Early Childhood Well Being (ECWB)

What if almost every young child referred for mental health services did not have a mental health problem? – It’s often about relationships.

Photo of Fred Cardenas
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Founding Story: Share a story about a key experience or spark that helps the network understand why this project got started or a story about how you became inspired about the potential for this project to succeed.

I hear demons telling me to be “bad”.
But I need my medicine to calm down.
Mom has a new boyfriend, but that’s okay cause dad has a new girlfriend.
No, I’m bad, I’m bad, I’m bad!!
Adult - I wish you had known what had been going on in my life when I was 4 years old.
Baby, pulling adult for attention, then quickly pushing away, then pulling in, then pushing away again…not knowing whether the adult can be trusted, or will leave baby alone again – working on a healthy attachment.
Child in her 5th foster home placement.

It's amazing & overwhelmingto consider that the statements above (except one) come from the experiences & words of 1-5 year old children.

Children 0-6, regularly get referred to our mental health program, mostly from classroom settings. Behaviors exhibited are often related to the relationships & interactions that the child is experiencing, or not experiencing. Some children as young as 3, who have been diagnosed with a mental health problem often have not been appropriately assessed . As a 31 year old man recalls with his former preschool teacher - "I just wish you had known what had been going on in my life when I was 4."

The program integrates various evidence-based practices: Parent Child Interaction Therapy strategies (parent follows child's lead and sets structure & clear expectations); 2nd Step Curriculum (social skills training curriculum); CLASS - assessment system focused on interactions between teachers and students; PBIS; Incredible Yrs

Which categories describe you? (the answer will not be public)

  • Hispanic, Latinx, or Spanish origin (for example: Mexican, Puerto Rican, Cuba, Salvadoran, Dominican, Colombian)

If you chose to self-identify your race, ethnicity, or origin, please share here: (the answer will not be public)

Mexican American

Website

https://www.family-service.org/early-childhood-well-being.html

Location: Where is your organization headquartered? [State]

  • Texas

Location: Where is your organization headquartered? [City]

San Antonio

Location: Where is your project primarily creating impact? [State]

  • Texas

Location: Where is your project primarily creating impact? [City]

All in Texas: San Antonio with some work in several small rural communities - Crystal City, Uvalde, La Pryor, Batesville.

Problem: What problem is this project trying to address?

ECWB was created in 2011 after years of recognition by Family Service Association of the link between many social problems & the roots often found in early childhood. Overwhelmed and confused parents, stressed teachers and medical professionals who want to provide relief often utilize traditional child mental health programs try to find a psychiatric diagnosis to find the solution. This program focuses on the context & relationships experienced by the child. Goal - prevention/early intervention - working directly w/parents, schools & community with true collaboration. Adolescent or adult mental health problems and often have their roots in early childhood and brain science has shown much can be done to maximize resilience starting in early childhood. High school drop out, adult mental health problems, or trauma responses can start with a fundamental resilient trajectory of healing

The program is promoting a better understanding that child mental health - (mental well-being) exists within a context of family and community who interact with young children on a regular basis. There are lots of dynamics that contribute to adults who may prefer a traditional child mental health approach that "blames the victim", tries to identify "quick and easy" solutions (such as psychotropic medication or blaming teachers or parents), and has parents who may have difficulty accepting that a child may have a developmental delay or other special need (and not a mental health issue), or teachers who work within school and childcare systems that are inadequately prepared to effectively address mental health concerns in the child's natural environments.

The solutions include maximizing those psychosocial interventions that include the context directly (classrooms, parents, community) and "slow down" the process to ensure adequate assessment where the environment or context of the child is examined as closely as the child and his/her behavior. These psychosocial interventions include early childhood practitioners who can effectively implement evidence-based practices in partnership with parents and teachers who can impact the full context of the child using EBP's such as Parent Child Interaction Therapy, Incredible Years parenting programs, 2nd Step Social Skills Curriculum, and Positive Behavioral Intervention and Support .

To provide an example of program services, the following describes what one of the early childhood clinicians may experience in a typical day. They often start at a campus to observe a referred child and conclude their 1-2 hour visit with a consultation for the teacher with written recommendations (usually classroom or behavioral management strategies). They will visit several campuses in a day. After so many visits for a referred child, the clinician may develop a behavioral plan in collaboration with the teacher and we do follow up coaching and support for the teacher. Staff may hold off on full family integration (for classroom referrals until after 2-3 visits) as 50-80% of those referrals are due to classroom management problems and not a true mental health problems although they may be difficult to differentiate without those extensive observations. Clinicians do home visits after a few classroom observations to do a family assessment and then begin individualized parenting sessions (PCIT and Incredible Years strategies used) with an option of brief counseling for child, parents, or other family members. Most of the interventions are integrated into the classroom so lots of training, coaching and guidance is given to teachers. Staff may attend an IEP meeting (called ARD meetings in Texas) to help parents advocate for their child. All staff provide training related to early childhood mental health (program does an average of 1-2 training sessions per month with teachers and parents being the primary participants). Late afternoon, eves or Saturday mornings may include home visits.  Program staff are quite excited about a new project, Early Intervention Court (baby court) in which 0-3 year olds in the foster care system get the comprehensive services that may include foster parents, biological parents, other caregivers and the child. It is modeled after drug courts so parents get increased visits and expedited reunification based on progress.

ECWB is also working on the child advocacy and policy advocacy side of mental health working in partnership with many local and state advocacy agencies to help remove barriers to availability and access to developmentally appropriate early childhood mental health services.  The program has led the creation of a local chapter of an infant mental health association, has brought policy experts to train community members and leaders in policy advocacy, and helped to create opportunities for professionals to help educate and bring awareness to policy makers regarding early childhood mental health and related issues.

The latest part of the program now is collaborating with a local Federally Qualified Health Center to provide integrated healthcare where the center's child psychiatrists and pediatricians divert mental health referrals of young children to ECWB to provide those more developmentally appropriate psychosocial interventions.

All of this work includes advocating for teachers and families and educating them and learning from them to maximize the effectiveness of early childhood mental health services.

Is your model focused on any of the following traditionally underserved communities?

  • Communities of color
  • Children who are differently abled
  • Low-income communities
  • Other

Does your model work within any of the following sectors?

  • Childcare
  • Child and Family Services
  • Criminal Justice
  • Education
  • Mental Health
  • Other

If you chose "other," please share the sector you work within here:

Family advocacy and child policy advocacy

Year Founded

2011

Project Stage

  • Growth (the pilot has already launched and is starting to expand)

Example: Walk the network through a specific example of what happens when a person or group engages with your solution.

A federally qualified health center recognized the importance of more appropriate early childhood mental health services for young children & now partner with the program to divert children from being inappropriately/prematurely diagnosed & medicated with psychotropic medications. The program is extending its home-based services (where the clinic could not do that) & integrates special education advocacy.

Early childhood mental health training is provided to to 900 people anually. A local community college & a child advocacy agency have also partnered with the program to provide policy advocacy training for community leaders, teachers & other professionals to support their efforts to raise awareness with state/local policymakers.

Impact: What was the impact of your work last year? Please also describe the projected future impact for the coming years.

About 200-250 children are impacted annually directly with early childhood mental health consultation services in classrooms and homes. 900 training participants (most of who are teachers) then impact the 10-20 children in their classrooms. Surveys and pre-post comparisons have resulted in over 90% of children exhibiting behavioral improvements, over 85% of teachers and parents expressing gained confidence in addressing their children's/student's behaviors. And over 90% of training participants have learned something they can utilize in their work with children.

Program services are bieng sought by many community entities and one goal of the program is to integrate this mental health approach in all elementary schools and into primary healthcare provider offices. Impact on policy to increase funding and access is an additional goal.

Organization Type

  • nonprofit/NGO/citizen sector

Annual Budget

  • $250k - $500k

Financial Sustainability Plan: What is your solution’s plan to ensure financial sustainability?

Currently a local health foundation has committed ongoing support and new foundations are also now supporting efforts. The program has also contracted with school districts, head start, early head start to provide child mental health services. One of the challenges is that while the program avoids diagnosing unless necessary, most insurance billing in Texas requires a label or diagnosis of the child. We are working on the policy advocacy.

Unique Value Proposition: How else is this problem being addressed? Are there other organizations working in the same field, and how does your project differ from these other approaches?

There are 2-3 other programs in Texas also doing early childhood mental health consultation all at different stages of development. Our program has existed for 5 years and also now secured state funding with a Texas SAMHSA grant. Most of these funding efforts are short-term so we plan to continue to seek long-term funding and also work with policy advocacy to get insurance providers to allow billing for these services. It is verty difficult to access developmentaearly childhood mental health services in Texas as is in the rest of the country.

Reflect on the Field and its Future: Stepping outside of your project, what do you see as the most important or promising shifts that can advance children’s wellbeing?

The field needs to get away from child mental health practice as usual- labeling, diagnosing, medical model, sometimes influenced by business oriented forces (pharma) Mental health professionals must examine children's experiences and environments much more closely and the most effective intervention is likely to more intentionally engage teachers and parents more effectively vs. "blaming the victim". True prevention is the key - why just treat the 10 year old diagnosed with ADHD when we can effectively prevent that trajectory with the 4 year old in partnership with home, school & community.

Source: How did you hear about the Children’s Wellbeing Challenge? (the answer will not be public)

  • Email
  • Other

Referral: If you discovered the Challenge thanks to an organization or person other than Ashoka, who was it? (the answer will not be public)

listserv from RWJ foundation.

Program Design Clarity

From an early childhood partner agency (over 10 partners/35 locations), a concerned teacher, parent or human service professional expresses concern over a child (ages 0-6) due to extremely aggressive, anxious, withdrawn or otherwise disruptive behavior. Concerned adult submits a referral - child is observed in his/her natural setting (school, home, childcare, etc). Child is assessed within the context of the natural environment. Behavioral specialist works closely with the adult providing weekly early childhood mental health consultation, on-location (home, classroom...), 80%+ kids improve.

Community Leadership

The program is developing an advisory council. It serves many Head Start programs which have parents and professionals who provide guidance and oversight over the programs operations including our progam mental wellness support/early childhood mental health consultation services. Special education advocacy is a big part of the work and this work entails being in tune with the desires of parents for their child and advocating WITH the parent.

Age of Children Impacted

  • Pregnancy - 0
  • 0-1.5
  • 1.5 -3
  • 3 - 5
  • 6 - 12

Spread Strategies

Training and community awareness presentations, partnerships throughout the state with statewide policy advocacy collaboration. Bringing evidence-based practices, training and resources to community partners and mentoring interns who then multiply program impact through their integration of developmentally appropriate early childhood mental health services into other systems. Policy advocacy extends reach to support child policy efforts.

Reflect on how your work helps children to thrive. How are you cultivating children’s sense of self, belonging, and purpose through your model?

Young children exhibiting agression become assertive and able to appropriately express their needs.
Children with developmental delays receive appropriate intervention, referrals and advocacy to link to appropriate school and early intervention services. ATTACHMENT and relationships are a foundational focus of the program, with and between (children, caregivers, parents, famlies, policymakers/decisionmakers, mental health professionals.

Leadership Story

Nancy Hard, CEO for Family Service Association, and her executive team decided that with its over 100 year history (at that time in 2010) of providing human services to some of the neediest and most vulnerable populations, the roots and trajectory of many social ills addressed by Family Service Association over the years could be found in early childhood. Fred Cardenas was selected as manager and he brought extensive experience in child mental health, childcare, early childhood education, grantwriting, and program development and management to help initiate the program with 3 staff to now 15.

What awards or honors has the project received? (Optional)

The Program was Recognized as a Community Partner by RAISING TEXAS, a statewide effort supported by then Governor of Texas, Rick Perry.
The Program which started with a grant from one local foundation and 3 staff, has now grown with contracts and other grants to have a team of 15 professionals.

Organization's Twitter Handle

@FamilyServiceSA

Organization’s Facebook Page (URL)

https://www.facebook.com/Family-Service-Association-of-San-Antonio-Inc-1165

Leader's LinkedIn Profile (URL)

https://www.linkedin.com/in/nancy-hard-24302012?au

4 comments

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Photo of Nathan M McTague, CPCC, CPDPE
Team

Hi Fred,

I really appreciate the approach you describe - investigating the context that the child is in and reinforcing healthy relationships, among other things, as a way of preventing heavy medication, improper labeling of the child as "mentally ill", and the wide variety of disruptive behaviors that arise when a child's needs go unmet in exchange for behavior modification. It sounds as though, instead of waiting for a child to become disruptive, or exhibit what could be considered signs of mental illness, you seek to work directly w/parents, schools & community when the child is still very young in completely alternative ways in order to achieve maximum and long-term effect.

You mention a few programs: Parent Child Interaction Therapy, Incredible Years parenting programs, and 2nd Step Social Skills Curriculum, can you include a description of these in your submission? How do they work? 
Also, it's always informative to see how your solution works on an individual basis. Would you be willing to include a story of a particular individual and how your solution helped them to not be mistakenly diagnosed and medicated and instead supported in a more wholistic and effective way?
Thanks so much for sharing your work!

Photo of Fred Cardenas
Team

Thanks so much for your interest and your comments. I'll include links to websites below which provide more information. Our early childhood clinicians integrate these evidence-based practices into a strategy called Early Childhood Mental Health Consultation ( http://gucchd.georgetown.edu/67637.html ) which can be best exemplified by a case of one of the typical children with whom we work. Last year A 4 year old boy was referred due to extreme aggressive and disruptive behaviors in his pre-k classroom. The child had physically hurt his teacher, principal and peers – causing scratches, bruises, and he had been briefly hospitalized. He was also exhibiting some obsessive compulsive behaviors. Developmentally the child was actually doing well, when he would not disrupt others. A child psychiatrist had prescribed medication for ADHD and to help him sleep at night. The referral to our program was provided by his teacher (a certified and degreed public school teacher) who had wonderful structure and was both nurturing and set clear appropriate limits. Parental consent was also provided. The assigned clinician began services with classroom observations to help assess the extent of his behavior and to consult with the teacher. Clinicians have specialized training and/or focus (Classroom Assessment Scoring System – a tool to measure the interaction between students and teacher) as we have found that 50-80% of observed behavioral challenges stem from the response or lack of response by the teacher – not that teachers cause the behavior but rather they may not know how to address it and their efforts or school lack of resources can sometimes exacerbate behaviors. So staff may also get involved in advocating for special education evaluation and subsequent resources in collaboration with parents. After several observations and providing the teacher with strategies, the clinician met with mom (home visits) and began to help mom and grandma implement strategies at home (on average our early childhood clinicians spend about 85% of their time in the classroom observing consulting and intervening directly, 10% in the home or office with family and the other 5% in ARD meetings, 1-1 sessions or group sessions) . The clinician also consulted with the community child psychiatrist who agreed to stop the medication briefly (two weeks) to help teacher and clinician get a baseline of his behavior without meds. Teacher was on board and clinicians made themselves more available at the school on his first few days of attending school without meds. Child did extremely well and teacher was fully on board with strategies provided. Being off his medication eliminated his obsessive compulsive behaviors (e.g. repeatedly packing his back-pack at the end of the school day over, and over, and over again even after his ride waited for him to take him to childcare). The clinician also helped to guide the family members (grandma, mom and siblings) to react in a supportive but less negatively reinforcing way – the family’s day to day lives were mostly determined by the mood of the child prior to intervention. After 2 additional weeks of supportive intervention, the teacher and parents were happy with his progress and clinicians stopped the classroom visits and offered follow up home visits. The doctor did continue to prescribe just the medication to help him sleep. The first week he was off his meds, teacher commented how she felt she was truly getting to know the real child. This case example is not provided for the purpose of saying that psychotropic meds are always inappropriate, but often, for young children, the context and responses of the child’s environments are not taken as strongly into consideration and are sometimes not as involved in the interventions. And meds are often too easy an answer for parents or teachers and can have the unintended consequence of reducing efforts with other psychosocial interventions. This case exemplifies the holistic nature of the intervention within the whole context of the child (services were also offered to his after school childcare program) involving parents, family, teachers and other providers. Program staff have also provided services in other natural environments such as by accompanying families to church or the local grocery store- again to help observe genuine behavior in the moment and provide immediate intervention and coaching for parents and teachers. Program staff also provide group and individual training on behavioral interventions and other related topics. More information about oujr policy work can be shared but no room on this posting. The program places a lot of emphasis on developing and sustaining meaningful community partnerships. Most recently the program is working with a community health center that is integrating medical and mental health and and the program is also working with partners in the early stages of an Early Intervention Court (baby court modeled after drug courts).

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