The Harvard Center on the Developing Child (Part 1)

Posted January 2018

The Harvard Center on the Developing Child wants us to remember the following 8 things about early childhood development.  In this blog, I will discuss 4 of them:

1. Even infants and young children are affected adversely when significant stresses threaten their family and caregiving environments.

Adverse fetal and early childhood experiences can lead to physical and chemical disruptions in the brain that can last a lifetime. The biological changes associated with these experiences can affect multiple organ systems and increase the risk not only for impairments in future learning capacity and behavior, but also for poor physical and mental health outcomes.

2. Development is a highly interactive process, and life outcomes are not determined solely by genes.

The environment in which one develops before and soon after birth provides powerful experiences that chemically modify certain genes in ways that then define how much and when they are expressed. Thus, while genetic factors exert potent influences on human development, environmental factors have the ability to alter family inheritance. For example, children are born with the capacity to learn to control impulses, focus attention, and retain information in memory, but their experiences as early as the first year of life lay a foundation for how well these and other executive function skills develop.

3. While attachments to their parents are primary, young children can also benefit significantly from relationships with other responsive caregivers both within and outside the family.

Close relationships with other nurturing and reliably available adults do not interfere with the strength of a young child’s primary relationship with his or her parents. In fact, multiple caregivers can promote young children’s social and emotional development. That said, frequent disruptions in care and high staff turnover and poor-quality interactions in early childhood program settings can undermine children’s ability to establish secure expectations about whether and how their needs will be met.

4. A great deal of brain architectureis shaped during the first three years after birth, but the window of opportunity for its development does not close on a child’s third birthday.

Far from it! Basic aspects of brain function, such as the ability to see and hear effectively, do depend critically on very early experiences as do some aspects of emotional development. And, while the regions of the brain dedicated to higher-order functions—which involve most social, emotional, and cognitive capacities, including multiple aspects of executive functioning—are also affected powerfully by early influences, they continue to develop well into adolescence and early adulthood. So, although the basic principle that “earlier is better than later” generally applies, the window of opportunity for most domains of development remains open far beyond age 3, and we remain capable of learning ways to “work around” earlier impacts well into the adult years.

Bobbie Watson
Executive Director
The Early Childhood Council of Boulder County

Worthy Cause IV

Posted October 2017

The County Commissioners have put a ballot measure on this fall called Worthy Cause IV-an extension of a 0.05% countywide sales and use tax which was first passed by Boulder County voters in 2000.  These funds are used to provide non-profit safety net providers with funds for ‘bricks and mortar’-that is to either buy new buildings and/or expand/renovate existing buildings.  I know that many of you are aware of programs who have benefited from these funds including:   the OUR Center, The Boulder Valley Women’s Health Center, the Homeless Shelter, The Wild Plum Center in Longmont, Clinic Campesina,  The Boulder Safehouse, EFAA and many others.  There continues to be increasing demands on all of our safety net providers.  You may recall the Neighbors Helping Neighbors campaign in 2014 which passed with broad approval.  Those funds go to support safety net program costs like:  salaries, program materials, etc.  But our non-profit partners also need have up-to-date facilities in which to provide their programs.  That is why I am urging you to support Worthy Cause IV.  The ECCBC Board has endorsed this ballot measure.  This extension would go until Dec 31, 2033 and revenues would be used in the following manner:

  • Affordable Housing: $2 million for permanently affordable housing throughout Boulder County
  • Senior and Aging Services: $600,000 for senior and aging services for agencies including but not limited to Meals on Wheels
  • Health and Mental Health Care: $900,000 for new and expanded health and mental health services throughout Boulder County

 

I urge you to continue to support your neighbors in Boulder County.  VOTE

Bobbie Watson

Executive Director

The Early Childhood Council of Boulder County

Don’t Flip Out, Just FLIP IT!

Posted July 2017

As early childhood educators, we learn a variety of strategies for handling challenging behaviors in the classroom, from our own experiences, schooling, trainings, or our colleagues. These strategies run the gamut in how we interact with a behavior—whether we ignore it to avoid giving it attention or have the child spend some time in the director’s office. That means they also vary wildly in effectiveness—some may provide successful control management while others may even support a child’s development. As we all know, some tactics work better than others and some methods work for different children. This is just one of the many ways early childhood educators have to be flexible, adaptable, and quick-thinkers.

In the midst of an inevitable chaotic moment, when a child is throwing, kicking, spitting, or demonstrating any number of other “challenging behaviors,” we need a tool that is easy to remember and easy to implement. FLIP IT was born from exactly these moments. The author, Rachel Wagner, was a preschool teacher in desperate need of a tool for handling challenges when all else was failing and she and her co-teachers felt like they were drowning.

FLIP IT is an evidence-based four-step strategy for addressing challenging behaviors, but it carries so much more than that. By talking a child through his or her Feelings, then setting loving Limits, posing an Inquiry to solve the problem, and offering Prompts to encourage creative solutions, we include the child not only in navigating their own obstacles, but in gaining a deeper appreciation of their emotions. FLIP IT doesn’t simply put a band-aid on the symptom; rather it focuses on attempting to understand the root of the child’s behavior and the factors that can influence these roots.

According to Wagner, the root of all behavior is emotion, whether positive or negative. When a child is experiencing positive feelings their behaviors mirror this with happiness, attentiveness, and a readiness to learn. But when a child is demonstrating challenging behaviors, this is a clue to teachers that their roots are experiencing negativity, or what we are calling their STRUGGLES.

By being in tune to a child’s emotions we not only guide their behavior, but more importantly we are supporting their mental health (maybe link here to blog post on Adverse Childhood Experiences). Teaching skills for social emotional development in the early years has monumental implications, helping children build their self-regulation, empathy, and coping skills. As we can all attest, life will continue to pose challenges, so we have the responsibility and the privilege to prepare our children to be problem-solvers in their own lives.

To read more about FLIP IT, visit the Devereux Center for Resilient Children.

Are you a childcare provider in Boulder County and interested in a FLIP IT training for you or your staff? Check our website for the next FLIP IT training.

Caitlin Moles
Quality Improvement Coach
Devereux-Recognized FLIP IT Trainer

Who Can Afford Childcare

Posted June 2017

If you are reading this, you are probably very aware of the high cost of childcare!  Those families of middle income (making anywhere from $70K to $120K annually) are being squeezed the most.

Families on the ends of the income spectrum can either: 1) afford to pay for childcare if they are in a higher income bracket or 2) access several childcare subsidy programs (i.e. CCAP, CPP and/or Head Start) if they are very low income (i.e. using the 2014 federal poverty level number for a family of four at $24,250/yr).  If you are middle income-it is another story altogether.

The US Department of Health and Human Services says that child care should cost around 7% of a family’s income at most.  Given that the cost of full time care of a toddler in Boulder County (link to the most recent Indicators Report) is $14,265 per year, to meet the 7% DHHS target, a family would need to have an annual income of $205,215.  The median income of families in Boulder County with children is $103,037.  To look at this in another way, for a family with the median income of $103,037, at current childcare rates for full time toddler care, this family would pay 14% of their income for childcare.  And heaven help them should they have a second child!

Professor James Heckman (Nobel laureate economist at the University of Chicago) has recently released a study entitled: “The Lifecycle Benefits of an Influential Early Childhood Program.” This research shows that high-quality birth-to-five programs for disadvantaged children can deliver a 13% per year return on investment—a rate substantially higher than the 7-10% return previously established for preschool programs serving 3- to 4-year-olds. Significant gains are realized through better outcomes in education, health, social behaviors, and employment.

An interesting sidelight in this study shows that boys in high quality childcare settings benefited more than the girls.  This finding meshes with other research findings that boys are more sensitive to disadvantaged circumstances than are girls but are also more responsive to interventions.

It will be interesting to watch where the Trump administration goes with Ivanka Trump’s support of affordable childcare-long a goal of the Democratic Party.

Bobbie Watson

Resource List for Comprehensive Early Childhood Mental Health Services

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:

  1. Comprehensive systems
  2. Integrated services
  3. Two generation models
  4. State and community policies
  5. Funding strategies for preventive services
  6. Examples of state strategies

Start by reading the brief summaries and if you find something interesting, follow the link to the full document.

Thank you.

Victoria Youcha, Ed.D.
ECCBC Board member


1. Alliance for Early Success – June 2016 blog

http://earlysuccess.org/blog/comprehensive-early-childhood-mental-health-systems-improve-outcomes-and-reduce-costs

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.

http://www.dhs.state.mn.us/main/groups/agencywide/documents/defaultcolumns/dhs16_194152.pdf

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

http://earlysuccess.org/sites/default/files/nurturing-change_0.pdf

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)

http://www.ecmhmatters.org/ForProfessionals/Documents/Toolkit/BPHC_PowerPoint_Project_Section_4_FINAL.pdf

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

https://www.acf.hhs.gov/sites/default/files/ecd/supporting_early_childhood_mental_health_consultation.pdf

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

http://www.aphsa.org/content/dam/aphsa/pdfs/Pathways/2013-06-BehavioralHealth-Prevention-Early-Identification-Intervention-PolicyBrief.pdf

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.

Recommendations

  • 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

http://www.caringforcolorado.org/sites/default/filesearly_childhood_mental_health_in_colorado_5_09_13.pdf

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

https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/parents-mental-health-problem/

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

http://nccp.org/publications/pdf/text_483.pdf

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.

  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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?
  1. 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?
  1. 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.
  1. 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.
  1. Develop a method to gather the kind of outcome data needed to refine and sustain funding for early childhood mental health strategies.
  1. 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

http://b.3cdn.net/ascend/5e6780f32400661a50_pgm6b0dpr.pdf

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.


 

Towards a Two-Generation Approach to Mental Health Services

Posted January 30, 2017

We know that children thrive when they have stable, supportive, and responsive relationships. But too often in the early childhood setting, we identify a behavioral concern in a young child without understanding the intricacies of family relationships.

A two-generation approach looks at the needs of children and their parents together. For example, in Boulder County, many primary pediatric providers already screen for maternal depression on well-baby visits. However, when an adult seeks mental health services, the needs of young children in the family may not be part of the initial assessment or a focus of treatment. There is a significant body of research indicating that parental mental illness can have a big impact on parenting capacity. But when services are one-generational, the risk to children’s safety can be overlooked.

Here is a summary of one study that looked at specific parental risk factors and recommendations for improved practice. It underscores the importance of recognizing the relationship between adult mental health and child protection. Adult and children’s services need to work together to safeguard children when a parent has mental health problems.

Parental mental health problems were identified as a factor in over half of a sample of 33 serious case reviews in England from 2009-2010 (Brandon, 2011). Published case reviews revealed that professionals are sometimes not aware of the significant impact a mental health problem may have on parenting capacity. As a result, child-related safety issues may be missed.

In these case reviews, children died or were seriously harmed in the following ways:

  • killed or seriously injured by a parent suffering from depressive mental illness or a severe psychotic episode
  • neglect as result of parents with mental health issues prioritizing their own needs.

https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/parents-mental-health-problem/ Published July 2015)

Risk factors for parents with mental health problems

The case reviews identified the following parental factors as increasing the risk of harm to children.

  • Disclosure of suicidal feelings: As well as leading to a referral to mental health services, disclosure of suicidal feelings should lead to full consideration of child protection issues in relation to a suicidal parent.
    Children should never be considered a protective factor for parents who feel suicidal.
  • Threats to kill: Threats of suicide or threats to kill the partner or children pose a significant risk of harm and should be taken seriously. They may be made particularly in the context of relationship breakdown, parental separation or disclosure of pregnancy within a new relationship.
  • Stress factors: The stresses of parenting can exacerbate mental health problems that in turn may affect the welfare of the child. Not getting enough sleep or having to adapt to a baby’s routine can make it more difficult for parents to cope with a mental health problem such as anxiety or depression.
  • Domestic abuse: The experience of domestic abuse impacts parents’ mental health and stress levels that increases the risk to the child. If a child is at risk of harm because of domestic abuse, a referral should be made to child protection services.
  • Drug or alcohol misuse: Substance abuse can trigger or intensify mental health problems and increase the risk for children.  The presence of drug misuse should lead to referral for substance misuse services. In particular, the presence of drugs or alcohol misuse alongside mental health problems and domestic abuse indicates the need for a thorough assessment of potential risks to the child.
  • Lack of engagement with services: Parents offered mental health services often failed to take them up or to keep appointments. Where a parent with mental health problems is reluctant to engage, health professionals sometimes step back from provision of a service. This loss of support to the adult may in turn impact on the wellbeing or safety of the child.

When parents with mental health problems do not engage, professionals should consider whether an assessment of the children’s needs is necessary.

Guidelines for Improved Practice

  • Understand the impact of mental health issues on parenting capacity: One of the most frequently made recommendations in these case reviews relates to mental health issues in the context of parenting capacity. It is essential to give better consideration to:
    • the impact of the stresses of parenting on the parent’s mental health
    • the impact of the parent’s mental health problems on the safety and well being of the child.

Paying attention to these factors will help to identify risk and make sure safeguarding opportunities are not missed.

  • Consider the pressures on family members living with a parent with a mental health problem: Failure to share information across professional groups resulted in assessments of the child without seeing the bigger picture posed by the parent’s mental health problems. In particular, professionals working with adults should ensure they share information about the parent’s mental health problems with practitioners in contact with the child.
  • Think family: Professionals over-estimated the ability of the well parent to cope simultaneously with parenting and with an adult with mental health problems. This impact should be properly assessed and support offered.
  • Listen to parents: Opportunities for intervention were lost when a parent gave clear warnings that they or their partner were not coping well with parental responsibilities. Really listening to what is being said may facilitate a conversation about family functioning, focus on potential risk and lead to recognition for the need for intervention.
  • Focus on the Child: The complexity of a parent’s mental health problems can feel overwhelming and require a lot of professional attention. These reports show that focusing on negotiating the difficulties of the parent often resulted in professionals losing sight of the child’s needs. It’s vital to think beyond the immediate needs of the adult and consider how their mental health difficulties impact on the welfare and development of children or pose a risk to their safety.

A number of case reviews revealed that the child wasn’t given the opportunity to be heard. Professionals must talk to the child and listen and respond to what they say.

  • Consider parental history: Details of both parents’ background, current circumstances and medical and psychiatric history should be explored. This ensures a better assessment of risks in relation to parenting capacity and should be done regardless of whether the parents live together or apart.

Don’t assume that parents and children see a single family primary provider. When making professional inquiries both the mother and the father’s primary providers should be identified to avoid missing potentially significant information.

  • Have the confidence to question and challenge: When professionals don’t have a full understanding of each other’s roles they may:
    • lack confidence to challenge decisions
    • make assumptions about areas of expertise.

All practitioners must have the confidence to challenge other agencies or professionals’ decisions if there seems to be a lack of appropriate response or case drift.

Social workers should have the confidence to ask adult mental health professionals questions about diagnosis, the effects of medication, about the parent’s behavior and chances of recovery. Child practitioners can then use this information to make an assessment that takes full account of the risks posed by the parent’s mental health problems.

  • Assessments: There is a clear message that where a parent or carer has mental ill health, professionals should approach an assessment as a shared task between children’s social workers and adult mental health practitioners. This sharing of professional expertise provides:
    • a full understanding of how the situation is impacting on the child
    • timely recognition of risk
    • appropriate categorization of risk.

The case reviews showed delays of several weeks between requests for an initial assessment and the first meeting. Assessments should be timely and planned and use appropriate frameworks to help identify risk.

Background information about both parents should inform any ongoing assessment. This provides an opportunity for interacting risk factors such as mental health problems, possible domestic abuse and substance misuse to be identified and a proper assessment made.

This kind of two-generation approach to mental health services may be the next best practice model.

Victoria Youcha, Ed.D.
ECCBC Board member

Executive Director Year End Update to the Community

Posted December 16, 2016

Dear Boulder County Partners and Stakeholders,

The ECCBC Early Childhood Framework has been the road map to kindergarten readiness across multiple agencies since 2009.  With the re-fresh of the Framework in 2014 we have been asked to prioritize the 51 strategies (defined by early childhood domain-health, social/emotional, family support, and early literacy).

It is our goal that these prioritized strategies, with very specific programmatic recommendations, can serve the following audiences:

  • Community partners: Many of our family-serving partner agencies have approached ECCBC to ask how they might specifically assist us in our goal of having all children in Boulder County be ready for kindergarten.  These detailed strategies will be able to assist them in implementing proven best practice strategies within their own agencies to improve kindergarten readiness for the young children within their programs.
  • Funders: The world of early childhood is extremely complex and rapidly changing.  Funders struggle to identify which programs and/or services which have proven track records in positively impacting kindergarten readiness.  The ECCBC prioritization process will assist them in determining which best practices have been given the ECCBC ‘seal of approval’. A suggestion might be to ask grant seekers to identify which strategy (as defined in the ECCBC Framework) they fall under and how they measure their programmatic impacts.
  • Policy Makers: Like funders, policy makers struggle to determine which proven strategies would be the best ‘fit’ for our community.  This ECCBC work will ensure that the recommended programs/activities have the full endorsement of the recognized early childhood experts across Boulder County.

Per the Framework, we have identified 4 ‘ready’ goals:

READY COMMUNITY:  The community recognizes the importance of early childhood as integral to the quality of life in Boulder County and as a crucial part of the continuum of social equity.

READY EARLY CARE AND EDUCATION:  Early Childhood professionals have the knowledge, skills and support to work effectively with and on behalf of families and children.

READY FAMILIES:  Families are empowered to nurture their children’s healthy growth and development.

READY CHILDREN:  Children arrive ready for school:  healthy, well-adjusted and having been exposed to the fundamentals of learning

The full Framework delineates 51 strategies targeted to improve school readiness.  The full listing of strategies is helpful for family-serving agencies in order to choose those strategies which are a good ‘fits’ for their specific agency.

However, for funders and policy makers, 51 strategies are not helpful.  This is why the Advisory Council has chosen 13 top strategies in order to meet the needs of other stakeholders.

Here is a listing of those strategies specific to the target populations:

READY COMMUNITY:  the target audience is the public

  • Educate the public about the social-emotional needs and potential of young children
  • Provide CCAP subsidy payments that are at least 100% of market rate
  • Develop a cost benefit model to support at-home option for the first year of life

READY EARLY CARE AND EDUCATION:  the target audience is Early Childhood professionals

  • Educate EC professionals to promote health for their staff and families
  • Support the ongoing development and practice of new skills and knowledge such as on-site coaching and mentoring
  • Promote increased quality of early childhood professional staff education, program quality and environment quality
  • Explore incentives for early childhood professionals to serve infants and toddlers and children with special needs
  • Make the continuum of support available to early childhood professionals (spanning brief consultation, on-site consultation, mentoring and coaching) focused on promotion, prevention and intervention within the social-emotional domain

READY FAMILIES:  the target audience is parents, families

  • Improve and expand health education to all parents
  • Expand family support and parenting programs to include services in the social-emotional and mental health domain
  • Expand outreach to parents of newborns; home visitation to include all 4 domains
  • Provide information to families to facilitate connection to services

READY CHILDREN

  • Ensure that all Boulder County children receive 3 developmental screening by age 3 (H)

During the upcoming year, the Advisory Council will be working in task groups (family, EC professionals, community and child) to further define the specific activities, services and/or programs which have proven to ‘move the needle’ on the desired outcome.

Any community member who would like to participate in this process is welcome to attend our Advisory Council meetings.  Should you wish to attend, please go to our website (www.eccbouldercounty.org) and click the calendar tab.  The AC meets the first Tues of every month from 1 to 3P in differing locations around Boulder County.  Should you have specific questions, please feel free to contact me at bwatson@eccbouldercounty.org .

Respectfully,

BA Watson Signature

Bobbie Watson Executive Director

The Early Childhood Council of Boulder County.

Investing in Young Children Part 2: Adverse Childhood Experiences

Posted November 29, 2016

Boulder County has made a commitment to investing in young children, but how do we identify those at greatest risk?

We actually know a lot about the experiences that can put children at risk for poor health, behavioral, and developmental outcomes — and we know how to support those children.

The CDC-Kaiser Permanente Adverse Childhood Experience (ACE) Study, https://www.cdc.gov/violenceprevention/acestudy/, is one of the largest investigations of childhood abuse and neglect and later-life health and well-being. The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors.

The study findings are not surprising — children with the most risk factors before age 18 had the poorest the outcomes. Risk factors include abuse, household challenges, and neglect. The total ACE score reflects the cumulative stress on the child. Exposure to three or more risk factors during childhood predicted significantly poorer adult outcomes. Specifically, things like domestic violence, substance abuse in the home, mental illness of a parent, or physical or emotional neglect put children at increased risk of poor outcomes in adulthood.

Everyone who works with children should be aware of these risk factors and the effective interventions that can help protect these vulnerable children from later problems.

Boulder County is already investing in our most at-risk children but there is more work to do. Our Early Childhood Framework, https://www.eccbouldercounty.org/media/eccbc_frametri_feb2014_forweb.pdf, provides a roadmap to school readiness, including support services, and the indicators that measure success.

Programs like early childhood home visitation, behavioral parent training, and preschool enrichment with family engagement can all buffer the effects of multiple negative experiences. Family friendly work policies and supports to enhance household financial security are also important preventive strategies.

Here’s a sample of what Boulder County offers:

In future blogs we’ll look more closely at these programs to see what’s working and where we could do more.

Victoria Youcha, Ed.D.
ECCBC Board member

Early Childhood Finally Has Its Day

Posted October 13, 2016

The learning needs of little kids have been overlooked for too many years. I never thought I’d see the day when the public finally “got it.” But thankfully that’s what’s happening now in Boulder County.

How do I know this?  When I began my work in early care and education, I spent the majority of my time educating folks about the high return-on-investment which early learning generates, both to the individual as well as to the community at large. We’ve had the evidence for a long time.  Rigorous, longitudinal analysis by the Nobel prize-winning economist James Heckman found a return of seven dollars for every one dollar of public investment in high quality early learning programs. (www.heckmanequation.org) .  This is certainly NOT news to those of us who work in the field.  But-what I have found over the past year or so is that I no longer have to ‘make the case’ for early learning-that the public is beginning to understand!

But has this understanding come too late?

Facts matter-for example, out of 29 industrial nations, the U.S. devotes less public spending to early learning as a percentage of gross domestic product (GDP or the value of all goods and services produced in the U.S. over a year) than 24 of our competitors.  Slovenia, Mexico, Chile and Argentina devote proportionally more public spending to early learning than we do.  And the U.S. is 28th among developed nations in our enrollment of four-year-olds in early learning. 

As a result of this missed opportunity to invest in our youngest children, the U.S. is falling far behind in our ability to generate a well-educated work force.  Thus we are losing economic ground in innovation and the production of cutting edge technology and services.   CEOs, military professionals, law enforcement officials, faith-based leaders, philanthropists as well as a bipartisan mix of governors are all promoting major investments in expanding high quality early childhood experiences.  For further reading click here.

Finally-the public is beginning to understand this message.  Boulder County is especially lucky to have local officials and policy-makers who have long understood the value of investing in young children.  The Boulder County Commissioners as well as the City Councils of Boulder and Longmont continue to make investment in high quality early childhood programs and services a priority even during challenging economic times.  ECCBC applauds their continued commitment to young families across Boulder County.

Warm regards,

BA Watson Signature
Executive Director
The Early Childhood Council of Boulder County