Several models of early childhood mental health consultation are described in this section. Contact information is given for each program.

DAYCARE CONSULTANTS, INFANT-PARENT PROGRAM

Daycare Consultants, a component of the Infant-Parent Program (IPP) at the University of California, San Francisco (Johnston, 1998), was founded in 1988 to address the needs of child care providers and to expand the role of mental health professionals within the child care setting. The program provides case-centered and programmatic consultation to caregivers serving children from birth to age 5. Two of the child care sites where Daycare Consultants provides early childhood mental health consultation also have integrated therapeutic playgroups into their regular child care milieus.

Before starting the Daycare Consultants project, the infant-parent psychotherapists in the IPP program were involved with the child care system because child care is frequently prescribed by the same professionals who refer families for infant-parent psychotherapy. The often misplaced hope is that child care, in addition to providing respite for the parents of difficult children, will serve as an intervention for the children. The infant-parent psychotherapists realized that the tasks of child care providers are very challenging. It is especially so for those with limited training and experience, large classrooms, and little or no assistance in understanding the extraordinary expressions of need posed by children whose early relationship experiences have been difficult and, therefore, make them challenging to manage.

Daycare Consultants responds to requests for case consultations on individual children (birth to age 6) who demonstrate behavioral or developmental problems in their child care centers. The consultant observes the child in the program to assess his functioning and the match between the child’s needs and the child care program. The goal of the consultation is to enhance the providers’ ability to understand, willingness to persevere, and ability to intervene effectively with difficult children.

The consultant meets weekly with child care center staff to interpret the meaning of the child’s behavior, to provide ideas on appropriate interactions and interventions in a group setting and, in general, to support staff.

The consultant works directly with the families of those children for whom case consultations are initiated. The goals of the consultation with families include:

• assessing the impact of the child’s past experiences on current functioning,
  
  
• providing guidance by suggesting available resources related to parenting practices,
  
  
• helping parents explore and implement more appropriate child-rearing practices, and
  
  
• promoting better understanding and mutual support between parents and child care staff.

The consultant helps families secure additional, mutually agreed-upon resources for the child. The consultant then acts as a liaison between the child care center and such direct service providers as counselors and family therapists.

Daycare Consultants believes that the usefulness of consultation is not limited to acute situations in which caregivers are especially worried, alarmed, or frustrated by a particular child’s behavior. The organization draws a parallel to concerns about the nutritional needs of children in child care only at the point at which signs of malnutrition appear in one child. Through program consultation, staff take a proactive approach to combating the ill effects that poor quality care has on children by creating an atmosphere in which the mental health of all children in programs is protected. This consultation is a preventive strategy designed to ensure the healthy growth and development of children by improving the overall quality of their relationships and their environment. In bi-weekly meetings with the program’s staff and director, the consultant assists with all aspects of program planning, that is, from improving communication among staff to implementing developmentally appropriate practices with the children.

The cost of early childhood mental health consultation to a program is $250 a child. The consultant spends an average of 10 hours a week at the center. Consultation costs usually are covered by special grants, but in some cases, fees are paid by the early childhood programs.

Daycare Consultants’ services were evaluated as part of the Miriam and Peter Haas Fund Early Childhood Mental Health Initiative evaluation conducted by James Bowman Associates. This 1-year evaluation assessed the effect of mental health consultation and services on 25 early childhood classrooms serving children ages 2 to 5 (see the evaluation description in Section III, “Essential Features of Early Childhood Mental Health Consultation”).

In certain cases, consultants may broaden their primary mandate and advise child care staff to provide direct services to children and their families. For example, Daycare Consultants’ therapeutic playgroups are co-led by a mental health professional and a child care provider who is a member of the child care center staff. Six or seven children participate in each of these playgroups three times a week. Within this environment, the co-leaders help the children make choices; organize their experiences; differentiate, label, and cope with emotions; communicate needs and ideas; and deal with anxieties and conflicts. The consultants meet regularly with both child care staff and the children’s families.

Contact: Kadija Johnston
Program Coordinator, Daycare Consultants
Infant-Parent Program
University of California at San Francisco
SFGH
2550 23rd Street, Building 9, Room 130
San Francisco, CA 94110
Telephone: 415-206-5082
Fax: 415-206-4722

DEVELOPMENTAL TRAINING AND SUPPORT PROGRAM, OUNCE OF PREVENTION FUND

The Chicago-based Ounce of Prevention Fund (OPF) works with community-based programs that support families of adolescent parents (usually mothers) and their children. OPF allocates funding, assists with program design and implementation, and monitors program activities. Although programs vary from community to community, each offers parent education and peer support, plus weekly or biweekly home visiting. Programs also share the common goals of helping teenage parents return to school, obtain vocational training, secure appropriate child care, and provide for the health and safety of their children. The programs aim to reduce subsequent pregnancies, child abuse, and neglect among the families they serve.

The target population of the Developmental Training and Support Program (DTSP) includes pregnant or parenting young mothers ages 13 to 21 and their children. The program provides ongoing training and consultation to home visitors, parent group facilitators, and supervisors for a 2-year period. The aim is to assist program staff in developing supportive, helping relationships with families, so that staff in turn may help teenage parents develop positive relationships with their young children.

The goal of the DTSP is to help programs and staff shift from a parent-centered approach that focuses on parents’ crises to a parent-child relationship approach that builds on family strengths to enhance successful family and child development. Through consultation, the program enables home visitors to work through the frustrations of intractable problems and gives supervisors greater structure for overseeing home-visiting staff. It also promotes new standards for interactions between home visitors and parents, and between parents and children.

The following paragraphs describe the key elements of DTSP’s intervention.

The main strategy for consultation is the use of home videos as a tool to enhance parent-child communication. The videos, developed by staff, feature parents and young children engaged in daily routines. The production and review of the home videos with staff and parents occur within the context of positive staff-parent relationships. With the consultant’s help, the home videos allow parents, home visitors, and executive staff to see for themselves how parents communicate with their children.

Consultants meet with staff (program directors, supervisors, home visitors, and parent group facilitators) in all-day consultation and training sessions once a month for 2 years. The goals of this consultation include learning how to (1) develop positive relationships, (2) observe and interpret parent-child interactions, (3) use these observations with parents to build on strengths present in the teenage parent-child relationship, and (4) use inquiry as an intervention.

Each consultation group has 8 to 10 home visitors (each home visitor serves 15 to 20 families) and about 10 to 15 supervisors and managers.

During the consultation meetings, the home-visiting, supervisory, and executive staff develop new insights into parent-child relationships and learn new ways to bolster relationships within the families they serve and also among program staff. The most critical content of each monthly meeting is distilled from discussions of the work that staff members currently do with families. DTSP facilitators encourage participants to discuss what goes well in their everyday work with families, why it might be happening, and how staff members contribute to the successes they see.

As staff review the home videos of the parents interacting with their children, they learn to look for and support those aspects of the parent-child relationship that have mutual benefits for both parents and children. This model provides the context for building the observation skills of workers. Staff learn to identify positive interactions and to point them out to parents as strengths to build on. When interactions cause concern, staff learn to ask questions, to gather more information, and to clarify what they have seen, rather than to make assumptions or to try to fix a situation or relationship. Supervisors, along with direct service providers, learn the skills of objective observation, inquiry, and supporting strengths.

Another goal of the consultation is for parents to learn to make their daily routines enjoyable rather than burdensome. This goal is accomplished by (1) involving the children during home visits; (2) making home videos of daily routines and reviewing them with the parents, emphasizing the positive interactions; (3) using Parent-Child Observation Guides to increase parents’ awareness of their relationships with their children; and (4) conducting developmental demonstrations using parents as co-demonstrators.

This type of early childhood mental health consultation implements a crucial sequence of support: supervisor and staff, staff and parent, and parent and child all learn from and respond to one another. The DTSP calls this sequence a chain of enablement.

The cost of the program ranges from $500 to $1,000 a day, depending on the qualifications and experience of the consultant. Average contact between consultant and staff or parents is between ½ day and 1 day a month. The consultation is financed by special grants or from training funds that are part of the regular program budget.

Documented outcomes of the DTSP include the following:

• Staff and parents stay in the program longer.
  
  
• Staff develop skills to focus on the parent-child relationship, even in the face of multiple family crises.
  
  
• Staff and parents indicate satisfaction with the program.
  
  
• Parent-child communication improves over time (as noted on Parent-Child Observation Guides).
  
  
• Staff turnover decreases.

DAY CARE PLUS, A POSITIVE EDUCATION PROGRAM

Day Care Plus is a collaborative effort of the Cuyahoga County Mental Health Board, a children’s mental health agency, and a child care resource and referral organization in Cleveland, Ohio (Bowdish, 1998). The program is designed to meet the needs of children under age 6 at risk, their parents, and staff of the day care centers they attend. The goals of the program are to improve the social, behavioral, and emotional functioning of children in child care at risk, as well as to increase the competencies of the parents and child care staff.

Early identification, screening, and intervention services are provided to child care settings. Parents receive information about intervention strategies to use at home and about appropriate services available in the community. Mental health consultation, training, and crisis intervention services are provided to child care staff, and the project’s interventionists work with staff to develop specific behavioral interventions for children who display signs of emotional or behavioral problems.

Day Care Plus has worked with 22 centers. Fourteen centers receive intensive consultation and 8 centers are on “follow-along” status. Every family with a child under the age of 6 years is eligible to receive services. There are approximately 340 staff and 1,175 children in the 22 centers. Approximately 25 to 30 families receive intensive, individualized services.

The program costs approximately $20,000 to $25,000 a center for 1 year. This cost includes the consultant fee, as well as money for other services, such as transportation and resources for families. Each consultant can carry five intensive consultative sites or four intensive sites and three to four follow-along sites.

A research study was designed and is currently being conducted by the Cuyahoga County Community Mental Health Board (the mental health authority), the Positive Education Program (the mental health agency), and the Cuyahoga Mental Health Research Institute. Twenty centers were recruited and paired based on the socio-demographic characteristics of the population served, the composition of staff, and the nature of the program. One member of each matched pair was randomly selected to receive Day Care Plus services. The other sites participate in the control group, with the understanding that they will be among the first sites eligible for expanded Day Care Plus services at the conclusion of the research demonstration phase.

The baseline measures on children, parents, and staff were gathered in spring 1997. Follow-up measures occurred at 12 and 20 months. Both qualitative and quantitative data were gathered.

The objectives for children focus on behaviors. Needs assessment data that led to the development of this project revealed that children often are expelled from child care because their behavioral problems create a risk for themselves and others. The study compares the number of expulsions at the service sites with the number at the control sites. It is hypothesized that, compared with expulsions during an equivalent period before the project’s implementation, there will be a greater reduction in the number of expulsions at the experimental service sites than at the control sites.

For parents, the program and research focus is on the ability to manage a child’s problematic behaviors. The project also helps parents obtain appropriate community supports to meet their needs and their children’s needs. A greater increase in the number of referrals to direct services for the service sites is expected.

The project also is designed to improve the competencies of child care staff. Specific goals include:

• increased ability to identify children who are at risk;
  
  
• increased ability to provide appropriate interventions and behavioral strategies;
  
  
• improved staff-parent relations; and
  
  
• reduction of staff stress, burnout, and turnover.

Focus groups have been held with center staff to gain insight into their ability to identify children at risk and to provide appropriate interventions. Baseline focus groups have identified several primary challenges: poor and insufficient and inconsistent communication among the adults in a child’s life, inadequate teacher education and training, and a lack of parent support group meetings. It is expected that the introduction of Day Care Plus services will diminish staff stress and burnout, leading to a reduction in staff turnover. Staff turnover, including information on why staff leave an organization, is monitored throughout the project.

Preliminary outcome data indicate a reduction in expulsion and a high level of participation. Staff and parents expressed the need for creating a follow-along track, through which consultants continue to provide consultation.

KIDSCOPE

KidSCope of Chapel Hill and Hillsborough, North Carolina, provides comprehensive mental health services to young children who experience emotional, social, behavioral, and developmental difficulties (KidSCope, 1998). Services are available to all Orange and Chatham County children ages 6 and under. Anyone may refer a child to KidSCope, provided that she has the consent of the child’s parent or guardian. Services, which include screening, evaluation, intervention planning, and support, are tailored to address the unique needs of each child, his family, and child care center staff. Through home and office visits, and flexible scheduling, counselors make consultation services accessible and convenient for families.

KidSCope’s five counselors provide consultation in approximately 40 programs every year. The cost of each counselor is about $40,000 a year. Costs are covered by grants from public and private foundations, local and state moneys, and Medicaid funds.

Consultants are mental health professionals trained to address the emotional and social issues unique to very young children. Areas of staff expertise include child development, family relationships and processes, early care and educational practices, and behavioral and therapeutic interventions.

KidSCope counselors provide consultation to families and child care staff to assist them in addressing the difficulties experienced by the referred children through the following continuum of services (from least intensive to most intensive):

• information and referral,
  
  
• workshops for child care providers and parents,
  
  
• child care consultation (not child specific),
  
  
• child and family screening,
  
  
• child-specific consultation,
  
  
• home visiting,
  
  
• parent counseling,
  
  
• service coordination, and
  
  
• Family Transitional Learning Classroom.

The Family Transitional Learning Classroom program is a family-focused early intervention and prevention program offered by KidSCope. It provides an alternative therapeutic classroom setting for preschoolers who have had long-standing emotional and behavioral difficulties. It offers family education and support, in addition to information and consultation to the child’s mainstream child care setting about child management and special behavior techniques.

During the 1997–98 school year, 100 percent of the children in Chatham County programs served by KidSCope maintained their enrollment. In Orange County,95 percent of the children in KidSCope programs maintained their enrollment.

APPENDIX B
Assessment in Child- and Family-Centered Consultation

The following questions are important for the the consultant and center staff member to consider:

Child

• What is the history of this child in this setting?
  
  
• What are the behaviors of concern?
  
  
• When do the behaviors tend to occur?
  
  
• What are the child’s strengths and abilities?
  
  
• What are the developmental issues to be considered?
  
  
• How does the child interact with staff? the family? other children?
  
  
• What cultural factors must be considered?
  
  
• What feelings does the child elicit from the staff?

Family

• How does the family view the situation? Is this view similar to the staff’s view?
  
  
• What are the family’s expectations for the child and the program?
  
  
• What are the family’s strengths and resources?
  
  
• What types of interventions are acceptable to the family?
  
  
• What constraints in the family must be considered?

Staff Member

• How does the staff member view the issues?
  
  
• What are the staff member’s expectations for self, family, and child?
  
  
• What intervention skills does the staff member possess?
  
  
• What types of interventions are acceptable to the staff member?
  
  
• Does the staff member have the necessary knowledge, skills, objectivity, and confidence to respond to the particular concerns raised?

Immediate Environment

• What are the philosophies of the classroom, program, and organization, and how do they influence the consultant and the staff member?
  
  
• What aspects of the environment contribute to, influence, reinforce, or maintain the child’s behavior?
  
  
• What external resources may be available (for example, extended family and a smaller group in the center)?
  
  
• What constraints in the immediate environment must be considered?

Larger Environment

• What larger environmental (community) characteristics contribute to the problem?
  
  
• What factors outside of the immediate environment affect the child’s behavior?
  
  
• Are the changes proposed for the child or staff member consistent with family, agency, and community norms and expectations?
  
  
• Are the proposed changes and change strategies culturally appropriate for this child and this staff member?

APPENDIX C
Assessment in Program Consultation

The following questions are important for the consultant and staff members to consider in program consultation:

• What is most important about this agency?
  
  
• For what does the agency most want to be known?
  
  
• How are decisions made or policies changed?
  
  
• How does each staff member understand the program’s “mandate”?
  
  
• How is the program or agency regarded by staff, families, and other agencies?
  
  
• How is the agency regarded by the general public?
  
  
• How do staff explain the situation that prompted the consultation?
  
  
• What do staff think needs to change in order for the concern to be addressed?
  
  
• Do staff view their relationships with clients as positive or negative, as generally successful or failing, or as accomplishing the agency’s mandate or not?
  
  
• Do staff feel a sense of satisfaction from their work with children and families?
  
  
• Do staff feel angry with families, with children, or with other staff members? If so, why?
  
  
• Do staff appear interested in gaining new skills for working with young children and their families?
  
  
• What is the quality of the early childhood program?

The following questions relate to content-based program consultation (which is different from general staff development training):

• What is the agency’s treatment regarding the presenting consultation issue?
  
  
• What actions has the agency taken to address the concern?
  
  
• What human, financial, and program resources can the agency use to address the presenting consultation issue?
  
  
• Can any program models or agency interventions be applied to the consultation issue?
  
  
• What are the organization’s covert and overt expectations of the consultant?

The following questions relate to inter-staff relationship consultation (for example, staff do not get along with one another, a high degree of conflict exists between two staff members, or a fierce split occurs between a staff member and a manager):

• Who defined the problem as requiring a consultation?
  
  
• For whom is it a problem?
  
  
• For whom is it not a problem?
  
  
• Who first identified the problem?
  
  
• Who talks to whom about it?
  
  
• Do some people identify other problems as more pressing?
  
  
• How has the system solved similar problems?

APPENDIX D
List of Contributors

• Anne Mathews-Younes, Ed.D., Director, Division of Prevention, Traumatic Stress, and Special Programs (DPTSSP), and Gail F. Ritchie, M.S.W., Prevention Initiatives and Priority Programs Development Branch/DPTSSP/Center for Mental Health Services, SAMHSA, provided invaluable support throughout the duration of the project.
  
  
• Jane Knitzer, Director of the National Center for Children in Poverty, Columbia University School of Public Health, has demonstrated long-standing leadership in advocating for improved mental health services for children and families.
  
  
• Maria dela Cruz Irvine, among other tasks, helped with the research on program descriptions.
  
  
• Katherine Froyen edited several versions of the monograph.
  
  
• Lauren Abramson, Marva Benjamin, Freddie Bettinger, Joan Dodge, Kadija Johnston, Edward Feinberg, Emily Fenichel, Betty Tableman, Victoria Vestrich, and Deborah Weatherston thoughtfully reviewed the manuscript and provided insightful comments and suggestions.
  
  
• Hortense DuVall edited the latest version of the monograph. Claude Tybaert did the layout and design of the latest version of the monograph.

Roundtable on Mental Health Consultation Participants:

• Lauren Abramson, Johns Hopkins University, Baltimore, Maryland
  
  
• Gina Barclay-McLaughlin, Chapin Hall Center for Children, Chicago, Illinois
  
  
• Victor Bernstein, University of Chicago, Chicago, Illinois
  
  
• Fredericka Bettinger, consultant, Charlestown, Rhode Island
  
  
• Elena Cohen, Educational Services, Inc., Washington, D.C.
  
  
• Joan Dodge, Georgetown Child Development Center, Washington, D.C.
  
  
• Gloria Elliott, La Clinica del Pueblo, Washington, D.C.
  
  
• Edward Feinberg, Anne Arundel County Infants and Toddlers Program, Glen Burnie, Maryland
  
  
• Emily Fenichel, Zero to Three, Washington, D.C.
  
  
• Lynn Harvey Clement, Center for Mental Health Services, Rockville, Maryland
  
  
• Kristen Hansen, Georgetown Child Development Center,* Washington, D.C.
  
  
• Marisa Irvine, Georgetown Child Development Center,* Washington, D.C.
  
  
• Kadija Johnston, University of California, San Francisco, California
  
  
• Roxane Kaufmann, Georgetown Child Development Center,* Washington, D.C.
  
  
• Amy Locke Wischmann, Georgetown Child Development Center,* Washington, D.C.
  
  
• Sue Martone, Office of Early Childhood, Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, Maryland
  
  
• Anne Mathews-Younes, Center for Mental Health Services, Rockville, Maryland
  
  
• Lynn Milgram-Mayer, Early Head Start Program, Alexandria, Virginia
  
  
• Jim Rast, Labette Mental Health Center, Parsons City, Kansas
  
  
• Gail Ritchie, Center for Mental Health Services, Rockville, Maryland
  
  
• Pat Salomon, Office of Early Childhood, Center for Mental Health Services, Rockville, Maryland
  
  
• Rebecca Shahmoon-Shanok, Institute for Clinical Studies of Infants, Toddlers, and Parents, New York, New York
  
  
• Betty Tableman, Michigan State University, East Lansing, Michigan
  
  
• Mary Telesford, Federation of Families for Children’s Mental Health, Alexandria, Virginia
  
  
• Victoria Vestrich, parent consultant, Falls Church, Virginia
  
  
• Deborah Weatherston, Merrill-Palmer Institute, Detroit, Michigan
  
  
• Maria Wolverton, Georgetown Child Development Center,* Washington, D.C.

*Now known as the Georgetown University Center for Child and Human Development

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