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HomeJournal ContentsIssue Contents
Volume 12 Number 1
©The Author(s) 2010

Meeting the Mental Health Needs of Poor and Vulnerable Children in Early Care and Education Programs

Lenette Azzi-Lessing
Wheelock College

Abstract

Across the United States, policy makers and early childhood experts are focusing on implementing and evaluating a range of interventions designed to improve school readiness for young children living in poverty. This article provides an overview of the various factors that threaten optimal development of young children living in poverty and that place them at risk for emotional and behavioral problems. The article then addresses the challenges to meeting the needs of these children and their families in early care and education settings. Four key strategies for improving the capacity of early care and education programs for preventing and addressing mental health problems in young children in poverty are outlined: (1) expanding use of early childhood mental health consultants, (2) building effective partnerships with mental health and other community-based systems, (3) providing support and training for teachers, and (4) establishing family-based supports such as those provided by Head Start and Early Head Start. The article concludes with suggestions for research and policy changes to remove barriers and support this work.

Introduction

Across the United States, policy makers and early childhood experts are focusing on implementing and evaluating a range of interventions designed to improve school readiness for young children living in poverty. Current strategies focus on the expansion and enhancement of state-funded preschool programs and of Head Start, the federally funded preschool program for children from low-income families. Efforts are also underway to improve the capacity of early care and education programs to promote optimal development for participating infants and toddlers through a wide variety of quality improvement initiatives. There is growing recognition that children who are especially vulnerable need additional interventions and support, including those that promote healthy social and emotional development and address mental health problems early in life (Knitzer & Lefkowitz, 2006).

Largely as a result of recent shifts in social policy, especially welfare reform, increasing numbers of young children from poor families are participating in early care and education programs (Douglas-Hall & Chau, 2007). Nearly one-half of young children in low-income families have a parent who is employed full time (National Center for Children in Poverty [NCCP], n.d.). Many of these children face significant challenges to their social, emotional, and cognitive development because they are more likely to be exposed to impaired parenting, family stress, and family and community violence than their non-poor peers (Knitzer, 2000; Brooks-Gunn & Duncan, 1997).

This paper provides an overview of the various factors that threaten optimal development of young children living in poverty and that place them at risk for emotional and behavioral problems. The article then addresses the challenges to meeting the needs of these children and their families in early care and education settings. Four key strategies for improving the capacity of early care and education programs for preventing and addressing mental health problems in young children in poverty are outlined: (1) expanding use of early childhood mental health consultants, (2) building effective partnerships with mental health and other community-based systems, (3) providing support and training for teachers, and (4) establishing family-based supports—such as those provided by Head Start and Early Head Start. The article points out the policy changes that are needed to remove barriers and support this work—improving the coordination of systems that serve young children and families in poverty and better preparing early care and education professionals to effectively serve these children and families.

 Conditions that Create Extreme Risk for Young Children

Poverty as a Significant Risk Factor

Approximately 20% of young children in the United States live in poverty, and children under 6 are more likely to be poor than any other age group. An additional 23% of young children live in low-income households with families earning between 100% and 200% of the federal poverty level (NCCP, n.d.). Children living in low-income families, and especially the 20% of young children living at or below the poverty level, are at risk for a plethora of poor outcomes, including school failure, teen pregnancy, and delinquency (Knitzer, 2000). There is increasing evidence that persistent poverty has a greater negative effect on children’s development when it occurs in their earliest years of life (Brooks-Gunn & Duncan, 1997). Young children in poverty demonstrate lower cognitive ability and are more likely to have behavioral or emotional problems than non-poor children (Petterson & Albers, 2001).

While it has long been recognized that a lack of resources, such as nutritious food and educational toys, plays a role in compromising the development of young children in poverty, more recent research shows that a variety of environmental factors, particularly those related to caregiver impairment and family stress, produce harmful effects on children’s ability to learn. Researchers consistently identify maternal depression, maternal substance abuse, and domestic violence as having particularly deleterious effects (Knitzer, 2000; Knitzer, Theberge, & Johnson, 2008). These risk factors are not unique to families in poverty, and the presence of one or more of them can threaten children’s well-being and development regardless of family income. However, the stress of living in poverty combined with a lack of resources and social support to buffer the effects of these factors conspire to increase the potency and the persistence of harmful impacts on young children (Brooks-Gunn & Duncan, 1997; Knitzer & Lefkowitz, 2006; Knitzer et al., 2008; Petterson & Albers, 2001).

Impacts of Depression, Substance Abuse, and Domestic Violence

The incidence of depression among low-income, single women with children appears to be significantly higher than that of the general population. In the multi-site evaluation of Early Head Start, 52% of participating mothers reported depressive symptoms, and studies of women in welfare-to-work programs indicated symptoms of depression in 35-58% of women participating in these programs (Knitzer et al., 2008). Given that a majority of young children in poverty are being raised by single mothers, the impairment that depression often brings to mothers’ capacity to care for and be responsive to their young children is a grave concern.

Depression can negatively affect a mother’s ability to meet a child’s basic needs for nutrition and safety—concerns that are even more serious when a child has a significant health problem or disability. Moreover, depressed mothers are less emotionally available to their children. This lack of responsiveness may harm mother-child relationships, may lead to problems with attachment and emotional self-regulation as the child develops, and may place children at greater risk for becoming depressed themselves (Petterson & Albers, 2001). Mothers who are experiencing depressive symptoms are often more vulnerable to other risk factors, including abusing drugs and alcohol or being victimized by domestic violence (Carter, Garrity-Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001; Lazear, Pires, Isaacs, Chaulk, & Huang, 2008; Osofsky & Thompson, 2000; Knitzer et al., 2008).

The prevalence of substance abuse among low-income women is more difficult to gauge than that of depression because of the greater stigma of substance abuse and concerns about involvement with the child protective system and other law enforcement entities. Substance abuse among mothers receiving welfare benefits has been estimated as ranging between 6% and 37% (Pollack, Danziger, Jayakody, & Seefeldt, 2002). Similar to depression, substance abuse can harm mother-child attachment and increase the likelihood that children’s physical and emotional needs go unmet. Money spent on drugs or alcohol reduces the already strained resources of poor families, and efforts to obtain drugs can distract parents from adequately caring for their children (Hans, Bernstein, & Henson, 1999; Osofsky & Thompson, 2000).

Maternal depression/substance abuse and domestic violence are often interrelated. Like substance abuse, domestic violence is often hidden, making estimates of its prevalence difficult to obtain. Studies of women on welfare found that 20% had experienced domestic violence within the past 12 months and that 65% reported having been victimized by domestic violence at some point in their lives (U.S. General Accounting Office, 1998). In addition to negatively affecting mother-child relationships and mothers’ abilities to care for their children, domestic violence often causes severe trauma for young children who witness it. Extreme or repetitive trauma is harmful to children’s social and emotional development and can lead to severe emotional disturbance, especially if left untreated (Webb, 2003; Scheeringa & Zeanah, 2001).

Transactional Effects of Risk Factors

By themselves, poverty, depression, substance abuse, and domestic violence have been shown to have deleterious effects on the development of young children. The fact that two or three, and sometimes all four, of these risk factors often coexist in the same parent-child relationship helps to explain why many children with serious emotional or behavioral problems are identified in early care and education settings, particularly those serving a large population of children from low-income families (Osofsky & Thompson, 2000; Whitaker, Orzol, & Kahn, 2006). Because many of the interventions typically available in these settings have a single focus—that is, improving children’s behavior or improving parenting skills—they are likely to fall short of adequately addressing the multiple, interrelated problems that these children and their families face (Knitzer, 2000; Knitzer & Lefkowitz, 2006).

Transactional effects between the risk factors discussed here often create a vicious cycle of stress and dysfunction. For instance, women living in poverty are more vulnerable to depression, and being poor and depressed increases a woman’s risk for abusing drugs or alcohol and becoming a victim of domestic violence. Conversely, having depression or a substance abuse problem or being the victim of domestic violence makes it even more difficult for a woman to escape poverty, because it often impairs her capacity to find and hold a job or to develop healthy relationships with other adults. Young children living in households where these risk factors are present are at increased levels of risk for child abuse or neglect and other forms of trauma, in addition to impaired cognitive, social, and emotional development (Corvo & Carpenter, 2000; Osofsky & Thompson, 2000). Transactional effects are at work here as well. Neglected or traumatized children may become withdrawn or exhibit serious behavior problems, which makes them more difficult to care for and places them at greater risk for being physically or emotionally abused or neglected—compounding the developmental threats that they already endure (Lyons-Ruth, 1996; Osofsky & Thompson, 2000; Shahinfar, Fox, & Leavitt, 2000). Further intensifying the effects of family risk factors are those commonly found in poor neighborhoods, such as high rates of community violence, inadequate housing, and social isolation. These conditions expose children to additional trauma and increase the level of stress experienced by their families (Webb, 2003). 

Challenges to Early Care and Education Programs

High Levels of Need and Meager Resources

For young children from highly stressed families and communities—especially for children who have been traumatized—early care and education programs offer an opportunity for safety and nurturance (Koplow, 1996). They also provide opportunities for children to learn in a calm and predictable environment and for parents to receive support and linkage to critical resources (Donahue, Falk, & Provet, 2007; Halpern, 2000). In order for this to happen, however, programs must have adequate capacity for meeting the needs of these children and their families.

Regrettably, many early care and education programs lack the necessary resources and are easily overwhelmed by the demands of highly vulnerable children and their families. It is ironic that the programs most likely to be used by these families are often those that have the lowest capacity to respond to their needs. Many of these programs, located in low-income communities, are unable to charge the higher fees set by their counterparts in more affluent areas. Moreover, state and federally funded subsidies to low-income families or the early childhood programs that serve them have not kept pace with demand and rising costs. These subsidies are often among the first items to fall when budgets are cut (Schaefer, Kreader, Collins, & Lawrence, 2006). Thus, many early care and education programs are confronted with high levels of need, while the revenue they produce is inadequate to fund the specialized services, supports, and small classroom size that best meet the needs of vulnerable children and families (Kagan & Neuman, 2000).

Head Start programs are somewhat of an exception because these programs receive federal funds and support to address children’s mental health needs. However, even with these additional resources, Head Start teachers have reported feeling overwhelmed by increased levels of aggressive behavior, depression, and other symptoms of emotional problems among participating children (Yoshikawa & Knitzer, 1997).

Children who have been traumatized as well as those whose basic needs have gone unmet often present with challenging behaviors, including aggressiveness and disorganization (Scheeringa & Zeanah, 2001; Webb, 2003). Such behaviors often overwhelm teachers and disturb the learning of other children in the classroom. These behaviors add to the stress of teachers and other personnel already under pressure from increasing demands to emphasize early academic skills and to demonstrate measurable gains in these skills and the cognitive development of the children they serve (Donahue et al., 2007).

Competing Demands: Increasing Academic Skills vs. Addressing Mental Health Needs

While early care and education programs usually have some capacity to address social and emotional needs, most programs are increasingly focused on improving the academic skills of the young children they serve. Many programs that serve children from low-income families are focused on tailoring their interventions to address gaps between these children’s scores on measures of early academic ability and those of their non-poor peers. Public policy makers and foundation leaders are pressing for programs to demonstrate their cost effectiveness, often by showing significant gains in participating children’s cognitive ability and academic skills as evidence of improved school readiness (Thompson & Raikes, 2007).

While movement toward improving the capacity of various early childhood programs to promote early academic skills in young children may be appropriate, it is important that other critical aspects of child development receive adequate attention. This is especially critical for programs serving children who are disadvantaged and at high risk for poor outcomes. Infants, toddlers, and preschoolers living in poverty need support and intervention to address these needs and overcome barriers to learning. Meeting these needs requires concentrated attention to the social and emotional aspects of children’s well-being as well as to that of their parents and other caregivers (Donahue et al., 2007; Fantuzzo, Stoltzfus, Lutz, Hamlet, Balraj, Turner, & Mosca, 1999).

Many early care and education programs—especially those that are of high quality—reflect an understanding of the importance of children’s mental health to their learning capacity and school readiness. These programs offer services, such as parent training and support, to address the emotional well-being of the children and families they serve. However, the challenges faced by families living in poverty, particularly those in extreme poverty, can easily outstrip the capacity of even the most responsive programs. Moreover, there is a shortage, especially in low-income communities, of appropriate resources to which these families can be linked. Early care and education professionals often find there is a dearth of services designed to meet the needs of vulnerable families with young children, and those that do exist often have long waiting lists (Kaufman & Hepburn, 2007).

Promising Strategies

In order to effectively serve vulnerable young children and their families, early care and education programs must develop approaches that simultaneously address the needs of these children, their families, and their teachers. The following strategies hold much promise for improving programs’ capacities to provide this critical support and intervention.

Expansion of the Utilization and Role of Early Childhood Mental Health Consultants

Early childhood mental health consultants are currently utilized in a variety of early care and education programs, including Head Start and preschool programs. Consultation is typically provided by mental health professionals who partner with early childhood educators to “promote healthy social-emotional development, prevent the development of problematic behaviors, and reduce the occurrence of challenging behaviors” (Perry & Kaufman, 2009, p. 1). Early childhood mental health consultants usually have extensive training or formal education in counseling or social work, especially with children and families. Consultants may be available through a contract with a local mental health agency or employed directly by an early care and education program.

A number of experts are calling for an expansion of consultants’ roles, which are often limited to observing children and providing guidance to teachers regarding the management of children with behavioral problems and similar challenges. Noting the numerous barriers that vulnerable families encounter when they are referred to formal mental health agencies, Donahue et al. (2007) propose expanded use of mental health consultants to assist staff members in addressing the needs of troubled children and their parents in preschool settings. They encourage full integration of consultants into the day-to-day practices of preschool programs as well as in the communities they serve.

In early care and education programs that serve high numbers of vulnerable children, there is a need for services beyond the traditional activities of mental health consultants, such as observing children and helping teachers to plan effective classroom strategies. These programs often require professionals with the expertise to respond to parents’ concerns, assess families’ needs, and to work directly with children—in small groups and individually—to address the effects of trauma and other mental health issues. These services could be provided through an expansion of the early childhood mental health consultant role or by augmenting consultation services with those provided by early childhood mental health clinicians.

In evaluating Connecticut’s system for early childhood mental health consultation, Gilliam (2007) found that children in classes receiving consultation showed significant decreases in behavior problems compared to children in classes in which consultation was not available. The strongest effects were for decreased oppositional behaviors and hyperactivity.

Evaluations of several other early childhood mental health consultation programs documented the success of consultation in improving staff competence and confidence in working with children with challenging behaviors. Some of the programs also showed reduction in staff members’ levels of stress and rates of staff turnover, as well as improvements in overall program quality (Raver, Li-Grining, Metzger, Jones, Zhai, & Solomon, 2009; Duran, Hepburn, Irvine, Kaufmann, Anthony, Horen, & Perry, 2009; Brennan, Bradley, Allen, & Perry, 2008; Perry, Allen, Brennan, & Bradley, in press; Johnston & Brinamen, 2006). These studies demonstrate the potential effectiveness of highly trained and supported mental health consultants in addressing problems that are among those most frequently identified as barriers to school readiness and school success (Raver & Knitzer, 2002).

Building Effective Partnerships with Mental Health and Other Systems

While increased availability and expansion of roles of early childhood mental health consultants may facilitate the on-site delivery of some mental health services to children and families, it will not meet all or even most of the needs of vulnerable families. Therefore, leaders of early care and education programs must develop effective partnerships with systems that offer the resources and services that these families need. Collaboration with mental health and domestic violence systems are especially important given the prevalence of substance abuse, depression, and other mental health disorders as well as domestic violence in the families of children who are often most vulnerable. Such partnerships should include clear procedures for making referrals and addressing confidentiality, as well as an exploration of opportunities to develop cross-training of program staff (Center on the Social and Emotional Foundations for Early Learning [CSEFEL], n.d.). The work of early care and education teachers would benefit from increased understanding of the symptoms and effects of parents’ mental illness, substance abuse, or domestic violence, while clinicians in these settings could develop increased capacity to provide holistic services with training in early childhood development. Similar partnerships could be developed with organizations that provide home visiting, family support, and child welfare services, as well.

Vermont’s Children’s UPstream Project (CUPS) is perhaps the best-developed, statewide model of this type of service linkage and cross-disciplinary collaboration. CUPS builds and expands partnerships between early childhood service providers with those providing health and mental health, substance abuse, and domestic violence services in an effort to better meet the needs of vulnerable young children and their families. This project has expanded opportunities for cross-disciplinary training, increased access to early childhood mental health consultation, and facilitated the delivery of comprehensive, customized “wraparound” services for high-risk families. The development of specialized services for mothers with substance abuse and mental health problems and their children is an especially noteworthy accomplishment of Vermont’s improved system (Bean, Biss, & Hepburn, 2007).

Ongoing Teacher Training and Support

Working with children who present a broad array of emotional and behavioral problems is challenging under the best of circumstances but is even more difficult when teachers do not have a good understanding of the causes of these problems and tools and strategies for addressing them. Experience suggests that early care and education personnel will benefit from access to preservice as well ongoing training on topics related to social and emotional development and interventions for addressing emotional and behavioral problems in their classrooms. Teacher training may be especially beneficial if it includes techniques for engaging low-income and difficult-to-engage parents, for communicating with them in strengths-based and supportive ways, and for forming effective teacher-parent partnerships (CSEFEL, n.d.).In order to support such relationship-building, some scholars have suggested that it is important to assist teachers in understanding the multiple challenges facing families in poverty and in addressing any negative stereotypes that they may hold regarding such families (Lott, 2002).

A strong example of a comprehensive teacher training and support program is Day Care Plus, which originated in Cleveland, Ohio. Through a partnership between the county community mental health board, the local child care resource and referral agency, and a nonprofit, social service agency, the leaders of this initiative developed a consultation and outreach program for neighboring child care centers. Day Care Plus uses a train-the-trainer approach to build the centers’ capacities for working with challenging young children and their families. The program also provides family advocates to assist parents with a range of needs (Manos, Farwell, & Rosenbaum, 2007).

Some research suggests that teachers need access to help for managing the stress associated with caring for groups of young children, particularly those with difficult behaviors. A national study of preschool expulsion rates found that children were most often expelled because of behavior problems and that teachers who reported expelling children also reported higher levels of overall stress. Preschool teachers with access to early childhood mental health consultation reported lower levels of stress and lower expulsion rates (Gilliam, 2008). Consultants use a number of tools, including reflective supervision, which focus on building relationships and developing carefully constructed approaches to challenging situations. This type of supervision facilitates well-planned, theory-based interactions with children, parents, and co-workers and is aimed toward reducing crises and disruptions in early care and education settings (Perry & Kaufman, 2009; Gilkerson, 2004).

In addition to providing access to mental health consultants, early care and education programs might find it helpful to offer teachers assistance with stress management skills and other wellness-promotion strategies. Maintaining manageable class size and teacher-student ratios and ensuring that the hours that teachers work are reasonable with an adequate frequency of breaks would also help mitigate levels of stress experienced by early care and education teachers (Gilliam, 2008).

Lessons from Head Start and Early Head Start

The federal Head Start program has developed a comprehensive approach to supporting early childhood mental health with the use of mental health consultants and a wide variety of training and technical assistance programs aimed toward improving staff members’ competence in addressing emotional and behavioral problems in preschool children from low-income families (Yoshikawa & Knitzer, 1997). As with other aspects of Head Start, emphasis is placed on engaging and strengthening families in order to provide comprehensive and culturally relevant services. Head Start’s Family Connections Project, based at Children’s Hospital Boston, is particularly noteworthy for its focus on working with families affected by parental depression and related adverse conditions. Family Connections offers a wide range of professional development tools for supporting children, parents, and program staff members in ameliorating the impact of these conditions in preschool settings (Family Connections Project, 2008).

Early Head Start has included a significant focus on early childhood mental health since it was launched in 1995. While this federal program’s inclusion of pregnant women and its home-visiting component distinguish it from most other early care and education programs, the strategies used by Early Head Start are applicable to a wide array of early childhood settings. Early Head Start service providers are encouraged to work toward preventing the development of mental health problems, intervene early when risks for such problems are identified, and address existing mental health problems in the infants and toddlers they serve (Solchany & Barnard, 2004). Early Head Start programs support this work by providing frequent, reflective supervision of staff members and access to consultation from mental health specialists as well as inservice training on methods for recognizing and meeting the mental health needs of young children and their families (Emde, Bertacchi, & Mann, 2001).

Early Head Start emphasizes strengthening parent-child relationships as critical to its objectives for healthy social and emotional development. Programs utilize a variety of tools and strategies in this work, including the Parent-Child Communication Coaching (P-CCC) program, which promotes healthy parent-child attachment while educating parents about the social and emotional development of their infants and toddlers. Home visitors coach parents in their interactions with their children and use specific activities, materials, and videotape to support positive relationships and optimal child development (Solchany & Barnard, 2004). Early Head Start’s approach to strengthening parent-child relationships through the P-CCC program and other strategies could be adapted for use in other early care and education programs, particularly those that serve a high number of vulnerable young children and their families.  

Implications for Research and Policy

Research and Program Evaluation Agenda

While there has been significant progress in a number of states and at the federal level toward providing a more comprehensive and coherent approach to promoting early childhood mental health, much remains to be accomplished. Despite the current focus on identifying evidence-based and scientifically proven interventions for vulnerable children and families, not enough is known about what works for those children and families at the highest levels of risk. While extreme poverty and the presence of parents’ mental illness or substance abuse and domestic violence are well recognized as having particularly deleterious effects on the development of young children, additional information is needed about the effectiveness of specific interventions or intervention strategies aimed toward ameliorating these effects (Raikes, Love, Kisker, Chazan-Cohen, & Brooks-Gunn, 2004). Emphasis should be placed on testing intervention strategies that are based on the recognition that there are strengths to be found in families even at extreme levels of poverty and that work to identify strengths and support resilience in children and their families (Saleebey, 2008; Walsh, 2002; Knitzer, 2000).

Much of the research in early childhood mental health has focused on mother-child relationships and the effects of impairments in mothers’ ability to nurture and respond to their children. Much less is known about the role of fathers in relation to the mental health of young children. It would be particularly informative to assess the degree to which healthy father-child relationships mediate against risk when mothers are unable to provide adequate care because of mental health or substance abuse problems. Perhaps Early Head Start, with its emphasis on engaging fathers as caregivers, would provide a suitable setting for this type of research (Johnson, 2004).

Similarly, more information is needed about how families’ cultural practices and beliefs affect risk for social and emotional problems in young children. This information is especially important given the disproportionate rates of poverty among families of color—including recent immigrant families. Many of the constructs that underlie prominent frameworks for understanding early childhood mental health, such as parent-child attachment, are based on cultural assumptions that may cause misunderstanding and misguided interventions when applied to a diverse population of young children and their families (Huang & Isaacs, 2007; Lazear et al., 2008; Rothbaum, Weisz, Pott, Miyake, & Morelli, 2000). Carefully designed studies that account for such differences are likely to be very useful in developing strategies that build on the strengths of various cultural traditions and practices to promote optimal mental health in young children, their parents, and other caregivers.

Additional program evaluation that focuses on early childhood mental consultation and its apparent role in reducing behavior problems and rates of expulsion in early care and education settings is needed. A key obstacle to rigorous evaluation, as noted by Gilliam (2007), is that the structure and functions of this type of consultation vary widely across systems and individual programs, making cross-program comparisons difficult. Further evaluation should focus on identifying the characteristics—including education and training—of effective early childhood mental health consultants and the frequency and intensity of consultation services needed for maximum effects. Information about the degree to which positive effects of the consultation—on both the children and the classrooms served—are sustained would also be very useful (Brennan et al., 2008; Gilliam, 2007).

Policies for Building Comprehensive Systems

A number of policy issues related to early care and education programs’ capacity to promote optimal social and emotional development in young children require attention. This capacity is often curtailed by policies at the state and federal levels that keep relevant resources in distinct funding categories or “silos” (Ripple & Zigler, 2003). Along with the separate administration of funding for early care and education, adult and child mental health, substance abuse, and domestic violence programs are separate sets of program objectives and strategies to achieve them. While efforts are being made, at both state and federal levels, to reduce barriers and improve the coordination of these programs, they remain poorly aligned and hamper efforts to develop truly comprehensive systems that address the needs of children in the context of their families and early care and education programs. Reducing barriers between early care and education programs and those that provide early intervention and child protective services is especially important given that a high number of vulnerable children and families are served by the latter two systems (Knitzer & Lefkowitz, 2006; Knitzer, 2000).

Through its “System of Care” initiative, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) is working with states to remove barriers and integrate substance abuse and mental health services with a broad range of other services and programs that serve children and families. SAMHSA’s Project Launch has begun to fund much-needed improvements in a number of states for planning, service coordination, workforce development, and promotion of best practices that support healthy social and emotional development in children ages birth through age 8 (SAMHSA, 2009).

A useful framework for structuring systems that support the social and emotional development of young children in early care and education programs is the Pyramid Model, developed by the Center on the Social and Emotional Foundations for Early Learning (CSEFEL) and the Technical Assistance Center on Social Emotional Intervention for Young Children (TACSEI), with support from the federal government and private foundations. The widest part of the Pyramid focuses on creating “nurturing and responsive care-giving relationships” and “high quality supportive environments” for all children, while a narrower portion represents the provision of “targeted social emotional supports” for children at-risk for behavior problems. The peak of the Pyramid represents “intensive interventions” for children exhibiting serious emotional and behavioral problems (TACSEI, n.d.; Perry & Kaufman, 2009). The Pyramid Model encompasses the primary prevention of mental health problems as well as levels of intervention for children already experiencing difficulties. Several states are working to implement an increasingly comprehensive approach to supporting early childhood mental health utilizing the Pyramid Model, which emphasizes the coaching of early care and education professionals in the use of evidence-based practices (Perry & Kaufman, 2009; TACSEI, n.d.).

At the foundation of the Pyramid Model is a workforce that is well trained in meeting the social and emotional needs of young children (TACSEI, n.d.). However, national surveys have identified shortages in the number of professionals with adequate proficiency in early childhood mental health services and in the number of programs for training them (Meyers, 2007; Korfmacher & Hilado, 2008). States should work toward increasing the number of professionals with extensive expertise in this area who could serve as coaches or early childhood mental health consultants. In order to be effective, early childhood mental health consultants must have expertise in child development and child and adult mental health. In addition, skills in working with very young children, parents, and other professionals, including teachers, are necessary. Mental health consultants must also be able to work across a wide variety of systems because they link both early care and education programs and families with other resources (Duran et al., 2009). This is a tall order, yet it aptly describes what early childhood mental health consultants are required to do. Moreover, there is a need for training in early childhood mental health among teachers, primary health care providers, child protective workers, and virtually all professionals and paraprofessionals who work with children and families.

Meyers (2007) reports on a few states that have developed systems that prepare a wide range of service providers to identify and address the social and emotional needs of young children and their families. Policy makers in Florida have created a system to provide training to a wide range of service providers, including foster parents and law enforcement personnel. Other efforts include establishing specialized graduate programs and continuing education programs for children’s mental health professionals. An integrated training model for health and mental health consultants in early care and education programs has been developed in Connecticut, while leaders in Vermont have created comprehensive core competencies that address four domains of mental health in young children: (1) child, (2) family, (3) community and interpersonal relationships, and (4) teamwork. Michigan has a well-developed professional development system that recognizes four levels of competence and expertise—the most advanced of which is the Infant Mental Health Mentor. At this level, a professional is considered qualified to train and supervise other professionals and lead programs and policy initiatives. Various elements of these systems could be adapted by other states to address both the shortage of early childhood mental health professionals and the need to develop expertise in a wide range of service providers.

A final policy and research issue pertains to the ways in which expected outcomes of early childhood programs are described. In an effort to gain widespread support for the expansion of prekindergarten and other early care and education programs, advocates are increasingly promising that these programs will produce large and enduring gains in school readiness and well-being for all, if not most, of the children who participate in them. Such outcomes are highly unlikely for programs serving large numbers of young children and families in poverty without the resources necessary to address the complex challenges that these children and families bring. It is critically important that leaders in the early care and education field describe these challenges and provide detailed information about the additional resources as well as the policy changes that are needed to enhance, expand, and better coordinate services—especially for young children at the highest levels of risk. Policy makers must be made to understand the powerful social and economic forces that jeopardize the current and future well-being of so many young children, what it really will take to meet the needs of these children in early care and education settings, and the consequences of not providing the necessary resources and failing to remove barriers to effective service delivery.

References

Bean, Brenda J.; Biss, Charles A.; & Hepburn, Kathy S. (2007). Vermont’s Children’s UPstream Project: Statewide early childhood mental health services and supports. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 169-188). Baltimore, MD: Paul H. Brookes.

Brennan, Eileen M.; Bradley, Jennifer R.; Allen, Mary Dallas; & Perry, Deborah F. (2008). The evidence base for mental health consultation in early childhood settings: Research synthesis addressing staff and program outcomes. Early Education and Development, 19(6), 982-1022.

Brooks-Gunn, Jeanne, & Duncan, Greg, J. (1997). The effects of poverty on children. Future of Children, 7(2), 55-71.

Carter, Alice S.; Garrity-Rokous, Elizabeth F.; Chazan-Cohen, Rachel; Little, Christina; & Briggs-Gowan, Margaret J. (2001). Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. Journal of the American Academy of Child & Adolescent Psychiatry, 40(1), 18-26.

Center on the Social and Emotional Foundations for Early Learning. (n.d.). Research synthesis: Infant mental health and early care and education providers. Retrieved January 11, 2010, from http://www.vanderbilt.edu/csefel/documents/rs_infant_mental_health.pdf

Corvo, Kenneth, & Carpenter, Elizabeth H. (2000). Effects of parental substance abuse on current levels of domestic violence: A possible elaboration of the intergenerational transmission processes. Journal of Family Violence, 15(2), 123-135.

Donahue, Paul J.; Falk, Beth; & Provet, Anne Gersony. (2007). Promoting social-emotional development in young children: Mental health supports in early childhood environments. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 281-312). Baltimore, MD: Paul H. Brookes.

Douglas-Hall, Ayana, & Chau, Michelle. (2007, November). Parents’ low education leads to low income, despite full-time employment. New York: National Center for Children in Poverty, Columbia University. Retrieved January 6, 2010, from http://www.nccp.org/publications/pub_786.html

Duran, Frances; Hepburn, Kathy; Irvine, Marisa; Kaufmann, Roxane; Anthony, Bruno; Horen, Neal; & Perry, Deborah. (2009, August). What works? A study of effective early childhood mental health consultation programs. Washington, DC: Georgetown University Center for Child and Human Development.

Emde, Robert N.; Bertacchi, Judith; & Mann, Tammy L. (2001). Organizational environments that support mental health. Zero to Three, 22(1), 67-69.

Family Connections Project. (2008). Family connections materials: A comprehensive approach in dealing with parental depression and related adversities. Washington, DC: Early Childhood Learning and Knowledge Center. Retrieved January 6, 2010, from http://eclkc.ohs.acf.hhs.gov/hslc/ecdh/Mental%20Health/Resources %20&%20Support%20for%20Families/Parental%20Depression/FamilyConnection.htm

Fantuzzo, John; Stoltzfus, Jill; Lutz, Megan Noone; Hamlet, Helen; Balraj, Vijaykumar; Turner, Colleen; & Mosca, Samuel. (1999). An evaluation of the special needs referral process for low-income preschool children with emotional and behavioral problems. Early Childhood Research Quarterly, 14(4), 465-482.

Gilkerson, Linda. (2004). Irving B. Harris distinguished lecture: Reflective supervision in infant-family programs: Adding clinical process to nonclinical settings. Infant Mental Health Journal, 25(5), 424-439.

Gilliam, Walter S. (2007, May 15). Early childhood consultation partnership: Results of a random-controlled evaluation. Retrieved January 6, 2010, from http://www.chdi.org/admin/uploads/5468903394946c41768730.pdf

Gilliam, Walter S. (2008, January). Implementing practices to reduce the likelihood of preschool expulsion. (Foundation for Child Development Policy Brief, Advancing PreK-3, No. 7). Retrieved January 6,2010, from http://www.fcd-us.org/usr_doc/ExpulsionBriefImplementingPolicies.pdf

Halpern, Robert. (2000). Early intervention for low-income children and their families. In Jack P. Shonkoff & Samuel J. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp. 361-386). Cambridge, UK: Cambridge University Press.

Hans, Sydney L.; Bernstein, Victor J.; & Henson, Linda G. (1999). The role of psychopathology in the parenting of drug-dependent women. Development and Psychopathology, 11(4), 957-977.

Huang, Larke N., & Isaacs, Mareasa R. (2007). Early childhood mental health: A focus on culture and context. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 37-62). Baltimore, MD: Paul H. Brookes.

Johnson, Jeffery M. (2004). Dads and babies: Early Head Start and fathers. In Joan Lombardi & Mary M. Bogle (Eds.), Beacon of hope: The promise of Early Head Start for America’s youngest children (pp. 96-107). Washington, DC: Zero to Three.

Johnston, Kadija, & Brinamen, Charles. (2006). Mental health consultation in child care: Transforming relationships among directors, staff and families. Washington, DC: Zero to Three.

Kagan, Sharon L., & Neuman, Michelle J. (2000). Early care and education: Current issues and future strategies. In Jack P. Shonkoff & Samuel J. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp. 338-360). Cambridge, UK: Cambridge University Press.

Kaufman, Roxane K., & Hepburn, Kathy S. (2007). Early childhood mental health services and supports through a systems approach. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 63-96). Baltimore, MD: Paul H. Brookes.

Knitzer, Jane. (2000). Promoting resilience: Helping young children and parents affected by substance abuse, domestic violence, and depression in the context of welfare reform. New York: National Center for Children in Poverty, Columbia University.

Knitzer, Jane, & Lefkowitz, Jill. (2006, January). Helping the most vulnerable infants, toddlers, and their families (Pathways to Early School Success Issue Brief No. 1). New York: National Center for Children in Poverty, Columbia University.

Knitzer, Jane; Theberge, Suzanne; & Johnson, Kay. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework (Project Thrive Issue Brief No. 2). New York: National Center for Children in Poverty, Columbia University.

Koplow, Lesley (Ed.). (1996). Unsmiling faces: How preschools can heal. New York: Teachers College Press.

Kormacher, Jon, & Hilado, Aimee. (2008). Creating a workforce in early childhood mental health: Defining the competent specialist (Research Report No. 1). Chicago: Herr Research Center for Children and Social Policy, Erikson Institute. Retrieved on February 26, 2010, from http://www.erikson.edu/hrc/publications/hrcpubsdate.aspx

Lazear, Katherine J.; Pires, Sheila A.; Isaacs, Mareasa R.; Chaulk, Patrick; & Huang, Larke. (2008). Depression among low-income women of color: Qualitative findings from cross-cultural focus groups. Journal of Immigrant and Minority Health, 10(2), 127-133.

Lott, Bernice. (2002). Cognitive and behavioral distancing from the poor. American Psychologist, 57(2), 100-110.

Lyons-Ruth, Karlen. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early attachment patterns. Journal of Consulting and Clinical Psychology, 64(1), 64-73.

Manos, Melissa; Farwell, Sally; & Rosenbaum, Jeffrey D. (2007). Early childhood mental health in Cuyahoga County, Ohio. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 189-210).Baltimore, MD: Paul H. Brookes.

Meyers, Judith C. (2007). Developing the work force for an infant and early childhood mental health system of care. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 97-120). Baltimore, MD: Paul H. Brookes.

National Center for Children in Poverty. (n.d.). United States early childhood profile. Retrieved January 6, 2010, from http://nccp.org/profiles/pdf/profile_early_childhood_US.pdf

Osofsky, Joy D., & Thompson, M. Dewana. (2000). Adaptive and maladaptive parenting: Perspectives on risk and protective factors. In Jack P. Shonkoff & Samuel J. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp. 54-75). Cambridge, UK: Cambridge University Press.

Perry, Deborah; Allen, Mary; Brennan, Eileen; & Bradley, Jennifer R. (in press). The evidence base for mental health consultation in early childhood settings: Research synthesis addressing child behavioral outcomes. Early Education and Development.

Perry, Deborah F., & Kaufman, Roxanne K. (2009, November). Policy brief: Integrating early childhood mental health consultation with the Pyramid Model. Tampa, FL: Technical Assistance Center on Social Emotional Intervention for Young Children. Retrieved January 6, 2010, from http://www.challengingbehavior.org/do/resources/briefs.htm

Petterson, Stephen M., & Albers, Alison Burke. (2001). Effects of poverty and maternal depression on early childhood development. Child Development, 72(6), 1794-1813.

Pollack, Harold A.; Danziger, Sheldon; Jayakody, Rukmalie; & Seefeldt, Kristin S. (2002). Drug testing welfare recipients—false positives, false negatives, unanticipated opportunities. Women’s Health Issues, 12(1), 23-31.

Raikes, Helen H.; Love, John M.; Kisker, Ellen Eliason; Chazan-Cohen, Rachel; & Brooks-Gunn, Jeanne. (2004). What works: Improving the odds for infants and toddlers in low-income families. In Joan Lombardi & Mary M. Bogle (Eds.), Beacon of hope: The promise of Early Head Start for America’s youngest children (pp. 20-43). Washington, DC: Zero to Three.

Raver, C. Cybele, & Knitzer, Jane. (2002). Ready to enter: What research tells policymakers about strategies to promote social and emotional school readiness among three- and four-year-old children. New York: National Center for Children in Poverty, Columbia University, Mailman School of Public Health.

Raver, C. Cybele; Li-Grining, Christine; Metzger, Molly W.; Jones, Stephanie M.; Zhai, Fuhua; & Solomon, Bonnie. (2009). Targeting children’s behavior problems in preschool classrooms: A cluster-randomized controlled trial. Journal of Consulting and Clinical Psychology, 77(2), 302-316.

Ripple, Carol H., & Zigler, Edward. (2003). Research, policy, and the federal role in prevention initiatives for children. American Psychologist, 58(6/7), 482-490.

Rothbaum, Fred; Weisz, John; Pott, Martha; Miyake, Kazuo; & Morelli, Gilda. (2000). Attachment and culture: Security in the United States and Japan. American Psychologist, 55(10), 1093-1104.

Saleebey, Dennis. (2008). The strengths perspective in social work practice (5th ed.). Boston: Allyn & Bacon.

Schaefer, Stephanie A.; Kreader, J. Lee; Collins, Ann M.; & Lawrence, Sharmila. (2006). Predictors of child care subsidy use. New York: National Center for Children in Poverty, Columbia University. Retrieved February 26, 2010, from http://www.nccp.org/publications/pdf/text_710.pdf

Scheeringa, Michael S., & Zeanah, Charles H. (2001). A relational perspective on PTSD in early childhood. Journal of Traumatic Stress, 14(4), 799- 815.

Shahinfar, Ariana; Fox, Nathan A.; & Leavitt, Lewis A. (2000). Preschool children's exposure to violence: Relation of behavior problems to parent and child reports. American Journal of Orthopsychiatry, 70(1), 115-125.

Solchany, JoAnne E., & Barnard, Kathryn E. (2004). First relationships: Infant mental health in Early Head Start. In Joan Lombardi & Mary M. Bogle (Eds.), Beacon of hope: The promise of Early Head Start for America’s youngest children (pp. 20-43). Washington, DC: Zero to Three.

Substance Abuse and Mental Health Services Administration. (2009, October 8). Project Launch. In SAMHSA portfolio of programs and activities (pp. 118-120). Washington, DC: Author. Retrieved January 6, 2010, from http://samhsa.gov/About/SPPA/SPPA2009.pdf

Technical Assistance Center on Social Emotional Intervention for Young Children. (n.d.). The Pyramid Model for promoting the social and emotional needs of infants and toddlers fact sheet. Retrieved on February 26, 2010, Retrieved January 6, 2010, from http://www.challengingbehavior.org/do/resources/briefs.htm

Thompson, Ross A., & Raikes, H. Abigail. (2007). The social and emotional foundations of school readiness. In Deborah F. Perry, Roxane K. Kaufmann, & Jane Knitzer (Eds.), Social and emotional health in early childhood: Building bridges between services and systems (pp. 13-36). Baltimore, MD: Paul H. Brookes.

U.S. General Accounting Office. (1998, November). Domestic violence: Prevalence and implications for employment among welfare recipients (GAO/HEHS-99-12). Washington, DC: Author.

Walsh, Froma. (2002). A family resilience framework: Innovative practice applications. Family Relations, 51(2), 130-138.

Webb, Nancy Boyd. (2003). Social work practice with children (2nd ed.). New York: Guilford Press.

Whitaker, Robert C.; Orzol, Sean M.; & Kahn, Robert S. (2006). Maternal mental health, substance use, and domestic violence in the year after delivery and subsequent behavior problems in children at age 3 years. Archives of General Psychiatry, 63(5), 551-560.

Yoshikawa, Hirokazu, & Knitzer, Jane. (1997). Lessons from the field: Head Start mental health strategies to meet changing needs. New York: National Center for Children in Poverty, Columbia University.

Author Information

Lenette Azzi-Lessing, Ph.D., is an assistant professor in the School of Social Work and Family Studies at Wheelock College, Boston. She has extensive experience in building and leading community-based programs for disadvantaged young children and their families.

Lenette Azzi-Lessing, Ph.D.
Assistant Professor of Social Work
Wheelock College
200 The Riverway
Boston, MA 02215
Telephone: 617-879-2377
Email: lalessing@wheelock.edu