early childhood mental health

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HealthyGenerations

A p blicati n the Center r LeadershipEd cati n in Maternal and Child P blic Health

Winter 2009-2010

Screening Y ng Children

Evidence-based Practices

Early Childh d Family Ed cati n

Mental Health Disparities in Early Childh d

Early Childh d Interventi ns

Tra matized Y ng Children

C mpetency-based Training and End rsement

Experts and Res rces

Early Childh dMental Health



Early Childh dMental Health

Winter 2009-2010

The Center f r Leadership Ed cati n in Maternal and ChildP blic Health is committed to improving the health o children, womenand amilies. Center aculty and sta o er a Master’s degree in Public Health(including an online degree program), continuing pro essional education, andconsultation and technical assistance to community- based organizations andagencies. Center aculty are involved in intervention and etiologic research inchild health, adolescent health, amily health, health dispar ities, reproductivehealth, and women’s health. See our web site at www.epi.umn.edu/mch.

Health Generati nsis produced with support rom the Maternal and Child Health Bureau,Health Resources and Services Administration, U.S. Department o Health and HumanServices (grant numberT76-MC00005-55)The University o Minnesota is committed to the policy that all persons shall have equalaccess to its programs, acilities, and employment without regard to race, color, creed,religion, national origin, se , age, marital status, disability, public assistance status, veteranstatus, or se ual orientation.Contact: [email protected] or (612) 626-8644© 2009 by University o Minnesota Board o Regents. All rights reserved.Graphic design/art direction: Carr Creatives(www.carrcreatives.com)

A Public Health Approach to EarlyChildhood Mental Health: Balancing MentalHealth Promotion and Treatment or MentalHealth Problems . . . . . . . . . . . . . . . . . . . . 2

J än M. Patters n, PhD, LP

Early E perience and the Science o BrainDevelopment . . . . . . . . . . . . . . . . . . . . . . . 5

Megan R. G nnar, PhD, and the Nati nal Scientifc C ncil n the Devel ping Child

Social-Emotional DevelopmentalScreening o Young Children. . . . . . . . . . . 7

Tr Hans n, MD, and J än Patters n,PhD, LP

Diagnosing Young Children with MentalHealth Concerns . . . . . . . . . . . . . . . . . . . 10

Catherine Wright, MS

Early Childhood Mental Health SystemsDevelopment in Minnesota . . . . . . . . . . . 11


Evidence-based Practices in Early ChildhoodMental Health. . . . . . . . . . . . . . . . . . . . . . 13

Glenace E. Edwall, Ps D, PhD, LP, MPP

Early Childhood Family Education (ECFE):A Mental Health Promotion Program orYoung Children and Families . . . . . . . . . . 15

L is Engstr m

Clinical and Public Health Perspectives onMental Health Disparities in EarlyChildhood . . . . . . . . . . . . . . . . . . . . . . . . 17

Andrea Aga

Family Home Visiting: A Public HealthProgram to Promote Healthy Social-Emotional Development . . . . . . . . . . . . . 19

Shar n Hesseltine, BSW Jill E. Sim n, MSW, LICSW, IMH-E® (IV)

Follow Along Program: An Early ChildhoodIntervention System at the MinnesotaDepartment o Health . . . . . . . . . . . . . . . 20

Andrea Ma feld

Part C IDEA, Early Intervention Services:Serving Children Under 3 Years with Mental

Health Concerns . . . . . . . . . . . . . . . . . . . 21Karen Adams n, RN, MPH

Minnesota Head Start: Addressing MentalHealth Needs Early . . . . . . . . . . . . . . . . . 22

Ga le L. Kell , MS

Promoting In ant Mental Health throughRelationship-Based Interventions . . . . . . 24

Martha Farrell Ericks n, PhD

Promoting Early Childhood Mental Healththrough Evidence-based Practice. . . . . . . 26

Gael Th mps n, MSW, LICSW

Supporting the Mental Health Needs o Traumatized Young Children . . . . . . . . . . 28

Abigail Gewirt , PhD, LP

Minnesota Early Childhood ComprehensiveSystem (MECCS): Building the In rastructureto Meet Developmental Needs o YoungChildren . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Kell M ns n MAEd, CFLE

Center or E cellence in Children’s MentalHealth: Linking University and CommunityE perts and Resources . . . . . . . . . . . . . . 32

Cari Michaels, MPH

Culturally Sensitive, Relationship-based Practice Promoting In ant MentalHealth: Competency-Based Training andEndorsement . . . . . . . . . . . . . . . . . . . . . . 33

Candace Kragth rpe, MSW, IMH-E® (IV)

Bringing Order to the Comple ity o EarlyE perience: The Role o Training in In ant

Mental Health. . . . . . . . . . . . . . . . . . . . . . 34Eli abeth A. Carls n, PhD, LP

IN THIS ISSuE


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LETTER FRoM THE EDIToRS

In this issue o Healthy Generations , we ocus on the mental health o young children, ages birth to ve.We are aware that this domain o early childhood has too o en been overlooked—only recently drawing considerable pro essional attention. Why this lack o attention? Perhaps too many have believed that young children, especially in ants, cannot experience mental health problems. In ants who cry inconsolably or preschoolers who show excessive biting have o en been viewed as “going through a stage” that they will outgrow. Tis dismissive attitude ts the societal stereotype about mental health problems in general; that is, the tendency to ignore such challenges because a parent or caregiver does not know what to do, or worse, ears being blamed or their young child’s behavior. Dramatic advances in our understanding o early braindevelopment, the critical importance o social environments that stimulate and nurture, and the untoward consequences when relationships to provide this care are absent or unpredictable have taught us that thedevelopmental trajectory towards positive mental health begins early. We now know what can and MUS bedone to ensure that ALL in ants and young children receive what they need rom their caregiving environmentsto develop into happy, healthy children with positive mental well-being who grow into productive, contributing members o our society.

We want to thank the many pro essionals who contributed to this volume and shared their expertiseabout early childhood mental health. We are excited to see that public health thinking is being brought tobear in assuring the mental health o our young children. o present a balanced perspective—promoting positive mental health with attention to mental health problems—we invited articles that provide examples o interventions that promote mental health, prevent problems in high-risk groups, as well as interventions that treat diagnosed mental health disturbances—in all cases, emphasizing evidence-based practice. Other articlesin this volume highlight cutting edge issues related to early childhood mental health—screening and diagnosticassessment, collaborative e orts to develop early childhood and mental health systems o care, and work orcetraining initiatives in Minnesota.

We are keenly aware o the need or policies that provide public support or the programs and interventionsdescribed in this issue, as well as policies that assure the social conditions that enable amilies and communitiesto create nurturing, supportive contexts where children’s mental health can ourish.

We are pleased to showcase the wealth o in ormation and strength o resources presented by our pro essional colleagues in Minnesota. We are also very proud to share with our readers several articles writtenby graduates o our Maternal and Child Health Program at the University o Minnesota, who are leaders inthis eld. As we nalized this volume, we read, with sadness, that Norman Garmezy died on November 21,2009. Dr. Garmezy, a Pro essor Emeritus o Psychology at the University o Minnesota, was considered the“grand ather o resilience theory.” Among the many ndings o Dr. Garmezy and his colleagues was that good

relationships with adults exert an e ect that is as power ul—or even more power ul—than the mitigating e ects o adversity on child mental health. His work urthered our understanding o how children can ourishin adverse environments and continues to stimulate researchers at the University o Minnesota and across the globe.

As always, we welcome your eedback about this issue as well as topics or subsequent issues.

—Joän Patterson, PhD, LP, Julia Johnsen, MPH, and Wendy Hellerstdt, MPH, PhD



However, awareness o social, emotional,and behavioral problems in young childrenis increasing, as re ected in the growingnumber o young children who are expelled

rom preschool.3 A limited number o studies o psychiatric disorders (e.g., anxiety disorders, disruptive behavior disorder,attention de cit/hyperactivity disorder, anddepression) have reported prevalence ratesin preschool children ranging rom 14%to 26%, which are similar to rates reported

or school-age children.2 Newer diagnosticschemes, developed speci cally or birthto three years (see page 10), emphasizerelationship disorders and stress-relateddisorders resulting rom exposure toenvironmental stressors, but prevalencerates have not yet been reported.

Determinants Mental

Health in Y ng ChildrenDeterminants o mental health or the birthto 5-year-old population include biological,geographical, social, and economic actorsassociated with both positive mental healthand mental health problems.

Te quality o early relationships is themost undamental determinant o healthy social-emotional development in in antsand toddlers. A secure attachment to aprimary caregiver has an enduring in uenceon the mental health o young children.

Relationships with parents (and othercaregivers) need to be nurturing, protective,consistent, and characterized by highsensitivity to in ant cues.

Biological actorswithin the in ant, such asa di cult temperament or premature birthand low birth weight, may pose a challengeto some parents’ abilities to respondsensitively to in ant cues and develop anurturing relationship.

Te mental health o parents and caregivers is another major determinant o in ant

mental health because it in uences thecaregivers’ capacity to be nurturing andresponsive to their in ants and provideadequate stimulation or learning.Untreated postpartum depression inmothers is a recognized risk actor a ectingin ants’ social-emotional development.4 Among child care workers, higher rates o depression have been reported compared toadults in the general population.5

Social environment.Other actors in thesocial environment that can underminehigh quality early relationships and put

young children at risk or mental healthproblems include violence in the home orneighborhood, intense marital discord,parental substance abuse, and child abuseand neglect. Te e ects o these exposuresin in ants and young children may mani est in behaviors such as excessiveand inconsolable crying; a heightenedsensitivity to touch and cuddling; excessivebiting, kicking and hitting; inability to

ocus on activities; at a ect (no emotiveexpressions); and/or depression.

Poverty. Many o the a orementionedrisks are con ounded by living in a

amily experiencing persistent poverty.Children rom low-income amilies showhigher rates o emotional and behaviorproblems.6 Because children o color aredisproportionately represented amonglow-income amilies, they are reported

to experience poorer social-emotionaldevelopment. Poor, minority children alsoare more likely to be in the child wel aresystem—another setting where higher rateso social, emotional, and behavior problemsin young children are ound.7

However, when any o these determinantsare identi ed early, at-risk children andtheir caregivers can receive interventionsand support that can bu er mental healthproblems and lead to positive emotionaland social developmental outcomes.

A Framew rk t G ideMental Health Interventi nsGeorgetown University, with support romthe Substance Abuse and Mental HealthServices Administration (SAMHSA),recently released a monograph that drawson public health values, principles, and

unctions to advance an intervention modelor children’s mental health.8

Di erentiating positive mental health rom mental health problems. Unlike the

historical emphasis on preventing andtreating mental health problems in childrenand adolescents, this new interventionmodel proposes a balanced ocus betweenpositive mental health and mental healthproblems. Positive mental health is viewedalong a continuum that is independent o the continuum o mental health problems.8 Te absence o a mental health problemdoes NO indicate positive mental health,nor does having a diagnosable mentalillness prevent a child rom experiencingsocial-emotional well-being. Te emphasis

on optimizing positive mental health drawsrom recent psychological literature that

describes persons who are “ ourishing” incontrast to “languishing,”9 and rom a recenInstitute o Medicine report emphasizing“developmental competencies” in children.1

Emphasis on positive mental health is alsocongruent with public health’s ocus onhealth promotion (and disease prevention),and in ant/toddler mental healthpro essionals emphasis on the promotiono social and emotional competencies inyoung children.

Categories o interventions.In theGeorgetown model, interventions are notrestricted to preventing and treating mentahealth problems, but include interventionsto promote positive mental health aswell. Interventions are grouped into ourdomains:

■ Promoting and optimizing positivemental health in ALL children by assuring that the determinants o positive mental health are present (e.g.,Early Child and Family Educationprograms to support parents in howto engage in nurturing, consistentrelationships with their babies—seepage 15);

■ Preventing mental health problems inyoung children, especially those knownto be at risk due to exposure to any o the

determinants o mental health problems(e.g., home visiting—see page 19);

■ Treating diagnosed mental healthproblems as early as possible todiminish or end the e ects o theidenti ed problem (e.g., the IncredibleYears program or young children withconduct disorders—see page 26); and

■ Re/Claiming health or those childrenwho have been or continue to betreated or mental health disordersso they can develop and experience

mental well-being even in the contexto managing their mental healthproblem.

Nearly all o the interventions include aocus on the quality o the young child’s

early relationships with parents/caregivers.Viewing a child alone as the source o the problem, without considering his/her relationships, can lead to ine ectiveintervention practices. Although examples

or each category o intervention aredescribed throughout this issue, many t

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more than one category. It is importantto remember, however, that assessing theoutcomes o an intervention requires ashi in ocus when selecting indicators orpositive mental health (e.g., social skillsor emotional regulation) versus mentalhealth problems (e.g., reduction in anxiety symptoms).

A Mental Health SystemsAppr achFamilies are embedded in multiple systemswithin their cultures and communitiesthat ideally are equipped to support themin meeting their children’s emotionalneeds by providing education and supportand by identi ying social-emotionalproblems in young children early throughscreening in naturalistic settings (see page7) which can be ollowed by diagnostic

assessment (see page 10) and treatmentwhen needed. Te mental health systemalone cannot accomplish this goal; itrequires coordination with other systems—education, child care, nutritional programs,and healthcare—to ensure that youngchildren receive what they need to promotepositive mental health and to identi y andtreat problems when they occur. Wright(page 11) describes the mental healthsystem in Minnesota and Monson (page 30)describes a comprehensive early childhoodsystem in Minnesota that includes mentalhealth as one o several domains thatintersect to ensure healthy development inyoung children.

R le P blic P liciesin Ass ring Early Childh dMental HealthAwareness o the determinants o positivemental health and mental health problemspoint to the importance o assuring thesocial conditions that will contribute to theability o parents and amilies to engage innurturing relationships with young childrenand to provide adequate stimulation andexperiences or learning. It is the role o public policies to assure that those socialconditions exist.

raining. As our awareness o the mentalhealth needs o young children hasincreased, we are con ronted with thedearth o clinicians who are trained toscreen, diagnose, and treat in ants, toddlersand preschool children with mental healthproblems. In one study, it was estimated

that between 80–90% o 3–5-year-oldswith identi ed mental health needs did notreceive services.11 In Minnesota, inroadsare being made to expand early childhoodmental health training across the state (seeKragthorpe page 33 and Carlson page 34).

Tere is a growing recognition that thetrajectory to success, both in school andin later li e, begins in the early years. Whathappens during the rst three years o li ecan lay the oundation or becoming aproductive, mentally healthy, contributing

member o society, or it can lay theoundation or intergenerational cycles o abuse, neglect, violence, dys unction, andmental illness. Te burgeoning scienceo early brain development points to thewisdom o investing resources “early” in achild’s developmental trajectory, beginningin utero to eliminate toxic exposures thatcompromise brain development, andthen assuring the social conditions thatsupport and contribute to high quality nurturing and responsive parent-in antrelationships.5,10 Meeting the mental healthneeds o all young children and amiliesthrough care ul planning, integrationo services and supports, and the ullparticipation o amilies, providers, andother community members makes goodeconomic sense and helps assure goodoutcomes or our children, their amilies,and our communities.

REFERENCES

1. Zero to Tree In ant Mental Health Steering Committee.De nition o in ant mental health. Washington, D.C.:Zero o Tree; 2001. Available rom: http://www.zerotothree.org

2. Egger HL, Angold A. Common emotional andbehavioral disorders in preschool children: prevention,nosology, and epidemiology. J Child Psychol Psychiatr2006; 47:313-337.

3. Gilliam W. Prekindergarteners le behind: explusionrates in stae prekindergarten systems. New Have, C :Yale University Child Study Center, 2005.

4. National Research Council and Institute o Medicine.From neurons to neighborhoods: the science o early childhood development. Shonko JP, Phillips DA(editors). Washington DC: National Academy Press,2000.

5. Whitebook M, Phillips D, Bellm D, et al. wo yearsin early care and education: A community portrait o quality and work orce stability. Berkeley, CA: Center

Study o Child Care Employment, U o CA at Berkel2004.

6. Duncan GJ, Brooks-Gunn J. Family poverty, wel arere orm and child development. Child Dev 2000; 71:18196.

7. Burns B, Phillips S, Wagner H, et al. Mental health neeand access to mental health services by youths involvewith child wel are. A national survey. J Am Acad ChiAdolesc Psychiatry 2004; 43:960-970.

8. Miles J, Espiritu R, Horen N, Sebian J, Waetzig E. Apublic health approach to children’s mental health: aconceptual ramework. Washington DC: GeorgetownUniversity Center or Child and Human DevelopmentNational echnical Assistance Center or Children’sMental Health, 2009.

9. Keyes C. Promoting and protecting mental health asourishing. Am Psychol 2007; 62(2):95-108.

10. National Research Council and Institute o MedicinePreventing mental, emotional and behavioral disordersamong young people: progress and possibilities.Washington DC: National Academies Press, 2009.

11. New M, Razzino B, Lewin A, et al. Mental healthservice use in a community Head Start population. ArcPediatr Adolesc Med 2002; 156:721-727.

Joän Patterson, PhD, LP, is an Associate Pro essorin the Maternal and Child Health Program inthe School o Public Health at the University o Minnesota.

INTERVENING MODEL FOR CHILDREN’S MENTAL HEALTH6

Early Childhood Mental Health rom page 3



Brains Are B ilt over Timer m the B tt m up

Te construction o the brain’s architecturebegins be ore birth and continues to bere ned into early adulthood. Brain systemsthat perceive sensation (e.g., hearing,

touch) and simple actions develop rst,ollowed by systems that are involved inemotions, more complex actions, andearly language. Later-developing systemssupport increasingly complex thinking,reasoning, planning, and sel -control. Aseach brain system develops, it is built on topo earlier-developing systems and can beonly as good as the architecture on whichit is built. Early experiences a ect whethera child’s brain architecture will provide asturdy or ragile oundation or all o thelearning and development that will ollow.

Interactive Inf ences Genes and Experience

Shape the Devel ping BrainIt is not just one’s genetic makeup, buthow those genes get used, that determinesbrain development. Once the child is born,

experiences in uence how genes are turnedon and o and thus how they are used.One important example o this process isthe “serve and return” nature o children’srelationships with adults. Young childrennaturally reach out or interaction throughbabbling, acial expressions, and gestures.Adults respond with the same kind o vocalizing and gesturing back at them. Inthe absence o such responses—or i theresponses are unreliable or inappropriate—the child’s brain architecture does not orm

as expected, which can lead to disparities ilearning and behavior.

The Brain’s Capacity rChange Decreases with AgeTe brain is most exible, or “plastic,” early in li e. As the maturing brain becomesmore specialized to assume more complex

unctions, it is less capable o reorganizinand adapting to new or unexpectedchallenges. For example, by the rst year,the parts o the brain that di erentiatesound are becoming specialized to thelanguage the baby has been exposed to. Atthe same time, the brain is already startingto lose the ability to recognize di erentsounds ound in other languages. Althoughthe “windows” or language learning andother skills remain open, these brain

Science tells us that what happensin early childhood can enhance

or impair the health and productivity of society. Research on the biology o stress in early childhood showshow major adversity, such as extremepoverty, abuse, or neglect, can weaken

developing brain architecture and alterthe body’s immune system in ways thatrisk the individual’s adult physical andmental health. Science also shows thatproviding stable, responsive, nurturingrelationships in the earliest years o li e can prevent or even reverse thedamaging e ects o toxic stress, withli elong bene ts or learning, behavior,and health. Tis conclusion is based on

the ollowing series o core principlesderived rom decades o scienti cresearch.

Megan R. Gunnar, PhD, and the National Scientifc Council on the Developing Child

Early E perience and the

Science o Brain Development

Continued on page 6



circuits become increasingly di cult to alterover time. Early plasticity means it is easierand more e ective to in uence a baby’sdeveloping brain architecture than to rewireparts o its circuitry in the adult years.

Chr nic Stress Can Be T xict Devel ping BrainsLearning how to cope with threat andchallenge is an important part o healthy development. When we are threatened, ourbrains activate a variety o physiologicalresponses, which together are called “stressbiology.” When a young child is protectedby supportive relationships with adults, she/he learns to cope with everyday challengesand the child’s stress response systems

quickly return to baseline. Scientists callthis positive stress. olerable stressoccurswhen more serious di culties, such as theloss o a loved one, a natural disaster, or a

rightening injury, are bu ered by caringadults who help the child adapt, whichmitigates potentially damaging biologicalstress reactions. When strong, requent,or prolonged adverse experiences suchas extreme poverty or repeated abuseare experienced without adult supportand intervention, stress becomes toxicas the biology o stress begins to damage

developing brain circuits.

Signi cant Early AdversityCan Lead t Li el ngPr blemsoxic stressin early li e and common

precipitants o toxic stress—such as poverty,abuse or neglect, parental substanceabuse or mental illness, and exposure to violence—can have a cumulative toll onan individual’s physical and mental health.(Te more adverse the experiences are in

childhood, the greater the likelihood o developmental delays and other problems.)Adults who had a greater number o adverse experiences in early childhood arealso more likely to have health problems,including alcoholism, depression, and heartdisease.

Early Interventi n CanPrevent the C nseq ences Early T xic StressResearch shows that later interventionsare likely to be less success ul—and insome cases ine ective. For example, whenchildren who experienced extreme neglectwere placed in the care o responsive andsupportive parents be ore age two, their IQsincreased more substantially and their brainactivity and emotional relationships were

more likely to become normal than i they were placed a er the age o two. While thereis no “magic age” or intervention, it is clearthat, in most cases, intervening as early aspossible is signi cantly more e ective thanwaiting.

Stable, Caring Relati nshipsAre Essential r HealthyDevel pmentChildren develop in an environment o relationships that begins in the home and

includes extended amily members, early care and education providers, and memberso the community. Studies show thatchildren who develop in a context o securtrusting relationships are better adjustedwhen they get to school, do better inschool, stay in school longer, become more

productive and healthier members o thework orce as adults and are better equippeto support the healthy development o thenext generation. Numerous scienti c studiesupport the conclusion that providingsupportive, responsive relationships as earlin li e as possible enhances uture prosperand can prevent or reverse the damaginge ects o toxic stress.Tis article is based on the collective work o theNational Scienti c Council on the Developing Child.Working papers with scienti c citations or the researstudies re erred to can be ound at their website: httpdevelopingchild.harvard.edu/initiatives/council/

Megan R. Gunnar, PhD, is a Regents Pro essor anDistinguished McKnight University Pro essor in tInstitute o Child Development at the University o Minnesota. She is a member o the National ScienCouncil on the Developing Child.

Cognitive, emotional, and social

capacities are inextricably intertwined throughout the life course. Te brainis a highly integrated organ, and its

multiple unctions operate in a richlycoordinated ashion. Emotional

well-being and social competence provide a strong oundation or emerging

cognitive abilities, and together, theyare the bricks and mortar that are

prerequisites or success in school and later in the workplace and community.

Early Experience and the Science o Brain Development rom page 5



Why Is Screening Imp rtant?Problems or delays in early social-emotionaldevelopment represent the precursors o what can become a maladaptive mentalhealth trajectory. Research in developmentalpsychopathology draws attention to thecascading e ects o untreated problems thato en adversely a ect realms o unctioningat a tremendous cost to the child, his/her

amily, and society.

It is estimated that one in three childrenages 3–5 years ail to meet age-appropriatesocial and emotional developmentalmilestones.1 Early identi cation o thesesocial-emotional problems and subsequentdiagnostic assessment can direct youngchildren and amilies toward e ective,evidence-based early interventions,which provide an amazing opportunity topositively alter mental health trajectoriesand improve mental health outcomesthroughout the li e course. I these delaysare not ound early, a child misses theopportunity or early interventions.

What Is S cial-Em ti nalDevel pmental Screening?Social-emotional screening is designedto identi y children who should receivemore intensive assessment and diagnosis

or potential delays in social-emotionaldevelopment. Screening shouldnot be done

to label a child and it does not provide adiagnosis. Rather, screening is the rst steptoward the possibility o a diagnosis. Ideally,screening is done using a standardizedtool to identi y social-emotional concernsor problems. Most general developmentalscreening tests that are designed to assessother domains—such as cognitive or motordevelopment—donot adequately capturesocial and emotional development. Tus

separate instruments have been designedto identi y children who are at risk o social-emotional problems.

Choosing a social-emotional screening instrument. A screener, rst o all, shouldbe easy or a parent to complete in a shortamount o time (30 minutes or less). Itshould have norms or speci c age groupstested; demonstrate good reliability, validity,sensitivity, and speci city; and have writtenprocedures or administration, scoring,and interpretation. Te screener should be

culturally sensitive or diverse populationsincluding those or whom English is asecond language. Tree screening tools thatmeet these criteria are recommended by the Minnesota Interagency DevelopmentalScreening ask Force2 (see the box).Te Ages and Stages Questionnaire:Social-Emotional (ASQ:SE)3 is thesocial-emotional screening tool most widelused by providers in multiple settings.

Settings r Devel pmentalScreeningEarly identi cation o social-emotionaldelays or problems necessitates thatscreening occurs in settings regularly accessed by in ants, young children, andtheir amilies, and where such screening isperceived as appropriate and acceptable.

Te primary health care setting is one o those regularly accessed settings because 1health supervision visits are recommended

or children between birth and 5 years.4

Social and emotional developmentalscreening is an essential component

in the early identi cation o mentalhealth problems in young children.Ideally, screening occurs with ALLchildren when there are no symptomspresent, long be ore an in ant’s or young

child’s development and unctioning areimpaired.

roy Hanson, MD, and Joän Patterson, PhD, LP

Social-Emotional Developmental Screening o Young Children

The First Step in Identi ying Mental Health Problems

Continued on page 8



Even with this relatively high number o potential contacts with health pro essionalit is estimated that only 20–40% o “at-riskor “pre-impaired” children are appropriatelyidenti ed during this period o peak neuraplasticity or receptivity to change.1

Barriers to early identi cation in primarycare. Tere are many reasons why somany young children “ all through thecracks” and remain unidenti ed duringhealth supervision visits—but one o the signi cant actors is ailure to use astandardized, validated screening tool.oo many providers use their subjective

judgment about whether a young childhas social-emotional problems. When anempirically validated social-emotionaldevelopmental screening tool issystematically employed, accurate detectiorates o social-emotional problems increas

to 70–80%.5

Many parents believe that their child cannohave a mental health problem, or that heor she will “outgrow” disruptive behaviorproblems, extreme shyness or anxiety,excessive irritability, di culty in orming

riendships, and so on. Tese societalattitudes are rooted in the stigma associatedwith mental illness generally, as well asa lack o mental health knowledge andawareness among some parents, child carepro essionals, and even health providers.

Te Centers or Disease Control andPrevention provide guidelines or healthproviders when interpreting screeningresults (see chart).6 Screening itsel can bean intervention when results are reviewedwith the parent/caregiver and strengthsas well as possible delays are discussed. Inaddition, anticipatory guidance can alertparents about what to watch or and do athome to oster healthy development.

Child care and early education settings are another regularly accessed setting usedby amilies o in ants and young childrenHead Start and Early Head Start nowrequire screening or social-emotionaldevelopment. However, there is a need toadvocate or the integration o screeninginto other child care and education settingsIn these settings, barriers to screeningmay include lack o training and expertisein child development or some providers,lack o access to early childhood mentalhealth consultants, and lack o resources toimplement screening.

SOCIAL-EMOTIONAL DEVELOPMENT SCREENING INSTRUMENTS

Ages and Stages Q esti nnaire–S cial-Em ti nal (ASQ-SE) 1

Parent report (5th grade reading level)Time: 10–15 minutes to complete; 1–3 minutesto scoreChild ages: 6, 12, 18, 24, 30, 36, 48 & 60 monthintervalsSensitivity: 71–85% Specificity: 90–98%Available in English, SpanishAreas assessed: sel -regulation, compliance,communication, adaptive unctioning, autonomy,a ect, and interaction with people

Pediatric Sympt m Checklist (PSC) 2

Parent report (5th grade reading level)

Time: 2–12 minutes to completeChild ages: 4–16 yearsSensitivity: 88–92%Specificity: 68–99%Available in English, Spanish, ChineseArea assessed: psychosocial dys unction

Brie In ant-T ddler S cial Em ti nalAssessment (BITSEA) 3

Parent report (5th grade reading level) 7–10minutes to complete

Child ages: 12–36 monthsSensitivity: 80–99% Specificity: 80–89%Available in English, SpanishAreas assessed: internalizing problems,e ternalizing problems, disregulation, andcompetence

REFERENCES

1. Beligere N, Bandepalli C, Helin R, et al. Parents reporto social and emotional status o the premature in ants.Ages and Stages Questionnaire (ASQ) on Social andEmotional (S/E) Assessment ASQ:SE. J Dev Behav Pediatr 2005; 26(6):472.

2. Jellinek MS, Murphy JM, Little E, et al. Use o thePediatric Symptom Checklist to screen or psychosocialproblems in pediatric primary care: a national easibility study. Arch Pediatr Adolesc Med 1999; 153:254-260.

3. Briggs-Gowan MJ, Carter AS, Irwin JR, et al. he Brie In ant - oddler Social and Emotional Assessment:screening or social-emotional problems and delays incompetence. J Pediatr Psychol 2004; 29(2):143-55.

Social-Emotional Developmental Screening o Young Children rom page 7



SOCIAL AND EMOTIONALDEVELOPMENTAL MILESTONE

Other settings where screening occurs.Asdescribed in other articles in this issue,there are several additional settings wherescreening o in ants and young childrenregularly occurs: the Follow Along Program,home visiting, Early Childhood Family Education, and child wel are visits. Early childhood screening is required or public

school entrance and is usually done at ages 3to 4. Both observation and parent report arerequired.

Early childhood social and emotionaldevelopmental screening represents animportant component o a public mentalhealth agenda and a necessary step towardimproving the li e course or mental healthand public health outcomes. It should remaina priority or uture public health e orts andpolicy.

REFERENCES

1. Shonko J, Phillips D. (Eds.). National ResearchCouncil and Institute o Medicine. From neuronsto neighborhoods: the science o early childhooddevelopment. Washington, DC: National Academy Press,2000.

2. Developmental and social-emotional screening o youngchildren in Minnesota. Developmental and social-emotional screening instruments. Minnesota Departmento Health. Available rom: http://www.health.state.mn.us/divs/f/mch/devscrn/instruments.html

3. Beligere N, Bandepalli C, Helin R, et al. Parents report o social and emotional status o the premature in ants. Agesand Stages Questionnaire (ASQ) on Social and Emotional

(S/E) Assessment ASQ:SE. J Dev Behav Pediatr 2005;26(6):472.

4. Hagan JF, Shaw JS, Duncan PM, eds. Bright utures:guidelines or health supervision o in ants, children andadolescents, 3rd edition. Elk Grove Village, IL: AmericanAcademy o Pediatrics, 2008.

5. Meisels SJ, Atkins-Burnett S. Developmental screeningin early childhood: a guide (5th ed.). Washington,DC. National Association or the Education o YoungChildren, 2005.

6. Pediatric screening developmental ow chart. Availablerom: http://www.cdc.gov/ncbddd/child/screen_provider.

htm#chart

roy Hanson, MD, is a board-certi ed amily medicine physician who works in several rural clinics and emergency departments in Minnesota. Dr. Hanson isa graduate student in the MCH MPH program. Healso completed the In ant Mental Health certi cate program in the University o Minnesota’s Institute o Child Development.

Joän Patterson, PhD, LP, is an Associate Pro essor inthe Maternal and Child Health Program in the School o Public Health at the University o Minnesota.

The Centers or Disease Control andPrevention’s (CDC) Learn the Signs—Act Earwebsite provides an interactive opportunity oparents and caregivers to learn about generaldevelopmental changes to e pect as their childdevelops in the irst 5 years. Some e amples o

social and emotional developmental milestonerom the website include:

By the end f Three M nths:

■ Begins to develop a social smile;

■ Enjoys playing with other people and may cwhen playing stops; and

■ Imitates some movements and aciale pressions.

By the end f one Year:

■ Cries when mother or ather leaves;

■ Enjoys imitating people in his play; and■ Repeats sounds or gestures or attention.

By the end f Tw Years:

■ Imitates behavior o others, especially adultand older children;

■ Demonstrates increasing independence; and

■ Begins to show de iant behavior.

By the end f Three Years:

■ Can take turns in games;

■ Understands concept o “mine” and “his/heand

■ E presses a wide range o emotions.

By the end f F r Years:

■ Cooperates with other children;

■ Increasingly inventive in antasy play; and

■ Negotiates solutions to con licts.

By the end f Five Years:

■ Wants to please riends;

■ Able to distinguish antasy rom reality; an

■ Sometimes demanding, sometimes eagerlycooperative.

For more in ormation about how the CDC ishelping parents, educators, and caregivers torecognize signs o healthy development o yochildren and provide care earlier or children wdevelopmental delays, please visit: http://wwwgov/ncbddd/actearly/milestones/inde .html



Diagn stic AssessmentAn early childhood mental health diagnostic

assessment is a ormal process conductedby a trained mental health pro essional thatincorporates comprehensive in ormationabout the child’s developmental history,current unctioning (including strengthsand vulnerabilities), and amily history.It also includes observations o the childinteracting with his/her caregivers and withthe mental health pro essional. Te purposeo diagnostic assessment is to determinei the child needs specialized services andmore speci cally, what treatment modalitiesmight be use ul or the child and amily.

Diagnostic assessment helps to in ormtreatment; it isnot a mechanism or labelingchildren. Diagnostic assessment is ongoing,requiring periodic re-evaluation as the childenters di erent developmental stages andexperiences di erent li e events.1

DC:0-3RTe Diagnostic Classi cation o Mental Health and Developmental Disorders o In ancy and Early Childhood: Revised Edition (DC:0-3R)was released by the

national organization, Zero to Tree, in2005. Te DC:0-3Rmanual is used toprovide developmentally appropriate

diagnostic assessments or children, birthto 4 years, with mental health conditions.Te diagnostic categories are research-basedand were developed by medical and mentalhealth pro essionals with expertise in in antand early childhood mental health anddevelopmental conditions.1,2 Te DC:0-3Rdiagnostic categories, based on early childhood development research, are notdescribed in other diagnostic systems.

Key principles and assumptionso the DC:0-3R include:

■ Te developmental domains or in antsare inter-related and require theintegration o pro essional perspectives

rom mental health, rehabilitationservices, medical, and social servicepro essionals.

■ In ants and young children develop inthe context o relationships, culture, andcommunity. Teir relationships withtheir primary caregivers are paramountto their development. Tus, cliniciansmust engage the children’s primary caregivers as partners in the assessmentprocess. Te children’s relationshipswith their primary caregivers, theircultures, and their communities mustbe incorporated into the diagnosticprocess.

■ In ants and young children are uniqueand their development, temperament,and other di erences a ect the way they experience various events.

■ Te diagnosis o young children is aprocess that must include in ormation

rom multiple sources, including allcaregivers who engage regularly with thechild, and must include observations o

the young child in multiple settings.1

Minnes ta’s Pr m ti n the DC:0-3R

Te Minnesota Department o HumanServices (DHS), Children’s Mental HealthDivision, in partnership with localcommunities, the Maternal and Child HealtAssurance Unit at DHS, and the MinnesotaDepartment o Health have promotedthe use o theDC:0-3Rby providing reetrainings to mental health pro essionalsacross the state. Over 700 Minnesota mentahealth pro essionals have been trained inthe use o theDC:0-3R. Te DHS Children’sMental Health Division o ers ongoingconsultation or mental health pro essionathrough a ree monthly clinical consultationgroup sta ed by a contracted nationalDC:0-3Rtrainer. For more in ormationabout the DC:0-3Rtrainings o eredthroughout Minnesota or the DC:0-3R monthly clinical consultation group, contactCatherine Wright at [email protected]

REFERENCES

1. Zero to Tree. Overview: Diagnostic classi cation o thmental health and developmental disorders o in ancy and early childhood: Revised. Unpublished paper, 2006

2. Zero to Tree. Diagnostic classi cation o mental healthand developmental disorders o in ancy and early childhood: Revised edition. Washington, DC: Zero toTree Press, 2005.

Catherine Wright, MS, is an Early Childhood MentaHealth Program Coordinator at the MinnesotaDepartment o Human Services, Children’s Mental Health Division.

I the result o social-emotional screening or an in ant or young child is po(i.e., indicates mental health problems or concerns), the next step is an assessm

to determine i the child needs specialized services.


Diagnosing Young Childrenwith Mental Health Concerns



C ntin m CareTe Minnesota statewide early childhoodmental health system includes our speci cdomains in the continuum o care:

■ Prevention—services available to allchildren;

■ Early intervention—services orchildren who demonstrate undiagnosedmental health concerns;

■ Intervention—services or children withdiagnosable mental health conditions;and

■ Intensive intervention—intensiveservices or children with signi cantdiagnosable mental health conditions.

Prevention. Trough a CommonwealthGrant, Assuring Better Child Development(ABCDII), the CMHD partnered with theDHS Maternal and Child Health AssuranceUnit to promote the use o standardizedmental health screening tools during

Child and een Check-Ups* conducted inmedical clinics. Te screening tools assistcaregivers and medical pro essionals inidenti ying social-emotional concerns inyoung children. Te Maternal and ChildHealth Assurance Unit was also recently awarded the ABCD III grant rom theCommonwealth Fund and the NationalAcademy or State Health Policy (NASHP).Tis grant will assist medical clinics inconnecting with local early intervention

services or children with identi ed mentalhealth and developmental concerns.

Early intervention. In 2006, the MinnesotaDepartment o Education, with support romstate and local agency partners, changedthe eligibility criteria or Part C o theIndividuals with Disabilities Education Act(IDEA) to include 13 early childhood mentalhealth diagnoses listed in theDC:0-3R(Diagnostic Classi cation o Mental Healthand Developmental Disorders o In ancy and Early Childhood: Revised Edition).1 Te

new eligibility criteria allow children birthto 2 years with mental health conditions toreceive the ull early intervention serviceso ered through Part C.2

Te CMHD also is working closely withthe Minnesota Head Start Association topromote the use o theIncredible Years3 curriculum, an evidence-based early intervention or children with potentialbehavioral concerns.

Intervention. For the past six years, theCMHD, in partnership with the MinnesotaDepartment o Health’s Minnesota Childrenwith Special Health Needs (MCSHN)section, has been working with the nationalorganization, Zero to Tree, to train andmentor mental health pro essionals in theuse o theDC:0-3R, a developmentally appropriate mental health diagnostic tool

For the past six years, the MinnesotaDepartment o Human Services

(DHS) Children’s Mental HealthDivision (CMHD) has been workingwith community stakeholders across thestate to develop an early childhood (birthto 5 years) mental health system o care.

Development o this system requiresintegration across multiple sectors:mental health, medical, early education,Head Start, early intervention, childwel are, and public health. Developmento this system has been in ormed by parents to ensure that it is comprehensive,

exibly designed, and inclusive o allsystems serving young children and their

amilies.


Early Childhood Mental Health Systems Development in Minnesota

Continued on page 12

*Child and een Checkups is Minnesota's name or EPeriodic Screening, Diagnosis and reatment (EPSDwhich is required by Medicaid.



or children ages birth to 4. Over 500 mentalhealth pro essionals have been trained in theuse o the tool.

In addition to diagnostic assessmenttraining, the CMHD is training mentalhealth pro essionals in the use o evidence-based mental health treatments

or young children. Over 21 clinicians rom13 agencies have been trained in the useo Parent Child Interaction Terapy, 4 anevidence-based treatment or young childrenand their amilies who have experiencedtrauma or are exhibiting other mental healthdisorders.

Intensive interventions.Te CMHD hasbeen working closely with Minnesota HealthCare Plans and mental health practitionersto provide an array o intensive interventions

or young children with signi cant mentalhealth conditions. Tese services include

mental health targeted case management,day treatment, and therapeutic preschools.

Eval ati nTe CMHD recently required all mentalhealth pro essionals who receive publicreimbursement or services to birthto 5-year-olds to use two evaluationinstruments: the Strengths and DifcultiesQuestionnaire6 (an assessment tool orchildren ages 3 to 5) and theEarly Childhood Services Intensity Instrument 7 (a unctional

assessment tool or children ages birth to5). Te State chose to evaluate state- undedmental health services so that amilies andconsumers would have in ormation tobetter choose rom the array o services andproviders or their children.5

In rastr ct re B ildingTrough the Governor’s MentalHealth Initiative o 2007, the CMHDhas released 3 million dollars in directservice/in rastructure building grants orearly childhood mental health systemsdevelopment across the state. In April 2009,10 communities were awarded these grantsto develop comprehensive services orchildren, birth to 5 years, employing the ourcategories o the continuum o care using thestate-required evaluation tools.REFERENCES

1. Zero to Tree. Diagnostic classi cation o mental healthand developmental disorders o in ancy and early childhood: Revised edition. Washington, DC: Zero toTree Press, 2005.

2. Minnesota Department o Health. Early childhoodintervention Part C. Available rom: http://www.health.state.mn.us/divs/f/mcshn/ecippkt.htm

3. More in ormation about the Incredible Years programs isavailable rom: http://www.incredibleyears.com/

4. Eyberg SM, Boggs SR, Algina J. Parent-child interactiontherapy: a psychosocial model or the treatment o young children with conduct problem behavior and their

amilies. Psychopharmacol Bull. 1995;31(1):83-91.

5. Minnesota Department o Human Services. Bulletin.DHS requires standardized outcome measures and levelo care determinations or children’s mental health. April2009. Available rom: http://www.dhs.state.mn.us/main/groups/publications/documents/pub/dhs16_144775.pd

6. Goodman R. Te Strengths and Di cultiesQuestionnaire: a research note. J Child PsycholPsychiatry 1997; 38:581-586.

7. American Academy o Child and Adolescent Psychiatry,Work Group on Community-based Systems o Care.Early Childhood Service Intensity Instrument (ECSII).2005. Available rom: http://www.aacap.org/galleries/PracticeIn ormation/In ormation_sheet_ECSII.pd

Catherine Wright, MS, is an Early Childhood Mental Health Program Coordinator or the Children’s Mental Health Division at the Minnesota Department o Human Services.

For more in ormation about early childhood systemsdevelopment e orts in Minnesota, please contact Catherine Wright at [email protected].

MINNESOTA ASSOCIATION OFCHILDREN’S MENTAL HEALTH:

FRoM A PARENT SuPPoRT GRouP To ASTATEWIDE ADVoCACy oRGANIzATIo

F r m re in rmati n ab t MACMH gt : http://www.macmh. rg/index.php

The Minnesota Association or Children’s MentHealth (MACMH) was established in 1989 by a

group o parents who shared the e perience o raising children with mental health disorders. TodMACMH is a statewide education and advocacyorganization. Its mission is “to promote the positimental health o all in ants, children, adolescenttheir amilies” and is carried out through educatadvocacy, and an annual con erence. MACMH hpublished curricula or parents, educators, andother practitioners and o ers numerous trainingin Minnesota. Among MACMH’s resources are iGuide to Early Childhood Mental Health, mentalhealth actsheets (in English and Spanish), and anewsletter. Its Open-Up magazine is one compono a new arts-based community outreach initiati

that showcases the work o young people througessays, poems, and visual arts to impart power umessages about mental health.

According to MACMH, its annual con erence islargest o its kind in the nation, o ering parentcaregivers, and pro essionals access to more than75 workshops o varying technical levels andnationally renowned keynote speakers. The 2010con erence will take place April 25-27 at the DuEntertainment Convention Center.

Early Childhood Mental Health Systems Development in Minnesota rom page 11



What Is the Meaning EBP?Te American Psychological Association(APA) has provided leadership in de ningand promulgating EBPs or children’s

mental health. In a 2008 task orce report,APA noted that the term EBP has come toconnote:

■ A broader ocus than evidence-basedtreatment, which is limited toprevention or intervention programs

or which there is a strong scienti cbase;

■ Te quality, robustness, and/orscienti c evidence about prevention,treatment, access, engagement, andretention o targeted client populations;

■ Incorporation o client characteristicsas well as clinical expertise; and

■ A coherent body o scienti cknowledge relevant to a range o service and clinician practices, whichallows or prediction o the impact o interventions. 1

EBPs: Q esti ns and Iss esParticularly as applied to early childhoodmental health services, a number o

challenging questions are o en raised aboutEBPs.

■ What “evidence” is required to establishan EBP? Early EBPs emphasized what

is now re erred to as a “gold standard”o evidence, including double-blind,randomized trials with control groups,using competing interventions,manualized practices, studies by morethan one group o researchers, andstatistically and clinically signi cantdi erences in outcomes avoring thepractice in question. .2 I we relied solely on this standard, there would be very little “evidence” or e ective practice.More recent approaches to EBPs haveincluded somewhat broader research

criteria. For example, the NationalRegistry o Evidence-based Practicesand Programs assigns ratings rom1 to 4 on speci c criteria: reliability and validity o measures, intervention

delity, missing data and attrition,potential con ounding variables, andappropriateness o analysis.3 Tedatabase that Minnesota is using totrain providers, developed rom thework o Dr. Bruce Chorpita (University o Cali ornia–Los Angeles), also assigns

a rating based on the quality o researchunderlying a speci c practice, as well asnotes the demographic and diagnosticapplication o the practice, to theextent that this in ormation is speci edin the practice’s research reports.Evidence that is still needed in theearly childhood domain is that romlongitudinal interventions.

■ Do EBPs privilege some values over others? EBPs are unapologetically rooted in the tradition o scienti cevidence derived rom experimentalresearch. As the eld has evolved,there has been increasing attentionto contextual actors related toevidence, including the importance

o individualized care, strengths- andamily-based care, and cultural

competency.

■ Do EBPs rein orce the “medical model” o mental health? EBPs are certainly rooted in health care, and particularly in evidence-based medicine. Comparedwith EBPs or adult care, EBPs orchildren generally have a moredevelopmental and preventive ocus.

E vidence-based practice (EBP)in mental health is a relatively

new phenomenon, with virtually nocitations prior to 1995 in the publishedliterature. However, only a decade later,PsycINFO contained 271 re erences toEBPs or children and adults. Tere

are many recent review articles andbooks about the emerging science o determining what works, or whom,and under what conditions.

Glenace E. Edwall, PsyD, PhD, LP, MPP

Evidence-based Practicesin Early Childhood Mental Health




■ Do EBPs work across diferent settings,e.g., clinics, home visits, preschools? Te range o settings in which thee ectiveness o EBPs has beendemonstrated is constrained by thepublished literature, but cross-settinggeneralizability can sometimes beextrapolated or tested in the nextiteration o a speci c practice.

■ How do EBPs relate to an emphasison outcome measurement? Te useo EBPs is dependent upon, not areplacement or, clear measurement o outcomes. EBPs are generally de nedby e cacy—the ability to produce adesired e ect in a controlled context; bute ectiveness—the degree to which theintervention produces the desired e ectin real-world, uncontrolled settings—demands rigorous measurement.

■ How do EBPs relate to amily pre erences and choice? Family pre erence and choice have beenempirically demonstrated to have a clearrole in the engagement phase o mentalhealth treatment. As more researchestablishes a wider range o alternatives

or the treatment o common children’smental health problems, more choiceamong e ective treatment modalities isopened or amilies.

■ Are EBPs used to restrict access to

services? Tis has been a common earabout EBPs, with limited examples,primarily in adult services. Morecommon practice among states is to useEBPs as part o quality improvementactivities and provider training. Tis hasbeen the case or the Children’s MentalHealth Division at the MinnesotaDepartment o Human Services (DHS).

■ What are the ethical considerationsin implementing EBPs? Assuringaccess to the highest quality o care

or all children, training, and adequatesupervision are all hurdles that statesmust plan or in implementing EBPs.

EBPs: Why and Why N w?Te Children’s Mental Health Divisiono DHS is requently asked why so muchattention is given to implementing EBPs

or intervention in children’s mental healthproblems. Te top answers are:

■ EBPs provide the best opportunity to maximize the e ectiveness o

interventions, including providing aclear ocus on outcomes.

■ EBPs clari y clinicians’ caseconceptualizations, particularly thoseemanating rom theoretical perspectives.

■ Adoption o EBPs creates the possibility o continuity and consistency o careacross providers.

■ EBPs create a common language orunderstanding interventions, much likeprior work on screening ( e.g., ASQ:SE) and diagnosis (DC:0-3R).

■ EBPs create the basis or training incore elements o interventions, thusincreasing the e ectiveness o allinterventions or children.

■ E ectiveness and quality are linked tobetter outcomes with lower resource use.

■ Rapid return to a typical developmentaltrajectory is particularly crucial oryoung children to lessen the possibility o more complex problems or acquiredco-morbid conditions.

■ Pragmatically, EBP implementation isincreasingly a requirement o ederaland private grant-making.

■ Te publication explosion around EBPsis making it ethically inde ensible notto o er children and amilies the bestcare available. Just as it once seemedlogical not to screen or problems in the

absence o treatment resources (but nolonger does), it is also no longer arguablethat any service is as good as any other.Te right care has become the right thingto do.

REFERENCES

1. American Psychological Association ask Force onEvidence-Based Practice or Children and AdolescentsDisseminating evidence-based practice or childrenand adolescents: a systems approach to enhancing care.Washington, DC: American Psychological Association,2008. Available rom: http://www.apa.org/pi/cy /evidencerpt.pd

2. Chambless D, Hollon S. De ning empirically supportabtherapies. J Consult Clin Psychol 1998; 66:7-18.

3. National Registry o Evidence-Based Practices and

Programs. NREPP Review Criteria, 2007. Available rohttp://nrepp.samhsa.gov/review-quality.asp.

Glenace E. Edwall, PsyD, PhD, LP, MPP, is theDirector o the Children’s Mental Health Division athe Minnesota Department o Human Services.

Evidence-based practices make it ethicainde ensible NO to o er children an

amilies the best care available...Te rigcare has become the right thing to do.

Evidence-Based Practices in Early Childhood Mental Health rom page 13



Imp rtance EarlyRelati nships

In the now classic report rom the Institute o Medicine,From Neurons to Neighborhoods;the Science o Early Childhood Development,1

the authors highlight the importance o early li e experiences and the highly interactivenature o genetics and environment. Early relationships are critical to the developmento the in ant brain and in turn, to theun olding patterns o human development,including social-emotional competence.Parents, other caregivers, and teachersneed to provide the environments andinteractions that enable children to learn to

trust others, gain sel -control, demonstrateage-appropriate levels o independence,and acquire the ability to take initiative andassert themselves in socially acceptable ways.

Parents have a pro ound in uence on theearly development o their children. Nearly all parents want to do the best they can

or their children at home and select highquality out-o -home care environments.Early childhood teachers and specialists ina variety o settings are trained to providethe most e ective learning environments

or young children as well as support orparents.

Minnes ta Legislati nS pp rts ECFEMinnesota is ortunate to have statutory provisions making Early Childhood Family Education (ECFE) available to all parents to

support them as their children go through various stages o development rom birthto kindergarten enrollment. ECFE began in1974 with six state- unded pilot programsadministered by the Minnesota Councilon Quality Education, which coordinateda variety o research and developmentstrategies unded by the legislature. Tenumber o pilots expanded gradually to 34 in1983 when the Minnesota Legislature beganto make the transition rom grant- undedpilots to a oundation aid ormula and

statewide implementation throughCommunity Education in public schooldistricts. Now ECFE is o ered essentially b

all school districts, either independently orin cooperation with other districts.

In accordance with Minnesota statute124D.13, all programs must provide:

■ Education to parents on the physical,mental and emotional developmento their children and enhancing theskills o parents* in providing or theirchildren’s learning and development;

■ Structured learning activities requiringinteraction between children and theirparents;

■ Structured learning activities orchildren that promote children’sdevelopment and positive interactionwith peers, which are held while parentsattend parent education classes;

■ In ormation on related community resources;

“I don’t have any riends.” “Nobodylikes me.” Tese words rom

a 4-year-old bring into ocus theimportance o addressing social-emotional development during a child’searly years. Until recently, this domaino early development had received less

attention compared to motor, cognitive,and language development. However,social-emotional competence is equally important and essential to children’swell-being and success in school and inlater li e.

Lois Engstrom

Early Childhood Family Education (ECFE):A Mental Health Promotion Program or Young Children and Families

Nearly all parents want to do the best they can or their children at home

and select high quality out-o -homecare environments. Many parents seekin ormation and support in this endeavor


*Te phrase “or relatives” was added to the statuterecently to include those who play a major parenting roin the lives o the children involved.



■ In ormation, materials, and activitiesthat support the sa ety o children,including prevention o child abuse andneglect; and

■ A community outreach plan to ensureparticipation by amilies who refect theracial, cultural, and economic diversity o the school district.

ECFE Pr grams Are Tail redt Parents’ NeedsParents and children attend ECFE programstogether. Programs are usually ree o charge.In addition to the program requirementsabove, school districts vary in the speci cprograms that are o ered as they adaptprograms to the changing structure andneeds o amilies in their communities. Forexample, some ECFE programs o er:

■ Daytime, evening, and Saturday classesto accommodate parents’ schedules;

■ Family literacy programs;

■ Classes or speci c a nity groups likeathers, single parents, and parents o

in ants;

■ Home visits;

■ Classes at hospitals or parents o newborns; and

■ Parenting education or court-orderedparents.

Within a given community, ECFEpro essionals collaborate and coordinatetheir e orts with other early educationprograms like child care, crisis nurseries,Head Start, early childhood specialeducation, interagency early interventionservices, and nurse home visiting.

Bene ts ECFENot only do parents and their childrenbene t directly rom ECFE, but society bene ts too, because healthy and supported

amilies are better able to develop nurturingrelationships with their children thatcontribute to their social and emotionalcompetence. In this way, ECFE promotespositive mental health or children. Oneo the greatest testimonials to the value o ECFE is that so many parents report ECFEhas helped them to understand and moree ectively meet their children’s needs, whilesimultaneously providing them with a strong

source o support and connectedness withother parents and amilies who o en becomelong-time riends.

For more in ormation about ECFE programsin your area, see www.ec e.in o/what_is_ec e.html

REFERENCE

1 Shanko J, Phillips D. (Eds.) and the National ResearchCouncil and Institute o Medicine. From neuronsto neighborhoods: the science o early childhooddevelopment. Washington, D.C.: National Academy Press,

2000.

Lois Engstrom is the Executive Director o the Minnesota Association or Family and EarlyEducation. She was statewide coordinator o ECFEat the Minnesota Department o Education rom1983-2003.

CULTURAL ADAPTATION OF A PARENT EDUCATIONPROGRAM FOR SOMALI WOMEN

I am a Somali immigrant to the U.S. and have beenliving in the Twin Cities or several years. I becameincreasingly aware o the social isolation o manyother Somali women who had more recentlyimmigrated to Minnesota. Many o these womenwere parenting children, some o whom were nottheir own because their parents had been killedor lost in their ight rom the war in Somalia.Many o these women had lost their partnersand their e tended amilies. They appeareddepressed, although the Somali culture doesnot really recognize depression as an illness orwhich medical help is available. I was concernedabout the health o these women and how theirdepressed mood was a ecting their ability to begood parents.

In 2003, I brought si o these mothers togetherand started teaching them parenting skills usinga curriculum developed by Family Services Inc.and Children’s Home Society. These agencies

wanted me to modi y the curriculum so itwould ft the cultural belie s o East A ricans.I struggled a lot because many o the parentsbelieved that I was introducing Western cultureand parenting practices and encouraging themto neglect their own culture and parenting style.I searched or in ormation about how Islam saidchildren were to be raised. I ound a book called,

Meeting the Challenge of Parenting in the West: AnIslamic Perspective, written by a child psychologistwho raised our o her children in the westernworld while adhering to her Muslim aith. Whatsurprised me was that this book contained

the same in ormation as the Family Servicesparenting curriculum. The major di erence was iused citations rom the Qura’n and sayings romProphet Mohamed. I started using this book as ateaching tool and re erence. It created a drasticchange o attitude in these Muslim mothers andgave them great reassurance that the parentingpractices we were talking about totally ft withtheir Islamic aith.

Meeting as a group o women with a sharedtrauma e perience who also wanted to be goodparents, they ound support and riendship romeach other, which seemed to relieve some o their depressive symptoms. The group quicklymushroomed into over 30 women and hascontinued to meet or several years. I have hadrequests rom other Somali women throughoutthe Twin Cities to start a similar group or them.

It taught me the importance o honoring culturalbelie s and practices and providing support to

su ering women who desperately wanted to begood mothers and protect their children romharm.

REFERENCE

Beshir E, Beshi MR. Meeting the challenge o parentinthe west: An Islamic perspective. Beltsville, MD: AmanPublications, 2000.

Nadi a Osman is a Minneapolis resident and Executive Director o a non-pro it, Women o AResource and Development Association (WARDA

Nadi a O

Early Childhood Family Education rom page 15



Envir nmental Exp s resRacial/ethnic minority children andthose rom low-income amilies havedisproportionate residential exposure toold housing, industrial waste, land lls, andenvironmental pollutants, like lead.3 Leadexposure comes primarily rom lead-basedpaint; toddlers ingest paint chips and dustthrough normal hand and mouth activity.Lead is also in the soil o high-tra c andindustrial areas, thus a ecting the play areaso children who live in such areas. Early exposure to lead is associated with aggressivebehavior and poor intelligence testing.Lead, mercury, dioxins, polychlorinatedbiphenyl compounds (PCBs), and othertoxins also cross the placenta, a ecting etalneural development.4,5 Te mechanisms by which speci c de cits develop are not wellunderstood.4,5 Among the many aims o the National Children’s Study (NCS) is tounderstand how environmental exposuresmay a ect neurodevelopment, rom etal li ethroughout young adulthood. Dr. Oberg is aco-investigator and Dr. Wendy Hellerstedt,Director o the Center or LeadershipEducation in Maternal and Child PublicHealth, is the co-Principal Investigator o the Ramsey Location or the NCS (www.nationalchildrensstudy.gov).

Family Ec n mic StressWhen the amilies o young childrenundergo persistent nancial strain, they are

aced with a number o stressors in theirdaily lives— ood insecurity, unemployment,homelessness, requent moves, and unsa eneighborhoods. Tis kind o stress makes itdi cult or parents and other caregivers todevelop nurturing, protective, and consistentrelationships with their in ants and youngchildren. Such relationships are essential

or the child’s development o secureattachment, emotional regulation, and otherdevelopmental milestones.

Clinical Care r StressedFamilies

Disparities persist beyond children'sresidential environment. In many clinicalsettings, there are variations in the servicesprovided or young children who experienceemotional and social developmental delaysor have mental health problems. While suchproblems should be recognized during thescreening portion o well-child exams—which includes anticipatory guidance andlistening to a amily’s concerns—there aredi erences in the quality o care and theamount o time devoted to such screening.

o address this variability and ensure thatchildren receive high quality care, Dr. Obersuggests “improved consistency in training,more readily available assessments, andhaving re errals in place to help address theneeds that are identi ed.”

Importance o provider training.Whilethe type o training providers receive haschanged over time, more must be done toensure that providers are able to competentladdress the social and emotional health

needs o children. Dr. Oberg supports theidea o a medical home, an approach thatgrew rom e orts to provide continuousand comprehensive care or children withspecial health care needs. Tis modelallows the provider to link with the amily,school, and community to coordinate carethrough multiple systems: health, educationand social services. Clinicians need moretraining and education to become amiliarwith the medical home model and skilled inimplementing it.

“H ealth disparities” re ers to the greater incidence, prevalence, mortality, andburden o disease among speci c population groups—based on actors

such as race, ethnicity, socioeconomic status, disability, etc. In the U.S., healthdisparities begin at very young ages (o en in utero) and persist throughout the li ecourse. Te disproportionate exposure o racial/ethnic minorities and low-income

amilies to high-risk, resource-poor environments may explain the disparities insocial-emotional problems among these young children, according to Dr. Charles

Oberg, a pediatrician and an Associate Pro essor in the Maternal and Child HealthProgram in the School o Public Health at the University o Minnesota. Tere isalso an achievement gap between children rom at-risk backgrounds and theirmore advantaged peers—a gap that is apparent even among young children 1,2 andlikely associated with disparate social-emotional development.

Andrea Ag

Clinical and Public Health Perspectives on

Mental Health Disparities in Early Childhood




Stigma and Lack Awareness Res rces

Families may not be aware that their youngchildren have mental health problemsor they may not be aware that resourcesexist to address them. Consequently, Dr.Oberg emphasizes the importance o early

childhood education programs becausethey are encouraged to evaluate andpromote a child’s emotional and mentalhealth. High-quality programs also providean environment that is developmentally appropriate and emotionally sa e, andsupport coordination between social andhealth care services.

Some amilies, and some cultures, may stigmatize mental health or be reluctant toseek services or other reasons. While stigmaexists, Dr. Oberg believes it has become lesso a barrier or accessing mental health care

or children. “What I’ve noticed when thereis an issue acing the amily in regards to thesocial and emotional health o their in ant,toddler, or child,” he said, “is that they arereaching out, looking or services. I think that speaks to an evolutionary change withinour society.” Due to this shi , Dr. Obergalso believes mental health is going to be amajor ocus or the next several decades inthe medical, public health, and social service

elds.

R le P blic HealthPractiti nersDr. Oberg believes public health practitionerscan be instrumental in addressing mentalhealth disparities. Child social and emotionalhealth and development should be parto a public health graduate curriculum,he suggests. He points to two certi cateprograms available at the University o Minnesota—one in in ant and early childhood mental health and another inearly childhood policy (see links, end o article). Tese certi cates blend disciplines

and enhance the public health curriculum.On a broader level, Dr. Oberg states thatpolicy development is necessary to supportthe economic well-being o amilies, giventhe higher risk or mental health problemsamong children in nancially stressed

amilies.

Dr. Oberg emphasizes that children,including those rom birth to 5 years,need good physical healthand good socialand emotional health. Children musthave adequate nutrition, quality housing,parents with livable wages to eliminate

nancial stresses, and resources to address violence in the home. According to Dr.Oberg, “intervention early on really doespay o substantially as children enter intomiddle childhood, adolescence and youngadulthood.”

For more in ormation about the a orementioned certi cate programs o ered at theUniversity o Minnesota, please visit:

■ In ant and Early Childhood MentalHealth Certi cate at the Center or Early Education and Development Program,www.cehd.umn.edu/CEED/pro dev/certi cateprograms/IECMH/de ault.html. Also see page 35.

■ Early Childhood Policy Certi cateProgram in the College o Educationand Human Development, www.cehd.umn.edu/students/Certi cates/ECPolicy.html

REFERENCES

1. Hart B, Risley . Te early catastrophe: the 30 millionword gap by 3. Am Educator 2003; 27(1);4-9.

2. Halle , Forry N, Hair E, et al. Disparities in early learning and development: lessons rom the Early Childhood Longitudinal Study – Birth Cohort (ECLS-B).Available rom: www.childtrends.org/Files//Child_

rends-2009_07_10_FR_DisparitiesEL.pd .

3. Powell DL, Stewart V. Children. Te unwitting target o environmental injustices. Pediatr Clin North Am 2001;48(5):1291-305.

4. Schantz SL, Widholm JJ, Rice DC. E ects o PCBexposure on neuropsychological unction in children.Environ Health Perspect 2003; 111(3):359-76. Available

rom: www.ehponline.org/members/2003/5461/5461.html

5. Patandin S, Lanting CI, Mulder PG, et al. E ects o environmental exposure to polychlorinated biphenylsand dioxins on cognitive abilities in Dutch children at 42months o age. J Pediatr 1999;134(1):33-41.

Andrea Aga is an MPH student in the Maternal and Child Health Program at the University o Minnesota.

“What I’ve noticed when there is an issue acing the amily in regards to the social

and emotional health o their in ant,toddler, or child, is that they are reaching

out, looking or services. I think that speaks to an evolutionary change within

our society.” - Dr. Charles Oberg

EARLY CHILDHOODLONGITUDINAL STUDY:

DISPARITIES IN EARLY CHILDEVELOPMENT

In June 2009,Child Trendspublished an analysisabout multiple potential risk actors ordevelopmental disparities at 9 and 24 months oage. Data were rom a nationally representativsample o in ants born in 2001, the Early ChiLongitudinal Study. The authors (Halle et al.)e amined three domains o development: coggeneral health, and social-emotional.

Some o the key fndings o this report were:

■ Disparities in cognitive, social, behavioral, ahealth outcomes by amily income were evat 9 months and were even greater at 24months o age.

■ In ants and toddlers rom certain backgrou(i.e., racial/ethnic minority groups, whose holanguage was not English, and/or who hadmothers with low maternal education) scorelower on cognitive assessments, had poorerbehavior ratings and were less likely to be ine cellent or very good health than children

rom such backgrounds.

■ The more sociodemographic risk actors a had (e.g., low-income amily, mother with leducation), the wider the disparities acrossoutcomes or 9- and 24- month-olds.

The sociodemographic risks e amined in this a ect a signifcant number o in ants and todin the US. For e ample, nearly hal o all intoddlers—appro imately 1.5 million children—in amilies with incomes below 200% o pov

The authors drew several policy implications their analyses:

1. Start Early. Meaning ul di erences in ouwere detected as early as 9 and 24 months.They recommended high quality, comprehenand continuous interventions or children ato 3, as well as ages 3 to 5.

2. Target Low-income Children. Low incomwas the most prevalent risk actor in the stu

3. Engage and Support Parents. Low materneducation was a prevalent risk actor. Theauthors suggested interventions that includeparental education about early childhooddevelopment and those that support parentaeducational attainment and/or income

sel -su fciency.4. Improve the Quality of Early Care Settings

Most in ants and toddlers (especially thoserom low-income amilies) are cared or i

home-based settings. High-quality early careducation may moderate the e ects o strresidential e posures and may promote sasupportive and stimulating environments oyoung children.

The ull report is available at:www.childtrends.org/Files//Child_Trends-200

_07_10_FR_DisparitiesEL.pd .

Clinical and Public Health Perspectives on Mental Health Disparities in Early Childhood rom page 17



B ilding a S pp rtiveRelati nshipEssential to the e ectiveness o ongoinghome visits is having the amily experiencea supportive and continuing relationshipwith a visitor. Tis relationship promotesthe parent’s capacity to care or thechild in a manner that osters healthy

attachment. Research shows that supportiverelationships in the parent’s li e have asigni cant and long-term positive in uenceon the parent-child relationship. It iswell-documented that an in ant’s healthy attachment is a major contributing actorin optimal social, emotional, and cognitivedevelopment o the child.2

o enhance the capacity o amily home visitors in the work o relationship-building,the Minnesota Department o Health(MDH) provides training, technicalassistance, and consultation.

TrainingA new amily home visiting trainingcurriculum, “Promoting Relationships withRelationships,” is available to public healthhome visitors in Minnesota. Tis trainingaddresses in ant mental health, parent-childattachment, and culturally responsivepractice. o emphasize the ongoingdevelopment o relationship-buildingskills and knowledge, the course material

is presented through a series o home visiting case scenarios. Tis method allowsparticipants the opportunity to learnconcepts by applying them to a home visiting situation and gain insight throughdiscussion with peers and trainers. In eachscenario, participants are encouraged to

ocus on how to use the visitor-parentrelationship as the primary vehicle to e ect

change. Future training development willcontinue to promote the undamentalskills and theoretical underpinnings o evidence-based home visiting practice andits relationship to in ant mental health.

One o the tools that home visitors use isthe Parent-Child Interaction (PCI) Feeding and eaching Scales,3 which assess thequality o parent-child interaction andcommunication behaviors. Results o thisassessment can be used by home visitorsto support parents’ learning about how to

respond to their in ants’ cues, which is acritical component o sensitive caregiving.Home visitors also receive training inmotivational interviewing,4 which is acollaborative, person-centered discussion toelicit and strengthen parents’ motivation ormaking healthy changes.

Refective PracticeAn essential component o mostevidence-based home visiting models is theuse o re ective practice, which involves

“stepping back” to consider the meaning oone’s pro essional and personal responses trelationship interactions. Te home visitorsteps back to ponder her own reactions,wonder about the parent’s perspective,and re ect on how she might best help theparent discover her or his own solutions.Likewise, the home visitor helps the parentthink about his or her thoughts and eelingconsider the child’s experience, and identisolutions that encompass both perspectivesEssentially there is a parallel process; thatis, the home visitor relates to the parent ina healthy respect ul manner, which buildsthe parent’s capacity to develop a healthy relationship with his or her child. Te goalo re ective practice is to gain a betterunderstanding o relationships—betweenthe parent and child, as well as betweenthe home visitor and parent—so that allrelationships support the healthy emotional

development o the child.MDH o ers a re ective practice consultanto local public health departments tosupport and strengthen home visitors’skills in using a re ective approach with

amilies. Te consultant acilitates re ectivpractice case con erences and providesmentoring and re ective practice groups

or supervisors. Re ective supervisioncontributes to an understanding o home visitor boundaries and roles and clari esgoals and areas o intervention.

Minnesota amily home visiting programs ocus on preventing children’smental health problems by o ering support directly to amilies in their

homes.1 Public health nurses or trained home visitors support parents o in antsand toddlers by providing in ormation and guidance about child health anddevelopment, promoting parenting skills, and enhancing parents’ ability toengage in positive interactions with their children. During these visits, potentialthreats to the emotional health o the child, including a parent’s mental health

problems, parent addictions, or amily violence are identi ed and re errals toneeded resources are made.

Sharon Hesseltine, BSW Jill E. Simon, MSW, LICSW, IMH-E® (IV)

Family Home VisitingA Public Health Program to Promote Healthy Social-Emotional Develop ment




origins the FAPLola Jahnke, a Public Health Social Work Specialist with the FAP, has seen theprogram grow rom its in ancy to statewide

implementation. In the 1980s, Jahnke andother service providers noticed that childrenwith developmental delays were not beingidenti ed until they reached school age.She explains, “at that point in time, therewasn’t much around or kids rom birth to

ve.” A group o providers collaborated tond a “low-cost option” that would identi y

and monitor the social and emotionaldevelopment o young children. Te FAPgrew out o these meetings.

Fr m Screening and

M nit ring t Re erralFamilies with children in the Programreceive the Ages and Stages Questionnaire(ASQ)and ASQ:SE(social-emotional)when the child reaches 4, 8, 12, 16, 20, 24,30, and 36 months o age. A er the amily completes the questionnaires, they arescored by public health sta at the localcounty agency. Families with children whoare developmentally on-track are sent a letterin orming them o the survey results alongwith an activity sheet with age-appropriate

activities to practice with their children.When there are concerns about a child’sdevelopmental progress, the publichealth nurse contacts the child’s amily toensure they responded to the questionsappropriately. I there are remainingconcerns, the nurse discusses options or

ollow-up, including re erral to a primary care physician, Part C o IDEA (Individualswith Disabilities Education Act), an early intervention program or in ants andtoddlers, or other health and social serviceprograms. Tis process ensures that parentsreceive support in learning about normalchild development and children withdevelopmental delays are identi ed andconnected with intervention services early.

F nding r FAPWhile FAP at the state level receives ederal

unding, local county agencies throughoutMinnesota support the cost o their FAPsthrough a variety o sources. As these

programs have “no direct line o undingthrough the MDH…they are given lotso exibility in terms o how they run theprogram,” explains Jahnke. As a result,counties use di erent recruitment strategiesand eligibility criteria. Some provide theprogram to all newborns, while othersonly o er the program to at-risk children.In counties that o er the program to allchildren, administrators obtain birthcerti cate in ormation rom the local publichealth department and invite parents o all

newborns to participate. Other re erralscome rom home visiting programs,hospitals, physicians, and word o mouth.

Enrollment in FAP varies throughout thestate. While 12% o children birth to 3years participated in FAP statewide in 2008enrollment ranged rom 4% in the metroarea to 29% in southwestern Minnesotawhere the program started rst.

Next Step a ter FAPWhen a child reaches 36 months,participating amilies receive in ormationabout the next step: Early ChildhoodScreening. Te state o Minnesota mandatesthat all children receive one screening(including social and emotional) prior tokindergarten. Results rom these screeningtests are reported to the MinnesotaDepartment o Education (MDE) andhelp determine i children are in need o special education. ogether, these programs

acilitate the timely identi cation o childrwith developmental delays, promote early access to intervention services whenneeded, and help to ensure that amilies areconnected with a health care provider aschildren enter the school-age years.

For more in ormation about the FollowAlong Program, please visit: http://www.health.state.mn.us/divs/f/mcshn/ ap.htm

Andrea May eld is an MPH student in the Maternaand Child Health Program at the University o Minnesota.

For in ants and young children with developmental delays, early interventionimportant to improve health outcomes and address challenging behaviors in t

school and home environments. A major challenge in providing early interventiservices is the ability to accurately identi y in ants and young children with soemotional, and other developmental delays early in childhood. Te MinnesotDepartment o Health (MDH) Follow Along Program (FAP) provides periomonitoring and screening to help amilies and health care pro essionals determin

in ants are meeting expected developmental milestones.

Andrea Mayfeld

Follow Along Program: An Early Childhood

Intervention System at the Minnesota Department o Health



In 2008, Hennepin County early childhoodsta administered nearly 500 mentalhealth screens using the Ages and StagesQuestionnaire: Social Emotional (ASQ:SE).2 In this sample o children with suspecteddelays, 17% o the in ants under 1 yearscored in the “concerns” area and 40% o 1to 3-year olds, had scores in the “concerns”range.3 In Minneapolis, all children underage 3 with scores indicating mental healthconcerns are re erred to IDEA Part C,Part C o the Individuals with DisabilitiesEducation Act (IDEA) Early InterventionServices through the Minneapolis SchoolDistrict.

What is IDEA and Part C?IDEA Part C is a ederal program thatassists states in providing statewide early intervention services or children, birth to3 years, with disabilities.4 Established in

1987 and reauthorized in 2004, all statesparticipate in the program, although there isconsiderable variation in how developmentaldelay is de ned and how many childrenare served. Services must be provided orthose who are experiencing developmentaldelays and or those who have a diagnosedmental or physical condition that has a highprobability o resulting in a developmentaldelay. States may choose to serve children“at risk” o experiencing a substantialdevelopmental delay, but currently, only seven states and one territory include those

“at risk” o developmental delay.1

Interagency C rdinati nPart C legislation requires coordinationamong education, health, and socialservice agencies in a state, with one agency designated as the lead. In Minnesota,education is the lead, and Interagency

Early Intervention Committees (IEIC)have been ormed throughout the state toenact this coordination unction. Schooldistricts are required to provide early intervention services or eligible childrenin their districts. Because the needs o very young children are requently complex andnot directly observable in a public K–12system, public health and social services areimportant partners with education in ndingyoung children experiencing developmentaldelays. Screening is just the beginning. PartC Early Intervention Services require a ull

evaluation or all children whose screensindicate developmental delays, and servicesare provided at no cost to amilies throughthe school district.

Early Interventi n Servicesr S cial-Em ti nal Delays

Determination o service need is based onan education model. As we screen youngchildren or mental health concerns, we ndthat there are some children who do notmeet the eligibility criteria or educational

intervention, but have very signi cantneeds as evidenced by their interactionsand behavior. It is or these children thatHennepin County social workers try toprovide additional in-home services orre errals to early childhood mental healthpro essionals or therapeutic intervention.Tese services are provided through county

unds or third-party billing.

Services r Ab sed andNeglected ChildrenTe Child Abuse Prevention and reatmentAct (CAP A)5 mandates social-emotionalscreening and, when warranted, re erralto Part C Early Intervention services.In 2008, child wel are sta in HennepinCounty administered mental health screensto all children under age 5 who had beenin oster care or at least 30 days. Many o these children have signi cant mental

health conditions and require therapeuticintervention in addition to services throughthe local school district. Nationally,one-third o children ages 2 to 5 in childwel are need mental health services andrelated interventions.6

As we improve our ability to screen moreyoung children in Hennepin County,Minnesota and other states, we realize thatwe need multiple resources to meet themental health needs o very young childrenIn addition, there is a need to assist agencie

W hile all states provide early childhood intervention services or childrenunder 3 years o age who are experiencing developmental delays,

screening and services or social-emotional delays have lagged behind servicesor other developmental delays in many states. 1 In Hennepin County, Minnesota,

sta provide developmental and social-emotional screening or re erred childrenunder age 3. Tese children are re erred rom amilies, pediatric providers,hospitals, and other community sources when a delay is suspected. Screening

is done in the home using standardized tools by public health nurses and childdevelopment specialists.

Karen Adamson, RN, MPH

Part C IDEA, Early Intervention Services:Serving Children Under 3 Years with Mental Health Concerns




Head Start G alsEchoing the Zero to Tree de nition o in ant mental health, Head Start’s goals areto ensure that all young children can ormstrong attachments with their caregivers,regulate their emotions, and reach out andexplore their environment to learn.1 Tese

goals underlie all Head Start e orts toprovide early learning experiences or youngchildren.

Federal Req irements rMeeting S cial-Em ti nalNeedsTe ederal Head Start Per ormanceStandards require programs to developsystems or screening, identi ying, andtreating children with emotional di culties.Tey also require Head Start to contract

with mental health pro essionals to o erconsultation services or enrolled childrenwith social or emotional problems. Mentalhealth consultants can provide a range o services including classroom observations,in-depth assessments o children, directtherapeutic services, training and/or support

or sta , and meetings with parents.

Te 2008 ederal Program In ormationReport demonstrated that Minnesota HeadStart sta sought consultation with mentalhealth pro essionals related to the mentalhealth problems o more than 2,100 enrolledchildren (or 13% o Minnesota’s Head Startenrollment).2 In-house pro essionals servedmany additional children and amilies.Te number o children in Head Startwith mental health concerns has growndramatically in the past 10 years.

Addressing Parent Ed cati nNeedsParents look to Head Start to understandtheir children’s social and emotionaldevelopment, and parent education is acritical component o Head Start’s amily development services. Te Ages and Stages

Questionnaire: Social-Emotional (ASQ:SE)3

has been adopted by every Head Startprogram in Minnesota to screen childrenand help initiate a dialogue with parentsabout their child’s development. ASQ:SEis completed by parents within the rst 45days o their children entering Head Start,and the results are reviewed with every parent. Parents whose children have apositive screening result can request urtheassessment, and all parents have a variety o options or urther discussion with staspecialists or mental health pro essionals.

W hen a young child has a ever,you call the doctor. Who do you

call when a baby is di cult to consoleand cries incessantly; or a young childexpresses extreme anger and rage; or apreschooler consistently bites and hitsother children? In 2004, Minnesota

Head Start sta and parents asked thesequestions as part o a statewide initiativeto nd better ways to support the socialand emotional well-being o youngchildren and their amilies. Increasedawareness o the requency that childrenin Head Start were showing challengingbehaviors led to an initiative to buildan improved system o mental healthpromotion, prevention, and intervention

services within Early Head Start andHead Start programs (collectively calledHead Start).

Gayle L. Kelly, MS

Minnesota Head Start:Addressing Mental Health Needs Early



New parent education o erings like theIncredible YearsParenting Program (seepage 26) are being o ered in partnershipsbetween Head Start and community mentalhealth organizations throughout Minnesota.

Mental Health C ns ltati nIn 2004, Minnesota Head Start programs

aced considerable challenges in ndingquali ed mental health consultants withearly childhood expertise. A partnershipbetween the Minnesota Head StartAssociation and the Minnesota Departmento Human Services (DHS), Division o Children’s Mental Health, has contributedto signi cant progress in improving mentalhealth supports or young children.

Building capacity through training.In 2004, Head Start adopted a “growyour own” approach by partnering withmental health pro essionals. Te HeadStart program identi ed community mental health pro essionals who lackedtraining and experience serving youngchildren, but were motivated and willingto acquire additional competencies. TeDHS Division o Children’s Mental Healthbegan o ering regional training groundedin neurobehavioral scienti c research anddesigned to develop trainee competencies inusing state-o -the-art methods or screening,assessment, and intervention with childrenunder the age o 5. Head Start programsin many communities provided nancialsupport to help their mental health partnersparticipate in this training. Tey also madetheir classrooms available as laboratoriesto help ground these pro essionals in thelanguage o early childhood development.

Re erral or diagnostic assessment.Priorto 2004, Minnesota Head Start programsre erred children with mental healthconcerns almost exclusively to their localeducational agency or evaluation by Early Childhood Special Education (ECSE) (or

or a child under 3 years, Part C Early Intervention). Very ew children were givena diagnosis related to their social-emotionaldelay or disability and hence, were noteligible or ECSE or Part C services. oday,more programs have access to mental healthpro essionals who have been trained indevelopmentally appropriate mental healthassessment techniques such asDC:0-3R and re errals are o en made concurrently to community mental health providers andtheir local ECSE or Part C team. Head Start

programs indicate they now serve many children with mental health problems whoare waiting or evaluation by their local PartC or ECSE team or have not quali ed orthose education services.

Changing role o mental health consultation. Increasingly, Head Start programs arepartnering with community mental healthorganizations with expertise in early childhood, thereby bringing assessment andtreatment services into Head Start settings.

oday, integrated service approaches areoccurring with dramatic positive results

or children and amilies. Examples o theevolving role o mental health consultants inHead Start include:

■ In the Duluth Head Start programs,mental health consultants conduct childobservations, work closely with parents,and work closely with classroom sta todevelop individualized strategies or allchildren showing challenging behaviors.Refective consultation is used to helpsta recognize the di culty in caring orchildren with social-emotional issues.

■ Trough the work o its consultingpsychologist, Parents in Community Action (PICA), Inc., the Head Startprovider in Hennepin County, hasdeveloped a collaborative partnershipwith Family and Children’s Servicesto provide on-site play therapy

or identi ed children. PICA’sre erral-to- ollow up ratio is nearly 100%.

Te Minnesota Head Start community is rede ning the roles o mental healthconsultants as an invaluable resource or thewell-being o children and amilies, as wellas sta . Te rst priority in comprehensiveschool readiness must be early learningpolicies and unding streams that ensureservices to promote the social and emotionalwell-being o children and their caregivers.

REFERENCES1. ask Force on In ant Mental Health. De nition o in ant

mental health. Arlington, VA: Zero to Tree, 2002.Available rom: www.zerotothree.org.

2. Kuklinski W. Data rom the 2008 Federal Head StartProgram In ormation Report or Minnesota. St. Paul,MN: Minnesota Department o Education.

3. Squires J, Bricker D, wombly E. Ages and stagesquestionnaires: social-emotional (ASQ:SE): a parent-completed, child-monitoring system or social-emotionalbehaviors. Baltimore: Brookes Publishing, 2009.

Gayle L. Kelly, MS, is Executive Director o the Minnesota Head Start Association, Inc.

that work with young children on a daily basis, such as preschools and child carecenters, to employ quali ed pro essionalwho are skilled in early childhood serviceREFERENCES

1. Cooper J, Vick J. Promoting social-emotional wellbeearly intervention services. A y-state view. New YNational Center or Children in Poverty, 2009. Avail

rom: http://www.nccp.org/publications/pd /text_882. Squires J, Bricker D, wombly MS, Heo K. Identi c

o social- emotional problems in young children usinparent completed tool.Early Child Res Q2001;16(4):4419.

3. Hennepin County Human Services and Public Health2008 Annual Report: Early Childhood Public HealthInternal publication, available upon request.

4. U.S. Department o Education. Individuals withDisabilities Education Act. Available rom: http://ided.gov/

5. Cutler C, Ward H, Yoon SY, et al. Children at risk in child wel are system: collaborations to promote schoreadiness. University o Southern Maine: Muskie Sco Public Service, April 2009. Available rom: http:

muskie.usm.maine.edu/schoolreadiness/6. Cooper J. Social and emotional development in early

childhood: what every policymaker should know. NeYork: National Center or Children in Poverty, 2009Available rom: http://www.nccp.org/publications/

Karen Adamson, RN, MPH, is Program ManagerChildren, Youth and Families at Hennepin CountyHuman Services and Public Health (Minnesota) ashe is the current Chair o the Minnesota Departo Health MCH Advisory ask Force. Karen recher MPH in Maternal and Child Health rom theUniversity o Minnesota.

continued rom page 21Part C IDEA, Early Intervention Services

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STEEP TM Pr gram Str ct reParticipants typically are recruited throughobstetric clinics during pregnancy. Bi-weekly home visits, tailored to the needs andstrengths o each amily, continue until thechild’s second birthday. Shortly a er thebabies are born, mothers begin attendingbi-weekly group sessions. Re ecting therelationship-based approach o S EEP™,each group is led by the person whoconducts the home visits or those 8–10

amilies.

Group sessions begin with mother-childactivities geared to the babies’ stage o development. Ten, ollowing a casualmeal, mothers gather or “mom talk,” ordiscussions ocused on their own personalgrowth and li e goals. Although groupmeetings are or mothers and babies, athersand other amily members are included inhome visits and periodic amily events.

Gr nded in AttachmentThe ry and ResearchTe primary pathway to a secureattachment and the oundation o in antmental health is parental sensitivity toa baby’s cues and signals. With that in

mind, S EEP™ promotes sensitivity andaddresses actors that can underminesensitive care. A centerpiece o the programis Seeing Is Believing™, a video-recordingo parent-in ant interaction or engagingparents in sel -observation and discovery as they watch the video with their home visitor.2 Trough open-ended questions,the acilitator encourages parents to ocuson what their babies are telling them andto recognize their own skills in adapting totheir babies’ needs. Video-recording helpsto keep the parent-child relationship atthe center o the intervention, provides apermanent record or monitoring progress,

and is a valuable aid when acilitators seeksupervision or consultation. Te videobecomes a treasured keepsake or the amiand, according to many participants, is apower ul incentive to participate in theprogram.

The S EEP™ program (Steps owardE ective, Enjoyable Parenting)

aims to promote healthy parenting andprevent social-emotional problemsamong babies in amilies acingrisk actors such as poverty, socialisolation, or a history o troubled

relationships. Attachment theory provides a ramework or the program,and longitudinal research on actorsthat underlie healthy parent-childrelationships in orms the program’sbroad goals.1

Martha Farrell Erickson, PhD

Promoting In ant Mental Health through

Relationship-based Interventions

Te primary pathway to asecure attachment and the

oundation o in ant menthealth is parental sensitivity

baby’s cues and signals.



Babies know what they experience—whethermom and dad can be counted on to o ercom ort when they cry, play with themwhen they’re eeling sociable, and respecttheir privacy when they’d rather sleep thanbe tickled. Many actors underlie a parent’sability to sustain sensitive, responsive care.Although each amily has unique strengthsand challenges, some major actors deservespecial attention in a program designed topromote sensitivity:

■ Knowledge and understanding o child development. Sensitive care is groundedin knowledge about child developmentand understanding o the developmentalmeaning o key behaviors such asseparation protest or toddler negativism.When parents lack that understanding,they o en hold unrealistic expectationsand get caught in a cycle o rustration

and anger, attributing negative qualitiesto their child just because he or she isdoing what children naturally do.

■ Social support. For parents to respondsensitively to their children’s needs, theirown needs must be addressed. Someparents are socially isolated; they lack supportive riends or amily members,and/or lack the skills or con dence toaccess supportive resources. Barriersto getting support may include lack o transportation and money. Sometimesparents are surrounded by amily and riends who do not support goodparenting and the best interest o thechild. Tis is dramatically evident, orexample, in amilies living in a culture

o drug abuse. S EEP™ helps parentsidenti y potential sources o supportand develop the skills to use supporte ectively.

■ Looking back, moving orward. Consistent with attachment theory and research on intergenerationaltransmission o parenting, an importantpart o S EEP™ is to help parents refecton what they learned in their own early relationships and how that infuencestheir responses to their children. Bothin home visits and groups, S EEP™creates a supportive environment inwhich parents refect on their history,con ront pain ul memories, and identi y positive experiences to pass on to theirchildren. Understanding that no one isa per ect parent, the ocus is on leavinghurt ul patterns behind and mustering

all available resources to become a“good enough” parent. As described inthe S EEP acilitators’ guide,3 groupactivities give parents permissionto begin looking back so they canmove orward. Home visits a ord anopportunity or more personalizedencouragement and support.

Br ad Disseminati nand Ad pti nSince the development and evaluation o

S EEP™ and Seeing Is Believing™ at theUniversity o Minnesota, these programshave been used in varied settings in NorthAmerica, Australia, and Europe. Teapproaches have been used e ectively

with several special populations, includingindigenous amilies, women who abusedsubstances during pregnancy, teen parents,mothers who are depressed, amiliesidenti ed as abusive or neglect ul, and

amilies o preterm, medically ragile in a

For urther in ormation about this work, orto inquire about training or sta in yourorganization, contact the author at m [email protected]

1. Egeland B, Erickson MF. Lessons rom S EEP™: linktheory, research and practice or the well-being o in aand parents. In Samero A, McDonough S, RosenblumK. editors. reating parent-in ant relationship problemsstrategies or intervention. New York: Guil ord, 2003, 213–242.

2. Erickson MF. Seeing is Believing™ raining DVD.Minneapolis, MN: Irving B. Harris raining Center,University o Minnesota, 2005.

3. Erickson MF, Egeland B, Simon J, Rose . S EEP™Facilitator’s Guide. Minneapolis, MN: Irving B. Harris

raining Center, University o Minnesota, 2002. .

Martha Farrell Erickson, PhD, retired in 2008 romher position as Director o the Irving B. Harris

raining Programs in the Center or Early Educatioand Development in the College o Education and Human Development at the University o MinnesoShe continues to consult and speak throughout the Uand abroad on in ant mental health, parenting, and evidence-based strategies or working with high-ri amilies. Dr. Erickson also appears regularly on Vand radio in the win Cities and, with her daughter,Erin Garner (a MCH student in the Maternal and Child Health Program at the University o Minneso

hosts the weekly talk show, Good Enough Moms™

Register Now! “Engaging Fathers: Strengthening Families”Minnesota’s Birth-to-Three ConferenceJanuary 13-15, 2010, Arrowwood Resort, Alexandria, MN

http://www.regonline.com/strongfoundations2010

The Center for Leadership Education in Maternal and Child Public Health is a co-sponsor of this event.



Missi n the WilderF ndati nWilder introduced the Incredible Years programs as part o their 100-year history o combining direct services, research,and community development to addressthe needs o the most vulnerable people inRamsey County, Minnesota. Trough morethan 70 diverse programs and services,Wilder works with thousands o individualsevery year to help them overcome barriersto learning, address mental health needs,live more independently, maintaina ordable housing, and engage in theircommunities.

The C ntin m Incredible

Years Pr gramsTe Incredible Yearsprograms havetwo oci: (1) comprehensive treatmentprograms or young children with early onset conduct problems, and (2) universalprevention programs to promote socialcompetence and prevent young children

rom developing conduct problems inthe rst place. Te curricula are designed

or teachers, parents, and children. Tedevelopment o materials was guidedby developmental theory and t intoan intervention pyramid with levels o

intervention corresponding to universal,selective, and indicated preventionprograms, plus an additional treatmentprogram.

At Wilder, three o theIncredible Yearsprograms have been implemented andtwo additional programs were added inNovember 2009:■ Dina Dinosaur is a classroom-based

prevention curriculum thatteaches social problem-solving andsel -regulation skills in order to preventand reduce aggression at home andschool (Level 2 o the interventionpyramid). It is delivered in theclassroom two to three times a week in15–20 minute circle time discussions

ollowed by small group activities. For

the past ve years, the Dina Dinosaur curriculum has been implemented inWilder’s Child Development Center,an accredited ull-day early child careand education program that workswith some o the most vulnerablemembers in the community. In

addition, Wilder trains and mentorsother early childhood pro essionalsto use the Dina Dinosaur curriculum,including those rom Head Start, early childhood special education, andcommunity-based child care centers.

■ Dina small group therapy program isa treatment program (Level 5 o thepyramid) designed speci cally oryoung children who show high rates o aggression, de ance, and oppositionalor impulsive behaviors. It is delivered

In 2004, the Amherst H. WilderFoundation introduced the Incredible

Years programs to the community.Tis set o evidence-based programs isdesigned to teach positive interactionskills, social problem-solving strategies,anger management, and appropriate

school behaviors to young children. Teprograms also strengthen parent-childrelationships and help parents developpositive behavior guidance strategies.

Gael Tompson, MSW, LICSW

Promoting Early Childhood Mental Healththrough Evidence-based Practice

Implementation o the Incredible years in Ramsey County, Minnesota

Photo used with permissioin o Te Wilder Foundation Early Childhood Programs



in small group sessions or 20–22 weeks.In addition to the weekly therapeuticsessions or children, the BASIC Parent Program is o ered to parents so they learn ways to oster healthy interactionsat home similar to what their childrenare learning in the group.

■ Preschool BASIC parent program isdesigned or parents o 3 to 6 year-olds.It ocuses on strengthening children’ssocial skills, emotional regulation, andschool readiness skills. Parents aretaught how to encourage cooperativebehavior and how to use positivediscipline by establishing rules, routines,and e ective limit setting.

■ Parents and babies program is designedor parents o in ants (ages 0–12

months). Te program ocuses onhelping parents learn to observe andread their babies’ cues and learn waysto provide nurturing and responsivecare, including physical, tactile, and visual stimulation as well as verbalcommunication.

■ Parents and toddlers program isdesigned or parents o 1 to 3 year-olds.Parents learn how child-directed play promotes positive relationships, how touse emotion coaching to build children’semotional vocabulary and encouragetheir expression o eelings, how to build

children’s sel -esteem through praiseand encouragement, and how to teachage-appropriate sel -care skills.

Pr gram o tc mesIn 2009, Wilder Research completed anoutcome report o data collected sinceimplementing the Incredible Yearsprograms(2005–2009). Children showed statistically signi cant improvements in all vebehavioral domains: emotional symptoms,conduct problems, hyperactivity-inattention,peer problems, and pro-social behavior.Parents and teachers reported that ewerchildren had di culties with emotions,concentration, behavior, or getting alongwith others at discharge compared to intake.Parents who participated in thePreschool BASIC Parent Programdemonstratedsigni cant improvement rom intake todischarge in six o seven parenting skillsareas: appropriate discipline, harsh andinconsistent discipline, positive verbaldiscipline, praise and incentives, physicaldiscipline, and clear expectations.

Nati nal Award RecipientOn September 25, 2009, the SubstanceAbuse and Mental Health ServicesAdministration announced that Wilder’sIncredible YearsProgram was selected as one

o 27 nation-wide recipients o their 2009Science and Service Awards. Tese awardsrecognize exemplary implementation o evidence-based interventions that have beenshown to prevent and/or treat mental illnessand substance abuse.

For more in ormation about the early childhood programs o ered at theWilder Foundation, go to www.wilder.org/432.0.html. For more in ormation aboutthe Incredible Yearsprograms, please go towww.incredibleyears.com.

Gael Tompson, MSW, LICSW, is the Early Childhood Intervention Program Coordinator at the Amherst H.Wilder Foundation Child Guidance Clinic, St. Paul, MN.

continued rom page 19 Family Home Visiting

REFERENCES

Visit www.health.state.mn.us/divs/f/mch/fv/index.html or in ormation about the

amily home visiting program and www.health.state.mn.us/divs/f/mch/fv/newsletter/documents/summer2009.pd in ormation about re ective practice.REFERENCES

1. Powers S, Fenichel E. Home visiting: reaching babiand amilies “where they live.” A report o the bestavailable in ormation rom 20 years o research andpractice on home visiting. Washington DC: Zero toTree, 1999.

2. Zeanah CH, Zeanah PD. owards a de nition o inmental health. Zero to Tree, 2001; 22(1):13-20.

3. Nursing Child Assessment Satellite raining (NCASAVENUW. Available rom: http://www.ncast.org/

4. Miller W, Rollnick S. Motivational interviewing.preparing people or change, 2nd edition. New York:Guil ord, 2002..

Sharon Hesseltine, BSW, is a Child DevelopmentIn ant Mental Health Specialist in the Family andCommunity Health Division o the MinnesotaDepartment o Health

Jill E. Simon, MSW, LICSW, IMH-E® (IV), is aRe ective Practice Consultant in the Family and Community Health Division at the MinnesotaDepartment o Health.



Risks Ass ciated with Tra maSeveral subgroups o very young childrenare at particularly high risk or exposure totraumatic events. Tese are young childrenwith backgrounds indicating high adversity or exposure to multiple stress ul events, ando en the caregivers o these children alsohave been exposed to signi cant trauma.Tese childhood experiences includehomelessness, having re ugee parents whohave ed war in their native countries, andhaving mothers eeing domestic violence.An additional group emerging as high-risk includes children whose parent(s) havebeen deployed to combat duty in Iraq orA ghanistan. Tese "high-risk" amilies areless likely to access mental health or relatedservices that might bu er poor parenting,2 enhance social support, and increase childand amily unctioning.

Homeless and poor amilies.Familiesliving in poverty—particularly those

who are homeless—are most likely to besingle-mother amilies with several youngchildren. Children living in homeless

amilies are signi cantly more likely tohave health and social-emotional problemscompared to poor children who havehousing.3

Military amilies.Recent studies have shownincreased risk o maltreatment amongchildren in military amilies where a parenthas been deployed to Iraq or A ghanistan.4 Parents remaining at home are challengedby the stressors associated with being a solecaregiver and having a deployed partnerin an unsa e environment. Reunions canalso be stress ul or all members o the

amily. Some returning soldiers may haveposttraumatic stress disorder (P SD),increasing both parenting and couplechallenges. In the military, supports oractive-duty service amilies are stronger than

or amilies with caregivers serving in theNational Guard or Reserves; the ormer tend

to live in communities (or on bases) withbetter social supports and more resources.

Treatment r Tra matizedY ng ChildrenWhat can be done to support young, highlystressed amilies dealing with traumaticexperiences? Over the past several decadese ective programs have been developedto both prevent and treat trauma-relatedproblems in adults and children. SAMHSA’sNational Child raumatic Stress Network (NC SN) is a nationwide network o Centers dedicated to developing,disseminating, and implementing bestpractices in child trauma.5 Te NC SN’s

A2009 study by the U.SDepartment o Justice indicates

that children (birth to 17 years)experience astonishingly high rateso traumatic events.* Over 60% ochildren studied had experienced orwitnessed at least one violent incident

in the past year. 1 Te youngestchildren—those ages birth to ve—were most vulnerable to abuse,neglect, and exposure to domestic violence. Such young children are themost dependent on caregivers, andcannot report on their own traumaticexperiences, complicating e orts togather prevalence data. 1

Abigail Gewirtz, PhD, LP

Supporting the Mental Health Needs o

Traumatized Young Children

* raumatic events include any event in which anindividual experiences actual or threatened death,serious injury, the threat to physical integrity, or the lior integrity o a close associate. Examples include abudomestic violence, community violence, wars, natural disasters such as tornados or ooding, terrorism, or movehicle or other accidents.



goal is to increase access to high-quality careor traumatized children and their amilies.

Parenting through change. Ambit Network is the NC SN Center in Minnesota. Acommunity-University partnership basedat the University o Minnesota, Ambitincludes multiple child-serving systemsand agencies. Over the past our years,Ambit ( ormerly known as the MN ChildResponse Center) has trained hundreds o practitioners in Minnesota to increase theircapacity to identi y and provide services

or traumatized children and amilies. TeCenter has ocused on the implementationo two types o interventions—treatment

or individual children and prevention tosupport parenting in traumatized amilies.Te latter, Parenting through Change(P C),6 is a 14-week group that enhancescritical elements o parenting that may

be adversely a ected when amilies haveexperienced traumatic events.P C has beenimplemented success ully in a shelter, atseveral supportive housing agencies, andat schools, in collaboration with severalnon-pro t agencies (the Family HousingFund and the Minneapolis Public Schools).In partnership with the Center or Victimso orture and the East A rican Women’sCenter, a P C group will begin with Somalimothers in Minneapolis in late 2009. Also inlate 2009, aP C group or returning military parents will be led by Ambit Network sta in

partnership with the Minneapolis VeteransAdministration Medical Center.

rauma- ocused cognitive behavioral therapy. For traumatized children agesthree and older, trauma- ocused cognitivebehavioral therapy ( F-CB )7 is a treatmentshown to be e ective in multiple settings.Over the past three years, Ambit Network, inpartnership with the Minnesota Departmento Human Service, Division o Children’sMental Health, has trained and providedtechnical assistance to almost 100 mental

health pro essionals across Minnesota todeliver F-CB .

Over the next three years, Ambit, incollaboration with Minnesota’s Departmento Human Services, will expand its e orts todevelop a trauma-in ormed mental healthsystem in Minnesota, to ensure that allchildren and amilies who have experiencedtraumatic events have access to the bestservices available.

For more in ormation about the programsor traumatized children and amilies o ered

through Ambit Network, contact Ashley Wahl at 612-624-7722.

REFERENCES

1. Finkelhor D, urner H, Ormrod R, Hamby S, KrackeK. Children’s exposure to violence: a comprehensivenational survey. Juvenile Justice Bul letin, WashingtonDC: Department o Justice, O ce o Justice Programs,

OJJDP Bulletin, 2009. Available rom: http://www.ncjrs.gov/pd les1/ojjdp/227744.pd

2. Gewirtz AH, Forgatch M, Wieling L. Parenting practicesas potential mechanisms or child adjustment ollowingmass trauma. J Marital Fam Ter 2008; 34(2):177–192.

3. Gewirtz AH, DeGarmo DS, Plowman E, August GJ.Parenting, parental mental health, and child unctioningin amilies residing in supportive housing. Am JOrthopsychiatry, in press.

4. Gibbs DA, Martin SL, Kupper LL, Johnson RE. Childmaltreatment in enlisted soldiers’ amilies duringcombat-related deployments. JAMA 2007; 298:528-535.

5. National Child raumatic Stress Network. Description,resources and products. Available rom: www.nctsn.org

6. Forgatch MS, Patterson GR, DeGarmo DS, Beldavs ZGesting the Oregon delinquency model with 9-yearollow-up o the Oregon divorce sudy. Dev Psychopath

2009; 21:637-660.

7. Cohen J, Mannarino A, Deblinger E. reating trauma antraumatic grie in children and adolescents. New York:Guild ord Press, 2006,

Abigail Gewirtz, PhD, LP, is an Assistant Pro essoin the Department o Family Social Science and thInstitute o Child Development at the University o Minnesota, and Director o Ambit Network.

A flexible program for working professionals who areconcerned about vulnerable populations and want toacquire leadership skills for addressing the health needs

of families, women, infants, children, and adolescents.

T o learn more: visit our Web sitewww.epi.umn.edu/mch/index.php/Page/View/Distance-Learning

or email [email protected] call (612) 626-8802

Earn an Online MPHIn Maternal and Child Health



M ving r m a Fragmentedt a C mprehensive SystemIn most states, policies and programs thataddress the developmental needs o youngchildren and their amilies are spread acrossgovernment agencies, unded throughdi erent sources, and delivered throughmultiple public and private providers incommunities.1 Tis ragmentation is costly,ine cient, and most importantly, results inmany needs o young children going unmet.In an e ort to encourage comprehensivesystems or young children 0–5 years andtheir amilies, the Health Resources and

Services Administration initiated the StateEarly Childhood Comprehensive Systems(ECCS) grants in 2003. Te purpose o ECCS grants is to integrate early childhoodpolicies and programs, including undingstreams. Te systems to be integrated includekey public, private, state, and local agenciesthat address ve critical components o early childhood:

■ Access to health insurance and medicalhomes;

■ Mental health and social-emotionaldevelopment;

■ Early child care and education;■ Parenting education; and

■ Family support.

Te Minnesota Department o Health(MDH) has been an ECCS grantee sinceJuly 2003. Te Minnesota Early ChildhoodComprehensive System (MECCS) ocuseson in rastructure and capacity buildingservices and involves representatives o key units within the state departments o health,education, and human services whosework is directly related to the ve criticalcomponents.

Ad pting a M delr Systems Devel pment

With this multi-sector partnership,Minnesota adopted the goal o “ amiliessupported and children thriving, healthy,and ready or school in the context o culture and community.” In 2007, MECCScollaborated with Ready 4K, the staterecipient o a national Build grant,3 to

adopt a model developed by the NationalChildhood Systems Working Group1,3 thatintegrates the key systems necessary or eachildhood development: (1) health, mentalhealth and nutrition; (2) early learning; (3)

amily support; and (4) special needs/earlyintervention.1,3

Te ve essential elements o ECCSare represented by one or more o the

our ovals in this systems model. Whileindividual programs within any o the ovalmay demonstrate some positive impactupon children’s healthy development andschool readiness, they will not realizetheir ull potential without support romthe programs in the other ovals.1 By adopting a systems model, mental healthwas incorporated into early childhoodsystems-building in Minnesota. Ensuringpositive mental health requires that childrenhave good sel -esteem, adaptive skills, andpositive social behaviors with peers andadults—and that any developmental delayso children are recognized and treated.1

Extensive research supports theimportance o a comprehensive

system o care and services or childrenin order or them to be ready orschool.1,2 Many state e orts to improveschool readiness have ocused onstrengthening early learning services

such as child care and preschool.However, to be prepared or school andthe interaction o normal li e situations,how young children eel and behave is just as important as what they know and think. All o these competenciesare inextricably linked.

Kelly Monson MAEd, C

Minnesota Early Childhood Comprehensive System (MECCS):Building the In rastructure to Meet Developmental Needs o Young Children



Key Indicat rs t M nit ran Early Childh d SystemIn collaboration with the Wilder Foundation,Minnesota Build and MECCS identi ed 22indicators o child and amily well-beingand systems quality that represent eacho the our ovals in the systems model.4

Identi cation and ongoing measuremento indicators are critical because such dataallow the state partners to:

■ rack trends in young child and amily well-being over time;

■ Measure progress toward improvingchild outcomes;

■ Improve programs or children andamilies;

■ In orm state and local planning andpolicymaking;

■ Monitor the impact o investments andpolicy choices;

■ Improve data quality and availability o current and emerging indicators; and

■ Expose and eliminate disparities by income and race/ethnicity. ..4

Some o the indicators selected that relatespeci cally to young children’s mental healthinclude:

■ Number/percent o children withpossible social-emotional problems

identi ed and re erred at early childhood screening;

■ Number/percent o children beingserved through publicly unded mentalhealth services compared to estimatedneed;

■ Number o children ages 0–2 and 3–4

enrolled in quality early childhoodprograms;

■ Participation rates in ECFE and otherparent education and support models;and

■ Number/percent o children birth to 3years who are served through Part CEarly Intervention.

Given the requently voiced concern by bothparents and pro essionals about the unmetsocial-emotional needs o young children,the in rastructure being developed throughMECCS is an important step in the directiono lling this gap and improving the mentalhealth o all young children in Minnesota.

For more in ormation about MECCS, visittheir website at: www.health.state.mn.us/divs/cf/meccs/. For more in ormation aboutthe BUILD initiative, visit their website at:www.buildinitiative.org/

REFERENCES

1. Bruner C. Connecting child health and schoolreadiness. Build Initiative and Child and Family PolicyCenter, February 2009. Available rom: http://www.buildinitiative.org/ les/IssueBrie _Bruner_Feb09_Finpd

2. Shonko J, Phillips D. (Eds.). National ResearchCouncil and Institute o Medicine. From neuronsto neighborhoods: the science o early childhooddevelopment. Washington, DC: National Academy Pres2000.

3. Build initiative: A project o the Early ChildhoodFunders’ Collaborative supporting state e orts to prepaour youngest children or success. Available rom: httpwww.buildinitiative.org/

4. Moore C, Chase R, Waltz M, et al. Early childhoodMinnesota Indicators and strategies or Minnesota’s earchildhood system, a joint report o Minnesota Build anMinnesota Early Childhood Comprehensive Systems. SPaul: Wilder Research, 2008. Available rom: http://wwwilder.org/download.0.html?report=2173

Kelly Monson MA Ed, CFLE, is a State EarlyChildhood Systems Coordinator at the Minnesota

Department o Health, Community and FamilyHealth Division.



Head Start G alsSince its inception, CECMH has displayeda strong commitment to strengtheningchildren’s mental health by promoting theuse o evidence in mental health practiceand policymaking. CECMH also workswith aculty members to promote publicly engaged research that is pertinent to theneeds o community members.

In order to engage a wide range o providers, parents and researchers intraining events, CECMH sponsors anannual Lessons rom the Field seminarseries that eatures local and nationalspeakers. Seminars are video-streamedlive to over 30 sites in Minnesota whereparticipants view and listen to the speakersand participate in discussions. EachLessons rom the Field series is organized around acommunity-identi ed theme. Because o CECMH’s strong interest in early childhood,the 2006–2008 seminars explored issueso attachment and its relationship tomental health, intervention, treatmentmethods, and intergenerational issues. Te2009–2010 series will ocus on race, culture,and children’s mental health.Tis series isco-sponsored by several partners, includingthe Center or Leadership Education inMaternal and Child Public Health.

CECMH also disseminates current,applicable, and accessible research toproviders and policymakers.CECMH eReviewis an online publication that eaturesa summary o published research in a

speci c area and a collection o responsesrom providers and policymakers regarding

the practical application o that research. Terst issue, “Attachment Relationships and

Adoption Outcomes,” and all subsequenteReviewissues are published on the CECMHwebsite (www.cmh.umn.edu).

One o the most critical areas o CECMHwork is to promote publically engagedresearch by building partnerships betweenresearch aculty and community members.CECMH sta bring University researchexpertise to bear on problems o signi canceto the community— acilitating thecommunity’s voice in guiding academicresearch. One example o this work is theCECMH’s active participation in a CulturalProviders Network o local cliniciansthat serves children o color. Tis diversegroup o dedicated providers incorporatesresearch-based evidence into their work and develops new, culturally appropriateinterventions.

CECMH is housed in the interdisciplinary Children, Youth, and Family Consortium(CYFC) at the University o Minnesota. Formore in ormation about CECMH and itsprojects, visit www.cmh.umn.edu or call(612) 625-7849.

Cari Michaels, MPH, is the Associate Director o theCenter or Excellence in Children’s Mental Health at the University o Minnesota.

The Center or Excellence in Children’s Mental Health (CECMH) was establishedin 2003 as part o the University o Minnesota President’s Initiative on Children,

Youth, and Families. Its mission is to promote the mental health o Minnesotachildren, their amilies, and their communities by in orming and integrating research,training, practice, and policy. oward that end, CECMH sta work with University

aculty, sta , and community members to improve children’s mental health in the stateo Minnesota.

Cari Michaels, MPH

Center or E cellence in

Children’s Mental HealthLinking University and Community E perts and Resources

SPEAKERS' SERIES CENTER FOR ExCELLIN CHILDREN’S MENTAL HEALTH LESSO

FROM THE FIELD 2009-2010:RACE, CuLTuRE AND CHILDREN’S MENTAL

December 4, 2009, 9:00 a.m. – 12:30 p.m.Historical Trauma, Microaggressions, and Identity:Framework or Culturally Based PracticeDr. Karina Walters

Febr ary 17, 2010, 9:00 a.m. – 12:30 p.m.Intersection o Culture and Children’s Mental Hein Working with Immigrant & Re ugee Families

March 18th, 2010, 9:00a.m. – 12:30 p.m.Promoting Child Well-being and Early Interventiowithin a Cultural Conte tBrenda Jones Harden, University o Maryland

May 12, 2010, 1:30p.m. – 3:30 p.m.Title TBDAlicia Lieberman, University o Cali ornia – SF

All sessions will be at the Co man Theater, Univo Minnesota and broadcast to sites in GreaterMinnesota.

Sp ns rs: Center or E cellence in Children’s

Mental Health in partnership with Center orAdvanced Studies in Child Wel are (UMN) and HPrograms (UMN).

C -sp ns rs: Center or Leadership Educationin Maternal and Child Public Health (UMN), MNADOPT, O fce or Equity and Diversity (UMN)Minnesota Community Foundation-Baby ProjectSheltering Arms Foundation.

For more in ormation, visit: http://www.cmh.umn.edu/culture/workshop1.html.



Training in Best PracticesIn ant and amily pro essionals requirespecialized pro essional development andconsultation rom in ant mental healthspecialists to ensure service quality ande ectiveness in addressing the diverse ando en complex needs o in ants, youngchildren, and amilies.

Te Minnesota Association or In antand Early Childhood Mental Health(MAIECMH) is a statewide membership

organization whose mission is to promotesocial and emotional development andmental health o children, rom birth to 5years. Founded in 2007 and a liated withthe World Association or In ant MentalHealth, MAIECMH operates as the in antand early childhood division o MACMH(Minnesota Association or Children’sMental Health). Te goals o MAIECMHinclude education and advocacy to enhanceculturally sensitive interdisciplinary capacity to serve in ants, young children, and their

amilies.

Pro essional competencies.MAIECMHworks to advance standards in practiceamong a range o pro essional disciplinesworking with in ants, young children, andtheir amilies. Tese standards are groundedin comprehensive pro essional competenciesbased on in ant mental health principles, asidenti ed by the Michigan Association orIn ant Mental Health (MI-AIMH). Teseprinciples include mutuality o caregivingrelationships and understanding and usingthe rich histories, eelings, and behaviors

that the child, parent/caregiver, andprovider/educator bring to these workingrelationships.

Refective practice.Tese principlesrequire that pro essionals actively engagein a re ective stance via supervision andconsultation. Tis re ective practice isan integral component o interventionsprovided along a continuum o care, rompromotion and prevention to intensivetreatment. Re ective supervision, providedregularly, leads to improved amily

outcomes, improved quality o services, ansupport or ethical practice and culturalcompetence.1

Endorsement.Pro essional competenciesare the ramework or a pro essionalendorsement program o ered in Minnesotaby MAIECMH, calledCulturally Sensitive,Relationship-based Practice Promoting In ant Mental Health.A number o statesacross the country o er the endorsementprogram, developed and copyrighted by MI-AIMH. Working with MI-AIMH,partner states, Minnesota organizations,and association members, MAIECMH ispromoting and evaluating the applicationo these competencies among a range o practitioners, providers, and educators.

Te set of professional competencies can beused to:

■ Guide and encourage continuouspro essional development and careerplanning;

■ Guide the development o pre-service

All providers and educators whowork with young children and their

amilies play critical roles in promotingoptimal mental health outcomes orin ants, toddlers, and preschoolers.Roles may include health promotion

or all children, preventive intervention

in at-risk situations, early interventionthat addresses developmental concerns,and intensive services and treatment

or children with serious emotionaldisturbances. Best practices or thispopulation ocus on supporting positiverelationships between parent, child,and other caregivers in the context o a

amily’s culture and community.

Candace Kragthorpe, MSW, IMH-E® (IV)

Culturally Sensitive, Relationship-based Practice

Promoting In ant Mental HealthCompetency-based Training and Endorsement




C nditi ns Necessary rIn ant Mental HealthTe well-being and well-becoming o youngchildren (in ant mental health) dependupon two essential conditions: (1) stable andloving relationships with a limited numbero adults who provide responsive, regulatory experience, encouragement or explorationand learning, and transmission o cultural values; and (2) a sa e and predictableenvironment that provides a range o

growth-promoting experiences in cognitive,linguistic, social, and emotional domains.3 While the majority o children experiencethe bene ts o both, signi cant numbers donot.

The Need r Training Speci ct In ant Mental HealthTe many practitioners engaged inaddressing the needs o young childrenand their amilies o en ace a host o challenges, including the need to movebeyond their own pro essional training andexperience. Well-de ned training withinone age range (e.g., middle childhood,adolescence) or within one discipline (e.g.,education, nursing, social work) o en doesnot equip providers to address the complexneeds o the birth-to-three populationand their amily li e circumstances, suchas amily stressors, issues associated withpoverty, and/or cultural diversity. Moreover,domain-speci c training may not prepare

pro essionals to work across disciplines norto develop a shared perspective or languageabout development and practice. As a result,providers and interventionists report eelingisolated, ine ective, and overwhelmed by thework.4

Ongoing evaluation research highlightsthe need or a common understanding o early development and the social contextsin which development un olds, as well asthe association between specialized training

and higher quality care and interventionoutcomes.3,4 Recent competency systems,5,6

including the Minnesota Association o In ant and Early Childhood Mental Health(MAIECMH) endorsement process, provideimportant guidelines or higher educationinstitutions and other organizations inestablishing e ective training programs.

Competencies needed. raining itsel iscomplex and involves a developmentalprocess including multiple levels o experience.7 Practitioners must acquire:■ A knowledge base rom which to

understand in ants and toddlers, theadults who care or them, and early relationship development;

■ Skills o observation, assessment, andintervention, and guidance in theirapplication; and

■ Opportunities or refection witha training supervisor who isknowledgeable about early development

and able to help sustain the work.Similar to processes o change or learningin other domains, the pro essionaldevelopment o skilled workers, teachers,and interventionists in early childhoodnecessitates more than new in ormation or new technique. It requires a trans ormationor shi in understanding o the natureo early experience and its role in later

unctioning.

Early childhood is unique in the human li e cycle or the rapidity andcomplexity o developmental change and trans ormation. 1 ypically, th

in ant progresses rom complete dependence upon the caregiver to a mobilecognitively sophisticated, sel -regulating child who is capable o understandinand participating actively in the social world. 1,2 However, development in the earlyyears is paradoxical; it is both highly robust and highly vulnerable, with cascadinge ects or later development.3

Elizabeth A. Carlson, PhD, LP

Bringing Order to the Comple ity o Early

E perience The Role o Training in In ant Mental Health



Pr essi nal Devel pmentPr gram at the university

Minnes taAs one o a number o training programsin the U.S., the University o Minnesota’s2-year post-baccalaureate In ant andEarly Childhood Mental Health certi cateprogram provides a pro essionaldevelopment opportunity or early interventionists and an illustration or modelo a process-oriented approach to training.Te program is designed or ront-lineservice providers (e.g., public health nurses,early childhood and amily educators,child wel are workers, home visitors) andcredentialed mental health pro essionalswho wish to build their knowledge and skillsin early childhood mental health, dyadic ortriadic treatment, and re ective consultation.Te Institute o Child Development, theacademic home o the program, o ersgraduate credits applicable to advanceddegrees; alternatively, participants may

complete the program or pro essionalcontinuing education units.

Te comprehensive series o courses andexperiences provides a background in early development, experience in observationand assessment, guidance in the applicationo developmental principles to prevention/intervention, and re ective practiceregarding the experience o amiliesthat are served and the interveners whoserve them. In ormed by developmentalresearch and theory, the training programattends to principles and processesthat underlie both typical and atypicaldevelopment in early childhood. Fromthis ramework, child behavior is viewedas an adaptation constructed over time, aproduct o regulatory history and currentenvironmental challenges and supports.Such a developmental perspective bringsorder to the complexity o early experience.Interdisciplinary training in development

acilitates communication and coordinationacross domains, provides direction inpractice, and instills hope in work withchildren and amilies.

For more in ormation about the In antand Early Childhood Mental Healthcerti cate program, contact Sara Zettervall(612-625-2252) or visit their website:www.cehd.umn.edu/ceed/pro dev/certi cateprograms/IECMH/de ault.html

REFERENCES

1. Srou e LA. (1996). Emotional development: theorganization o emotional li e in the early years. NewYork: Cambridge University Press, 1996.

2. Zeanah CH (Ed.). Handbook o in ant mental health, 3rdedition. New York: Guil ord Press, 2009.

3. Shonko J P, Phillips DA. From neurons toneighborhoods: the science o early childhooddevelopment. Washington, D.C.: National Academy Press, 2000.

4. Erickson MF, Kurz-Riemer K. In ants, toddlers, andamilies: a ramework or support and intervention. New

York: Guil ord Press, 1999.

5. Kor macher J, Hilado A. Creating a work orce in early childhood mental health: de ning the competentspecialist. Research Report rom the Herr ResearchCenter or Children and Social Policy at EriksonInstitute, 2008. Available rom: http://www.erikson.edu/hrc

6. Weatherston DJ, Dowler Moss B, Harris D. Buildingcapacity in the in ant and amily eld throughcompetency-based endorsement: three states’experiences. Zero to Tree 2006; 26(3):4-13.

7. Fraiberg S. Clinical studies in in ant mental health. NewYork: Basic Books, 1980.

Elizabeth A. Carlson, PhD, LP, is Director o theHarris Programs and is a Research Associate at the Institute o Child Development, University o Minnesota.

continued rom page 33Promoting In ant Mental Health

and continuing education curricula;

■ Document and demonstrate to amiliescolleagues, employers, and unders apro essional’s growing pro ciency inspecialized knowledge and skills;

■ Enhance sta development activities;

■ Promote e ective, culturally-sensitiveprogram development;

■ In orm policy development and systemenhancements; and

■ Identi y research agendas.

Endorsement orCulturally Sensitive,Relationship-based Practice Promoting In Mental Healthis available to providers,clinicians, and educators who work in arange o settings and disciplines at ourpro essional levels spanning the continuuo care.2 Depending on the education and

experience o the pro essional, competeinclude:

1. theoretical oundations

2. law, regulation and policy

3. systems expertise

4. direct service, refection and leadershipskills and

5. research and evaluation.

F r m re in rmati nab t end rsement:Contact MAIECMH sta at 651-644-733or 1-800-528-4511

Continuing requirements or endorsemeninclude MAIECMH membership and 15hours annually o related training approvby MAIECMH. A central registry o endorsees and consultants is maintained athe MACMH o ce, 165 Western AvenueNorth, Suite 2, St. Paul, MN 55102

REFERENCES

1. Lamb-Parker F, LeBu e P. A strength-based, systemimental health approach to support childen’s social anemotional development. In ants & Young Children2008;21(1):45-55.

2. MAIECMH Endorsement or Culturally Sensitive,Relationship-based Practice Promoting In ant MentaHealth. Available rom: http://www.macmh.org/maiecmhweb/2PageEndorsemntFlyer.pd

Candace Kragthorpe, MSW, IMH-E® (IV), is Dio the Minnesota Association or In ant and EaChildhood Mental Health (MAIECMH), a Divisi MACMH.

…the pro essional development o skilled workers, teachers, and interventionists inearly childhood requires a trans ormation

or shi in understanding o the natureo early experience and its role in later

unctioning.



For Lauren Gilchrist, a typical day at work always has “an exciting element o the unexpected.” Gilchrist is a health policy advisor or Minnesota Senator Al

Franken. As the nation is engaged in a debate about health care re orm, it is notsurprising that Capitol Hill would provide a stimulating pro essional venue orthis recent MCH Master's o Public Health graduate.

Interested in Making a Di erence?Consider a Master’s in Public Health (MPH) degree in Maternal and Child Health (MCH)

A native o Rochester, Minnesota, homeo the world-renowned Mayo Clinic,Gilchrist grew up believing that people“deserve a high standard o health careand health status.” A er graduating romWesleyan University, Gilchrist pursued this view, working or several years in directservices with underserved communities.Tat experience gave Gilchrist perspectiveabout the day-to-day challenges con rontingdisen ranchised people. o Gilchrist,“direct services were rarely getting to theroot o problems…I elt like I was puttingband-aids on things instead o helpingproblems be resolved or improved in alarger sense.”

Gilchrist pursued a degree in public healthbecause she wanted to use research andpolicy as tools to make systemic changes toimprove people’s lives. Trough the MCHProgram at the University o Minnesota,Gilchrist was able to take classes aboutthe health o children and amilies anddevelop strong analytic and quantitativeskills through the program’s epidemiology emphasis curriculum.Particularly in uential in her current work as a policy advisor are the skills Gilchristgained in epidemiology and programevaluation as a student in the MCHprogram. Her training in epidemiology gaveGilchrist the “ability to look critically atresearch” and assess its quality. Te skills shedeveloped in program evaluation help herto determine i a policy has accountability.

“Te hands-on experience and historicalperspective on policy as a strategy or publichealth” that Gilchrist received throughJean Forster’s legislative advocacy classesgave her a way to pull all o her skillstogether. During her MCH training, shespent a semester working with the statelegislature at the Children’s De ense Fundo Minnesota. Trough that experience sherealized that public policy work was a good

t or her skills and personality.

A er receiving her MPH in 2007, Gilchristworked as the Outreach Director or theDeborah E. Powell Center or Women’sHealth at the University o Minnesota,where she planned programs to promotethe health o women and girls. In 2008,Gilchrist received a one-year Health Policy Fellowship rom the Association o Schoolso Public Health. Her placement with thelate Senator ed Kennedy on the U.S. SenateCommittee or Health, Labor, Education,and Pensions helped her transition romdesigning public health programs andworking on state policy to working onpolicy at the ederal level.

A er her Fellowship Gilchrist began work with Minnesota Senator Al Franken. Herposition o ers “a great opportunity… to betied to what is going on…in [Washington]D.C…and at the same time…work onMinnesota issues.” Gilchrist spends her

time meeting with Minnesota constituents,collaborating with other Senate o ces, anddra ing and evaluating original legislationto develop and support policies that will“enhance the health o Minnesotans.”Gilchrist’s experiences as a Minnesotan, apublic health pro essional, and a specialistin maternal and child health give her aunique perspective on health policy: “I look at everything through a Minnesota lens,a public health lens, and…an MCH lens.

And I use that as a way to evaluate policy opportunities, and to rame ideas that weare thinking o putting orth or supportingideas that other olks have put orth.”

Gilchrist’s work with Senator Franken isa good t because the health o womenand children throughout the li e course

are among his policy priorities. Accordingto Gilchrist, “maternal and child healthissues are critically important when we aredesigning public health programs…andpolicy. Also, when we are looking at healthcare re orm, we want to make sure…thateverything we do is in the best interest o maternal and child health because we knowthat those investments have the greatestpay-o in the long run.”

Gilchrist’s uture goals in her positionare “to pass national health care re ormand make sure it is implemented ina way that will be most bene cial toMinnesotans.” Additionally, Gilchristhopes to “continue to make our country a more prevention- ocused place,” so thatdiscussions about health care re orm are a jumping-o point or a movement towardshealth promotion, health maintenance, andaddressing barriers to optimal health at thecommunity level.

Learn more about getting an MPH inMaternal and Child Health, visit:

www.sph.umn.edu/education/mch/home.html

email: Kathryn Schwartz,[email protected]



In addition to the websites identifed in this issue’s articles, the ollowing list provides additional select web resources related to early childhoodmental health and social-emotional development.

Website Resources for Early Childhood Mental Health

American Academy f Pediatrics advocates at the ederal and statelevel or children’s mental health as well as provides in ormational resources

to parents and pro essionals about the behavioral and mental health o in antsand young children.www.aap.org

Bright F t res is a national initiative that seeks to strengthen theconnection between state and local programs, health and service providers,and amilies through cross-agency training and distance-learning curricularelated to children’s mental health. www.brightfutures.org

Center f r Early Ed cati n and Devel pment (CEED) and the IrvingB. Harris Training Center or In ant and Toddler Development at the University o Minnesota support the social-emotional development o young children

throughout Minnesota through applied research on in ant mental health, trainings to help educators address challenging behaviors, and outreach topromote quality early child care. www.cehd.umn.edu/ceed

Center n S cial and Em ti nal F ndati ns f Early Learning(CSEFEL) is a national resource center that provides training materials,videos, and print resources to help early child care, health, and educationproviders implement the Pyramid Model or Supporting Social Emotional

Competence in In ants and Young Children.www.vanderbilt.edu/csefel

Ge rget wn university Center f r Child and H manDevel pment provides national technical assistance, trainings, and policy resources, and conducts research and evaluation to address mental healthneeds o young children.www.gucchd.georgetown.edu

Minnes ta Ass ciati n f r Family and Early Ed cati n (MNAFEE) is a membership organization that o ers pro essional development meetings,con erences, and networking opportunities to providers and coordinators o early childhood education throughout Minnesota. www.mnafee.org

Nati nal Center f r Children in P verty at Columbia University’sMailman School o Public Health, conducts research on states’ e orts tomaximize polices to provide services that e ectively promote social andemotional development in early childhood, particularly or at-risk children.www.nccp.org

Nati nal Early Childh d Technical Assistance Center (NECTAC)is supported by the U.S. Department o Education’s O fce o SpecialEducation Programs to strengthen service systems to ensure that children withdisabilities (birth through 5 years) and their amilies receive and beneft romhigh quality, culturally appropriate, and amily-centered supports and serviceswww.nectac.org

S cial and Em ti nal Devel pment in Children and Ad lescents–MCH Kn wledge Path o ers a selection o recent scientifc researchabout the promotion o healthy social and emotional development in youngchildren as well as tools or keeping up-to-date with new research. http://wwwmchlibrary.info/knowledgepaths/kp_mental_healthy.html

Technical Assistance Center n S cial Em ti nal Interventi ns(TACSEI) translates research on e ective practices or improving the socia

and emotional health outcomes or young children into ree products andresources to help caregivers and service providers apply best practices in their everyday work. www.challengingbehavior.org

Zer t Three provides resources or parents and pro essionals onsocial-emotional development and mental health o young children as well asin ormation or policymakers and advocates on relevant public policy initiativand advocacy opportunities. www.zerotothree.org



Save these datesor upcoming con erences and events

Center r Leadership Ed cati n inMaternal and Child P blic HealthSchool o Public HealthDivision o Epidemiology and Community HealthUniversity o Minnesota1300 So 2 nd St Suite 300Minneapolis, MN 55454www.epi.umn.edu/mch

Nonproft OrU.S. Postag

PAIDMpls., MN

Permit No. 1

DECEMBER 2, 2009National Children’s Study Speakers SeriesFatherh d in the 21st Cent r : Fr m Pregnanc Planning tParenting Robert “Clarence” Jones, MA; Community Outreach Director,Southside Community Health Services/Q Health Connections3:00–4:30 p.m., FREEWilder Center, 451 Le ington Parkway North, St. Paul, MNSponsors: National Children’s Study, Center or Leadership Educationin Maternal and Child Public HealthRegistration: Laurie Ukestad,[email protected]

DECEMBER 4–6, 2009The National Federation o Families or Children’s MentalHealth Con erenceChildren’s Mental Health MattersWashington, D.CRegistration:www.ffcmh.org/

DECEMBER 4–6, 2009National Training Institute: Zero to ThreeDallas, TxRegistration:www.zttnticonference.org/registration.aspx

JANuARY 13–15, 2010Strong Foundations Con erence & MN Fatherhood SummitEngaging Fathers – Strengthening FamiliesArrowwood Resort, Ale andria, MNSponsors: Minnesota Departments o Health, Education and HumanServices; MN Fathers and Families Network, CEED, Center orLeadership Education in Maternal and Child Public HealthRegistration:www.regonline.com/strongfoundations2010

JANuARY 20, 2010National Children’s Study Speakers SeriesFetal origins Ad lt Disease

Kristin Oehlke, MS, CGC; State Genomics Coordinator,Minnesota Department o Health3:00–4:00 p.m., FREEWilder Center, 451 Le ington Parkway North, St. Paul, MNSponsors: National Children’s Study, Center or Leadership Educationin Maternal and Child Public HealthRegistration: Laurie Ukestad,[email protected]

JANuARY 25–27, 2010Child Wel are League o America National Con erenceChildren 2010: Leading a New EraMarriott Wardman Park Hotel, Washington, D.C.Registration:www.cwla.org/conferences/conferences.htm

MARCH 6-10, 2010

Association o Maternal and Child Health Programs Annual ConferenceWashington, D.C.Registration:www.amchp.org/conference

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