The Intersection of Early Childhood Mental Health Consultation and Early Intervention

Early Childhood Interventions March 03, 2017

Nine percent of US children between the ages of two and three have at least one diagnosed mental, behavioral, or developmental disorder (Bitsko et al., 2016). In 2015, 350,581 children received early intervention services under Part C of the Individuals with Disabilities Education Act (IDEA). However, a recent study found that 24% of all two-year olds were deemed ineligible for early intervention services (EI) at two years of age but experience poor academic and behavioral outcomes upon entering kindergarten (Nelson et al., 2016). Social emotional and behavioral difficulties seen at early ages often predict social challenges later in life (Briggs-Gowan, 2008). However, EI rarely addresses the needs of the children who display social, emotional and/or behavioral challenges and their families unless the child demonstrates a significant developmental delay.

This is concerning considering the vast body of research (Mistry et al, 2010; Sektnan, 2010; Shonkoff, 2012) indicating “long-term developmental-behavioral and educational outcomes are strongly associated with socioeconomic factors” (Nelson et al., 2016). Children who are exposed to multiple social risk factors, such as poverty, domestic or community violence, substance abuse, etc., have a higher risk of experiencing mental health issues (Bjorkenstam, 2017). Unfortunately, the current EI system doesn’t seem to have the capacity to adequately address the social emotional needs of these children. This blog will explore opportunities for the current EI system to improve its services related to social emotional development.

Early Intervention

Early intervention, as described by Part C of the Individuals with Disabilities Education Act (IDEA), is a comprehensive, multidisciplinary system of services intended to enhance the development of infants and toddlers; maximize the capacity of families to meet their child’s needs; and encourage independent living (ECTA, n.d.). In 1986, Congress established Part C to assist states in supporting the developmental needs of children birth to age three in five developmental categories: physical, cognitive, communication, social emotional, and adaptive. Although the federal government requires each state to have an EI program to address these 5 developmental domains, the eligibility requirements and implementation guidelines vary from state to state.

Due to a variety of factors, (administrative, professional licensure, payment, etc.), the implementation of early intervention is more in line with a predominantly medical model of service provision despite research supporting family-centered models as the preferred practice (Bruder, 2010; Hoffman et al., 2016). Over the past 30 years, the idea of addressing an underlying medical concern or impairment has become central to early intervention service systems (NCCP, 2009). This traditional model is based on a direct service delivery system, in which one provider delivers specific therapeutic intervention to an individual child.

The narrow, developmental delay-based eligibility criteria in use by many states may also prevent children with social-emotional considerations from being found eligible for services (Ringwalt, 2015). Unless a child has delays in other areas of development, children with social emotional concerns are considered at-risk. As of 2015, only seven states offered services to at-risk children (Ringwalt, 2015). This statistic is especially troubling when considering the growing body of knowledge on children with social-emotional difficulties, as well as behavioral concerns, contributing to preschool and child care expulsions (Gillman, 2005; Perry et al., 2008; US Department of Education, 2014).

As concerns about social emotional development in young children increase, it may prove worthwhile to explore how EI programs can collaborate with early childhood mental health professionals. In contrast to a variety of direct therapeutic services offered by EI, Early Childhood Mental Health Consultation (ECMHC) indirectly supports children who are experiencing social-emotional or behavioral difficulties, their families, and their teachers. It seems reasonable that the EI and the ECMH fields would be natural collaborators but there exists little evidence to support this. How then, can these two support systems collaborate to build a truly comprehensive, well-coordinated system of care that effectively promotes positive development in all domains?

Early Childhood Mental Health Consultation  

ECMHC is a “problem-solving and capacity-building intervention” intended to improve the ability of caregivers to “prevent, identify, treat, and reduce the impact of mental health problems among children from birth to age six and their families” (Duran et al., 2009). Multiple states across the nation have begun implementing their own ECMHC programs, as ECMHC has been shown to be an effective strategy for improving challenging behaviors and “supporting young children’s social/emotional development in early childhood education settings” (Duran et al., 2009). Maryland’s ECMHC Evaluation, a three-year study designed to evaluate ECMHC’s impact on early childhood education (ECE) environments, found that ECMHC intervention in childcare settings decreased problem behaviors in the classroom, improved social and emotional functioning of the child, and decreased parental stress (Stephan et al., 2011). Despite the research supporting ECMHC as an effective intervention strategy, many children and families do not have access to this service.

Unlike EI, ECMHC programs are not available in every state. According to Duran, et al (2009), 29 states have formalized ECMHC services. The implementation of these programs varies from state to state, as there is no standardized set of core competencies outlining effective ECMHC (Duran et al, 2009). Based on an analysis of the 29 states with ECMHC, Duran, et al proposed a framework for effective, high-quality ECMHC (Figure 1).

Figure 1: Framework For Effective Early Childhood Mental Health Consultation Programs
Figure 1: Framework For Effective Early Childhood Mental Health Consultation Program

This framework outlines the three core components of an effective ECMHC program: 1) solid program infrastructure, 2) highly qualified mental health consultants, and 3) high-quality services. Additionally, the Duran et al study (2009) identified two key elements as the “catalysts for success”: 1) positive relationships between the consultant and consultees and 2) readiness of families and ECE providers/programs for ECMHC.

ECMHC and EI: Similarities and Differences?

Figure 2: The Intersection of Early Intervention and Early Childhood Mental Health Consultation
Figure 2: The Intersection of Early Intervention and Early Childhood Mental Health Consultatio

Despite having a number of similarities, EI and ECMHC remain largely unaware of each other. What obstacles may be preventing communication between these two service systems?

Possible Obstacles

While EI and ECMHC both focus on caregiver capacity-building, the providers’ approach differs. EI providers work with the child and caregiver directly to meet a list of child-specific, family-centered outcomes. Mental health consultants, however, work almost exclusively with caregivers, as their purpose is to address the caregiver’s concerns within an early care and education setting (Duran et al, 2009). Consultants respond to the caregiver’s concerns by recommending strategies and interventions that promote the successful participation and regulation of the child. As their focus is on the caregiver, the ECMHC may not recognize the need to refer the child to EI. Evidence supporting this argument can be found within Maryland’s ECMHC Evaluation’s Final Report (Stephan et al, 2011).

Maryland’s ECMHC Evaluation provided a commentary on the mental health consultants’ knowledge and skills (Stephan et al, 2011). Consultants reported feeling confident about their knowledge of social emotional development. However, consultants felt “least confident about their grasp of early intervention service systems, treatments and family support services” (Stephan et al., 2011). Additionally, the consultants reported having the least amount of experience in providing direct therapy. This feedback indicates that mental health consultants may not be considering delay and/or disability as a contributing factor to the child’s behavior and/or and social-emotional health. However, the argument could also be made that EI providers may not consider the impact poor social emotional health may have on the function of a child with a delay and/or disability.

Intersection of EI and I/ECMHC: Opportunity for the Collaboration

Under Part C of IDEA, EI providers support developmental in all 5 areas (communication, physical, cognitive, social emotional, and adaptive). However, most children receive EI support because of identified delays in motor and/or language development (Bruder, 2010; NCCP, 2009). Even though Part C providers aim to promote positive social-emotional skills, this is often overlooked when determining IFSP outcomes. As a result, EI services are often based on an identified developmental delay and most children receive therapeutic services (occupational therapy, physical therapy, or speech therapy) to remediate a delay (NCCP, 2009). If EI programs focus too narrowly on development delay, children experiencing social emotional and behavioral difficulties may not be receiving the support they need. Collaborating with ECMHC may help raise awareness around the importance of social emotional development at an early age within the EI network as well as support caregivers in promoting this development.

Pairing ECMHC’s effective connections with caregivers with EI’s extensive evaluation and service delivery model provides an opportunity to build resilience among the most vulnerable children.

REFERENCES

Bitsko, R. H., Holbrook, J. R., Robinson, L. R., et al. (2016). Health care, family, and community factors associated with mental, behavioral, and developmental disorders in early childhood — United States, 2011–2012. Morbidity and Mortality Weekly Report. 65(9), 221–226. http://dx.doi.org/10.15585/mmwr.mm6509a1

Björkenstam, E., Pebley, A. R., Burström, B., & Kosidou, K. (2017). Childhood social adversity and risk of depressive symptoms in adolescence in a US national sample. Journal of Affective Disorders, 212, 56-63. doi:http://dx.doi.org/10.1016/j.jad.2017.01.035

Briggs-Gowan, M. J. & Carter, A. (2008). Social-emotional outcomes screening status in early childhood predicts elementary school outcomes. American Academy of Pediatrics. 121(5), 957-962. http://doi:10.1542/peds.2007-1...

Bruder, M. B. (2010). Early childhood intervention: a promise to children and families for their future. Council for Exceptional Children, 76 (3), 339-355.

Cooper, J. L. & Vick, J. (2009). Promoting social emotional wellbeing in early intervention services. New York, NY: National Center for Children in Poverty.

Duran, F. et al. (2009). What works? A study of effective early childhood mental health consultation programs. Washington, DC: Georgetown University Center for Child and Human Development.

The Early Childhood Technical Assistance Center (ECTA). (n.d.). Early intervention program for infants and toddlers with disabilities (Part C of IDEA). Retrieved from http://ectacenter.org/partc/partc.asp

Gilliam, W. S. (2005). Prekindergarteners left behind: explusion rates in state prekindergarten systems. New Haven, CT: Yale University Child Study Center.

Hoffman, T. K. (2016) An exploration of service delivery in early intervention over the last two decades. International Journal of Early Childhood Special Education (INT-JECSE), 8(2), 107-112. DOI:10.20489/intjecse.284568

Mistry, R. S., Benner, A. D., Biesanz, J. C., Clark, S. L., & Howes, C. (2010). Family and social risk, and parental investments during the early childhood years as predictors of low-income children’s school readiness outcomes. Early Childhood Research Quarterly, 25(4), 432-449. doi:http://dx.doi.org/10.1016/j.ecresq.2010.01.002

Nelson, B. B., Dudovitz, R. N., Coker, T. R., et al. (2016). Predictors of poor school readiness in children without developmental delay at age 2. American Academy of Pediatrics, 138(2), 2-12. doi: e20154477

Perry, D.F., Dunne, M.C., McFadden, L. & Campbell, D. (2008). Reducing the risk for preschool expulsion: mental health consultation for young children with challenging behaviors [Abstract]. Journal of Child and Family Studies. 17(1), 44-54.

Ringwalt, S. (2015). States’ and territories’ definition of/criteria for IDEA part C eligibility. Retrieved from http://ectacenter.org/~pdfs/topics/earlyid/partc_elig_table.pdf

Sektnan, M., McClelland, M. M., Acock, A., & Morrison, F. J. (2010). Relations between early family risk, children’s behavioral regulation, and academic achievement. Early Childhood Research Quarterly, 25(4), 464-479. doi:http://dx.doi.org/10.1016/j.ecresq.2010.02.005

Shonkoff, P. J. & Garner S. A. (2012). The lifelong effects of early childhood adversity and toxic stress. American Academy of Pediatrics, 129(1), 232-246.

Stephan, S. et al. (2011). Maryland’s early childhood mental health consultation evaluation. University of Maryland, MD.

U.S Department of Education Office for Civil Rights. (2014). Data snapshot: early childhood education. Retrieved from https://www2.ed.gov/about/offices/list/ocr/docs/crdc-early-learning-snapshot.pdf

Ehvyn McDaniels (Diversity Fellow, 2017)