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An enhanced Early Intervention Mentalh health Consultation Project.


INTRODUCTION

The prevalence of emotional and behavioral problems in preschoolers is estimated to be between 10% and 25%. A study by Pavuluri, Luk, & McGee (1995) found that one in every five preschool-age children has some form of behavioral or emotional problem. If left untreated, opposition, aggression, and conduct problems may persist or even worsen later on in a child’s life. Research informs us that those preschool children who have significant behavioral problems continue to exhibit symptoms into later years (Koot & Verhulst, 1992). Lerner et al. (1985) followed a group of preschoolers for 11.5 years and found that those who scored highest for behavioral problems had the highest need for future psychiatric services. Webster-Stratton (1998), among others, demonstrated that conduct disorders can be identified in preschool-age children and treated successfully.

Therefore, early intervention plays a vital role in the prevention of future emotional and behavioral problems for at-risk children (Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, 2000). Over 30 years ago, an effective form of prevention was suggested: mental health consultations in early childcare settings for young children (Greenspan, Nover, & Brunt, 1975).

The Los Angeles Child Guidance Clinic’s Stepping Up to School Readiness (SUSR) Program uses an enhanced mental health consultation model. SUSR includes a range of on-site consultations and trainings for preschool educators on early childhood mental health development and strategies for effectively managing early behavioral and emotional problems. The program also includes direct services and supports for a targeted group of children who are at risk for involvement in mental health services or school failure in the future.

The goal of the training and consultation components of SUSR is to develop the knowledge and competencies of early childhood educators to respond to the emotional and behavioral problems of at risk children in the classroom. This is achieved through teacher participation in a variety of training sessions, modeling and coaching activities, and consultation. Training workshops and in-classroom coaching are specifically designed for teachers to enrich their professional development in the area of early childhood mental health. As teachers gain new skills and knowledge, they are able to have more positive interactions with the children they serve, thus enriching the child’s educational experience.

SUSR operates in 11 Head Start Centers located in South and Central Los Angeles. The population of families and young children served by these Centers is 89% Latino, 5% African-American and 3% Asian. The families served by these Centers are greatly impacted by a variety of stressors, including poverty, community and domestic violence, child abuse and neglect, low parental education and parental mental illness.

By working collaboratively with Head Start Centers, the Clinic fulfills its mission to “provide quality mental health services to a community in great need by ensuring easy access and promoting early intervention.” This type of partnership is an ideal fit: Head Start programming focuses on the school readiness of children ages three to five by addressing health, social services and special needs, and encouraging parental involvement and valuing community partnerships. The Los Angeles Child Guidance Clinic brings its expertise in prevention, early intervention, and preschool mental health to this partnership, thus supporting the increased likelihood that students at-risk for future involvement in bonafide mental health services are helped early on so they can enter kindergarten ready to learn.

Mental Health Consultation Framework

The Stepping Up to School Readiness Program incorporates the components of mental health consultation as detailed in SAMHSA’s (2005) related monograph. SUSR provides specialty trainings and consultation for Head Start staff to increase their competencies in supporting positive social and emotional development and in intervening with children who exhibit early behavioral and emotional problems. Thus, SUSR staff work at the 11 Head Start Centers and are consistently available on-site to teachers and parents alike, to address opportunities for improvement in classroom management and to consult and provide coaching on behalf of specific students.

The Mental Health Consultation Model places a high value on assisting parents in understanding the social and emotional needs of their children. The parent is the best source of information about the child. Therefore, parents are engaged in treatment and participate in multi-disciplinary team meetings and family sessions in conjunction with Head Start staff and SUSR staff, to ensure that goals and strategies are appropriate for their child and their family.

As noted by Cohen and Kaufmann (2000) early childhood mental health consultation is a “problem solving and capacity building intervention.” According to the authors, this type of consulting relationship includes joint efforts between mental health consultants and childcare providers to intervene at two levels: 1) at the program level, where training, coaching, and support are provided to assist teachers in better serving children with early emotional and behavioral problems, and 2) at the level of the child, where direct services are rendered for children and families,

Up to 15% of enrolled Head Start children also benefited from targeted interventions delivered by SUSR therapists and behavioral interventionists. These children faced the highest risk for poor educational outcomes including expulsion from Head Start or entering kindergarten with disruptive behaviors that interfered with learning.

Background of Stepping Up to School Readiness Program

The Stepping Up to School-Readiness Program was designed largely by replicating another Clinic operated school-based early intervention program, Building Blocks. Building Blocks received the 2003 American Academy of Child and Adolescent Psychiatry Reiger Award for Service Excellence and was a collaborative partnership between the Clinic and Los Angeles Unified School District (LAUSD). The program was funded by First 5 LA, The California Endowment and other sources of private philanthropy. Building Blocks placed teams of clinical therapists and behavioral interventionists in 11 LAUSD Early Childhood Education Centers in South and Central Los Angeles. The goals of the program were to 1) increase LAUSD’s early education teaching staff’s skills and competencies to more effectively manage children’s emotional and behavior problems within the classroom, 2) improve communication with and support parents in addressing their concerns about their child’s development and behavior, 3) increase access to early intervention mental health services for children enrolled in 11 targeted LAUSD early education centers, 4) provide direct interventions with a select population of students who were exhibiting early emotional or behavioral problems in order for them to benefit from their early educational experience, and 5) reduce the kinds of behaviors that place children at high risk for future involvement in bonafide mental health services and/or school failure.

The outcomes of the Building Blocks Program were impressive. They showed statistically significant decreases in children’s emotional and behavioral problems and levels of impaired functioning; increases in teachers’ knowledge of preschool development and behavioral principles; increased support for parents, and increased parental receptiveness to mental health services.

 

II PROGRAM DESCRIPTION

In partnership with the Pacific Asian Consortium (PACE), which operates 11 Head Start Centers in South and Central Los Angeles, we modified the Building Blocks model to develop an early childhood mental health consultation service design geared for use in this setting. Our collaborative partner shares the Clinic’s commitment to creating access to services for historically underserved ethnic minority committees and supporting parents in confronting cultural, linguistic, and economic barriers to services.

As an indicator of our successful collaboration, PACE teaching staff were open to learning new information and acquiring new skills that increased their ability to effectively address and respond to emotional and behavioral problems exhibited by young students, resulting in a more positive learning experience for all children. These teachers were also committed to identifying and working with children in need of additional attention and making referrals for mental health services as appropriate.

The specific objectives of Stepping Up to School Readiness were to:

  • Enhance the quality of the preschool setting by improving mental health services and increasing the mental health-related knowledge, skills and practices of Head Start teaching staff as they work with children in a classroom environment.
  • Increase parent/caregiver involvement in the learning process and their awareness of children’s emotional and developmental needs.
  • Increase the social competencies of preschool children and reduce behavioral problems, thereby maximizing their potential for future academic and social success.

The SUSR Program Coordinator plans training modules and on-site teacher activities, coordinates consultations, and provides clinical supervision for four Clinical Therapists and four Behavioral Interventionists who work in teams as they partner with Head Start Center staff to provide consultations and mental health services. The program also employs two bilingual Parent Partners, who have children enrolled in PACE Head Start Centers. Parent Partners provide outreach, recruit other parents to participate in program and Clinic activities, and advocate for the needs of children. Parent Partners are integral in communicating the importance of early intervention mental health services to other parents, resulting in successful recruitment and increased parent involvement in the classroom and in other activities.

From 2002 through 2007, SUSR provided consultation/education services to teaching staff at 11 Centers including four half-day training sessions annually as well as weekly, on-site teacher modeling and coaching; 10 to 12 parent education and support activities annually; access to mental health services for over 800 children (enrolled in the centers annually) and targeted interventions to a total of 597 high-need, at-risk children and their families. In the final two years of the program, PACE father-focused activities were enhanced by the SUSR Program so that in the last year, there were 6 specific sessions addressing the importance of family relationships and building a base for successful child development.

SUSR Training and Consultation

SUSR provides in-service trainings, modeling and coaching activities and consultation services to Head Start staff, including teachers, administrators, teacher’s assistants, site supervisors and family development advocates. Sessions are conducted by experts in the field of psychology and education and cover a wide variety of topics to help educators and parents meet children’s individual socio-emotional needs, while also acknowledging the role of the cultural context in children’s upbringing. Selected training topics to support Head Start staff include: social and emotional development; brain development; cultural sensitivity; and anger management skills. In addition, as part of the collaborative process, the teachers are informed about program outcomes and their input is solicited for future program planning.

Head Start staff are also trained in strategies to effectively communicate with parents/caregivers in culturally competent ways around mental health issues with great respect to the family’s different cultural traditions and values. When appropriate, parents are invited to attend training workshops and sessions.

Parent Training Institute and Support Group

SUSR also includes a Parent Training Institute (PTI) that conducts educational workshops at the Head Start sites with topics including: n utrition, child growth and development, parenting strategies, developmental stages, recognizing problem areas, goal setting, and physical health care. Parent support groups are also held to provide an opportunity for them to receive support and guidance from other parents as they seek to develop more effective parenting skills. Groups engage parents in dialogues on child development topics such as self-esteem, goals of misbehavior, discipline, cultural and family dynamics, and communication skills. Services are provided in a context to appropriately meet the language and literacy needs of parents.

Mental Health Services

Protocols have been established to support child mental health needs, with teachers and administrators at Head Start committed to identifying and referring children who need services. Referred children typically present with one or more of the following: low impulse control, aggression, withdrawal, separation anxiety, and short attention span. Child abuse, parental drug abuse, and/or domestic violence are often a part of the child’s experience. In partnership with the parents, service plans are established to include in classroom support for the child as well as in-home services that include family therapy and other parent support.

III PROGRAM OUTCOMES

Based on various outcome measure tools, the SUSR Program is successfully meeting its objectives of enhancing the quality of the preschool setting by increasing the mental health-related knowledge and skills of Head Start teaching staff; increasing parent/caregiver involvement in the learning process and their awareness of children’s emotional and developmental needs; and increasing the social competencies of children and reducing their behavioral problems. SUSR is thereby maximizing children’s potential for future academic and social success.

In teacher trainings, participant feedback is elicited through surveys with the intent to learn about their knowledge after completing the training and how it related to and helped to improve their everyday work. Surveys asked the participants to rate their knowledge of topics presented before and after the training, as well as the training’s usefulness and the presenter’s knowledge and ability to communicate effectively. The data from the last year of the project provides ample evidence that the SUSR trainings were highly valued by the participants of all training modules. All ratings for various aspects of the training received high remarks, with participants reporting improved knowledge and understanding that they could implement in their daily work. Following the Parent Training Institute and parent support activities, a feedback survey indicated “excellent” satisfaction ratings. Specifically, parents appreciated the child-rearing information that provided insight on expanding and improving parental practices.

IV CONCLUSION

The heart of the Stepping Up to School Readiness model is to increase the ability of Head Start staff to more effectively manage students’ early emotional and behavioral problems within the classroom setting. Based on analyses of topical trainings and in-classroom coaching, modeling and consultations, Head Start staff were open to learning new information and skills in support of a more positive school experience for all children and, more specifically, helping those special children who exhibited early behavioral and emotional problems. Administered retrospective surveys of teachers’ knowledge of both preschool development and child mental health-related issues documented an increase in their knowledge base. Feedback from Head Start staff supported the high value of having access to consistent mental health consultations as well as the SUSR program’s ability to directly intervene with a high risk population of children.

A recent study undertaken by Gilliam (2005) found that the expulsion rate of pre-kindergarten students is a striking 3.2 times higher the K-12 students. The study also documented that the expulsion rate of preschoolers was reduced when preschool staff had access to consistent mental health consultation services. Thus, the Clinic’s SUSR Program not only supported Head Start staff in improving their mental health-related competencies, but also provided much needed targeted interventions to young students who were facing poor developmental outcomes in the absence of early intervention services. The fact that these interventions took place in the classroom and/or students’ homes-natural settings - served to remove much of the stigma associated with mental health- related interventions.

During our five-year relationship with PACE, almost 600 children received targeted interventions. Overall there was a statistically significant decrease in the problem behaviors that brought these children to our attention. The assessment of children’s behavior through multiple informants and measures provided considerable support for the positive outcomes of SUSR.

One of the challenges faced by both SUSR and Building Blocks was how to infuse its offerings into the work-a-day world of busy teachers and teaching assistants. The Clinic staff’s ability to be flexible and closely collaborate with teaching staff has been vitally important to the success of these programs. Trainings were arranged in accordance with our partner agencies’ schedules. Moreover, the SUSR staff’s availability to be consistently on-site to coach and intervene in the classroom setting was instrumental in supporting the program’s positive outcomes.

Equally, SUSR staff had to take into consideration the availability of parents, often those who are “working poor”, and how to best fit into their schedules. Taking advantage of parent/teacher events hosted by partner agencies was important, as was the conducting of home visits. SUSR staff also worked to increase the involvement of fathers in their services. Efforts were very modest in the beginning but by the fifth year the program offered special father’s sessions, supported by parent partners who increased the effective engagement of dads. Another successful feature of the program was when we extended an invitation for parents to attend trainings that had been developed for Head Start teachers. This “side-by-side” approach fostered the parent/teacher partnership to support the positive social and emotional development of children. These and other promising developments deserve more attention in the future as ways to increasingly engage not only Head Start parents but also community members at large in issues of concern related to early childhood development

REFERENCES

Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA Preschool Forms & Profiles. Burlington, VT: University of Vermont Department of Psychiatry.

The California Endowment. (2006, July). Case study: Building Blocks: A preschool-based early intervention program. Los Angeles , CA : The Lewin Group

Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, U.S. Dept. of Health and Human Services (2000). Early childhood mental health consultation (monograph). Washington, DC: National Technical Assistance Center for Children’s Mental Health, Georgetown University Child Development Center.

Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, U.S. Dept. of Health and Human Services (2000). Early Childhood Mental Health Consultation: Promotion of Mental Health and Prevention of Mental and Behavioral Disorders (2005 Series, Volume 1). Georgetown University Center for Child and Human Development.

Cohen, E., & Kaufmann, R. (2000). Early childhood mental health consultation. Washington, DC: Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration and the Georgetown University Child Development Center.

Greenspan, S., I., Nover, R. A., & Brunt, C. H. (1975). Mental health consultation to child care. In F. Mannino, B. W. MacLennan, & M. Shore (Eds.), The practice of mental health consultation (pp. 105-131). Washington, DC: U.S. Department of Health and Welfare, National Institute of Health.

Hodges, K (1994). Preschool and Early Childhood Functional Assessment. Ann Arbor. MI.

Johnson, K., Knitzer, J., & Kaufman, R. Making dollars follow sense: Financing early childhood mental health services to promote healthy social and emotional development in young children. New York: National Center for Children in Poverty, Mailman School of Public Health, Columbia University.

Koot, H., & Verhulst, F. (1992). Prediction of children’s referral to mental health and special education services from earlier adjustment. Journal of Child Psychology and Psychiatry, 33(4), 717-729.

Pavuluri, M., Luk, S., & McGee, R. (1995). A community study of preschool behaviour disorder in New Zealand. Austrialian New Zealand Journal of Psychiatry, 29(3), 454-462

Zeanah, P., Stafford, B., & Zeanah, C. (2005). Clinical Interventions to enhance infant mental health: A selective Review. University of California at Los Angeles, National Center for Infant and Early Childhood Health Policy.

Webster-Stratton, C. (1998). Preventing Conduct Problems in Head Start Children: Strengthening Parenting Competencies. Journal of Consulting and Clinical Psychology, Vol. 66, No. 5, pages 715-730.

Gilliam, W.S., Ph.D. (2005). Pre-kindergarteners Left Behind: Expulsion Rates in State Pre-kindergarten Systems. Yale University Child Study Center.

Lerner, J.A. et al (1985) Preschool Behavior Can Predict Future Psychiatric Disorders. Journal of the American Academy of Child Psychiatry, Vol. 24, No. 1, pages 42-48.

Rutter (1979). Protective factors in children’s responses to stress and disadvantage. In Kent, M.W. & Rolf, J.E. (eds). Primary Prevention of Psychopathology: Vol. 3: Social Competence in Children. Hanover, NH: University Press of New England, pages 49-74.

ATTACHMENT A

Stepping Up to School Readiness

Presentations

  • California Institute for Mental Health - The Cultural Competence and Mental Health Summit XV (October, 2007)
  • National Head Start Association Annual Training Conferences (April, 2007)
  • CDI Learning Exchange 8, First 5 LA (June, 2006)  
  • Zero to Three National Training Institute (November, 2005)

Building Blocks

Presentations

  • Zero to Three Conference (December, 2003)
  • Neurons to Neighborhood Conference (May, 2003) 
  • California Mental Health Advocates for Children and Youth conference (April, 2003) California Mental Health Directors’ State Conference (February, 2003)
  • The President’s New Freedom Commission at a special convening (November, 2002) 
  • California Mental Health Advocates for Children and Youth conference (April, 2002)
  • Mental Health in Schools: Partners in Promoting School Success Conference (November, 2001)

Awards

  • American Academy of Child and Adolescent Psychiatry, Reiger Service Award for Program Excellence (July, 2003)
  • Los Angeles County Department of Mental Health Commission 2002 Outstanding Program of the Year (May, 2002)
  • Los Angeles County Department of Mental Health Service Innovation Award for the Early Intervention Services Division (2002).

 

 
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