SECTION IV
Challenges and Strategies in the Consulting Process

Early childhood mental health consultants may encounter critical challenges in their work. This section presents a discussion of the challenges and suggestions for ways to address them. The challenges include:

• difficulty in implementing the intervention plan;
  
  
• organizational setting;
  
  
• value conflicts;
  
  
• racial, ethnic, and socio-economic issues;
  
  
• lack of mental health professionals with early childhood consultation experience; and
  
  
• funding.

DIFFICULTIES IN IMPLEMENTING THE INTERVENTION PLAN

Staff members may find it difficult to follow through on the plan developed in the consultation process for these reasons:

• Ambiguity. The consultant’s expectations may not match those of staff. This situation can arise when insufficient structure has been introduced early in the consultation and when staff members do not fully understand the consultation process. The consultant and staff can avoid ambiguity by carefully discussing the consultation process at the outset, by writing a plan with concrete behavioral objectives and outcomes, and by occasionally revisiting the plan as the process continues.
  
  
• Overwork. Consultants sometimes fail to remember that staff members are involved in a variety of activities. Consultants may take too much of their staff members’ time in meetings (especially internal consultants), or they may design interventions that require just too much extra work. Awareness, careful scheduling, and choice of interventions that require less time can reduce the risk of encountering this barrier to effective consultation.
  
  
• Complexity of the intervention. The design of the intervention is a major determinant of the outcome of the consultant’s efforts. Interventions aimed at change must be tailored to the setting, to the provider, and to the power structure. In addition, the consultant should suggest interventions that increase some aspect of the staff member’s comfort, require little change in the agency, do not threaten the worker’s approach, and can be communicated easily. Depending on the complexity of the intervention, it may be more difficult for staff members to implement the plan.

  For example, consultants sometimes suggest that family child care providers use behavior modification charts to help change the behaviors of young children. This strategy has been found to be successful in some settings, but it is particularly difficult to implement when only one person cares for several children. In addition, the time required to learn and implement this intervention is significant, which may temporarily reduce the child care provider’s effectiveness.

• Entrenched habits. Individuals, families, groups, and organizations develop traditions in how they function and relate. A tradition, or habit, develops mainly because the practice is both comfortable and successful. The habit also may be continued, even when it is no longer successful, because of concern that new practices may make matters worse. New approaches threaten tradition—the “way we’ve always done it”—and may create ambiguity and even fear related to the staff member’s competence in doing his job.

  Changing entrenched habits requires first an acknowledgment that fear of the unknown and concern about the consequences of change are normal coping behaviors. Consultants should communicate thoroughly the need for the change, the design of the change strategies, and the implications of the change for the people involved. As noted above, a relationship of mutual trust between those initiating the change and those who will be affected most by it is essential to break through these barriers.

ORGANIZATIONAL SETTING

The setting in which consultation takes place also affects follow-through in the consultation process. Unfortunately, programs sometimes hire mental health consultants who are unfamiliar with the organizational complexities of early childhood and child care centers for young children, or with issues related to quality of care and outcome, or with the challenges of involving parents. Even experienced consultants may find their work complicated by such organizational issues as shoestring budgets, overworked staff, high staff turnover, and low morale. Other barriers may include staff burnout, autocratic decision-making processes, and inadequate community resources.

To deal effectively with organizational variables, consultants must begin the process by defining the organizational structure, by establishing the consultant and staff roles and the boundaries of those roles within the organization, by setting achievable goals, and by establishing accountability. Many other circumstances can facilitate or impede the consultant’s work, such as the level of administrative support for consultation and agency change, the level of trust afforded consultants, the agency’s process of implementing change, the relationship between staff and administration, the agency consensus about approaches to children with challenging behaviors and their families, and overt and covert agency attitudes toward the families, children, and other agencies.

The consultation process may provide a forum, when appropriate, for developing and implementing such interventions as systems-oriented staffing, staff educational programs, or skill development seminars, which may help address an agency’s organizational issues.

VALUE CONFLICTS

The traditional approach to mental health focuses mainly on an individual’s problems. The strengths-based approach to mental health (which is increasingly gaining favor in the field) assumes that an individual’s strengths and capacities can play an important role in assessing a problem and designing and implementing a treatment plan.

Acknowledging that families and children struggle with mental health issues may seem inconsistent with the strengths-based approach. Rather than focus only on a child’s specific emotional, social, or behavioral problems, mental health consultants and child care staff can approach the identified problems within the context of the individual or family strengths and the family’s ability to use support services effectively.

Taking the traditional approach may not adequately capitalize on the strengths that families show when they acknowledge the problems they face and seek the support and treatment they need. It is essential to be aware of strengths as mental health consultants address problem areas.

RACIAL, ETHNIC, CULTURAL, AND SOCIO-ECONOMIC ISSUES

Successful consultation requires the consultant to be both culturally empathic and culturally knowledgeable. Cultural empathy requires a rational understanding of cultural differences. It also requires that the consultant understand and appreciate the staff member’s culture (and the child and family’s culture, if appropriate), view the problem through the staff member’s eyes (and the family’s eyes), and adapt both style and technique to the cultural perspective of the staff member (and the family). Intolerance in any form from the consultant can give rise to resistance, not only from culturally different families and staff, but also from anyone who is sensitive to and supportive of the special needs of these and other groups.

In addition, consultants working in cross-cultural situations should be aware that cultural differences between the consultant and the staff member may present challenges to the success of the consultation. Addressing these differences openly and nonjudgmentally is essential.

Effective cross-cultural consultants have an awareness of their own personal values, a well-developed awareness of their personal consultation styles, cultural empathy, and the ability to adapt interventions appropriately to meet staff members’ needs.

LACK OF MENTAL HEALTH PROFESSIONALS WITH
EARLY CHILDHOOD CONSULTATION EXPERIENCE

Agencies, staff, and families who interact with young children may find it difficult to identify local mental health consultants who are trained in both child development and family systems, who understand the complexities of the child care and early childhood education systems, and who have training or experience in working with families and staff facing multiple challenges. In addition, few higher education programs provide mental health training courses that teach students how to be consultants.

On the positive side, Daycare Consultants of San Francisco (see Appendix A) and the Institute for Clinical Studies of Infants, Toddlers, and Parents in New York City offer specialized training to mental health professionals in early childhood mental health consultation. For information on this institute, contact Rebecca Shahmoon-Shanok, Child Development Center, Jewish Board of Family and Children’s Services, 120 W. 57th Street., New York, NY 10019.

FUNDING

One of the most frequently cited barriers to mental health consultation is lack of funding. Some programs cited in Appendix A are funded through grants from private foundations, universities, model demonstration programs, and other time-limited funding sources that may be difficult to sustain.

A number of publicly funded programs address the mental health needs of young children, including:

• Head Start and Early Head Start;
  
  
• Individuals with Disabilities Education Act (IDEA; both Part B, Section 619, and Part C);
  
  
• Mental Health and Substance Abuse Block Grants;
  
  
• Child Care and Development Fund;
  
  
• Child welfare funds, such as Title IVE of the Social Security Act;
  
  
• Maternal and Child Health Block Grant under Title V of the Social Security Act;
  
  
• Temporary Assistance for Needy Families (TANF) program, which has replaced Aid to Families with Dependent Children, used in states to support the inclusion of children with special needs (including mental health needs) in community child care settings; and
  
  
• Medicaid.

Federal legislation requires several of these programs to collaborate with other publicly funded programs at the national, state, and local levels. The 1997 reauthorization of IDEA adds stronger requirements for this kind of collaboration to Special Education programs under Part B to match the responsibility for interagency cooperation under the Part C Program for Infants and Toddlers.

A significant source of revenue for many programs receiving mental health consultation services is Medicaid. Medicaid eligibility is highest for young children under age 6, and through its Early and Periodic Screening, Diagnosis, and Treatment program, it must provide or pay for the full range of health and mental health services needed by each Medicaid-enrolled child. This support can include mental health consultation with an enrolled child’s teacher or program. This requirement remains in force when a state Medicaid program contracts with managed care programs to deliver Medicaid services to eligible children and their families. In fact, under managed care systems, considerable flexibility and significant incentives have emerged to promote consultative services. In some instances, mental health providers may be able to demonstrate both lower cost of consultation services and potential for improved outcomes.

Obtaining funds for program consultation is much more challenging than paying for child-focused consultation. Head Start is one of the few programs that acknowledge the importance of both child- and program-focused mental health consultation in their performance standards. It is also one of the few sources that provide some funding for these services.

Because child care and other early childhood programs typically are inadequately funded or understaffed, making it difficult to pay for additional services or staff development, interagency collaboration is essential to build the advocacy resources needed to find flexible funds to pay for mental health consultation. Some states and communities are beginning to recognize the benefits of providing mental health services to young children and their families at home, in child care, and in other early childhood programs, and they are using creative approaches to plan, provide, and pay for services (Bazelton Center for Mental Health and the Law, 1998). A few of these initiatives are summarized below. For more information, contact the Georgetown University Center for Child and Human Development (see Section VI, “Selected Resources”).

• Vermont is using a statewide planning process to provide regionally driven mental health services and supports to young children with mental health needs and their families. Under the leadership of the state mental health and child welfare agencies, other relevant child-serving programs, agencies, universities, and many family members are involved in the process.
  
  
• North Carolina has a special category of Medicaid funding called High Risk funding. Any child under age 3 who is found to have even one risk factor for mental illness is eligible for a broad range of mental health services. North Carolina also has a Smart Start initiative that enhances the ability of child care and Head Start staff to serve children who need specialized interventions.
  
  
• Several counties in California are saving money through a reduction in psychiatric hospitalizations for older children and adolescents. The counties then “reinvest” these funds in early intervention.
  
  
• Anne Arundel County, Maryland, has implemented an initiative based on a county-wide needs assessment that identifies as its highest priority young children with behavioral problems who are at risk for removal from child care. The county is using county funds to establish a multi-tiered service system that includes a “warm line” for telephone consultation, on-site training and behavioral consultation to child care providers, and behavior management training.

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