Connecting the Dots model for early intervention in child care: Two years of challenge and success

Behavioral/psychosocial health in early childhood is an area of need throughout the US. The National Advisory Mental Health Council has suggested that childhood mental health disorders will be one of the top five causes of sickness, disability, and death among children by the year 2020. Without treatment, behavioral problems are highly persistent and worsen with time, greatly increasing the likelihood of a child being expelled from child care and experiencing difficulty in kindergarten and beyond. Out-of-home child care presents an opportunity to prevent minor behavioral/ psychosocial issues from developing into more serious mental health problems before young children reach school age. In North Carolina, 274,026 children participated in out-of-home child care in 9,007 regulated facilities across the state in October 2007; this number continues to grow annually. The increased demand and the inclusion of more children with special needs requires a system of services to establish linkages among child care providers, child care health consultants, primary health care providers, and pediatric mental health specialists, with an emphasis on primary prevention and coordination among the family, the child care facility, and the medical home.

The Connecting the Dots program takes advantage of the existing relationship between the Cleveland County Health Department and community-based out-of-home child care providers, as facilitated by the local child care health consultant (CCHC). The CCHC's position involves training child care providers in a variety of health and safety practices, including sanitation in diapering and hand washing, medication administration, and emergency preparedness. One day per week of her position is spent on this social-emotional-behavioral project. Each year, children ages two through five in an additional 10 child care centers and new enrollees in Cleveland County's Head Start program will receive the program's services. The project is now completing its third of five funding years, and operates on the following four levels (see below). The first funded year was spent in preparation and start-up. In the second year, Levels I and II of the program were fully and successfully operationalized, and progress was made on Levels III and IV. In the current year, the project has added nine new child care centers, continues to serve six of the centers served last year as well as Head Start, and is bringing Levels III and IV into fuller operation.

Level I - Classroom intervention has been and is being carried out in 15 child care centers and 14 Head Start classrooms. In our first year of operation we served 562 children. Thus far in the second year, we are serving 712. Using the curriculum designed by the Center for the Social and Emotional Foundations of Early Learning from the University of Illinois, the CCHC trains the child care staff in designing scheduling, space utilization, and classroom rules to maximize age-appropriate development and in promoting desired behaviors and responding appropriately to challenging behaviors. Training takes place both in scheduled workshops for teachers (well-attended and evaluated positively in both years). Center and Head Start staff members consistently report improvements in behavioral outcomes as a result of the classroom interventions. An Event Sampling Form is completed by the CCHC at three points during each school year, measuring changes across a range of physical, social, and teaching technique parameters.

Level II - Screening: In the first year of operation, 10 child care centers and 14 Head Start classrooms completed the ABLEŠ I screening form on all children whose parents had not declined participation. Of a total of 562 children served, 142 (25.3%) screened positively, and were then screened using the ABLEŠ II form. Of these, 59 (41.5%) needed further behavioral evaluation, and 33 (23.2%) needed help with speech/language issues. As of February 2008, 15 centers and all Head Start classrooms have completed this year's ABLEŠ I screenings on all 712 children. ABLEŠ II screenings are largely completed but still in progress, and children who enter our centers and Head Start classrooms over the year will also be screened. Of 114 children screened to date with the ABLEŠ II, we have identified 35 children (30.7%) needing further behavioral evaluation and 19 (16.7%) who needed help with speech/language. The ABLEŠ screening program has proven both sensitive and user-friendly.

Level III - Primary care intervention: The CCHC will facilitate referrals to primary care for behavioral intervention. Many children enrolled in participating child care centers are seen at Shelby Children's Clinic (SCC); this practice is by far the largest in the County and is a strong partner in the program. Dr. Leslie Richardson at SCC is a pediatrician and developmental specialist, and is a member of the Connecting the Dots Advisory Board. SCC's child mental health case manager is funded by the Carolina Community Access Program, and their child psychologist is available to see children who need that level of intervention. Both positions were created with the impetus of the Connecting the Dots program. The goal is for most children requiring behavioral intervention to be assessed and treated at the primary care level, but it is essential to have ready access to a highly trained specialist when needed. In 2006-2007, only 32 of the 59 children needing behavioral evaluation and follow-up (54.2%) received services, while 27 of 33 (81.8%) who needed speech/language evaluation and follow-up received it. We plan to be more proactive in meeting the behavioral needs of those children eligible for referral as the current school year proceeds.

Level IV - Pediatric mental health intervention: The primary care providers will refer those few children needing this level of care to providers in Cleveland County, such as the SCC psychologist. Head Start has its own mental health specialist, and the Cleveland Counseling practice treats preschool children as well. The SCC child psychologist has seen many of the behavioral referrals from the 2006-2007 school year, although we are not able to follow children using provider's records, due to HIPAA regulations.

This pilot project is a promising model that we anticipate will expand into other North Carolina counties in the near future. Recently Randolph County hosted our project at a monthly meeting of its Mental Health Task Force, and members were excited about its implementation and have followed up for more information. The program is community-based, using the county health department as a foundation, and the known and respected CCHC(s) as the primary agent of change. It draws upon the expertise of a broad-based Advisory Board that includes parents, child care providers, and pediatric health experts, meeting monthly or bi-monthly to make decisions on the conduct and expansion of the project. Awareness of the program is steadily growing throughout the NC, and response has been unequivocally positive.