SECTION II
Definition and Description of Types of Mental Health Consultation

This section defines and describes two different types of mental health consultation for young children in child care settings and their families. The two approaches are child- and family-centered and program-centered consultation. A fictional—but typical—example, presented in boxes throughout this section, illustrates how mental health consultation can work in center-based settings.

Mary, the toddler classroom teacher at the Flower Street Child Care Center, has been increasingly concerned about Robert G, a 2-year-old boy who has been in the agency’s early childhood education program since he was 2 months old. Robert has always seemed shy and withdrawn, but during the past 3 months—ever since he moved up from the younger group to a new class—he has been having difficulties during nap time. His crying not only reveals his own distress, but also prevents other children from falling asleep. Robert stops crying when the teacher’s aide sits by his side, but he begins to scream again the moment she leaves. Mary also has noticed that he has not been eating very much. Empathizing with Mary’s concern and frustration, the center supervisor decided to request a mental health consultation on Robert’s behavior.

As Mary made plans to ask Robert’s parents to consent to the consultation, she realized that no center staff had ever discussed any concerns about Robert with his parents (although it was apparent now that center staff had had several concerns about his behavior). The parents had completed a social services needs assessment some time ago, but neither had ever attended any parent involvement activities.

Robert’s father (and sometimes an aunt) brings him to the center in the mornings on the way to work, and his mother picks him up in the afternoons. Although both parents are courteous, Robert’s parents and staff have little interaction.

When Mary approached Mr. G to request a meeting with both parents to discuss her concerns about Robert, Mr. G was taken very much by surprise. He responded that because of work responsibilities, he and his wife could not attend a meeting together. He indicated clearly that although he did not really understand what a “mental health consultation” meant, he saw no need for a consultant to observe his child. He seemed angry at Robert when he left the classroom.

The following morning, he deposited Robert’s things in his cubby and hurriedly left the center.

Mary discussed the incident with her supervisor. She expressed her angry feelings toward Mr. G and her anxiety about the next steps to take. Mary and her supervisor decided to ask the mental health consultant for assistance in introducing the need for a consultation to Robert’s parents.

Definition and Types of Mental Health Consultation

Mental health consultation in early childhood settings is a problem-solving and capacity-building intervention implemented within a collaborative relationship between a professional consultant with mental health expertise and one or more individuals, primarily child care center staff, with other areas of expertise. Early childhood mental health consultation aims to build the capacity (improve the ability) of staff, families, programs, and systems to prevent, identify, treat, and reduce the impact of mental health problems among children from birth to age 6 and their families.

The goal of early childhood mental health consultation is neither to “rescue” child care staff (by shifting their responsibility for dealing with difficult situations to a consultant) nor to transform them into mental health professionals. Rather, the goals are to assist staff in understanding the mental health perspective, and incorporating it into their work, and to use their own roles, skills, and experience to:

• foster positive learning and development of each child through careful observation;
  
  
• implement strategies that enhance learning experiences;
  
  
• promote social, emotional, and behavioral development of each child;
  
  
• build relationships and communicate with parents; and
  
  
• seek further consultation, when necessary.

Mental health consultation is one of a number of problem-solving and capacity-building interventions useful in improving adults’ effectiveness in their interactions with young children. Other common capacity-building interventions include teaching and training, clinical supervision, and psychotherapy. Although a specific mental health consultation may incorporate one or more of these techniques, the consultative approach is distinctly different from that of its three “cousins.” A summary of relationships between these approaches is as follows:

• Teaching and training. A traditional teacher or trainer chooses the content and format of the information to be conveyed. By contrast, a mental health consultant to an early childhood program provides information on topics specifically requested by program staff. Teaching is commonly used as a tool in the consultative process, but much of that teaching is informal and involves various forms of modeling, rather than presentations in a typical classroom format.
  
  
• Clinical supervision. Both clinical supervisors and mental health consultants help program staff improve their skills to understand and accomplish their work and to increase their capacity to master future problems. A supervisory relationship implies administrative and legal accountability of staff members for following the supervisor’s recommendations, but in a consulting relationship, staff take responsibility for deciding whether or not to implement the consultant’s recommendations.
  
  
• Psychotherapy. In therapy, as in consultation, a client seeks assistance (or treatment) to solve a problem. Both therapeutic and consultative relationships are characterized by genuineness and trust, and the goal of each is to foster the client’s understanding. Therapists focus on personal problems, but consultants do not. Consultants may look at the factors in a staff member’s experience that contribute to his subjective perception of the situation. Sometimes, consultants may suggest that a staff member seek therapeutic services; at other times, the consultation can have coincidental therapeutic results. But consultation is mainly focused on improving the effectiveness of the individual staff member in her specific work.

The important tools of training, clinical supervision, and therapy span a continuum of overlapping supports and processes. Mental health consultants use these strategies often. However, it is important to differentiate between the goals and features of the various strategies to avoid confusing the role of the consultant with the role of other professionals, such as counselors or therapists. The underlying principle is that mental health consultants work directly with staff members, not with children.

A variety of factors enter into choosing the best intervention to address a particular issue. They include the following:

• specific goals of the mental health consultation,
  
• nature of the issues or concerns,
  
• setting,
  
• availability of mental health practitioners and other experts in the field,
  
• time frame, and
  
• cost.

The Flower Street Child Care Center decided to enlist a mental health consultant to help Mary develop a strategy regarding Robert for the following reasons:

• The situation required problem solving. The goal of the intervention was to work with Mary to develop a plan to help center staff address more effectively their concerns about Robert’s behavior.
  
  
• Mary wanted to build her capacity not only to respond more effectively to Robert and his family, but also to master similar problems in the future.
  
  
• The goal of this consultation was only indirectly related to the child. The overarching objective was to enhance the staff’s and the family’s capacity to work together toward the mutual goal of enhancing Robert’s emotional development.

TYPES OF EARLY CHILDHOOD MENTAL HEALTH CONSULTATION

Early childhood mental health consultation generally advises programs in one of two approaches. One approach focuses on a particularly challenging child or the family of that child; the other addresses a general program issue that impacts the mental health of staff, children, or families.

Child- and Family-Centered Consultation

Child- and family-centered consultation is the most traditional form of mental health consultation. Staff initially seek the assistance of a mental health consultant because they are worried, alarmed, or frustrated by a particular child’s behavior. The primary goal of this type of consultation is to develop a plan to address both the factors that contribute to a child’s difficulties in functioning well in the early childhood setting and the family’s role.

Like Robert, children who experience difficulties may generate feelings of anxiety, anger, or even guilt in child care staff and families. Moreover, parents and parent-child interactions evoke complex emotions in staff that may make it difficult for them to respond in ways that support the parents and the child, and the relationships between them (Johnston, 1998).

Because they were concerned about Robert’s behavior, Mary and other staff became resentful when they felt Mr. G had not “heard” their concerns: They blamed the father for Robert’s behavior.

The initial step in the consultation process was for the consultant to understand the staff’s feelings toward Robert and his father and to respond to the staff’s immediate need to obtain parental consent for the consultation. After listening to and empathizing with staff, the consultant elicited strategies that staff had used successfully in the past to involve parents. As staff and the consultant developed trust and mutual respect, they began to plan nonthreatening strategies to introduce the consultation service to both parents.

In contrast to the approach she had taken with Mr. G, this time Mary askedMrs. G whether she could remain at the center the following day for several minutes to talk about Robert. Mary also arranged for the teacher’s aide to take over her class at the end of the day. In the privacy of the teacher’s lounge, Mary initiated the conversation by describing some of Robert’s favorite activities, described the friends with whom he played, and talked about his love for finger painting. Mary asked Mrs. G about Robert’s favorite activities at home, and she shared with Mrs. G her observations of Robert’s strengths and talents at child care. When Mrs. G seemed at ease, Mary asked her about Robert’s sleeping and eating habits and learned that he was having many of the same difficulties at home that he was having at the center.

Mary explained to Mrs. G how the mental health consultant could assist both center staff and her family in responding better to Robert’s needs. Only then did Mary request and obtain consent for the consultation. Mary told Mrs. G that her husband had said he opposed the consultation, so the mother and teacher discussed ways in which Mr. G could be approached with more success.

Several days later, the mental health consultant helped Mary plan ways to bring Robert’s father back into the discussions about Robert, to avoid generating conflict between the two parents.

To assess Robert’s abilities, limitations, vulnerabilities, and strengths, the consultant visited the center and observed him at various times during the course of a day. The consultant assessed the quality of the interactions in the room—both those involving Robert and those involving the other children. Child care staff worked attentively at feeding the children, setting up and cleaning up materials, and conducting small-group activities, such as reading books. Staff members responded warmly to the children with verbal expressions that reflected many of the children’s activities and behaviors. In the classroom, Robert was observed to be a loner, preferring to play by himself rather than with other children.

After lunch, staff helped all the children go to their cots for nap time and dimmed the lights in the room. All the children, except Robert, fell asleep almost immediately. Robert had started protesting “no sleep” as soon as he realized it was nap time. He cried loudly each time the aide would try to leave his side. During this time, both Mary and her aide shuttled back and forth trying to respond to his requests (water and a book), threatening a “time-out” when nap time was over and, finally, holding his hand until he went to sleep. He did not fall asleep until about 15 minutes before the other children began to awaken.

In a subsequent conversation, Mrs. G told the consultant that after a fight some months ago, during which her husband had physically hurt her, Mrs. G awakened Robert and his 4-year-old brother and took them to her sister’s home. They stayed there for about 3 weeks. Mrs. G managed to transport both boys to and from the center every day so that she could work her day job. She also left them at her sister’s house during the night and on weekends when she went to her second job.

Although the boys were familiar with their aunt, they both cried every time their mother would leave. During these 3 weeks, the boys had no contact with their father, about whom Robert asked constantly. About 3 weeks later, Mrs. G and the children returned to their home. She stated that there had not been a violent incident since her return.

Then the consultant and Mrs. G discussed possible ways to work with staff, with Robert, and with Mr. G, taking into consideration the new information that Mrs. G had provided.

Mr. G never consented to meet the consultant at the center, but he agreed, warily, to meet her at home. During the home visit, Mr. G spoke in a soft voice and responded to the consultant’s questions monosyllabically. He did not discuss the time when his wife and children moved out of the house. Observing the interactions between Mr. G and Robert, the consultant noted that Mr. G understood and responded warmly (and sometimes playfully) to Robert’s expressed needs and desires. Mr. G was far more affectionate with Robert than with his elder brother. The consultant later learned that the elder boy was not Mr. G’s own son.

Observation of Robert at home and at the center helped expand the consultant’s understanding of Robert and his family. In subsequent meetings with center staff (one of which Mrs. G attended), the participants considered the mental health ramifications of Robert’s experience. The mental health consultant, with both parents’ permission, explained her observations to help staff understand and interact better with Robert.

Initial discussions focused on how Robert might have felt when he abruptly left home in the middle of the night and no longer saw his father—to whom he was very attached—without explanation. Also, despite Mrs. G’s efforts to protect her elder son, Mr. G constantly reprimanded or punished him, clearly favoring Robert. Witnessing his father’s disparate behavior was very confusing for Robert, who could not account for the difference in treatment, and Robert frequently perceived his mother as taking his elder brother’s side.

Mr. and Mrs. G and center staff were better able to understand Robert’s reactions to the unpredictability of his abrupt separation from his father and to the confusing behavior of his mother. The consultation increased the staff’s understanding of Robert’s needs and helped them consider how they might respond to these needs.

With the consultant’s assistance, staff developed new strategies to help Robert develop a sense of predictability. For example, the same staff member greeted Robert each morning when he arrived at the center. Staff anticipated the transition to and from nap time, establishing a routine and “rules” under which Robert would always be given the same toy and a book that the teacher’s aide would read before he went to sleep. Periodically, Mary asked each parent about Robert’s behavior at home.

The mental health consultant met with both Mr. and Mrs. G in their home one additional time and discussed ways to enhance Robert’s sense of predictability and stability. The family made the important step of acknowledging the feelings and needs underlying Robert’s behavior. However, the family only partially used the mental health consultation, because they did not follow up on the recommendation to obtain family counseling for issues related to domestic violence and the relationship between Mr. G and Robert’s elder brother.

Mental health consultation in this case also helped staff consider the need to establish stronger relationships with the children’s parents, to be able to share with parents their own observations and understandings of children’s experiences at the center. Rather than comply with the agency’s requirement of conducting only initial needs assessments, staff decided to communicate informally and regularly with parents, sharing anecdotes that provided parents with opportunities to participate in their children’s experiences at the center. As a result, the parents’ participation increased, and staff gained a better understanding of the children in their care.

Case consultation around individual children who exhibit difficult behaviors is not always sufficient to solve behavioral or emotional problems. To help those children, some early childhood programs have developed therapeutic groups, such as the Early Childhood Group Therapy Program (Shahmoon-Shanok, 1998). By their nature, these therapeutic groups involve a disproportionately high percentage of children who exhibit significant behavioral difficulties. Early childhood mental health consultation in such groups is directed toward addressing the needs of staff working with these children. The Day Care Consultants Program of San Francisco, for example, meets with staff regularly to enhance their understanding of children’s individual needs and the skills used to address them (see Appendix A). The consultants sometimes meet with the parents of these children to offer immediate assistance and, when necessary and mutually agreed upon, to provide referrals for mental health treatment and other community-based support services to the families (Johnston, 1998).

Programmatic Mental Health Consultation

Mental health consultation to programs focuses on (1) improving the overall quality of the program or agency and (2) assisting the program in solving a specific issue that affects more than one child, staff member, and family.

Consultation to programs usually takes a preventive perspective. By identifying strategies to improve the overall quality of care, the consultation empowers staff to enhance the healthy social and emotional development of children and the functioning of families—and of staff members, too.

Typically, the mental health consultant in early childhood settings is called on to engage staff and families in assessing a problem and designing a plan to deal with specific issues within the overall program. In programmatic mental health consultation, the consultants usually do not focus on individual children; rather, they facilitate the program’s success in reaching such objectives as:

• developing a mental health approach to strengthen the quality of the program, including a staff development plan;
  
  
• developing opportunities for staff to discuss their concerns and to examine how stress affects their work;
  
  
• providing a forum to explore cultural differences and workplace conflicts; and
  
  
• providing a “safe space” in which staff members can identify, examine, and discuss their feelings about their relationships with children and families.

Initial mental health consultation with Mary regarding Robert expanded to a more programmatic concern: devising better channels of communication between staff and parents. Also, the issues of instability and unpredictability in Robert’s life were seen as relevant to all the children in a number of ways and became an important theme for staff discussion.

Many features of a family- or center-based child care program or a home-visiting program resulting in a request for consultation on particular children can help promote the healthy emotional development of all children or identify early signs of emotional and behavioral difficulties (Johnston, 1998). For example, the specific recommendations and interventions designed to help Robert are generalizable to other aspects of the classroom setting.

Consultation with the goal of improving the overall quality of the program need not always be an expansion of child- or family-centered consultation. Programs also can make specific requests for early childhood mental health consultation to improve their ability to respond to the needs of all young children in their care.

The program consultation in Robert’s case ultimately aimed to assist all staff in moving beyond the usual parent involvement activities and their practice of involving families only at times of crisis. The focus of the consultation shifted purposefully to developing collaborative relationships between staff and families to actively promote the emotional well-being of the children.

At the request of staff in this classroom, the mental health consultant and staff of the entire center—having developed a mutually respectful and trusting relationship—held a series of weekly meetings. Through these weekly consultations, staff began to realize their importance to parents, and they discussed ways that they could be supportive to families. For example, staff could help families acknowledge and understand both their child’s strengths and the child’s areas of difficulty. Also, staff could explain to parents the role of the mental health consultant in helping staff and parents better understand a child’s behavior. As staff—and parents—begin to understand a child’s behavior more comprehensively, they are better able to respond empathetically and appropriately. Another recommendation that may stem from these discussions is for staff to assist parents in understanding how consultation can help them with child rearing, as well as to ensure that parents are linked with other appropriate supports.

Other related issues that had an impact on the mental health aspects of the program became apparent to the consultant as she worked with Mary and other staff members. In reviewing the way information was shared with Mr. and Mrs. G, the consultant observed the staff’s lack of knowledge regarding the cultural background of Robert and his family. Knowing how culture influences communication, behavior, and interactions between staff and families and among staff, she suggested that the program director focus on the staff’s cultural competence. She also recommended further consultation with an expert in the field.

In Robert’s case, the consultant helped a child care provider develop a specific strategy to engage Robert’s parents so that staff and parents together could plan effective ways to help Robert. Child care staff were then able to generalize this strategy and apply it in a programmatic way to all parents. With the consultant’s guidance, staff began to examine which interactions between staff and families promoted or inhibited the goal of engaging the parents in working with them to enhance the child’s development.

Previous | TOC | Next