Early Childhood Mental Health Consultation

Contributing Authors

Frances B. Duran

Kathy S. Hepburn

Roxane K. Kaufmann

Lan T. Le

Georgetown University

Mary Dallas Allen

University of Alaska Anchorage

Eileen M. Brennan

Portland State University

Beth L. Green

NPC Research

his synthesis has been developed

to describe early childhood

mental health consultation

(ECMHC) and the existing evidence

base for its effectiveness in fostering

healthy social and emotional

development in young children, birth

through age 6. It provides a description

of the emerging evidence base that

many of the beliefs and much of the

current body of knowledge about

consultation is grounded in literature

and the experiences of mental health

and early care and education (ECE)

providers, educators, and other experts

(i.e., practice-based evidence). Most

empirical research focuses on the

impact of consultation on child,

program, staff and, to a lesser extent,

family outcomes. Still, research efforts

are occurring and data to support

ECMHC as an effective model for

service delivery are accumulating.

Overview

Young children’s healthy social

and emotional development is critical

to school readiness and positive long-

term outcomes (National Research

Council & Institute of Medicine, 2000;

Raver & Knitzer, 2002; Thompson &

Raikes, 2007). Although most children

progress in their development without

any significant challenges, research on

the high rates of preschool expulsion

due to challenging behaviors (Gilliam,

2005) coupled with estimates

suggesting that one in 10 young

children exhibit problem behaviors

(Raver & Knitzer, 2002) underscores

that this is not the case for all children.

In fact, early childhood providers have

increasingly voiced concerns about

young children showing signs of

serious emotional distress and have

expressed the need for training and

Early Childhood Mental Health

Consultation

Research Synthesis

The Center on the Social and Emotional

Foundations for Early Learning

Child Care

Bureau

Office of

Head Start

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

What Is Early Childhood Mental

Health Consultation?

Early childhood mental health

consultation builds upon the well-

established field of mental health

consultation, pioneered by Gerald

Caplan in the mid-sixties. In Caplan’s

seminal work (1964), he outlined an

approach that involves mental health

professionals working with human

services staff to enhance their

provision of mental health services to

clients. Similarly, in ECMHC, a

professional consultant with mental

health expertise “works collaboratively

with ECE staff, programs, and families

to improve their ability to prevent,

identify, treat, and reduce the impact of

mental health problems among

children from birth through age 6”

(Cohen & Kaufmann, 2000; revised

2005). Ultimately, early childhood

mental health consultation seeks to

achieve positive outcomes for infants

and young children in early childhood

settings by using an indirect approach

to fostering their social and emotional

well-being.

Although the field has not reached

full consensus on the scope of early

childhood mental health consultation,

Cohen and Kaufmann (2000) identified

two sub-types of ECMHC that are

frequently cited: child- or family-

centered and programmatic

consultation. The former and more

traditional type of consultation aims to

address the needs of an individual child

who is exhibiting challenging

behaviors or whose social and

emotional well-being may be at risk

due to a family crisis (e.g., death in the

family, divorce). Typically, child- or

family-centered consultation is

provided to the child’s teacher(s) and

parents, and is focused on helping

these adults support children more

effectively. In contrast, programmatic

consultation takes a more systemic

approach, focusing on “improving the

overall quality of the program and/or

assisting the program to solve a

specific issue that affects more than

one child, staff member, and/or family”

(Cohen & Kaufmann, p. 8). This type

assistance around managing

challenging behaviors (Hemmeter,

Corso, & Cheatham, 2006; Knitzer,

2000).

One approach to addressing

challenging behaviors, as well as

promoting social and emotional health

and preventing the onset of behavioral

issues, is early childhood mental health

consultation. This approach is gaining

popularity among ECE programs (e.g.,

child care centers, Head Start and Early

Head Start programs, and family day

care homes), and preliminary research

findings are encouraging. In fact,

recent reviews of research indicate that

ECMHC yields positive social and

emotional outcomes for young children

in early childhood settings, including

reductions in preschool expulsions

(Perry, Brennan, Bradley, & Allen,

2006). In addition, research shows

positive outcomes among ECE staff

and programs receiving consultation

services, such as increased staff

confidence in dealing with young

children’s difficult behaviors and

overall improvements in ECE

classroom climates (Brennan, Bradley,

Allen, & Perry, in press).

Within the growing evidence base,

currently there are only two

randomized control studies guiding the

field. Thus, this synthesis will integrate

available research with the more

sizeable collection of knowledge from

literature and practice to explore

various aspects of this “emerging

practice” and address the following key

questions:

• What is ECMHC?

• What are the benefits of ECMHC?

• What are the characteristics of

effective consultants and

consultation models?

• What are the key challenges in

developing and implementing

ECMHC?

Key Terms

Best practices: Guidelines or

practices driven by clinical wisdom or

other consensus approaches that do

not necessarily include systematic use

of available research evidence

(definition adapted from Resource

Guide for Promoting an Evidence-

Based Culture in Children’s Mental

Health, http://systemsofcare.samhsa.

gov/ResourceGuide/index.html).

Cultural competence: A set of

behaviors, attitudes, and policies

within a system, agency, or among

professionals that allows them to work

in cross-cultural situations (Cross,

Bazron, Dennis, & Isaacs, 1989).

Early childhood mental health:

The developing capacity of infants,

toddlers, and young children to

experience, manage, and express

emotion; form close, secure

relationships; and actively explore the

environment and learn. Essentially

synonymous with healthy social and

emotional development (adapted from

ZERO TO THREE,

www.zerotothree.org).

Emer

ging practices

: Innovations in

clinical or administrative practice that

address critical needs of a particular

program, population, or system, but

do not yet have scientific or broad

expert consensus support (Hyde, Falls,

Morris, & Schoenwald, 2001).

Evidence-based practices

Interventions for which there is

consistent scientific evidence showing

that they improve client outcomes

(Drake et al., 2001).

Practice-based evidence:

A range of

treatment services and supports that

are accessible and culturally

appropriate and known to be effective

by families, youth, and providers

(National Federation of Families for

Children’s Mental Health,

www.ffcmh.org)

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

of consultation is usually provided to

ECE program administrators and staff

and is intended to have a more

widespread impact. Still, it is important

to note that these distinctions are not

always clear-cut when put into

practice, as consultants may

intermingle various strategies to meet

identified needs.

Unlike traditional one-on-one

therapeutic mental health services,

ECMHC is primarily an indirect

approach. Early childhood mental

health consultants (MHCs) strive to

improve children’s social and

emotional well-being by building the

capacity of ECE staff, parents, and

other caregivers to promote healthy

child development and manage

challenging behaviors. Consultants

educate, train, and “coach” caregivers

so that they develop the skills and

confidence to effectively address

children’s social and emotional

needs—whether it be the needs of one

child or an entire classroom of

children. Although the consultant may

provide some direct services (e.g.,

observing children, conducting

individual assessments, modeling

effective practices), these activities are

ultimately designed to enhance

caregiver competence. In sum,

ECMHC is both a problem-solving and

capacity-building intervention.

Another hallmark of early

childhood mental health consultation is

the strong emphasis on collaboration.

ECMHC’s approach acknowledges that

in order to understand and address a

child’s challenging behavior, one must

look holistically at the environments in

which the child functions (e.g., home,

classroom, community settings). This

holistic or “ecological systems

perspective” (Brack, Jones, Smith,

White, & Brack, 1993) in ECMHC

necessitates that the consultant partners

with ECE staff and families to jointly

assess the challenge, determine

appropriate intervention, and

implement a coordinated plan of action

across all settings. These collaborative

relationships are essential to effective

consultation and have become a special

research interest in the field (Green,

activities will be determined, helping

to guide effective service delivery.

The Promotion–Prevention–

Intervention Continuum

Early childhood mental health

consultation recognizes that achieving

positive social and emotional outcomes

for young children requires a

comprehensive approach that spans a

continuum of mental health services

and supports—from promotion to

prevention to intervention (Perry,

Kaufmann, & Knitzer, 2007). Although

many consultants are initially engaged

to provide consultation focused on an

individual child needing intervention,

Everhart, Gordon, & Gettman, 2006;

Johnston & Brinamen, 2006).

Finally, ECMHC differs from

many other approaches or evidence-

based practices in that it is not

manualized (i.e., there is no curriculum

to follow). It is characterized by

adherence to a core set of principles

(e.g., relationship-based) as opposed to

delivery of specific activities in a

prescribed sequence. Accordingly,

ECMHC encourages customized

service delivery to meet the diverse

needs of various children, families, and

ECE programs. As the evidence base

for ECMHC grows, the core principles

of this approach will be further

solidified 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 children

with challenging behaviors

importance of building an effective

workforce that is well-trained on best

practices in children’s mental health.

The Pyramid model is designed to

help organize a variety of evidence-

based approaches and activities

focused on young children’s healthy

social and emotional development.

ECMHC is just one tool that might be

used to support teachers and other

caregivers to implement the practices

at each level of the Pyramid. .

To complement the Pyramid

model and support implementation of

activities at each level, CSEFEL has

developed accompanying training

materials and a number of practical

tools that can be used in the

implementation of the model (e.g.,

scripted stories to teach children about

expectations in various social

situations, “cue cards” to prompt

positive social skills). In addition,

researchers involved in the

development of the Pyramid model

have created a classroom assessment

tool (“Teaching Pyramid Observation

Tool,” or “TPOT”) to help programs

and practitioners evaluate how well

each Pyramid level is being addressed

(Hemmeter, Fox, & Snyder, 2008).

These resources have been well-

received by the early childhood

community, particularly ECE staff and

MHCs, who find them practical and

effective. Consultants report working

successfully with ECE staff to apply

CSEFEL techniques and activities in

their classrooms, and many

simultaneously they often intentionally

broaden their focus to include

promotion and prevention-level

activities as trust is established and

staff skills in managing challenging

behaviors improve.

For example, a consultant might

focus on mental health promotion by

conducting a workshop for parents on

the importance of parent-child

interactions and practical ways to

maximize the benefits of those

interactions. Similarly, to build

capacity around prevention of

behavioral problems, a consultant may

train ECE staff on teaching strategies

that enhance children’s emotional

literacy and their ability to express

feelings in appropriate ways. It is

important to note that promotion and

prevention activities do not replace

intervention activities; all three are

important elements within the

consultants’ array of services. Table 1

provides other examples of activities

MHCs might do along “the

continuum.”

The Pyramid Model: A

Companion to “The Continuum”

For consultants striving to implement

this comprehensive, three-pronged

approach, the Pyramid Model for

Promoting the Social Emotional

Competence of Infants and Young

Children developed by CSEFEL

(Center on the Social and Emotional

Foundations for Early Learning) and

the Technical Assistance Center on

Social Emotional Intervention

(TACSEI) provides a framework for

organizing activities along the mental

health continuum. The Pyramid

(below) emphasizes “nurturing and

responsive relationships” and “high-

quality, supportive environments” for

all children (promotion); “targeted

social emotional supports” for children

at risk for behavioral problems

(prevention); and “intensive

intervention” for children exhibiting

challenging behavior (intervention)

(Fox, Dunlap, Hemmeter, Joseph, &

Strain, 2003). In addition, the bottom

level of the Pyramid acknowledges the

consultants have become CSEFEL

trainers and/or used the TPOT to help

ECE programs improve quality

(Kaufmann & Horen, 2008).

Practical Resources for MHCs

The Center on the Social and

Emotional Foundations for Early

Learning (CSEFEL) has developed a

number of user-friendly resources to

help consultants and others promote

social and emotional competence in

infants and young children. The

resources are highlighted below. All

are available for free at

http://www.vanderbilt.edu/csefel.

• Training modules for infant/toddler,

preschool, and parent with

accompanying slides, handouts,

video clips, and facilitator’s guide.

• Tools and resources that provide

“Practical Strategies” for teachers

and caregivers. These resources

include tools for working on

building relationships; a list of

recommended children’s books that

support social and emotional

development, and accompanying

activity ideas to bolster the themes

discussed in those books, teaching

social emotional skills; and tools for

developing behavior support plans,

including observation cards and

functional assessment interview

forms.

• What Works Briefs that summarize

effective practices for supporting

children’s social-emotional

development and preventing

challenging behaviors. The Briefs

describe practical strategies, provide

references to more information

about the practice, and include a

one-page handout highlighting

major points. Based on the What

Works Briefs topics, short training

packages are available that include

PowerPoint slides with

accompanying note pages,

activities, and handouts, which

provide a trainer with the materials

needed to conduct a short staff

development program on a focused

topic.

• A series of six modules to help

professionals working with parents

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

theoretical frameworks, such as

attachment theory or child

development theory. An additional

strategy that has emerged is providing

ECMHC services in combination with

other services or with other early

childhood mental health curricula, such

as The Incredible Years (see

www.incredibleyears.com) or Second

Step (see www.cfchildren.org). Two

examples of this blended approach are

highlighted below.

OMBINING CONSULTATION AND

DIRECT

SERVICES

Given the complementary nature

of therapeutic intervention and

consultation, some ECMHC programs,

including California’s Early Childhood

Mental Health program, offer direct

services (e.g., psychotherapy and

therapeutic play groups) when

consultation services alone are not

enough to address a child’s or family’s

identified needs. Direct therapeutic

intervention services are provided to

the child, family, or staff member by

the mental health professional to reach

specific treatment goals. It is not

unusual for mental health professionals

to serve in both roles—as a consultant

and as a therapist—particularly in

communities where there are few

individuals trained in early childhood

mental health. While both roles are

important, they are distinct. An MHC

provides consultation services, whereas

a therapist offers direct services or

therapeutic interventions. Currently,

there is a need for research that

formally evaluates the effect of adding

a direct service component to an

ECMHC model. Although the

evaluation of the Early Childhood

Mental Health program did identify

some promising outcomes, it did not

measure the specific impact of

therapeutic intervention (James

Bowman Associates & Kagan, 2003).

OMBINING

ECHMC

WITH

ESTABLISHED

EARLY

HILDHOOD MENTAL HEALTH

URRICULA

Another variation to enhance the

impact of ECMHC involves infusing

promote positive and effective

parenting behaviors that encourage

children’s social and emotional

development and address the

challenging behaviors and mental

health needs of children in child

care and Head Start programs.

• Short one- to two-page decision-

making guideline documents to aid

programs in making decisions

about practical issues (e.g.,

selecting a social-emotional

curriculum, selecting screening and

assessment tools focused on social-

emotional competence).

• State planning materials are

available from several states

working with CSEFEL to

implement the Pyramid model.

Additional resources can be found

on the website for the Technical

Assistance Center for Social

Emotional Intervention for Young

Children (www.challenging behavior.

org), including

• A review of screening instruments

for social-emotional concerns.

• Teaching Tools: A guide that helps

classroom teachers develop

practical interventions for

disruptive behavior, including

ready-made materials for use in the

classroom.

• A manual of guidance and

materials that can be used to

implement the individualized

positive behavior support process.

• Webinars on topics relevant to

early childhood systems, policy,

and professional development.

Variations in ECMHC Models

As programs continue to explore the

potential of mental health consultation

to produce positive outcomes, varying

methods of implementing this

approach have surfaced. For example,

some programs provide ongoing, on-

site consultation, whereas others

provide intensive consultation for a

relatively brief time period, followed

by additional support as needed or

requested. Further, some programs

have grounded their models in certain

established evidence-based practices

into service delivery, such as curricula

that support early childhood mental

health. In two recent studies of

ECMHC (Raver, Jones, Li-Grining,

Metzger, Champion, & Sardin, 2008;

Williford & Shelton, 2008), researchers

examined the efficacy of integrating

ECMHC with the Incredible Years

Parent and Teacher Training Series, a

well-established, empirically supported

program designed to educate parents

and teachers on techniques to address

challenging behaviors and promote

social and emotional competence and

well-being (Webster-Stratton, 1999a,

1999b). Although both studies

evaluated the impact of the same

evidence-based practice on

consultation, each applied the

intervention in a slightly different

manner.

In the Chicago School Readiness

Program model that Raver et al. (2008)

evaluated, Incredible Years was adapted

to fit into five six-hour training sessions

delivered to teachers. This training was

complemented by mental health

consultation services one morning a

week, including three months of child-

centered consultation towards the end

of the study. Similarly, the North

Carolina model that Williford and

Shelton (2008) studied included one

group training session for teachers on a

modified version of the Incredible

Years, followed by individual

consultation sessions with teachers to

guide their learning and use of relevant

concepts and techniques in Webster-

Stratton’s program. In addition, North

Carolina offered a shortened (10-week)

parent training based on the Incredible

Years. Both research teams found

promising results from these integrated

approaches, including a better

emotional climate (i.e., more teacher

responsiveness and less harshness) in

intervention classrooms than in control

classrooms (Raver et al., 2008), and a

more positive impact on child behavior

(according to reports by teachers and

caregivers) in the intervention group

than in the comparison group (Williford

& Shelton, 2008).

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

that involve greater numbers of

children. Several factors have

contributed to the focus on

intervention in ECMHC. First,

programs typically engage MHCs

because their most pressing need is for

help with a particular child or

children. Further, consultants often

have limited time to spend with early

childhood programs and providers,

due to large caseloads and/or lack of

program funds for consultation

services. Limited access to

consultation can greatly undermine the

ability to integrate promotion and

prevention activities into early

childhood settings—not only because

much of the consultant’s time is spent

“putting out fires,” but also because it

is hard for consultants to build the

trust and rapport necessary to shift

attention towards promotion and

prevention. In their study of Head

Start centers, Yoshikawa and Knitzer

(1997) learned that when a consultant

was only available on an “on-call”

basis, mental health promotion

activities were essentially ignored.

Funding also plays a role in

channeling services to children

exhibiting behavioral challenges.

Financing mechanisms are typically

designed to provide reimbursement for

direct services to individual children,

particularly those with a mental health

diagnosis. Children at risk for social

and emotional challenges are generally

excluded from funders’ eligibility

criteria (Johnson & Knitzer, 2005).

These funding constraints not only

undermine promotion and prevention

efforts, but ECMHC in general, given

its indirect, capacity-building design.

To broaden the impact of mental

health consultation, provisions need to

be made to widen access to mental

health consultation in home-based care

and education settings (i.e., licensed

family child care homes and

unlicensed family/friend/neighbor

arrangements), and to expand the

focus to include promotion and

prevention activities that benefit all

children as part of the array of

consultation services. Ideally, ECMHC

Who Receives ECMHC Services

and in What Settings?

Currently, most ECMHC services

are provided to children (birth through

age 6), staff, and families in center-

based care. Licensed family child care

homes and unlicensed child care

providers (e.g., family, friends, and

neighbors) are less likely to receive

consultation services, although some

consultation models, (such as Instituto

Familiar de la Raza’s Early

Intervention Program in San

Francisco; www

.ifrsf.or

g) offer

services to licensed family child care

homes. Still, even in Early Head Start,

which serves a large number of infants

and toddlers through home visiting

(41%), the majority of services are

provided in a center-based

environment (51%; Hoffman & Ewen,

2007).

Primary consumers of early

childhood mental health consultation

services across the country are Early

Head Start and Head Start (E/HS)

programs, as their performance

standards require them to “secure the

services of mental health professionals

on a schedule of sufficient frequency

to enable the timely and effective

identification of and intervention in

family and staff concerns about a

child’s mental health” (Head Start

Performance Standards and Other

Regulations, 45 CFR Part 1304.24.2).

Outside of E/HS programs, there is

generally limited availability of

consultation. Although a few states

(including Maryland, Connecticut, and

Michigan) have statewide consultation

programs/initiatives, most states have

consultation programs that serve

limited geographic areas or service

populations, or have not yet

implemented consultation beyond

what is offered through E/HS

programs.

Regardless of whether

consultation is provided through E/HS

or another ECE setting, there has been

a tendency for consultants to focus on

intervention for children who exhibit

challenging behavior as opposed to

promotion and prevention activities

would be available to all early care and

education settings and subsidized or

reimbursable through a variety of

sources.

What Are the Benefits of

ECMHC?

Studies on the impact of mental

health consultation in early childhood

settings are increasing in complexity,

and evidence of the effectiveness of

this approach is mounting (see below).

However, the field still lacks

randomized controlled trials that

provide rigorous evidence of the link

between the effects of consultation on

staff knowledge, attitudes, and

behavior, and better outcomes for

young children and their families.

MPROVEMENTS IN

TEACHER ATTITUDES,

KILLS,

AND STRESS

LEVELS

, AND

CLASSROOM

CLIMATES

In a clustered randomized control

study of Chicago School Readiness

Program classrooms, outside observers

found that teachers receiving ECMHC

had significant improvements in

teacher sensitivity and enhanced

classroom management skills,

compared with teachers in classrooms

without consultation (Raver et al.,

2008). Observers also found that the

classroom climates improved after

consultation, with more positive

interactions between teachers and

children and fewer negative exchanges,

in contrast to classrooms where no

consultation was present. Staff

members also rated themselves as

significantly more able to manage

children’s difficult behavior after

consultation in 9 of 11 studies

reviewed by Brennan et al. (in press;

see, for example, Alkon, Ramler, &

MacLennan, 2003; James Bowman

Associates & Kagan, 2003; Olmos &

Grimmer, 2004). Finally, teachers have

also generally reported lower levels of

job stress after they receive

consultation services (Green et al.,

2006; Langkamp, 2003; Olmos &

Grimmer, 2004).

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

(Brennan, Bradley, Ama, & Cawood,

2003; Field & Mackrain, 2004).

Although several researchers tracked

parenting stress level over time, no

significant decreases in stress were

detected before and after consultation

(Lehman, Lambarth, Friesen, MacLeod,

& White, 2005; Williford & Shelton,

2008).

Who Are the Professionals

Providing ECMHC?

Mental health consultants have

diverse educational and training

backgrounds, and bring a wide range of

knowledge, skills, and experience to

their work. This is due, in part, to the

absence of a national licensing or

accreditation process that establishes

required competencies for those

providing ECMHC services. Consistent

with Head Start regulations, the

consultant pool is largely comprised of

mental health professionals licensed or

certified within their state to practice a

variety of human service disciplines,

including counseling, marriage and

family therapy, psychology, psychiatry,

and social work (Green, Everhart,

Gettman, Gordon, & Friesen, 2004). In

addition, some states employ early

childhood or special education

professionals with training, but not

licensure/certification, in early

childhood mental health. These

professionals provide similar services

with the exception of clinical mental

health interventions.

Educational attainment among

MHCs is mixed, indicative of varying

program-level competency requirements

and diversity in the type of mental

health services consultants provide. For

example, some programs may require

MHCs who provide screening,

assessment, or intervention services to

have at least a master’s degree.

Consultants are also employed in a

number of differing ways: a national

survey of 69 Head Start programs found

that a relatively small proportion of

mental health consultants were

employed directly by the programs

(22%), while the majority were

employed outside of Head Start by a

BETTER OUTCOMES FOR CHILDREN

Teachers in classrooms with ECMHC

services reported that children had

fewer problem behaviors after these

services were implemented (Bleecker

& Sherwood, 2004; Gilliam, 2007;

Perry, Dunne, McFadden, &

Campbell, 2008; Upshur, Wenz-Gross,

& Reed, 2008). Particularly, there is

evidence that externalizing

(aggressive, disruptive) behavior was

less frequent after consultation

(Gilliam, 2007; Raver et al., 2008;

Williford & Shelton, 2008). Children

with difficult internalizing (withdrawn,

disconnected) behavior showed

improvement in some studies

(Bleecker, Sherwood, & Chan-Sew,

2005; Raver et al., 2008), but not in

others (Duffy, 1986; Gilliam, 2007).

Positive social skill development also

accelerated for children with ECMHC

services in several studies (Bleecker &

Sherwood, 2003, 2004; Farmer-

Dougan, Viechtbauer, & French, 1999;

Upshur et al., 2008). Finally, there is

evidence that when mental health

consultation is available in early

childhood programs, the rate of

expulsion of children with difficult or

challenging behavior decreases

(Gilliam, 2005; Perry et al., 2008).

NCLEAR

IMPACT ON

AMILIES

There are fewer studies that report

on the effects of ECMHC on families,

and the impact on family-level

outcomes is less clear. Most

evaluations of mental health

consultation do not report family data,

making the determination of family-

level effects problematic. However,

several researchers have found

evidence that staff and families

communicated more effectively after

consultation of longer duration (Alkon

et al., 2003; Pawl & Johnston, 1991;

Safford, Rogers, & Habashi, 2001),

and that parents interacted with their

children in a more positive and

effective way after services were

received (Langkamp, 2003; Pawl &

Johnston, 1991; Williford & Shelton,

2008). Additionally, there were reports

that consultation provided greater

family access to mental health services

non-profit agency (23%), by a

government agency (7%), by a school

or other agency (15%), or were in

private practice (33%; Green et al.,

2004).

What MHC Competencies Are

Most Important for Effective

Consultation?

Despite the variation in MHCs’

professional affiliations and level of

education, a set of core competencies

essential to the provision of effective

consultation is emerging from practice-

based knowledge. These skills and

attributes include the following:

• Knowledge, skills, and experience in

early childhood mental health, child

development, and early childhood

education

• Ability to build positive

relationships with staff and families

• Knowledge of community services

and supports

• Cultural sensitivity

KNOWLEDGE

KILLS, AND EXPERIENCE

Effective mental health consultation

requires a unique set of knowledge and

skills. While expertise in early

childhood mental health is essential, it

must be coupled with an ability to work

successfully in early childhood settings

and within family and community

contexts. Based on feedback from a

roundtable of experts in early childhood

mental health (Cohen, E., & Kaufmann,

R. K. (2000)), the recommended

competencies for consultants include

the following:

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

“The early childhood mental health

consultation workforce is in

transition from one of broad

diversity in terms of training,

experience, roles, responsibilities,

and work expectations to one that

has specific expertise in early

childhood mental health and the

specific skills required to take on

the role of consultant.”

(Allen, Brennan, Green, Hepburn,

& Kaufmann, 2008, p.21)

considerations; and advocating for

policies, resources, program

evaluation, and other components that

support effective service delivery.

In addition, participants in a

qualitative study of Head Start MHCs

stated that consultants who work in

early childhood environments should

have experience in early childhood

education and an understanding of the

challenges of teaching young children

(Allen, 2008). In some instances,

MHCs may also need specialized

expertise in certain areas (e.g.,

maternal depression, post-traumatic

stress) to address the needs of a child

or family. When the consultant does

not have this expertise, it underscores

the need for knowledge of local

systems, providers, and resources and

the ability to facilitate these linkages.

ELATIONSHIP

BUILDING WITH

TAFF AND

FAMILIES

Another essential skill for MHCs

is the ability to develop strong

relationships with ECE staff and

families. Positive relationships

between early childhood staff and

MHCs are an important predictor of

whether staff believe that consultation

improves child outcomes (Green et al.,

2006). Further, Green and colleagues

(2004) found that “[h]aving a mental

health consultant who is trusted, who

makes him/herself accessible to staff,

and who is perceived as being ‘part of

the team’ may be more important than

the actual number of hours a consultant

is available” (p. 58). With respect to

families, a strong relationship between

a MHC and a young child’s parents is

critical, because those caregivers act as

gatekeepers for the child’s access to

mental health services (Allen, 2008)

and are the primary source of ongoing

Knowledge of…

• Normal growth and development of

young children, including

developmental milestones

• Atypical behavior in infants,

toddlers, and preschoolers

• Underlying concepts of social and

emotional development, such as

attachment, separation, and

relationship development

• Best practices and various

intervention strategies

• Early childhood, child care, family

support, and early intervention

systems

• Adult learning principles

As well as the following skills and

experience…

• Ability to integrate mental health

activities and philosophies into

group settings

• Child and classroom observation

and assessment

• Ability to work with staff and

families and recognize their diverse

perspectives

• Communication facilitation

• Sensitivity to community attitudes

and strengths

• Cultural competence

(adapted from Cohen & Kaufmann, 2005)

The competencies outlined above

mirror many of those identified by

researchers in Colorado, who

developed a checklist of core

knowledge and competencies for

MHCs to guide workforce

development in their state (JFK

Partners, 2006). Informed by literature

review, expert opinion, and a survey of

Colorado professionals involved in

ECMHC, the checklist reflects the

importance of a strong background in

child development and early childhood

mental health, and the ability to

collaborate with ECE staff to foster

high-quality care and to build linkages

with child- and family-serving systems

and community-based organizations.

Colorado’s checklist also highlights

skills that support effective service

delivery, such as reflective practice;

developing strategies that integrate

health and mental health

support for social and emotional

development in the home.

Developing positive relationships

with early childhood staff requires

MHCs to avoid an expert stance, have

good listening skills, use a strengths-

based approach, and be a non-

judgmental, supportive team player

(Donahue, Falk & Provet, 2000;

Johnston & Brinamen, 2006).

Similarly, developing these

collaborative relationships with

families requires MHCs to have

opportunities to connect with families,

to maintain a family-centered

approach, and to be culturally sensitive

(Allen, 2008). Consultants can help to

facilitate these relationships by

routinely spending time in ECE

classrooms, particularly during events

when parents are present, for example,

drop-off and pickup times. This

regularly scheduled time also allows

consultants to observe staff, children,

parents, and overall environments, and

to model approaches for working with

children, thus helping staff to develop

these skills themselves. Further, it

underscores the role of the consultant

in preventing serious emotional and

behavioral issues, rather than being

called on only when problems have

already emerged.

ULTURAL AND

LINGUISTIC C

OMPETENCE

Cultural and linguistic competence is a

vital skill for MHCs if they want to

build solid partnerships with staff and

families. An important step in

achieving cultural and linguistic

competence, which is a developmental

process that evolves over time, is an

awareness of one’s own culture and

how that impacts personal beliefs and

values (Cross et al., 1989; National

Center for Cultural Competence, n.d.).

According to Hepburn and Kaufmann

(2005), indicators that a consultant is

culturally and linguistically competent

include the following:

• Demonstrated respect for diverse

backgrounds

• Understanding of the variance

across cultures in mental health

practices and how clinical issues

present

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

“[T]he effective consultant not only

has expertise in the particular

content area in which she offers

assistance, but also has the

interpersonal skills to motivate staff

to take action.”

(Cohen & Kaufmann, 2005, p. 19)

What Preparation and Support

Do Mental Health Consultants

Need?

TRAINING

Although the number of mental

health consultation programs across the

country is growing, there is a scarcity

of research to guide the training and

ongoing support of consultants. Few

states or universities provide training or

coursework on early childhood mental

health, and even fewer offer instruction

on mental health consultation (Cohen

& Kaufmann, 2005). Michigan has

made strides in this area with its

Michigan Association of Infant Mental

Health (MI-IMH) endorsement, which

is designed to build workforce capacity

around early childhood mental health.

There are four professional levels of

attainment within the MI-IMH

endorsement, which looks at skills and

competencies for all professional

personnel working with infants and

young children, including early

childhood mental health consultants.

Each level has guidelines describing

areas of expertise, responsibilities, and

behaviors that demonstrate

competency, and requires the

preparation of a portfolio, references,

and evidence of having met the

competency-based requirements for

work experience and education. At this

time, a number of other states are

working to implement Michigan’s

model, including Arizona, New

Mexico, Texas, Oklahoma, Kansas,

Minnesota, and Connecticut.

Training efforts focused

exclusively on building the capacity of

MHCs are happening sporadically

• Provision of treatment and

information in the appropriate

language or literacy level (through

interpreters, as necessary and

appropriate)

• Utilization of culturally appropriate

screening, assessment, and

intervention tools and service plans

• Ability to distinguish between

resistance to change and a desire to

uphold culturally appropriate

behavior

According to findings from

Allen’s (2008) focus groups with

MHCs, cultural sensitivity is also

demonstrated through a non-

judgmental approach, a willingness to

learn, and a sense of curiosity that

allows an MHC to identify,

understand, and respect differences.

Focus group participants also asserted

that MHCs need to understand how

cultural and community contexts

influence stigma towards mental

illness and, in turn, affect a family’s

willingness to partner with the

consultant.

In essence, to be effective, MHCs

need to develop a complex set of

competencies and have the ability to

draw on the skills and knowledge that

are most relevant at any given time to

the needs of children, staff, and

families in diverse programs and

communities. As summarized by the

team of researchers from Colorado,

“[t]he competencies define the range

of skills that a mental health

consultant needs while programs

dictate which of the skills will be most

important for a mental health

consultant working within their

setting” (JFK Partners, 2006).

across the United States. Many of these

efforts include standard training

protocols for consultants that build or

reinforce skills and provide

opportunities for practicing new skills.

Adding a practice component is

consistent with current research on

acquiring new skills (Fixen, Naoom,

Blasé, Friedman, & Wallace, 2005).

Johns (2003) describes the intensive

training provided by Daycare

Consultants at the University of

California, San Francisco, which offers

intensive training to all mental health

clinicians who desire to become

consultants, including experienced

clinicians. As Johnston and Brinamen

(2006) explain, “training in mental

health consultation is essential for both

veteran therapists and newcomers from

different disciplines…[because] new

application [of skills] requires new

knowledge” (p. 7). Daycare

Consultants’ training integrates mental

health principles and knowledge of

early childhood education and

development, and is comprised of four

key elements: 1) a didactic training

seminar; 2) a clinical conference; 3)

clinical supervision; and 4) direct

consultation experience (Johns, 2003;

Johnston and Brinamen, 2006).

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

“A consultant’s advice, no matter

how intelligent and how ‘right,’ is

useless if it does not consider the

caregiver’s perspective and

understanding of the situation and,

ultimately, the caregiver’s willingness

to participate in particular changes.”

(Johnston & Brinamen, 2006, p. 14)

Workforce Development/

Training Resource

Michigan Association for Infant

Mental Health, MI-AIMH

Endorsement (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 member

from the ECE program(s) with whom

the MHC works. This level of support

is important since most consultants are

not formally employed by ECE

programs/providers, and supervisors

from the consultants’ hiring entity may

be detached from the environment in

which the consultant is working.

Regardless of whether the consultant

benefits from clinical supervision

and/or peer consultation, this additional

supervisory structure is important for

communication and integration of the

consultant into the early childhood

program. The supervisory relationship

should be clarified within any

contractual agreement between the

program and a consultant from an

outside organization or agency. For

those consultants who are employed

directly by the ECE program, the

supervisory relationship fits within the

organizational structure.

What Can ECE Programs and

Providers Do to Support

Effective Consultation?

ECE D

IRECTORS/ADMINISTRATORS

Strong program leadership is

critical to forming a foundation for

effective mental health consultation

(Green et al., 2004). Early care and

education program directors and

administrators greatly influence

collaboration between staff,

consultants, and families through their

leadership style and their attitudes

toward consultation and early

childhood mental health. To facilitate

positive relationships, they can

SUPERVISION AND PEER CONSULTATION

Mental health consultants also

need adequate support and supervision

in order to be successful in their work.

This includes opportunities to share

lessons learned, express feelings and

frustrations, and discuss challenges

and appropriate next steps with those

who can relate to their experiences

and provide informed guidance. These

opportunities are particularly

important for MHCs because without

them, many consultants are isolated

from other early childhood mental

health providers due to the

independent and itinerant nature of

their work.

To address this need, many

consultants receive regular clinical

supervision from a senior clinician

who is associated with the

organization, agency, or entity where

the consultant is employed.

Consultation programs in some states

and communities, including Michigan,

Kentucky, San Francisco, and

Louisiana, employ the practice of

“reflective supervision,” in which an

experienced clinician supervises

MHCs—individually or in groups—

by providing support and knowledge

to guide decision making; offering

empathy to help supervisees explore

their own reactions to the work; and

helping supervisees manage the stress

and intensity of the work (Parlakian,

2002, p. 1).

An additional supportive strategy

that some states and communities are

using is providing a forum for

consultants to gather with their peers

to discuss issues, tackle problems,

share strategies, and celebrate

successes. In Sarasota, Florida,

consultants benefit from a hybrid

model that integrates reflective

supervision and peer consultation.

MHCs get together for monthly team

meetings and meet either weekly or

bi-weekly for individual supervision

depending on the intensity of services

the consultant provides (Wu, Driver,

Jaekel, & Skoklund, 2008).

Another level of support that

some consultants may have is

administrative supervision by the

demonstrate a commitment to ECMHC

by championing a shared vision for

promoting children’s mental health and

supporting positive social and

emotional development, and ensuring

that this vision permeates all aspects of

the program (what is sometimes called

a “mental health perspective”; Knitzer,

1996).

Early care and education program

directors and administrators also have a

strong impact through their oversight of

key administrative processes such as

the following:

• Determining the consultant’s

organizational role (external

consultant or staff member?)

• Specifying the consultant’s scope of

work

• Recruiting and choosing which

consultant to hire

• Negotiating the contractual

agreement

• Facilitating the consultant’s entry

into the program

• Evaluating the impact of

consultation and making

adjustments as needed

These decisions have significant

implications for the success of the

consultation. With respect to hiring,

Hepburn and Kaufmann (2005)

emphasize that it is critical to “match”

the program’s needs with a consultant’s

skills, and to find a consultant who

shares the program’s philosophy on

early childhood mental health.

Similarly, the roles and responsibilities

of the MHC should be shaped by this

intersection of program need and

consultant ability and evaluated at least

annually to ensure that services

provided continue to meet the

program’s needs.

Another important consideration in

defining the work scope and structuring

the consultant role is the extent to

which it provides a framework for

collaboration with staff and families.

Research suggests that consultants who

are integrated into program functioning,

whom program staff view as “part of

the team,” and who are accessible and

available to program staff and families

are more effective (Gilliam, 2005;

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

“Supportive relationships between

staff members and leaders are the

foundation for nurturing

relationships between parents and

children. Strong supervisory

relationships provide the staff with a

model of, and experience with,

supportive, individualized

responses.”

(Parlakian, 2002, p.1)

ECE P

ROVIDERS

ECE providers (i.e., teachers,

assistant teachers) also play an

important role in maximizing the

effectiveness of consultation services.

Often, providers are the ones identifying

consultation needs, and ultimately, they

are the ones charged with implementing

the consultant’s classroom

recommendations. The extent to which

providers engage the consultant,

participate with the MHC and parents as

part of a team, and follow through with

consultant recommendations has clear

Green et al., 2006; Yoshikawa &

Knitzer, 1997). The way in which a

consultant’s role is structured can

greatly impact program integration

and, likewise, the quality of the

relationship between the consultant,

staff, and families. For example, will

the MHC be in classrooms on a

regular basis to provide ongoing

support to staff or only when there is a

problem? Furthermore, to elicit staff

trust, it is important to structure the

consultant role in a way that focuses

on supporting staff, not monitoring

them (Donahue et al., 2000).

Directors and administrators

should also consider highlighting the

value of consultation services by

encouraging staff to utilize the

consultant’s services and making sure

consultants have the opportunity early

in the school year to talk about their

role and how they can help support

both staff and parents. In fact, Allen’s

(2008) focus groups with MHCs

found that having a program director

take the time to introduce the

consultant to staff early on goes a long

way in building the foundation for

trusting relationships.

Providing these communication

opportunities at the onset of

consultation is particularly important

given that teachers are sometimes

reluctant to admit they are facing

challenges with certain children or

families, and therefore hesitate to

work with the consultant, as doing so

might imply that they have somehow

“failed” in their job. The program

director (as well as the consultant him-

or herself) plays an important role in

addressing these concerns and being

clear that working with the consultant

does not indicate a lack of teacher

skills. In fact, the director should

assure staff that the consultant is not

there to report on teacher performance,

but rather to provide support. Table 2

provides additional guidance on how

directors and administrators can lay

the groundwork for effective

consultation by fostering positive

relationships.

implications for whether consultation

will succeed or not.

First and foremost, providers can

support effective consultation by

setting the tone for a good working

relationship with the consultant. This

includes reaching out to the consultant

for help and remaining open to his/her

ideas, while sharing their own thoughts

and perspectives. In addition, providers

can help facilitate the development of

positive relationships between the

consultant and parents so that the three

partners can work collaboratively to

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

Hire or contract with an MHC who

has experience in early childhood and

ECMH, as well as in providing

consultation (not just direct therapy)

Provide the MHC with training about

your program

Be clear with staff about the role of

the MHC and when, how, and what

services will be provided

Put processes in place that protect

confidentiality, but do not hinder

information-sharing among a child’s

teacher and MHC, nor compromise

open communication with parents

Make sure all staff and parents have a

chance to meet the MHC early in the

school year

Allow staff to have direct access to

the MHC through email or phone

Have scheduled time for the MHC to

be in classrooms regularly

Have the MHC provide training in

mental health issues to staff and

families

Have the MHC attend ongoing

meetings to discuss specific children

and families with staff

Establish a long-term relationship

with a consultant (or consultants)

DON’T

Assume the MHC knows what it

means to be a “consultant” rather than

a direct service provider

Assume that the MHC knows about

early childhood programs generally, or

your program in particular

Assume that staff will welcome the

MHC into their classroom

Establish a process for obtaining

parental permission that puts up

unnecessary obstacles for the MHC in

working with a child

Wait until issues arise before

introducing the MHC

Put up a lot of barriers that hinder staff

members’ ability to access the MHC

Only have MHCs visit classrooms

when there is a problem

Use the MHC just for one-on-one

services

Assume the problem is solved once a

referral to the MHC is made

Have a “rotating” consultant who

changes from year to year

Table 2. Do’s and Don’ts for Fostering Staff–Consultant–Family

Relationships

(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 to

provide?

• What level of service intensity is

needed to effect change?

• Which outcomes should be targeted

and how should these be

measured?

• Is mental health consultation more

effective when used in conjunction

with an evidence-based practice

(e.g., MHC and The Incredible

Years or MHC and Second Steps)?

Given the variability in

consultation models, answering these

questions will be challenging and

require an incremental approach.

Additional challenges facing

evaluators are the lack of agreement

on which outcomes should be tracked,

which outcome measures should be

used, and the ethical issues associated

with establishing control groups in

early care and education settings

(Allen, 2008). Other methodological

considerations include how to design

research projects that focus on the

effects of consultation alone, as

opposed to the cumulative impact of a

number of program enhancements. In

a climate where service dollars are

limited, there are fewer dollars

available to support high-quality

evaluation studies. These issues must

be taken into consideration when

researchers and programs engage in

evaluation efforts.

To expand the evidence base for

ECMHC, high-quality process and

impact evaluations need to be funded

and implemented through partnerships

between researchers and program

managers. As states and communities

expand their capacity to provide

mental health services to young

improve behaviors at home and in the

classroom. Clearly, MHCs must do

their part if these provider overtures

are to lead to successful consultation.

As Allen’s (2008) qualitative research

suggests, providers are more likely to

engage parents in working with an

MHC if they themselves have had a

good experience with the consultant.

Another way providers can support

effective consultation is by trying to

implement the consultant’s

recommendations, seeking guidance

and support as necessary, and

providing feedback to the MHC so

that modifications can be made to the

recommended strategies as needed.

What Are Some of the

Challenges That Need to Be

Addressed?

As discussed earlier in this

synthesis, making ECMHC available

in all of the ECE settings that

need/want it is a fundamental

challenge. Relatively few early

childhood programs and providers

across the country benefit from

consultation, and those that do receive

services of varying type and intensity

from a diverse group of consultants.

Issues stifling widespread

implementation and presenting

obstacles the field must overcome

include limited rigorous research, lack

of sustainable funding, and insufficient

workforce capacity.

ESEARCH

Although the evidence base for

the overall effectiveness of the

ECMHC approach is growing

(Brennan et al., in press; Perry et al.,

2006), there are still lingering

questions about which aspects of

consultation are causally related to

positive outcomes and, hence, most

important to retain across ECMHC

programs. This lack of clarity has led

to variability in program models

across the country and made it

challenging to expand the field and

establish ECMHC as an evidence-

based practice. Thus, more research is

needed to decisively respond to these

children and their families and the

field of ECMHC continues to grow,

the capacity of programs to evaluate

their service components and

outcomes should also be developed. To

this end, Hepburn et al. (2007)

developed an evaluation toolkit to help

stakeholders better address these gaps

in the evidence base.

UNDING

While limited scientific evidence

of the effectiveness of ECMHC is one

barrier to obtaining steady funding in

many states and communities, there

are a variety of fiscal challenges that

keep ECMHC from going to scale.

Some of these funding issues are

common to expanding children’s

services in general: scarce public and

private resources, and a high demand

for these limited dollars. There are also

unique aspects of ECMHC that make

sustainable funding particularly

challenging.

First, it is much more difficult to

obtain reimbursement for

“consultation”—particularly program-

focused consultation—than for direct

intervention with one child, given the

funding structures inherent in private

insurance and public programs like

Medicaid, the State Children’s Health

Insurance Program (SCHIP), and the

Individuals with Disabilities Education

Act (IDEA). Current reimbursement

systems are geared toward paying for a

single, face-to-face encounter with an

identified patient with a diagnosed

condition. Additionally, it is

challenging to secure funds for

promotion and prevention activities

because funders may only be willing

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

Research & Evaluation

Resource

Early Childhood Mental Health

Consultation: An Evaluation Toolkit

(Hepburn, Kaufmann, Perry,

Allen, Brennan, & Green,

2007) Available at

http://gucchd.georgetown.edu

In Vermont, services—including

ECMHC—provided through the

statewide Children’s UPstream Project

(CUPS) were funded equally through

federal grant dollars and Medicaid.

This funding mix was established by

project leaders to promote

sustainability after the grant period

ended. The grant monies stemmed

from the Comprehensive Community

Mental Health Services for Children

and their Families Program,

administered by the Children’s Mental

Health Services (CMHS) division of

the Substance Abuse and Mental

Health Services Administration

(SAMHSA). To generate the other half

of the funding, local agencies were

tasked with maximizing the use of

Medicaid funds and providing the

necessary Medicaid match money

through existing regional allocations

of State General Funds. Interagency

sharing of General Funds, coupled

with a state-level policy change that

authorized payment for services for

children birth to age 6 with the

diagnosis of a parent-child relationship

disorder (a “V” code in the Diagnostic

and Statistical Manual of Mental

Disorders [DSM]), made it possible

for the program to support and

gradually expand its array of mental

health services (Bean, Biss, &

Hepburn, 2007).

Clearly, ECMHC’s inherent array

of services and the mode of service

delivery present significant challenges

to those endeavoring to develop and/or

to cover expenses associated with

meeting the needs of children who

exhibit serious social and emotional

problems and/or have a mental health

diagnosis (Florida State University

Center for Prevention & Early

Intervention Policy, 2006).

Some consultation programs are

funded through private foundations,

universities, and/or

pilot/demonstration projects, while

others rely on public funding or some

combination of both. This blending or

braiding of funds is often critical

because, as Collins et al. (2003)

suggest, funds that are earmarked to

address social or emotional challenges

in young children are often tied to

individual children, whereas

“[f]lexible resources that can be used

to support child care–mental health

partnerships generally do not focus on

children’s social and emotional

development” (Collins, Mascia,

Kendall, Golden, Schock, & Parlakian,

2003, p.45).

Medicaid, particularly the Early

and Periodic Screening, Diagnosis and

Treatment (EPSDT) program, is a

significant source of revenue for many

programs that receive ECMHC

services. Other sources of public

funding include the following:

• Early Head Start/Head Start

• Individuals with Disabilities

Education Act (IDEA Part B,

Section 619, Part C)

• Mental Health and Substance

Abuse Block Grants

• Child Care and Development Fund

• Child welfare funds, such as Title

IVE of the Social Security Act

• Maternal and Child Health Block

Grant under Title V of the Social

Security Act

• Temporary Assistance to Needy

Families (TANF)

• Supplemental Security Income

(SSI, Title XVI of the Social

Security Act)

(

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

sustain consultation programs. Yet,

there is practical and theoretical

guidance available. For example, in

addition to Vermont, several other

states have succeeded in applying state

funds toward early childhood mental

health consultation, including Maryland

(Early Childhood Mental Health

Project), Massachusetts (Together for

Kids), and Connecticut (Early

Childhood Consultation Partnership).

Further, in her chapter titled “Strategic

Financing of Early Childhood Mental

Health Services,” Perry (2007) outlines

a multiple-step process model (adapted

from Striffler, Perry, & Kates, 1997) for

braiding together federal, state, public,

and private funds to support early

childhood mental health services that

address the continuum of promotion,

prevention, and intervention.

ORKFORCE

Finally, workforce capacity is a

significant challenge facing the

ECMHC field. As Johnston and

Brinamen (2006) suggest, mental health

consultants need such a broad

knowledge base that no one could

possibly have all the relevant skills and

experience without targeted training

and preparation. Per previous

discussion, provision of quality mental

health consultation requires multiple

competencies, including a firm grasp of

best practices in mental health and

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

Through the Early and Periodic

Screening, Diagnosis and Treatment

(EPSDT) program, states are required

to provide a comprehensive set of

benefits and services—including

mental health services—for children

enrolled in Medicaid. Given that an

estimated one in three children

under age 6 is eligible for Medicaid

(Health Resources and Services

Administration), EPSDT can be a

valuable funding source for child-

focused ECMHC.

Funding Resources

Funding Early Childhood Mental

Health Services and Supports

(Wishmann, Kates, &

Kaufmann, 2001)

Available at

http://gucchd.georgetown.edu

Spending Smarter: A Funding

Guide for Policymakers and

Advocates to Promote Social and

Emotional Health and School

Readiness

(Johnson & Knitzer, 2005)

Available at www.nccp.org

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