Arkansas’ State Strategic Plan for Supporting Early Childhood Mental Health

1. Arkansas’ State Strategic Plan for Supporting Early Childhood Mental Health AECCS Social-Emotional Workgroup Report to the AR Children’s Behavioral Health Care Commission April 17, 2014 Nikki Conners-Burrow Carol Amundson Lee

2. Purpose • Review background/purpose of workgroup • Briefly review recent relevant science • Evidence of need in Arkansas • Overview of process to develop plan • Overview of draft plan: broad goals and key strategies

3. AECCS SE Workgroup • 1 of 5 workgroups for the Arkansas Early Childhood Comprehensive Systems Initiative • funded by the Maternal-Child Health Bureau • operates under DHS • The past accomplishments include: • contributions to the state Quality Rating Improvement System • identifying a social-emotional screening tool for statewide used • toolkit for addressing maternal depression • development of graduate certificate program in ECMH

4. AECCS SE Workgroup • This long lived committee was engaged in the earliest DHS DCCECE and DBHS early child mental health treatment and consultation efforts. • Representatives have included DBHS Divisions, UAMS, ACH, Community Mental Health Centers, ADH, Head Start, Educational Cooperatives, Private Providers, Higher Education and more.

5. AECCS SE Workgroup Task for this 2012-2013: development of a state plan for supporting early childhood mental health • Requested by DHS/DCCECE • Utilizing a public health approach • Cross-discipline, cross-agency, public/private

6. Public Health Model for Supporting Children’s Mental Health From: A Public Health Approach to Children's Mental Health: A Conceptual Framework

7. Infant & Early Childhood Mental Health • Synonymous with healthy social-emotional development • Social development - communicating needs, getting along with others and making friends. • Emotional development –able to be soothed when upset, recognizing feelings and expressing them appropriately. • Supports the ability of the young child to learn and explore the world around them.

8. Early Relationships Support or Undermine ECMH • Children develop in the context of relationships • The brain is shaped by the experiences adults provide • Nurturing caregiving supports brain development and is the foundation for lifelong mental health • Serious problems in early relationships can have negative effects on the brain, developmental delays, problems in learning and mental health

9. ECMH is Undermined by Early Adversity • Chronic adversity makes children most vulnerable • Recurrent abuse, neglect • Witnessing domestic violence • Serious parental mental health or substance abuse problems • Unresponsive or inconsistent caretaking • Has effects on body and brain that carry into adulthood

10. Early Adversity and Stress Response System • These adversities activate the biological stress response system • Abnormal levels of stress hormones that can damage brain architecture • Supportive relationships help child cope and bring hormones back into balance • Undermines development of executive function skills – processes by which we learn • Can alter immune function and inflammatory markers

11. Problems in ECMH Adapted from Egger & Angold, 2006

12. Problems in ECMH in AR • 16% of AR pre-k children screened have significant behavioral concerns • High rates of ‘preschool expulsion’. • Postpartum depression rate of 17.7% • Large parts of the state with no quality-rated child care programs. • Lack of mental health professionals trained to work with families of young children • 4,614 victims of abuse or neglect aged 0-5

13. Intervention for Vulnerable Children - Lessons from Evaluation Research • Improving outcomes involves enhancing the quality of a child’s environment and relationships. • There are evidence based interventions that can be implemented across service sectors: • mental health • home visiting • parenting education • high quality child care • The earlier the intervention the more cost-effective and efficient it is

14. Intervening Early is Cost Effective • Studies of early childhood mental health problems reveal that 50% or more of these children will continue to have these difficulties in later childhood and adolescence. • The costs of failing to intervene are high • Lifetime costs of an untreated high risk child estimated at 2M • School, social, legal, substance abuse, suicide, teenage pregnancy

15. Process for Development of Plan Recruitment of additional workgroup members for this purpose. • Developed a shared understanding ECMH and supports for ECMH; • Completed an environmental scan of existing programs that support ECMH in the state; • Identified gaps and needs to be addressed; • Identified 5 broad goals that focus on the gaps in existing programming in the state; • Develop strategies under each goal; • Distributed for comment.

16. How Should Plan Be Used? • The plan is a guide for Arkansas’ public and private agencies and universities to support the development of a comprehensive system that supports early childhood mental health. • Recommendations target interagency collaborations, education and training, infrastructure, and investments of time and resources. • Broad goals are intended to be long-term. Specific strategies include short-term opportunities.

17. Five Overarching Goals 1. Families most at risk will be supported with services designed to keep families together. 2. Young children and their families will be fully represented in state cross-systems initiatives to support mental health. 3. Evidenced based screenings and referrals for social- emotional problems in young children and serious family risks will be expanded. 4. Early childhood mental health and early care and education providers will receive the supports necessary to improve child social-emotional outcomes. 5. Multiple public awareness efforts will focus on the mental health needs of young children.

18. Goal One - Families most at risk will be supported with services designed to keep families together. Family support services must be embedded into settings where high risk families are identified. This will require: • The expansion of accessible evidence-based/ promising parenting education and mental health interventions. • These services must be made available in all settings that serve children considered to be at high risk.

19. Family-centered court systems supported, replicated and expanded through the development and expansion of evidence-based, collaborative practices. • Utilizing the existing AR Safe Babies Court Team resources to raise awareness of needs of young children; • Expanding cross system partnerships between court systems and DHS divisions, in order to develop guiding policies and procedures for mental health and substance abuse providers working with identified families. Recommending: • The replication the Court Team model

20. Goal Two: Young children and their families will be fully represented in state cross-systems initiatives to support mental health. Best practices for young children and their families will be identified and implemented across interdivisional and interagency efforts led by the Arkansas Department of Human Services. Recommending that this would best supported by: • An identified staff member within DHS to work across divisions to support ECMH initiatives.

21. Young children and their families will become a priority in our behavioral health system. Early childhood mental health and interventions are dependent on early relationships and parent/caregiver involvement. The availability of a full continuum of services must include: • Promotion and prevention: e.g. parenting/caregiver education • Early intervention and supportive services: e.g. social skills curriculum & classroom supports • Treatment (e.g. mental health services such as parent-child interaction therapy, trauma focused cognitive behavioral therapy) • The usage of evidenced based treatments for children 0-5 with their caregiver.

22. Guided by the following principles: • An emphasis on developmentally appropriate assessments. • A focus on very young children - recognizing that evidence-based treatments are available to support high-risk parent-child dyad as early as infancy and continuing throughout early childhood. • The understanding that young children are best served in their natural settings.

23. Supported by: • State Child and Adolescent Service System Program (CASSP) council and local CASSP and Care Coordination Council teams increasing the engagement of young child serving entities and prioritize effective young child interventions. • That young child who meets the current Multiple Agency Planning (MAP) and Wraparound criteria (e.g. serious diagnosis, multi-agency involvement) are able to access the full array of all appropriate services and supports. • Data development through the DHS Division of Medical Services to track involvement of young children; The development of referral uniformity that addresses disparities through education and training.

24. Goal Three: Evidenced based screenings for social-emotional problems in young children and serious family risks will be expanded and referrals to appropriate services will be enhanced. Screen for family risk factors to identify children at high risk for early onset of social-emotional difficulties. • Providers of services to pregnant women will screen to identify mothers at highest risks for problems in parenting. • Screening for pregnant women and mothers of young children will include mental illness, substance abuse, domestic violence, catastrophic events, chronic illness and child welfare involvement. • The use of established and successful AR screening tools will be encouraged in primary care, home visiting and early education settings.

25. Children with early emerging social emotional problems will be identified through the expansion of routine standardized screening. • Routine screening with standardized questionnaires expanded in primary care, home visiting and early care and education. • In coordination with DHS, monitoring systems will be developed to ensure that groups of children identified as being at high risk receive screening on a recommended schedule. • Reimbursement incentives for screening and preventive services require development.

26. Goal Four: Early childhood mental health care providers and early care and education providers will receive the supports necessary to improve child social-emotional outcomes. Advocacy for the rollout of the Early Childhood Mental Health (ECMH) graduate certificate for behavioral Health providers to work with young children. • Increasing the collaboration between Higher Education, behavioral health and early childhood education training programs to support current and future workforce development. • Working with the State behavioral health licensing boards.

27. The promotion of promising and evidence-based mental health services for young children and their families through investment in training and support. Through: • DHS Divisional supported early childhood liaisons in local communities. • Investing in training and evidenced based mental health treatments for young children and their families. • Expanding the network of mental health professionals serving young children • Identifying and supporting the professional training needs of public and private providers. • Using tele-health for enhancing training and interventions.

28. Defining the appropriate role of mental health in the treatment of autism spectrum disorders and resolution of inconsistencies between private insurance and Medicaid. Recommendation: • To consider the successful approach used in the AR BEST program to disseminate the best practice of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

29. Invest in training for early care and education providers to Improve social-emotional outcomes by: • Providing additional training and supports for early care and education providers targeting the improvement of child social-emotional outcomes. • Adopting standardized Social-Emotional curriculums (ages 3-5) across providers. • Expanding AR Early Childhood Mental Health Consultation services using the AR Project Play model, across the state. • Developing protocols for increasing the coordination and communication across multiple systems including mental health, Part C, Part B and the Department of Education.

30. Goal Five: Public awareness of the mental health needs of young children will be increased. An ECMH toolkit with simple targeted messages about early childhood mental health will be designed for use with varied audiences. • Enhanced screening efforts will be accompanied with materials designed to facilitate the reduction of stigma related to screening. • AR customized materials will target the general public as well as behavioral health professionals, physicians and other medical providers and educators.

31. Public awareness campaigns will promote the importance of early childhood mental health and simple ways to promote children’s social and emotional development. Requiring: • Collaboration between DHS, ADH and AAIMH for development of media materials • A “train the trainer” format to prepare for an expansion of state-wide advocates who will be available to use the toolkit in their community with diverse audiences