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State Case Studies of Infant and Early Childhood Mental Health Systems: Strategies for Change

In recent years, states have made progress in identifying and referring children for developmental and mental health problems at a young age, particularly through the Assuring Better Child Health and Development initiatives in primary care. There is more awareness of the potential of intervening in the early years, with an increasing amount of literature that documents policy recommendations to implement and fund systems of early identification and early education and care. Less is known, however, about the strategies state leaders have used to develop comprehensive infant and early childhood mental health systems, and the progress they have made. This report describes mental health identification and intervention systems for children from birth to age 5 in Colorado, Indiana, Massachusetts, and Rhode Island, and focuses on state achievements and the process of change. Interviews with leaders and stakeholders in each state are combined with additional research to profile innovative strategies and initiatives. The findings underscore the importance of collaborative partnerships and point toward a vision of mental health systems for the nation’s youngest children and their families.

Highlights of State Achievements
Together, the states in this study demonstrated similar strategies and objectives, with each state showing signature achievements. Colorado was notable for its strategic approach in stakeholder engagement and planning, actively backed by high levels of government. This resulted in a major federal Substance Abuse and Mental Health Services Administration (SAMHSA) systems initiative, as well as the development of a highly effective statewide medical home model, the adoption of a developmentally appropriate diagnostic classification system, and the implementation of expert infant and early childhood mental health (IECMH) consultation in child care and mental health clinic settings. Indiana’s signature achievements include innovative interagency screening and service tracking for children in child welfare, development of parent-friendly, Web-based information, and advanced interagency planning. These efforts show potential for federal funding when sufficient political will is generated. Growing interagency collaboration in Massachusetts, accelerated by court order, has supported major Medicaid systems change in children’s mental health. The state also has an exceptionally progressive IDEA Part C Early Intervention system (for children from birth to age 3 with developmental disabilities) that has collaborated with child welfare to identify and serve young children at risk. Rhode Island illustrates a long-term vision of community-based early childhood health and development services, driven by a highly collaborative department of health and an integrated children’s services agency. Rhode Island has achieved incremental v i system building through federal and foundation grant initiatives, supported by innovative Medicaid models and active partnerships with parents.

Lessons Learned
The challenges states faced include administrative and financial hurdles, early identification and access challenges, and workforce issues, but the ways in which they have been addressed provide important lessons. The financial hardships of the current economy are exacerbated by challenges in identifying, tracking, and integrating sources of funding. Unnecessary administrative eligibility and reimbursement barriers impede early identification and access to services. These challenges are magnified by dramatic gaps in the IECMH workforce. The National Scientific Council for the Developing Child points to a larger, national issue, the “gap between what we know and what we do.” That is, the gap between scientific knowledge about the importance of early brain and mental health development and the current abilities and limitations of policy and practice in working with young children and their families. These challenges all present opportunities for change. There are strategies for achieving change that should begin before system planning and should continue throughout implementation. These are: comprehensive stakeholder involvement in planning, inclusive needs assessment, shared learning, social marketing, evaluation, sustainability planning, and collaborative partnership. Full stakeholder involvement in planning can be expensive and time-consuming, but is critical for buy-in and support. Needs assessment engages communities, providers, and state officials at all levels of government in objective analysis of the system and development of a shared vision of needs. Shared learning helps to refine the vision, gain needed tools, and strengthen the commitments of agency leaders to collaborate and contribute resources. Social marketing engages the general public and lawmakers in understanding and supporting systems change, and in making use of services. Evaluation provides data for quality improvement activities, social marketing, and sustainability planning, a key ingredient. Collaborative partnership is central to successful strategies. The most significant achievements were realized through strong relationships and engaging a broad range of stakeholders and funders in developing a shared vision. This review resulted in the following recommendations, all aimed at narrowing the gap between what we know and what we do. 

    Administration and finance. It is important to establish expert IECMH advisory groups or councils, which can be highly effective if they cut across agencies and key vi i programs and have genuine support at the highest levels of government. Initiatives aimed at sharing child-specific data regarding needs identification, service utilization, and outcomes show great promise for tracking children and families across systems and allocating interagency resources effectively. Similar efforts toward “mapping” federal, state, and local sources of funding and documenting where they are spent can reduce duplication and increase the likelihood of cost-sharing, cost effectiveness, and the identification of potential new funding streams. This is especially important while states continue to advocate for more stable sources of federal funding. 

    Early identification and access. Requiring frequent mental health screens with specified screening tools in Medicaid’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) program can help achieve the goal of improving the health of low-income children. Making similar services a requirement of other third-party payers is critical to ensuring that no child, regardless of family income status, falls through the cracks. The most progressive states require frequent screening with clearly identified, developmentally appropriate and validated IECMH tools. Some states, recognizing the profound effects that the mental health of parents can have on infant and early childhood development, are also seeking to establish routine parent depression screening in prebirth obstetric and postpartum pediatric visits. Those with the most success are providing reimbursement rates that make screening possible. At the service level, states can expand capacity for identification and service by providing expert IECMH consultation in key settings funded by Medicaid, state dollars, local, grant or foundation funds, or in many cases, a combination of these funding streams. Consultation models include child care consultation and consultation in Early Intervention, mental health clinics, and primary care settings. These models greatly enhance the ability of professionals with little or no formal IECMH training to identify and address the mental health problems of very young children and to make referrals. Embracing diagnostic and eligibility criteria that are developmentally appropriate for infants and young children is also critical. Some states are working on systemwide acceptance by Medicaid and third-party insurers of an infant–toddler diagnostic system so the lack of age-appropriate diagnoses will no longer be a barrier to needed services. States should also continue to work with federal and state agencies to revise definitions of other terms that are often gateways to service, such as “seriously emotionally disturbed” and “medical necessity.” 

    Workforce development. Even if children are found eligible, there is a significant barrier—commonly voiced by pediatricians—that there is little point in mental vi ii health screening if there are no or few IECMH programs or practitioners available for referral. Solutions to this problem include maintaining accessible, updated information on available services and developing a workforce that is properly trained in this specialized area. All of the states reported that there were only a handful of fully qualified IECMH clinicians, many of whom do not or cannot accept Medicaid clients because of inadequate rates, exclusion from managed care panels, or denials of reimbursement for the work of professionals in training. Despite ongoing efforts, all the states need statewide, properly funded interagency plans for cross-disciplinary IECMH higher education and in-service training, as well specialty area credentialing. 

    The gap between what we know and what we do. State feedback suggests that it is critical to use public policy at the federal level to narrow the gap between scientific knowledge about early brain development and what we do in IECMH practice. President Obama’s emphasis on early childhood development now opens opportunities to build on visionary federal programs such as Part C Early Intervention, Head Start, and Early Head Start by continuing to integrate a mental health component in many of the services that reach very young children. This requires a fully articulated national vision statement that supports the universal identification of young children with mental health problems or risks and provides equal access to developmentally and culturally appropriate infant and early childhood mental health services.

Publication Details



D. R. Lyman, W. Holt, and R. H. Dougherty, State Case Studies of Infant and Early Childhood Mental Health Systems: Strategies for Change, The Commonwealth Fund, July 2010.