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2 Initiative Quarterly • IQmag.org

WINTER 2008

CONTENTSFEATURES

14Silent StormInside Minnesota’sYoungest Minds

19Minnesota ThriveBrochurePeace of Mind for ourYoungest Kids

23The Key 3Mental HealthDisorders of YoungChildren

30The Kid’sInstructionManual Essential Tips for Raisinga Socially & EmotionallyHealthy Child

34Kicked OutIs Mental Health behindMinnesota’s ChildcareExpulsions?

38The Long &Winding WaitMental HealthcareShortages LeaveFamilies Hanging

INITIATIVE FOUNDATION GOALSStrengthen Economic Opportunity

Preserve Key Places and Natural ResourcesSupport Children, Youth, and Families

Build Organizational EffectivenessEncourage the Spirit of Giving

Cass

CrowWing

MorrisonTodd

Wright

Benton

Sherburne

Isanti

Chisago

Stearns

Wadena

Pine

Kanabec

MilleLacs

4 BeginningsEmotions

6 The Home FrontDeployments AmbushMinnesota’s YoungestChildren

8 What Babies WishWe KnewEven Infants can haveMental Health Issues

10 Mom, InterruptedPostpartum DepressionTakes Toll on Infants, Too

44 Gray MatterKids’ Mental HealthCoverage Not Black andWhite

46 Age of InnocenceMore Young ChildrenForced to Cope withParental Incarceration

48 KeynotesThe Initiative FoundationNewsletter

52 Guest EditorialMind Your Business

Like a silent storm, early childhood mental health problems are voiceless and threatening in Minnesota.

Debut photo by new IQ photographer,John Linn

DEPARTMENTS

COVER

“Our mission is to unlock the power ofcentral Minnesota people to build

and sustain healthy communities.”

Young children are complex.

My husband, Neal, and I learned this lesson twenty-four years ago, when we broughthome our twin boys from the hospital. We tried to prepare our two-year-old daughter,Melanie. We told her that we would always love her and she was still special. She hugged usand said she loved us, too.

When we burst through the door holding a baby apiece, we expected an unforgettablefamily moment. We got one. Cross-armed and scowling, Melanie hinted at her disapproval by

having a “potty accident” over the heat register.Little girls are so cute.It turns out that she had room in her heart for only one

baby brother. She fawned over Mark and ignored the exis-tence of Luke. She wouldn’t even look at him or talk abouthim for a couple of days and she defiantly clung to “Marky”as her baby.

Melanie’s actions affirmed to us how much we didn’tunderstand about our kids’ emotional health. It’s a trend thatmany families are experiencing today.

Minnesota healthcare professionals report a steadyincrease in early childhood mental health problems that arefar more serious than sibling resentment. No one can pinpointwhy, but there are some theories. Stressed and splintered fam-ilies and greater exposure to media violence are among them.

Perhaps just as damaging is the myth that infants and young children can’t suffer frommental health disorders. Or that treatment involves Freudian couches and over-medication.That’s wrong.

Busting myths is one of the reasons that we decided to take on this groundbreaking issuethat no one else seems to be talking about. We’ve boiled it down for parents and caregivers ofyoung kids, but it’s an issue that impacts entire communities. Thankfully, there’s help andhope available.

Meanwhile, Neal and I just learned that Mark and his wife, Melissa, will join the ranks ofparenthood in June. As you might expect, Melanie is thrilled once again.

Enjoy the magazine,

Kathy Gaalswyk, PresidentInitiative Foundation

P.S. Special thanks to the Medica Foundation, Otto Bremer Foundation, and the MinnesotaInitiative Foundations for their financial and editorial support of IQ. Learn more aboutMinnesota Thrive Initiative for early childhood mental health on page 19.

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Initiative Quarterly • IQmag.org

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INITIATIVE FOUNDATIONExecutive Editor & Director of Communications / MATT KILIAN

Grants & Communications Specialist / ANITA HOLLENHORST

PUBLISHERSEvergreen Press / CHIP & JEAN BORKENHAGEN

EDITORIALEditorial Director / JODI SCHWEN

Managing Editor / TENLEE LUND

Staff Writer / DAWN ZIMMERMAN

Staff Writer / SARAH COLBURN

ARTArt Director / ANDREA BAUMANN

Senior Graphic Designer / BOB WALLENIUS

Graphic Designer / BRAD RAYMOND

Production Manager / BRYAN PETERSEN

Lead Photographer / JOHN LINN

ADVERTISING / SUBSCRIPTIONSBusiness & Advertising Director / BRIAN LEHMAN

Advertiser Services / MARY SAVAGE

Subscriber Services / ANITA HOLLENHORST

IQ EDITORIAL BOARDInitiative Foundation President / KATHY GAALSWYK

MN Dept. of Human Services / ANTONIA APOLINARIO-WILCOXON

Northwest Minnesota Foundation / LIN BACKSTROM

Northland Foundation / ZANE BAIL

St. Cloud Parent / TODD BLUM

Southwest Initiative Foundation / SARA CARLSON

Sauk Rapids-Rice School District / JANE ELLISON

University of Minnesota / MICHELE FALLON

MN Fathers & Families Network / MELISSA FROEHLE

St. Cloud Area Child Link / CAROL GIBSON-MILLER

Northland Foundation / LYNN HAGLIN

West Central Initiative / NANCY JOST

Initiative Foundation / LINDA KAUFMANN

MN Assoc. for Children’s Mental Health / CANDACE KRAGTHORPE

Southern Minnesota Initiative Foundation / ANNI O’NEILL

St. Cloud State University / DR. GLEN PALM

Initiative Foundation / JANA SHOGREN

MN Department of Human Services / DR. L. READ SULIK

Brainerd Public Schools / GEORGE TETREAULT

Initiative Foundation405 First Street SE Little Falls, MN 56345320.632.9255 | www.ifound.org

Published in partnership with Evergreen Press, IIQQ MMaaggaazziinneeunlocks the power of central Minnesota leaders to understand and take action on regional issues.

> VOLUME 6, WINTER 2008

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lives of infants and toddlers.“Early relationships are the

foundation for mental healthand very young children reallydo miss that relationship and thesense of security that it pro-vides,” she said. “When the rela-tionship is disrupted, the loss isfelt. Babies and young childrenneed to know that other peoplewill be there for them.”

Immediately after Brandondeployed, Jodi Johnson noticedthat Gracie changed her sleeppattern, but not much more. Itwasn’t until Brandon returned that the realimpact of his absence hit home.

“She didn't want to be alone with himat first and would get jealous if we wouldbe sitting next to each other on thecouch,” Jodi recalled. “The first few nights,she would say goodbye like he was goingto leave.”

Zero to Three recommends that care-givers create and maintain routines—suchas bath time, play groups, and readingtime—that help foster a sense of securityand dependability. Prior to deployment,parents can videotape the deploying parentreading or playing with the child. Keepingphotos of the deployed caregiver withinreach of the young child, doing artworktogether, talking about the deployed par-ent, having childcare providers create proj-ects to send to the deployed parent—all areways to help ease stress on children.

“Little children cannot express whatthey are feeling with words, so they actout or withdraw,” Fraga said. “Regression

SERVICE

The Home FrontDeployments Ambush Minnesota’sYoungest Children

It was a magical box. It sat on the count-er out of her reach. Gracie could see it

better from the opposite corner of thekitchen, where she’d stand and watch,waiting. Now there was no voice, no pic-ture. Gracie pointed to the silver laptop.

“Daddy! Daddy!” she said.Jodi tried to hide the tears as reality

sank in that her two-year-old daughternow called the laptop, “Daddy.” And it allmade perfect sense. Daddy had been goneto war for more than a year. The webcam—and Jodi’s persistent attempts to get herdaughter to, “Wave to Daddy”—had con-vinced the little girl that her father andcomputer were one and the same.

It was just one of many poignantmoments Jodi and Brandon Johnson ofLittle Falls experienced during the twenty-two months he was deployed to Iraq. Andlike so many military families inMinnesota, the Johnsons discovered thateven the youngest of children sense thatsomething isn’t as it was before.

According to Operation: MilitaryKids, more than 17,000 Minnesota chil-dren are impacted by a parental deploy-ment. They are among more than500,000 American children under agefive who are waiting for a military parentto return home.

Dr. Lynette Fraga, director of militaryprojects for Zero to Three, works tirelesslyto help families and caregivers understandhow young children express deploymentstress and how every caregiver can supportthem. Zero to Three is a national nonprofitorganization that supports parents, profes-sionals, and policymakers to improve the

(going back to earlier stages of develop-ment), clinginess, whining, changingfeeding, eating, and sleeping patterns—these are all ways that children expressthemselves.

“What we want to do is keep thebaby in the mind of the parent, and theparent in the mind of the baby. It’s allabout staying connected.”

According to Fraga, concerned com-munities can raise awareness of a militaryfamily’s needs—what life is like fordeployed families and their children. Whenseeing young patients, medical doctors andtherapists should check if families haveexperienced deployment, she said.

“Take one day at a time,” Brandonadvises reunited families. “You have toadjust to a new life, to find a new ‘normal’because things will never be the same asbefore. All three of us have changed. Justtake one day at a time.”

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LITTLE SOLDIER: Gracie Johnson (right) is among the 17,000Minnesota children who have waited for a deployed parentto return home.

BY BRITTA REQUE-DRAGICEVIC

6 Initiative Quarterly • IQmag.org

Winter 2008 7

EARLY LIFE

What BabiesWish We KnewEven Infants can have Mental Health Issues

When C.C. was born at the WillmarHospital, her parents were

thrilled. From prenatal vitamins to nurs-ing, her mother tried to do everythingright. Her father was able to be home forher first weeks. By the time C.C. was threeweeks old, both parents could discernbetween her hungry cry and her uncom-fortable cry. At three months old, she sleptlonger and cried less, knowing her needswould be met.

Christopher was born, without pre-natal care, to a single mother in poverty.With formula and diapers costing somuch, Christopher’s mother often ignoredhis cries. At times, she watered down hisformula or left him in dirty diapers. Atthree months old, he slept longer andcried less, knowing that his needs wereunlikely to be met.

So, which of these babies has thebest prognosis for good mental health—C.C., who received constant attention,or Christopher, who was forced to fendfor himself?

“The child at age three who has hadher needs met is more likely to be confi-dent and properly attached to caregivers,”said Dr. Molly Minkkinen, early childhoodprofessor at the University of Minnesota-Duluth. “The child who hasn’t had hisneeds met is more likely to act out and dis-associate from caregivers.”

Scientific research and extreme casesof abandonment have dispelled one of themost enduring myths of early childhood,that parents shouldn’t “spoil” their baby.

In the late 1980s, thousands of

BY NANCY LEASMAN

8 Initiative Quarterly • IQmag.org

babies in poorly staffed orphanages suf-fered from malnutrition and emotionalneglect. With little time to provide morethan the most basic needs, nurses left thebabies alone in iron cribs for hours at atime. These babies, many of whom werelater adopted, exhibited severe develop-mental delays, as well as physical, neuro-logical, and psychological problems.

“Another challenge is that many peo-ple refuse to believe that infants can sufferfrom mental health issues, even those whoare properly cared for,” said LindaKaufmann, Initiative Foundation seniorprogram manager for children, youth, andfamilies. “It conjures up images of over-medicated children and babies on thera-pist’s couches, neither of which are accu-rate. This is a huge barrier, because wecan’t deal with a problem if people don’tbelieve it exists.”

Dr. Christopher Watson, director ofprofessional development at the Universityof Minnesota’s Center for Early Educationand Development (CEED), said the greatestthreats to healthy infant development aredue to family stressors, some of which havebeen present throughout history and are onthe upswing today.

“Among the risk factors are parentalsubstance abuse, domestic violence, and

the lack of responsive parenting, whichcan be passed on from one generation tothe next,” he said.

Equally important is recognizing thepositive impact of good parenting andencouraging new parents, as well as othercaregivers, to understand their impor-tance. “What infants and children requirefor healthy development are primary care-givers who offer them consistent, positive,and responsive care,” Watson added.

But what about the parents who aredoing their very best and yet have concernsabout their baby’s development? For themit’s important to realize that they know theirinfant best. Consulting a pediatrician maybe advised if they have concerns.

Still, it isn’t always easy to discernbetween a fussy temperament and a poten-tial mental health issue. “It’s important tolook at a baby, not in isolation, but in thecontext of relationships,” Minkkinen said.“If a baby is unsoothable or not able toengage, you need to dig and find out why.If it’s not organic or biological, then youneed to explore the environment.”

For more information on infantmental health symptoms, visitwww.zerotothree.org.

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“The longer thedepression lasts, themore likely a long-termimpact will be seen inthe child’s ability toattach to others, self-reg-ulate, develop relationswith others, and learn,”said George Tetreault, athirty-year-veteran psy-chologist at the PaulBunyan EducationCooperative in Brainerd.

“Children areresilient to a point,” headded. “PPD that lasts a few weeks to a fewmonths followed by ‘good parenting’ willprobably result in the normal developmentof the child. Children (exposed to pro-longed PPD) are at significant risk for anattachment disorder, and the later develop-ment of anti-social behavioral disorders.”

Attachment disorders may includeextreme behaviors on both ends of thesocial spectrum, from avoiding physicalcontact and resisting affection to exaggerat-ing needs and seeking comfort fromstrangers, according to the Mayo Clinic.

Fortunately, Sarah knew what waswrong. Her two sisters had been throughPPD before. “I knew that, little by little, itwould go away,” Sarah recalls. “When itwas at its worst, I’d talk myself through myday, asking myself, ‘What do I need to doright now?’”

She also had family support. Whilemany people around the mother may findPPD hard to understand, Sarah’s husbandand other relatives helped to ensure that

DEPRESSION

Mom, InterruptedPostpartum Depression Takes Toll onInfants, Too

Apiano teacher of fifteen years, Sarahsuddenly stopped playing. She didn’t

want to hear music anymore. She wasn’tsleeping well, didn’t have any energy, anddidn’t feel like eating. Worst of all, she did-n’t want to hold her new baby. She could-n’t even bring herself to say the baby’sname. Her guilt was overwhelming.

And that’s only half of postpartumdepression (PPD), which affects up to 15percent of new mothers during the firstyear after childbirth, according to the U.S.Department of Health and HumanServices. The other half is experienced bythe infant.

“It feels like having a huge, heavymantle placed on you, and the weight is soconsuming that you can think of nothingelse,” explained Sarah. “The thought ofpicking up an eight-pound baby andexpending even a small amount of emo-tional energy is almost too much to bear.”

According to the MinnesotaAssociation for Children’s Mental Health,symptoms usually begin within the sixmonths after childbirth. They include feel-ing sad, guilty or empty, a lack of energy,changes in sleeping or eating patterns,problems concentrating, or thoughtsabout suicide or hurting the baby.

PPD affects a mother’s ability to par-ent. In healthy attachment, an infantlearns to trust the primary caregiver, usu-ally the mother. Depressed mothers lackthe energy to carry out consistent feed-ing, diaper changing, and sleeping rou-tines, reading to their children, playing oreven cuddling with them. This impactshealthy development.

her baby was held and nurtured as muchas possible.

To distinguish between PPD and morecommon “baby blues,” a woman shouldseek medical attention if symptoms lastmore than two weeks. Therapy and med-ications are the most common and effectivetreatments, according to Dr. SuzanneSwanson, Minnesota coordinator for PPDSupport International. Support groups arealso helpful in treatment, she said. Onlinegroups provide anonymity and accessibili-ty when symptoms make it difficult to getout of the house.

“The message is that PPD is commonand very treatable, but left untreated, it canseriously impact the mental health ofyoung children,” said Jana Shogren,Initiative Foundation children, youth, andfamilies specialist. “Being a good mommeans doing whatever it takes to find helpand support for you and your baby.”

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OUT OF TUNE: About 15 percent of new mothers like Sarahexperience the debilitating effects of postpartum depression,which can cause infant mental health disorders.

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10 Initiative Quarterly • IQmag.org

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14 Initiative Quarterly • IQmag.org

By Dawn Zimmerman | Photography by John Linn

No news media are reporting on it. Few peopleare talking about it. Many refuse to believe itexists. The invisible statistic is that one out oftwenty children has mental health problemsserious enough to affect their development andthat number appears to be growing.

Behind the trend are young children sufferingin silence, parents scrambling for answers, andMinnesota’s early childhood community joiningforces to put the issue on the public radarscreen. Here’s what you should know and whyyou should care.

16 Initiative Quarterly • IQmag.org

Like most two year-olds, Devon loved finger painting andmaking a mess. One day, that changed. Devon watched ashis father struck his mother again and again, until she final-

ly shrunk to the bedroom floor. After his father left the room,Devon scurried over and patted her back.

“Mommy’s okay,” Tiffany Jacobsen would tell her young sonbefore slipping into the bathroom to cry and regain her compo-sure. In the days and weeks after each bout of violence, Devonstarted pulling away from his mom and feared what would happenif his father saw any “mess.”

Jacobsen didn’t know if he would remember those moments,but she knew they were stripping Devon of his security. She alsoknew that they could have a lasting impact. Abusive experiencesin Jacobsen’s own childhood continue to affect her as an adult. “Itdoes make a difference,” she said. “I’m living proof of it.”

National surveys indicate that one-third of U.S. children haveat least two risk factors that may increase the chances of poor men-tal health, according to a 2006 Maternal and Child Health Journalreport. These risk factors include race, existence of maternal men-tal health issues, parental education level, and living in poverty.

At its core, mental health is simply a child’s ability to formrelationships, regulate emotions, learn, and explore. While muchattention has been given to the impact of trauma and a youngchild’s environment, many mental health disorders are rooted ingenetics and biology. According to the U.S. Surgeon General, somechildren are born with chemical imbalances or inherit a biologicalvulnerability that causes them to be less resilient to adversity.

“You can do everything right, and your child may still expe-rience barriers to social and emotional development,” said LindaKaufmann, senior program manager for children, youth, and fam-ilies at the Initiative Foundation. “Traumatic events like a car acci-dent or the death of a loved one can also trigger sudden changesin children.”

a DIFFERENT worldIncreased research on early childhood development has

refuted the common belief that infants, toddlers, and preschool-ers are too young to have mental health problems.

Today’s youngest children live in a more violent world thanpast generations, said Dr. L. Read Sulik, a St. Cloud child psy-chiatrist who now serves as assistant commissioner forChemical and Mental Health Services for the MinnesotaDepartment of Human Services.

With the proliferation of mass media, young children maybe immersed in a twenty-four-hour torrent of unsettling images,scary warnings, and conflicting messages that helps to form theirsense of self and the world around them.

“The world also runs at a much faster pace, and psycholog-ically, I don’t think we’re keeping up,” said Sulik, who alsobelieves that hectic schedules have caused families to spendless time nurturing children. “Over the past decade, I’venoticed an increase in young children suffering from significantemotional problems.”

Young children may be the most vulnerable. Medicalresearch shows that the brain develops most rapidly in the firstthree to five years of life. 90 percent of a child’s brain is devel-oped by age five, according to Zero to Three, a Washington D.C.-based nonprofit organization focused on providing early child-hood information for professionals, policymakers, and parents.

Early childhood experiences determine how the brain’s neu-rons are connected, said Dr. Troy Hanson, board-certified familyphysician with Locum Tenens in Buffalo and a member of theState Advisory Council on Mental Health.

“(Young children) do not have the capacity to process whatthey’re seeing, hearing, or experiencing, but they are definitelyimpacted by it,” Hanson said. “There’s a lot going on in theminds of children from zero to three years old.”

CONTINUED ON PAGE 18

Jana Shogren & Linda Kaufmann, Initiative Foundation

One of the most formidable challenges to raising awareness about early childhood mental health problems isthe widespread belief that they don’t exist, or that they’re someone else’s problem. We asked three Minnesotadoctors to give us their four most common myths. Here’s what they said . . .

Infants and young childrendon’t remember events earlyin life, so they can’t beimpacted by them.The truth is, young children may bethe most vulnerable. When childrenfeel pain or sense trauma, their bod-ies respond by releasing chemicalsthat can affect brain development

and can have lifelong effects, Dr.Troy Hanson said. He added thatviolence, trauma and a lack of secu-rity can damage existing pathways inthe brain or prevent new pathwaysfrom forming.

This research prompted sever-al mental health associations andchild psychiatrists to send protestletters to NBC for its airing of TheBaby Borrowers, a 2008 realityshow that placed infants in the careof inexperienced teenagers as ameans of “birth control.” Whilebabies cried, the cameras rolled. Professionals were outraged thatinfants, who were in the process offorming healthy attachments to theircaregivers, were placed at risk ofemotional trauma from being sepa-

rated from their parents. Theyargued that these stressful experi-ences could lead to fearfulness,attachment disorders, and evenpost-traumatic stress disorder laterin life.

Holding infants every timethey cry just spoils them.Crying is one of the few ways babiescan communicate with their care-givers. When babies cry, they aresignaling a need. “Kids are notcapable of soothing themselves,” Dr.Hanson said. “Sitting there and let-ting them cry is not going to helpthem learn to soothe.” Caregiversshould follow their instincts andrespond to that cry, particularly inthe first eight months. “The rule isthat you can’t spoil a child undertwelve months,” he added.

Medication & psychoanalysisare the only ways to treatmental health problems.Absolutely not. Young children arenever shown ink blots or asked tointerpret their dreams—that’s amyth for the movies. Medication isoften the last resort when treatingyoung children with mental disor-ders, said Dr. Read Sulik. Often, par-ent education and making changesto the child’s environment yield thebest return. Early childhood inter-ventions always involve the parent

and child together. When a childfeels safe, secure, and comfortablein his environment, he can focus onplaying, learning, and growing, saidDr. Martha Farrell Erickson.

It won’t happen to my child.We don’t have a family histo-ry of mental health issues.While biology plays a role, mentalhealth isn’t always inherited. Newmedical research clearly shows thatenvironmental factors such as achild’s relationship with her care-givers, exposure to violence andtrauma, or feelings of insecurity canalso lead to mental health issues.“It’s much more prevalent than itused to be,” Hanson added, “and itcan happen to anybody.”

Sources: Dr. L. Read Sulik, Minnesota Department of Human Services; Dr. Troy Hanson, State AdvisoryCouncil on Mental Health; Dr. Martha Farrell Erickson, University of Minnesota.

18 Initiative Quarterly • IQmag.org

HELP neededSocial stigmas and lack of access to

early childhood mental health specialistsmake it challenging for young children toreceive the attention they need—leavingmany to suffer in silence.

Because early childhood mental healthissues are becoming more prevalent, evenMinnesota’s regional medical centers have ashortage of professionals who specialize inpreventing, identifying, and treating mentalhealth issues in the state’s youngest citizens.Sulik said that many children have had to waitsix to nine months just to get an initialappointment with him or his colleagues.

“When you’re talking about infants andtoddlers, these months are a huge chunk oftheir development time,” Kaufmann added.

The Minnesota Initiative Foundations’Thrive Initiative, a statewide early childhoodmental health project, is working to changethat. More than 2,700 parents and profession-als have attended sixty-eight Thrive-spon-sored training events on a variety of topics.

Goals of the Thrive Initiative includeeducating parents on the importance of nur-turing their children and educating profes-sionals on early identification and interven-tion techniques. “We definitely can preventmore of our common mental health illnessesby promoting mental wellness,” Sulik said.“We can strive to have our children achieveemotional fitness just like we want them toachieve physical fitness.”

EMOTIONAL fitnessChildren need to feel secure in their envi-

ronments and have their needs met in order toproperly develop and grow to their potential,said Dr. Martha Farrell Erickson, an inde-pendent mental health consultant who retiredfrom the University of Minnesota last summer.

Erickson, an expert on community-basedapproaches and former adviser to Al Gore,said children need to connect with their pri-mary caregiver as much as they need food.

“The foundations of healthy, positivemental health are established at a young age,”she said. According to Erickson, caregiversmust help children learn to regulate theiremotions and behavior, develop trust andempathy, and experience a healthy amount ofautonomy to develop most effectively.Preschool years, especially, are critical to lay-ing the foundation for emotional developmentand for future social and cognitive learning.

A child can be born with a genetic dispo-sition of depression or another mental healthdisorder, but that child’s environment canshape how he or she will respond and adaptto it. “There are a lot of things that we can doto promote health, but we can still get dis-ease,” Erickson said. “The same is true formental health.”

Modern treatment techniques foryoung children struggling with mentalhealth issues often include play therapy,parent education, and environmentalchanges, rather than medication.

CONSEQUENCESWithout effective early intervention, men-

tal health issues can lead to academic failure,increased crime, poor employment opportuni-ties, and poverty in adulthood, according to thePresident’s New Freedom Commission reporton mental health. The report found that 75percent of girls and 66 percent of boys in thenation’s juvenile detention system had at leastone mental health disorder.

“We’re neglecting it significantly and we’regoing to pay the price later,” Hanson said. “Ifwe don’t start paying attention to it, the prob-lems we’re dealing with will still be there andmagnified even more.”

The U.S. Surgeon General estimates that90 percent of children who commit suicidehave a mental health disorder and recentlyreported the highest youth suicide in fifteenyears. Early childhood provides a foundationfor good mental health.

Tiffany Jacobsen understands the worst-case scenarios and is working to create abrighter future for her son. Now separatedfrom her abuser and rebuilding her life,Jacobsen helps to improve Devon’s mentalhealth by educating herself, changing the wayshe responds to his behavior, and participatingin play therapy. Just saying his name helpsrebuild trust and shows him that he is special.

“If we can improve early childhoodmental health outcomes,” Hanson added,“we can improve the health of our communi-ties in the long-term.”

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What We DoStatewide surveys by Minnesota Early Childhood Initiativecommunities revealed that an alarming number of GreaterMinnesota children are struggling with mental health issuesand a striking lack of access to professional help. These sur-veys, national studies and heartbreaking stories promptedthe six Minnesota Initiative Foundations (MIFs) to launchthe Minnesota Thrive Initiative in 2007.

Early childhood is the period of rapid brain development thatoccurs between birth and age five, often forming a blueprintfor life. Mental health is simply a child’s capacity to experi-ence and regulate emotions, form close and secure relation-ships, and to play.

Our goals are to shatter the mythology about early childhoodmental health and build powerful community action teamsthat work to increase awareness, early intervention and pre-vention efforts among families, childcare providers, andhealthcare professionals.

21Winter 2008

Northwest Minnesota FoundationThe Bemidji-Blackduck-Kelliher Thrive team is fillingservice gaps by hiring a professional to serve familiesin a variety of early education settings. Another proj-

ect will enable mothers with mental healthneeds to receive services together with

young children.

Northland FoundationDuluth, Proctor and Hermantown are creating moreresponsive and nurturing early care and education settings that ensure children are fully supported intheir social and emotional development. The reflective-practice pilot project is underway at eight sites.

Initiative FoundationThe Greater St. Cloud Area is addressing shortages inearly childhood mental health services. Higher educa-tion faculty joined forces with community professionalsto integrate mental health curriculum into collegecoursework and internships.

West Central InitiativePope County volunteers are training mentors, who suc-cessfully faced their children's mental health concerns,to help other families navigate the system. Mentorsencourage parents to pursue early interventions toavoid more significant and costly issues later.

Southern Minnesota Initiative FoundationNew parents at the Albert Lea Medical Center are beingintroduced to infant and early childhood mental healthduring prenatal visits and classes. Each family receivesa toolkit and is invited to attend a "Meet the Baby" eventto reconnect with other parents.

Southwest Initiative FoundationMcLeod County volunteers are coordinating parent andcaregiver training efforts. Using evidence-based cur-ricula such as the Incredible Years, they are providing awide variety of mental health supports and interven-tions for young children and caregivers.

Communities in ActionOur approach—one community at a time. That’s why we help torecruit and train Action Teams of local leaders who care deeplyabout early childhood mental health. Thrive uses a proven grass-roots community organizing model to engage a wide array ofpeople at the local level. More than 400 leaders are alreadyinvolved in the statewide effort.

Right now, our Action Teams are working to ensure that all fam-ilies have access to the information and resources they need.They reach out to families from all cultures and income levelsthrough community events, parent forums, and early childhoodactivities. Each community’s top priority is to build a knowledgebase and professional network for early childhood mental healthresources and services in Greater Minnesota.

Nicholas screams, sobs and shields his eyes and ears asif the busy environment is hurting him. Hunter displaysno sense of feeling, wanders impulsively, and hurlsvicious words and objects at his grandmother. Craigcries for no reason, finds little joy in life, and believesthat nobody likes him. Three boys. Three stories. Threeunfortunate disorders that speak volumes about theimportance of early childhood mental health.

Sources: Dr. L. Read Sulik, Assistant Commissioner for Chemicaland Mental Health Services, Minnesota Department of HumanServices; Dr. Glenace Edwall, Director of the Children’s MentalHealth Division at the Minnesota Department of Human Services; Dr. Troy Hanson, State Advisory Council on Mental Health.

25Winter 2008

Amy and Todd Chantry knew something wasn’t rightwith their two-year-old son, Nicholas. When theytook him to a department store, he sunk to the floor,

curled into a ball, and sobbed relentlessly. He squeezed hiseyelids to dodge what seemed like damaging rays from thestore’s lights. He cupped his tiny hands over his ears as if thestore’s commotion was deafening.

His exceptional anxiety intensified the sights, sounds,and smells that surrounded him, making pleasant trips to thegrocery store, zoo, or pumpkin patch unbearable for Nicholas.“He couldn’t be in public places. He couldn’t throw somethingin the garbage. He couldn’t be near where a toilet was flushed,”said Amy, a mother of three from Rice. “Things most kids do,he couldn’t do.”

The family consulted Dr. Read Sulik, a St. Cloud childpsychiatrist who now serves as assistant commissioner forChemical and Mental Health Services for the MinnesotaDepartment of Human Services. Sulik diagnosed Nicholas,now age five, with an anxiety disorder and set a course fortreatment. “It’s totally changed his life,” Amy said. “It’schanged our life.”

Which conditions are most common?Anxiety affects about nineteen million Americans and

many disorders begin in childhood and adolescence. “It’sprobably one of the most prevalent mental health disorders inearly childhood, but it is probably the least understood andleast clearly identified,” Sulik said.

Separation anxiety and social anxiety are the most com-monly diagnosed anxiety disorders. Children with anxiety notonly experience fear; their brain also produces a psychologicalresponse that prevents them from calming down in a reason-able amount of time. Children like Nicholas have very sensi-

tive nervous systems that trigger anxious responses easily andin greater severity. For example, a common fear of the darkcan be greatly intensified in affected children and they cannotquickly overcome it.

What are the symptoms?Nicholas and other children with anxiety disorders often

demonstrate what Sulik calls the “fight or flight” response.They may become agitated, exhibit combative behavior, orwithdraw socially. Some experience selective mutism, aninability to speak in certain settings. Nicholas would panic inpublic places. His heart would race and he would cry to apoint that he couldn’t catch his breath.

How can children get better?Treatment options can range from play therapy to med-

ication, depending on how the anxiety affects the child’sfunctionality and development. During weekly one-hour ses-sions of occupational therapy, Nicholas works on skills tohelp him respond better to various textures of materials andfood. Through behavioral therapy, he learns how to calm hisfears and become more aware of trigger points, such as tight-ened muscles or a stomach ache.

Nicholas’ parents noted almost an immediate improve-ment in his behavior after they began practicing theresponse techniques they learned. Today, they are able tomore effectively respond to their son’s anxieties by provid-ing “quiet time” or holding him in a tightly wrapped blan-ket like a newborn.

Nicholas also takes daily medication—treatment reservedfor children that experience extreme psychological responsesto anxiety. It was not an easy decision for the Chantrys, butone they believe has given Nicholas his life back.

“He couldn’t be in public places. He couldn’t throw something

in the garbage. He couldn’t be near where a toilet was flushed.

Things most kids do, he couldn’t do.”

27Winter 2008

Since his parents divorced nearly four years ago, Craighas not been his happy, energetic self. Despite hismother’s efforts to hug, hold, and reassure him, the

six year-old remains scared and often bursts into tears. Hewill cry endlessly—often for what appears to be no reason.“He can be sitting and playing and then, all of a sudden,he’s crying,” his mom, Julie Henning, said.

Many times, he doesn’t want to play with friends andoften shares that he feels like nobody likes him or wants tobe his friend. Even riding the school bus and startingkindergarten did not bring him joy.

It’s more than the typical sadness children experienceafter their parents’ divorce. Craig, and his eight year-oldsister, Megan, were diagnosed with depression, a disorderusually associated with adolescence or adulthood.Researchers and clinicians now recognize that children canexperience depression at any age—even shortly after birth.

“Severe depression is not very common in young chil-dren, but it can be very debilitating in the long term if it isnot treated,” said Dr. Read Sulik, St. Cloud child psychia-trist and assistant commissioner for Chemical and MentalHealth Services for the Minnesota Department of HumanServices. Untreated depression is the primary cause of sui-cide among teens, according to the U.S. Surgeon General.

Living in an abusive St. Cloud area home likely ledCraig to develop depression as young as two years old, hismother said. “I was hoping it wasn’t going to have theimpact it has,” she said. “I thought I hid it well enough sothey didn’t see or hear it.”

Which conditions are most common?Depression is the most common mood disorder

among young children. Depression affects about one in

thirty-three children, according to the Federal Center forMental Health Services. Children are at higher risk if theyhave a family history or have experienced significant stressor trauma such as losing a parent, divorce, abuse, or suf-fering from a chronic illness.

What are the symptoms?Craig and other children with depression withdraw

from friends, family, and activities that once brought themjoy. They may also exhibit major changes in their eatingand sleeping habits. Frequent sadness, irritability, tearful-ness, and a loss of natural curiosity are the most commonsymptoms.

Children may communicate their feelings in draw-ings, paintings, or play time. They may also have dullfacial expressions and less responsive to hugs or holding.“People think that if there is no bruise on the outside,everything is okay on the inside,” Henning said. “That’sjust not the case.”

How can children get better?The first step to treating childhood depression and

other mood disorders is educating caregivers. Most treat-ments involve both child and family therapy. Professionalsoften combine cognitive therapy and play therapy to teachchildren how to cope with their feelings and changethoughts that affect their behavior.

Craig responds well to a regular routine and talkingthrough his feelings with his mother and teachers.Medication typically is a last resort. “We only use medica-tions if nothing else works,” said Dr. Troy Hanson, board-certified family physician and a member of the StateAdvisory Council on Mental Health.

“People think that if there is no bruise on the outside,

everything is okay on the inside. That’s just not the case.”

29Winter 2008

Curious about the world around him, Hunter began tocrawl out of his crib at just nine months. At age two, heunlocked dead bolts, opened doors, and climbed over

the chain-link fence that surrounds his St. Cloud home. Hewould wander the neighborhood, knock on a door, and askthe stranger for a cookie. Meanwhile, his grandmother—andprimary caregiver—would scour the streets with police.

Jan Larson realized her grandson was different. “He hadno tears until he was a year old,” she said. “He would run intoa hard surface, fall or become sick, but not shed a tear.”

She searched for answers. At eighteen months, Hunterwas diagnosed with Sensory Processing Disorder, a conditionthat results in what has been called a neurological "traffic jam.”It leads children to either be overly sensitive or almost numb,as in Hunter’s case.

Now age three, Hunter has become extremely defiant. Hethrows tantrums for a full hour, argues with his “nana” at everyturn, and has viciously hit her with a remote control. Aftermore than a year of tedious research, Larson finally found aspecialist who diagnosed Hunter with Oppositional DefiantDisorder. He will soon begin a new Catholic Charities programfor children with ODD.

Hunter’s grandmother believes that his lack of feeling andother behavioral issues are the direct results of his motherusing methamphetamine during pregnancy.

Which conditions are most common?Sensory Processing Disorder can serve as a gateway to

behavior disorders such as Oppositional Defiant Disorder(ODD) or Attention Deficit Hyperactivity Disorder (ADHD).ADHD has received much of the attention in the past twentyyears, but ODD is becoming increasingly prevalent in youngchildren, affecting 2 to 16 percent of school-agers. That’s com-

pared to ADHD that affects about 3 to 5 percent of childrenunder five years old and 5 to 7 percent of school-agers.

What are the symptoms?Impulsivity, hyperactivity and the inability to pay atten-

tion are the most common symptoms of children with ADHD.Children with ODD display an ongoing pattern of uncooper-ative, defiant, hostile and irritable behavior. They may exces-sively argue, disobey or talk back to their caregivers for anextended period of time. Other symptoms include repeatedtantrums, spiteful, or revenge-seeking behavior, and sayingmean and hateful things when upset.

How can children get better?Children with moderate symptoms may respond to par-

ent and child education. Play therapy, reward charts, dietary,and schedule changes may also be beneficial. While child psy-chiatrists often resist prescribing medications for young chil-dren, it is more commonly used to help affected children reg-ulate their emotions and behavior.

Sensory Processing Disorder sufferers like Hunter haveeven fewer options due to a lack of evidence to guide treat-ment. Some of the best known occupational therapies includebrushing the children’s limbs with a soft brush. For Hunter,play therapy takes him to indoor jungle gyms and involvesactivities that encourage lifting, pushing, and pulling to helphis body become more aware of its surroundings.

“It’s not that the caregiver is a bad parent or a badguardian. It’s not that the child is bad,” Larson said. “(Thesechildren) just can’t control their behavior. It’s a bad wire thatneeds to get connected.”

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“It’s not that the caregiver is a bad parent or a bad guardian.

It’s not that the child is bad. (These children) just can’t control

their behavior. It’s a bad wire that needs to get connected.”

31Winter 2008

t three months, she is a flurry of flailing armsand kicking feet, cooing as she smiles. She is

creating relationships.

At thirteen months, he tastes his toys, dumpsover clothes baskets, and pulls himself upon chairs. He is exploring his world.

At three years, she screeches in the middle of thenight. “It’s okay, honey,” comes a soft voice fromacross the hall. She is learning to self-soothe.

These are among the first milestones of social andemotional health. They mark the ideal path ofhuman life, the foundation of everything we areand everything we hope our children will become.If you have ever wished your son or daughter camewith an instruction manual, rejoice.

You’ve come to the right place.

32 Initiative Quarterly • IQmag.org

This is not about extraordinary—it’s aboutordinary,” said Dr. Terrie Rose, presidentof Baby’s Space, a Minneapolis-based

organization that provides early education andservices to families in poverty. “We have goodevidence to show that social and emotionaldevelopment sets the stage for life.”

Emotionally and socially healthy childrenwill learn how to get their needs met. They’lllearn how to rely on others and create relation-ships. They’ll learn how to regulate their emo-tions and soothe themselves while exploringthe world around them, knowing that there’s anadult to fall back on.

These simple lessons begin in the firstdays of life. According to Rose, early child-hood research suggests that infants areaffected by stress and trauma in the sameway as adults, crumbling common miscon-ceptions that young children are insulatedby a lack of awareness.

In infants, stress and trauma can manifestas fussiness and inconsolable crying. Toddlersoften respond to stress through meltdowns,kicking, screaming, and biting.

While genetics set the stage for biologicalbrain development, it is experience andnuance that teach the young brain how tofunction and learn. If a child is fortunate to

have good caregivers,the brain learns toform trusting relation-ships and is free toexplore. If a child’s lifeis filled with stress,tension, or abuse, thebrain becomes wiredfor those negative sit-uations.

Children can usu-ally move past nega-tive experiences, butparent and caregiversupport are crucial.Rather than brushingoff their fears, parentsshould help their chil-dren work throughthem, Rose said.

“It’s more com-fortable for us tobelieve childrendon’t remember,” she

added. “They do remember and they needto be nurtured through life’s events, traumasand stresses.”

However, a child’s behavior is oftenmore directly related to his or her geneticpredisposition. For example, some childrenare hypersensitive to loud, busy environ-ments or new social situations. Some havecertain biological arousals and sensationsthat they can’t control, which may requirehelp from a mental health professional.

“It impacts their ability to engage in rela-tionships and regulate emotions,” Rose said.

The good news is that parents and care-givers can help steer children back onto theroad of social and emotional well-being. Youngbrains are malleable and healthy interactionscan reshape neurological connections.

According to Marlys Johnson, a mentalhealth consultant for Minnesota Head Start,children should be encouraged to expressthemselves and their wide range of emotions.

“We want our children to be happy,”Johnson said. “When they’re not happy orwhen they’re angry or sad, it’s disturbing to usand we try to shut that down.”

Instead, it’s important for kids to hear thattheir feelings are normal and that adults willkeep them safe when they need to express

those feelings. Instead of demanding that achild go to his room until the tantrum is over,Johnson said it’s better to explain that youunderstand that he is tired or frustrated.

“When they’re whining, angry or sad, ifthe only message they hear is that they can’t bearound us, that’s not helpful to them,” Johnsonadded. “We learn from them as we help thembegin to calm down.”

Adults can help children identify theirfeelings and explain how to handle anger andfrustration, perhaps by taking a few deepbreaths or counting out loud. Textured toys,firm hugs, or safe relaxation places can alsohelp a child calm down.

It can be difficult for parents and child-care providers to determine whether a child’soutbursts are normal, related to a stressfulexperience, or indicative of a serious social oremotional development issue.

To help pinpoint possible challenges, theMinnesota Department of Human Services’(DHS) Children’s Mental Health Division ispromoting the national “Ages and StagesQuestionnaire: Social/Emotional.” The ques-tionnaire asks about age-specific milestonesand helps to determine whether a child’sbehaviors are normal. Through a pilot pro-gram that encourages doctors to administerthe questionnaire during well-child checks,the department hopes it will eventually beadopted as a routine procedure.

“We want to train mental health specialistsand primary-care providers to look at the childearly and not dismiss a mother’s concern,” saidAntonia Apolinario-Wilcoxon, consultant andproject coordinator for Minnesota DHS.

Jana Shogren, children, youth, and fami-lies specialist at the Initiative Foundation,advises all parents and caregivers to pursuelow-cost services from Early Childhood FamilyEducation (ECFE) and Head Start, which areavailable in every Minnesota school district.She also recommends quality, structured pro-grams in childcare and preschool.

“Ideally, parents are a child’s first and bestteacher, but parents need support, too,”Shogren said. “That’s why many resources areavailable, so we can develop skills and allies forthe wonderful and stressful experience of par-enting young children.”

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DR. TERRIE ROSE: “(Children) need to be nurtured through life’s events,traumas, and stresses.”

“

JOH

NLI

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Strong social and emotional health are built from a foundation of daily teaching moments. If you know

a young person, you’ve probably experienced these challenging situations. What’s the best way to

handle them? With patience and love, experts say . . .

THE MOMENT THE RESPONSE THE REASON

Your three month-old is fussy andcrying. You change her, feed her, andshe’s still not happy. You worry thatresponding to every cry will teach her tocry for everything.

You can’t spoil a baby—that’s a myth.Responding to your newborn’s criesteaches her that she can rely on you. Shealso learns that she is an effective com-municator.

These experiences allow her to develop astrong trust in others and in herself. Theyteach her that the world is a good, safeplace and that she can play an active rolein it. Security gives her the freedom toexplore.

Bedtime for your seven month-oldis a nightmare for you. You lay him downand he immediately cries and fusses.People tell you to give him time to fallasleep on his own, but you feel guilty.

Set a bedtime routine that offers yourchild predictability. Consider a warmbath, a book, and a soft toy to cuddle.Predictability helps children feel moresecure.

When you provide a special routine foryour child, he learns that he is important.Allowing a child time to put himself tosleep without rocking or feeding teacheshim to self-soothe.

You drop off your one-year-old atchildcare. She cries and clings to you.When she becomes distracted by a toy,you consider slipping out the door with-out saying goodbye.

Experts agree that it’s better to say a lov-ing and quick goodbye even though it’slikely to incite a tantrum. Once you walkout the door, the crying will likely stopwithin minutes.

Developing a goodbye routine pairedwith happy reunions teaches your childto trust that you will return. It builds achild’s confidence in you and your rela-tionship.

Your two year-old is developing amyriad of fears—fear of bees, fear ofgoing to the doctor, fear of the dark, fearof being in a room alone.

Acknowledge your child’s fears withrespect, and make suggestions for easingthe fear. “Sometimes darkness can bescary. Do you want a flashlight?” Usepretend play to reenact a situation.Practicing can help build a sense of con-trol and self-confidence.

It’s important to help children learn tocope with their fears while preservingtheir dignity. As you help your child grad-ually become familiar with the unknown,his experience mastering the unfamiliarwill give him the confidence to try newthings and face new situations.

When you make dinner or do house-work, your three year-old whinesat your feet. He asks you to play a gameor give him a treat. Saying “no” elicitsmore serious outbursts and puts him onthe edge of a full-blown meltdown.

Tell him that you understand that his feel-ings stem from being tired and hungry.Explain that there are rules even whenhe’s having a hard time—no screaming,hitting, or throwing toys. Offer calmingideas like taking deep breaths or countingout loud. Avoid telling him to go to hisroom until he stops crying.

Young children are easily overwhelmedby emotions. It’s important for childrento know they can safely express themwithout negative consequences. Helpingthem identify causes can often providecomfort and defuse the situation.

Sources: Center for Early Education and Development; University of Minnesota Children’s Hospital KidsHealth; Early Childhood Consultants, Michele Fallon and Marlys Johnson.

Crying Foul: Annah and Eli Frost were amongthose searching for new childcare in 2008.

35Winter 2008

By Sarah Colburn | Photography by Jim Altobell & John Linn

For the Frost family, it came on Sunday evening after a long and relaxing week-end. “Oh, it’s Eli’s daycare,” Annah said before picking up. Her husband, Jeremy,could sense that something was wrong. More than once, Annah had arrived tofind her three-month-old son in inconsolable hysterics. Constant holding wasthe only way to calm him and the provider had seven other children to handle.“I hate to do this to you,” the woman said nervously, “but I think Eli might behappier somewhere else, somewhere with fewer kids.”

Annah hung up and cried. She wondered how Eli would cope. She wonderedwhether she was a good parent. She wondered how long it would take to findanother provider she trusted. The Frost family was in a tailspin. And inMinnesota, they’re not the only ones.

It was the phone call that every parent dreads.

Cindy Croft, director of the Center for Inclusive Childcareat Concordia University, said that she receives weekly calls fromdistraught parents, which have steadily increased over the pastfew years. Expulsions have also become a popular conversationtopic among her colleagues.

She said that many expulsions stem from possible mentalhealth symptoms that are often mistaken for bad behavior orbad parenting. Children may lash out, cry constantly, throwtantrums or toys, and at worst, hit, or bite other children.

With 75 percent of Minnesota families regularly usingchildcare, the recent uptick in expulsions may pose even biggerproblems for those seeking new providers. In 2007, theMinnesota Childcare Resource & Referral Network reported anet loss of 121 programs throughout the state. With an averagetenure of eleven years, childcare providers work about fifty-fivehours per week for less than a living wage. Many also lack sup-port and training in early childhood mental health, Croft said.

Croft added that it’s difficult for the public to acknowledgethat young children have mental health needs and that behav-iors are related to their development. “These kids are so littleand they’re carrying these stigmas around with them.”

Another witness to the steady increase in childcare expul-sions, Marit Appeldoorn, is the director of preventative interven-tion services for St. David’s Child Development and FamilyServices, a Twin Cities-based program that provides training toearly childhood educators and runs therapeutic preschools forchildren with social and emotional needs.

A doubling of expulsion-related calls led St. David’s to offermore training programs and on-site consultations for preschoolproviders working with special-needs children. Staff membersrecently referred eight struggling children for additional help,after just one visit to the Northwest YMCA preschool programin New Hope.

“(If a child enters) the public school system with mul-tiple failures, they are also more likely to fail in school,”said Appeldoorn. “It can destabilize an entire family andcommunity.”

Carol Gibson-Miller of St. Cloud Area Child Link said someexpulsions are linked to a lack of communication between theparent and provider. Others come after long, emotionally-drain-ing talks and numerous changes to the childcare environment.Gibson-Miller also believes that many providers choose to avoid

uncomfortable confrontations by claiming that their home orcenter is full, leaving parents unaware of issues and vulnerableto future expulsions for the same reasons.

“They aren’t always told why or how it happened,” she said.“It’s easy to point the finger at the providers,” added Jana

Shogren, Initiative Foundation children, youth, and familiesspecialist. “But they are overworked, underpaid, and just tryingto get through their day. They need our support in identifyingand working with children who have special needs.”

A provider armed with early childhood development train-ing can combat that trend, picking up on cues that a child isstruggling socially and emotionally, not just acting out. State andnonprofit agencies are offering more workshops in early child-hood mental health, but they are not yet mandatory.

Licensed providers in Minnesota are only required to havetraining in Sudden Infant Death Syndrome, Shaken BabySyndrome, CPR, first-aid and two hours of child development.Home providers must have eight hours of continuing educationeach year.

Without advanced training, providers must rely on theirown experiences to help kids. And though some providers sim-ply won’t make changes to the environment when a child isstruggling, many more go above and beyond.

Mary Anderson, co-owner of Kids Incorporated inHutchinson, represents the next generation of Minnesota’s pro-fessional childcare providers. She is responsible for more thanfourteen children with special social and emotional needs, manyof whom have been expelled from four or five childcare pro-grams before finding hers.

“We’re not going to remove a child at the first sign ofa problem,” Anderson said. “The child doesn’t need onemore challenge.”

Anderson said that she can immediately spot a child’s out-of-bounds behavior when they come through her door. Whilemany parents are hesitant to explain

Jeremy and Eli.

Minnesota childcare agencies are getting more referral requests fromparents whose young children have been expelled from childcare settings. It’s a trend that stresses providers, parents, and childrenalike. When children are bounced from childcare settings in theirformative years, it can affect their healthy attachments and ability toform future relationships.

37Winter 2008

why they left their previous provider, she said that information isvital in order to create a new, sound relationship.

Even Annah Frost admits that she withheld informationduring her first provider interview, afraid that she wouldn’t findanother place for Eli. Eventually, she asked questions about howeach provider would handle constant crying. Today, Eli’s newprovider communicates regularly with Annah and Jeremy abouthis day and any changes to his schedule or environment thatcould affect his mood.

Anderson documents behavior concerns and discussesthem with parents to see if the behavior may be caused by anymajor traumas or upheavals in the child’s life. Then, she adjuststhe childcare environment accordingly, sometimes shortening astory time for those who struggle to sit still or providing a quieterspace for overstimulated infants.

“It’s like finding a key to a lock and once you unlock it youcan deal with it,” Anderson said.

Mary and other Minnesota providers are also giving them-selves a time-out from the childcare setting to learn new strate-gies and talk to each other.

The practice is called “Reflective Consultation,” linkingproviders with peers and mental health experts to step back andthink about a child’s behaviors, identify possible causes, andreflect on their personal feelings and experiences. Along withparent communication and continuing education, ReflectiveConsultation is being hailed as a model to substantially improvechildcare at all levels.

Marcia Schlattman, program manager of Childcare Resourceand Referral, said her agency is hoping to provide support forprofessionals who don’t have many opportunities to connectwith their peers.

Annah Frost advises other parents to maintain an open lineof communication with their childcare provider and consider achange if a child continues to have challenges. For all the stressshe endured, she considers Eli’s expulsion a blessing in disguise.“We probably would have stayed, had she not asked us to leave,”she said. “Now, it’s really night and day about how I feel about Eligoing to daycare.”

For more information about choosing childcare, localavailability, special needs programs, and provider resources,visit the Minnesota Childcare Resource & Referral Networkat www.mnchildcare.org.

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39Winter 2008

Six months of waiting.

Six months of wondering.

Six months of watching your child suffer from the inside out.

Six months of guilt, stress and helplessness.

Six. Months.

Such is the slow-motion waiting list for an appointment with Minnesota’s thinly scattered child psychiatrists and early

childhood mental health professionals.

Welcome to the race against time.

Kris Beehler remembers her exact breakingpoint. Her three year old son, Landon, had hishead down on a restaurant table, both hands

clamped over his ears, crying and screaming that thenoise was too loud.

“I said, ‘enough is enough.’ Something neededto be done right then.” Landon was put on a waitinglist to see a child psychiatrist in St. Cloud, a list thatcan linger for six to nine months, according to areahealthcare professionals.

“They said they would call if there were any can-cellations, but there weren’t,” said Kris. So theBeehlers waited, watching their two-year-old sonbecome more and more troubled. “There’s such ahigh demand for child psychiatry, there just aren’tenough doctors.”

Meanwhile, early childhood experts say thatmental health issues can be hardest hitting during achild’s first five years of life, when the brain developsat a rapid pace and social and emotional connections are formed.

“Many affected kids will experience challenges in school and later inlife,” said Nancy Jost, early childhood coordinator at West CentralInitiative in Fergus Falls. “Simply put, they can’t wait for help. And rightnow, they have no other choice.”

The Rural DroughtThere is a documented shortage of licensed early childhood mental

health professionals throughout Minnesota, especially in rural areas.Jessica Croatt Niemi, mental health professional with Stellher HumanServices in Bemidji, has been advertising to hire a mental health profes-sional for two years. “They don’t even need expertise with families ofyoung children,” she said. “I’m willing to provide and pay for that train-ing, yet we’ve had very little response.”

It’s a familiar challenge for Sandy Tubbs, director of Douglas CountyPublic Health, who said that the Douglas County Hospital has continual-ly tried to recruit a child and adolescent psychiatrist. “It’s a huge, ongoingchallenge,” she said.

Such shortages of trained personnel can result in long waitinglists and insufficient doctor visits. “In rural Minnesota there may beone child psychiatrist within a 150-mile radius,” said Sara Carlson,program officer and early childhood specialist with the SouthwestInitiative Foundation. “Parents drive two hours one way for a 15-minute office visit, and then they’re put on a waiting list for monthsbefore they can get in for services on a regular basis.

“Family doctors are trying to be the first line of defense,” she added.“Often they are the only line of defense, since many areas don’t have anymental health professionals who will see children under the age of eight.”

The field of infant and early childhood mental healthcare is a rela-tively new frontier. The patients are frequently too young to talk, and thebest interventions usually involve therapy and observation sessions con-ducted with parents or caregivers, either in the child’s home or childcaresetting. Frequently, the time commitment is higher and the pay scalelower than if a practitioner focused on older patients.

“We don’t have a lot of licensed therapists that work with childrenunder the age of five,” said Carol Gibson-Miller, interagency service coor-dinator at St. Cloud Area Child Link, a program that connects familyresources for young children with special needs. “I think a lot of mentalhealth professionals don’t feel well-trained in early childhood, so they juststay away from it.”

Train of ThoughtAccording to Dr. Troy Hanson, board-certified famiily physician with

Locum Tenens in Buffalo and a member of the State Advisory Council onMental Health, his family practice education provided no training in earlychildhood mental health. In order to better serve families with young chil-dren, Hanson pursued additional training on his own, enrolling in thenew Infant and Early Childhood Mental Health Certificate Programthrough the University of Minnesota.

Mental health issues can be hardest hitting during a child’s first five years of life,when the brain develops at a rapid pace. “Simply put, they can’t wait for help.”

CONTINUED ON PAGE 42

GOOD CALL: When Landon (right) revealed extreme anxieties, the Beehler family contactedCarol Gibson-Miller (left) at St. Cloud Area Child Link for help.

http://adep.css.eduSt. Cloud Campus: (866) 211-2337

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Winter 2008 41

“A lot of the problems that I see in the clinic or the emergencyroom have some component of a mental health issue within them,”Hanson said.

“Parents usually go first to their primary care provider withquestions about their babies,” said Antonia Apolinario-Wilcoxon,mental health program consultant with the Children’s Mental HealthDivision of the Minnesota Department of Human Services (MDHS).

Wilcoxon coordinated the MDHS-facilitated Great StartMinnesota Project, a three-year program to introduce early childhoodmental health screening into primary care practices. She said theDiagnostic Classification Zero to Three program has trained morethan 1,000 mental health professionals and 300 primary careproviders at 15 statewide sites.

“My dream would be that we would have, at every clinic, all ofthe LPN and RN level staff, the nurse practitioners, and the physi-cians at least aware of this training,” Carlson added. “I would love tosee mental health screening being done routinely for all children.”

Difficult DiagnosisWell-baby visits offer the perfect opportunity for routine

screening, but screening doesn’t always lead to a definitive diagno-sis or treatment plan.

Landon Beehler has what his mother, Kris, describes as, “‘the five-bucket syndrome.’ You put five buckets in front of you with differentdiagnoses and take a little bit out of each bucket.

“The psychiatrist said it’s hard to diagnose at such a young age,but it seems that Landon has a little bit of everything—obsessive-com-pulsive disorder, ADHD, Turrette’s, depression, Asperger’s. There’s notenough to diagnose any one thing.”

Then there is the stigma of a mental health label, which manypractitioners avoid applying to very young children. When testing anddiagnostics don’t point in a specific direction, they may use a diagnos-tic code like “Pervasive Developmental Delay-Not Otherwise Specified”or “Disorder of Infancy or Childhood-Not Otherwise Specified.”

Such ambiguous diagnoses may also affect a family’s ability to getfurther testing or treatment covered by health insurance.

“There are more services available for children and families whenthere is something diagnosable,” said Susan Schultz, licensed psychol-ogist at the Infant Parent Psychotherapy Practice in Edina. “I might usea generic code for a child that is never going to get a spectrum diagno-sis. It just means that development is derailed in a couple of areas.”

According to Dr. Hanson, it is difficult to provide a specific men-tal health diagnosis in young children because many problems havesimilar symptoms or behaviors. “To distinguish those and figure outexactly what they mean in early childhood can be very difficult.”

Collaborators WantedHealthcare leaders agree that improving collaboration among

providers would be a major step forward. Patient confidentiality pres-ents a major barrier. With mental health issues, patient records become

proprietary. A referring physician may never be informed of hispatient’s diagnosis or treatment.

However, two separate pilot programs are tackling this issue. One,instituted by PrimeWest HEALTH, utilizes a clinic care coordinator totake the referral from the primary caregiver, connect the family to therecommended mental health professionals or community organiza-tions, follow up, and keep everyone informed.

Another approach explored by St. Cloud’s CentraCare HealthSystem involves bringing a mental health professional into the clinic,so that he or she is accessible to primary caregivers and families.“CentraCare found ways to make this work, financially and opera-tionally, to provide something their patients needed,” Apolinario-Wilcoxon said.

The Beehler family had to take a different route. Their family doc-tor referred Kris to the Foley school district, which then referred her toGibson-Miller at St. Cloud Area Child Link. Within a week, a speechtherapist, a child psychologist, and Gibson-Miller visited the Beehlerhome to conduct initial assessments.

Landon, who is now four, is enrolled in an early childhood pre-school designed to help him adjust to a classroom environment. He istaking medication, and the family has learned coping techniques tohelp ease difficult situations.

“Infant and early childhood mental health, from my perspective,is really about understanding the social-emotional development of veryyoung children,” Gibson-Miller said. “Teaching strategies to supportwhoever is touching the lives of children ages zero-to-three will makea lifelong difference in our families and our communities.”

React at IQMAG.ORG

CONTINUED FROM PAGE 40

Dr. Troy Hanson.

43Winter 2008

“This concept could reform how wepay for healthcare,” Bence said. “It’s beingtalked about at the national level, butMinnesota actually has legislation that ismoving it forward.”

At this point, traditional health insur-ance still isn’t designed to cover early inter-vention or prevention for children’s mentalhealth, according to Rep. Larry Hosch ofSt. Joseph, Minnesota.

As vice-chair of the Health andHuman Services Finance Committee, Rep.Hosch is among state legislators workingto reform mental healthcare and coverage.

“One of the things we’ve struggled to rec-ognize is how important early interventionis,” he said. “We can make significantimpacts on children’s lives, families’ lives,and hopefully also save the state money inthe long run.”

“We shouldn’t have to apply specialcreative thinking to this,” said CandaceKragthorpe, director of the MinnesotaAssociation for Infant and EarlyChildhood Mental Health. “If it were anyother children’s health condition, it wouldbe covered. It boggles my mind in this dayand age that we do not have paritybetween children’s medical and mentalhealth conditions.”

PrimeWest HEALTH in Alexandria,Minnesota is rewriting the rules. Createdby thirteen western Minnesota counties,the nonprofit health plan serves individu-als and families on medical assistance.

A pilot program at two Alexandria

INSURANCE

Gray MatterKids’ Mental Health Coverage Not Black and White

Your three-month-old infant is con-stantly irritable and squirms uncom-

fortably when you try to comfort her. Thedoctor can find no physical malady, butyou’re worried that things just don’t seem“right.” After you answer a questionnaireabout your infant’s routine and responses,further mental health assessments are rec-ommended—and that’s when you find outyour health insurance won’t pay for them.

Now what? Can you afford to pay outof pocket? Can you afford not to? Whyaren’t these assessments covered foryoung children?

“Mental health coverage varies wide-ly by insurance provider and plan,” saidSara Carlson, program officer and earlychildhood specialist with SouthwestInitiative Foundation. “The system is setup to pay only for the person who isexperiencing the difficulty, no one else.Many times, you can’t treat young chil-dren without their caregivers beinginvolved, but insurance doesn’t alwayspay for family therapy.”

Minnesota is in the vanguard of statesaddressing gaps in mental health coveragefor very young children. According to KenBence, director of community health ini-tiatives for Medica Health Plans, a newapproach to coverage resembles, “themedical model, looking at mental healthas any other illness.” That means provid-ing insurance coverage for whatever treat-ments are prescribed in order to help thechild get well.

BY TENLEE LUND

44 Initiative Quarterly • IQmag.org

medical clinics requires all PrimeWest chil-dren to be screened during well-baby vis-its. Questionnaires are administered andtabulated while parents and children are inthe waiting room.

“The doctor already has the question-naire results and can discuss them with theparents right away,” said Jeanne Barlage,PrimeWest depression disease manage-ment/integrated shared care manager. Thedoctor decides if the child needs furtherdiagnostic assessment, and underPrimeWest, it’s all covered by insurance.

Douglas County, which includes

Alexandria, formed one of Minnesota’s firstchildren’s mental health collaboratives,which includes the school district, countysocial services, corrections, and mentalhealth providers.

“We have a unique partnership withPrimeWest,” said Sandy Tubbs, DouglasCounty director of public health. “Theyhave been extremely proactive at takingaway the payment barriers. It’s amazingwhat we can do when we don’t have toworry about who is paying for services.”

According to Carlson, however,reform efforts are not about sticking theinsurance companies with the bill. “Webelieve it’s about helping our youngest kidswho can’t speak for themselves and savingmoney over the long-term by avoidingmore expensive and less effective interven-tions later in life.”

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“The system is set up to pay only for the person who is experiencing the difficulty,no one else. Many times, you can’t treat young children without their caregivers

being involved, but insurance doesn’t always pay for family therapy.”

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Charities is findingitself among theorganizations onthe front lines.“Mentoring is an ideal intervention forchildren of inmates,” said Jackie Johnson,program director. The nonprofit programreceived a federal grant for specializedtraining, which has helped its volunteersreach out to local children.

“I don’t have a dad—he’s in jail,” saidfour-year-old Tony to his foster grand-mother. The boy wouldn’t obey, was oftenangry, and hit other children. “No, don’ttouch me!” he’d yell. “I only love my moth-er!” “Gramma” combined her training withpositive reinforcements. Eventually Tonywas hugging Gramma and telling her heloved her, too.

“Incarceration affects the entire familystructure, encouraging the children tobecome like their parents,” said JoeGibbons, executive director of the CentralMinnesota Re-Entry Project for prisoninmates. Intervening during a child’s form-ative years can break the cycle of genera-tional crime and imprisonment, he added.

Many Minnesota prisons and countyjails are offering help to those who want it.Minnesota Correctional Facility-St. Cloudencourages families to visit and write tooffenders. MCF-Shakopee allowsovernight visitation privileges to qualifiedmothers residing in a parenting unitequipped with trundle beds, toys, and kid-friendly amenities. MCF-Stillwater offersfour visitation days per week, staggeringhours to make it easier for families.

“We get great feedback from instruc-

SEPARATIONS

Age of Innocence?More Young Children Forced to CopeWith Parental Incarceration

Toddler Luke watched as his father washandcuffed and taken away, arrested

for felony kidnapping. Luke suffers fromrage and recurring nightmares. “Daddy”faded into the periphery of Luke’s life—aregret, a potential threat—who never for-got his son’s birthday.

“For many prison and jail sentences,another sentence is passed along to youngchildren,” said Linda Kaufmann, seniorprogram manager for children, youth, andfamilies. “Many kids suffer from emotionalissues that they can’t handle. As a society,we have to support these children and notpunish them for their parents’ choices.”

More than fifteen thousandMinnesota children currently have anincarcerated parent, according toParenting with Purpose, a Brooklyn Park-based nonprofit organization. Nationally,about 25 percent of all children of incar-cerated parents are age four or younger.

Since 1987, Minnesota’s prison popu-lation has swelled by more than 350 per-cent, with the State Department ofCorrections expecting to add another2,697 inmates in ten years. “This is agrowing problem for the children leftbehind,” Kaufmann added.

The Arizona Children of IncarceratedParents program reports that childrenoften suffer from trauma, abuse, neglect,poverty, and the stigma that comes withhaving a parent in prison. Other mentalhealth symptoms include aggression,withdrawal, excessive crying, feelings ofguilt, and nightmares.

In central Minnesota, the FosterGrandparent Program of Catholic

tors and graduates,” said Stillwater warden,John King. “It’s difficult to do much more,given my custody level and the fundingchallenges we face.”

Through its Children, Youth andFamilies Initiative, the Initiative Foundationis laying the groundwork to help communi-ty coalitions provide parenting educationand support to children of incarcerated par-ents. Its Inside-Out Connections Project isreceiving support from Volunteers inService to America (VISTA).

“Maintaining contact with an incarcer-ated parent improves a child’s social andemotional well-being,” Kaufmann said.

A CHILD’S BILL OF RIGHTSI have the right . . . • to be kept safe and informed at the time

of my parent’s arrest.• to be heard when decisions are made

about me.• to be considered when decisions are

made about my parent.• to be well cared for in my parent’s

absence.• to speak with, see, and touch my parent.• to support, as I struggle with my parent’s

incarceration.• not to be judged, blamed, or labeled

because of my parent’s incarceration.• to a lifelong relationship with my parent.Source: San Francisco Children of Incarcerated Parents

React at IQMAG.ORG

BY MARY BELISLE

46 Initiative Quarterly • IQmag.org

CHRIS

McALLISTER

47Winter 2008

> K E Y S T O R Y

Tabbing strong leadership efforts in thefight against poverty, the Initiative Foundationrecently welcomed Chris Close, co-owner ofClose-Converse Commercial & PreferredProperties of Brainerd, to its board of trustees.

“Chris’s passion for helping disadvan-taged people, combined with his businessand economic development expertise,makes him an excellent addition to ourboard,” said Kathy Gaalswyk, InitiativeFoundation president.

According to Close, joining theInitiative Foundation will allow him tobuild on his impressive résumé of commu-

nity service, which already includes missiontrips to Botswana and Malaysia, as well as aboard appointment with Bridges of Hope inBrainerd.

“I have always had a strong desire toparticipate in such a high-caliber, influentialorganization like the Initiative Foundation,and I am excited to be a part of their mis-sion,” Close said. “I also hope to be instru-mental in discovering out-of-the-boxapproaches to successfully improving therecurrence of generational poverty.”

Close joined his father, Kevin, at Close-Converse in 2002, where he now specializes

in commercial and investment real estate andleasing. In 2007, Realtor Magazine namedhim among the top thirty realtors under agethirty in the nation.

Close holds bachelor’s degrees in finance,entrepreneurial management, and marketingfrom the University of Minnesota’s CarlsonSchool of Management. He lives in Baxterwith his wife, Amber, and two children,Joshua and Annie.

CLOSE CALLBrainerd Realtor Joins Board of Trustees

48 Initiative Quarterly • IQmag.org

As central Minnesota families and busi-nesses look to regain an economic foothold in2009, the Initiative Foundation is shifting itspriorities to support them.

Though the tumbling stock market hashad an impact on all U.S. foundations, theInitiative Foundation plans to maintain itsgrants and business investments to supporteconomic recovery. Instead of knee-jerk reac-tions to recent events, the foundation uses athree-year rolling endowment average todetermine its annual budgets.

“It’s a long-term, steady approach,” saidKathy Gaalswyk, Initiative Foundation presi-

dent. “We’ve had many great investment yearsto counterbalance the challenging ones.”

In 2009, the foundation plans to award$1 million in nonprofit grants and $2.5 mil-lion in business loans, investing in local own-ership and living-wage jobs with benefits. Tenpercent of its grant funds will be tabbed toenhance workforce skills and to build thecapacity of nonprofit organizations that servefamilies in economic distress.

“Now is the time for optimism and lead-ership,” said Kathy Gaalswyk, foundationpresident. “In the 1980s, the MinnesotaInitiative Foundations were created as a coun-

terpunch to economic hardship. Twenty-threeyears later, we don’t plan to watch and hopefrom the sidelines.”

Gaalswyk added that all philanthropicorganizations will need financial and volun-teer support to sustain their safety-net opera-tions in 2009.

“Our communities and families needhelp more than ever, and many nonprofits areoperating at maximum capacity,” she said.“Every dollar or hour of service is a symbol ofhope for our region.”

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> K E Y S T O R Y

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Winter 2008 51

shapes the development of achild’s brain during the early years.Love really does matter!

However, love alone isn’t always theanswer. A parent’s emotional state and achild’s biological temperament play an enor-mous role in how well a child can be soothed.

Young children who are not easy tosoothe may have “difficult” temperaments, bevery sensitive to sensory stimulation, be anx-ious, depressed, or have other problemscausing behavioral and emotional dysregula-tion such as ADHD (Attention DeficitHyperactivity Disorder).

A child with such behavior problemssuffers in his ability to learn and receivesmostly negative attention from adults. Thiscan have a profound impact on the child’sdevelopment and sense of self.

Biology isn’t always the answer, either.Children may be difficult to soothe becausetheir parents are stressed or have their ownmental health issues. Their environment maybe chaotic or even violent. The inability to besoothed is often an early sign of a child whois suffering from a more serious mentalhealth problem.

All of our children need help in devel-oping those skills that will keep them men-tally healthy. They need regular amounts ofsleep, healthy diets, regular physical and

If we don’t know where we’re going, thenwe’re never going to get there. As a child

psychiatrist and pediatrician, I realize that ifI can’t clearly define what mental health is,then I can’t help children get better.

Whenever I give a presentation, I beginby asking audiences to give me their owndefinition of children’s mental health. Hereare three common responses—1) being ableto engage and relate to others, 2) being ableto soothe oneself when stressed or upset,and 3) being able to explore and learn fromthe world around them.

These three phrases sum it up. Everychild deserves help if he or she is unable toexplore and learn, relate to others, regulatetheir emotions, or self-soothe. Early child-hood mental health is as simple as that.

In spite of the widespread belief thatyoung children cannot suffer from mentalhealth problems, I have noticed an increasein young children suffering significant emo-tional problems over the past decade. Thepace of our lives is faster than ever before.The amount of stress and pressures on fami-lies is also greater.

Minnesota has a drought of healthcareand mental health professionals who aretrained to treat young children. During thepast several years, many families had to waitfrom six to nine months to get an initialappointment with me or one of my partners.

Many children struggle with attach-ment—the relationship between a caregiverand a child. The caregiver of a well-attachedchild is able to successfully respond to achild’s arousal when they become overlystimulated or upset.

Parents must create a warm, nurturingenvironment where their child can first besoothed and later develop the ability to self-soothe. The amount and quality of affection

relaxation activities, and healthy, loving,supportive families and environments.

I commend the leaders of theMinnesota Initiative Foundations andMinnesota Thrive for having the courage tocover an issue that few people are talkingabout. I hope that reading this magazineleads you to take action.

As adults, it is our responsibility tostand up for the children who cannot ask forhelp. We need to stop denying the existenceof children’s mental health problems. Weneed to stop condemning and stereotyping.And we need to support efforts to buildawareness, affordability, and quality intoearly childhood mental health efforts atevery level. We must do all we can to ensurethat we identify those children and parentswho are suffering and provide access to careas early as possible.

Because sooner or later, it may be yourchild who needs help.

React at IQMAG.ORG

Dr. L. Read Sulik is a child and adolescentpsychiatrist and pediatrician. He is the newlyappointed AssistantCommissioner of theMinnesota Departmentof Human Services,overseeing the Chemicaland Mental HealthServices Administration.

BY DR. L. READ SULIK, MD

52 Initiative Quarterly • IQmag.org

As adults, it is ourresponsibility tostand up for the

children who cannotask for help.

Mind Your BusinessA Crash Course in Early Childhood Mental Health

CHRIS

McALLISTER

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