A Presentation at NASP, 2011 ConferenceSan Francisco, CA

Tuesday, February 22, 2011 Shannon Sweitzer, Ph.D., PCOM School Psychology

Annemarie Clarke, Ph.D., SPIN, Inc. Behavioral & Developmental Services

Implementing Early Childhood Mental Health Consultation in

Urban Childcare Centers

Goals for Today

• Establish the rationale for ECMH Consultation within Early Care and Education Programs

• Link ECMH outcomes to academic achievement

• Review projects/programs implemented within Philadelphia, PA

• Discuss future of this work in ECE programs

Why Early Childhood Mental Health?

• 10 – 15% of all typically developing preschool children will have chronic mild to moderate levels of behavior problems– Think “PBS”/”SWEBS” Models from School-Age Programming

• Children who are poor or developing atypically are more likely to develop behavior problems at a rate approaching 30% ( Campbell, 2002; Qi & Kaiser, 2003).

Risk Factors and Outcomes• Adverse Childhood Experiences Study

– As the number of ACES increases, so does the risk of disease, victimization, unhealthy behaviors, impairment, disability, and premature death.

– Substance Abuse, one or no parents,

mental illness, mother treated violently,

criminal behavior, incarcerated

household member, Abuse (emotional,

physical, sexual), & neglect (emotional

or physical).

• Living at or below the poverty level is associated with higher prevalence of risk factors to emotional health & well being & diminished protective factors.

Philadelphia’s Children• Philadelphia recently named as the poorest of

America’s largest cities……• Approximately 26% of the city’s families with children

under 18 years of age live at or below the federally established poverty level (US Census, 2000)

– Among those same households with children under 5 years of age, the figure jumps to over 31%

• When single parent households alone are analyzed, the number of children under 18 living at or below poverty jumps to nearly 41% (US Census, 2000)

– Among those same households with children under 5 years of age, the figure jumps to over 47%

Philadelphia’s Children• Availability of behavioral health treatment for young

children in Southeastern PA continues to be a problem• Lack of child psychiatrists and other behavioral health

professionals with particular expertise in early childhood • Lack of available intervention and treatment options• According to a report by Public Citizens for Children and

Youth (PCCY, 2008), there are approximately 128,000 children and adolescents with mild to severe behavioral health problems in Philadelphia, yet only 22.8% (22,900 children) of them receive behavioral health services.

• 48% of local early care and education programs reported removing, suspending, or expelling at least one child over the past year as a result of behavioral concerns (PCCY, 2008)

Pennsylvania’s Response• Instituted Office of Child Development and Early

Learning (OCDEL) to connect all early childhood-serving systems– Developed both Infant-Toddler and Pre-K Standards to be implemented in all

early care and education (ECE) programs – Strong focus on social-emotional/behavioral standards – Hired state-wide ECMH Consultants to begin to address issues

• Implemented “Keystone Stars Program” with a focus on continuous quality improvement for all ECE providers– Use of both ITERS (Infant Toddler Environmental Rating Scale) and ECERS

(Early Childhood Environmental Rating Scale) to support strengthening programming at Tier 1 Level

Pennsylvania’s Response

• Used ARRA funds (2009-2011) to support the implementation of an ECE PBS program state-wide– Implemented with consulting teams at a county

level in limited number of ECE centers– External “coaching team” collaborated with

each center’s “core team” to gather child- and classroom-specific data, monitor behavioral incidents, provide professional development re: behavior management, and improve internal capacity

Pennsylvania’s Response Cont.

• AARA funds cont:– Built on the platform of Vanderbilt University’s

Center for Social-Emotional Foundations of Early Learning (CSEFEL) www.csefel.edu

– Emphasis is on ECMH Consultation and skill transfer to the internal teams at participating sites to facilitate sustainability beyond grant

CSEFEL Framework

WHY? WHY? Linking Emotional Health &

Academics• Social emotional difficulties negatively impact school

readiness and academic achievement in urban youth (Fantuzzo, 2007; Philadelphia Citizens for Children and Youth, 2006).

• Difficulties demonstrated across other domains impacts a child’s ability to develop typical peer relationships and behave in ways conducive to learning (Pianta, Nimetz, & Bennett, 1997; Vaughn, Hogan, Lancelotta, & Shapiro, 1992).

WHY? WHY? Linking Emotional Health &

Academics

• Ratings of first graders on items describing a cheerful, outgoing temperament predicted adult educational attainment better than preschool or first grade achievement scores (Entwistle et al.,2005)

• Children with consistently high levels of aggression from ages 2 -9 were more likely than other children to have achievement problems in third grade (NICHD, 2004)– On-grade achievement in third grade is strong predictor of high-school

graduation

WHY? WHY? Linking Emotional Health &

Academics• Teachers and challenging behaviors:

• Professionals within early childhood programs have historically received little training in behavior support/management

• Nationwide survey of teachers across all grade levels indicated that teachers feel a strong need for additional training and support in classroom management (Coalition for Psychology in the Schools and Education, 2006).

• Leads to stress, burnout, and turnover

Other Philadelphia/Pennsylvania

Initiatives

What’s Happening?

• Varied……Somewhat fragmented…… Integration is emerging gradually…..

• Statewide ECMH workgroup and Philadelphia’s Blue Ribbon Commission on Children’s Behavioral Health provided backdrop

• Variety of smaller/larger projects funded through assorted stakeholders with similar goals but different approaches

SPIN’s ECMH Grant (2007-2010)

• Funded under a grant from The Pew Charitable Trusts

• Paralleled the framework of the CSEFEL Pyramid Model, however, it provided a more intensive site-wide approach to ECMH consultation

• Major goal was “capacity building” to increase professionals trained to work in this area

• Five (5) sites per year received at least 8 hours of ECMH consultation services per week

• Each consultant provided three tiers of service based on components of Incredible Years curriculum (Webster-Stratton)

SPIN’s ECMH Grant (2007-2010)

• Incredible Years Curriculum (Webster-Stratton)

• Multi-pronged approach:• Direct social skills instruction for children through

“circle time” activities • Consultation and training on issues related to social-

emotional development to teachers and directors• Parent training program • ALSO: offered an option for one-on-one intensive

intervention (therapy/clinical services) for children/families requiring more intensive support or unable to attend parenting group.

Annual Timeline of Service Provision• August/September: Centers enrolled in grant

• September/October: Observations, initial data collection, information provided to teachers and parents regarding program

• November-May: Dinosaur School Runs; curriculum focuses on: feelings; problem solving skills; anger management; friendship skills

• January: Mock Dinosaur School “assembly” for parents to solicit participation in Parenting Groups

• January-May: Parenting Group runs• Ongoing: Teacher and Director consultations on variety of topics

related to childhood development, collaborating with parents, child-specific or classroom management PBS strategies; classroom modeling; individual therapy with parents

Children’s Program

• Also called Dinosaur School– Emotional literacy

– Perspective taking

– Friendship skills

– Anger management

– Interpersonal problem-solving

Teacher Program of IY

• Skills include:– Effective use of teacher coaching skills– Attention, praise and encouragement– Use of incentives for difficult behavior problems– Proactive teaching strategies– How to manage inappropriate classroom behaviors with

discipline hierarchies– The importance of building positive relationships with students– How to teach empathy, social skills and problem-solving in the

classroom.

Parenting Program of IY

• Skills include:– How to play with children

– Effective praise and use of incentives

– Establishing predictable routines and rules Promoting responsibility

– Effective limit-setting

– Strategies to manage misbehavior

– Teaching children to problem solve.

Research Supporting the IY Curriculum

• Studies by both Carolyn Webster Stratton (author) as well as independent evaluators support the curriculum as effective in the prevention of and intervention with children within clinical populations, as well as within general populations– Parent: Beauchaine, et al., 2005; Reid, et al., 2003; Scott, 2001; Taylor,

Schmidt, Pepler, & Hodgins, 1998; Webster-Stratton, 1992 ; Webster-Stratton, et al., 2004

– Teacher: Webster-Stratton & Reid, 1999; Webster-Stratton et al., 2004

– Child: Webster-Stratton, 2004 ; Webster-Stratton & Hammond, 1997

Above studies described at http://www.incredibleyears.com/ResearchEval/studies.asp

Results

Year Children Teachers Parent Group

Individual

1 210 26 30 0

2 252 47 41 13

3 201 31 40 1

Results: Teachers

• Years 2 & 3:• 79% increased or stayed the same in their ability to

use positive approaches in relating to parents if young children regarding their challenging behaviors.

• 67% teachers demonstrated an increased use of both proactive strategies and praise and incentives to support appropriate behavior

• 79% decreased use of inappropriate behavioral strategies

• 62% increased their skill for setting limits

Results: Parents

• Years 2 & 3• 77% report increase in their use of positive parenting

practices with their children• 69% report increase in their overall positive attitude

toward their relationship with their children• 85% reported a decrease in negative attitude toward

their children• 58% reported a decrease in the use of harsh parenting

practices• 65% reported being more consistent in parenting

Results: Children

• Children demonstrated improved social skills and self regulation behaviors evidenced by qualitative reports from teachers and parents.

• Beneficial to measure child progress through a more defined process, such as behavior rating scales over time.

Challenges

• Student Transiency

• Parents preferred drop-in consultation approach rather than parent group– This is similar to a direction that is emerging where BH

services are structured within other primary services

• Teacher Turnover

Other Activities• Currently at least 2 additional grants focusing

on ECMH funded through The Pew Charitable Trusts

• City’s Mayor’s Early Childhood Advisory Committee Exploring additional avenues to address social-behavioral/emotional development through pilot programs

• State is exploring methods for continuing PBS work done for past two years under ARRA grant project; future uncertain at this date

• Retracted social service funds will likely impede the speed of progress of this work

Areas for Future Development – School Psychology’s Role

• Develop a formal observation system to measure a classroom’s climate as well as the quality of teacher-child interactions

• Create a less expensive, more teacher-friendly social-emotional preschool curriculum

• Establish prevention and intervention programs for families within visible, easily accessible, and frequently utilized centers (e.g. child care centers or primary care offices).– This will likely emerge through healthcare reform initiatives that seek to

embed/marry primary care medicine and behavioral health services

For more information….

Shannon Sweitzer, Ph.D.ShannonSw@pcom.edu

215-871-6681

Annemarie Clarke, Ph.D.aclarke@spininc.org

215-612-7575