Addressing Mental Health in Early Childhood Settings: The Role of Mental Health Consultation 1
Lead Presenter: Eileen Brennan Project Collaborator, Transforming Transitions to Kindergarten Project Research and Training Center on Family Support and Children’s Mental Health Portland State University PO Box 751, Portland OR 97207-0751 Phone: (503) 725-5003; Fax (503) 725-5545
[email protected] Co-authors and Co-presenters: Jennifer Bradley Co-Principal Investigator, Transforming Transitions to Kindergarten Project Research and Training Center on Family Support and Children’s Mental Health Portland State University Mary Dallas Allen Graduate Research Assistant, Transforming Transitions to Kindergarten Project Research and Training Center on Family Support and Children’s Mental Health Portland State University Donna Bennington Head Start Education Specialist Community Action Head Start Washington County, OR Deborah F. Perry National Technical Assistance Center for Children’s Mental Health Georgetown University Medical Center Washington, DC Adey Tsega National Technical Assistance Center for Children’s Mental Health Georgetown University Washington, DC
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Author Note: The preparation of the research review was supported by funding through the Research and Training Center on Family Support and Children's Mental Health, NIDRR Grant H133B40038 and the National Technical Assistance Center for Children’s Mental Health, Georgetown University, through the Center for Mental Health Services SAMHSA Grants RX4285309 and SM-05-013. A preliminary version of the research review was presented at Establishing the Evidence Base for Early Childhood Mental Health Consultation, Tampa, FL.
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Background and Context Capizzano and Adams (2003) have documented that the majority of children in the United States who are under five years of age are participating in non-relative child care or early education. Early childhood settings can provide important experiences that lay the foundation for cognitive and socialemotional development for young children (NICHD Early Child Care Research Network, 2003). However, some preschool-aged children are having difficulty succeeding in group care settings due to their troubling or difficult behavior (Duncan, Brooks-Gunn, & Klebanov, 1994; Qi & Kaiser, 2003). Walter Gilliam (2005) has recently discovered in a national study that large numbers of young children are expelled from prekindergarten programs due to challenging behavior. Mental health consultation is a strategy used to assist early childhood staff and family members with transforming difficult or troubling behavior in young children. Cohen and Kaufmann (2000) have defined mental health consultation as: A problem-solving and capacity-building intervention implemented within a collaborative relationship between a professional consultant with mental health expertise and one or more individuals with other areas of expertise – primarily child care, child development, and families – or individuals with child care responsibilities (p. 4). Two types of mental health consultation have been identified: (a) child- or family-centered consultation, and (b) programmatic consultation. Child or family-centered consultation has as its primary goal the addressing of factors that contribute to a child’s or family’s difficulties in functioning well in the early childhood setting. For the children with the most challenging behavior, this form of consultation results in the development of a plan to deal with the child’s difficult or troubling behavior. On the other hand, programmatic consultation focuses on improving the overall quality of the program, and assists staff with addressing specific issues that affect more than one child, family, or staff member. Program-focused consultation increases the capacity of staff to respond to the needs of all young children in their care. Head Start programs are mandated to employ mental health consultants to assist staff and families to promote the social and emotional development of children in the programs. Donna Bennington affirmed the positive outcomes consultation had for staff and children in their programs when she spoke about the effectiveness of mental health consultation (MHC) in Community Action Head Start classrooms in Washington County, Oregon. Although MHC is a widely utilized strategy, its effectiveness has not been established through a systematic review of literature. In order to respond to an increasing emphasis on evidence-based programs, investigators from the Research and Training Center on Family Support and Children’s Mental Health and from the National Technical Assistance Center on Children’s Mental Health studied the extant research literature addressing mental health consultation in early childhood settings. Research Focus Our research group intended to examine the design elements and findings of studies of MHC in early childhood settings and to determine the level of evidence for consultation effectiveness. Because of a lack of peer-reviewed articles, the use of research designs that did not permit treatment and control comparisons, few replications of research, and varied study methodology, we decided to conduct a research review and synthesis rather than a meta-analysis. Our research review was designed to answer two key questions: 1. What is the level of evidence in the current body of research on the effectiveness of mental health consultation (MHC) in early childhood settings?
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2. What are the effects of MHC on outcomes for: (a ) children and families, and (b) staff and programs? Methods The research review and synthesis began using established search procedures (Cooper & Lindsay, 1998) to unearth published and unpublished research on early childhood mental health consultation. Electronic databases, including ERIC, Dissertation Abstracts, PsychInfo, Social Work Abstracts, and Social Services Abstracts, and online early childhood databases were searched for keywords. We also searched national organization, government, and university-based websites on early childhood and children’s mental health. Finally, we were in contact with experts in early childhood mental health consultation and participants in a specialized conference on early childhood MHC and requested that they send us any relevant materials. In order to be included in the review, studies had to have: (a) used empirical methods, either quantitative or mixed methods approaches; (b) focused on MHC, not health consultation or early intervention; (c) involved consultation in programs serving children from birth to 8 years of age; and, (d) been conducted between 1985 and 2005. Qualitative methods were used to analyze articles meeting the study criteria. An extensive matrix, in which key elements were recorded, was constructed. Articles were then classified and outcomes were examined through content analysis. Study Findings A total of 33 studies meeting all four criteria were identified and coded in the study matrix. As can be seen in Table 1, 21 studies had staff and program outcomes; 22 studies included child outcomes, and 6 had other types of outcomes. Figure 1 reveals the studies with unique and overlapping sets of outcomes.
Table 1. Mental Health Consultation Studies
Table 1. Classification of Mental Health Consultation Studies
Type of Outcomes
Type of Study With Comparison Group
Without Comparison Group
Descriptive / Correlational
(Type I)
(Type II)
(Type III)
Staff & Program
N=7
N = 10
N=4
N = 21
Child
N=7
N = 10
N=5
N = 22
Other
N=0
N=0
N=6
N=6
Total
Total Studies Reviewed: N = 33
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Figure 1. Search Results
Figure 1: Classification of Search Results
Both Child & Program Outcomes
Child Outcomes
N = 16
Staff & Program Outcomes
N=6
Total Studies
N=5
N = 33
Other N=6
Consulting activities. The investigations used consultant self-reports, effectiveness ratings by directors and teachers, and observational studies to learn about the activities of mental health consultants. A wide range of activities was identified as being performed by MH consultants encompassing both program-focused consultation (consulting on program structure, scheduling, staffing, and administration) and child- or family-focused consultation (observation, assessments, direct interventions, family assistance, referrals). Consultation intensity was found to vary from setting to setting. Child outcomes. Mental health consultation was shown to improve child social skills, behavior, and resilience scores (Field, Mackrain, & Sawilowsky, 2004; Perry, Dunne, O’Neill, & Campbell, 2005). Tyminski (2001) also found that children had increases in emotional competence scores that were in excess of normal gains. Externalizing problems declined (Kupersmidt, & Bryant, 2004; Langkamp, 2003) and children at risk of expulsion were retained in their early childhood settings (Gould, 2003; Perry et al, 2005). Family outcomes. Mental health consultation was found to reduce parent stress levels in some settings (Lehman, Lambarth, Friesen, MacLeod, & White, 2003; Quist, Spanish, Oja, & Dalton, 2004), but not others (Shelton, Woods, Williford, Dobbins, & Neal, 2001). Consultants helped parents deal with challenging behavior (Cagle, 2003) and promoted parent involvement in early childhood settings (Brennan, Bradley, Ama, & Cawood, 2003). Staff outcomes. Staff working in early childhood settings were also found to be affected by MHC. Staff reported improved feelings of competency and self-efficacy (Green, Everhart, Gettman, Gordon, & Friesen, 2004; Bleecker, Sherwood, & Chan-Sew, 2005). Ratings of job stress by staff members also were reduced (Alkon, Ramler, & MacLennan, 2003). Finally, consultation may increase teacher attunement and promote skills in effective communication with families (Bleecker & Sherwood, 2004, Elias, 2004).
Program outcomes. Based on current evidence, the impact of consultation on program quality is unclear (Alkon et al., 2003; Bleecker & Sherwood, 2003; Perry et al., 2005). However, consultation was
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linked to reduced staff turnover (Alkon et al, 2003; Olmos & Grimmer, 2004). The integration of MHC into the program and its acceptance by staff were found to be important (Green et al, 2004; Green, Simpson, Everhart, Vale, & Gettman, 2004). Finally, it was found that MHC may enable families who might otherwise be excluded to have access to mental health services (Elias, 2004). Conclusions and Implications Mental health consultation has taken on a variety of forms and encompasses a wide range of activities. Research and evaluative studies have begun to establish favorable outcomes for children, families, and staff in early childhood settings. However, the evidence base includes few peer-reviewed studies, lacks studies with rigorous research designs, and has inconsistencies in the measures used to establish effectiveness. Additionally, few researchers were able to examine the effects of mental health consultation in isolation; most investigations had MHC embedded in other types of interventions or enrichment programs. In order to advance the field, researchers and evaluators must analyze early childhood programs’ needs for mental health consultation, define intervention goals, and specify anticipated outcomes. Logic models should be constructed for interventions that include a theory of change and testable outcomes. Additionally, we need to learn more about the context of consultation (program quality, staff-child ratios, culture of the organization, resources available), and then include these variables in the research study. The relationship of consultant qualifications, training, and support to MHC outcomes also needs to be established. Finally, research is needed to examine staff-consultant and family-consultant interactions and to discover ways in which these interactions can be most effective.
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References Alkon, A., Ramler, M., & MacLennan, K. (2003). Evaluation of mental health consultation in child care centers. Early Childhood Education Journal, 31(2), 91-99. Bleecker, T., & Sherwood, D. L. (2003). A final report of the 2001-2002 evaluation of the High Quality Child Care Mental Health Consultation Initiative. San Francisco: City and County of San Francisco, Department of Public Health, Community Health Programs. Bleecker, T., & Sherwood, D. L. (2004). San Francisco high quality child care mental health consultation initiative. San Francisco: Department of Public health, Community Behavioral Health Services. Bleecker, T., Sherwood, D., & Chan-Sew, S. L. (2005). San Francisco high quality child care mental health consultation initiative. San Francisco: Department of Public Health, Community Behavioral Health Services. Brennan, E. M., Bradley, J. R., Ama, S. M., & Cawood, N. (2003). Setting the pace: Model inclusive childcare centers serving families of children with emotional or behavioral challenges. Portland, OR: Portland State University, Research and Training Center on Family Support and Children's Mental Health. Cagle, M. L. J. (2002). Conjoint behavioral consultation with parents and teachers of Hispanic children: A study of acceptability, integrity, and effectiveness. (Doctoral dissertation, Oklahoma State University, 2002). Dissertation Abstracts International, 64(2-A), 394. Capizzano, J. & Adams, G. (2003) Children in low-income families are less likely to be in center-based care. Snapshots of America’s Families III. Washington DC: Urban Institute. Cohen, E., & Kaufmann, R. (2000, May). Early childhood mental health consultation. Washington, DC: Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration and the Georgetown University Child Development Center. Cooper, H. M., & Lindsay, J. J. (1998). Research synthesis and meta-analysis. In L. Bickman, L., & D. J. Rog, (Eds.), Handbook of applied social research methods (pp. 315-337). Thousand Oaks, CA: Sage Publications. Duncan, G. J., Brooks-Gunn, J., & Klebanov, P. K. (1994). Economic deprivation and early childhood development. Child Development, 65, 296-318. Elias, C. F. R. (2004). Mental health consultation services in community based early childhood settings: A survey of preschool teachers (Doctoral dissertation, Hartford University, 2004). Dissertation Abstracts International, 64(11-B), 5778. Field, S., Mackrain, M., & Sawilowsky, S. (2004). Caring for Kids Initiative: Evaluation report, May 1, 2003-April 30, 2004. Detroit, MI: Wayne State University, College of Education. Gilliam, W. S. (2005). Prekindergarteners left behind: Expulsion rates in state prekindergartener systems. New Haven, CT: Yale University Child Study Center. Gould, M. (2003). Evaluation of the early intervention program for young children and the consolidated child care pilot mental health mini grants. Denver: Center for Human Investment Policy, Graduate School of Public Affairs, University of Colorado at Denver.
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Green, B. L., Everhart, M., Gettman, M. G., Gordon, L., & Friesen, B. (2004). Mental health consultation in Head Start: Selected national findings. Portland, OR: Portland State University, Research and Training Center on Family Support and Children’s Mental Health. Green, B. L., Simpson, J., Everhart, M. C., Vale, E., & Gettman, M. G. (2004). Understanding integrated mental health services in Head Start: Staff perspectives on mental health consultation. NHSA Dialog, 7(1), 35-60. Kupersmidt, J. F., & Bryant, D. (2004). Socioemotional interventions to enhance school readiness. Chapel Hill: University of North Carolina, North Carolina Head Start Quality Research Center. Retrieved from http://www.acf.hhs.gov/programs/core/ongoing_research/qrc/unc_2001.html Langkamp, D. L. (2003). Evaluation of the early childhood mental health initiative. Akron, OH: Ohio Department of Mental Health, Office of Program Evaluation and Research. Lehman, C., Lambarth, C. H., Friesen, B., MacLeod, M., & White, D. (2005). Evaluation of the incredible years and mental health consultation to child care centers. Unpublished manuscript. Portland, OR: Portland State University, Regional Research Institute for Human Services. National Institute of Child Health and Human Development Early Child Care Research Network. (2003). Does amount of time spent in child care predict socioemotional adjustment during the transition to kindergarten? Child Development, 74. 976-1005. Olmos, A., & Grimmer, M. (2004). The Parent/Provider Effectiveness in Early Learning Environments (PEARL) Project. Denver, CO: Mental Health Corporation of Denver. Perry, D., Dunne, C., O'Neil, M., & Campbell. (2005). Does mental health consultation increase social skills, decrease problem behaviors, and avoid expulsion for young children in child care? Unpublished manuscript. Washington, DC: Georgetown University, Center for Child and Human Development. Quist, R., Spanish, M., Oja, M., & Dalton, S. (2004, June). Riverside County Research and Evaluation. Preschool 0-5 program. Main findings. Paper presented at the Training Institutes on Developing Local Systems of Care for Children and Adolescents with Emotional Disturbances and their Families: Early Intervention, San Francisco. Qi, C. H., & Kaiser, A.P. (2003). Behavior problems in preschoolers from low-income families: review of the literature. Topics in Early Childhood Special Education, 23(4), 188-216. Shelton, T. L., Woods, J. E., Williford, A. P., Dobbins, T. R., & Neal, J. M. (2001). System of care interventions for hard to manage preschoolers in Head Start. Paper presented at the 14th Annual Conference. A System of Care for Children's Mental Health: Expanding the Research Base, Tampa, FL. Tyminksi, R. (2001). A final report of an evaluation of mental health consultation in child care centers: San Francisco's High Quality Child Care Initiative (1999-2001). San Francisco: San Francisco Department of Children Youth and Families, Department of Human Services, and Department of Public Health.
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