gratefully acknowledges support for this educational activity from…

1. gratefully acknowledges support for this educational activity from… • Improving Mental Health in Primary Care Through Access, Collaboration, and Training grant provided to the AAP through the Maternal and Child Health Bureau • Child Care and Healthy Partnership grant provided to the AAP through the Child Care Bureau and the Maternal and Child Health Bureau • Many colleagues

2. Partnering to Address Mental Health Concerns in Early Education and Child Care Webinar brought to you by: American Academy of Pediatrics March 23, 2009

3. Disclosures • We have no relevant financial relationships with the manufacturer(s) of commercial product(s) and/or provider of commercial services discussed in this CME activity. • We do not intend to discuss any unapproved/ investigative use of a commercial product/device in our presentation.

4. Welcome! Marian Earls, MD, FAAP Guilford Child Health Inc Task Force on Mental Health Section on Early Education & Child Care Section on Developmental & Behavioral Pediatrics

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7. Outline of Webinar • Overview: Health Professionals Involved in Early Education and Child Care Regarding Mental Health Concerns • Bringing it All Together: The Importance of the Medical Home • Successful Start: Rhode Island’s Early Childhood Systems Plan • Office of Head Start: Early Childhood Development and Mental Health Concerns and the Role of Community Pediatric Clinicians • Wrapping it Up: How to Find and Connect with Local Health Consultants • Question & Answer Session

8. Overview: Health Professionals Involved in Early Education and Child Care Regarding Mental Health Concerns Abbey Alkon, RN, PNP, PhD UCSF School of Nursing California Childcare Health Program www.ucsfchildcarehealth.org Section on Early Education & Child Care

9. US Children in Child Care A majority of children less than 6 years old (60-70%) spend time in out-of-home child care. Young children’s socio-emotional development is based on relationships. Early identification of mental/behavioral and physical health problems can help children get needed services and be ready for kindergarten Center on the Developing Children; Mental health problems in early childhood can impair learning and behavior for life. Working paper #6; 2008 9

10. US Children in Child Care 12 million children: more than 9 million are in licensed child care facilities. 105,444 child care centers. 213,966 family child care homes. 16,110 other licensed facilities. About 3 million children are cared for in unlicensed and unregulated care. 10

11. Background The most common health concerns for child care providers are: Infectious diseases (for children < 2 years of age) Challenging behaviors Expulsion rates in child care are higher than elementary school High child care staff turnover Children need to be physically and mentally healthy to be ready to enter kindergarten 11

12. Prevalence and Risk • 13%-23% of preschool children have mental health problems. • Higher rate with the co-occurrence of other risk factors • Less than 1% of preschool children receive mental health services. 12 Raver, etal. 2008. ECRQ. Per Yoshikawa and Knitzer, 1977; Pottick & Warner, 2002.

13. Social and Emotional Development in Young Children How they feel about themselves Confident, secure,, eager to learn, proud of their culture versus always scared, afraid of being wrong How they behave Constantly fighting, easily upset, temper tantrums versus able to deal with conflict Withdrawn, shy Eating problems How they relate to others Especially people who matter to them, e.g., parents, teachers, and friends National Center for Children in Poverty. www.nccp.org/pub_rps05.html 13

14. Goals 14 Promote healthy physical and emotional development. Identify early signs of emotional and/or behavioral difficulties.

15. Health ProfessionalsInvolved in Child Care Child Care Health Consultants (CCHC) Early Childhood Mental Health Consultants (ECMHC) Primary Care Clinician (PCC) 15

16. Communication and the Medical Home Primary CareClinician Childand Family Early Childhood Mental Health Consultant Child Care Health Consultant

17. Child Care Health Consultants “A health professional who has interest in and experience with children, has knowledge of resources and regulations and is comfortable linking health resources with facilities that provide primarily education and social services” Health Professionals: nurses, physicians, health educators, social workers, etc Training: National Training Institute (train-the-trainer program) Gold Standard: National Health and Safety Performance Standards (Caring for Our Children) Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care, 2nd Edition, 2002. 17

18. Child Care Health Consultants Job Responsibilities Establish a trusting relationship Conduct baseline needs assessment Identify health problems to target for intervention Develop or update written health policies Provide workshops for child care providers and families Provide regular telephone or email advice Provide referrals to community services Review health records Develop care plans for children with special health care needs 18

19. Impact of Child Care Health Consultation National health and safety standards (CFOC) Increased # and quality of written health and safety policies Medication administration, exclusion of ill children, care of mildly ill children, daily health check, emergency preparedness, and inclusion of children with special needs Improved health and safety practices consistent with CFOC Emergency preparedness Reduction in risk of SIDS 19

20. Impact of Child Care Health Consultation, Continued Child Health Status Immunizations up-to-date Medical home Health care plan for children with special health care needs Health Insurance The influence of child care health consultants in promoting children’s health and Well-being: A report on selected resources. 2006. http://hcccnsc.edc.org/resources/data/CC_lit_review_Screen_All.pdf 20

21. Early Childhood Mental Health Consultants Providers with mental health expertise and training on early care and education “…collaborate with administrators, staff and family members of children from birth through 6 years of age participating in group care and early education settings…” Builds staff capacity To promote children’s social and emotional development To address challenging behaviors Brennan, EM, Bradley JR, Allen MD, Perry DF. (2008). The evidence base for mental health consultation in early childhood settings: Research synthesis addressing staff and program outcomes. Early Education and Development, 19(6): 982-1022. 21

22. Early Childhood Mental Health Consultants Types of Consultation Child- or Family-Centered Consultation Programmatic Consultation Focus on relationships Staff and consultant, child, parent Cohen, E., and Kaufmann, R. Early Childhood Mental Health Consultation. DHHS Pub. No. CMHS-SVP0151. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2005. 22

23. Knowledge of child development, normal growth and development, and ability to identify atypical behavior Understand concepts underlying young children’s socio-emotional development Observation, listening, interviewing, and assessment skills Understanding of cultural differences Ability to work with adults and knowledge of adult learning principles Ability to recognize the diverse perspectives of staff and to facilitate communication of these perspectives Knowledge of early childhood, child care, family support and early intervention systems, both public and private Early Childhood Mental Health Consultants Cohen, E., and Kaufmann, R. (2005). 23

24. Consult with Staff for Children Who May Not Succeed in School Transition Engage in frequent fighting, shouting, or other aggressive behaviors Are unable to control impulsive behavior Are unable to pay attention to tasks or follow directions Engage in oppositional, noncompliant, even defiant behavior Are unable to cooperate with others Constantly seek attention from peers or teachers Ignore peers or teachers Raver and Knitzer (2002) Ready to Enter: What research tells policymakers about strategies to promote social and emotional school readiness among three- and four-year-old children. National Center for Children in Poverty. 24

25. Impact of Early Childhood Mental Health Consultation Review of 26 studies from 1985-2008 of staff and program outcomes (not child level) Programs generally served urban, ethnically diverse children 2 to 5 years old Results: Staff increased self-efficacy/confidence and competence in dealing with troubling or difficult behaviors Staff improved sensitivity and had lower job-stress Improved overall quality of child care program Reduced staff turnover Brennan, EM, Bradley JR, Allen MD, Perry DF. (2008). 25

26. Developmental Screening of Young Children Where? Primary care office Child care What screening instrument? PEDS; www.pedstest.com ASQ, ASQ- SE; www.pbrookes.com ABLE; http://abletest.com Others How are results shared between PCC, child care provider, and child care consultants (CCHC, ECMHC)? 26

27. Primary Care Clinicians Rosie D. Reforming the Mental Health System in Massachusetts. Center for Public Representation Web site. Available at: http://www.rosied.org/Default.aspx?pageId=67061. Accessed March 9, 2009 27 • Primary care clinicians have a critical role to play in meeting children’s mental health needs. In fact, Massachusetts is now requiring, by court order, universal mental health screening by primary care clinicians for all children on Medicaid in that state. • Provide guidance to families • Help parents find high quality early care and education experiences for their children • Complete health forms and care plans for children with special health care needs • Communicate health issues and/or treatment raised in PCC office or child care program

28. Primary Care Clinicians Provide health consultation services to child care programs Support child care in your local community to meet national standards for health and safety of child care for all young children. Advocate for quality child care State regulations to support health consultation American Academy of Pediatrics. The Pediatrician's Role in Promoting Health and Safety in Child Care. Elk Grove Village, IL: American Academy of Pediatrics; 2001:25-27 28

29. Bringing it All Together: The Importance of the Medical Home Jack Levine, MD, FAAP Section on Early Education & Child Care Section on Developmental & Behavioral Pediatrics

30. The Medical Home: A Concept rather than a Building Accessible Family-centered Continuous Comprehensive Coordinated Compassionate Culturally Effective

31. Successful Early Child Care Informed, activated family Integrated, supportive community Community resources and agencies Medical Home Based on Wagner et al.

32. Integral Part of Community-based System Coordinates with community-based services designed to promote the healthy development and well being of children and their families Facilitates access to and collaborates with a broad range of specialty, ancillary and related community services

33. Communication and the Medical Home Primary CareClinician Childand Family Early Childhood Mental Health Consultant Child Care Health Consultant

34. Effective Communication Among Health Professionals • Primary Care Clinician – Family – Consultant • Results of screening or initial evaluations • Reason for referral to mental health consultant • Share important medical information • Collaborate and cooperate on care plan for children • Medications • Emergencies • STAY INVOLVED!

35. Communication With Child Care Providers • Written communication • Clear language with no jargon • Write-out care plan and instructions • Appreciation for child care provider • Know children’s behavior in group situations • Experience with range of children’s behaviors

36. Successful Start: Rhode Island’s Early Childhood Systems Plan Susan Dickstein, PhD Bradley/Hasbro Children’s Research Center Brown Medical School

37. Successful StartRhode Island’s Early Childhood Systems Plan Improved Outcomes for Children & Families through A More Effective Early Childhood System

38. Successful Start VISION To create a comprehensive and coordinated early childhood system that supports families and communities in promoting positive early childhood development so that allchildrenenterschoolhealthyandreadytolearn. Successful Start MISSION To ensure that all young children reach their full potential through a system of services that promotes healthy social-emotionaldevelopment, quality earlycareandeducation, coordinated medicalhomes, and effective parenteducationandfamilysupport services.

39. Critical Components of Early Childhood Systems SOCIAL-EMOTIONAL COMPETENCE Optimal Outcomes for Young Children and their Families MEDICAL HOMES EARLY CARE & EDUCATION PARENT EDUCATION & FAMILY SUPPORT

40. Critical Components of Early Childhood Systems: Programs SOCIAL-EMOTIONAL COMPETENCE CCSN Early Learning Standards CCHC EHS/HS PEP/PBIS Early Intervention Family Outreach Strengthening Families Watch Me Grow KIDSCONNECT Child Outreach Bright Stars (QRiS) PPEP T.E.A.C.H. FCCP IYS LAUNCH Nurse Family Partnership MEDICAL HOMES EARLY CARE & EDUCATION PARENT EDUCATION & FAMILY SUPPORT

41. Mental health consultation to improve child care contexts Child Care Support Network Early Childhood Mental Health Consultation Funding provided by:RI Dept of Human Services,RI Dept of Health, and the RI Maternal & Child Health Bureau

42. CCSN-Supported Activities Classroom Outcomes Child Outcomes • Child Social-Emotional Behavioral Functioning • Social-Emotional Competence at School • Behavior Regulation at School Classroom observation and feedback to staff Classroom Support Program support In-service training workshops of topics relevant to early childhood mental health • Classroom Functioning • CR Environment • CR Atmosphere • CR Quality • CR Behavior Patterns • Teacher Practices • Teacher Strategies • CR Map • Parent Involvement • Supervision practices • School Success: • Decreased suspensions & expulsions • Decreased mobility

43. CCSN MHC ImplementationQuestions (Pilot Year 1) • How Were Child Care Centers Enrolled? • Who Participated? • How Did Classroom Observations Inform ECMHC Activities? • What ECMHC Activities were Implemented?A) Type?B) Amount?

44. How Were Child Care Centers Enrolled? • Active Recruitment by RI Dept of Health • Priority to centers serving children with DHS child care subsidies • Eligible centers assigned to ECMHC for up to 12 months • ECMHC conducted on-site enrollment Interview • Collaborative plan to determine needs of the center; center “point person” for ECMHC; schedule of consultation services, etc. • Pre-ECMHC classroom observations scheduled & staff questionnaires completed • 2-session workshop training scheduled (based on CSEFEL principles)

45. Age range (months) # classrooms # children # staff Center 1 0-60+ 5 50 10 Center 2 0-60+ 4 47 11 Center 3 36-60 1 25 6 Center 4 0-36 4 27 10 Center 5 0-36 7 84 29 Center 6 36-60+ 2 45 14 TOTALS 23 278 80 2. CCSN MHC Pilot Yr 1: Who Participated?

46. How did Classrooms Observations Inform ECMHC Activities? • Classroom observations in every classroom by evaluation team using standardized tools • Clinical feedback provided to ECMHCs • ECMHC worked with program to incorporate feedback into consultation plan and ongoing consultation activities

47. What ECMHC Activities were Implemented? Classroom Support • Consultation- classroom, child, or family concerns • Classroom improvement plans • Program enhancements for challenging behaviors and/or developmental concerns • Communication with parents about child behavior/development • Community-based referrals Program Support • Case management reviews • Reflective supervision practices • Team building • Workshop Trainings

48. Summary of Pilot Year 1 Direct ECMHC Activities • Most (83%) MHC activities were conducted at the classroom support level (ranging from 57-97%) • Some (11%) MHC activities were conducted at the program level (ranging from 3-25%) • 5/6 programs participated in the 2-session workshop series

49. Engagement with ECMHC Activities • On-site Consultation: Average rating of satisfaction with MHC activities=4.36 on scale from 1(low) to 5 (high) • MHC Workshops: 94% participants reported strong agreement with stated learning objectives (e.g., I can describe how classroom environments support child development, etc.)

50. Evaluation Questions Were there pre-post ECMHC changes in: • classroom functioning? • teacher practices? • program supervisory practices? • rate of expulsion from child care centers?