1. Early Childhood Mental Health: What’s Happening in NH

2. Early Childhood Mental Health is… The social/emotional well being of children aged birth to six years which promotes the capacity to: Experience, manage and express emotions Develop and sustain stable relationships with others (adults and peers) Safely explore the environment and learn Demonstrate developmentally appropriate behavior

3. Prevalence of Early Childhood Mental Health Concerns 74,689 children under the age of 5 in NH 13.5% (10,218) live in poverty, (NCCIC, 2010) 912 cases of founded child abuse in 2007, a 10.9%increase over 2006 In 2007, of 1,084 children not living with parents, 290 were under the age of 5, (Administration for Children and Families, 2009, www.cwla.org)

4. Prevalence of Early Childhood Mental Health concerns NH Center for Public Policy Studies (NHCPPC) estimated that 20% of NH children ages 5-15 could have a mental health disorder 10-20% of preschool children experience- behavioral/mental health concerns, (Dunlap, 2006) This suggests that over 7,500 under age 5 are in need of mental health services, (NHAIMH, 2009)

5. Prevalence of Early Childhood Mental Health concerns (cont.) Of 173 families surveyed, 46.2% were worried that their child (under age 6) might have a social emotional or behavioral disorder, (NHAIMH 2009,Mental Health Services for NH’s Young Children and their families: Planning to Improve Access and Outcomes)

6. Prevalence of Early Childhood Mental Health concerns (cont.) Nationally, the rate of child care/preschool expulsion due to challenging behavior of preschool age children is three times greater than for kindergarten and toddler (Gilliam, 2005). NHAIMH 2001 Child Care Expulsion survey found that in a 15 month period, 53% of child care programs reported they had either expelled a child or enrolled a child that had been expelled elsewhere.

7. Prevalence of Early Childhood Mental Health concerns (cont.) Toxic stress is known to negatively impact brain development. Between 75 and 130 of every 1,000 children in the US under the age of 5 live in homes with 1 of 3 common precipitants of toxic stress (maltreatment, parental substance abuse and maternal depression) www.developingchild.harvard.edu

9. Where people go for help 80% of families report they first seek help from their medical provider when concerned about their child’s mental health or behavior 72% of medical providers report they need more information regarding child development 80% report they need information and resources about behavior (NHAIMH, 2009)

10. Some Risk Factors for Early Childhood Mental Health Issues Toxic Stress Parents with significant mental health issues, (including depression, personality disorders, anxiety, PTSD, Bi-Polar, Schizophrenia) Current or history of abuse and neglect, homelessness, substance abuse, domestic violence High level of family stress, (chronic or multiple acute stressors) Child with developmental or medical issues, colic, challenging temperament, attachment concerns Parent-infant temperament mismatch

12. Why early intervention is so important “Well designed early childhood interventions have been found to generate a return to society ranging from $1.80 to $17.07 for each dollar spent on the program.” Economics Nobel Laureate, James Heckman University of Chicago http://www.ideainfanttoddler.org/pdf/200 8_Good_News.pdf

13. Why early intervention is so important “Effective early childhood programs generate benefits to society that far exceed program costs. Investments in the earliest years of life show the greatest returns- $3.00-$16.00 dollars per dollar invested through reduced crime, welfare, educational remediation, etc. www.developingchild.harvard.edu www.developingchild.harvard.edu

14. Home Visiting “Home visiting influences maternal parenting practices, the quality of the child’s home environment and children’s development…. Greatest benefit for low- income first time adolescent mothers.” (Howard, Brooks-Gunn, 2009) 15 year follow up from home visiting project in Elmira, NY, (David Olds), found 48% less incidents of abuse and neglect through age 15 (Robert Wood Johnson Foundations, 2006)

15. So, where are these children? Child care Medical Care Providers Home and community Schools (pre-school and kindergarten)

16. …and what are the services? Child Care Early Head Start Head Start Home Visiting Programs Early Supports and Services Special Education Watch Me Grow Child Protection Mental Health Services Community and Family Support Programs (Family Resource Centers) Other Community services

17. Recommended Levels of Service 3 Tiered Approach Tier 1- safety, health, supportive and nurturing relationships for all Tier 2- Center-based care and education and Parent and Family Supports for families in poverty Tier 3- specialized support and clinical services for families most likely to experience toxic stress and or high risk in other ways. www.developingchild.harvard.edu

18. In NH…. General family support and parent education Child care site-focused support and education, (i.e. PTAN child care consultation) General child development support Child/family specific support/ intervention based on eligibility Enhanced services based on eligibility, diagnosis and/or finding of abuse or neglect; (ie through ESS or Mental Health)

19. Provider Type/Type of Service Assess./ Diagnosis Case Mgmt. / Service Coordination Therapies Emer./ Trauma Services Social Skills Training / Behavioral Consultation to Early Care and Education Programs Community Mental Health Centers 1 XXXXXX Early Supports and Services 2 XXXXX Child Development ClinicsX Private PracticeXXXXX Early Care and Education/ Preschool Special Education 3 XX Early Head Start/ Head StartXXXXX Primary Care Physicians/ Health Care 4 X Division of Children, Youth and Families X Community Home Visiting Programs 5 X Private Non-Profit Mental Health X Preschool Technical Assistance Network (PTAN) X

20. State Supported Programs ProgramAgeEligibility CriteriaServices Provided Early Head Start 0-3Income basedHome visiting, parent education and support, screening, mental health consultation, center-based socialization Head Start 3-5Income basedEducational, center-based, parent education and support (in group), screening, enriched child care, mental health consultation Early Supports And Services 0-333% developmental delay Atypical social emotional Development, Established Condition, or meets “At Risk” criteria Assessment, Parent education and support, Developmental therapy and support (includes behavioral and counseling), and case management Home Visiting NH Preg.-1 Medicaid eligibleParent education and support (improved birth outcomes, child development, family planning, smoking cessation, impact of substance use) Child Care 0-6Income based for subsidyChild care Child care subsidy to eligible Child Care consultation (PTAN)

21. State Supported Programs cont. Program Age Eligibility CriteriaServices Provided Preschool Special Education 3-5Educational disability, including Emotionally Disturbed Assessment, Educational therapies and support Division of Children Youth and Families 0-6Finding of Abuse or Neglect Case management, child care, parent education, support, remediation services, placement as needed, referral and funding for assessment, parent education, support, therapies Community Mental Health ?-6Determination of SED or at Risk of SED and DX by DSM IV R Varies by region- assessment, emergency services, psychiatric evaluation, some family tx, some play tx some Child-Parent Psychotherapy, some parent education and support Watch Me Grow 0-6NoneCommunity based screening (development, some Autism, some social emotional) Community0-6NoneRecreation, community resources, private therapies

22. ProgramNumbers Served Costs Early Head Start 318$3,656414, average cost per child, $11,498 Head Start 1,146$11,471,019 avg. cost per child, $7,933 Early Supports And Services 3598 in 2009 4.04% (1,744/43,201) of the NH general population $2,950 per child annually Numbers Served & Costs

23. ProgramNumbers Served Costs Home Visiting NH 900 families in SFY 2010$3,175 - $4,398 per child pregnancy – birth (Health Metrics, 2004) Child CareDecember 2010 child care scholarship served 4,376 children under 6.5 years old. 1,108 were under 18 months old 1,200 were 18 to 35 months old 1,758 were 36 to 79 months old December cost per child for children 1-79 months was $371.80. The total cost for the month for children 1-79 months was $1,623,361.74 * Fasting growing group in child care- children under the age of one. Numbers Served & Costs cont.

24. ProgramNumbers Served Costs Preschool Special Ed3 yo- 867, (55 ASD, 0 ED) 4 yo 1120, (64 ASD, 3 ED) 5 yo 1105, (88 ASD,3 ED) (Dec.1, 09) Unknown DCYF Comprehensive Child & Family Support 2008 Founded Cases 0-3yo 308 (24% of all) 4-7yo 241 (23% of all) Unknown Community Mental Health Unknown Numbers Served & Costs cont.

25. ProgramNumbers Served Costs Watch Me Grow178Approx $25,000 Communityunknown

26. Identified Gaps/Needs and Existing Promising Practices

27. Gaps and Needs Information, support and resources for primary care providers Support and consultation for childcare providers Professional training at all levels Earlier identification of social emotional needs Access to and availability of quality services across regions Clear eligibility criteria for community mental health services Expansion of evidence-based practices

28. Information, Support and Resources for Primary Care Providers Watch Me Grow ASQ-SE and other screening tools Developmental specialists and Mental Health Providers in primary care offices

29. Support and Consultation for Childcare Providers PTAN and other existing child care consultation models The Head Start Early Childhood Mental Health Consultation Model NH Early Learning Guidelines Healthy Child Care NH Maine RELATE Model of Early Childhood Consultation NH Early Childhood and Family Mental Health Competencies

30. Professional training at all levels Mental Health Expertise on Early Supports and Services Teams ECMH expertise in Community Mental Health Training in Child-Parent Psychotherapy NH Early Childhood and Family Mental Health Competencies

31. Access and availability of quality services across regions Evidence-based home visiting models (i.e. www.futureofchildren.org) www.futureofchildren.org Child care consultation and support Family Resource Center Programs Local ECMH grant funded programs Some community mental health expertise Child-Parent Psychotherapy consultation model

32. Community Mental Health Services Some community mental health expertise Child-Parent Psychotherapy consultation model Preventative services Consistent eligibility evaluation criteria and process DC 0-3 for diagnosis

33. One Last Thought…. Promoting Early Childhood Mental Health requires an integrated comprehensive community-based system of care. So… it is a really good thing that we are all here and working together. Our future is our children.