HD3 - Feasibility Study of Developing an Early Childhood Mental Health Consultation Program (HJR 51, 2020)
House Joint Resolution 51 (HJ51) was passed by the Virginia General Assembly in the 2020 legislative session. This legislation tasked a workgroup, led by the Virginia Department of Education, the Virginia Department of Social Services, and the Virginia Department of Behavioral Health and Developmental Services, with studying the feasibility of adopting a statewide Early Childhood Mental Health (ECMH) consultation model to prevent suspensions and expulsions of young children attending early care and education programs in Virginia. The resolution outlined five specific tasks for the workgroup to complete:
i. identify the appropriate state agency to scale up a statewide ECMH consultation program,
Suspensions and Expulsions from Early Care and Education Programs
Over the past decade, the alarming use of suspensions and expulsions in early care and education settings has received much attention from researchers, practitioners, and policymakers.(*1) In Virginia, nearly 6 children for every 1,000 enrolled are suspended or expelled from public preschool – a rate that is the sixth highest in the nation.(*2) This rate increases to 13 children for every 1,000 enrolled when including a variety of early care and education settings, including Head Start, Early Head Start, child care centers, Virginia Preschool Initiative (VPI), day home providers, and early childhood special education (ECSE) programs.(*3) The use of suspension and expulsion in preschool, much like in K-12 education, is inequitable.(*4) Children with mental health issues and behavior problems, Black children, and boys are at an especially heightened risk of being disciplined through these exclusionary practices in early childhood.(*1),(*5)
The COVID-19 Pandemic’s Negative Impact on Young Children
Critically, Virginia, along with the United States and world, is facing an unprecedented health and economic crisis with the current COVID-19 pandemic. The pandemic is having an outsized impact on low-income families and communities of color.(*24),(*25) Young children’s daily routines, early learning, and social experiences have been upended resulting in significant and serious negative impacts on young children’s lives. Given the current context and deep concerns about rising inequities due to the pandemic, Virginia should strongly consider initially prioritizing access to an ECMH consultation for the most under-resourced communities, early care and education programs, and children.
Early Childhood Mental Health (ECMH) Consultation
States are increasingly investing in ECMH consultation to address children’s challenging behaviors, support their mental health well-being, and prevent suspensions and expulsions from group-based early care and education settings. ECMH consultation is an intervention strategy that pairs a mental health professional (i.e., “consultant") with the adults (i.e., caregivers, teachers, and families) who work with infants and young children in the settings where they grow and learn.26 ECMH consultation improves children’s social, emotional, behavioral, and mental health outcomes by building the capacity of the adults who interact with children and their families.(*26),(*27)
Previous research demonstrates that the use of ECMH consultation is associated with improvements in children’s behavior, including decreases in challenging behavior and increases in social skills, communication, and self-control.(*28) Further, ECMH consultation is consistently linked with improvements in quality of teacher-child interactions and classroom quality.(*29) Of particular relevance to the current study, ECMH consultation is associated with fewer instances of expulsion; some theorize that ECMH consultation, although not created to address implicit bias, may reduce implicit bias among teachers, thus affecting disciplinary decisions, particularly for young boys of color.(*37)
ECMH consultation must be of sufficient quality and dosage in order to improve adults’ interactions with children and children’s social-emotional skills and mental health. Experts in the field, including the Center of Excellence for Infant and Early Childhood Mental Health Consultation, strongly encourage the use of master’s level mental health professionals for ECMH consultation. Additionally, research consistently points to the consultative alliance, or the degree to which the consultant and consultee perceive that they are working as partners, as a key factor for promoting the effectiveness of ECMH consultation.(*39),(*48),(*49)
Implementing ECMH Consultation Within the Pyramid Model Framework
In order for an ECMH consultation program to be used effectively and strategically, it should be implemented within a multi-tiered system of support (MTSS). MTSS is a data-driven, problem-solving framework that uses a continuum of evidence-based practices matched to student needs to improve outcomes for all students. The Pyramid Model for Promoting Young Children’s Social Emotional Competence is a MTSS system designed specifically for early childhood education and care settings. The Pyramid Model is a framework of evidence-based practices provided by teachers, home visitors, coaches, behavior specialists, ECMH consultants, program leaders and others to support young children’s social and emotional development and prevent challenging behavior in early childhood settings.(*50),(*51) The Pyramid Model starts with universal strategies to support all children in the classroom and moves toward more targeted interventions for children with severe and persistent challenging behavior.(*54) This tiered model of support results in strategically utilizing mental health professionals for the children who need it most, while also utilizing other prevention and early intervention options that are available within the early childhood system (e.g., evidence-based professional development opportunities, practice-based coaching, use of a behavior specialist). At all tiers of support, all providers serving children and families must be trained to promote social and emotional development, driven by developmentally appropriate practices including nurturing and supportive interactions and trauma-informed approaches.
Funding and Scaling ECMH Consultation in Group-Based Early Care and Education Settings
States across the nation are increasingly investing in ECMH consultation to address children’s challenging behaviors, support their mental health well-being, and prevent suspensions and expulsions from group-based early care and education settings because it is recognized as a cost-effective strategy.55 Funding ECMH consultation can be challenging, though, due to the prevention-based nature of the service and lack of a dedicated funding source. States use a myriad of approaches and sources to fund their ECMH consultation programs, but the most prevalent funding sources being leveraged are state general funds and federal grants such as the Child Care and Development Block Grant.56 States also approach scaling ECMH consultation programs in different ways, however, it is common for states to implement an ECMH consultation program in a smaller-scale pilot before expanding to reach statewide capacity.
The following recommendations were developed by the HJ51 workgroup members, led by the Virginia Department of Education, the Virginia Department of Social Services, and the Virginia Department of Behavioral Health and Developmental Services. To develop these recommendations, workgroup members consulted with national experts, conducted research on effective ECMH consultation programs, reviewed other states’ ECMH consultation programs, analyzed the existing set of resources in Virginia to draw from, and held rich discussions through a series of workgroup meetings. Further context and details for these recommendations are provided on pages 26-33 of this report.
1. Recommendations for Developing an ECMH Consultation Program:
• Continue investments in the larger infant and early childhood mental health system in Virginia. Additionally, further study how to build and coordinate a comprehensive and connected system of infant and early childhood mental health that includes consultation in other settings (e.g., home visiting, primary care) as well as other mental health services that serve Virginia’s infants, toddlers, and preschoolers.
• Within group-based early care and education settings, situate an ECMH consultation program within the education system and a multi-tiered system of support (i.e., Pyramid Model Framework).
• Coordinate an ECMH consultation program across the infant and early childhood mental health and the early education systems more broadly and within the larger early childhood education workforce (teachers, home visitors, coaches, behavior specialists, program leaders, and ECMH consultants). Draw from services that already exist in Virginia.
• Develop a centralized system to receive requests for services.
• Consider implementing ECMH consultation services using regional networks.
• Ensure that ECMH consultants are sufficiently trained and will offer consultation services that are evidence-based.
2. Recommendations for Building a Qualified Early Childhood Workforce, including ECMH Consultants:
• Build a comprehensive and diverse workforce within a tiered system of support that includes early childhood teachers, coaches, behavior specialists, home visitors, program leaders, and ECMH consultants.
• Invest in the development of a skilled and diverse ECMH consultant workforce.
• Make intentional efforts to recruit and retain ECMH consultants who represent the demographic make-up of the children being served.
• Further develop coursework and training related to infant and early childhood mental health at universities.
• Create opportunities for professionals seeking to become an ECMH consultant to obtain relevant work experience.
3. Recommendations for ECMH Consultant Qualifications and Competencies:
• Require that ECMH consultants meet the following basic qualifications:
• Ensure that ECMH consultants display the competencies outlined by the Center of Excellence for Infant and Early Childhood Mental Health Consultation (included in Appendix C). These competencies are very comprehensive and are intended to guide the hiring, training, professional development, and evaluation of ECMH consultants.
• Explore ways of credentialing ECMH consultants to distinguish them from other, similar workforce roles that do not have the same level of clinical mental health expertise in early childhood.
4. Recommendations for Building the Infrastructure to Implement a Statewide ECMH Consultation Program:
• House the contract centrally within the Department of Education and create formalized partnerships with other relevant agencies including the VDBHDS.
• Develop state-wide infrastructure for coordinating and monitoring ECMH consultation across regions.
• Create an advisory committee with cross-agency representation to get buy-in and support or use an existing group such as the Early Childhood Mental Health Virginia Advisory Board.
• Explore the feasibility of developing out to the broader mental health system to create a comprehensive service system for infants, toddlers, preschoolers, and their caregivers beyond early care and education.
5. Recommendations for Funding an ECMH Consultation Program Within a Fully Implemented Pyramid Model System:
• Fund prevention and promotion efforts at tiers 1 and 2 of the Pyramid Model and partner with organizations doing this work currently.
• Develop a sustainable funding mechanism for ECMH consultation that utilizes multiple funding sources, including a mix of both federal and state funds.
6. Recommendations for Evaluating the Impact of an ECMH Consultation Program:
• Require evaluation of the ECMHC model to ensure that the investment is leading to improvements, including the prevention of suspensions and expulsions.
• Gather and connect data from multiple sources and systems to understand the effectiveness of an ECMH consultation program.
• Determine categories of data that are being collected and include both implementation and outcome data.
• Make data available to the public.
Summary and Next Steps
The recommendations presented here are broad and comprehensive. Additional time and study will be required to determine specifics related to funding and statewide implementation of an ECMH consultation model. Consistent with other states who have adopted ECMH consultation models, the General Assembly may wish to begin by funding an initial smaller program, evaluating its success, and then scaling to a comprehensive and statewide model over a few years. In response to the disparate impact of the COVID-19 pandemic on disadvantaged children and families, the General Assembly may wish to prioritize access to an ECMH consultation program for the most under-resourced children attending early care and education programs.
(*a) Note that some have argued that a bachelor’s degree may be substituted with substantial experience and supervision by a licensed mental health professional, although this is not aligned with guidance from the Center of Excellence for Infant and Early Childhood Mental Health Consultation.