EARLY CONNECTIONS NETWORK

2010 – 2016final report

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RESEARCH AND EVALUATION TEAMElizabeth McInerney, M.Ed., Lead Evaluator, Centerstone Research Institute

Christy Holleman, B.S., Research Associate II, Centerstone Research Institute

Joan Sykora, Ph.D., Supervising Evaluator, Centerstone Research Institute

Kathryn Mathes, Ph.D., VP of Research & Evaluation, Centerstone Research Institute

Connie Maples, M.S., Senior Research Associate & Data Liaison, ICF Macro

PROGRAM LEADERSHIP TEAMElizabeth Ball, LCSW, Project Director, Early Connections Network

Kim C. Gray, ScD, Executive Director, Advantage Behavioral Health

Debbie Cagle, Former CEO for Advantage Behavioral Health.

Rikki Harris, M.A., CEO, Tennessee Voices for Children

Vickie Harden, LMSW, Senior Vice President of Grant Services and Business Development, Volunteer Behavioral Health Care

Susan K. Phillips, LMSW, Center Director Cumberland Mental Health, Volunteer Behavioral Health Care

Centerstone of Tennessee Clinical ServicesSejal West, M.A., Assistant Commissioner of Mental Health Services, Tennessee Department of Mental

Health and Substance Use Services (TDMHSAS)

Kristy Leach, M.A., Director, Office of Children and Youth Mental Health, TDMHSAS

Justine Bass, B.S., Mental Health Grants Manager, Office of Children and Youth Mental Health, TDMHSAS

The families who participated in the ECN program are acknowledged for their courage, strength, and dedication to improving the lives of their families.

Centerstone Research Institute acknowledges the significant contributions and partnership with the following agencies.

ACKNOWLEDGEMENTS

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Table of ContentsKey Highlights 6

Introduction 8

Evaluation Design 13

Findings 14

Demographics 15

Conclusions 25

References 27

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ECN served 228 children and their families during the six year grant period.

25.3% of families reported they were currently in the military or veterans. The area served by ECN included a large military post.

The majority of referrals to ECN were from mental health agencies and physical health care providers.

95.7% of primary caregivers were female, under 35 years of age, Caucasian, and held a high school diploma or above.

72% of ECN children were male, and 28% were female. The average age of ECN children was 3.3 years old.

85.6% of children lived with their biological family at intake; 63.4% of custody resided with two parents.

Focus groups conducted at the beginning of the grant highlighted the need for mental health services for young children and social and emotional support for caregivers. A need for evidence-based training and integrated care were also highlighted as were promotion of social and emotional development and prevention of mental health problems in very young children.

KEY HIGHLIGHTS

FAMILIES AND CHILDREN

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73% reported disruptive behaviors in young children as the presenting problem for services.

18.5% of children had run off or away without his or her caregiver knowing where he or she was.

53.8% of caregivers reported their children had a chronic or recurring physical health problem.

Caregivers reported attention and aggressive problems that were considered to be in the clinically high range.

66% of caregivers reported a family history of depression; 53.5% of children had lived with someone with depression.

88.6% of caregivers reported a clinically significant level of parental stress at intake.

ECN OUTCOMESCaregivers reported a reduction in child impairment from intake to 6- and 12-months as well as a reduction in aggressive behavior.

Caregivers reported a reduction in caregiver strain from intake to 6- and 12-months.

Families reported an overwhelmingly positive System of Care experience. Caregiv-ers found care to be individualized, child-centered, and family-driven, and skill build-ing and community-based care was also mentioned as being helpful.

MENTAL AND PHYSICAL HEALTH

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Ensuring that infants and children get off to a healthy start in life is recognized as fundamental to the well-being of individuals, communities, and larger societies. Addressing these issues saves behavioral and physical health care costs throughout the lifespan, in addition to preventing human suffering, social costs, and psychological stresses. Infant and Early Childhood Mental Health (IECMH) refers to the “social, emotional, and behavioral well-being of children and their families” (Georgetown University Center for Child and Human Development). IECMH, when attended to by caring families and competent professionals, includes children’s capacity to regulate their emotions, form relationships, explore the world in which they live, and develop as healthy, productive, and harmonious members of society.

It is estimated that up to 20 percent of young children under five experience social, emotional, and behavioral problems (Bayer, Hiscock, Ukoumume, Price, & Wake, 2008; Brauner & Stephens, 2006). These problems greatly impact children and their family’s well-being, children’s later school performance and the quality of their lives overall (Poulou, 2013).

Children experiencing social, emotional, and behavioral problems often have complex needs that are not easily met. Furthermore, it is not just the child who is impacted by his or her struggles, but also the family, who is likely to need help and support.

INTRODUCTION

“Anyone involved with the mental health of infants must be concerned fundamentally with the context in which they are developing.” (Zeanah, 2000)

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System Of Care OverviewIn the early 1980s, policy makers in the United States were becoming increasingly aware of what families had known for a long time: some children have serious, complex mental health needs that affect their behavior, relationships, and overall well-being. Pressure from teachers, families, and child-care providers was mounting not simply to increase service availability, but to ensure that fragmented services were replaced with a comprehensive, coordinated system of care to adequately address the mental health needs of children and adolescents. This resulted in federal policies requiring states to address these complex needs. Federal demonstration project funding was made available, and “systems reform” was underway. Gradually, as these efforts evolved, families, researchers, and policy makers broadened the focus of this initiative to include prevention, early intervention, and addressing mental health needs starting from birth (and before).

A system of care is a broad array of effective services and supports for children and adolescents with behavioral health disorders and their families that is organized into a coordinated network, integrates care planning and management across multiple levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery, management, and policy levels (Pires, 2002).

The purpose of a System of Care is to coordinate what historically has been a fragmented service delivery system. Multidisciplinary teams that include family members and service providers take the place of individual providers rendering uncoordinated services. The initiative is meant to maintain a focus on prevention and early intervention and “wrap” needed services around families in a coordinated manner that is designed to achieve access to a comprehensive set of needed services.

SOC VALUESA System of Care is envisioned to be1. Child-Centered and Family-Driven:

The strengths and needs of the child and family determine what services are needed. The family is actively involved and has a primary decision-making role in determining services as well as in the evaluation and management of programs 

2. Individualized: An individualized service plan is developed under the leadership of the child’s parents/caregiver that meets the unique needs of the child.

3. Culturally and Linguistically Competent: Agencies, programs, and services are sensitive to the cultural, racial, ethnic, and linguistic differences of the communities served in order to provide high quality services to all families.

4. Community-Based: Services, as well as the management of programs and decision-making responsibility, rest at the community level. Services and supports should be realistically accessible.

PURPOSE OF THE REPORTThe purpose of this report is to describe the characteristics and experiences of the young children and their families served by ECN and to inform and strengthen decision making and public policies in Tennessee.

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EARLY CONNECTIONS NETWORK DESCRIPTION

The mission of the Early Connections Network is to develop a service infrastructure that will give caregivers, providers, teachers and others the essential knowledge, skills, resources and support they need to respond effectively to the social, emotional, cognitive, and behavioral needs of young children and their families. —ECN Evaluation Plan

The purpose of the Early Connections Network (ECN) has been to build a System of Care for very young children (ages 0-5) with social, emotional, and behavioral needs. ECN brings together families, caregivers, teachers, providers, governmental agencies, and natural supports to improve access to quality care for those with mental health challenges and to prepare children for school and for life. ECN is active in five Middle Tennessee counties: Cheatham, Dickson, Montgomery, Robertson and Sumner, as well as in Ft. Campbell—one of the largest military posts in the country.

Through promotion, prevention, and treatment, ECN aims to improve the social and emotional well-being of young children and their families by strengthening relationships with caregivers and promoting age-appropriate social and emotional skills. ECN seeks to achieve five primary goals:

1. Develop a comprehensive System of Care for young children and their families that can be replicated in other areas of the state.

2. Establish a reliable infrastructure to sustain a comprehensive System of Care for children 0-5 and their families.

3. Increase community awareness of social emotional health and early child mental health needs and reduce stigma.

4. Improve outcomes for children birth through age five who have significant behavioral or relational symptoms related to trauma, parent/child interaction difficulties, or impaired social emotional development.

5. Provide statewide training and local coaching for providers, families, and community members regarding evidence-based practices for effectively treating early childhood mental health support groups, workforce development trainings, and other services as needed.

The ECN initiative includes the provision of direct services in the home, care coordination, parent education, and support groups. The ECN governance structure includes “Full Partnership” Meetings, a Coordinating Council, work groups, a state-level leadership team, and an administrative team.

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COMMUNITY NEEDS ASSESSMENTThe Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) received funding for the Early Connections Network (ECN) from the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2010. Although many of the activities that are described in this report were mandated by SAMHSA funding, there was also some flexibility in terms of specific services ECN would provide and the manner in which they would be delivered. In an effort to better understand the communities served by ECN and the needs related to early childhood services, a needs assessment was conducted in 2011.

From the need assessment, important themes emerged that impacted the implementation of ECN.

1. Resource mapping found varying service availability in each county and suggested there was a need for mental health services for young children and services that supported healthy development in early childhood.

2. Caregivers needed social and emotional support. For example, one out of every five adults in Robertson & Sumner Counties reported that they received inadequate social and emotional support.

3. Participants argued the need for a focus on prevention and promotion of early childhood mental health - not just intervention.

4. There was a need for an increased number of early childhood mental health providers and an increased access to providers.

5. Services and resources needed to be responsive to the diverse needs in the community (e.g., children who speak English and a second language, military families, and diverse rural and urban communities).

6. Integration of services was a priority – participants spoke of getting families and service providers “on the same page.”

Additionally, early work highlighted the need for family support services, care coordination, and individualized service planning to be reimbursable under TennCare, Tennessee’s Medicaid program, as well as under private insurers.

OVERVIEW OF SERVICE MODELThe Early Connections Network works toward achieving all the grant goals in the five counties and Ft. Campbell. ECN uses a public-health tiered model, which includes initiatives for promotion of appropriate social, emotional, and behavioral well-being, prevention of social, emotional, and behavioral problems, and intervention for children and families experiencing early childhood mental health problems.

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At the intervention level, ECN utilizes care coordination by a Family Support Provider (FSP) or an Early Childhood Specialist (ECS) in addition to family advocacy services and/or parent child therapeutic services, depending on the family’s need. Specifically, the ECN service delivery model emphasizes providing care to families through the collaborative efforts and services of a family-driven, integrated, multidisciplinary, multi-provider team. Families are referred to ECN by a variety of sources.

To be eligible for enrollment in ECN, children with a mental health need must be 5-years of age or younger at intake and live in Cheatham, Dickson, Montgomery, Robertson, or Sumner Counties in Tennessee or on post at Ft. Campbell. Children 3 years of age or younger must exhibit significant behavioral or relational symptoms identified in the Diagnostic Classification of Mental Health Development Disorders of Infancy and Early Childhood—Revised (DC:0–3R). Children 4 or 5 years of age must have a diagnosable disorder consistent with the Diagnostic Interview Schedule for Children (DISC) or for any child age five and under they must have been determined by a licensed professional to be at imminent risk of serious emotional disturbance.

After referral to ECN and screening for eligibility by an Enrollment Coordinator, a child is assigned to a Care Coordinator who serves as the facilitator of the integrated care plan, providing linkages to other service providers. Care Coordinators work closely with FSPs and ECSs, (depending on the needs of the family) having monthly Child and Family Team Meetings, where both the family and service providers work together in coordination on an Integrated Care Plan.

Treatment

Prevention

PromotionPromoting Early Childhood

Mental Health & Fighting Stigma

Education & Skills Building

Direct Services

TREATMENT SERVICE MODEL

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Centerstone Research Institute (CRI) was contracted to design and implement the evaluation of ECN throughout the six-year span of the grant. The purpose of the evaluation was to describe the children and families served by ECN’s system of care, and assess program, policy, and service effectiveness. A fundamental purpose of the grant was to generate data to inform policy and practice decisions about infant and early childhood mental health needs, services and outcomes in Tennessee.

NATIONAL EVALUATION

SAMHSA contracted with ICF International, a contractual organization with evaluation and measurement expertise, to design and implement the evaluation. ICF International also provided ongoing technical assistance to grant sites to support evaluative and data management efforts. The ECN evaluation utilized a cross-sectional descriptive and longitudinal design to describe children and their families and to examine how children and their families changed over time. CRI partnered with ICF International on their National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families (CMHS) SAMHSA program. Using ICF’s designated instruments, CRI collected data from ECN participants at their intake to the program and a 6-, 12-, 18-, and 24-month intervals. Data collected included demographics of all children enrolled in ECN as well as their families. Additionally, a subset of ECN participants who enrolled in the National Evaluation also completed ICF designated measures of outcomes to assess change over time. Data from the ICF evaluation is included in this report.

LOCAL EVALUATION

A number of smaller evaluative efforts took place in addition to the national ICF guided evaluation:

■ Needs Assessment

■ Parenting Class outcomes

■ Inquiring Minds parent and staff meetings, focused on utilization of the ECN data

■ Semi-structured interviews to explore satisfaction and improvement suggestions

■ Surveys of members of the governance structure

EVALUATION DESIGN

“…there is increasing recognition that the very properties of complex systems make it especially difficult to evaluate” -Stroul et al. (2010)

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PARTICIPANT DEMOGRAPHICS AND NEEDS

The Early Connections Network project provided direct services to 228 children and their families in Cheatham, Dickson, Montgomery, Robertson, and Sumner Counties as well as the Ft. Campbell military post. Children were referred from a wide array of systems and service providers, with the majority of

referrals from mental health agencies and physical health providers such as pediatricians.

Once a family was enrolled in ECN, they were given the option of enrolling in the evaluation. Close to half of families elected to participate in the evaluation and the data in this report is reflective of their experiences.

FINDINGS

REFERRAL SOURCE

0.5%

1.0%

1.0%

1.5%

1.5%

2.9%

3.0%

3.9%

4.4%

8.3%

23.0%

49.0%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Self

School

 Early Head Start

 Early Intervention

 Family Court

 Head Start

Other Caregiver

Public Child Welfare

Other Early Care

Physical HealthProvider

Mental Health Agency

The majority of ECN referrals were from mental health agencies and physical health providers like pediatricians, which comprised 72% of referrals.

“My child has learned to recognize his own emotions. That has helped our communication about how he is feeling and how he is behaving.” -Caregiver

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The majority of children enrolled in ECN were white males. The average age was 3.3 years of age, and the majority of children (54%) were between the ages of birth and three. Just over 25 percent of families were in the military.

DEMOGRAPHICS OF CHILDREN SERVED

72% 28%

72% of ECN participants were male; 28% were female.

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BEHAVIORAL HEALTH AT INTAKEAt intake, 20 percent of children enrolled in ECN had been diagnosed with a DSM-IV Axis I or Axis II diagnosis.

Caregivers were asked what the problems were that lead to their children being referred to ECN. There were thirty-one possible problems identified, and caregivers could pick more than one. While a variety of problems were reported, the most common problems were disruptive behaviors and attention-related.

57 percent of caregivers reported at least four presenting problems, and 34 percent reported at least seven.

73%HAD DISRUPTIVE BEHAVIOR PROBLEMS

20%HAD A DSM-IV AXIS 1 or AXIS 2

HAD HYPERACTIVE &ATTENTION RELATED PROBLEMS45%

DSM-IV Axis I and Axis II Diagnoses at Intake

Presenting Problems at Intake

73%HAD DISRUPTIVE BEHAVIOR PROBLEMS

20%HAD A DSM-IV AXIS 1 or AXIS 2

HAD HYPERACTIVE &ATTENTION RELATED PROBLEMS45%

73%HAD DISRUPTIVE BEHAVIOR PROBLEMS

20%HAD A DSM-IV AXIS 1 or AXIS 2

HAD HYPERACTIVE &ATTENTION RELATED PROBLEMS45%

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95.7 percent of primary caregivers were female.

Caregivers were also primarily white (83%) and 35 years of age of younger (76%) with a high school diploma and above (90%).

CUSTODIAL STATUS AND LIVING SITUATION AT INTAKE

The majority of children’s custodial status was with two parents at intake (63%), with biological mothers as the next most common custodial status (16%).

The majority of children lived at home with their biological family at intake (86%) or a non-parent relative (13%).

PHYSICAL HEALTH

In addition to social, emotional, and/or behavioral problems, caregivers reported that 54% of children had chronic or recurring physical health problems. The most commonly reported physical health problems were allergies (38%) and asthma (27%).

Caregivers reported that their children had a primary health provider (n = 93) and that the majority had a routine physical health exam in the past 6 months (84%).

95.7%OF PRIMARY CAREGIVERSWERE FEMALE

CAREGIVER DEMOGRAPHICS

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Over half of caregivers reported a family history of depression (66%) and substance use (61%). Furthermore, 48% of caregivers reported a family history of mental health problems other than depression. Over 18% of caregivers reported that their child had run off or away without them knowing where he or she was.

FAMILY AND CHILD HISTORY

0.0% 100.0%

27.5% 72.5%Witnessed domestic violence?

53.0% 47.0%Lived with someonewho was depressed?

28.2% 71.8%Lived with someone who had amental illness other than depression?

21.3% 78.7%Lived with someone whowas convicted of a crime?

20.2% 79.8%Lived with someone who hada substance use disorder?

9.3% 90.7%Experienced physical assault?

2.3% 97.7%Experienced sexual assault?

18.5% 81.5%Run away?

Yes No

Children enrolled in ECN had experienced stressful life events.

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COLUMBIA IMPAIRMENT SCALE The Columbia Impairment Scale (CIS) is adminis-tered to caregivers to obtain a global measure of child impairment. It includes 13 problems commonly encountered among children, including behavioral, emotional, and relationship problems. Caregivers

were asked about how much of a problem his or her child was having in different areas. Scores ranged from 0 to 52, with higher scores indicating a greater level of impairment. Scores over 15 are considered in the clinically impaired range.

A one-way repeated measures ANOVA was conducted to compare scores on the Columbia Impairment Scale at Time 1 (intake), Time 2 (6-months), and Time 3 (12-months). There was a significant effect for time, Wilk’s Lambda = .57, F (2, 52) = 9.45, p =. 005, multivariate partial eta squared = .43. Pairwise comparisons revealed that there was a significant difference between each time point, suggesting that scores improved significantly from intake to 6- and 12-months.

FUNCTIONINGChild Behavioral Health

0

5

10

15

20

25

Intake 6-Months 12-Months

There was a reduction in impairment from intake to 6-months and from 6-months to 12-months.

CIS scores were compared from intake to 6- and 12-months for a matched sample of evaluation partici-pants (n = 27). Children in ECN had a reduction in average (mean) impairment from intake (M = 23.22) to 6-month (M = 21.07) and 12-month (M = 15.33) follow-ups. The difference between these time points was significant. That is, calculations show the reduction in impairment did not just happen by chance.

Columbia Impairment Scale Average Score at IntakeOverall level of Impairment at Intake (n = 77) 21.9

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CHILD BEHAVIORAL CHECKLIST The Child Behavioral Checklist (CBCL) assesses caregivers’ report of behavioral and emotional prob-lems in children aged 1.5 to 5. There are seven nar-row-band syndrome scores: 1) emotionally reactive; 2) sleep problems; 3) withdrawn; 4) somatic complaints;

5) anxious and/or depressed; 6) attention problems; and 7) aggressive behavior. The CBCL also has two broadband syndromes (internalizing and externalizing problems), and a total problems scale.

CBCL Behavioral and Emotional Problems (n = 90) Average Score Clinical RangeEmotionally Reactive** 67.6 > = 70.0

Sleep Problems 62.7 > = 70.0

Withdrawn** 65.1 > = 70.0

Somatic Complaints 58.9 > = 70.0

Anxious/Depressed 61.9 > = 70.0

Attention Problems** 65.3 > = 70.0

Aggressive Problems* 72.3 > = 70.0

Internalizing Problems* 64.7 > 63.0

Externalizing Problems* 70.0 > 63.0

Total Problems* 68.3 > 63.0

*Above clinical range **Borderline clinical range

Average Aggressive Problems were above the clinical range at intake. When scores were compared for children at intake to 6- and 12-months (n = 25), we found that Aggressive Problems fell steadily from intake (M = 73.68) to below the clinical range at 6-months (M = 67.60) and to below the borderline clinical range at 12-months (M = 61.36).

Aggression Scores fell steadily from intake to 12-months.

0

20

40

60

80

100

6-MonthsIntake 12-Months

Blue indicates average score.Gray indicates spread where most of scores fell.

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PARENTING STRESS INDEX The Parenting Stress Index (PSI) measures the relative stress in the parent-child system. The PSI yields total stress score and three subscales: parental distress, parent-child dysfunctional interaction; and

difficult child. A high total stress score (at the clinical significant range) indicates a caregiver is experiencing high levels of parenting stress.

88.6% of caregivers (n = 87) reported clinically high levels of total stress on the PSI at intake. Furthermore, caregivers (n = 91) also reported clinically high levels of stress on the Parent-Child Dysfunctional Interaction subscale, and 93.5% (n =91) of caregivers at intake reported clinically high levels of stress on the Difficult Child subscale.

FUNCTIONINGCaregiver and Family

88.6% OF CAREGIVERS SCOREDIN HIGH STRESS RANGE

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CAREGIVER STRAIN QUESTIONNAIREThe Caregiver Strain Questionnaire (CGSQ) measures the extent to which caregivers are impacted by caring for a child with emotional and behavioral problems. The CGSQ has three subscales and a global score: 1) Objective Strain: Observable disruptions in family and community (e.g., lost work, financial strain); 2) Subjective Externalized Strain: Negative feelings about child such as resentment or anger; 3) Subjective Internalized Strain: Negative feelings a

caregiver may experience such as guilt or worry; and 4) Global Strain: A sum of three subscales, which ranges from 0 to 15 and provides an indication of the total impact on the caregiver of caring for a child with emotional and behavioral problems. Higher scores indicate a greater level of strain. Caregiver reported on strain experienced in the 6 months prior to the interview.

Global Strain scores on the CGSQ were compared from intake to 6- and 12-months for a matched sample of evaluation participants (n = 30). Caregiver strain scores reduced from intake (M = 7.66) to 6- (M = 6.43) and 12-month (M = 5.22) follow-ups. The difference between these time points was significant. That is, calculations show the reduction in impairment did not just happen by chance.

Caregiver Strain Questionnaire Subscales at Intake Average Score

Objective Strain (n = 92) 2.4

Subjective Externalized Strain (n = 91) 1.9

Subjective Internalized Strain (n = 90) 3.0

Global Strain (n = 90) 7.3

A one-way repeated measures ANOVA was conducted to compare scores on the CGSQ Global Strain Score at Time 1 (intake), Time 2 (6-months), and Time 3 (12-months) for a matched sample of participants. There was a significant effect for time, Wilk’s Lambda = .55, F (2, 58) = 11.41, p <.0005, multivariate partial eta squared = .45. Pairwise comparisons revealed that there was a significant difference between each time point, suggesting that Global Strain scores reduced significantly from intake to 6- and 12-months.

0

3

6

9

12

15

Blue indicates average score.Gray indicates spread, where most of the caregiver scores fell.

6-MonthsIntake 12-Months

Global Stress scores dropped steadily at each time period.

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Youth Service Survey for Families The Youth Service Survey for Families (YSS-F) examines caregiver’s perceptions of his or her system of care experience. The measure has seven domains: 1) access; 2) participation in treatment; 3) cultural sensitivity; 4) satisfaction; 5) outcomes; 6) functioning; and 7) social connectedness. Caregivers’

scores on the YSS-F were compared at 6-months and 12-months (n = 22). Scores range from 1 to 5, with higher scores indicating a more positive service experience. Scores 3.5 and above were considered positive responses.

Caregivers also reported highly positive experiences at 12-months with access to services (91%), participation in treatment (100%), cultural sensitivity (95%), and satisfaction with services (86%).

SERVICE EXPERIENCE

indicates 6-month averages; indicates average scores at 12-months.

0% 20% 40% 60% 80% 100%

Outcomes

Functioning

Social Connectedness 

27% 46%

27% 50%

82% 91%

Percentage of caregivers who reported that outcomes, functioning, and social connectedness increased between 6-months to 12-months

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“The therapist spends one-on-one time with her [child] to find out what her needs are and specializes her treatment to the child.”

“The services are customized to meet my child’s needs.”

“Having someone to understand and validate my feelings. I feel I have a strong support system.”

“The training and support that I received have helped us meet our goals together. I needed as much help as my child did.”

“This program has taught me how to deal with his behaviors in a more positive manner, how to deal with his frustration, and has enlightened me on how to manage and

maintain as a parent and help him with his behaviors and emotions.”

“ECN has taught our family to act as a unit and how to better cope with [child’s] meltdowns and tantrums.”

“The training and support that I have received have helped us meet our goals together.”

“Having that connection with every person involved in his care on the same page, teaching parents the leadership role, and driving parents to learn.”

“The Family Support Provider has given me access and information to programs and services I never would have known existed.”

“Being able to get the information I needed for multiple services from one source. Services were able to get everyone on the same page for my child.”

CAREGIVERS REPORTED SYSTEM OF CARE EXPERIENCE

Caregivers Shared the Following Experiences:

What is the most helpful thing about the services you received in the last 6-months? Caregivers were asked this question at 6-, 12-, 18-, and 24-months, and several common themes emerged.

Families Need Individualized Child-Centered and Family-Driven Care

Skill Building for Children and Caregivers was Highly Effective

Families Benefited from Comprehensive, Coordinated, Community-Based Care

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CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS1. Children enrolled in ECN had complex

needs. ECN provides services for very young children. The average age at intake was 3.3 years of age, and the largest age group served was between birth and three. Twenty percent of children have a DSM-IV Axis I or II diagnosis at intake. Furthermore, caregivers reported that their children had multiple presenting problems at intake. Fifty-seven percent of caregivers reported at least four presenting problems as their reason for ECN services, and 34 percent reported at least seven. Of these presenting problems, 73 percent reported disruptive problems in young children, and 45 percent reported hyper-active and attention-related problems as the reason they were seeking ECN services. In addition to social, emotional, and behavioral problems, children enrolled in ECN had experienced stressful life events. Sixty-six percent of caregivers reported a family history of depression, and 61 percent reported a family history of substance use. Moreover, 27.5% of caregivers reported that their child had witnessed domestic violence, and 18.5% reported that their child had run off or run away without knowing their child’s whereabouts.

2. Caregivers reported their children had high levels of impairment and problems at intake as well as high levels of stress and strain in their own lives.

Caregivers reported impairment in their children at intake as well as social, emotional, and behavioral problems that were in the clinical range. Aggressive and externalizing problems were especially common, as measured on the CBCL. Eighty-six percent of caregivers reported clinically high levels of parenting stress on the PSI at intake. Caregivers also reported moderate levels of caregiver strain from the impact of caring for a child with emotional and behavioral problems.

3. Levels of impairment, aggressive problems, and caregiver strain were reduced in children enrolled in ECN from intake to 6- and 12-months.

There was a significant reduction in impairment on the CIS from intake to 6- and 12-months. On average, aggressive problems on the CBCL also declined from intake to below the clinical range at 6- and 12-months. Caregivers also reported a reduction in global stress on the CGSQ from intake to 6- and 12-months.

4. Caregivers reported an overwhelmingly positive System of Care experience.

Caregivers reported a positive System of Care experience at 12-months on the YSS-F. They were particularly satisfied with their access to services, participation in treatment, and satisfaction with services. Furthermore, they had positive opinions of the cultural sensitivity of the program. Although caregivers’ ratings of their children’s outcomes and functioning were lower than the other domains at 6-months, caregivers reported a 67 percent increase on outcomes and 83 percent increase on functioning from 6- to 12-months. When asked what the most helpful thing about the services they had received on the YSS-F, families reported that they appreciated the individualized child-centered and family-driven care provided by ECN. Caregivers also found the skills they and their children had learned from ECN to be effective and reported that they benefited from comprehensive, coordinated, community-based care.

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RECOMMENDATIONSA number of recommendations were identified in the analysis and interpretation of the evaluation data.

1. Increase the awareness of the prevalence, symptoms, and treatments of mental health needs in young children. Very young children have mental health needs that need to be addressed. Social, emotional, and behavioral problems impede healthy development when left untreated and can cause stress that impacts the whole family. Furthermore, there is still a need for providers who are trained to meet the unique needs of young children.

2. Provide and make accessible age-appropriate, individualized services that specifically address early childhood mental health. The average age of children in ECN was 3.3 years of age, and the largest group of children served was between the ages of birth and 3. Each child and family had unique needs and varying levels of problems. Families reported they need individualized child-centered family-driven care.

3. Provide services that focus on the child within the family unit. Many caregivers reported that ECN helped them build skills that impacted their whole family. Children cannot be treated in isolation from their family.

4. Continue to build the System of Care in these communities and across Tennessee. This effort should include partnerships between early childhood organizations, child care providers, schools, and physical health care providers.

5. Hold providers accountable for effective services as well as service coordination. The services provided by the coordinated care teams of ECN can only be available if the services are reimbursable by insurers. ECN’s partner, TVC, has successfully worked to make the services provided by FSPs reimbursable by TennCare. However, there is still work to be done in making sure that insurers also reimburse for care coordination.

CONCLUSION

Much was accomplished in the System of Care development for young children in Middle Tennessee, yet much more remains to be done. The experiences of ECN identify not only a wide range of mental health needs in young children, but also significant needs of families in need of ongoing support, skill development and individualized care to be able to nurture their children and help them grow and develop. Many of these children have very challenging behaviors.

All of the efforts of ECN begin with the recognition that all human beings, regardless of age, have both physical and mental health needs that society must be prepared to address in effective ways, resulting in improved outcomes. Moreover, early identification and intervention reduce later social, emotional, and financial costs for families and for society.

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Brauner, C. & Stephens, C. (2006). Estimating the prevalence of early childhood serious emotional/behavioral disorders: Challenges and recommendations. Public Health Reports, 121, 303-310.

Early Connections Network. (n.d) What we do. Retrieved August 1, 2016, from http://www.earlyconnectionstn.org/#!what-we-do/c1iay

Georgetown University Center for Child and Human Development. (n.d) Early Childhood Mental Health. Retrieved August 1, 2016, fromr http://gucchd.georgetown.edu/78132.html

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Stroul, B., Blau, G., & Friedman, R. (2010). Updating the system of care concept and philosophy. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health.

Stroul, B., & Friedman, R. M., 1986. A system of care for children and adolescents with severe emotional disturbances. Washington DC: Georgetown University Center for Child Development, National Technical Assistance Center for Children’s Mental Health.

Zeanah, C. H., Jr., 2000. Handbook of Infant Mental Health (2nd ed.). New York: Gilford Press.

The Early Connections Network evaluation was conducted and this report was written by: Centerstone Research Institute, Nashville, Tennessee.