and Jane Knitzer, editors of Social and Emotional Health in Early Childhood: Building Bridges Between Services and Systems, argue that states should adopt a public heath perspective by infusing or embedding mental health care in all services to families.

But, too often, say Perry, Kaufmann, and Knitzer, critical services offered by model demonstration projects, community-based service programs, and family support organizations are not sustained, regardless of popularity, need, efficacy, or will. To end the revolving door, they contend, states need to initiate an organized, cross-system effort.

So, what are the ingredients of a sustainable system? And what are states doing to incorporate them? Take a look at these examples.

1. Strategic Planning

Strategic planning is key to defining an early childhood system of care with a strong mental health component. To start, states can investigate promising practices in other communities and engage informed, neutral parties as facilitators to help move key partners through the discovery, discussion, planning, and decision-making process.

By building on diverse opportunities, such as grants, statewide legislation, pilot projects, advocacy efforts, and even court orders, states can plan and fund services through a variety of mechanisms supported by numerous stakeholders.

Maryland has a statewide early childhood mental health steering committee led by two key agencies—Mental Health and Mental Hygiene and the Department of Education—that includes representatives of advocacy groups, child and family service agencies, family members, and providers. Guided by a clearly stated vision and four long-term goals, the steering committee contracted with Georgetown University to facilitate the planning process. Before planning statewide services, the committee wanted an accurate picture of what was already available to children and families in each county and what services were missing or inadequate. As a first step, the steering committee engaged in a county-by-county capacity assessment process.

In recognition of strong county autonomy in Maryland, regional forums were convened across the state to develop community buy-in, gather information about county priorities, and provide the latest research findings on early childhood mental health. These meetings and the mapping process helped cement a partnership between communities and the state, thereby ensuring local buy-in from the beginning of the planning process. Data from county self-assessments combined with outcome data from several state-funded pilot sites led the legislature to appropriate funding for mental health consultation statewide.

2. Interagency and Collaborative Partnerships

Collaboration is at the heart of system building. A truly effective early childhood mental health system encourages broad-based collaboration of services, supports, and system-level integration that includes early care and education, primary care, mental health, child welfare, early intervention, special education, and court-linked agencies.

States that are successful at building collaborations take specific steps to generate public interest and support, engage service system and agency leadership, partner with family and community advocacy groups, and build on or expand existing partnerships.

The Miami-Dade County, Florida Juvenile Court, Early Head Start, Part C of IDEA, and Mental Health joined as partners for a pilot project that addresses the well-being of infants, toddlers, and their families who are at risk of foster care placement. Screening and assessment are provided to all infants with referral to services as needed. An Early Head Start Program is directly connected to the court. An evaluation of the pilot showed that 100% of the infants were reunited with their families.

3. Policies and Procedures

Policies and procedures concretize the hard work that occurs in committees and task forces. Policies might explain which type of providers can deliver services, establish billing codes for reimbursement, and determine eligibility criteria—typically statewide. Procedures are less formalized and describe how business is accomplished.

One component of policy development is formalizing a decision-making body and process. Some governing bodies are created by legislation and others by executive order, memoranda of agreement, or community will. State interagency collaborating committees legislated by Part C of IDEA are one such body. State Early Childhood Cabinets convened by governors are another; and the Early Childhood Comprehensive Systems grants provide another.

The Illinois Legislature’s Children’s Mental Health Act of 2003 addresses mental health for children birth to 18 and brings mental health and education together to create social-emotional learning standards and policies for school districts and school buildings.

4. Family Involvement and Advocacy

Family involvement and advocacy must be structured, well-funded, and valued by states as an essential cornerstone of service systems. Historically, family organizations and advocacy groups were founded on the mission of serving older children or those with more intense intervention needs. The end result is that many families of young children have been overlooked.

An understanding of the early childhood mental health perspective provides advocacy organizations the opportunity to expand their focus to include promotion and prevention, to educate the public about the importance of early identification, and to reduce the stigma associated with mental illness.

In an effort to reach out to diverse families, the Los Angeles All About Children (ABC) project, a newly funded SAMHSA [Substance Abuse and Mental Health Services Administration] system of care grantee, has established relationships with multiple, ethnic-specific, community-based family support agencies. Many of these programs have not addressed the mental health needs of children and families in the past but are willing to do so with support and training from ABC.

5. Maximized and Flexible Funding

Building a systemic approach to financing early childhood mental health services is a complex process that requires fullly utilizing all existing funding resources. Because early childhood mental health addresses relationships among infants, toddlers, and preschool-age children and their adult caregivers, both adult and child funding streams must be accessed.

Each state or community must determine how it will pay for each component of its comprehensive system of services, including screening, direct services, flexible dollars for informal supports, and infrastructure.

To be successful, states have to be creative in funding program-level interventions, such as mental health consultation, reflective supervision, and multigenerational efforts (e.g., mentoring and grandparent support groups). Having a strategic process for fiscal planning that maximizes the impact of multiple funding sources from existing funding streams, redirected budget line items, and billable sources is key.

Many states have identified ways to maximize funding from different federal, state, and local resources. For example, Medicaid cannot be used for infrastructure development, but Title V funds through the Maternal and Child Health Bureau can. Paying for early childhood mental health services, however—particularly those targeted to young children experiencing significant risk factors—remains difficult.

After successful pilot efforts in Ohio, state general funds pay for mental health consultation across the state. Many counties are adding to state funds using local dollars and billing Medicaid.

6. Prepared Work Force

A prepared work force must be available to support all services within a state system, including those focused on the three levels of care: promotion, prevention, and intervention. Those who provide or oversee the provision of services need a range of skills: developmental knowledge, clinical sensitivity and expertise, understanding of family dynamics, and skill in working with individuals and families from diverse cultures.

Specialized education and masters’ or certificate programs in early childhood and family mental health are in place or in development in only a few states. More commonly, states and communities build work force capacity by establishing provider competencies, implementing self-assessments, providing in-service training, and offering consultation, reflective supervision, and support.

In Colorado, the Early Childhood Comprehensive System interagency group is broadening a focus on professional development for child care providers to one that includes all service providers of young children and families. Core competencies for different levels of personnel will be developed to ensure that social-emotional mental health modules are infused into the professional development of early care and education providers, mental health clinicians, physicians, nurses, and social workers.

7. Outcome Evaluation and Data Management

Outcome evaluation is an essential part of a strategic plan for building an early childhood system of care. Stakeholders use outcomes, indicators, and data management procedures to define their goals and objectives and determine how to effectively achieve these goals. Evaluation at all system levels—state, community, and provider—is part of building an infrastructure to deliver services.

Connecticut’s Early Childhood Consultation Partnership developed a statewide data system to collect information and measure outcomes for the more than 4,000 people served through mental health consultation. Results showed a 94% increase in the quality of child care, and 98% of children at risk for expulsion remained in care.

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It is the right time to build systems of services, supports, and care for early childhood mental health. Although a relatively new field, early childhood mental health is receiving the recognition it has long deserved backed by research and a growing evidence base. Across the country, there is increased political will, public and private interest, a commitment to invest in early childhood, a growing culture of collaboration among service systems and agencies, and a strong voice of testimony by families and caregivers.

For specific suggestions on how to put a strategic plan for early childhood mental health services in place in your state, refer to Social and Emotional Health in Early Childhood: Building Bridges Between Services and Systems.