Posted March 20, 2017
Looking for information about comprehensive early childhood mental health services? Want to learn more about evidence-based practices and cutting edge policies? Here is a place to start.
This bibliography contains 10 resources about:
- Comprehensive systems
- Integrated services
- Two generation models
- State and community policies
- Funding strategies for preventive services
- Examples of state strategies
Start by reading the brief summaries and if you find something interesting, follow the link to the full document.
Victoria Youcha, Ed.D.
ECCBC Board member
1. Alliance for Early Success – June 2016 blog
Early environments and experiences in young children’s lives matter, and evidence-based interventions designed to promote children’s healthy social-emotional development can make a difference. Many states and communities are developing comprehensive strategies that recognize the importance of early childhood mental health as part of overall health and well-being, and school readiness and success. Several of these efforts were featured at a recent meeting, Cross-Systems Collaboration for Children’s Social-Emotional Development, hosted by the National Academy for State Health Policy (NASHP) in partnership with the Alliance for Early Success.
Below are five key themes with selected state examples identified as being essential to addressing the healthy social-emotional development of children.
- Address family risk factors. Through federal Project LAUNCH grants, states like Massachusetts are identifying family stressors and risk factors affecting early childhood mental health. Research indicates that maternal mental illness is a powerful predictor of a child being diagnosed with a mental health condition. The Minnesota Department of Human Services conducted an analysis of children enrolled in its public health insurance programs to assess the prevalence of family risk factors, such as parental mental illness or chemical dependency, affecting children. As a result of the findings, the state implemented strategies such as systematically training mental health providers in interventions targeting the parent-child relationship, particularly for children whose primary caregiver has a mental health diagnosis such as depression. The Medicaid agency also reimburses maternal depression screening conducted at a well-child visit.
- Seek to integrate behavioral health services in pediatric primary care settings. Pediatric primary care practices are important settings for addressing early childhood mental health given the frequency of well-child visits. Healthy Steps at the Children’s Hospital at Montefiore in New York has fully integrated mental health specialists in pediatric primary care at 21 sites. Specialists provide a range of services including universal mental health screening, assessment, treatment and referral of infants and their caregivers, optional home visits, parent discussion groups, and provider education about infant mental health. Payment for early childhood mental health services that address family needs is an ongoing challenge since our health care delivery system is based on payment for individual, rather than family, services. Strategies for braiding or blending different funding sources are an area of continued interest.
- Explore innovative financing and strategic planning efforts to leverage and integrate cross-sector investments and planning in early childhood health. For example, Louisiana developed an early childhood systems integration budget to reflect state early childhood investments in health care, early care and education, family supports, and mental health services. The integrated budget was an important tool for leveraging limited resources, comparing early childhood investments including early childhood mental health to the total state budget, and in strategic planning.
- Leverage health care delivery transformation opportunities to align health care and early learning policies. In recognition that good health is critical for school success, Oregon is leveraging federal health care and education grants to align early learning system transformation and health care delivery reform. The state has developed shared responsibilities and measures across health care and early learning systems. Improvement in developmental screening is already a key focus area among both systems, and state leaders are exploring options to promote early childhood mental health as part of this alignment.
- Engage in public-private partnership. The Illinois Action Plan to Integrate Early Childhood Mental Health in Child- and Family-Serving Systems, Prenatal through Age Five was developed with the engagement of broad cross-section of public and private stakeholders in the state to outline plans for integrating early childhood mental health promotion, early intervention and treatment services and supports into the state’s child and family-serving systems. This plan builds upon decades of targeted investments and an intentional focus on early childhood development, and in a statewide gubernatorial initiative, The Illinois Children’s Mental Health Partnership, to transform the state’s mental health system for children and adolescents.
2. Minnesota: 13 percent of children receiving Medicaid have parent with mental illness, 10% have parent with substance abuse issue.
Parental mental illness: Parents of five percent of MHCP children met the criteria for Serious and Persistent Mental Illness (SPMI). Only people who are receiving intensive mental health services and have one of four serious Family Risk Factors 19 diagnoses meet this criterion. Children who received Child Protection services had this risk factor more often (13 percent of children). A more common indicator is that of “Serious Mental Illness” (SMI). This indicator does not require intensive services but only particular diagnosis codes. In the general population, the estimate is that 5.4 percent of people have a SMI. A much larger 13 percent of MHCP children have parents who meet this criterion. These are different units of analysis and are not directly comparable. But it indicates that a significant minority of DHS children are growing up with parents who a health care professional recently identified as having a SMI. Mental illness in a parent can be a concerning situation, especially if untreated. These children may encounter many barriers to their own healthy emotional development (Orel, Groves & Shannon, 2003). They may experience fear, anger, guilt, shame or other feelings about their parent’s illness (Blanch, Nicholson & Burcell, 1998). They may also be required to take on adult-like responsibilities at an early age, thus focusing less on their own development.
3. Nurturing Change: State Strategies for Improving Infant and Early Childhood Mental Health: February 2013
The six states profiled in this paper—Wisconsin, California, Michigan, Florida, Ohio, and Louisiana—offer compelling and varied examples of successful work in I-ECMH. Though each state is unique in geography, budget, leadership, and political landscape, they all share a commitment to:
- identifying and breaking down barriers to I-ECMH services;
- Making the necessary policy improvements and investments to ensure that infants and young children receive the I-ECMH services they need;
- Ensuring that there are qualified and trained professionals to provide I-ECMH services; and
- Identifying funding sources and procedures to pay for the services.
Two State Examples:
Louisiana: TANF Funds I-ECMH Direct Services In 2002, Louisiana’s Assistant Secretary of Mental Health, alongside clinicians from Tulane and Louisiana State University, secured funding through Temporary Assistance to Needy Families (TANF), plus some state general funds, to create the Early Childhood Supports and Services (ECSS) program. ECSS was a direct-service program that brought together practitioners from across early childhood to provide comprehensive services (including but not limited to mental health services) to TANF-eligible children. The program was a public health intervention that combined intensive multisystem case management and I-ECMH services using clinical assessment and evidence-based interventions. I-ECMH provided the framework for all evaluation and service provision.
California: Advocates in California used the legal system to address barriers to reimbursement and eligibility determination for infant-family and early childhood mental health (IFECMH) services. In Smith v. Belshe, a group of California-based attorneys argued that the California Department of Health Services was out of compliance with federal law relating to diagnostic and treatment services under Medicaid’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT). In fact, before the 1993 lawsuit, the state provided almost no mental health services to children under age 4. This changed when the court ruled in favor of the plaintiffs. The ruling led to implementation of the EPSDT mental health benefit and increased the availability of state general funds for financing specialty mental health services for children ages birth to 21. The expansion of services was implemented through an interagency agreement between the state departments of health services and mental health.
In Katy A v. Bonta, filed in July of 2002, the state was challenged for not providing necessary mental health treatment services to children in foster care or to those who were at imminent risk of placement in foster care. Several counties settled the class action lawsuit early and took steps to prioritize referrals between child welfare and mental health. The state settled in 2011 and, as part of the settlement, developed a guide that describes practice standards and activities that are to be used by child welfare and mental health. This lawsuit led to increased attention to IFECMH services because the majority of cases in the child welfare system are children under age 5. Following the lawsuits, the cost of mental health services was covered by a combination of federal funds (50%), state funds (40%), and county funds (about 10%). In 2012–13, Governor Edmund G. Brown’s budget eliminated the California Department of Mental Health. As a result, mental health services became the fiscal responsibility of each county. Counties now receive a capped match allocation. Once the match is spent, counties are responsible for the entire 50% nonfederal share of EPSDT-funded services.
4. Financing and Sustaining the Early Childhood Mental Health Model of Integrated Care (2014)
The model suggested here aims at optimal service delivery. Important features of this model are not generally reimbursable at present. These elements are:
- Integrated Early Childhood Mental Health (IECMH) staff who are available as needed to provide consultation to staff and/or families.
- IECMH staff time that is set aside to provide training to medical staff.
- Regular promotion and prevention services available to families, such as family game nights and back-to-school groups.
- A warm handoff for more involved mental health services.
Medical practices regularly carry out non-billable activities, sometimes by absorbing the cost reimbursement for billable services, and sometimes by finding outside funding from grants, contributions or other sources.
Some of the services you may want to offer will fall into this category if you want to provide the most comprehensive and helpful support to families and children. In your practice, you will need to determine what nonbillable activities are worth this investment.
Ultimately, it is likely that you will need to combine reimbursement with grant or general practice funds to cover staff involved in early childhood mental healthcare.
5. Supporting Early Childhood Mental Health Consultation
Infant-Early Childhood Mental Health Consultation (I-ECMHC) is a multi-level preventive intervention that teams mental health professionals with people who work with young children and their families to improve their social-emotional and behavioral health and development. I-ECMHC builds the capacity of teachers, providers and families, and includes skilled observations, the strengthening of teacher-family relationships, the identification of children with or at-risk for behavioral, developmental or mental health difficulties, and linkages to additional support services, as needed. I-ECMHC has demonstrated impacts for improving children’s social skills, reducing challenging behaviors, preventing preschool suspensions and expulsions, improving child-adult relationships, and reducing teacher stress, burnout, and turnover.
While there is no single dedicated funding source available for early childhood mental health consultation, there are a number of federal funding streams that can be paired with State and local funds to support this important service for young children and their families.
6. Behavioral Health—Prevention, Early Identification, and Intervention
The American Public Human Services Association
Pathways calls for an integrated, holistic service delivery system addressing prevention, early intervention, bridge supports, capacity building and sustainable strategies. State and local health and human service agencies are achieving better health outcomes through flexible funding, a prepared workforce, modern technology, accountability, and effective engagement of those we serve, blended with simultaneous efforts to enhance organizational effectiveness and leverage the resources of private and community partners.
- Promote public and private collaboration between public agencies at all levels and the community as a way to create social and physical environments that enable good health through prevention for all age groups. This includes placing an emphasis on the training of professionals in all settings to be able to identify and screen for mental health and substance use conditions.
- Support collaboration across state and local health and human service agencies to identify where investments can be made that can prevent the social, emotional, and cognitive impairments that, in turn, contribute to at risk behaviors leading to disease, disability, social problems, and early morbidity.
- Promote utilization of integrated service delivery options (e.g., health homes) that blend new payment methodologies like value-based purchasing with holistic care coordination for all populations with chronic conditions.
- Support public and private research to examine the systematic return on investment (ROI) received through holistic preventive services as well as the ROI on more costly forms of care (e.g., increased utilization of emergency rooms for primary and behavioral health treatment).
- Support efforts to enable information to be shared across agencies and programs that will more effectively coordinate care, and achieve better outcomes among those serving the same individuals and families.
7. Early Childhood Mental Health in Colorado: An Environmental Scan of Challenges, Progress and Recommendations for the Social and Emotional Health of Colorado’s Young Children
Despite notable accomplishments and new opportunities related to each of the goal areas, a review of the data highlighted challenges to improving and expanding Colorado’s system of early childhood mental health and led to the proposed recommendations. For example, the current workforce is insufficient, and there is a notable lack of incentives and supports for professionals to seek specialized training and remain in the field. While quality programs and services exist, availability is often unequal and limited to certain geographic areas.
Despite the importance of early identification and treatment, screening for childhood social and emotional difficulties is inconsistent among providers. Moreover, current Medicaid policies are often not flexible enough to cover treatment appropriate for young children.
The accompanying full report includes recommendations for funders to address these and related challenges as they work with other funders, government, social service agencies, and mental health professionals to find enduring, systemic solutions
8. Parents with a mental health problem: learning from case reviews
Summary of risk factors and learning for improved practice around parental mental health and child welfare
This small study presents a critical, thematic analysis of recommendations from 33 of the serious case reviews (cases of child death or serious injury through abuse or neglect) completed in 2009-2010. The central aim of the study was to consider what part recommendations can play in aiding agencies and individuals ‘to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children’ (HM Government 2010:246).
See ECCBC blog for a summary of findings and recommendations.
9. Promoting the Emotional Well-Being of Children and Families Policy Paper No. 4. Making Dollars Follow Sense: Financing Early Childhood Mental Health Services to Promote Healthy Social and Emotional Development in Young Children Kay Johnson • Jane Knitzer • Roxane Kaufmann August 2002
Drawing on lessons from six case studies, this policy paper highlights the most innovative approaches states and communities are currently using to finance early childhood mental health services and explores what else might be done to mix, match, and leverage all available resources. The focus is on prevention and early intervention services to not only help children directly, but equally important, to help their families and other caregivers address the social and emotional challenges children face. The case studies are based on interviews with policy and program leaders in the states of Florida, Indiana, Ohio, and Vermont, as well as two metropolitan areas—San Francisco and Cuyahoga County, Ohio (where Cleveland is located).
Lessons from the Sites
Sites are using broad early childhood initiatives as a platform from which to launch early childhood mental health services. Leadership comes from many different agencies and individuals, and the scope of the effort varies considerably across the sites. For example, the focus may be on one age group (e.g., infants and toddlers) or one service (e.g., early childhood mental health consultation). Only one site has developed and implemented a comprehensive system of care fully integrated into the early childhood community.
Because of the initiatives, young children, their families, and their caregivers have access to resources and services that simply did not exist before. Across the sites, investments have increased by about $12 million.
Although most sites are emphasizing early childhood mental health consultation, a broad range of services are being funded (including training for early childhood staff in mental health issues, parent-to-parent support groups, and behavioral aides in the classroom).
Funding strategies vary in complexity across the sites. In most there has been a heavy reliance on federal dollars. But in some sites, state dollars provide the only major funding stream. In others, there has been a deliberate effort to draw funds from multiple sources, including entitlement dollars, and state and local public funds, as well as private dollars and special grants.
Major federal funding sources include Medicaid/ EPSDT, the Child Care and Development Fund, TANF, the Children’s Mental Health Services Program, and the Part C Early Intervention Program of the IDEA.
State Medicaid agencies in several sites have developed new policies to maximize the use of Medicaid funds for mental health services to young children, but no site has taken full advantage of what is possible. Other federal programs have played a supporting role in some, but not all of the sites. For example, Part C has been central in Indiana, TANF in San Francisco.
The sites are using four major strategies to maximize funding: blending funds, braiding funds, maximizing Medicaid, and using state funds strategically to match federal dollars and to pay for support services—such as staff and parent training—that cannot otherwise be supported.
Common fiscal challenges include the difficulty of providing preventive and early intervention services without requiring a diagnosis, using all available funds, and sustaining funding, particularly given the worsening larger economic context.
Interagency and public-private collaboration are essential to developing and financing a system of care that provides a continuum of early childhood mental health services. Collaboration, once set in motion, works best where sustained by formal mechanisms. Financial arrangements frequently are supported by legislation, regulation, memoranda of understanding, and other formal guidance.
Ten Action Steps for States and Communities
Building on the lessons of these pioneering sites, below are action steps that other communities and states can take to strengthen their attention to the social, emotional, and behavioral needs of young children.
- Start small. Apply for small grants or turn to local foundations to jump-start a community- or state level planning process, building on other collaborations on behalf of young children.
- Test out new service approaches to make sure they fit with the community. Consider evidence-based practice, where there is an evidence base, and lessons from prior efforts.
- Develop cross-training initiatives to build a shared understanding of what early childhood mental health services are, how they are related to other shared goals, such as promoting school readiness, and how they might be funded.
- Build or strengthen collaborative relationships to develop a systematic funding strategy that will support the development of preventive and early intervention services. For example, use child care improvement funds for mental health consultation; establish or use existing formal mechanisms at the cabinet, state agency, or local agency level; make sure parents are involved.
- Analyze existing levels of funding for early childhood mental health. How do the funds flow to reach local service providers and meet family needs? Are funds being used for the right services? Are the funds sufficient? Do services address the needs of infants and toddlers as well as preschoolers?
- Assess the funding streams that could be used and what barriers they pose: for example, does the state Medicaid agency pay for all covered services, including child and family therapy?
- Develop a targeted strategy to maximize the impact of Medicaid/EPSDT. For example, include age appropriate developmental, emotional, and behavioral measures in the recommended EPSDT screening protocol; make sure that reimbursed services are appropriately defined for young children; make sure that parent-child therapies are covered.
- Consider redesigning reimbursement and billing practices to maximize the use of all available dollars, exploring some of the strategies used by the sites described in this report such as blended or braided funds.
- Develop a method to gather the kind of outcome data needed to refine and sustain funding for early childhood mental health strategies.
- Promote the development of targeted federal funding as a catalyst for the development of early childhood mental health services.
10. Two Generation Handbook, Ascend, The Aspen Institute
Two-generation approaches provide opportunities for and meet the needs of children and their parents together. They build education, economic assets, social capital, and health and wellbeing to create a legacy of economic security that passes from one generation to the next.
We all want to see families thrive, but fragmented approaches that address the needs of children and their parents separately often leave either the child or parent behind and dim the family’s chance at success. Placing parents and children in silos ignores the daily challenges faced by parents who are working or studying while raising a child, a challenge even more pronounced for those with low wages.
Research has documented the impact of a parent’s education, economic stability, and overall health on a child’s trajectory. Similarly, children’s education and healthy development are powerful catalysts for parents. Two-generation approaches help both generations make progress together.