research synthesis early childhood mental health...

Contributing AuthorsFrances B. DuranKathy S. HepburnRoxane K. KaufmannLan T. LeGeorgetown University

Mary Dallas AllenUniversity of Alaska Anchorage

Eileen M. BrennanPortland State University

Beth L. GreenNPC Research

This synthesis has been developedto describe early childhoodmental health consultation

(ECMHC) and the existing evidencebase for its effectiveness in fosteringhealthy social and emotionaldevelopment in young children, birththrough age 6. It provides a descriptionof the emerging evidence base thatmany of the beliefs and much of thecurrent body of knowledge aboutconsultation is grounded in literatureand the experiences of mental healthand early care and education (ECE)providers, educators, and other experts(i.e., practice-based evidence). Mostempirical research focuses on theimpact of consultation on child,program, staff and, to a lesser extent,family outcomes. Still, research effortsare occurring and data to supportECMHC as an effective model forservice delivery are accumulating.

OverviewYoung children’s healthy social

and emotional development is criticalto school readiness and positive long-term outcomes (National ResearchCouncil & Institute of Medicine, 2000;Raver & Knitzer, 2002; Thompson &Raikes, 2007). Although most childrenprogress in their development withoutany significant challenges, research onthe high rates of preschool expulsiondue to challenging behaviors (Gilliam,2005) coupled with estimatessuggesting that one in 10 youngchildren exhibit problem behaviors(Raver & Knitzer, 2002) underscoresthat this is not the case for all children.In fact, early childhood providers haveincreasingly voiced concerns aboutyoung children showing signs ofserious emotional distress and haveexpressed the need for training and

Early Childhood Mental HealthConsultation

Research Synthesis

The Center on the Social and EmotionalFoundations for Early Learning

Child Care Bureau

Office ofHead Start

The Center on the Social and Emotional Foundations for Early Learning Vanderbilt University vanderbilt.edu/csefel

What Is Early Childhood MentalHealth Consultation?

Early childhood mental healthconsultation builds upon the well-established field of mental healthconsultation, pioneered by GeraldCaplan in the mid-sixties. In Caplan’sseminal work (1964), he outlined anapproach that involves mental healthprofessionals working with humanservices staff to enhance theirprovision of mental health services toclients. Similarly, in ECMHC, aprofessional consultant with mentalhealth expertise “works collaborativelywith ECE staff, programs, and familiesto improve their ability to prevent,identify, treat, and reduce the impact ofmental health problems amongchildren from birth through age 6”(Cohen & Kaufmann, 2000; revised2005). Ultimately, early childhoodmental health consultation seeks toachieve positive outcomes for infantsand young children in early childhoodsettings by using an indirect approachto fostering their social and emotionalwell-being.

Although the field has not reachedfull consensus on the scope of earlychildhood mental health consultation,Cohen and Kaufmann (2000) identifiedtwo sub-types of ECMHC that arefrequently cited: child- or family-centered and programmaticconsultation. The former and moretraditional type of consultation aims toaddress the needs of an individual childwho is exhibiting challengingbehaviors or whose social andemotional well-being may be at riskdue to a family crisis (e.g., death in thefamily, divorce). Typically, child- orfamily-centered consultation isprovided to the child’s teacher(s) andparents, and is focused on helpingthese adults support children moreeffectively. In contrast, programmaticconsultation takes a more systemicapproach, focusing on “improving theoverall quality of the program and/orassisting the program to solve aspecific issue that affects more thanone child, staff member, and/or family”(Cohen & Kaufmann, p. 8). This type

assistance around managingchallenging behaviors (Hemmeter,Corso, & Cheatham, 2006; Knitzer,2000).

One approach to addressingchallenging behaviors, as well aspromoting social and emotional healthand preventing the onset of behavioralissues, is early childhood mental healthconsultation. This approach is gainingpopularity among ECE programs (e.g.,child care centers, Head Start and EarlyHead Start programs, and family daycare homes), and preliminary researchfindings are encouraging. In fact,recent reviews of research indicate thatECMHC yields positive social andemotional outcomes for young childrenin early childhood settings, includingreductions in preschool expulsions(Perry, Brennan, Bradley, & Allen,2006). In addition, research showspositive outcomes among ECE staffand programs receiving consultationservices, such as increased staffconfidence in dealing with youngchildren’s difficult behaviors andoverall improvements in ECEclassroom climates (Brennan, Bradley,Allen, & Perry, in press).

Within the growing evidence base,currently there are only tworandomized control studies guiding thefield. Thus, this synthesis will integrateavailable research with the moresizeable collection of knowledge fromliterature and practice to explorevarious aspects of this “emergingpractice” and address the following keyquestions:

• What is ECMHC? • What are the benefits of ECMHC?• What are the characteristics of

effective consultants andconsultation models?

• What are the key challenges indeveloping and implementingECMHC?

Key Terms

Best practices: Guidelines orpractices driven by clinical wisdom orother consensus approaches that donot necessarily include systematic useof available research evidence(definition adapted from ResourceGuide for Promoting an Evidence-Based Culture in Children’s MentalHealth, http://systemsofcare.samhsa.gov/ResourceGuide/index.html).

Cultural competence: A set ofbehaviors, attitudes, and policieswithin a system, agency, or amongprofessionals that allows them to workin cross-cultural situations (Cross,Bazron, Dennis, & Isaacs, 1989).

Early childhood mental health: The developing capacity of infants,toddlers, and young children toexperience, manage, and expressemotion; form close, securerelationships; and actively explore theenvironment and learn. Essentiallysynonymous with healthy social andemotional development (adapted fromZERO TO THREE,www.zerotothree.org).

Emerging practices: Innovations inclinical or administrative practice thataddress critical needs of a particularprogram, population, or system, butdo not yet have scientific or broadexpert consensus support (Hyde, Falls,Morris, & Schoenwald, 2001).

Evidence-based practices:Interventions for which there isconsistent scientific evidence showingthat they improve client outcomes(Drake et al., 2001).

Practice-based evidence: A range oftreatment services and supports thatare accessible and culturallyappropriate and known to be effectiveby families, youth, and providers(National Federation of Families forChildren’s Mental Health,www.ffcmh.org)


of consultation is usually provided toECE program administrators and staffand is intended to have a morewidespread impact. Still, it is importantto note that these distinctions are notalways clear-cut when put intopractice, as consultants mayintermingle various strategies to meetidentified needs.

Unlike traditional one-on-onetherapeutic mental health services,ECMHC is primarily an indirectapproach. Early childhood mentalhealth consultants (MHCs) strive toimprove children’s social andemotional well-being by building thecapacity of ECE staff, parents, andother caregivers to promote healthychild development and managechallenging behaviors. Consultantseducate, train, and “coach” caregiversso that they develop the skills andconfidence to effectively addresschildren’s social and emotionalneeds—whether it be the needs of onechild or an entire classroom ofchildren. Although the consultant mayprovide some direct services (e.g.,observing children, conductingindividual assessments, modelingeffective practices), these activities areultimately designed to enhancecaregiver competence. In sum,ECMHC is both a problem-solving andcapacity-building intervention.

Another hallmark of earlychildhood mental health consultation isthe strong emphasis on collaboration.ECMHC’s approach acknowledges thatin order to understand and address achild’s challenging behavior, one mustlook holistically at the environments inwhich the child functions (e.g., home,classroom, community settings). Thisholistic or “ecological systemsperspective” (Brack, Jones, Smith,White, & Brack, 1993) in ECMHCnecessitates that the consultant partnerswith ECE staff and families to jointlyassess the challenge, determineappropriate intervention, andimplement a coordinated plan of actionacross all settings. These collaborativerelationships are essential to effectiveconsultation and have become a specialresearch interest in the field (Green,

activities will be determined, helpingto guide effective service delivery.

The Promotion–Prevention–Intervention ContinuumEarly childhood mental healthconsultation recognizes that achievingpositive social and emotional outcomesfor young children requires acomprehensive approach that spans acontinuum of mental health servicesand supports—from promotion toprevention to intervention (Perry,Kaufmann, & Knitzer, 2007). Althoughmany consultants are initially engagedto provide consultation focused on anindividual child needing intervention,

Everhart, Gordon, & Gettman, 2006;Johnston & Brinamen, 2006).

Finally, ECMHC differs frommany other approaches or evidence-based practices in that it is notmanualized (i.e., there is no curriculumto follow). It is characterized byadherence to a core set of principles(e.g., relationship-based) as opposed todelivery of specific activities in aprescribed sequence. Accordingly,ECMHC encourages customizedservice delivery to meet the diverseneeds of various children, families, andECE programs. As the evidence basefor ECMHC grows, the core principlesof this approach will be furthersolidified and the impact of various

Table 1. What Do Mental Health Consultants Do?

A few examples:

Promotion Activities (All Children )Child- or Family-Centered Consultation• Provide families with information on children’s social and emotional development • Provide tips to families on how to create a home environment that supports healthy social

and emotional development

Programmatic Consultation• Assess strengths and challenges within the early childhood setting/environment • Support early childhood staff in creating a more prosocial learning environment

– Engage early childhood staff and programs in promoting and encouraging staff wellness

Prevention Activities (Children At Risk for Behavioral Problems)Child- or Family-Centered Consultation• Conduct home visits with families and children with identified risks• Offer families training on effective strategies for addressing challenging behaviors• Design and help implement targeted supports to meet the needs of a child or children at

risk• Model effective strategies and coach early childhood staff in using them to support a child

or children at risk

Programmatic Consultation• Offer ideas and resources for teaching young children social skills and appropriate behavior • Guide selection and use of social and emotional screening tools • Support early childhood staff with classroom management strategies

Intervention (Children Exhibiting Challenging Behavior)Child- or Family-Centered Consultation

–Provide crisis intervention services for early childhood staff regarding a child’s behavior• Engage families and staff in developing individualized behavior support plans

–Link child/family to community mental health services and assist with care coordination

Programmatic Consultation• Train early childhood staff in creating and implementing individualized behavior support

plans–Help early childhood program foster relationships with community services and providers

• Work with early childhood program to develop inclusive policies for working with childrenwith challenging behaviors

importance of building an effectiveworkforce that is well-trained on bestpractices in children’s mental health.

The Pyramid model is designed tohelp organize a variety of evidence-based approaches and activitiesfocused on young children’s healthysocial and emotional development.ECMHC is just one tool that might beused to support teachers and othercaregivers to implement the practicesat each level of the Pyramid. .

To complement the Pyramidmodel and support implementation ofactivities at each level, CSEFEL hasdeveloped accompanying trainingmaterials and a number of practicaltools that can be used in theimplementation of the model (e.g.,scripted stories to teach children aboutexpectations in various socialsituations, “cue cards” to promptpositive social skills). In addition,researchers involved in thedevelopment of the Pyramid modelhave created a classroom assessmenttool (“Teaching Pyramid ObservationTool,” or “TPOT”) to help programsand practitioners evaluate how welleach Pyramid level is being addressed(Hemmeter, Fox, & Snyder, 2008).These resources have been well-received by the early childhoodcommunity, particularly ECE staff andMHCs, who find them practical andeffective. Consultants report workingsuccessfully with ECE staff to applyCSEFEL techniques and activities intheir classrooms, and many

simultaneously they often intentionallybroaden their focus to includepromotion and prevention-levelactivities as trust is established andstaff skills in managing challengingbehaviors improve.

For example, a consultant mightfocus on mental health promotion byconducting a workshop for parents onthe importance of parent-childinteractions and practical ways tomaximize the benefits of thoseinteractions. Similarly, to buildcapacity around prevention ofbehavioral problems, a consultant maytrain ECE staff on teaching strategiesthat enhance children’s emotionalliteracy and their ability to expressfeelings in appropriate ways. It isimportant to note that promotion andprevention activities do not replaceintervention activities; all three areimportant elements within theconsultants’ array of services. Table 1provides other examples of activitiesMHCs might do along “thecontinuum.”

The Pyramid Model: ACompanion to “The Continuum”For consultants striving to implementthis comprehensive, three-prongedapproach, the Pyramid Model forPromoting the Social EmotionalCompetence of Infants and YoungChildren developed by CSEFEL(Center on the Social and EmotionalFoundations for Early Learning) andthe Technical Assistance Center onSocial Emotional Intervention(TACSEI) provides a framework fororganizing activities along the mentalhealth continuum. The Pyramid(below) emphasizes “nurturing andresponsive relationships” and “high-quality, supportive environments” forall children (promotion); “targetedsocial emotional supports” for childrenat risk for behavioral problems(prevention); and “intensiveintervention” for children exhibitingchallenging behavior (intervention)(Fox, Dunlap, Hemmeter, Joseph, &Strain, 2003). In addition, the bottomlevel of the Pyramid acknowledges the

consultants have become CSEFELtrainers and/or used the TPOT to helpECE programs improve quality(Kaufmann & Horen, 2008).

Practical Resources for MHCs The Center on the Social andEmotional Foundations for EarlyLearning (CSEFEL) has developed anumber of user-friendly resources tohelp consultants and others promotesocial and emotional competence ininfants and young children. Theresources are highlighted below. Allare available for free athttp://www.vanderbilt.edu/csefel.• Training modules for infant/toddler,

preschool, and parent withaccompanying slides, handouts,video clips, and facilitator’s guide.

• Tools and resources that provide“Practical Strategies” for teachersand caregivers. These resourcesinclude tools for working onbuilding relationships; a list ofrecommended children’s books thatsupport social and emotionaldevelopment, and accompanyingactivity ideas to bolster the themesdiscussed in those books, teachingsocial emotional skills; and tools fordeveloping behavior support plans,including observation cards andfunctional assessment interviewforms.

• What Works Briefs that summarizeeffective practices for supportingchildren’s social-emotionaldevelopment and preventingchallenging behaviors. The Briefsdescribe practical strategies, providereferences to more informationabout the practice, and include aone-page handout highlightingmajor points. Based on the WhatWorks Briefs topics, short trainingpackages are available that includePowerPoint slides withaccompanying note pages,activities, and handouts, whichprovide a trainer with the materialsneeded to conduct a short staffdevelopment program on a focusedtopic.

• A series of six modules to helpprofessionals working with parents


theoretical frameworks, such asattachment theory or childdevelopment theory. An additionalstrategy that has emerged is providingECMHC services in combination withother services or with other earlychildhood mental health curricula, suchas The Incredible Years (seewww.incredibleyears.com) or SecondStep (see www.cfchildren.org). Twoexamples of this blended approach arehighlighted below.

COMBINING CONSULTATION AND DIRECT

SERVICES

Given the complementary natureof therapeutic intervention andconsultation, some ECMHC programs,including California’s Early ChildhoodMental Health program, offer directservices (e.g., psychotherapy andtherapeutic play groups) whenconsultation services alone are notenough to address a child’s or family’sidentified needs. Direct therapeuticintervention services are provided tothe child, family, or staff member bythe mental health professional to reachspecific treatment goals. It is notunusual for mental health professionalsto serve in both roles—as a consultantand as a therapist—particularly incommunities where there are fewindividuals trained in early childhoodmental health. While both roles areimportant, they are distinct. An MHCprovides consultation services, whereasa therapist offers direct services ortherapeutic interventions. Currently,there is a need for research thatformally evaluates the effect of addinga direct service component to anECMHC model. Although theevaluation of the Early ChildhoodMental Health program did identifysome promising outcomes, it did notmeasure the specific impact oftherapeutic intervention (JamesBowman Associates & Kagan, 2003).

COMBINING ECHMC WITH ESTABLISHED

EARLY CHILDHOOD MENTAL HEALTH

CURRICULA

Another variation to enhance theimpact of ECMHC involves infusing

promote positive and effectiveparenting behaviors that encouragechildren’s social and emotionaldevelopment and address thechallenging behaviors and mentalhealth needs of children in childcare and Head Start programs.

• Short one- to two-page decision-making guideline documents to aidprograms in making decisionsabout practical issues (e.g.,selecting a social-emotionalcurriculum, selecting screening andassessment tools focused on social-emotional competence).

• State planning materials areavailable from several statesworking with CSEFEL toimplement the Pyramid model.

Additional resources can be found on the website for the TechnicalAssistance Center for SocialEmotional Intervention for YoungChildren (www.challenging behavior.org), including• A review of screening instruments

for social-emotional concerns.• Teaching Tools: A guide that helps

classroom teachers developpractical interventions fordisruptive behavior, includingready-made materials for use in theclassroom.

• A manual of guidance andmaterials that can be used toimplement the individualizedpositive behavior support process.

• Webinars on topics relevant toearly childhood systems, policy,and professional development.

Variations in ECMHC ModelsAs programs continue to explore thepotential of mental health consultationto produce positive outcomes, varyingmethods of implementing thisapproach have surfaced. For example,some programs provide ongoing, on-site consultation, whereas othersprovide intensive consultation for arelatively brief time period, followedby additional support as needed orrequested. Further, some programshave grounded their models in certain

established evidence-based practicesinto service delivery, such as curriculathat support early childhood mentalhealth. In two recent studies ofECMHC (Raver, Jones, Li-Grining,Metzger, Champion, & Sardin, 2008;Williford & Shelton, 2008), researchersexamined the efficacy of integratingECMHC with the Incredible YearsParent and Teacher Training Series, awell-established, empirically supportedprogram designed to educate parentsand teachers on techniques to addresschallenging behaviors and promotesocial and emotional competence andwell-being (Webster-Stratton, 1999a,1999b). Although both studiesevaluated the impact of the sameevidence-based practice onconsultation, each applied theintervention in a slightly differentmanner.

In the Chicago School ReadinessProgram model that Raver et al. (2008)evaluated, Incredible Years was adaptedto fit into five six-hour training sessionsdelivered to teachers. This training wascomplemented by mental healthconsultation services one morning aweek, including three months of child-centered consultation towards the endof the study. Similarly, the NorthCarolina model that Williford andShelton (2008) studied included onegroup training session for teachers on amodified version of the IncredibleYears, followed by individualconsultation sessions with teachers toguide their learning and use of relevantconcepts and techniques in Webster-Stratton’s program. In addition, NorthCarolina offered a shortened (10-week)parent training based on the IncredibleYears. Both research teams foundpromising results from these integratedapproaches, including a betteremotional climate (i.e., more teacherresponsiveness and less harshness) inintervention classrooms than in controlclassrooms (Raver et al., 2008), and amore positive impact on child behavior(according to reports by teachers andcaregivers) in the intervention groupthan in the comparison group (Williford& Shelton, 2008).


that involve greater numbers ofchildren. Several factors havecontributed to the focus onintervention in ECMHC. First,programs typically engage MHCsbecause their most pressing need is forhelp with a particular child orchildren. Further, consultants oftenhave limited time to spend with earlychildhood programs and providers,due to large caseloads and/or lack ofprogram funds for consultationservices. Limited access toconsultation can greatly undermine theability to integrate promotion andprevention activities into earlychildhood settings—not only becausemuch of the consultant’s time is spent“putting out fires,” but also because itis hard for consultants to build thetrust and rapport necessary to shiftattention towards promotion andprevention. In their study of HeadStart centers, Yoshikawa and Knitzer(1997) learned that when a consultantwas only available on an “on-call”basis, mental health promotionactivities were essentially ignored.

Funding also plays a role inchanneling services to childrenexhibiting behavioral challenges.Financing mechanisms are typicallydesigned to provide reimbursement fordirect services to individual children,particularly those with a mental healthdiagnosis. Children at risk for socialand emotional challenges are generallyexcluded from funders’ eligibilitycriteria (Johnson & Knitzer, 2005).These funding constraints not onlyundermine promotion and preventionefforts, but ECMHC in general, givenits indirect, capacity-building design.

To broaden the impact of mentalhealth consultation, provisions need tobe made to widen access to mentalhealth consultation in home-based careand education settings (i.e., licensedfamily child care homes andunlicensed family/friend/neighborarrangements), and to expand thefocus to include promotion andprevention activities that benefit allchildren as part of the array ofconsultation services. Ideally, ECMHC

Who Receives ECMHC Servicesand in What Settings?

Currently, most ECMHC servicesare provided to children (birth throughage 6), staff, and families in center-based care. Licensed family child carehomes and unlicensed child careproviders (e.g., family, friends, andneighbors) are less likely to receiveconsultation services, although someconsultation models, (such as InstitutoFamiliar de la Raza’s EarlyIntervention Program in SanFrancisco; www.ifrsf.org) offerservices to licensed family child carehomes. Still, even in Early Head Start,which serves a large number of infantsand toddlers through home visiting(41%), the majority of services areprovided in a center-basedenvironment (51%; Hoffman & Ewen,2007).

Primary consumers of earlychildhood mental health consultationservices across the country are EarlyHead Start and Head Start (E/HS)programs, as their performancestandards require them to “secure theservices of mental health professionalson a schedule of sufficient frequencyto enable the timely and effectiveidentification of and intervention infamily and staff concerns about achild’s mental health” (Head StartPerformance Standards and OtherRegulations, 45 CFR Part 1304.24.2).Outside of E/HS programs, there isgenerally limited availability ofconsultation. Although a few states(including Maryland, Connecticut, andMichigan) have statewide consultationprograms/initiatives, most states haveconsultation programs that servelimited geographic areas or servicepopulations, or have not yetimplemented consultation beyondwhat is offered through E/HSprograms.

Regardless of whetherconsultation is provided through E/HSor another ECE setting, there has beena tendency for consultants to focus onintervention for children who exhibitchallenging behavior as opposed topromotion and prevention activities

would be available to all early care andeducation settings and subsidized orreimbursable through a variety ofsources.

What Are the Benefits ofECMHC?

Studies on the impact of mentalhealth consultation in early childhoodsettings are increasing in complexity,and evidence of the effectiveness ofthis approach is mounting (see below).However, the field still lacksrandomized controlled trials thatprovide rigorous evidence of the linkbetween the effects of consultation onstaff knowledge, attitudes, andbehavior, and better outcomes foryoung children and their families.

IMPROVEMENTS IN TEACHER ATTITUDES,SKILLS, AND STRESS LEVELS, AND

CLASSROOM CLIMATES

In a clustered randomized controlstudy of Chicago School ReadinessProgram classrooms, outside observersfound that teachers receiving ECMHChad significant improvements inteacher sensitivity and enhancedclassroom management skills,compared with teachers in classroomswithout consultation (Raver et al.,2008). Observers also found that theclassroom climates improved afterconsultation, with more positiveinteractions between teachers andchildren and fewer negative exchanges,in contrast to classrooms where noconsultation was present. Staffmembers also rated themselves assignificantly more able to managechildren’s difficult behavior afterconsultation in 9 of 11 studiesreviewed by Brennan et al. (in press;see, for example, Alkon, Ramler, &MacLennan, 2003; James BowmanAssociates & Kagan, 2003; Olmos &Grimmer, 2004). Finally, teachers havealso generally reported lower levels ofjob stress after they receiveconsultation services (Green et al.,2006; Langkamp, 2003; Olmos &Grimmer, 2004).


(Brennan, Bradley, Ama, & Cawood,2003; Field & Mackrain, 2004).Although several researchers trackedparenting stress level over time, nosignificant decreases in stress weredetected before and after consultation(Lehman, Lambarth, Friesen, MacLeod,& White, 2005; Williford & Shelton,2008).

Who Are the ProfessionalsProviding ECMHC?

Mental health consultants havediverse educational and trainingbackgrounds, and bring a wide range ofknowledge, skills, and experience totheir work. This is due, in part, to theabsence of a national licensing oraccreditation process that establishesrequired competencies for thoseproviding ECMHC services. Consistentwith Head Start regulations, theconsultant pool is largely comprised ofmental health professionals licensed orcertified within their state to practice avariety of human service disciplines,including counseling, marriage andfamily therapy, psychology, psychiatry,and social work (Green, Everhart,Gettman, Gordon, & Friesen, 2004). Inaddition, some states employ earlychildhood or special educationprofessionals with training, but notlicensure/certification, in earlychildhood mental health. Theseprofessionals provide similar serviceswith the exception of clinical mentalhealth interventions.

Educational attainment amongMHCs is mixed, indicative of varyingprogram-level competency requirementsand diversity in the type of mentalhealth services consultants provide. Forexample, some programs may requireMHCs who provide screening,assessment, or intervention services tohave at least a master’s degree.Consultants are also employed in anumber of differing ways: a nationalsurvey of 69 Head Start programs foundthat a relatively small proportion ofmental health consultants wereemployed directly by the programs(22%), while the majority wereemployed outside of Head Start by a

BETTER OUTCOMES FOR CHILDREN

Teachers in classrooms with ECMHCservices reported that children hadfewer problem behaviors after theseservices were implemented (Bleecker& Sherwood, 2004; Gilliam, 2007;Perry, Dunne, McFadden, &Campbell, 2008; Upshur, Wenz-Gross,& Reed, 2008). Particularly, there isevidence that externalizing(aggressive, disruptive) behavior wasless frequent after consultation(Gilliam, 2007; Raver et al., 2008;Williford & Shelton, 2008). Childrenwith difficult internalizing (withdrawn,disconnected) behavior showedimprovement in some studies(Bleecker, Sherwood, & Chan-Sew,2005; Raver et al., 2008), but not inothers (Duffy, 1986; Gilliam, 2007).Positive social skill development alsoaccelerated for children with ECMHCservices in several studies (Bleecker &Sherwood, 2003, 2004; Farmer-Dougan, Viechtbauer, & French, 1999;Upshur et al., 2008). Finally, there isevidence that when mental healthconsultation is available in earlychildhood programs, the rate ofexpulsion of children with difficult orchallenging behavior decreases(Gilliam, 2005; Perry et al., 2008).

UNCLEAR IMPACT ON FAMILIES

There are fewer studies that reporton the effects of ECMHC on families,and the impact on family-leveloutcomes is less clear. Mostevaluations of mental healthconsultation do not report family data,making the determination of family-level effects problematic. However,several researchers have foundevidence that staff and familiescommunicated more effectively afterconsultation of longer duration (Alkonet al., 2003; Pawl & Johnston, 1991;Safford, Rogers, & Habashi, 2001),and that parents interacted with theirchildren in a more positive andeffective way after services werereceived (Langkamp, 2003; Pawl &Johnston, 1991; Williford & Shelton,2008). Additionally, there were reportsthat consultation provided greaterfamily access to mental health services

non-profit agency (23%), by agovernment agency (7%), by a schoolor other agency (15%), or were inprivate practice (33%; Green et al.,2004).

What MHC Competencies AreMost Important for EffectiveConsultation?

Despite the variation in MHCs’professional affiliations and level ofeducation, a set of core competenciesessential to the provision of effectiveconsultation is emerging from practice-based knowledge. These skills andattributes include the following: • Knowledge, skills, and experience in

early childhood mental health, childdevelopment, and early childhoodeducation

• Ability to build positiverelationships with staff and families

• Knowledge of community servicesand supports

• Cultural sensitivity

KNOWLEDGE, SKILLS, AND EXPERIENCE

Effective mental health consultationrequires a unique set of knowledge andskills. While expertise in earlychildhood mental health is essential, itmust be coupled with an ability to worksuccessfully in early childhood settingsand within family and communitycontexts. Based on feedback from aroundtable of experts in early childhoodmental health (Cohen, E., & Kaufmann,R. K. (2000)), the recommendedcompetencies for consultants includethe following:


“The early childhood mental healthconsultation workforce is intransition from one of broaddiversity in terms of training,experience, roles, responsibilities,and work expectations to one thathas specific expertise in earlychildhood mental health and thespecific skills required to take onthe role of consultant.”(Allen, Brennan, Green, Hepburn,& Kaufmann, 2008, p.21)

considerations; and advocating forpolicies, resources, programevaluation, and other components thatsupport effective service delivery.

In addition, participants in aqualitative study of Head Start MHCsstated that consultants who work inearly childhood environments shouldhave experience in early childhoodeducation and an understanding of thechallenges of teaching young children(Allen, 2008). In some instances,MHCs may also need specializedexpertise in certain areas (e.g.,maternal depression, post-traumaticstress) to address the needs of a childor family. When the consultant doesnot have this expertise, it underscoresthe need for knowledge of localsystems, providers, and resources andthe ability to facilitate these linkages.

RELATIONSHIP BUILDING WITH STAFF AND

FAMILIES

Another essential skill for MHCsis the ability to develop strongrelationships with ECE staff andfamilies. Positive relationshipsbetween early childhood staff andMHCs are an important predictor ofwhether staff believe that consultationimproves child outcomes (Green et al.,2006). Further, Green and colleagues(2004) found that “[h]aving a mentalhealth consultant who is trusted, whomakes him/herself accessible to staff,and who is perceived as being ‘part ofthe team’ may be more important thanthe actual number of hours a consultantis available” (p. 58). With respect tofamilies, a strong relationship betweena MHC and a young child’s parents iscritical, because those caregivers act asgatekeepers for the child’s access tomental health services (Allen, 2008)and are the primary source of ongoing

Knowledge of…• Normal growth and development of

young children, includingdevelopmental milestones

• Atypical behavior in infants,toddlers, and preschoolers

• Underlying concepts of social andemotional development, such asattachment, separation, andrelationship development

• Best practices and variousintervention strategies

• Early childhood, child care, familysupport, and early interventionsystems

• Adult learning principles

As well as the following skills andexperience…• Ability to integrate mental health

activities and philosophies intogroup settings

• Child and classroom observationand assessment

• Ability to work with staff andfamilies and recognize their diverseperspectives

• Communication facilitation• Sensitivity to community attitudes

and strengths• Cultural competence

(adapted from Cohen & Kaufmann, 2005)

The competencies outlined abovemirror many of those identified byresearchers in Colorado, whodeveloped a checklist of coreknowledge and competencies forMHCs to guide workforcedevelopment in their state (JFKPartners, 2006). Informed by literaturereview, expert opinion, and a survey ofColorado professionals involved inECMHC, the checklist reflects theimportance of a strong background inchild development and early childhoodmental health, and the ability tocollaborate with ECE staff to fosterhigh-quality care and to build linkageswith child- and family-serving systemsand community-based organizations.Colorado’s checklist also highlightsskills that support effective servicedelivery, such as reflective practice;developing strategies that integratehealth and mental health

support for social and emotionaldevelopment in the home.

Developing positive relationshipswith early childhood staff requiresMHCs to avoid an expert stance, havegood listening skills, use a strengths-based approach, and be a non-judgmental, supportive team player(Donahue, Falk & Provet, 2000;Johnston & Brinamen, 2006).Similarly, developing thesecollaborative relationships withfamilies requires MHCs to haveopportunities to connect with families,to maintain a family-centeredapproach, and to be culturally sensitive(Allen, 2008). Consultants can help tofacilitate these relationships byroutinely spending time in ECEclassrooms, particularly during eventswhen parents are present, for example,drop-off and pickup times. Thisregularly scheduled time also allowsconsultants to observe staff, children,parents, and overall environments, andto model approaches for working withchildren, thus helping staff to developthese skills themselves. Further, itunderscores the role of the consultantin preventing serious emotional andbehavioral issues, rather than beingcalled on only when problems havealready emerged.

CULTURAL AND LINGUISTIC COMPETENCE

Cultural and linguistic competence is avital skill for MHCs if they want tobuild solid partnerships with staff andfamilies. An important step inachieving cultural and linguisticcompetence, which is a developmentalprocess that evolves over time, is anawareness of one’s own culture andhow that impacts personal beliefs andvalues (Cross et al., 1989; NationalCenter for Cultural Competence, n.d.).According to Hepburn and Kaufmann(2005), indicators that a consultant isculturally and linguistically competentinclude the following: • Demonstrated respect for diverse

backgrounds• Understanding of the variance

across cultures in mental healthpractices and how clinical issuespresent


“[T]he effective consultant not onlyhas expertise in the particularcontent area in which she offersassistance, but also has theinterpersonal skills to motivate staffto take action.”(Cohen & Kaufmann, 2005, p. 19)

What Preparation and SupportDo Mental Health ConsultantsNeed?

TRAINING

Although the number of mentalhealth consultation programs across thecountry is growing, there is a scarcityof research to guide the training andongoing support of consultants. Fewstates or universities provide training orcoursework on early childhood mentalhealth, and even fewer offer instructionon mental health consultation (Cohen& Kaufmann, 2005). Michigan hasmade strides in this area with itsMichigan Association of Infant MentalHealth (MI-IMH) endorsement, whichis designed to build workforce capacityaround early childhood mental health.There are four professional levels ofattainment within the MI-IMHendorsement, which looks at skills andcompetencies for all professionalpersonnel working with infants andyoung children, including earlychildhood mental health consultants.Each level has guidelines describingareas of expertise, responsibilities, andbehaviors that demonstratecompetency, and requires thepreparation of a portfolio, references,and evidence of having met thecompetency-based requirements forwork experience and education. At thistime, a number of other states areworking to implement Michigan’smodel, including Arizona, NewMexico, Texas, Oklahoma, Kansas,Minnesota, and Connecticut.

Training efforts focusedexclusively on building the capacity ofMHCs are happening sporadically

• Provision of treatment andinformation in the appropriatelanguage or literacy level (throughinterpreters, as necessary andappropriate)

• Utilization of culturally appropriatescreening, assessment, andintervention tools and service plans

• Ability to distinguish betweenresistance to change and a desire touphold culturally appropriatebehavior

According to findings fromAllen’s (2008) focus groups withMHCs, cultural sensitivity is alsodemonstrated through a non-judgmental approach, a willingness tolearn, and a sense of curiosity thatallows an MHC to identify,understand, and respect differences.Focus group participants also assertedthat MHCs need to understand howcultural and community contextsinfluence stigma towards mentalillness and, in turn, affect a family’swillingness to partner with theconsultant.

In essence, to be effective, MHCsneed to develop a complex set ofcompetencies and have the ability todraw on the skills and knowledge thatare most relevant at any given time tothe needs of children, staff, andfamilies in diverse programs andcommunities. As summarized by theteam of researchers from Colorado,“[t]he competencies define the rangeof skills that a mental healthconsultant needs while programsdictate which of the skills will be mostimportant for a mental healthconsultant working within theirsetting” (JFK Partners, 2006).

across the United States. Many of theseefforts include standard trainingprotocols for consultants that build orreinforce skills and provideopportunities for practicing new skills.Adding a practice component isconsistent with current research onacquiring new skills (Fixen, Naoom,Blasé, Friedman, & Wallace, 2005).Johns (2003) describes the intensivetraining provided by DaycareConsultants at the University ofCalifornia, San Francisco, which offersintensive training to all mental healthclinicians who desire to becomeconsultants, including experiencedclinicians. As Johnston and Brinamen(2006) explain, “training in mentalhealth consultation is essential for bothveteran therapists and newcomers fromdifferent disciplines…[because] newapplication [of skills] requires newknowledge” (p. 7). DaycareConsultants’ training integrates mentalhealth principles and knowledge ofearly childhood education anddevelopment, and is comprised of fourkey elements: 1) a didactic trainingseminar; 2) a clinical conference; 3)clinical supervision; and 4) directconsultation experience (Johns, 2003;Johnston and Brinamen, 2006).


“A consultant’s advice, no matterhow intelligent and how ‘right,’ isuseless if it does not consider thecaregiver’s perspective andunderstanding of the situation and,ultimately, the caregiver’s willingnessto participate in particular changes.”(Johnston & Brinamen, 2006, p. 14)

Workforce Development/Training Resource

Michigan Association for InfantMental Health, MI-AIMHEndorsement (IMH-E)

See http://www.mi-aimh.org /endorsements_overview.php

Daycare Consultants Training for Mental Health Consultants

The Early Childhood Mental Health Project: Child Care Center Consultation in Action, Section VII: Training Mental Health Consultants (Johns, B., 2003) Available at http://www.jfcs.org

director or another senior staff memberfrom the ECE program(s) with whomthe MHC works. This level of supportis important since most consultants arenot formally employed by ECEprograms/providers, and supervisorsfrom the consultants’ hiring entity maybe detached from the environment inwhich the consultant is working.Regardless of whether the consultantbenefits from clinical supervisionand/or peer consultation, this additionalsupervisory structure is important forcommunication and integration of theconsultant into the early childhoodprogram. The supervisory relationshipshould be clarified within anycontractual agreement between theprogram and a consultant from anoutside organization or agency. Forthose consultants who are employeddirectly by the ECE program, thesupervisory relationship fits within theorganizational structure.

What Can ECE Programs andProviders Do to SupportEffective Consultation?

ECE DIRECTORS/ADMINISTRATORS

Strong program leadership iscritical to forming a foundation foreffective mental health consultation(Green et al., 2004). Early care andeducation program directors andadministrators greatly influencecollaboration between staff,consultants, and families through theirleadership style and their attitudestoward consultation and earlychildhood mental health. To facilitatepositive relationships, they can

SUPERVISION AND PEER CONSULTATION

Mental health consultants alsoneed adequate support and supervisionin order to be successful in their work.This includes opportunities to sharelessons learned, express feelings andfrustrations, and discuss challengesand appropriate next steps with thosewho can relate to their experiencesand provide informed guidance. Theseopportunities are particularlyimportant for MHCs because withoutthem, many consultants are isolatedfrom other early childhood mentalhealth providers due to theindependent and itinerant nature oftheir work.

To address this need, manyconsultants receive regular clinicalsupervision from a senior clinicianwho is associated with theorganization, agency, or entity wherethe consultant is employed.Consultation programs in some statesand communities, including Michigan,Kentucky, San Francisco, andLouisiana, employ the practice of“reflective supervision,” in which anexperienced clinician supervisesMHCs—individually or in groups—by providing support and knowledgeto guide decision making; offeringempathy to help supervisees exploretheir own reactions to the work; andhelping supervisees manage the stressand intensity of the work (Parlakian,2002, p. 1).

An additional supportive strategythat some states and communities areusing is providing a forum forconsultants to gather with their peersto discuss issues, tackle problems,share strategies, and celebratesuccesses. In Sarasota, Florida,consultants benefit from a hybridmodel that integrates reflectivesupervision and peer consultation.MHCs get together for monthly teammeetings and meet either weekly orbi-weekly for individual supervisiondepending on the intensity of servicesthe consultant provides (Wu, Driver,Jaekel, & Skoklund, 2008).

Another level of support thatsome consultants may have isadministrative supervision by the

demonstrate a commitment to ECMHCby championing a shared vision forpromoting children’s mental health andsupporting positive social andemotional development, and ensuringthat this vision permeates all aspects ofthe program (what is sometimes calleda “mental health perspective”; Knitzer,1996).

Early care and education programdirectors and administrators also have astrong impact through their oversight ofkey administrative processes such asthe following:• Determining the consultant’s

organizational role (externalconsultant or staff member?)

• Specifying the consultant’s scope ofwork

• Recruiting and choosing whichconsultant to hire

• Negotiating the contractualagreement

• Facilitating the consultant’s entryinto the program

• Evaluating the impact ofconsultation and makingadjustments as needed

These decisions have significantimplications for the success of theconsultation. With respect to hiring,Hepburn and Kaufmann (2005)emphasize that it is critical to “match”the program’s needs with a consultant’sskills, and to find a consultant whoshares the program’s philosophy onearly childhood mental health.Similarly, the roles and responsibilitiesof the MHC should be shaped by thisintersection of program need andconsultant ability and evaluated at leastannually to ensure that servicesprovided continue to meet theprogram’s needs.

Another important consideration indefining the work scope and structuringthe consultant role is the extent towhich it provides a framework forcollaboration with staff and families.Research suggests that consultants whoare integrated into program functioning,whom program staff view as “part ofthe team,” and who are accessible andavailable to program staff and familiesare more effective (Gilliam, 2005;


“Supportive relationships betweenstaff members and leaders are thefoundation for nurturingrelationships between parents andchildren. Strong supervisoryrelationships provide the staff with amodel of, and experience with,supportive, individualizedresponses.”(Parlakian, 2002, p.1)

ECE PROVIDERS

ECE providers (i.e., teachers,assistant teachers) also play animportant role in maximizing theeffectiveness of consultation services.Often, providers are the ones identifyingconsultation needs, and ultimately, theyare the ones charged with implementingthe consultant’s classroomrecommendations. The extent to whichproviders engage the consultant,participate with the MHC and parents aspart of a team, and follow through withconsultant recommendations has clear

Green et al., 2006; Yoshikawa &Knitzer, 1997). The way in which aconsultant’s role is structured cangreatly impact program integrationand, likewise, the quality of therelationship between the consultant,staff, and families. For example, willthe MHC be in classrooms on aregular basis to provide ongoingsupport to staff or only when there is aproblem? Furthermore, to elicit stafftrust, it is important to structure theconsultant role in a way that focuseson supporting staff, not monitoringthem (Donahue et al., 2000).

Directors and administratorsshould also consider highlighting thevalue of consultation services byencouraging staff to utilize theconsultant’s services and making sureconsultants have the opportunity earlyin the school year to talk about theirrole and how they can help supportboth staff and parents. In fact, Allen’s(2008) focus groups with MHCsfound that having a program directortake the time to introduce theconsultant to staff early on goes a longway in building the foundation fortrusting relationships.

Providing these communicationopportunities at the onset ofconsultation is particularly importantgiven that teachers are sometimesreluctant to admit they are facingchallenges with certain children orfamilies, and therefore hesitate towork with the consultant, as doing somight imply that they have somehow“failed” in their job. The programdirector (as well as the consultant him-or herself) plays an important role inaddressing these concerns and beingclear that working with the consultantdoes not indicate a lack of teacherskills. In fact, the director shouldassure staff that the consultant is notthere to report on teacher performance,but rather to provide support. Table 2provides additional guidance on howdirectors and administrators can laythe groundwork for effectiveconsultation by fostering positiverelationships.

implications for whether consultationwill succeed or not.

First and foremost, providers cansupport effective consultation bysetting the tone for a good workingrelationship with the consultant. Thisincludes reaching out to the consultantfor help and remaining open to his/herideas, while sharing their own thoughtsand perspectives. In addition, providerscan help facilitate the development ofpositive relationships between theconsultant and parents so that the threepartners can work collaboratively to


DO

Hire or contract with an MHC whohas experience in early childhood andECMH, as well as in providingconsultation (not just direct therapy)

Provide the MHC with training aboutyour program

Be clear with staff about the role ofthe MHC and when, how, and whatservices will be provided

Put processes in place that protectconfidentiality, but do not hinderinformation-sharing among a child’steacher and MHC, nor compromiseopen communication with parents

Make sure all staff and parents have achance to meet the MHC early in theschool year

Allow staff to have direct access tothe MHC through email or phone

Have scheduled time for the MHC tobe in classrooms regularly

Have the MHC provide training inmental health issues to staff andfamilies

Have the MHC attend ongoingmeetings to discuss specific childrenand families with staff

Establish a long-term relationshipwith a consultant (or consultants)

DON’T

Assume the MHC knows what itmeans to be a “consultant” rather thana direct service provider

Assume that the MHC knows aboutearly childhood programs generally, oryour program in particular

Assume that staff will welcome theMHC into their classroom

Establish a process for obtainingparental permission that puts upunnecessary obstacles for the MHC inworking with a child

Wait until issues arise beforeintroducing the MHC

Put up a lot of barriers that hinder staffmembers’ ability to access the MHC

Only have MHCs visit classroomswhen there is a problem

Use the MHC just for one-on-oneservices

Assume the problem is solved once areferral to the MHC is made

Have a “rotating” consultant whochanges from year to year

Table 2. Do’s and Don’ts for Fostering Staff–Consultant–FamilyRelationships (adapted from Green et al., 2004)

seminal questions: • What are the service boundaries of

ECMHC? • When does a service shift from

being “consultation” to “therapy”?• What are the characteristics of

effective consultants? • What is the value-added of

reflective supervision?• What are the best service models? • What types of activities are most

important for the consultant toprovide?

• What level of service intensity isneeded to effect change?

• Which outcomes should be targetedand how should these bemeasured?

• Is mental health consultation moreeffective when used in conjunctionwith an evidence-based practice(e.g., MHC and The IncredibleYears or MHC and Second Steps)?

Given the variability inconsultation models, answering thesequestions will be challenging andrequire an incremental approach.Additional challenges facingevaluators are the lack of agreementon which outcomes should be tracked,which outcome measures should beused, and the ethical issues associatedwith establishing control groups inearly care and education settings(Allen, 2008). Other methodologicalconsiderations include how to designresearch projects that focus on theeffects of consultation alone, asopposed to the cumulative impact of anumber of program enhancements. Ina climate where service dollars arelimited, there are fewer dollarsavailable to support high-qualityevaluation studies. These issues mustbe taken into consideration whenresearchers and programs engage inevaluation efforts.

To expand the evidence base forECMHC, high-quality process andimpact evaluations need to be fundedand implemented through partnershipsbetween researchers and programmanagers. As states and communitiesexpand their capacity to providemental health services to young

improve behaviors at home and in theclassroom. Clearly, MHCs must dotheir part if these provider overturesare to lead to successful consultation.As Allen’s (2008) qualitative researchsuggests, providers are more likely toengage parents in working with anMHC if they themselves have had agood experience with the consultant.Another way providers can supporteffective consultation is by trying toimplement the consultant’srecommendations, seeking guidanceand support as necessary, andproviding feedback to the MHC sothat modifications can be made to therecommended strategies as needed.

What Are Some of theChallenges That Need to BeAddressed?

As discussed earlier in thissynthesis, making ECMHC availablein all of the ECE settings thatneed/want it is a fundamentalchallenge. Relatively few earlychildhood programs and providersacross the country benefit fromconsultation, and those that do receiveservices of varying type and intensityfrom a diverse group of consultants.Issues stifling widespreadimplementation and presentingobstacles the field must overcomeinclude limited rigorous research, lackof sustainable funding, and insufficientworkforce capacity.

RESEARCH

Although the evidence base forthe overall effectiveness of theECMHC approach is growing(Brennan et al., in press; Perry et al.,2006), there are still lingeringquestions about which aspects ofconsultation are causally related topositive outcomes and, hence, mostimportant to retain across ECMHCprograms. This lack of clarity has ledto variability in program modelsacross the country and made itchallenging to expand the field andestablish ECMHC as an evidence-based practice. Thus, more research isneeded to decisively respond to these

children and their families and thefield of ECMHC continues to grow,the capacity of programs to evaluatetheir service components andoutcomes should also be developed. Tothis end, Hepburn et al. (2007)developed an evaluation toolkit to helpstakeholders better address these gapsin the evidence base.

FUNDING

While limited scientific evidenceof the effectiveness of ECMHC is onebarrier to obtaining steady funding inmany states and communities, thereare a variety of fiscal challenges thatkeep ECMHC from going to scale.Some of these funding issues arecommon to expanding children’sservices in general: scarce public andprivate resources, and a high demandfor these limited dollars. There are alsounique aspects of ECMHC that makesustainable funding particularlychallenging.

First, it is much more difficult toobtain reimbursement for“consultation”—particularly program-focused consultation—than for directintervention with one child, given thefunding structures inherent in privateinsurance and public programs likeMedicaid, the State Children’s HealthInsurance Program (SCHIP), and theIndividuals with Disabilities EducationAct (IDEA). Current reimbursementsystems are geared toward paying for asingle, face-to-face encounter with anidentified patient with a diagnosedcondition. Additionally, it ischallenging to secure funds forpromotion and prevention activitiesbecause funders may only be willing


Research & EvaluationResource

Early Childhood Mental HealthConsultation: An Evaluation Toolkit

(Hepburn, Kaufmann, Perry, Allen, Brennan, & Green, 2007) Available at http://gucchd.georgetown.edu

In Vermont, services—includingECMHC—provided through thestatewide Children’s UPstream Project(CUPS) were funded equally throughfederal grant dollars and Medicaid.This funding mix was established byproject leaders to promotesustainability after the grant periodended. The grant monies stemmedfrom the Comprehensive CommunityMental Health Services for Childrenand their Families Program,administered by the Children’s MentalHealth Services (CMHS) division ofthe Substance Abuse and MentalHealth Services Administration(SAMHSA). To generate the other halfof the funding, local agencies weretasked with maximizing the use ofMedicaid funds and providing thenecessary Medicaid match moneythrough existing regional allocationsof State General Funds. Interagencysharing of General Funds, coupledwith a state-level policy change thatauthorized payment for services forchildren birth to age 6 with thediagnosis of a parent-child relationshipdisorder (a “V” code in the Diagnosticand Statistical Manual of MentalDisorders [DSM]), made it possiblefor the program to support andgradually expand its array of mentalhealth services (Bean, Biss, &Hepburn, 2007).

Clearly, ECMHC’s inherent arrayof services and the mode of servicedelivery present significant challengesto those endeavoring to develop and/or

to cover expenses associated withmeeting the needs of children whoexhibit serious social and emotionalproblems and/or have a mental healthdiagnosis (Florida State UniversityCenter for Prevention & EarlyIntervention Policy, 2006).

Some consultation programs arefunded through private foundations,universities, and/orpilot/demonstration projects, whileothers rely on public funding or somecombination of both. This blending orbraiding of funds is often criticalbecause, as Collins et al. (2003)suggest, funds that are earmarked toaddress social or emotional challengesin young children are often tied toindividual children, whereas“[f]lexible resources that can be usedto support child care–mental healthpartnerships generally do not focus onchildren’s social and emotionaldevelopment” (Collins, Mascia,Kendall, Golden, Schock, & Parlakian,2003, p.45).

Medicaid, particularly the Earlyand Periodic Screening, Diagnosis andTreatment (EPSDT) program, is asignificant source of revenue for manyprograms that receive ECMHCservices. Other sources of publicfunding include the following: • Early Head Start/Head Start• Individuals with Disabilities

Education Act (IDEA Part B,Section 619, Part C)

• Mental Health and SubstanceAbuse Block Grants

• Child Care and Development Fund• Child welfare funds, such as Title

IVE of the Social Security Act• Maternal and Child Health Block

Grant under Title V of the SocialSecurity Act

• Temporary Assistance to NeedyFamilies (TANF)

• Supplemental Security Income(SSI, Title XVI of the SocialSecurity Act)

(Cohen & Kaufmann, 2005; Collins et al., 2003)

sustain consultation programs. Yet,there is practical and theoreticalguidance available. For example, inaddition to Vermont, several otherstates have succeeded in applying statefunds toward early childhood mentalhealth consultation, including Maryland(Early Childhood Mental HealthProject), Massachusetts (Together forKids), and Connecticut (EarlyChildhood Consultation Partnership).Further, in her chapter titled “StrategicFinancing of Early Childhood MentalHealth Services,” Perry (2007) outlinesa multiple-step process model (adaptedfrom Striffler, Perry, & Kates, 1997) forbraiding together federal, state, public,and private funds to support earlychildhood mental health services thataddress the continuum of promotion,prevention, and intervention.

WORKFORCE

Finally, workforce capacity is asignificant challenge facing theECMHC field. As Johnston andBrinamen (2006) suggest, mental healthconsultants need such a broadknowledge base that no one couldpossibly have all the relevant skills andexperience without targeted trainingand preparation. Per previousdiscussion, provision of quality mentalhealth consultation requires multiplecompetencies, including a firm grasp ofbest practices in mental health and


Through the Early and PeriodicScreening, Diagnosis and Treatment(EPSDT) program, states are requiredto provide a comprehensive set ofbenefits and services—includingmental health services—for childrenenrolled in Medicaid. Given that anestimated one in three children under age 6 is eligible for Medicaid(Health Resources and ServicesAdministration), EPSDT can be avaluable funding source for child-focused ECMHC.

Funding Resources

Funding Early Childhood MentalHealth Services and Supports

(Wishmann, Kates, & Kaufmann, 2001)Available at http://gucchd.georgetown.edu

Spending Smarter: A FundingGuide for Policymakers andAdvocates to Promote Social andEmotional Health and SchoolReadiness

(Johnson & Knitzer, 2005)Available at www.nccp.org

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