Promoting the Emotional Well-Being of Children and · PDF filePromoting the Emotional Well-Being of Children and Families Policy Paper No. 4 ... developing a state strategic plan to

Promoting the Emotional Well-Beingof Children and FamiliesPolicy Paper No. 4

Making Dollars Follow Sense: Financing EarlyChildhood Mental Health Services to PromoteHealthy Social and Emotional Developmentin Young Children

Kay Johnson • Jane Knitzer • Roxane Kaufmann

August 2002

2 Making Dollars Follow Sense National Center for Children in Poverty

Making Dollars Follow Sense: Financing Early Childhood Mental Health Servicesto Promote Healthy Social and Emotional Development in Young Children

Copyright © 2002 by the National Center for Children in Poverty

The Authors

Kay Johnson operates an independent policy consulting firm based in Vermont and is an associateresearch professor at Dartmouth College. Her expertise encompasses a wide range of child healthpolicy and financing issues.

Roxane Kaufmann, M.A., is director of early intervention policy for the Georgetown UniversityChild Development Center (GUCDC). Through GUCDC’s National Technical Assistance Centerfor Children’s Mental Health, Ms. Kaufmann provides technical assistance to states and communi-ties working to develop early childhood mental health systems of care.

Jane Knitzer, Ed.D., is deputy director of the National Center for Children in Poverty. She alsodirects its research on vulnerable families experiencing multiple stresses and on children’s mentalhealth.

Acknowledgments

This report would not have been possible without the commitment of state and local leaders topolicies and programs that promote the emotional well-being of young children and families. Theirwillingness to give up time for interviews, repeatedly review drafts, and provide encouraging wordswere essential to completing this work. Most of all, they are to be thanked for their leadership indeveloping the state and community initiatives highlighted in this policy paper. We would like toespecially acknowledge the assistance of Ann Bowdish in Cuyahoga County–Ohio, Sandra Adamsin Florida, Marla Himmeger in Ohio, Steve Viehweig and Maureen Greer in Indiana, Sai-LingChan-Sew and Anita Fong in San Francisco, and Brenda Bean and Charlie Biss in Vermont.

This project was jointly carried out by the National Center for Children in Poverty and theGeorgetown University Child Development Center. Funding has come from both the MargueriteCasey Foundation (formerly Casey Family Programs), which has generously supported the largerbody of work carried out by NCCP to promote the emotional well-being of young children and theirfamilies as well as this study, and from the U.S. Department of Health and Human Services, Sub-stance Abuse and Mental Health Services Administration (SAMHSA) through its grant toGeorgetown. Kay Johnson, working as a consultant to the project, designed and conducted the casestudies and collaborated on the writing of this policy paper.

The authors are also grateful to Vermont State Senator Janet Munt who participated with KayJohnson in the Vermont and Florida case studies, to Bill Miller of the University of Massachusettsand Robert Fordham who read earlier drafts, and to Sandra Adams who read the close to final draft.Special thanks to Billie Navojosky of the Positive Education Program, Early Intervention CenterWest, in Cleveland, Ohio, for making the comment that led to the title of this report.

Last, but not least, thanks also to the NCCP production team, Carole Oshinsky, Kate Szumanski,and Telly Valdellon, who always make NCCP’s publications look special and to Gina Rhodes for hercopyediting of this and other publications in this series.

National Center for Children in Poverty Making Dollars Follow Sense 3

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Executive Summary

Drawing on lessons from six case studies, this policypaper highlights the most innovative approaches statesand communities are currently using to finance earlychildhood mental health services and explores whatelse might be done to mix, match, and leverage all avail-able resources. The focus is on prevention and earlyintervention services to not only help children directly,but equally important, to help their families and othercaregivers address the social and emotional challengeschildren face. The case studies are based on interviewswith policy and program leaders in the states of Florida,Indiana, Ohio, and Vermont, as well as two metropoli-tan areas—San Francisco and Cuyahoga County, Ohio(where Cleveland is located).

Snapshots of the Sites

Florida

Early childhood mental health efforts in Florida haveincluded: developing a state strategic plan to providesupportive services to all young children, children fac-ing special risks, and children needing more intensivetreatment; addressing some of the most vexing Medic-aid-linked barriers to funding; and piloting treatmentprograms for more vulnerable infants and their families.

Indiana

Efforts to address issues of social and emotional devel-opment and mental health in young children in Indi-ana have been embedded in a broader effort to enhanceearly intervention services (Part C) for all at-risk youngchildren. In that context, mental health-related ini-tiatives have focused specifically on prevention andearly intervention services designed to improve profes-sional training and increase referrals. Funding has in-volved diversifying, maximizing, and blending multiplefunding streams.

Ohio

The early childhood mental health efforts in Ohio haveused targeted state general fund dollars to create astatewide grant program to promote early childhoodmental health consultation, primarily addressing

“Policies and programs aimed at improving the lifechances of young children come in many varieties...

They all share a belief that early childhood developmentis susceptible to environmental influences and that

wise public investments in young children can increasethe odds of favorable developmental outcomes.”

National Research Council and Institute of Medicine, Board on Children, Youth,and Families, Commission on Behavioral and Social Sciences and Education;

Shonkoff, J. P. & Phillips, D. (Eds.). (2001). From neurons to neighborhoods: The scienceof early childhood development. Washington, DC: National Academy Press., p. 10

prevention and early intervention. Local activities aremainly led by community mental health boards andinvolve an array of child-serving agencies.

Vermont

The early childhood mental health efforts in Vermontinvolve the expansion of both direct treatment andconsultation, encompassing prevention, early interven-tion, and treatment services. Using a federal children’sservices mental health grant as the entry point to cre-ate the Children’s UPstream Project (CUPS), a com-prehensive early childhood mental health initiative,the state has developed a strategic approach to maxi-mizing the impact of its federal grant dollars utilizingMedicaid and Early and Periodic Screening, Diagno-sis, and Treatment (EPSDT) funds and state child carematch dollars.

Cuyahoga County, Ohio

Early childhood mental health efforts in CuyahogaCounty have been embedded in a larger early child-hood initiative. Supplementing the existing capacityto provide more intensive treatment to young childrenand their parents, the county has expanded its preven-tion and early intervention services by integrating con-sultation into existing early childhood programs. Pilotefforts to improve Medicaid reimbursement strategiesand diagnostic categories are underway. The county hasused significant local public and private dollars, as wellas state and federal funding streams.


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San Francisco, California

Early childhood mental health efforts in San Franciscohave been built on existing collaboration, spurred byflexible funding from TANF welfare reform. The cityhas created a network of early childhood mental healthconsultants responsive to different ethnic needs, pri-marily providing prevention and early interventionservices. The initiative uses a pooled funding strategythat involves multiple agencies and federal, state, andlocal funding streams.

Lessons from the Sites

� Sites are using broad early childhood initiatives as aplatform from which to launch early childhoodmental health services. Leadership comes from manydifferent agencies and individuals, and the scope ofthe effort varies considerably across the sites. Forexample, the focus may be on one age group (e.g.,infants and toddlers) or one service (e.g. , early child-hood mental health consultation). Only one sitehas developed and implemented a comprehensivesystem of care fully integrated into the early child-hood community.

� Because of the initiatives, young children, their fami-lies, and their caregivers have access to resourcesand services that simply did not exist before. Acrossthe sites, investments have increased by about $12million.

� Although most sites are emphasizing early childhoodmental health consultation, a broad range of ser-vices are being funded (including training for earlychildhood staff in mental health issues, parent-to-parent support groups, and behavioral aides in theclassroom).

� Funding strategies vary in complexity across the sites.In most there has been a heavy reliance on federaldollars. But in some sites, state dollars provide theonly major funding stream. In others, there has beena deliberate effort to draw funds from multiplesources, including entitlement dollars, and state andlocal public funds, as well as private dollars and spe-cial grants.

� Major federal funding sources include Medicaid/EPSDT, the Child Care and Development Fund,TANF, the Children’s Mental Health Services Pro-gram, and the Part C Early Intervention Programof the IDEA.

� State Medicaid agencies in several sites have devel-oped new policies to maximize the use of Medicaidfunds for mental health services to young children,but no site has taken full advantage of what is pos-sible. Other federal programs have played a support-ing role in some, but not all of the sites. For ex-ample, Part C has been central in Indiana, TANFin San Francisco.

� The sites are using four major strategies to maxi-mize funding: blending funds, braiding funds, maxi-mizing Medicaid, and using state funds strategicallyto match federal dollars and to pay for support ser-vices—such as staff and parent training—that can-not otherwise be supported.

� Common fiscal challenges include the difficulty ofproviding preventive and early intervention serviceswithout requiring a diagnosis, using all availablefunds, and sustaining funding, particularly given theworsening larger economic context.

� Interagency and public-private collaboration areessential to developing and financing a system ofcare that provides a continuum of early childhoodmental health services. Collaboration, once set inmotion, works best where sustained by formalmechanisms. Financial arrangements frequently aresupported by legislation, regulation, memoranda ofunderstanding, and other formal guidance.

“Its about leadership, about not saying no or thatyou can’t do something because of rules and money.

We need to say yes, to solve problems andmake kids safer and healthier.”

James Hmurovich, Director, Family and Children Division,Family and Social Services Administration, Indiana


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Ten Action Steps for States and Communities

Building on the lessons of these pioneering sites, be-low are action steps that other communities and statescan take to strengthen their attention to the social,emotional, and behavioral needs of young children.

1. Start small. Apply for small grants or turn to localfoundations to jump-start a community- or state-level planning process, building on other collabo-rations on behalf of young children.

2. Test out new service approaches to make sure theyfit with the community. Consider evidence-basedpractice, where there is an evidence base, and les-sons from prior efforts.

3. Develop cross-training initiatives to build a sharedunderstanding of what early childhood mentalhealth services are, how they are related to othershared goals, such as promoting school readiness,and how they might be funded.

4. Build or strengthen collaborative relationships todevelop a systematic funding strategy that will sup-port the development of preventive and early in-tervention services. For example, use child careimprovement funds for mental health consultation;establish or use existing formal mechanisms at thecabinet, state agency, or local agency level; makesure parents are involved.

5. Analyze existing levels of funding for early child-hood mental health. How do the funds flow to reachlocal service providers and meet family needs? Arefunds being used for the right services? Are thefunds sufficient? Do services address the needs ofinfants and toddlers as well as preschoolers?

6. Assess the funding streams that could be used andwhat barriers they pose: for example, does the stateMedicaid agency pay for all covered services, in-cluding child and family therapy?

7. Develop a targeted strategy to maximize the im-pact of Medicaid/EPSDT. For example, include age-appropriate developmental, emotional, and behav-ioral measures in the recommended EPSDT screen-ing protocol; make sure that reimbursed servicesare appropriately defined for young children; makesure that parent-child therapies are covered.

8. Consider redesigning reimbursement and billingpractices to maximize the use of all available dol-lars, exploring some of the strategies used by thesites described in this report such as blended orbraided funds.

9. Develop a method to gather the kind of outcomedata needed to refine and sustain funding for earlychildhood mental health strategies.

10. Promote the development of targeted federal fund-ing as a catalyst for the development of early child-hood mental health services.


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Introduction

A recent and compelling synthesis of developmentalknowledge and neuroscience highlights the importanceof a child’s earliest emotional development and rela-tionships. A report from the Institute of Medicine/Na-tional Research Council, From Neurons to Neighbor-hoods: The Science of Early Childhood Development,1 sug-gests that for some children, emotional and behavioralproblems serve as a kind of red flag. Without help, theseyoung children have a higher probability of experienc-ing problems in infancy and toddlerhood and duringthe preschool years, and in making a successful transi-tion to school. In response, states and communities areincreasingly planning and implementing early child-hood mental health service strategies to respond to theneeds of these children, their families, and their othercaregivers (e.g., child care providers, home visitors,Head Start, Early Head Start, and prekindergartenteachers). But too often, these efforts are hampered bydifficulties in designing sustainable funding strategies.

Drawing on lessons from six case studies, this policypaper highlights the most innovative approaches statesand communities are currently using to finance not justmore traditional treatment services for young children,but also preventive and early intervention services. Italso explores what else might be done to mix, match,and leverage all available resources. These case studiesare based on interviews with policy and program lead-ers in the states of Florida, Indiana, Ohio, and Vermont,as well as two metropolitan areas—San Francisco andCuyahoga County, Ohio (where Cleveland is located).

This policy paper is one of a series developed by theNational Center for Children in Poverty entitled Pro-moting the Emotional Well-Being of Children and Fami-lies. It is organized in four sections. The first sectionprovides a “snapshot” of each of the sites as a contextfor the more specific discussion of funding streams andfunding strategies. Collectively, these descriptions shedlight on the nature of the early childhood mental healthservices that are being funded. The second section de-scribes the major federal funding streams that are be-ing used to finance early childhood mental health ser-vices (as well as some that have not been used, butmight be). It also highlights the role of state and pri-

“If dollars don’t follow sense, we will be faced withthe same repetitive problems—a slow moving waveof kids coming through with preventable problems.”

Billie Navojosky, Director, Positive Education Program,Early Intervention Center West, Cleveland, Ohio

vate funds. For each funding stream, there is a briefdescription of the program, of its implications for earlychildhood mental health, and of how the case studysites have (or have not) used it.

The third section explores the funding strategies in depth,focusing on the funding mechanisms that states are us-ing to maximize the impact of fiscal resources, as well asthe related planning, collaborative, and administrativestructures that are emerging to sustain early childhoodmental health initiatives. The section concludes with adiscussion of the common challenges the sites have en-countered and their efforts to address these challengescreatively. The final section summarizes the lessons andexplores the implications for others seeking to developearly childhood mental health services. Fuller descrip-tions of the sites are available on the Web sites of theNational Center for Children in Poverty (www.nccp.org)and the Georgetown University Center for Child andHuman Development (gucdc.georgetown.edu).

How the Information Was Gathered

The information in this policy paper was developed us-ing a case study method. Case studies aim to illumi-nate a question or decision by looking at the subject inrich detail: in this instance, to investigate early child-hood mental health financing within its real-life con-text.2 Six sites were selected, each with illustrative earlychildhood mental health activities underway. Thesestates and communities are among those previouslyidentified and described through the work of the Na-tional Center for Children in Poverty and theGeorgetown University Child Development Center.This group of six was chosen to represent a range ofpossible state and local approaches.


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Interviews were conducted with 122 state governmentofficials, local program staff, and other providers, par-ents, and advocates between April and October 2000.Approximately 20 individuals were interviewed in eachlocation, based on their experience with the initiativeor their role in a related government or service agency.The initial contacts were identified from previouslypublished program descriptions. Additional individu-als were identified by key informants using an expand-ing circle technique.3 All the interviews involved semi-structured, face-to-face interviews using open-endedquestions that permit the participants to determine thedirection of the response and to provide their ownknowledge, attitudes, and opinions.4 A pretest of theinterview instrument and related tools was conductedin April 2000. Tapes and notes of interviews, along withdocuments describing programs and policies, were usedto develop the profiles.

A Note on Terminology

Some initiatives use the terms infant and toddler men-tal health, others early childhood mental health. Inmost instances, both terms refer to the development ofservices and strategies to support young children frombirth through age five, although in a few sites, the fo-cus is on infants and toddlers or preschoolers. The terminfant and toddler or early childhood mental healthservices refers to “strategies and service delivery mecha-nisms to help families and other caregivers gain accessto information, mentoring, support, early intervention,and, if needed, treatment to prevent further damageand reverse early harms related to problematic social,emotional, and behavioral development. Sometimes,these strategies involve the child directly. But often,because of their age, the best way to help young chil-dren is to help their caregivers—family members, childcare providers, home visitors, and teachers—to be moreeffective.”5

SECTION 1:

Snapshots of the Study Sites

As a context for the more detailed discussion of fund-ing streams and strategies, this section provides a briefsnapshot, in alphabetical order, of each of six studysites—four state and two local. The point-in-time snap-shots highlight the key components of the early child-hood mental health efforts: the types of services thatare being developed, the core funding strategies, andthe major challenges.

To provide some commonality, the service approach issummarized using the framework that was developedin Florida. That framework calls for three levels of in-fant mental health/early childhood mental health ser-vices. (See Florida’s Strategic Plan for Infant MentalHealth at: www.cpeip.fsu.edu.)

� Level I services are preventive strategies intendedto strengthen caregiver/child relationships for allchildren. This includes, for example, mental healthconsultants who work in child care settings or serveas consultants to home visiting workers, or even asupport/supervision group for child care providers.

� Level II services are early intervention strategiestargeted to children at risk of poor developmentaloutcomes, including social and emotional outcomes.This includes, for example, mental health consult-ants in child care settings who develop specific strat-egies to help a child in a family affected by domesticviolence or substance abuse, or a behavioral aideplaced in a child care setting to help a child whosebehavior is very disruptive.

� Level III services involve specialized treatment forthose young children and families who need inten-sive help. It includes, for example, dyadic, mother-baby therapy for a child who has been abused orneglected, or wraparound services that support boththe mother and child for a young child with a diag-nosed serious emotional and behavioral disorder.


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“We didn’t want to simply train mental healthspecialists but rather to infuse the concepts

and competencies across the board into earlychildhood care, education, and intervention.”

Maureen Greer, former assistant deputy director, Bureau of Child Developmentand Part C coordinator, Indinapolis, Indiana

Florida

The early childhood mental health efforts in Floridahave focused on creating a broad state vision and planfor implementation, addressing some of the most vex-ing Medicaid-linked barriers to funding and seedingLevel III treatment strategies for more vulnerable in-fants and their families.

Efforts to enhance the healthy social and emotionaldevelopment of young children in Florida have beenspearheaded by a group of strong and effective advo-cates with support from key officials in state agencies.They have:

� Developed and widely disseminated Florida’s Strate-gic Plan For Infant Mental Health that was based onthe work of a broad coalition of advocates, govern-ment officials, and service providers and was sup-ported with both public and private dollars.

� Revised state Medicaid guidelines to encourage theuse of more appropriate assessment tools for youngchildren and to provide reimbursements to a broaderrange of providers.

� Gained legislative support for three pilot infantmental health demonstration projects based in aChild Development Center, a Community MentalHealth Center, and a Circuit Juvenile Court, thelast of which has also developed an Early Head Startprogram for infants and toddlers involved in depen-dency proceedings.

In addition, the Center for Prevention and Early Inter-vention at Florida State University has designed andtested a relationship-based training program for thestate’s network of Part C early interventionists. (TheFSU Center has also developed and provided Level Itraining for home visitors and child care providers. Theyalso received funding from a private foundation and achildren’s services council to do a year-long trainingprogram in order to increase Level III work force ca-pacity that will train 30 infant/early childhood mentalhealth therapists starting in September 2002.) Miamihas also been the site of a Starting Early Starting Smartgrant funded through the Substance Abuse MentalHealth Services Administration and a private founda-tion, the Casey Family Programs (now the MargueriteCasey Foundation).

The efforts to raise visibility of the need for infant andtoddler mental health services has won support fromthe legislature and some state leaders. Given a growingbudget crisis, however, there is concern about the ex-tent to which the effort can be sustained and expanded.

Indiana

In Indiana, efforts to address issues of social and emo-tional development and mental health in young chil-dren have been embedded in a broader effort to en-hance early intervention services for all at-risk youngchildren. Mental health-related initiatives have focusedspecifically on Level I and II services designed to im-prove professional training and increase referrals. Fund-ing has involved diversifying, maximizing, and blend-ing multiple funding streams.

RECOMMENDATIONS REGARDING CHILDREN’S SERVICES

RECOMMENDATIONS REGARDING CHILDREN’S SERVICES

From Changing Lives: Ohio’s Action Agenda for Mental Health(released January 2001 by the Ohio Commission on Mental Health)

� The Department of Mental Health and the mental health community shoulddetermine an appropriate balance between treating children and youth withthe most severe mental illnesses and providing prevention and early inter-vention services.

� The Department of Mental Health should work with all shareholders toimprove access to mental health services delivered where children spendmost of their time. This strategy must include true shared funding ofprevention and early intervention services.


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To promote more attention to early childhood mentalhealth issues within the wider effort to improve thedelivery of early intervention services to young chil-dren, Indiana has:

� Developed a broad state fiscal strategy with a cen-tralized billing mechanism to maximize the impactof available state and federal resources for early in-tervention, including early mental health services,by blending existing funds from a variety of sourcessupported at high levels of state government.

� Invested in training and mentoring strategies to pro-mote professional and parental awareness about in-fant and toddler mental health as part of a broadereffort to address the special health care needs ofyoung children with funding from a federal Title VMaternal and Child Health grant. The training sys-tem, while based in the state Part C early interven-tion program, often includes developmental special-ists, social services agency staff, early interventionproviders, child care staff, and child health staff fromhealth departments at the local level. Parents alsoare included in these efforts.

� Created a statewide infant mental health develop-ment team to oversee the training of providers basedon a set of core competencies in infant mentalhealth, set up mentoring teams across the state, andestablished an infant mental health association.

By maximizing funds and streamlining the enrollmentprocess, an enhanced continuum of care for childrenfrom birth to three years of age became possible, andexisting dollars reached more children. In this process,the state has taken deliberate steps to identify and serveinfants and toddlers with social-emotional risks anddelays. As a result of interagency collaboration, pro-gram promotion, provider training, and single-point-of-entry mechanisms, referrals to the early interven-tion system increased threefold from 1996 to 2000, with13 times the number of referrals from mental healthagencies. In addition, through the network of HoosierAssurance Plan contracts, the state’s mental health pro-gram providers are annually serving nearly 2,500 chil-dren under age six in families with incomes up to 200percent of the poverty level.

Ohio

The early childhood mental health efforts in Ohio haveused targeted state general fund dollars to create a state-wide grant program to promote early childhood men-tal health consultation, primarily involving Level I andII services. Local activities are primarily led by com-munity mental health boards and involve an array ofchild-serving agencies.

In an effort to promote greater attention to early child-hood mental health, the Ohio Department of MentalHealth (ODMH):

� Created the Early Childhood Mental Health Ini-tiative, a $2.6 million state grant program for localagencies (primarily local community mental healthboards) to build statewide capacity within the men-tal health and early childhood care and educationsystems to promote the healthy social and emotionaldevelopment of young children.

Grant funds could be used for: (1) mental health con-sultation to center- and home-based early childhoodprograms, (2) training for early childhood staff in men-tal health issues, (3) cross-system training for mentalhealth and early childhood professionals and parents,(4) creation of parent-to-parent family support groups,(5) work with families to enhance caregiver skills, and(6) public awareness activities.

In fiscal year 2001, as a result of Ohio’s Early Child-hood Mental Health Initiative, 63 mental health con-sultants provided services to over 7,000 children andnearly 500 child care, Head Start, Early Head Start,and home visiting programs statewide. At the locallevel, the grant program has led to greater collabora-tion with the state’s home visiting and early interven-tion programs in some communities.

However, despite a recent Ohio Commission on Men-tal Health report urging more attention to preventionand early intervention for children, (see box on page 8)using Medicaid in addition to state funds for preven-tion and early intervention remains very difficult. Thisis so because current interpretations of medical neces-sity and individualized service plan requirements arenot appropriate for young children. Significant budgetconcerns may also limit continuing efforts.


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Vermont

The early childhood mental health efforts in Vermontinvolve the expansion of both direct treatment and con-sultation, encompassing Level I, II, and III services. Us-ing a federal children’s services mental health grant asthe entry point, the state has worked to develop a stra-tegic approach to funding by maximizing the impact offederal dollars, especially Medicaid and Early and Peri-odic Screening, Diagnosis, and Treatment (ESPDT)funds, and using state match dollars strategically.

Vermont has developed the most comprehensive ef-fort in the country to infuse early childhood mentalhealth services into the early childhood community,using a six-year, $5.7 million federal grant from theCenter for Mental Health Services of the federal Sub-stance Abuse Mental Health and Services Adminis-tration (SAMHSA). The aim of the grant has been tostimulate local activities targeted to prevent seriousemotional and behavioral disorders. Vermont has:

� Created the Children’s UPstream Project (CUPS)to develop statewide prevention, early intervention,and treatment strategies for young children, theirfamilies, and their caregivers. (See box.)

� Integrated the effort to promote early childhoodmental health services into the ongoing efforts toenhance other early childhood programs that areled by the State Early Childhood Work Group,which includes interagency state staff as well as par-ents, providers, and advocates.

� Implemented a local planning process for commu-nities to decide how best to allocate the CUPS fund-ing that they received in order to effectively meetlocal needs.

� Developed a strategic funding approach that in-volves maximizing the use of Medicaid/EPSDT aswell as the strategic use of state dollars as matchmonies for these and other federal programs. Ver-mont targeted state funds for prevention as its con-tribution to the federal SAMHSA grant.

Using these combined strategies, Vermont has creatednew staff positions for 26 CUPS workers across the stateand expanded both behavioral health consultation and

CORE GOALS FOR VERMONT’S CUPS

� Support and preserve families of young children experiencing or at risk forexperiencing severe emotional disturbance through access to behavioral healthand other community-based services designed to meet their individual needsand build on their strengths.

� Strengthen the behavioral health of families with young children.

� Decrease the incidence of children entering kindergarten lacking emotionaland social skills needed to succeed.

treatment capacity. During the first three years ofCUPS, more than 1,000 children and families receivedrespite, crisis outreach, home-based services, case man-agement, or other direct services, and more than 1,000additional consultations—reaching over 4,000people—were provided to early care and educationagencies.

Notwithstanding this success, the state faces a chal-lenge once the grant has ended in financing preven-tive and supportive services that are not reimbursableunder Medicaid. These include training, parent-sup-port services, resource and referral services, volunteercoordination, and public awareness.

Cuyahoga County, Ohio

The early childhood mental health efforts in CuyahogaCounty have been embedded in a larger early child-hood initiative. Supplementing the existing Level IIIservices, the county has expanded its capacity to pro-vide Level I and II services, integrating consultationinto existing early childhood programs. The county hasused significant local as well as state and federal fund-ing streams.

The Cuyahoga County effort to promote more atten-tion to early childhood mental health issues is part ofthe larger countywide Early Childhood Initiative,which is a public-private partnership designed to im-prove, expand, and better coordinate child care qual-ity efforts, home visiting, health coverage outreach, andspecial-needs child care. To meet early childhood men-tal health needs, the leaders have:


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� Established Day Care Plus, an early childhood men-tal health consultation program that grew out of apartnership among the Cuyahoga County Board ofMental Health, Starting Points, the local child careresource and referral agency, and the Early Inter-vention Centers of the Positive Education Program(PEP) that serves seriously behaviorally and emo-tionally challenged young children and families.

� Crafted, with funding from the state Early Child-hood Mental Health Initiative and local funds, athree-agency Early Childhood Mental Health PilotProject for the purpose of demonstrating improvedoutcomes using best practices.

� Linked Cuyahoga County’s early childhood mentalhealth project to other service systems to strengthenthe local Early Childhood Initiative and to provideconsultation in early intervention centers and homevisiting programs, as well as child care centers andchild care resource and referral agencies.

� Used the Early Childhood Mental Health PilotProject of PEP’s Early Intervention Centers to teststrategies to reduce administrative barriers to financ-ing early childhood mental health services throughMedicaid. The aim is to eliminate the use of inap-propriate assessment tools and conflicting mentalhealth and special-education planning requirements.The other two agencies participating in the pilotproject are testing new diagnostic tools for Medic-aid reimbursement.

The Early Childhood Initiative, into which the men-tal health strategies are infused, has ambitious goals: toreach 50,000 parents each year with information onparenting skills and community resources; to provide8,000 “Welcome Home” visits to babies born to first-time and teen mothers; to provide 4,000 higher-riskfamilies with home visiting through Early Start; to in-crease the percentage of eligible children enrolled inMedicaid and the State Children’s Health InsuranceProgram (SCHIP); to provide certified child care for4,000 additional children each year; and to offer en-hanced child care to 500 children with special healthcare needs, including those facing social and emotionalchallenges.

Through Day Care Plus, 83 center-based and familychild care providers have received services and support,259 children at risk for removal were maintained intheir child care settings, over 300 training sessions wereheld for parents, and over 1,500 child care staff partici-pated in training.

As a result of the focus on early childhood mentalhealth, the County Community Mental Health Boardhas recognized the need to improve mental health ser-vices to infants and toddlers as well as to provide pre-vention and early intervention services. The county isalso hopeful that its efforts to address administrativebarriers will provide the needed impetus for the stateto use Medicaid more effectively to benefit young chil-dren in need of mental health services across Ohio.

San Francisco, California

The early childhood mental health efforts in San Fran-cisco were spurred by welfare reform. The city has cre-ated a network of early childhood mental health con-sultants responsive to different ethnic needs, primarilyproviding Level I and II services. The initiative uses apooled funding strategy that involves multiple agen-cies and funding streams.

The San Francisco efforts to increase the focus on earlychildhood mental health issues grew out of the plan-ning and coordination strategies developed by the SanFrancisco Starting Points Early Childhood InteragencyCouncil and the San Francisco Children and FamiliesCommission (part of a statewide initiative known asProp 10), as well as child care planning bodies. SanFrancisco has:

� Identified, through a planning process initially spear-headed by the Starting Points Early Childhood In-teragency Council and subsequently the Proposition10 Children and Families Commission, the criticalneed for early childhood mental health consulta-tion and services as part of its efforts to help fami-lies successfully transition from welfare to work.

� Established a network of ethnically diverse earlychildhood mental health consultants who are reach-ing a majority of child care centers, building rela-tionships with family day care providers, supporting


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the mental health components of Head Start cen-ters, and strengthening the child care componentsof homeless and domestic violence shelters.

� Used $700,000 of $2 million allocated by the SanFrancisco Board of Supervisors for a High QualityChild Care Initiative to provide mental health sup-port and consultation to child care providers work-ing to help families transition successfully from wel-fare to work.

� Enhanced funding for the mental health consulta-tion program by creating an administrative strategyto identify appropriate funding streams for differentservices, using pooled funds from multiple sources(e.g., general revenue, Medicaid, city funds, andTemporary Assistance for Needy Families (TANF)monies transferred to child care) pursuant to memo-randa of understanding among the agencies respon-sible for the funds.

� Established a framework for reimbursement of con-sultation services through the administering agency,the Department of Public Health, Community Men-tal Health Services - Children, Youth, and FamilySection.

Reimbursed services include: (1) program consultationto enhance the quality of the program through workwith child care program staff, (2) case consultation toaddress concerns about individual children exhibitingdevelopmental or emotional difficulties, (3) directtherapy such as therapeutic play groups to help chil-dren learn acceptable ways to express themselves andinteract with others, and (4) support groups for parentsand providers.

In calendar year 2000, more than 70 child care centersand approximately 100 family day care homes receivedmental health consultation services. This group in-cludes more than two-thirds of subsidized child carecenters across San Francisco, with higher penetrationin some neighborhoods. More than 70 percent of HeadStart and Early Head Start centers were receiving men-tal health consultation. Nearly 4,000 children in ap-proximately 2,000 families were served throughout thecity. Efforts are underway to expand services to youngchildren in shelters for homeless families. San Fran-

“In terms of early childhood mental health andemotional wellness, what [San Francisco] diddifferently was link to the notion of quality inchild care. This conceptual linkage opened up

additional resources. For early childhood educationand care initiatives, we have always looked broadly.In this case, as in others, we did the documentation

of need and from that built a strategy.”

Deborah Alvarez-Rodriguez, former director of the San FranciscoDepartment of Children, Youth, and Their Families (DCYF)

cisco is also the site of a Starting Early Starting Smartdemonstration program, although to date its programhas not been integrated with the larger effort describedhere.

However, financing treatment services is an ongoingchallenge. Financing treatment for parent/child pairsor for children without a mental illness diagnosis is es-pecially difficult under Medicaid. For children inHealthy Families (the name for SCHIP in California),the mental health benefits are limited and not wellstructured to fit with early childhood developmentalneeds. For the remaining uninsured children, many ofwhom are U.S. citizens with immigrant parents, thechallenge is even greater. As at the other sites, there isgrave concern about the ability to sustain the efforts,particularly if the state cuts flexible TANF money.

Moreover, California currently faces a budget crisis thatthreatens many social programs. At the time of the ini-tial allocations, San Francisco was drawing down fundsfrom the state reserve. In the last fiscal year, supple-mental appropriations were needed to meet the baselinebudget. Contingency planning is now underway to ex-plore options in the event that the state cuts flexiblefunding or TANF child care funding ends.


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Together, these snapshots paint a picture of the statusof early childhood mental health developments acrossthe country. Five points seem noteworthy.

� The scope of the early childhood mental health ini-tiatives varies considerably: from a beginning focuson infant and toddlers in one site, to a comprehen-sive system of care fully integrated into the earlychildhood community in another. Two sites havecarefully designed early childhood consultation pro-grams. Two sites are focusing primarily on infantsand toddlers, although their vision encompasses allyoung children, including preschoolers.

� It is clear that in these jurisdictions, young children,their families, and their caregivers have access toservices that simply did not exist before. Althoughmost sites are emphasizing early childhood mentalhealth consultation, a broad range of services arebeing funded, including training for early childhoodstaff in mental health issues as well as training formental health providers, parent-to-parent supportgroups as well as support groups for caregivers, and,in some sites, more specialized services, includingdyadic therapy, wraparound services, respite and cri-sis care, and the use of behavioral aides in child caresettings. (See box.) However, with the exception ofVermont, not all of these services are being financedfor young children and at a specific site.

� The sites illustrate how early childhood and mentalhealth professionals have worked with public offi-cials to augment the services of child care centers,Head Start programs, family resource centers, homevisiting programs, child development centers serv-ing children with physical disabilities, early inter-vention programs, medical settings, homeless anddomestic violence shelters, and the justice system.In sum, they have brought services to the settingsin which children spend their days and where high-risk families receive support.

� Funding strategies vary in complexity across the sites.In some sites, such as Ohio, state dollars providethe only major funding stream. In contrast, in Indi-ana, there has been a deliberate effort to draw funds

from multiple sources, with a heavy reliance uponfederal dollars, and in Vermont, maximizing federal-state matching has been a high priority.

� State investments of both federal dollars and statedollars along with local and private dollars have re-sulted in new investments in early childhood men-tal health. For example, this has included: $2.3 mil-lion in state funds over three years to the Early Child-hood Mental Health Initiative in Ohio; more than$1.2 million local public/private funds for the EarlyChildhood Mental Health pilot in CuyahogaCounty; $5.7 million federal plus state match oversix years for Children’s UPstream Services in Ver-mont; more than $2 million TANF, local, and otherdollars for Child Care Mental Health Consultationin San Francisco; and more than $1 million in stategeneral revenue funds for three Florida Infant Men-tal Health pilot projects. However, given the rap-idly declining economic context, most of the sitesare worried about whether they will be able to sus-tain and grow the gains that they have made in ad-dressing a very pressing issue for the larger earlychildhood agenda.

EARLY CHILDHOOD MENTAL HEALTH SERVICESFUNDED BY THE STUDY SITES

� Screening and assessment for emotional-behavioral concerns.

� Enhanced screening and assessment through placement of social workers inpediatric care settings.

� Early childhood mental health consultation for individual children.

� Early childhood mental health consultation and training for early childhoodprogram staff.

� Relationship-based, parent-child therapy for families at risk as well as fami-lies who have entered the child welfare system.

� Specialized (day) treatment in a variety of early childhood settings.

� Care coordination and case management for children entering the childwelfare services system, particularly those entering foster care.

� Wraparound treatment for young children with serious emotional disturbances.


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SECTION 2:

An Overview of the Major FundingSources for Early Childhood MentalHealth Services

This section explores the major funding sources to sup-port early childhood mental health initiatives, focus-ing mainly on federal programs and funding streams.These have been the primary working tools in the de-velopment of early childhood mental health strategies,typically supplemented with state, local, and privatefunds. This section provides a brief overview of thefunding sources, highlights their implications for earlychildhood mental health, and indicates the extent towhich the sites have actually made use of these differ-ent funding streams.

Health Programs

Medicaid and EPSDT

Medicaid is the largest and most important public sourceof health care financing for children. It is a federal-state entitlement program that provides health care forone in four poor children. All children younger thansix with family incomes up to 133 percent of the fed-eral poverty level ($17,650 annual income for a familyof four in 2001) are eligible. At their option, state eli-gibility levels may be higher. In the study sites, whencombined with SCHIP (see below) Medicaid eligibil-ity levels vary from 200 percent to 250 percent of thepoverty level. States have considerable flexibility indesigning their Medicaid programs for children as longas they meet certain basic requirements, but they mustmatch their Medicaid dollars with nonfederal dollars.

The Early and Periodic Screening, Diagnosis, and Treat-ment (EPSDT) program is the child health benefitpackage of Medicaid that mandates states to cover afull range of preventive, diagnostic, and treatment ser-vices for all Medicaid beneficiaries under age 21.EPSDT benefits are based on a broad standard: a ser-vice is medically necessary if needed for the “early” di-agnosis and treatment of a condition.

Because the purpose of EPSDT is prevention, the medi-cal necessity standard for children in Medicaid must

take into account not only whether a service will cureor restore health, but also whether it may prevent theonset of a physical or mental condition or ameliorate acondition. The EPSDT pediatric medical necessitydefinition is thus more inclusive than the definitionsused in standard commercial insurance. However, con-fusion about the scope of covered services is widespread,and the definition of medical necessity under EPSDTis widely misinterpreted. Thus, although federal EPSDTlaw requires that all child Medicaid beneficiaries haveaccess to any covered service when medically neces-sary, states must adopt guidelines, benefit definitions,eligibility processes, and payment mechanisms in or-der to effectively carry out this entitlement. Few stateshave created such mechanisms in a systematic fashion.

Implications for Early Childhood Mental Health

Medicaid is a critical source of financing for mentaland behavioral health assessment, therapies, and wrap-around services for children. However, to date, Medic-aid mental health services have largely been designedfor older children and adolescents. As a result, reim-bursable services and assessment tools are often notdefined in ways that are appropriate for young childrenand their families. For example, some states do not re-imburse for infant-toddler therapies; others do not in-clude prevention or early intervention services, butserve only children with a diagnosis of SED (seriousemotional disturbance). Under EPSDT, there are op-portunities to provide more preventive and early inter-vention services. Here too, however, states have nottaken advantage of the possibilities.

View from the Sites

Although most of the sites are working to make Med-icaid/EPSDT better fit children’s needs, Vermont andFlorida have been especially innovative in crafting moreappropriate administrative rules and in using statematch money strategically for early childhood mentalhealth services. Cuyahoga County is piloting strategiesthat could be adopted by the state of Ohio. Even so, nosite has fully maximized the possibilities through bothMedicaid and EPSDT.


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State Children’s Health Insurance Program—SCHIP

All states have used the federal option to create a StateChildren’s Health Insurance Program. States may useMedicaid, a separate insurance plan, or a combinationof the two. Under a Medicaid (M-SCHIP) plan, all ofthe Medicaid policies and benefits described aboveapply to covered children. Under separate state plans,mental health coverage may be limited, and all sepa-rate (S-SCHIP) plans have more limited benefits thanfederal Medicaid-EPSDT requirements.


While some states have designed SCHIP benefit pack-ages that provide reasonable mental health coverage,none of the study sites (and no others that we are awareof) have developed special provisions for early child-hood mental health.

OPPORTUNITIES FOR EARLY CHILDHOOD MENTAL HEALTHIN STATE IMPLEMENTATION OF MEDICAID AND EPSDT

� Use Medicaid financing for covered services given to children in child caresettings, Head Start, and other settings that provide early childhood careand education.

� Track the results of developmental screening and assessment under EPSDTthat might identify opportunities to intervene and support the healthy emo-tional development of young children showing problems.

� Eliminate treatment barriers that require a mental or behavioral health diag-nosis for young children.

� Finance intervention services for children at high risk for emotional prob-lems, such as those who have witnessed domestic violence or have a parentwith documented substance abuse or depression.

� Establish billing codes and approve payments for family therapy that in-cludes parents and children together and is focused on strengthening theirrelationships.

� Use EPSDT case management to improve care coordination, particularly forchildren entering foster care or other child welfare arrangements.

� Specify early childhood mental health responsibilities under Medicaid man-aged-care contracts.

� Permit early childhood “preventive mental health” services to be deliveredoutside of mental health centers by other providers.

View from the Sites

No state in this study reported specific efforts to usethe SCHIP plan to finance early childhood mentalhealth. However, Vermont uses the Medicaid benefitplan and the EPSDT pediatric medical necessity stan-dard for SCHIP. This means that children with familyincome up to 300 percent of poverty can benefit fromthe early childhood mental health services fundedthrough these mechanisms.

Title V Maternal and Child Health (MCH)Services Block Grant

The Title V MCH Services Block Grant provides flex-ible funding to states (matched at one dollar for everythree federal dollars) to enable states to plan, promote,provide, coordinate, and evaluate health care for preg-nant women, mothers, infants, children, and adoles-cents. It also provides grants for special projects. A por-tion of MCH Block Grant funds are dedicated to serv-ing children with special health care needs. Funding islimited and is often used to fill gaps, assure access, oraffect systems change. Many states provide financingonly for selected services such as those not covered byMedicaid or for children who are uninsured.

Title V Programs for Children with Special Health CareNeeds. The Title V MCH Block Grant program includesan emphasis on children with special health care needs.This group has been defined in federal guidance as:“Children who have or are at increased risk for chronicphysical, developmental, behavioral, or emotional con-ditions and who also require health and related servicesof a type or amount beyond that required by childrengenerally.”6

Title V SPRANS Grants. Title V also sets aside federaldollars to carry out an array of demonstration and otherspecial projects. The oldest set aside is for SpecialProjects of Regional and National Significance(SPRANS) in maternal and child health.


State laws, regulations, and program guidance deter-mine who qualifies as a child with special health careneeds, who will receive services, and what services willbe financed. Although they could, most states do not


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currently include mental and behavioral health condi-tions in the state-determined definition of children withspecial needs who qualify for services or supports.

View from the Sites

Using a SPRANS grant, Indiana has promoted and en-hanced “Integrated Services for Children with SpecialHealth Care Needs” to strengthen the state’s focus oninfant and toddler mental health as well as several otherstrategies on behalf of children with special health careneeds. In Indiana, San Francisco, and Vermont, TitleV state block grant dollars have been blended withother funds to finance early childhood mental healthprojects, and special project grants have been used topilot innovative efforts.

Early Care and Education Programs

Child Care and Development Fund (CCDF) andState and Local Child Care Dollars

The Child Care and Development Fund (formerly theChild Care Development Block Grant—CCDBG)makes grants to states and tribal governments to assistlow-income families in securing child care for childrenunder age 13 (or up to age 19 at state discretion). Theauthorized activities include making direct subsidies forchild care expenses, informing and empowering par-ents to make their own decisions, and assisting withthe implementation of licensing standards and regula-tions. Discretionary funds may be set aside for qualityexpansion, strategies to improve the quality of infantand toddler child care, child care resource and referral

activities, and after-school child care. Federal estimatessuggest that overall about 12 percent of children eli-gible for subsidies receive them (although the propor-tions are higher in some jurisdictions).


The increasing time that young children, includinginfants and toddlers, are spending in child care settingshas turned the spotlight on the need to develop earlychildhood mental health consultation and other strat-egies to help teachers promote healthy social and emo-tional relationships and manage classrooms with a sig-nificant number of young children whose behavior ischallenging. Early childhood mental health strategies,particularly consultation to child care staff, are a “two-fer.” They help young children directly, but they alsohelp child care providers improve the quality of theirclassrooms and/or interactions with young children andtheir families.7

View from the Sites

Four of the six study sites have made the developmentof funding strategies for early childhood mental healthconsultation to child care centers, family day carehomes, Head Start, Early Head Start, family resourcesupport programs, shelters, and other settings whereyoung children are found a central component of theirinitiatives. The catalysts have been a concern aboutschool readiness as well as welfare reform. In two of thesites, child care funds have been key: in San Francisco,TANF funds were transferred for child care purposes(including support for the mental health consultation

.

EARLY CHILDHOOD MENTAL HEALTH CONSULTATION

Early childhood mental health consultation is a way to promote emotional well-being and provide needed interventions, beginning where most young childrenspend their days. Consultation is a “two-for-one” strategy; early childhood mentalhealth consultants can both intervene with individual children and families andimprove the quality of early childhood care and education programs. Mentalhealth consultation is being used by each of the case study sites and, throughthese programs and initiatives, reaches child care centers, family day care homes,Head Start centers, family resource/support programs, shelters, and other set-tings. Different funding streams are being used, including mental health, childcare, TANF, and Medicaid funding

“The issue that kept coming up [in the Early ChildhoodSteering Committee meetings] was an unmet need,

not so much mental health services for kids,but for mental health consultation for those

who work with young children.”

Cheryl Mitchell, Deputy Secretary in the Agency for Human Services, Vermont


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program); in Vermont, state match dollars for the fed-eral child care program are being used to support bothconsultation and special aides to help more troubledyoung children remain in their classrooms.

Head Start and Early Head Start

Head Start was created in 1965 to provide comprehen-sive educational, social, nutritional, health, and otherservices to low-income children ages three to five years.Early Head Start, created in 1993, is designed to pro-vide funding for family-centered services to pregnantwomen, infants and toddlers, and their families to pro-mote child development and family self-sufficiency. Atleast 90 percent of enrollees must come from familieswith incomes at or below the federal poverty level. Noless than 10 percent of the total enrollment opportuni-ties must be available to children with disabilities. HeadStart programs are generally local, and any local gov-ernment, tribal government, or public or private non-profit agency may apply for a grant when the federalgovernment requests solicitations. With some excep-tions, Head Start grantees are required to provide 20percent of the total cost of the program.


Head Start has long had a commitment to promotingmental health and emotional development as an inte-gral part of a comprehensive child development pro-gram. Each Head Start program must have a mentalhealth component. Current guidance calls for HeadStart program sites to use the consultation services of amental health professional.8 However, implementingthe mental health component has been difficult for lo-cal Head Start program sites. Long-standing challengesinclude reluctance to label children, skepticism aboutthe effectiveness of mental health therapy, limited tech-nical assistance, a limited pool of providers willing totake referrals, and inadequate resources to finance ser-vices and consultation.9 Early Head Start has developedan Infant Mental Health Initiative to build on newknowledge about the importance of early development.

View from the Sites

In each case study, state officials reported that HeadStart was a part of the early childhood care and educa-tion system and linked to efforts to promote emotional

well-being. San Francisco has made a deliberate effortto reach Head Start centers with mental health con-sultation. However, no state or local area in this studyis using Head Start as the primary vehicle for change.

Mental Health Programs

Comprehensive Community Mental Health Servicesfor Children with Serious Emotional Disturbances(SED)/Child Mental Health Services Initiative

The federal Children’s Mental Health Services Initia-tive is administered by the Substance Abuse and Men-tal Health Services Administration. The purpose of thisprogram is to provide multi-year funding to help com-munities develop community-based systems of care forchildren and adolescents with serious emotional dis-turbance along with their families. State, city/county,and tribal governments may apply for grant funds todevelop services, including intensive day treatment,therapeutic foster care, intensive home-based services,and development of care plans. Federal dollars must bematched with state or local funds. SAMHSA also ad-ministers a number of grant programs related to theprevention or treatment of substance abuse and men-tal illness, sometimes calling for integrated attentionto children as well as their parents.

HEAD START AND MENTAL HEALTH

Reports on the mental health component of the Head Start program* foundthat effective strategies typically:

� Integrate a mental health perspective.

� Focus on adults as well as children.

� Are strength-based and nonstigmatizing.

� Start where families are.

� Are clinically and culturally sensitive.

� Aim to improve program quality and support the culture of caring.

� Integrate mental health consultants as part of the program team.

� Are open to partnerships with parents and other providers.

� Link to other services for children with more serious emotional and behav-ioral disabilities.

__________

* Yoshikawa, H. & Knitzer, J. (1997). Lessons from the field: Head Start mental health strategies to meetchanging needs. New York, NY: National Center for Children in Poverty, Columbia University Mailman School ofPublic Health and American Orthopsychiatry Association.


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There has been no special emphasis on serving youngchildren through this program, although informal datasuggest that a number of the more than 67 sites nowfunded are serving at least some young children. Thefederal guidelines, however, require a focus exclusivelyon children with serious emotional and behavioral dis-orders and do not permit services to children at risk forserious emotional and behavioral disorders. For youngchildren, this has a particularly chilling effect on ser-vice delivery.

View from the Sites

Vermont is the only state in the country that has re-ceived funding to focus its children’s mental health ser-vices grant on young children. One of the other sitesmentioned linkages with an existing system of care ef-fort to serve older children.

Programs for Young Children with Disabilities

Part C of IDEA: Early Intervention

Part C of the Individuals with Disabilities EducationAct (IDEA) authorizes state Early Intervention pro-grams for children ages birth to three years. Federaldollars pay for a portion of the program costs, with stateawards based on the proportion of children aged birthto three in a state. Most, but not all states augmentthese federal funds with state appropriated dollars.Medicaid and private insurance pay for covered earlyintervention services. Some states’ Early Interventionprograms call for family cost-sharing through co-pay-ments. No state is permitted to deny services to fami-lies who cannot pay. In every state, prior to the thirdbirthday, children who have a developmental disabil-ity are entitled to services. The law also permits statesto include infants and toddlers at risk for disabilities ordelays. Only 11 states (California and Indiana in thisstudy) have chosen this option.


In theory, Part C could be a very important resourcefor young infants and toddlers experiencing social andemotional problems and delays. States might also de-

fine eligibility in ways that include young children mostat risk for developmental consequences from early ex-posure to factors such as documented parental substanceabuse or clinical maternal depression, or exposure tosignificant domestic violence or abuse. In practice, how-ever, infants and toddlers with or at risk for social-emo-tional delays and behavioral conditions are not as likelyto be identified and receive services as children withcognitive, physical movement, or language delays.

View from the Sites

In Indiana, the Part C program has been the center ofthe state’s effort to address infant and toddler mentalhealth issues. Florida and Indiana are both making ef-forts to train Part C early intervention providers andagencies to be more sensitive and skilled in workingwith young children experiencing relationship-relatedproblems and disorders. In Vermont, at least one of thestate’s regions has integrated the CUPS program andthe Part C program.

IDEA Part B: Preschool Special EducationProgram

Part B of IDEA authorizes state preschool special edu-cation programs for children ages three to five years.Federal support is blended with state general revenues,public and private insurance, and family out-of-pocketpayments to finance the services. In every state, a childwho has an identified disability is entitled to a free andappropriate public education. Identified disabilities in-clude: mental retardation, hearing impairments, visualimpairments, orthopedic impairments, autism, trau-matic brain injury, developmental delays, emotional/behavioral disorders, or specific learning disabilities thatrequire special education and related services.

Federal guidelines require a focus exclusively onchildren with serious emotional and behavioral disordersand do not permit services to children at risk for seriousemotional and behavioral disorders. For young children,this has a particularly chilling effect on service delivery.


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Unlike the Part C early intervention program, the pre-school special education program does not give statesthe option to serve young children at risk for social,emotional, and behavioral delays. Part B services arelimited to children identified as having severe emo-tional and behavioral disorders.

View from the Sites

Case study interviews did not reveal any special effortsin Part B programs to promote the emotional well-beingof young children or to link with the other identifiedinitiatives. Some state agency and local program staffdid report concerns that children with social, emotional,and behavioral problems who received services underPart C were not able to continue receiving services aspreschoolers because of the more restrictive definitions.Others reported concerns about transitions to kinder-garten. For instance, child care program directors whowere able to maintain more troubled children in theirclassrooms through inclusion strategies raised concernsthat, despite efforts to begin communication about thetransition as much as a year in advance, schools aretypically not prepared to serve young children with se-rious emotional and behavioral disorders.10

Temporary Assistance for Needy Families—TANF

Under the Personal Responsibility and Work Opportu-nity Reconciliation Act of 1996 (P.L. 104-193), theTANF block grant program was created to replace theAid to Families with Dependent Children entitlementprogram. Adoption of this policy changed the rules gov-erning cash assistance and increased states’ flexibilitywith regard to public assistance for low-income familieswith children. Under TANF, families receiving cash as-sistance and other benefits are subject to strict require-ments, including a five-year limit on receiving publicassistance, particularly cash benefits. At the same time,states have been given considerable flexibility in usingTANF dollars to meet the legislated goals of the pro-gram, which are: to provide assistance to needy familieswith children in order to reduce dependency, promotework and marriage, reduce out-of-wedlock pregnancy,and encourage the formation and maintenance of two-parent families.


There are two sets of implications. First, young chil-dren, particularly those at highest risk for social disad-vantages and family crisis, are a core group affected byTANF changes. Children make up over two-thirds ofall welfare recipients, with half of these being childrenunder age six. The quality of child care is a huge chal-lenge for this population, with many children in needof preventive and early intervention services. Researchis also beginning to suggest that young children whoseparents face the most significant barriers to employ-ment (such as substance abuse, domestic violence, anddepression, or who are threatened with or receive sanc-tions) may also experience higher rates of behavioralproblems and poor cognitive development.11 The sec-ond implication is that the flexibility of TANF to meetthe broad purposes of the legislation offers states andcommunities an opportunity to use these dollars to pro-mote healthy early social and emotional developmentfor children affected by TANF processes.

View from the Sites

Only San Francisco reports using TANF dollars as acentral funding tool for its early childhood mentalhealth initiative, although other sites report blendingTANF dollars.

Social Services Block Grant—SSBG

The Social Services Block Grant provides grants tostates to carry out a wide array of social welfare pro-grams and policies. These flexible funds may be spenton services, training, and administration. SSBG fundsmay only be used for services to families with incomesbelow 200 percent of the poverty line. Federal law per-mits transfer of up to 10 percent of a state’s SSBGallocation to programs for preventive health services,

The flexibility of TANF to meet the broad purposesof the legislation offers states and communitiesan opportunity to use these dollars to promotehealthy early social and emotional development

for children affected by TANF processes.


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mental health services, alcohol and drug abuse services,and maternal and child health services. States may alsotransfer up to 10 percent of their TANF funds to theSSBG. Services delivered under the SSBG are not sub-ject to the five-year federal life time limits of TANF.Furthermore, states may use SSBG dollars for noncashvouchers to families at risk for involvement in the childwelfare/child protection systems due to sanctions ortime limits.


SSBG funds may be used to support and augment earlychildhood mental health services. Federal funds maybe used for activities that promote early childhoodemotional well-being, such as child care services thatmeet state standards, parent education, or social ser-vices related to alcohol and drug rehabilitation.

View from the Sites

While no major new programs primarily supported bySSBG were reported, states are blending these dollarsinto pooled funds to enhance early childhood systemsof care. For example, Indiana’s finance system for FirstSteps Early Intervention uses a pool of combined stateand federal dollars that includes funds from the SSBG.

State General Revenue Funds

Every state has discretion about how general revenuefunds are used. For example, as of 2000, all but five stateswere investing in some kind of child development andfamily support programs for infants, toddlers, andpreschoolers, as well as whatever investments they makein supplementing federal child care funds.12 In manystates, investments include home visiting programs. Moststates have to augment federal IDEA Part C Early Inter-vention and Part B Preschool Special Education dollarsjust to meet their obligations under these entitlementprograms. A few states are investing in state versionsof Early Head Start. States also invest general revenuefunds in child and adolescent mental health services,usually through their mental health departments.


There are two sets of implications. The first is that manyof the early childhood programs in which states are in-

vesting could benefit from access to early childhoodmental health services. The second is that states canuse general revenue monies to match federal dollarsbeing used to develop and pay for early childhood men-tal health services (and particularly to pay for thoseservices that the federal funding streams cannot be usedfor) as well as to seed new initiatives.

View from the Sites

Most, but not all sites were thinking about how best touse state funds and how to match federal dollars strate-gically. In some sites, state officials have tried to usethe state general revenue dollars for services, such asprevention, that are harder to fund under federal en-titlements. In other sites, these discretionary dollarswere being used to fund pilot projects. For example, inVermont, state-appropriated funds for the CUPS matchwere designated for preventive services. Vermont hasalso used its state child care, mental health, and healthmonies as a strategic match for early childhood mentalhealth services. In contrast, the state of Ohio used itsstate money to fund early childhood mental health pro-grams without matching Medicaid or other federal dol-lars. In Florida, new state general revenues, withoutmatch, were dedicated to three pilot project sites. Inaddition, states can use general revenue funding to payfor services for which federal funding streams cannotbe used.

Private Funds

States and communities also have access to privatefunds through foundations, United Way, and otherphilanthropic organizations. These, of course, vary con-siderably in size and in purpose. Nationally, founda-tion efforts have already played a role in promotingattention to early childhood mental health. For ex-ample, the Marguerite Casey Foundation, in partner-ship with SAMHSA, has provided substantial grantsto promote early childhood mental health and emo-tional wellness programs across the country throughthe Starting Early Starting Smart Initiative.13 TheEwing Marion Kauffman Foundation is working to buildgreater understanding of the relationship between earlyschool success and social and emotional development.14


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Private money is an important catalyst in seeding pilotprograms that can become models for public adoptionand in providing money for services for which publicfunds cannot be easily used. Most importantly, privatemonies can be very critical in raising awareness aboutthe importance of early childhood mental health.

View from the Sites

Private foundation grants were part of the initial or corefunding in each of these case studies. The CarnegieCorporation of New York provided “Starting Points”grants designed to promote coordination, public en-gagement, and strategic planning for early childhoodinitiatives and thereby indirectly promoted attentionto early childhood mental health issues in Vermont andSan Francisco. The Peter and Miriam Haas Founda-tion supported early efforts to design and implementchild care consultation services in San Francisco. TheMailman Foundation provided a grant to support earlychildhood mental health efforts in Florida. The Com-monwealth Fund, through an early childhood devel-opment initiative, has provided dollars to Vermont forfurthering a continuum of early childhood supports andmaximizing Medicaid funding. Community founda-tions, United Way community organizations, and oth-ers have provided small grants that help launch or sus-tain training and service delivery efforts.


� Although there is no one categorical source of fund-ing for early childhood mental health services, statesand communities have a variety of funding streamsto draw on in crafting funding strategies. These in-clude entitlement dollars, state and local publicfunds, as well as private dollars and special grants.

� Major federal funding sources include Medicaid/EPSDT, the Child Care and Development Fund,TANF, the Children’s Mental Health Services Pro-gram, and Part C, the Early Intervention Programof the IDEA.

SECTION 3:

Financing Strategies

This section focuses on the strategies that the sites areusing to develop and sustain early childhood mentalhealth service initiatives. Building on the discussion offunding streams, it addresses three questions: Whatfunding mechanisms are emerging to maximize fiscalresources? What planning and administrative mecha-nisms support efforts to finance early childhood men-tal health services? How are the sites addressing com-mon barriers?

Funding Mechanisms toMaximize Fiscal Resources

To maximize existing funds, states and local areas areblending and “braiding” funds. The sites are also mak-ing specific efforts to maximize the impact of Medicaidfunding, since that is potentially an important sourceof reimbursement.

Blending Funds

The term blended funds is used here to describe mecha-nisms that actually pool dollars from multiple sourcesand make them in some ways indistinguishable.

� The San Francisco mental health agency has devel-oped a common billing process that it says workslike “Pac-Man”—finding a path through the fund-ing streams toward the payers of last resort. For ex-ample, in the case of mental health program con-sultation, the fees are primarily paid from the pooledfund of flexible dollars. Services that qualify for re-imbursement from MediCal (the name for Medic-aid in California) or Healthy Families (the namefor SCHIP in California) are billed to those sources.

� The finance system for Indiana’s initiative was re-designed by establishing the Central ReimbursementOffice. This electronic system authorizes servicesbased on each eligible child’s Individualized FamilyService Plan (IFSP), and providers are paid a uni-form rate, being blinded to the source of payment.All reimbursements are settled using a “pay andchase” method—meaning that the state pays the


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providers and then seeks reimbursement based on afunding hierarchy individualized to the eligiblechild. This new financing system depends on mecha-nisms that pool state and federal resources acrossprogram lines. Specifically, First Steps spendingcomes from a pool of combined state and federaldollars from state appropriations for early interven-tion services, federal Part C allocations, Title VMCH Services Block Grant Program for Children’sSpecial Health Care Services, the Social ServicesBlock Grant, Medicaid, and TANF. With a moreintegrated claims payment and data system, the mostappropriate funding for each service can be used,and agency competition is being reduced.

Braiding Funds

In braiding, the funding streams remain visible but areused in common to give greater strength, efficiency,and/or effectiveness. In some states, funds are braidedtogether to maximize multiple sources of state generalrevenues to match Medicaid federal dollars, depend-ing on the nature of the service (e.g., child care, school-based, or home visiting).

� Vermont is an example of a state using a braidingstrategy. The willingness of the Vermont Medicaidagency to share responsibility for managing specificaspects of the Medicaid program, combined withattention to opportunities for matching state withfederal dollars, has greatly expanded the potentialto meet the health needs of children. The VermontDepartment of Mental Health Services managesthose Medicaid services provided through the com-munity mental health agencies and has been ableto advance early childhood mental health financ-ing through these centers. The Vermont Child CareDivision also has maximized opportunities to matchstate funding with federal dollars for mental healthservices provided to children in child care settings.The Vermont Department of Health managesEPSDT and has been able to better blend fundingfor maternal and child health, children with specialhealth care needs, and early intervention. Medic-aid matching in the CUPS project also has beenthe result of cooperative arrangements.

Maximizing the Impact of Medicaid

The Florida, Vermont, and Cuyahoga County, Ohiocase studies highlight innovative policies and promis-ing practices in Medicaid for funding early childhoodmental health services for young children. In thesecases, public officials and private organizations haveworked together to devise mechanisms which maxi-mize existing Medicaid coverage.

� Florida has made substantial changes to improve thestructure of Medicaid in order to meet the emotionalneeds of young children. Through joint leadershipof the Florida Medicaid and state mental healthagencies, the state implemented a new mental healthpolicy for children ages birth to five years in May2002. The new policy recognizes that additionaltraining is needed to serve very young children andtheir caregivers and includes changes to address theunmet needs of young children. Among other things,the new guidelines: (1) added a section clarifying

MAXIMIZING THE IMPACT OF MEDICAID:LESSONS FROM THE SITES

To improve the applicability of Medicaid to early childhood mental health ser-vices, study sites have developed:

� Screening and assessment for emotional-behavioral concerns.

� Policies that clearly specify the range of early childhood mental health ser-vices covered.

� Policies that permit and/or encourage the use of mental health screeningand assessment tools appropriate for young children, such as the recentclassification system developed by Zero to Three, DC: 0–3.

� Policies that clarify the roles and responsibilities of mental health providersserving young children under EPSDT.

� Billing codes that can be used by providers of mental health services andsupports for young children, their families, and their other caregivers.

� Centralized billing systems that blend or “pool” funds, thereby simplifyingprovider claims filing and maximizing use of available federal, state, andlocal funds.

� Appropriation of additional state funds to match with federal Medicaid dol-lars.

� Identifying previously untapped sources of state or local funds that can beused to match with federal Medicaid dollars.

� Approval for use of state child care, foster care, public health, maternal andchild health, early intervention, mental health, and social services dollars asMedicaid matching funds in programs serving young children.


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“We need to better define what Medicaid andmental health dollars can and cannot finance…

There are still a lot of red flags raised regarding servicesthat appear to be social services or education.”

Brett Jones, Finance Division, Ohio Department of Mental Health

the “zero to five” coverage/assessment process andrecommended use of the DC: 0–3 and other child-oriented diagnoses, although it still requires thatdiagnoses be linked with ICD 9 codes (InternationalClassification of Diseases, 9th edition); (2) changedto permit billing for either individual or familytherapy, which allows for relationship-based dyadictherapy; and (3) revised provider qualifications topermit a broader array of mental health service pro-viders (i.e., nonphysician providers) to be reim-bursed. Together these changes make it possible foryoung children enrolled in Medicaid to receive moreappropriate assessment, diagnosis, and treatment.

� Vermont has made extensive use of opportunitiesto maximize the use of Medicaid. Vermont uses fed-eral/state Medicaid dollars to finance a variety ofservices for young children with or at risk for men-tal health or behavioral health problems, including:early childhood mental health consultations, nursehome visits for at-risk families with young children,public health nurse case management for childrenentering the foster care system, and therapeutic playgroups. These efforts reflect collaboration amongVermont’s Department of Health that administersEPSDT, the Division of Mental Health that man-ages the majority of mental health spending underMedicaid, the Child Care Services Division of theHuman Services Agency, and Medicaid. The ChildCare Services Division’s use of state child care fund-ing matched to Medicaid in order to fund early child-hood mental health and emotional wellness servicesis particularly innovative. Child care mental healthconsultation and individual aides for children withbehavioral problems were initially financed by usingstate-only child care grant dollars. Now, the state isusing and then blending state dollars to match Med-icaid and other resources. Each of two communitymental health centers received awards of approxi-mately $40,000 for child care mental health consul-tation. These funds were used as a match to leverageMedicaid dollars, yielding more than $100,000 foreach locality to provide mental health services toMedicaid beneficiaries in child care settings.

� Cuyahoga County (including Cleveland), Ohio haslaunched an Early Childhood Mental Health PilotProject for the purpose of demonstrating improved

outcomes with best practices and enhancing avail-able resources. Three agency pilot projects arefunded. One agency—the Positive Education Pro-gram—is using the pilot project as an opportunityto validate use of the DC: 0–3 diagnostic codes forMedicaid billing. It is also evaluating mechanismsto coordinate and integrate the Individual ServicePlan required under state mental health rules andthe IFS Plan required for children ages birth to threeyears served under the Part C program of IDEA inorder to facilitate billing. Information from a suc-cessful pilot project could be used to restructure Med-icaid financing for early childhood mental healthservices in Ohio.

� In San Francisco, the early childhood mental healthconsultation project sets out incentives for billingMedicaid and for making grant dollars stretch far-ther. If contractors bill Medicaid, their contractaward is not reduced and they have more resourcesto spend on services not covered by Medicaid.

Using State Funds Strategically

Across the sites, state-appropriated mental health fundsare being used to support pilot programs, match Med-icaid funding, and finance nondirect program compo-nents such as staff and parent training.

� In Vermont, the Mental Health Agency was able tosecure state-only dollars sufficient to match a fed-eral grant and to focus on prevention. The state gen-eral fund “hard dollar” cash match for the CUPSprogram was approximately $1.5 million from men-tal health, $100,000 from child welfare, and $8,000from education funding.


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“Medicaid has changed its community mental healthservices program policy to make terms, definitions,

and coverage more relevant to young children, to takeinto account the symptoms and needs of young children…

We are not just throwing money at a problem.The potential for prevention is well documented.

The new strategy for 0-5 behavioral health assessmentwill become mandatory and, along with other Medicaid

financing modifications, drive our system of care foryoung children toward prevention and early intervention.”

Celeste Putnam, assistant secretary, Mental Health,Florida Department of Children and Families

� Vermont adds state dollars intended to improve childcare quality to the Child Care and DevelopmentFund. The Vermont State Child Care Services Di-vision allocates a portion of these child care qualitydollars to child care mental health consultation andindividual aides for children with behavioral prob-lems. These activities were financed first using state-only grant dollars and now are financed from blendedfunds that include federal Medicaid match and otherstate and local resources. Leaders in the VermontChild Care Services Division and the Departmentof Human Services in which it is located believethat quality child care should be able to meet thespecial needs of children with emotional and physi-cal delays and conditions. The state legislature andMedicaid agency have supported this commitment.

Collaborative Planning andAdministrative Mechanisms

Interagency and public-private collaboration are essen-tial to developing a system of care that provides a con-tinuum of services. Collaboration, once set in motion,works best where sustained by formal mechanisms. Fi-nancial arrangements frequently are supported by leg-islation, regulation, memoranda of understanding, andother formal guidance. For example, interagency agree-ments are being used to support and manage blendedfunding, overlapping eligibility categories, cross-systemtraining, and care plan interfaces and transitions. Manyof these elements are found across the sites.

� Indiana’s new Part C financing system that blendsstate and federal funds depends on mechanisms thatpool resources across program lines. Inter- and in-tra-agency collaborative partnerships (and the writ-ten memoranda of understanding which undergirdthese partnerships) were essential for coordinatingresources for children ages birth to three years andin redesigning the Indiana financial system for earlyintervention. State financial planning has alsolinked closely with community planning initiatives.

� In Indiana, in addition to financing changes, thesingle-point-of-entry approach allowed for combinedenrollment and created a single application form forEarly Intervention, Medicaid/SCHIP (Hoosier

Healthwise), Children with Special Health CareNeeds, Women, Infants, and Children NutritionProgram (WIC), and other public health maternaland child health projects.

� Across the city of San Francisco, early childhoodmental health consultation is supported by a range offederal, state, and local funds, including federal childcare dollars, local general fund dollars, and theChildren’s Fund (Prop J, a city property tax set-aside).The San Francisco Children and Families Commis-sion also dedicates a portion of the state revenues(from tobacco taxes) set aside in each county for in-vestment in children ages birth to five years. Formalinteragency agreements support these arrangements.

� Vermont used CUPS project funds for statewideexpansion of key services such as: crisis outreach,intensive home-based services, respite care, inten-sive case management, individualized or wraparoundservices, and related training (including behavioralhealth consultation and mentoring). The intensivecase management and wraparound services havebeen delivered in conjunction with a planned ex-pansion of the Vermont Medicaid Waiver forchildren’s services. Specialized rehabilitation forchildren in child care is happening in some regions,aided by collaboration with the Child Care ServicesDivision of the state’s child welfare agency.


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Strategic planning is underway at different levels. In-diana has focused their efforts through a single programplan that links other programs. Florida’s private sectorleaders have developed a statewide strategic plan withconsiderable involvement of the state government.Vermont state grants are used to promote communitylevel planning. In Cuyahoga County, planning for earlychildhood mental health is a component of a broaderplanning and service development strategy.

� For more than a year, key stakeholders from acrossFlorida participated in a strategic planning processfocused on early childhood mental health. An ad-visory committee included representatives from keystate agencies, universities, foundations, the judi-cial system, community-based providers, and privateorganizations concerned with the health and wellbeing of young children. The project was based atthe Florida State University Center for Preventionand Early Intervention Policy. The Florida Devel-opmental Disabilities Council, Florida Departmentof Children and Families, and Ounce of Preventionof Florida played an instrumental role by support-ing this planning effort. The resulting product—Florida’s Strategic Plan for Infant Mental Health—is ablueprint for establishing a system of mental healthservices for young children and their families. Theoverarching goal of the plan is to develop a compre-hensive system to effectively prevent, identify, andtreat emotional and behavioral disorders in familieswith children birth to age five years.

� Through parallel state and regional planning pro-cesses, Vermont CUPS regional project staff haveco-located or developed service linkages with par-ent-child centers, community mental health agen-cies, Part C early intervention programs, child carecenters, visiting-nurse associations, and other localearly childhood programs. CUPS activities are build-ing the capacity of communities to fund, adminis-ter, and deliver behavioral health treatment for fami-lies with young children birth to age six years andbehavioral health consultation for the early child-hood care and education system.

� Through the Cuyahoga County Early ChildhoodInitiative, local public and private agencies are link-ing child care quality efforts, home visiting (Wel-

come Home and Early Start), health coverage out-reach, and special needs child care. A central strat-egy is to use a “no wrong door” concept for servicecoordination. Local leaders recognized that muchwork needed to be done to build a system of carethat could finance and deliver appropriate servicesto promote the emotional well-being of young chil-dren. Cuyahoga County launched an Early Child-hood Mental Health Pilot Project to address theseneeds.

Common Challenges to Adequate Funding ofEarly Childhood Mental Health Services

These case studies highlight the impact of local andstate leadership in addressing a major concern acrossthe early childhood community: strengthening earlychildhood mental health services. But they also high-light three common barriers and dilemmas that thesesites and other jurisdictions interested in moving for-ward will continue to encounter.

Funding for Early Intervention and Prevention

Perhaps the most common and repeated barrier reportedby these sites (and by others as well) is the difficulty ofproviding preventive and early intervention servicesto children without requiring that they have a psychi-atric diagnosis. Each of the sites has struggled and con-tinues to struggle with this unfortunate reality. Programrules that link eligibility to diagnosis are a major bar-rier to promoting emotional development and preven-tive intervention. In every case study site, programmanagers identified problems in financing services tochildren and families without a specifically diagnosedmental health condition. In other words, it is most dif-ficult to finance services to children at risk (i.e., early

Perhaps the most common and repeated barrierreported by these sites (and by others as well)is the difficulty of providing preventive and earlyintervention services to children without requiring

that they have a psychiatric diagnosis.


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intervention services) and services to support thehealthy emotional development of young children (i.e.,preventive services). State rules regarding Medicaid,SCHIP, Part C and Part B of IDEA, and Title V fi-nancing of mental health services are part of the prob-lem, since federal rules would generally permit broadercoverage.

The requirement that children have a diagnosis is un-fortunate because it ignores a compelling body of sci-entific research both from developmental psychologyand developmental psychopathology about the role ofrisk factors in the development of serious emotionaland behavioral disorders, which, in young children, areespecially predictive of later disorders.15 Sites are try-ing to address this in two ways: first, by confrontingthe Medicaid barriers directly, and second, by mixingand matching funds to create a continuum of preven-tive, early intervention, and treatment services. It isalso worth noting that the federal government has en-acted the Foundations for Learning Grants program16

that provides a model for how states might address thechallenge of diagnosis and risk in still more innovativeways.

Using All Available Funds

A second challenge is how to maximize available fundsacross all potential funding sources. It is clear that onlytwo of the sites have made a strategic effort to blend

and braid funds across a wide range of programs, therebycreating the needed billing and monitoring changes.Yet all states and, in turn, local areas use funds frommany sources. The challenge is twofold: to maximizeavailable federal funds from the range of programs (in-cluding Medicaid, IDEA, Title V, child care, Head Start,and other federal grants) and to be strategic about thestate match. The payoff, as the Indiana and Vermontexperiences show, is likely to involve increased collabo-ration, more efficient use of public dollars, and an im-proved array of services and training for young chil-dren, their families, and their other caregivers, as wellas mental health and other professionals.

Sustaining Funding

A third challenge that is a constant theme in the casestudies is a concern that turning short-term grant dol-lars into statewide, sustainable efforts is difficult in tightbudget times. Pilot and demonstration projects can helpvalidate tools and test model approaches, but sustain-ing the activities beyond the pilot phase requires re-newed efforts to secure funds. Across each of the sites,state and local agencies face these challenges, whichare compounded by state budget shortfalls and budgetcuts.

“Policies and programs aimed at improving the lifechances of young children come in many varieties...

They all share a belief that early childhood developmentis susceptible to environmental influences and that

wise public investments in young children can increasethe odds of favorable developmental outcomes.”

National Research Council and Institute of Medicine, Board on Children, Youth,and Families, Commission on Behavioral and Social Sciences and Education;

Shonkoff, J. P. & Phillips, D. (Eds.). (2001). From neurons to neighborhoods: The scienceof early childhood development. Washington, DC: National Academy Press., p. 10

ELIGIBILITY GUIDELINES FOR LEARNINGGRANTS PROGRAM

Children eligible for social and emotional services to prevent early school failureunder the Foundations for Learning Grants Program of the No Child Left BehindEducation Act must have any two or more of the following risk factors:

� Abuse, maltreatment, or neglect.

� Homelessness, removed, or at risk for removal from child care, Head Start,or preschool for behavioral reasons.

� Exposure to parental depression or other mental illness or parental sub-stance abuse.

� Identified early behavioral and peer relationship problems.

� Low birthweight.

� Family income below 200 percent of the poverty line.

� Cognitive deficit or developmental disability.


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SECTION 4:

Key Findings and Recommendations

Taken together, these case studies offer important les-sons to other jurisdictions seeking to invest in strate-gies to promote healthy social, emotional, and behav-ioral development in young children, particularly thosewhose development is threatened by poverty or otherrisk factors. Across the sites:

1. Early childhood mental health initiatives build on andare linked with larger efforts to promote positive out-comes in young children. Broad early childhood ini-tiatives provide a platform on which to build, lay-ing the ground work for further development ofcollaboration, pooled funding, and preventive in-vestments related to early childhood mental health.In each of the case study sites, both collaborationand creative thinking and planning about earlychildhood were underway, frequently with high-level gubernatorial support. This made it easier tocraft initiatives that aimed to infuse early child-hood mental health principles and practices intosettings where young children are found.

2. There is no single right approach to funding early child-hood mental health supports and services. Each stateor community studied started with a different pro-gram approach, population, or funding stream. Inmany instances, the efforts evolved and grew overtime, taking on a clearer focus and vision. In oth-ers, the efforts are more limited and fragmented butstill provide a foundation for future development.

3. Collaboration across agencies has been key to develop-ing more comprehensive funding strategies, with bothmental health and child care agencies playing a key rolein most, but not all, sites. Across all the sites, stateand county mental health agencies are activelyengaging in efforts to promote early childhoodmental health services. Similarly, focusing on childcare quality and access for children facing specialchallenges, a number of child care agencies havecommitted resources to support the emotional de-velopment of young children. Both San Franciscoand Vermont allocate a portion of their qualitychild care dollars for mental health consultation.

In Indiana, the catalyst was a desire to improve thestate’s early intervention program, again by engag-ing a broad group of stakeholders, including manyagency administrators.

4. State Medicaid agencies have developed new policies toaddress early childhood program needs, but are not fi-nancing many of the covered services that children needto prevent or ameliorate early social, emotional, andbehavioral problems. No case study site has fullymaximized Medicaid to fund a variety of mentalhealth services. Florida has revised its policy guid-ance to provide more appropriate assessment andtreatment for young children, while Vermont is us-ing Medicaid to fund a variety of mental healthservices. But even in these states, Medicaid’sEPSDT policies have not been used to their fulllegal potential. One site, San Francisco, has builtin local incentives for maximizing the use of Med-icaid at the local level.

5. Other federal programs have played supporting roles insome but not all of the sites. For example, Part C hasbeen central in Indiana, TANF in San Francisco.No state has pooled monies across all the poten-tially applicable funding streams, although Vermontand Indiana are both trying to do this more sys-tematically.

6. Some, but not all of the sites have been using state gen-eral revenues or federal match monies strategically. Forthose sites that do use this approach, the San Fran-cisco and the Indiana experience suggest the im-portance of reviewing billing processes to stream-line the burden at the local level.

7. There is more flexibility in federal programs and otherfunding streams than has been effectively used. Thesecase studies illustrate how states could better usekey financing opportunities, particularly federalfunding streams. Federally defined entitlement pro-grams are the most reliable and sustained sourcesof funding and are important because they can fol-low an individual child according to need. Beyondthese entitlement programs, federal and state fund-ing for mental health, children with special healthcare needs, substance abuse interventions, and earlychild care and education are used to pay for smaller


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efforts but rarely to finance early childhood men-tal health services in a systematic fashion.

8. External resources can serve as a stimulus for an en-hanced programmatic effort. In most cases, grant dol-lars or special funds—both public and private—were instrumental in launching new efforts. In In-diana and Vermont, federal grants through Title Vand Children’s Mental Health grants were the fis-cal catalysts. In San Francisco, the flexibility ofTANF provided the financial lever. But in eachinstance, the dollars were not explicitly designedto promote early childhood mental health. It tookstate and local leaders to put together the vision,application, and implementation effort.

9. A broad array of early childhood mental health servicesare being funded, although not necessarily within allthe sites. Despite the difficulty of providing preven-tive and early intervention services, many of thesites are concentrating on funding just these kindsof services, particularly early childhood mentalhealth consultation, training, and support groupsfor those who work directly with the children andfamilies. A few sites are focusing on screening andassessment strategies, trying to build the knowledgebase of what can be reimbursed. A few sites, Floridaand Vermont, for instance, are also addressing theneeds of the most troubled young children.

10. Exercising leadership does not depend upon where youwork but how you work. Leadership comes in manyforms at many levels. In every site, leadership wasa key element of success. An individual hired toadminister a short term federal grant project canprovide the leadership for broad systems change;one early intervention or child care program di-rector can hold up a vision for change that otherswill help implement; one legislator champion canprovide the momentum for substantially increasedfinancing; and one provider/advocate can set out tofix a problem and end up creating a new initiative.

Ten Action Steps for States and Communities

Building on the lessons of these pioneering sites, be-low are action steps that other communities and statescan take to strengthen their attention to the social,emotional, and behavioral needs of young children.

1. Start small. Apply for small grants or turn to localfoundations to jump-start a community- or state-level planning process, building on other collabo-rations on behalf of young children.

2. Test out new service approaches to make sure theyfit with the community. Consider evidence-basedpractice, where there is an evidence base, and les-sons from prior efforts.

3. Develop cross-training initiatives to build a sharedunderstanding of what early childhood mentalhealth services are and why they should be funded.

4. Build or strengthen collaborative relationships todevelop a systematic funding strategy to permit thedevelopment of preventive and early interventionservices. For example, use child care improvementfunds for mental health consultation; establish oruse existing formal mechanisms at the cabinet, stateagency, or local agency level; make sure parents areinvolved.

5. Analyze existing levels of funding for early child-hood mental health. Are funds being used for theright services, including early intervention? Are thefunds sufficient? Do services address the needs ofinfants and toddlers as well as preschoolers?

6. Assess the funding streams that could be used andwhat barriers they pose. For example, does the stateMedicaid plan pay for child and family therapy?Must the language be changed?

7. Develop a targeted strategy to maximize the im-pact of Medicaid/EPSDT. For example, include age-appropriate developmental, emotional, and behav-ioral measures into the recommended EPSDTscreening protocol; make sure that reimbursed ser-vices are appropriately defined for young children;make sure that parent-child therapies are covered.


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8. Consider redesigning reimbursement and billingpractices to maximize the use of all available dol-lars, exploring some of the strategies used by thesites described in this report.

9. Develop a strategy to gather the kind of outcomedata needed to refine and sustain funding for earlychildhood mental health strategies.

10. Promote the development of targeted federal fund-ing as a catalyst for the development of early child-hood mental health services. One way would be toencourage the Center on Medicare and MedicaidServices, formerly the Health Care Financing Ad-ministration, to provide technical assistance tostates through groups, conferences, and other meth-ods to help them fund early childhood mentalhealth services.

“Early childhood mental health is a problem.Families don’t know how to get what they need.We seem to have nowhere to refer families with

kids who have mental health problems….The system is difficult. Parents are in a terrible

circle of frustration rather than a circle of support.If a child is in a wheelchair, there is not a question

about what to do or when to diagnose a condition.”

Connie Wells, Florida Institute for Family Involvement


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APPENDIX A

Key Contacts

Florida

Sandra Adams, Director of Special ProjectsFlorida State UniversityCenter for Prevention and Early Intervention Policy1339 East Lafayette StreetTallahassee, FL 32301Phone: (850) 922-1300Fax: (850) 922-1352E-mail: [email protected]

Satellite Office:306 Golden Gate Pointe #5Sarasota, FL 34236

Indiana

Steve Viehweg, ChairIndiana Association for Infant and Toddler Mental HealthRiley Child Development Center703 Barnhill Drive, Room 5387Indianapolis, IN 46202Phone: (317) 638-3501E-mail: [email protected]

Maureen GreerEmerald Consulting40 North Ridgeview DriveIndianapolis, IN 46219-6119Phone: (317) 353-8075Fax: (317) 353-8737E-mail: [email protected]

Ohio

Marla Himmeger, Mental Health AdministratorChildren’s Mental Health InitiativeOffice of Children’s Services and PreventionOhio Department of Mental Health30 East Broad Street, 8th FloorColumbus, OH 43215Phone: (614) 466-1984E-mail: [email protected]

Ohio – Cuyahoga County

Ann Bowdish, Program DirectorEarly Intervention CentersPositive Education Program3100 Euclid AvenueCleveland, OH 44115Phone: (216) 361-4400, ext. 120 dayor (216) 361-7760, ext. 120 evening

San Francisco – High Quality Child Care Mental HealthConsultation Initiative

Sai-Ling Chan-Sew, DirectorChild Youth and Family ServicesSan Francisco Department of Public HealthCommunity Mental Health/Children, Youth, and Families1380 Howard Street, 5th FloorSan Francisco, CA 94103Phone: (415) 255-3439E-mail: [email protected]

Anita Fong, PlannerChild Youth and Family ServicesSan Francisco Department of Public HealthCommunity Mental Health/Children, Youth, and Families1380 Howard Street, 5th FloorSan Francisco, CA 94103Phone: (415) 255-3439E-mail: [email protected]

Vermont – Children’s UPstream Project (CUPS)

Brenda Bean, Program DirectorChildren’s UPstream ServicesChildren’s Mental Health ServicesDepartment of Mental Health103 South Main Street, Weeks BuildingWaterbury, VT 05671Phone: (802) 241-2650E-mail: [email protected]

Charles Biss, DirectorChildren’s Mental Health ServicesVermont Department of Mental Health103 South Main Street, Weeks BuildingWaterbury, VT 05671Phone: (802) 241-2650E-mail: [email protected]


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APPENDIX B

Selected References and Resources on EarlyChildhood Mental Health and Child Development

Bazelon Center for Mental Health Law

http://www.bazelon.org

Bazelon Center for Mental Health Law. (1998). A blueprint forcoalition-building to address the needs of very young children andtheir families with mental health and/or substance abuse issues.

Bazelon Center for Mental Health Law. (1999). Where to turn:Confusion in Medicaid policies on screening children for mental healthneeds.

Koyanagi, Chris & Brodie, J. R. (1994). Making Medicaid work:An advocacy guide to financing key components of a comprehensivestate system of care.

Commonwealth Fund (child development projects)

http://www.cmwf.org

Budetti, Peter; Berry, Carolyn; Butler, Pamela; Scott-Collins,Karen; & Abrams, Melinda. (February 2000). Assuring the healthydevelopment of young children: Opportunities for states (ABCDCommonwealth Fund Issue Brief).

Scott-Collins, Karen; Taaffe-McLearn, Kathryn; Abrams,Melinda; & Biles, Brian. (November 1998). Improving the De-livery and financing of developmental services for low-income youngchildren (Commonwealth Fund Issue Brief).

Rosenbaum, Sara; Proser, Michelle; & Sonosky, Collene. (June2001). Health policy and early child development: An overview(Commonwealth Fund Issue Brief).

Rosenbaum, Sara; Proser, Michelle; Schneider, Andy; &Sonosky, Collene. (June 2001). Room to grow: Promoting childdevelopment through Medicaid and CHIP (Commonwealth FundIssue Brief).

Rosenbaum, Sara; Proser, Michelle; Shin, Peter; Wilensky, SaraE.; & Sonosky, Collene. (January 2002). Child development pro-grams in community health centers (Commonwealth Fund IssueBrief).

Rosenbaum, Sara; Proser, Michelle; Schneider, Andy; &Sonosky, Collene. (January 2002). Using the Title V Maternaland Child Health Services Block Grant to support child developmentservices (Commonwealth Fund Issue Brief).

Georgetown University Child Development Center

http://www.georgetown.edu/research/gucdc/

Kaufmann, Roxane & Dodge, Joan. (1997). Prevention and earlyintervention for young children at risk for mental health and sub-stance abuse problems and their families:A background paper. Dis-tributed by: National Technical Assistance Center for Children’sMental Health, Georgetown University Child DevelopmentCenter.

Wishmann, Amy; Kates, Donald; & Kaufmann, Roxane. (2001).Funding early childhood mental health services and supports. Dis-tributed by: National Technical Assistance Center for Children’sMental Health, Georgetown University Child DevelopmentCenter.

National Academy of Sciences

http://www.nas.edu

National Research Council and Institute of Medicine, Boardon Children, Youth, and Families, Commission on Behavioraland Social Sciences and Education, Committee on Integratingthe Science of Early Childhood Development; Shonkoff, JackP. & Phillips, Deborah A. (Eds.) (2000). From neurons to neigh-borhoods: The science of early childhood development. Distributedby: National Academy Press.

Institute of Medicine. (1994). Reducing risks for mental disor-ders: Frontiers for preventive intervention research. Distributed by:National Academy of Sciences.

National Center for Children in Poverty

http://www.nccp.org

Knitzer, Jane. (2002). Building services and systems to support thehealthy emotional development of young children (Promoting theEmotional Well-Being of Children and Families Policy PaperNo. 1).

Knitzer, Jane & Bernard, Stanley. (1997). The new welfare lawand vulnerable families: Implications for child welfare/child protec-tion systems (Children and Welfare Reform Issue Brief No. 3).

Substance Abuse and Mental Health Services Agency(SAMHSA)

http://www.samhsa.gov

Hanson, Loi; Deere, David; Lee, Carol; Lewin, Amy; & Seval,Carolyn. (2001). Key principles in providing integrated behavioralhealth services for young children and their families: The StartingEarly Starting Smart Experience. Published with Marguerite CaseyFoundation.

Zero to Three: National Center for Infants, andToddlers and Families

http://www.zerotothree.org

Zero to Three. (1994). Diagnostic classification of mental health anddevelopmental disorders of infancy and early childhood (DC: 0–3).

Zero to Three. (1997). DC: 0–3 casebook.


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Endnotes

1. National Research Council and Institute of Medicine, Boardon Children, Youth, and Families, Commission on Behavioraland Social Sciences and Education; Shonkoff, J. P. & Phillips,D. (Eds.). (2001). From neurons to neighborhoods: The science ofearly childhood development. Washington, DC: National Acad-emy Press.

2. Yin, R. K. (1994). Case study research: Design and methods,2nd ed. Thousand Oaks, CA: Sage Publications.

U.S. General Accounting Office. (1990). Case study evaluations.(Transfer Paper 10.1.9) Washington DC: U.S. GovernmentPrinting Office.

3. King G.; Keohan, R. O.; & Verba S. (1994). Designing socialinquiry: Scientific inference in qualitative research. Princeton, NJ:Princeton University Press.

4. Weiss, R. S. (1994). Learning from strangers: The art and methodof qualitative interview. New York, NY: The Free Press.

5. Knitzer, J. (2002). Building services and systems to support thehealthy emotional development of young children: An action guidefor policymakers (Promoting the Emotional Well-being of Chil-dren and Families Policy Paper No. 1). New York: NY. NationalCenter for Children in Poverty, Columbia University MailmanSchool of Public Health.

6. McPherson, M. (1998). A new definition of children withspecial health care needs. Pediatrics, 102(1), pp. 137–140.

U.S. Department of Health and Human Services, Maternal andChild Health Bureau, Division of Services for Children withSpecial Health Needs. (1999). A national agenda for children withspecial health care needs: Measuring success for Healthy People 2010.Rockville, MD: Health Resources and Services Administration,U.S. Department of Health and Human Services.

7. Raver, C. & Knitzer, J. (2002). Ready to enter: What researchtells policymakers about strategies to promote social and emotionalschool readiness among three- and four-year-old children (Promot-ing the Emotional Well-being of Children and Families PolicyPaper No. 3). New York, NY: National Center for Children inPoverty, Columbia University Mailman School of Public Health.

8. Head Start Performance Standards (Program PerformanceStandards for the Operation of Head Start Programs by Granteeand Delegate Agencies, Part 1304, Subpart C: Family and Com-munity Partnerships) available at <http://www2.acf.dhhs.gov/programs/hsb/regs/regs/1304_C.HTM>.

9. Yoshikawa, H. & Knitzer, J. (1997). Lessons from the field:Head Start mental health strategies to meet changing needs. NewYork, NY: National Center for Children in Poverty, ColumbiaUniversity Mailman School of Public Health and AmericanOrthopsychiatry Association.

10. Inclusion strategies refer to efforts to integrate young chil-dren with disabilities into normal settings to the extent pos-sible. These are required under the terms of the Americans withDisabilities Act.

11. Ahluwalia, S.; McGroder, S.; Zaslow, M. & Hair, E. (De-cember 2001). Symptoms of depression among welfare recipients:A concern for two generations (Child Trends Research Brief).Washington, DC: Child Trends.

Knitzer, J. (2000). Promoting resilience: Helping young childrenand parents affected by substance abuse, domestic violence and de-pression in the context of welfare reform (Children and WelfareReform Issue Brief No. 8). New York, NY: National Center forChildren in Poverty, Columbia University Mailman School ofPublic Health.

Kaufmann, R. & Dodge, J. (1997). Prevention and early interven-tion for young children at risk for mental health and substance abuseproblems and their families: A background paper. Washington, DC:National Technical Assistance Center for Children’s MentalHealth, Georgetown University Child Development Center.

12. Cauthen, N. K.; Knitzer, J.; & Ripple, C. (2000). Map andtrack: State initiatives for young children and families. New York,NY: National Center for Children in Poverty, Columbia Uni-versity Mailman School of Public Health.

13. Casey Family Programs & the U.S. Department of Healthand Human Services. (2001). Starting Early Starting Smart: Sum-mary of early findings. Washington, DC: Casey Family Programsand the U.S. Department of Health and Human Services, Sub-stance Abuse and Mental Health Services Administration(SAMHSA).

14. The Kauffman Early Education Exchange. (2002). Set forsuccess: Building a strong foundation for school readiness based onthe social-emotional development of young children. Kansas City,MO: The Ewing Marion Kauffman Foundation.

15. Section 5542 of the No Child Left Behind Education Act.

16. Raver in endnote 7.

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Promoting the Emotional Well-Being of Children and · PDF filePromoting the Emotional Well-Being of Children and Families Policy Paper No. 4 ... developing a state strategic plan to