AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
JANE KNITZER: I'm glad Walter said that, because I have no cartoons, and you're a very hard act to follow. So, um, okay, I'm going try to talk fast. I don't know if we can possibly squeeze some questions in, but I would like to do this. So how many of you actually know about the National Center for Children in Poverty? Oh, good. Okay.
The rest of you, your assignment, go home, do www.nccp.org. You will actually find a couple of things besides SpendIng smarter. One of them is a new report called Pathways to Early School Success, Helping the Most Vulnerable Infants and Toddlers.
And I want to say that right now, I wasn't going to. But I think, you know, what Walter has done to turn the spotlight on the issue of children, young children with challenging behaviors is, um, priceless in a sense. I mean, where could we get that kind of coverage?
However, then what? Okay. You all are the then what's. Because, you know, the coverage lasts and then it goes away and then we get something else. All right? And I think it's really important that the message not be ‑‑ one way of handling this expulsion data is to create a pull‑out mental health system where we label all these kids and get them therapy. Real danger. Not. Okay? Another is to say it all happens, you know, at three‑ and four‑year‑olds. Not. It happens much, much earlier in the relationship.
So first message, mental health starts with early positive relationships. Okay? I just think it's really important. This isn't exactly how I planned to start the speech, but that's okay.
So go to our web site, and let me just tell you two sentences about NCCP. We are mission‑driven in the university, which is already a little challenging. Our mission is to promote economic security, health and well‑being of America's low‑income children and families. We're university‑based. You can't read any of that, can you? Well, maybe. Part of the Melman School of Public Health. And what we are really trying to do is advance research‑informed, policy‑oriented solutions.
We really have a huge gap between what we know and how do we structure our policies. And everybody in this room is working to close that gap and we want to try to help all of you. In addition to Project Thrive, which you heard about from Kay and which we host, and I'm very proud, I have to say I'm really proud to be a part of. I've spoken to a lot of different groups. I've never really encountered AMCHP before and it's a real pleasure. I've encountered some of you individually, but not as this group, and I'm really delighted to be part of this today.
But NCCP also has other resources, including something called Child Care and Early Education Research Connections. Where, if you do want to find out about what research about, for example, child health and child care, you can Google that. Those of you who get the 4:00 call from the commissioner, or if you are the commissioner from the legislature, people tell us this is very useful for policy makers so check it out.
My task here is to talk about, okay, so what is a support system for early childhood social ‑‑ healthy social and emotional development? I'm not even going to go through the questions. You're just going to have to listen and assume this is a very logical presentation.
Okay. So you all know healthy social and emotional development, and I think it's really important to demystify this. I don't know how many conversations I've had with people who say to me, "I don't know anything about social and emotional development in young children." And I say, "Do you put your arm around your baby when you read?" And they say, "Yes." I say, "That's social‑emotional development." It's a little bit like what Ed's slides had yesterday. Parents really worry about all of these things, but they also are very puzzling to them and mysterious.
So what we're really talking about helping children regulate, manage emotions in an age‑appropriate way, relate to adults and relate to their peers. And also to feel good about themselves. To trust that they are confident, and this really happens very early, to able to reach out and explore. When we talk about building systems to support healthy social and emotional development, this is what we're talking about, and the key is healthy relationships.
It's not one size fits all. You already have gotten that. But it is because it's not one size fits all, it's a very complicated to think about building. And even in the context of early childhood consultation, consultants deal with children who are seriously emotionally disturbed, but they deal a lot more with stress in providers.
And not only stress, providers not knowing how to handle children and how to respond when they do something that they don't like. And you know how one kid can set off ‑‑ well, I don't know how many of you the last time you were in a child care with a group of kids, but one kid can really set off the whole room. And if the teacher doesn't know what to do, that child becomes the scapegoat. And rather quickly, that child can in fact develop social and emotional problems. Because if you're told you're bad all the time, you really believe it.
So we have some serious issues if our goal is really entering school ready to succeed. A huge component of which is actually social and emotional. Feeling that you can succeed, being able to sit still.
So early detection and prompt interventions matter. Interventions targeted to specific needs matter. I think there's one other thing to worry about. In the older kids' children's mental health system, we're beginning to see research that tells us that usual and customary care has zero size effects.
There's some new research, which is really very troubling. Now, we all know that there are therapists who are gifted and there are other therapists who are not gifted. Probably it washes out in the usual and customary care studies, but I do worry about the importance of our being careful about and evaluating, as Connecticut is doing, what we are actually investing in as we develop these systems.
There is no one strategy, nor is there one setting. Early childhood mental health needs to be wherever children and families are, period. Not negotiable. Not pull‑out therapy. So we're talking about intentional strategies to promote social and emotional health, and we're talking about an infusion principle. We infuse the mental health into the settings where children and families are. And if you don't remember anything that either of us said, remember two I's, intentional and infusion. Those of you who are cooks, you know how you put garlic in oil and you infuse it? This is something I've just learned. This is what we need to do to make it taste better in across early childhood settings.
Pediatric practices, home visiting, early Head Start, child care and pre‑k. And the universal pre‑k public dialogue conversation is remarkably devoid and has made very little connection with Walter's powerful date. You may notice that in the conversations. It is, in fact, all about the return on investment.
But I'll tell you something, unless we pay attention to the quality of universal pre‑k, we're not going to get the returns on investment that everybody is promising. So a word to the wise, and as you do your ECCS grants, think about that.
We're talking about clearly, you know all this, probably you know it better than anybody else in the country. A continuum of services. If you juxtapose promotion, prevention and intervention against your pyramid, I think that we begin to see some ways of creating a matrix that can sort out how you pay for the kinds of support services that we're talking about.
So what is a policy framework? What does this really mean when we're talking about social and emotional development? We're talking about a system of supports for young children, listen up, for young children, for their families and for their other caregivers ‑‑ I want to really reinforce that. For their families and for their other caregivers, including pediatricians ‑‑ to promote age‑appropriate social and emotional development. And I would add, especially for children's whose development is compromised by poverty and other risk factors.
We have 24,000,000 children under six in this country. 43 percent of them are in families earning 200 percent of the poverty level or less, and 20 percent of them are growing up in poor families. These are the children that we really need to worry about.
A public health approach, I hardly have to say what that means. But we clearly need to strengthen parental ‑‑ I'm going keep saying this actually, but I think I'm talking to the choir, so, um ‑‑ and addresses prevention, early intervention and treatment.
And you all probably have discovered in some of your states, hopefully, you've had conversations with people from the mental health system. Some of them know nothing about early childhood and actually don't believe that mental health issues start before six. That is official state policy still in some states. So your partnership really is a two‑way partnership that will be very, very important.
So policy system goals. I'm going to say it again, promote early learning and healthy behaviors, foster skills in other caregivers, reverse poor social and emotional development trajectories, remove parental barriers and risks to effective parenting. Okay? Depression, substance abuse, domestic violence, are all barriers to effective parenting that play out in young children's behavior. We do not organize our systems to address that. We have a system for adults, sort of, and we have a system for children, sort of. And your challenge is to put these two systems into a family‑focused support system together.
And the depression issues are huge, as you all know. I think there was a challenge in this slide from Illinois as well today, which is, I know a lot of you are of beginning to develop perinatal and prenatal and all this depression stuff. We need to link that with the ECCS grants in a very visible and clear kind of way.
And the last challenge is, yes, Virginia, there are seriously emotionally disturbed young children and they need to have access to the best treatment that we can get them.
Policy building blocks, research, lessons from other states, the kind of thing that you heard in this wonderful presentation this morning, and implementing intentional strategies that have a likelihood of paying off. You can't read this. I'm not even going to spend much time on it.
The policy building blocks in through a social and emotional lens, screening. There are also classroom screening efforts that become teacher training tools. So you need to see what's going on in your state. And gosh knows, you know, Commonwealth and all of you are out front on this. And I would say the three things that Ed talked so eloquently about at lunch yesterday.
But also think about investing some of your infrastructure dollars in cross‑system training. Okay? At a community level, we waste gobs of money on one‑shot training workshops that don't mean anything to anybody. Okay? So cross‑system training on what we are learning about early brain development, all that stuff.
Classroom‑based curricula. I can tell you a really interesting story about a different model of mental health interventions. It is a program called Tools of the Mind and the aim is to help young children regulate and think about their emotional behaviors, as well as their cognitive behaviors. Anybody here familiar with it? Okay. One person. You can be the spokesperson.
So Tools of The Mind, I visited a class ‑‑ school in New Jersey where they were implementing Tools of The Mind. It's really quite amazing to see. Using a hangman kind of thing, the kids either draw or say what part of the circle, you know, the room they want to go and then they do it every day. And at the end of the week, they look back and they say, you know, "This week I did this." It's really, um, a very rich and theoretically‑grounded intervention.
So I asked the principal in this school, which was an old, horrible public school looking like the ones that I went to, um, was all pre‑k programs. I asked the principal what difference having this in this school made. And she said to me, "This is the only classroom that I don't have to send the security guards in." And they were burly guys with security guards in yellow. And they went into classrooms. And I went into some of those classrooms and I saw one of the classrooms where they called the security guard. And I can assure you, it really had to do with the teacher feeling, had no clue about what to do. So there are all kinds of strategies that you can, through your partnerships, support.
Examples of early intervention. Clearly early childhood mental health consultation, and not just focused on the child. We have to go in and really assess what's going on in the classroom, perhaps in the family, and then in the child.
You can invent family‑focused interventions in pediatric and early child care settings. We have several new documents that actually talk about ‑‑ there's some really interesting example. For example, in home visiting, people aren't talking as much as they should be about the families that we can't help through home visiting. Okay? But in general, they're the ones with mental health issues, domestic violence, substance abuse.
In a program, a regional program called Every Child Succeeds, for the Cleveland area ‑‑ is anybody here from there? Do you know about it? No. Okay. They are embedding cognitive behavioral therapy into the home visits. They're partnering ‑‑ they're bringing a therapist into the homes. There have been dramatic changes in the depression levels in the moms and dramatic change in the language of the infants and toddlers. And if there's one thing we should all be promoting, it's early language development.
In that program, the rate of parental depression was about 44 percent. It's 48 percent in early Head Start. And the other hidden reality that we don't talk about in working with these families is the role of parental trauma. 69 percent of these moms, who were served in this program, which is ‑‑ which actually was they were implementing Healthy Families America and the Nurse Partnership Program, 69 percent of them had experienced themselves, some kind of violence or abuse. So these are traumatized moms. We're asking them to be their child's first teacher in the way that some of us who have not been so traumatized are also asked to do. We need to embed interventions for the moms and the kids. So I think if you take away three things, I, I and embed, and you can even think of that as the third I, it's okay.
Examples of treatment strategies. I'm not going to go into this too much. There are some really important new ways of thinking about treatment. One of the target populations that you should all be worried about, young children in the child welfare system. And I don't know to what extent you ECCS teams have been able to reach out to the child welfare system, but find out how many young children are entering in the child welfare system. That is an opportunity. And we even have some evidence‑based treatments.
I'm going to just quickly talk a little bit about infrastructure examples, but I suspect that you know this out the wazoo. Planning capacity, common cross‑system tools, including think about common definitions of who is at risk? What are the risk factors? Right now we make it very complicated, because every program that is serving at risk has a different set of at risk. And you all know I should have said, but the hardest group of children to serve, of course, are those who don't have a diagnosis. If they have a diagnosis, we have some mechanisms and that's where we have to put our emphasis.
Examples of best fiscal policy practice. And Kay talked about Spending Smarter, and you certainly heard what Illinois is doing. But I think it's really important to get into the nutty-gritty. A couple that are really important, obviously paying for ‑‑ paying pediatric providers, but also paying for family‑focused treatment.
Go home and find out if your state pays for infant and parent therapy. We still have some places where children's mental health, through the Medicaid program, are only paying for child‑focused therapy. The child is the indicated client, which is really a miserable word.
And some of you have heard me speak have heard about a story, this was many years ago and I'm sure it would never happen in your own states, but a State, a community mental health center they made a decision to serve an infant. Who was the indicated client, the infant or the mom? It's a little hard to serve the infant alone, right? Who was the indicated client? They chose the infant. The controller got very upset because the infant couldn't sign the treatment plan. I swear this really happened. Because I'm not a cartoon person, so I couldn't have made it up. So I said, "Well, what about a thumb print, you know, or a footprint?"
Now, fortunately, there were people from that state who had figured out how to game the system. The problem is it's getting too much to keep gaming the system. So go back and if you're one of those states, fix it.
Pay for screening for parental depression, but not only for screening for treatment. And do it so that you do depression, you help the mom and the parents with the adult issues. You help the child and you deal with the parent‑child relationship. Because not to deal with the parent‑child relationship isn't going get it anywhere.
I'm not going to really talk about state strategies and action. You heard about Connecticut. You have a workshop tomorrow, I think, on Kentucky. Louisiana has been trying to build. There are states that are trying to build systems. What's interesting about them is they're all doing different interventions. They're doing different payment strategies. They're reflecting differently partnerships. There's no one way and we're just at the beginning of doing the learning about what really is most effective.
We are analyzing all the State plans for ECCS and NCCP. This is an acronym test. And you've told us what you need and what some of your goals are. You really want to focus increasing partnerships with primary health care. Create incentives to screening, improve Medicaid screening.
I think develop common‑shared referral mechanisms is really something to pay special attention to. And I would say cross‑generational referral mechanisms, as you think about the social and emotional piece of this.
Some challenges, I don't have to say this, but what the heck, tough and uncertain federal context. Multiple consultants to child care. We had a very, very interesting panel conversation at a recent child care technical assistance network meeting, where we brought together people talking about mental health consultation to child care, health consultation to child care and the emerging network of infant‑toddler specialists around the country.
We need to actually impose some reason and help all of you think about what's the best investment? And so, if you've got both those things going, figure out how to really maximize the impact. The fear, of course, is you've got people going to the same place and other people going no place. So we're going to actually try to do some work on that.
Identifying and using evidence‑based practices. I really believe that's very important, because this is going to come home to haunt us if we don't. Making our knowledge fit with fiscal practices. Increasing the workforce capacity is a big problem, and it's a big problem in all we do. But really, mental health people aren't trained, in general, in child development. I have had many a friend say, "Well, I'd rather train a child development person in mental health than the other way around." So go for it.
But there is a group of people across the states who really want to be those mental health consultants and provide support to families and children. And we need to nurture them, build incentives, build in to professional development strategies, et cetera. And I think we have to invest in more research to make sure that we are paying for what we know works over time.
I mean, the first hump is getting kids to enter school and succeed. And that is really important, because I'll tell you, unless we can show that, we're never going to have any money for these "seen as soft support services."
So we have a large agenda. NCCP and Project Thrive stand ready to help you in any way we can. We welcome your feedback about what would be helpful to you. What should we put together that would be helpful to push the knowledge and the agenda? I thank you very much and appreciate the chance.