of - ericdocument resume ed 330 170 ec 300 142 author martner, jan, ed.; magrab, phyllis, ed....

DOCUMENT RESUME

ED 330 170 EC 300 142

AUTHOR Martner, Jan, Ed.; Magrab, Phyllis, Ed.'2ITLE Mental Health Services for Infants and Toddlers: A

Three-State Perspect±ve on the Implementation of PartH of P.L. 99-457, The Education of the HandicappedAct Amendments of 1986.

INSTITUTION Georgetown Univ. Child Development Center,Washington, DC. CASSP Technical Assistance Center.

SPONS AGENCY Hoalth Resources and Services Administration(DHHS/PHS), Rockville, MD. Office for Maternal andChild Health Services.; National Inst. of MentalHealth (DHHS), Rockville, MD. Child and AdolescentService System Program.

PUB DATE Nov 89NOTE 77p.

AVAILABLE FROM CASSP Technical Assistance Center, GeorgetownUniversity Child Development Center, 3800 ReservoirRd., N.W., Washington, DC 20007 ($8.00).

PUB TYPE Reports - Research/Technical (143) --Tests/Evaluation Instruments (160)

EDRS PRICE MF03/PC04 Plus Postage.DESCRIPTORS *Administrative Organization; *At Risk Persons;

Community Control; Delivery Systems; *Disabilities;*Early Intervention; Federal Legislation; Infants;*Mental Health Programs; Program Development;Psychiatric Services; Psychological Services; StaffDevelopment; State Programs; Toddlers

IDENTIFIERS Case Management; *Education of the Handicapped ActAmendments 1986; Maine; North Carolina; Ohio

ABSTRACT

This study addresses seven components of Public Law99-257 which relate to mental health intervention to meet thecomprehensive early needs of infants and toddlers with, or at riskfor, disabilities. The seven components incPide: the definition of"developmentally delayed"; multidisciplina avaluation; theindividualized family service plan, including case managementservices; a comprehensive Child Find system; a public a%arenessprogram; a central resource directory; and personnel development andstandards for training. The study focused on three states' efforts toincorporate a mental health perspective into their overall philosophyand service delivery systems for young children. It examined varioussystems that were in place or were evolving for children and the roleof mental health in those systems. Each of the three states has itsown pattern of providing mental health services: Maine has astate-driven system of service deliv'ary; Ohio has a strong system oflocal control; and North Carolina has a blended state and localsystem. Appendices contain case vignettes of three families withyoung children and a copy of the instrument used in the study.(JDD)

U.S. MPARTIOINT OP IDUCATIONVice al Educational Research end Improvement

ED ATIONAL RESOURCE0 INFORMATION!* CENTER flin

This document NW beer reproduced IsfeCeived from the person or organizationoriginating it

a Minor chenges hers been made to improveraproductiOn Quality

Points of view or opinions staled in ausdocument do not neceilsanly represent officialOERI position or policy

BEST COPY AVAILA

SCOP1 OF INTEREST NOMEThe CM Fealty hes esthis document forto:

In our judgment, this documentis also of interest to the Clear-inghoueen noted to the right. psIndexing should reflect theirMimi points of view.

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MENTAL HEALTH SERVICES FOR INFANTS AND. TODDLERS:

A Three-State Perspective on theImplementation of Part H of P.L. 99-457

The Education of the Handicapped Act Amendments of 1986

t* Edited by

Jan Martner, M.S.W., Project CoordinatorPhyllis Magrab, Ph.D., Project Director

Child and Adolescent Serve System ProgramTechnical Assistance Center

Georgetown University Child Development Center

Contributing Authors

Emily Schrag Fenichel, M.S.W.Associate Director, National Center for Clinical Infant Programs

Edward Feinberg, Ph.D.Director, Anne Arundel County Parent Infant Program

Gary Delago, B.S.Consultant, Georgetown University Child Development Center

Available From

CASSP Technical Assistance CenterGeorgetown University Child Development Center

3800 Reservoir Road, N.W.Washington, D.C. 20007

(202) 687-8635

November 1989

The CASSP Technical Assistance Center of the Georgetown University ChildDevelopment Center is funded through an interagency agreement between theChild and Adolescent Service System Program, National Institute of MentalHealth, and the Bureau of Maternal and Child Health and Resources Development,US. Department of Health and Human Services.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS vii

INTRODUCTION 1

THE BACKGROUND 1

The Problem 1

The Law 2

THE STUDY 2The History 2The Methodology 3The State Profiles 3

STATE PROFILES 5

THE ISSUES 5

Mental Health Services Pre-P.L. 99-457 5Philosophy and History of Mental Health Services

to Infants, Toddlers, and Their Families 5Service Characteristics 5Training of Professionals 6

Mental Health Services Post-P.L. 99-457 6Philosophy of Early Intervention Services

to Infants and Toddlers 6Development of a Service Delivery System 6Definition of "Developmentally Delayed" 7Personnel Development 7

Next Steps 7

MAINE 8

Mental Health Services Pre-P.L. 99-457 9The Interdepartmental Coordinating Committee

for Preschool Handicapped Children 9Zero-to-Three Committee 11

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MAINE (continued)

Mental Health Services Post-P.L. 99-457 13Definition of "Developmentally Delayed" 13Development of a Service Delivery System 14Programs -- A Closer Look 15

Project AIMS 15Rockland and Norway Sites 16

Personnel Development and Standards for Training 17

Service Delivery System: Strengths and Challenges 18

Next Steps 18

Recommendations for Other States 20

Resources Available to Other States 20

NORTH CAROLINA 21

Mental Health Services Pre-P.L. 99-457 22Initial Efforts 22Programs -- A Closer Look 23

Project Enlightenment 23The Family, Infant and Preschool Program 24

Mental Health Services Post-P.L. 99-457 24Definition of "Developmentally Delayed" 25Development of a Service Delivery System 28Identification and Assessment of Infants and Toddlers

in Need of Mental Health Services 28Treatment Services 30Personnel Development and Standards for Training 31

Training Pla.. for CASSP Demonstration Projects 31Nursing Child Assessment Satellite Training 32


Next Steps 34



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OHIO 37

Mental Health Services Pre-P.L. 99-457 38Networking Projects 39Child and Adolescent Service System Program (CASSP) 39Special Projects of Regional and

National Significance (SPRANS) 40Project Zero-to-Three 40The "Essential Components" Service Model 40State Incentive Grant Projects 41

Mental Health Services Post-P.L. 99-457 42Definition of "Developmentally Delayed" 42Development of a Service Delivery System 43Comprehensive Child Find System 44IFSP and Case Management Services 45Personnel Development and Standards for Training 45


Next Steps 47



SUMMARY OF STATE PROFILES 49

LEARNING FROM EXPERIENCE: A THREE-STATE PERSPECTIVE 51

APPENDIX A: Mental Health Services for Infants, Toddlers, and Their Families:A Three-State Perspective -- Survey Instrument

APPENDIX B: Case Vignettes: Maine, North Carolina and Ohio

VOMP

ACKNOWLEDGEMENTS

It is a great pleasure to extend our gratitude to Judith Katz-Leavy, Assistant Chief, Childand Family Support Branch, National Institute of Mental Health, for her inspiration inrecognizing the importance of this project and for ensuring that fiscal resources weremade available for its completion. Her expertise in family mental health and her nationalperspective on issues related to children's mental health greatly mriched this project.

Two staff members of the Georgetown University Child Development Center hare hadparticularly important roles in this endeavor. Roxane Kaufmann, Director of SpecialProjects, made a vital contribution to the initial planning and coordination of the study.Sybil Golainan, Associate Director, Child and Adolescent Service System Program (CASSP)Technical Assistame Center, has served as an ongoing mentor to the project and madeinvaluable contributions to the thoroughness and readability of this document.

Special thanks also are extended to the contributing authors Edward Feinberg, EmilySchrag Fenichel, and Gary De lago for their continued interest in and enthusiasm for thisproject. Ed's and Emily's knowledge and understanding both of theoretical andimplementation issues related to Part H of P.L. 99-457, as well as their individual skillsand expertise in the area of infant and toddler mental health a-id the delivery of earlyintervention services were essential to the development of this monograph. Gary Delago,in addition to co-authoring the Ohio profile, applied his research and organizational skillsto the development of the information-gathering protocol and assisted in organizing thesurvey information into a useful format.

Material for this monograph was collected from many generous individuals in the threeparticipating states, Maine, North Carolina, and Ohio, by teams of experts in the area ofinfant and toddler mental health and early intervention. The time, knowledge, and manyskills they contributed to the information-gathering and analysis process is deeplyappreciated. Their insights have been critical to the success of this project. Theseindividuals are specifically acknowledged in the related section of this monograph.

Finally, we wish to give a heart-felt thank you to Marie Keefe and Cappie Morgan, ourtechnical editors, for encouragement and support during many long hours with hurriedturn-around leadlines that were always met. Debbie Waring, our expert word processor,who worked so cooperatively with the authors, editors and technical editors, deservesmuch more than the roses she. received.

Jan Martner, M.S.W.Project Coordinator

Pnyllis Magrab, Ph.D.Project DirectorGeorgetown University Child Development Center

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INTRODUCTION

THE BACKGROUND

Good mental health forms the veryfoundation of the development of allyoung children. From birth, children arebusy with the process of integrating newskills and increased awareness into a widevariety of domains. Through thisintegrative process, children's self-esteem, competency in interpersonalrelationships, and patterns of attachmentto caregivers emerge. The complexitiesand rapidity of this process put youngchildren in the position of almostconstant challenge. Warm and nurturingenvironments which focus on theircompetencies enable them to meet thechallenge.

The mental health of children whohave a range of special needs isparticularly critical to their successfuldevelopment, but it may be jeopardizedby both the difficulties they face andthose they present to caretakers. Amongthese children, the ones who learn tovalue their own achievements and takepleasure in their efforts are more likelyto meet such difficulties head on. Theiremotional development is closely tied totheir positive experiences within thefamily and with caretakers. Yet illnessand disabilities can make it difficult forchildren to respond to their parents'attention. Such disruption in an evolvingrelationship can be confusilig andfrustrating for parents.

Certain environmental factors canalso put infants and toddlers at risk forabnormal or atypical emotionaldevelopment. These factors can include ahistory of mental illness or substanceabuse in the family, or such

environmental stresses as poverty,teenage parenthood, and a parentalhistory of neglect during childhood.Parents and caregivers who are not ableto respond to the emotional needs ofchildren may unintentionally discouragethem from engaging in the humaninteraction which is essential to theiroverall development. Subsequently, thesechildren may experience emotionalproblems or delays. There are alsochildren who have atypical emotionaldevelopment apparently unrelated to anyother physical disability or stressors.

All of these children need a sensitive,understanding family environment.Achieving such an environment mayrequire special and critical services.

The Problem

No truly comprehensive continuumof mertal health services for handicappedinfants, toddlers, and their families hasexisted in any state or community todate. Mental health services traditionallyhave not focused on prevention or earlyidentification and intervention because ofa variety of obstacles. These obstaclesinclude: limited public resources formultiple populations (most fiscalresources are allocated for serviceprovision to chronically mentally ill andseriously emotionally disturbedadolescents), an insufficiency of mentalhealth professionals trained to deal withthe problems of young children,restrictive eligibility criteria, lack ofreimbursement to private sector mentalhealth professionals for early interventionand prevention activities, inadequate

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assessment tools, reluctance to labelchildren, limited mental health outreachinto the cot. munity, cultural insensitivity,and fragmented services. Most socialservice, education, and health systemshave experienced similar obstacles. Theneed to integrate a mental healthperspective into early intervention andprevention efforts was present at thetime Congress enacted Public Law99-457.

The LawA

1

Part H of Public Law 99-457, TheEducation of the Handicapped ActAmendments of 1986, has created anopportunity for providing mental healthservices to children birth to age threeand their families. The congressionalintent of this program is to encouragestates through limited funding to:1) develop and implement acomprehensive, coordinated, multi-disciplinary, interagency program of earlyintervention services; 2) facilitate thecoordination of early interventionresources from federal, state, local, andpri,v...e sources (including privateinsurers); and 3) enhance the provision ofquality early intervention services.

Although the law's design does notspecify provision of a full continuum ofmental health services to meet the needsof infants, toddlers and their families, itopens the door.. P.L. 99-457 providesmany opportunities for professionals andagencies with expertise in infant mentalhealth to contribute their uniquesensitivities, skills, and services toaddress the emotional well-being ofchildren and their families during thecritical first three years of life.

For those children with diagnosablemental health disorders like failure tothrive, autism, pervasive developmentaldisorders, and disorders of attachment,

early intervention treatment may be alifesaving intervention, may redirect thedevelopmental course, or may reduce theseverity of the condition. For infants andtoddlers at risk for psychosocial orsocial/emotional developmental delays,P.L. 99-457 encourages early interventionto support families, to reduce stress, andto promote children's optimaldevelopment.

In order to meet the comprehensiveearly needs of infants and toddlers with,or at risk for, disabilities, P.L. 99-457 hasas its foundation fourteen components.Seven of these components provideopportunities for mental healthintervention and contributions: thedefinition of developmentally delayed,multidisciplinary evaluation, theindividualized family service planincluding case management services, acomprehensive Child Find system, apublic awareness program, a centralresource directory, and personneldevelopment and standards for training.These seven areas are addressed in thisstudy.

THE STUDY

The History

In 1984, Congress designated fundingto assist states and communities inimproving their service delivery systemsfor children and adolescents with seriousemotional problems. The NationalInstitute of Mental Health (NIMH)initiated the Child and AdolescentService System Program (CASSP) toprovide support to states as they beganinteragency efforts to improve theirservice delivery systems.

CASSP created a major technicalassistance center at Georgetown

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University Child Development Center togive direct technical assistance to CASSPgrantees and other interested states. Thecenter conducts state-of-the-art studiesor such topics as community-basedservice alternatives for seriouslyemotionally disturbed children and thefinancing of mental health services forseverely emotionally disturbed childrenand adolescents.

In December of 1987, NIMH and theCASSP Technical Assistance Center helda Mental Health/P.L. 99-457 meeting inVirginia to gain an understanding of howstates might take advantage of theopportunities of the law and integratemental health into their service delivery.This national meeting resulted in an issuepaper, Sensitivities. Skills and Services:Mental Health Roles in thern

Implementation of Part H of P.L. 99-457The Education of the Handicapped Act

As an outgrowth of the issue paper,in the fall of 1988 NIMH and the CASSPTechnical Assistance Center embarked ona study of three states' efforts toincorporate a mental health perspectiveinto their overall philosophy and service0.-l.ivery systems for young children. Thestudy examined the various systems thatwere in place or were evolving forchildren and the role of mental health inthose systems. This report is a result ofthat study.

The Methodology

A panel of noted mentai healthprofessionals chose states withdemonstrated interest in the provision ofmental health services to young children.In addition, each state had participated inProject Zero to Three. This project wasa six-year effort (1983-1989) of theNational Center for Clinical InfantPrograms and fifteen participating statesto share information and expertise

concerning the integration of health andeducation services for disabled and at-risk infants, toddiers, and their families.The Office of Maternal and Child Healthof the Department of Health and HumanServices supported this project.

The states selected for this studywere Maine, North Carolina and Ohio.All three had state departments ofmental health and local agenciesinterested in participating in theimplementation of P.L. 99-457. Sinceeach state was at a different stage in thedevelopment of mental health servicesfor infants and toddlers, the study wasable to explore a range of experiences.

Study teams traveled to each site andused a key informant technique duringtheir three-day visit to obtain a broadperspective of the service system in eachstate. With the assistance of the stateCASSP director and other state leaders,the individuals to be interviewed wereselected from four groups: state agencyrepresentatives participating on theP.L. 99-457 Interagency CoordinatingCouncil (ICC), local agencyrepresentatives, local service providerswho were specifically addressing themental health needs of very youngchildren and their families, and parentswho were recipients of services. The sitevisits were coordinated by Jan Martner,Project Coordinator, GeorgetownUniversity Child Development Center,and were conducted by a team ofindividuals knowledgeable about infantand toddler mental health and stateservice delivery systems. The team useda structured questionnaire to gatherinformation about legislation,organization, and resources at both thestate and local levels, and to obtaindescriptions of exemplary programs (seeAppendix A, Survey Instrument).

The State Profiles

This monograph presents the datagathered from these site visits, organized

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in the form of state profiles. Each stateprofile is structured to reflect theevolution and status of the state's mentalhealth services to very young childrenprior to the passage of P.L. 99-457, theimpact of the law, and envisioned nextsteps.

The profiles were reviewed by thekey informants in each state. Because ofthe uniqueness of each state and thedesire to preserve the individualperspective of the team leaders, theprofiles will vary. The document waswritten in a personal style because it is asummation of personal involvement andeffort.

In conducting this study the teamsfound that the responses of individualsreflected their state's history ofproviding mental health services ingeneral and, specifically, the state'shistory related to the care of very youngchildren and their families. Theseparallel histories reveal a pattern of thestate's philosophy, values, process ofgoverning, decision making, and servicedelivery. These patterns are importantbecause they provide a starting place toutilize the information presented in thestudy.

Each of the three states studied hasits own pattern: Maine has a state-drivensystem of service delivery, Ohio has astrong system of local control, and NorthCarolina has a blended state and localsystem. It may be valuable for otherstates to assess their systems within thefour primary areas of study:

Structure: The overallcoordination and service deliverymechanisms of one of these statesmay contain more similarities to onestate's system than another.

Antecedents: State history andvalues related to service delivery forvery young children and to mentalhealth services in general are criticalindicators that will help states toassess their historical patterns ofintervention services to this veryyoung population.

Similarities: Examination of eachof the states in the study will helpother states determine what "pieces"of their pattern may be in place atthis time in the area of legislation,key individuals, values, and vehiclesfor coordination and for servicedelivery. Analyzing these pieces willguide states in determining whethertheir system is evolving in aneffective manner.

Opportunities: Each of thepatterns studied illustrates differentmechanisms to attain desired goals.Policy makers will need to evaluatetheir state's goals and determine thebest way to meet them. Perhaps oneof the patterns prosented t or acombination, will help identify along-sought missing piece.

Because states are in a period ofrapid change in planning services tochildren and families, the informationshared by the informants in this study isever-changing as each state learns fromthe decisions it has made. It is hopedthat this study will provide guidance toresidents of other states interested in theprocess of integrating mental healthprinciples into the many components ofP.L. 99-457. Creative use of thisinformation may prevent the loss ofvaluable time and provide stimulation forlively discussion, whether it be in theInteragency Coordinating Council, thelocal collaborative group, a staffmeeting, or a meeting of parents. Ascorroborated by many informants, it onlytakes one person to spark the creation ofchange. This study may provide a newway of looking at philosophy, structure,and service delivery systems for veryyoung children.

The editors are grateful to theagencies and individuals in the states ofMaine, North Carolina, and Ohio whoparticipated in this study.

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STATE PROFILES

THE ISSUES

Key individuals were interviewed ineach state to address the following issues:philosophy and history, servicecharacteristics, and training ofprofessionals.

The questions listed under the issueswere among those asked of each state inan effort to elicit consistent informationabout mental health services pre-P.L. 99-457 and post-P.L. 99-457. Similarquestions can help states to organizeinformation as they begin to integrate amental health perspective into earlyintervention services. This process maybegin through the organization ofinteragency committees, parent advocacygroups, and other inter- and intra-agencyactivities which would facilitatecommunication and planning efforts onthe state, county, and local levels.

Mental Health ServicesPre-P.L. 99-457

Philosophy and History of MentalHealth Services to Infants, Toddlers, andTheir Families. In order to fullyunderstand how any state has developedits current mental health servicesystem(s) of care, it is useful to grasp theevolution of that system. Each state hasa history that has helped to shape itscurrent philosophy related to mentalhealth services for very young childrenand their families.

Questions

How had the state agency policiesconcerning mental health forchildren, especially young children,

developed during the passage ofP.L. 99-457?

What mental health service systemfor young children, if any, was inplace in the state in 1986?

What were the catalysts to theevolution of the system, e.g.,individuals, federal and state laws,major university involvement,advocacy groups and litigation?

Service Character:stics. Under-standing the framework within which astate is making its current servicedelivery decisions is critical to futureplanning efforts. The focus here is toglean a historical perspective on the wayseach of the states has developed itscurrent delivery system(s) of mentalhealth service to infants, toddlers, andtheir fk. nilies.

Questions

What was the prevention focus tomental health system-wide, i.e.,what attention was paid tochildren's social and emotionaldevelopment beyond the servicesprovided in mcntal healthprograms for identified children?

How were children and/or familiesidentified and referred?

What service system modalitieswere utilized, i.e., methods ofidentification, evaluation andintervention?

Did the service componentsfunction as a system?

Was there a system in place fortracking these children andfamilies once identified and forproviding ongoing casemanagement?

How were services funded?

Training of Professionals. The focusof this issue is to understand what thecapacity and expertise of personneltrained in the area of infant and toddlermental health in the state was prior toP.L. 99-457.

Questions

Did the state provide any type oforganized, ongoing trainingprogram?

What professionals were targetedfor the training?

What were the operative principlesof training for professionals in thearea of infant mental health?

What type of pre-service and in-service training was available?

Mental Health ServicesPost-P.L. 99-457

Philosophy of Early InterventionServices to Infants and Toddlers.Opportunities to address the mentalhealth needs of infants, toddlers, andtheir families through P.L. 99-457 mayoccasion a new look at mental he ithservices as a whole and specifically atmental health services provided withinthe system of early intervention.

Questions

Is there a common vision of earlyintervention shared by serviceproviders, administrators, andfamilies? Is mental healthincluded in this vision?

How has the state's philosophy ofincorporating mental health into

early intervention changed as aresult of P.L. 99-457?

What impact is the new law havingon the mental health servicesystem?

Development of a Service DeliverySystem. Because of the mandate for astatewide interagency system of care,states have been assessing theiradministrative structures at both thestate and local level. For many states, acoordinated system of care is a newconcept; for others, it will help them toexpand service provision. The issuesrelated to effective service delivery aremany and varied. They can become evenmore complex when states choose toinclude preventive mental healthpractices in the development of programsfor infants and toddlers. The process ofassessing children and the inclusion ofmental health in this collaborative effortis emphasized in the study.

Questions

How does the state mental healthdepartment fit into the structureof P.L. 99-457 -- is it the leadagency; does it participate on theInteragency Coordinating Council,local Child Find efforts, andcommittees examining eligibil:tycriteria?

How has Pl. 99-457 served as animpetus to moving toward a moreeffective service system?

What has the process been forinvolving and obtaining mentalhealth expertise in planning andimplementing P.L. 99-457?

If mental health agencies orpractitioners are not representedon the State Interagency Council,how is this expertise included --are there additional mechanisms?

Are local mental health agenciesinvolved in planning earlyintervention services?

How have mental health servicesbeen defined? What types ofservices are available?

What role will mental healthpractitioners play in identification,evaluation and assessment;development of the IndividualFamily Service Plan (IFSP); andcase management?

Definition of "DevelopmentallyDelayed." Part H, the section ofP.L. 99-457 that concerns infants,toddlers, and their families, requires eachstate to define the term "developmentallydelayed" as it will be used by that stateto determine eligibility for services. Thisstudy also focuses on the role of mentalhealth in each state's definition.

Questions

How are int mental healthissues reflertt. 'n the definitionsof eligibility ft); services?How was the definition developed?

Are at-risk children being served?Are other statewide efforts beingdeveloped that might providemental health services to infants,toddlers, and their families?

Personnel Development. Currentlyall states are facing a critical shortageof individuals qualified to provideprevention and early intervention servicesfor infants and toddlers. They arestruggling to improve standards, to trainnew personnel, and to provide in-servicetraining to current personnel.

Questions

Is there a philosophy, type, andfocus of training for professionalsand paraprofessionals working ortraining to work in the earlyintervention area?Does training include a preventivemental health philosophy and skillsimplementation?

What role will mental healthprofessionals play in trainingefforts for other professionals andparaprofessionals?

What efforts will be made torecruit mental health professionalsto meet expanding needs?

Next Steps

Although P.L. 99-457 will beimplemented in states by 1991, theprocess of refining this new legislationwill continue for many years. Because ofthe unique histories, philosophies,legislation, and personalities involved ineach state, "next steps" will vary greatly.The integration of mental healthperspectives in this complex process islikely to encounter significant barriers.Strategies to ensure the involvement ofmental health and to overcome potentialbarriers must be developed.

Questions

What are the barriers to developingmental health services for infants,toddlers, and their families withinthe context of P.L. 99-457?

What strategies can be undertakento overcome these barriers?

Determining the role of mentalhealth in the service delivery process forP.L. 99-457 is not easy for any state.Rarely does the consumer of mentalhealth services think of mental healthfrom a wellness perspective. More often,the perspective is one of illness orpsychopathology. A primary task may beto define what mental health service tothe population of very young children andtheir families means from the perspectiveof legislators, policy makers, serviceproviders, and consumers. A second taskmay be to determine how principles orpreventive mental health can beintegrated into service delivery systemsand programs.

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MAINE

byEdward Feinberg

Site Visit Team: Edward Feinberg, Ph.D., Director, Anne Arundel County ParentInfant Program, Glen Burnie, Maryland; Ellen Kagen, M.S.W., Assistant Directorfor Technical Assistance, CASSP Technical Assistance Center, GeorgetownUniversity Child Development Center, Washington, D.C.; Cindy Hirschfeld, R.N.,M.S., Administrator, Early Intervention Unit, Division of Maternal and ChildHealth, Ohio Department of He2"-i!; Paula Clarke, Ph.D., Director, CASSP,Division of MH/MR/SAS, Department of Human Resources, Raleigh, NorthCarolina, at the time of this study; currently, Chief of Child and AdolescentServices, North Carolina Department of Hui .ian Resources.

Contributors From Maine: Robert Durgan, Director, lureau of Children withSpecial Needs, Department of MH/MR, Augusta, Maine, deserves special thanksfor his support of Maine's involvement in this study. Ed Hinckley, ChiefOperations Manager, also from the Bureau of Children with Special Needs, offereda comprehensive view on the integration of a mental health perspective intoinfant and toddler services. He has had an ongoing interest in this project and,hasgraciously reviewed draft manuscripts. John Hornstein, Director, InfantDevelopment Center, South Portland, Maine, offered the perspective of a localservice provider on issues related to implementing Part H of P.L. 99-457. Hisviews helped the team produce a practical document. John's technical assistancein negotiating the back roads of Maine and in finding local Maine delicacies alsowas greatly appreciated.

In addition, we would like to thank individuals who met with us during our Mainesite visit. These valuable contributors include: The administrative staff of theBureau for Children with Special Needs; Michael Cohen, Director, and the staffof Tri-County Mental Health Center, Norway, Maine; Devene Fahy, Coordinator,and the staff of Mid-Coast Child Development Services, Rockland, Maine; EileenFair, Tri-County Mental Health Services, The Family Center, Lewiston, Maine;Roy Gedat, Director, and the staff of the Child Health Center, Norway, Maine;Susan Mackey-Andrews, Executive Director, and the members of theInterdepartmental Coordinating Committee for Preschool Handicapped Children(ICCPHC); Sue Ellen Myers, Coordinator, and the staff of Project Opportunities,Norway, Maine; Susan Soule and the staff of the Neonatal Intensive Care Unit,Maine Medical Center, Portland, Maine; Jane Weil, Acting Project Director, andDebbie Devine, Psychologist, Project AIMS, University of Southern Maine,Portland, Maine.

Maine's system of mental health/prevention services for infants is one thatespouses the goal of greater attention toearly childhood issues and recognizes thelimitations of fiscal and professionalresources. Of the three states surveyed,

Maine has the smallest and the most ruralpopulation; it is served by a small cadreof professionals with scant resources. Itsservice delivery system endeavors to beboth practical and visionary as it utilizesexisting resources creatively while

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remaining sufficiently flexible toincorporate new ideas.

A variety of factors -- some that areunique to Maine, others that aregeneralizable to states with similardemographic and value profiles, and stillothers that are generalizable to stateswith dissimilar profiles -- havecontributed to the evolution of thinkingand service delivery in Maine. A processto provide children's mental healthservices has evolved that has included keyagencies, critical individuals andsignificant events. In the area of infantmental health, the adage that "as Mainegoes, so goes the nation" would indeedherald an era of compassion andpragmatism.

MENTAL HEALTH SERVICESPRE-P.L. 99-457

A creative, flexible mental healthsystem for children has evolved in Maineduring the past decade. This system ischaracterized by a family-centered,community-based prevention orientation.It relies on a strong interagency andmultidisciplinary foundation with a focuson multiple points of access andindividually tailored programs. Thisglimpse of Maine's mental health systemincludes a description of the history andnature of the present system; thedevelopment of consensus on principles ofinteragency coordination; an analysis ofstate and local decision making; adescription of model local programs; andfuture considerations.

The InterdepartmentalCoordinating Committee forPreschool Handicapped Children

In 1977, following the passage ofP.L. .14-142 (the Education for AllHandicapped Children Act of 1975), theMaine Departments of Educational and

Cultural Services, Mental Health andMental Retardation, and Human Serviceswere directed -- by a joint legislativeorder -- to study the provisions ofP.L. 94-142 and to recommend anynecessary actions which may be requiredto put Maine into compliance.

The emphasis on state inter-departmental planni.ig was a criticalfactor in the 1978 passage by the statelegislature of an "Act Concerning PilotProjects for More Effective and EfficientDelivery of Services to PreschoolHandicapped Children" (T. 20-A M.R.S.A.,S.7703). The responsibility for programdevelopment would remain with anInterdepartmental CoordinatingCommittee for Preschool HandicappedChildren (ICCPHC). The ICCPHC, aprecursor to the Interagency CoordinatingCouncils mandated under P.L. 99-457, hashad representation from the Division ofPublic Health Nursing of tI-e Departmentof Human Services; the FamilyPrevention Program of the Department ofHuman Services; the Child ProtectiveServices of the Department of HumanServices; the Division of SpecialEducation of the Department ofEducation and Cultural Services; theEarly Childhood Consultant of theDepartment of Educational and CulturalServices; the Bureau of MentalRetardation of the Department of MentalHealth and Mental Retardation; theBureau of Children with Special Needs ofthe Department of Mental Health andMental Retardation; parents ofhandicapped children; private serviceproviders; and coalitions, such as HeadStart and the Association of YoungChildren with Special Needs.

Individual membership on thiscommittee has been remarkably stablesince its formation. This has enabled thecommittee to develop collective trust,define a shared mission, and put intooperation program goals that arereflective of common values and localneeds. Because of the absence of afederal or state-driven timeline for

implementation of a specific array ofpreschool services, the ICCPHC has beenable to evaluate local services, determinethe nature of its state plan, modify itssystem as needed, and incorporate newservice delivery philosophies andstrategies.

The initial focus of the ICCPHC wason the development of a coordinationmechanism for services to the three- tofive-year-old population. A needsassessment conducted during the late1970s revealed that services at the locallevel were uneven throughout the state,frequently inadequate, and generallyfragmented. It was determined by thestate legture that a pilot system of"Preschool Coordination Sites" should bedeveloped. These sites would implement,on a local level, the state-levelphilosophical commitment to multi-agency and multidisciplinary coordination.Five sites were initially established. By1983, sixteen sites (one in each county)had been created, and a full-timeconsultant had been hired through theDepartment of Education and CulturalServices to provide technical assistanceat the local level. Mental healthprofessionals sit on the multidisciplinarycoordination teams at these sites and actas a liaison with private mental healthproviders within the community.Activities at these PreschoolCoordination Sites have continued tofocus on the identification, referral, andcase management of children withestablished handicaps as well as those atrisk for developmental delays ordisabilities due to biological and/orenvironmental factors.

It should be noted that historicallythere has been resistance in Maine tolimiting eligibility for services to childrenwith the traditional handicappingconditions as outlined by the Office ofSpecial Education Programs. Serviceproviders and policy makers have

considered biological and environmentalrisks increasingly apprNoriate forinclusion in service delivery mordinationand planning within the context of aholistic perception of children's andfamilies' needs.

In 1984 -- when all sixteen PreschoolCoordination Sites had beenestablished -- new state legislationallowed the coordination sites to expandtheir services to the birth to age threepopulation. Funding was prcvided forlimited direct service, staff assistance,in-service training, and technicalassistance. The legislature also requestedthat there be "specific plans for thedevelopment of a statewide program ofprevention intervention, including goals,objectives, activities, criteria forevaluation and projected impact onhandicapped or at-risk zero to three-year-old infants and their families"(C.624, P.L. 1984).

This legislation was the result of twofactors. The first was the naturaloutgrowth of the ICCPHC's deliberationsand evaluations of its first five years ofoperation. As committee membersassessed the work of the localcoordination sites, including mentalhealth activities, it became clear that acrucial time to conduct both a child anda family intervention was in the firstthree years of the child's life.

The second factor was the substantialimpact that Michael Trout and StanleyGreenspan had on the formulation of aphilosophy of service delivery in themental health and emotional developmentof infants and young children in the early1980s. Michael Trout's work evolvedfrom his study under Selma Freiberg atthe 1. iversity of Michigan. He iscurrently in private practice at theInfant-Parent Institute, Champaign,Illinois, and teaches workshops on infantmental health across the country.Stanley Greenspan, formerly of the

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National Institute of Mental Health, is apsychiatrist and author specializing inissues affecting young children.

On-site training sessions attended bykey state decision makers, includinglegislators, as well as direct serviceproviders -- particularly public healthnurses -- galvanized a multidisciplinarycadre of professionals responsible for thedevelopment and delivery of services toinfants. It appears that several themesblended together to create a receptiveclimate for embracing the Trout/Greenspan thinking:

There was recognition in theprofessional community that amental health/early interventionsystem was needed but no previousconsensus had existed on how thatsystem would be fashioned andwhat it should include.

It was imperative that existingpersonnel continue to be utilizedsince there was neither the desirenor possibility of advocating for anew professional specialty or evenin training a single professionalgroup. Personnel shortages and thehistory of interdisciplinarycollaboration meant that trainingin infant mental health would needto have a transdisciplinaryorientation to include allprofessional and paraprofessionalgroups.

The Trout/Greenspan emphasis onthe family as the client wascongruent with the tradition ofpublic health nursing, a disciplinethat was particularly dominant inthe most isolated and rural areasof the state, and with the state'sevolving activities in children'smental health.

The training could be accomplishedthrough a variety of methods.Although mastery might requireformal, university-based, out-of-state training, a beginningappreciation of infant mentalhealth principles and techniques ofintervention could be conveyed ina variety of modes, ranging from afour-day intensive workshop to afifteen-week graduate telecourse.

The interdisciplinary nature of thetraining contributed to aninterdepartmental consensus andthe development of a critical massof supporters who could continueto advocate for an expansion ofinfant mental health programmingwithin their professional groups.

The relatively high numbers ofschool-aged children with"seriously emotionally disturbed"handicapping conditions hadpromoted interest among publicschool officials for a statewidemental health/prevention effort.

Zero-to-Three Committee

An interdepartmenta:, multi-disciplinary "Zero-to-Three" Committee,eventually subsumed undar the ICCPHC,adopted a set of principles during thisperiod that became incorporated as partof the birth-to-five philosophy of serviceorientation. This committee was formedto manage a three-year HandicappedChildren's Early Education Programs(HCEEP) grant (1984-87) obtained by theBureau of Children with Special Needs,DMHM12. Project services includedhospital and home-based screening of allnewborns and coordinated intervention asneeded. These principles evolved as aresult of project experiences:

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MWSIM1141111O

Every child should receivepreventive health and othersupportive services which result inoptimal physical and mentalwellness for that child.

Individuals must be able to developtrusting relationships with othersin their family and community.Infants and young children need todevelop this capacity within their'iome environments. In somesituations, families need assistancein developing this capacity to trustand build relationships. Thisassistance may need to comethrough the combined effort ofindividuals and public/privateservices.

Identification and treatment shouldbe carried out to the maximumextent possible by currentlyavailable public and private sectorresources.

The model should be implementedby a local interagency group and,at the state level, by a stateinterdepartmental group. Thedelivery system should beinterdepartmental in itsorganizational structure. Theintervention should bemultidisciplinary.

Services should be family-focused,rather than child-focused. Thefamily is a team memberthroughout the model.

Intervention with zero-to-three-year olds should be integrated intothe current state system for three-to-f ive-year-old handicappedchildren.

Initial and ongoing education shouldbe developed and provided to thosewho will identify and supporthandicapped or at-risk infants,young children, and their families.

In 1985, the legislature approved aneffort to centralize and coordinatechildren's mental health services throughthe creation of a Bureau of Children withSpecial Needs within the Department ofMental Health and Mental Retardation.Still strongly committed to coordinationof multidisciplinary services with amental health prevention focus, theBureau's enabling legislation includedcommitment to the following services:advocacy, assessment and diagnosis, childdevelopment, consultation and education,crisis intervention, family guidance andcounseling, preventive intervention,professional consultation and training,respite care and treatment. The Bureau'starget populations, also defined in thestatute (1.34-B M.R.S.A., C.6), were:

A. A child age 0 to 5 years who isdevelopmentally disabled or whodemonstrates developmentaldelays; and

B. A child age 6 to 20 years who hastreatment needs related to mentalillness, mental retardation,developmental disabilities oremotional or behavioral needsthat are not under currentstatutory authority of existingstage agencies.

The vision, philosophy, legislationstructure, and service delivery systemmodel described above has been evolvingsince the passage of P.L. 94-142. By1985, a clear system of mental healthservice delivery to very young childrenwas already operational.

Discussion with policy makers andservice providers revealed a commonvision of a continuum of services. Thisvision regarded mental health as anatural, "demystified," and easilyaccessible component of child and familyservices. Mental health services forinfants were variously described as a kind

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of anticipatory guidance, an opportunityfor learning how to identify and interpretbehaviors, and a forum to develop skillsthat would foster confidence in parentsas they encourage cognitive,social/emotional, motor, andcommunicative development in infants.Maine was the only state to reflect thisphilosophy in legislation.

MENTAL HEALTH SERVICESPOST-P.L. 99-457

P.L. 99-457 has greatly reinforcedMaine's initial impetus towards betterand more effective mental healthservices for infants and toddlers. Policymakers, legislators, and service providerscontinue to seek creative means toalleviate the state's serious fiscal andprofessional resource shortages, whichimpinge on a well-defined system.

Definition of "DevelopmentallyDelayed"

As of June 1985, Maine haddefinitions in place for children with anarray of handicapping conditions. Maine'sdefinition oC "developmentally delayed"clearly reflects a desire to serve childrenin light of the previously discussedphilosophical principles developed by theZero-to-Three Committee. The definitionembraces a clear belief that thesocial/emotional well-being of very youngchildren is a priority and that services tothis population related to mental healthissues must consider not only diagnosablehandicapping conditions, but also thosechildren at risk for developmental delays.

The definition of developmentallydelayed/non-categorically handicapped isbroken down by age:

Age

1

Criteria

3 or len months delaychronologically in one ormore areas of development.

2 3 to 6 months delaychronologically in one ormore areas of development.



5 More than 18 months delaychronologically i1 1 one ormore areas of development.

Maine policy makers continue torethink and modify this definition in lightof new research, new societal concerns,and new legislation. After the passageof P.L. 99-457 in November 1987, thefollowing Ilescriptors were added for thedefinition of "emotionally handicapped":

Pervasive developmental disordersor behavioral disorganization, suchar.. autism, extreme sensitivity inint ancy or toddlerhood, andatypical development;

Psychological disorders related tobodily functioning such as seriouseating, sleeping, eliminating,stuttering problems;

Affective and interaction disorderssuch as separation anxiety, electivemutism, oppositional disorder,phobias, avoidant disorder,attachment problems, depression;

Conduct or behavioral disordersthat are severe enough to interferewith learning and social relations;

Problems with identity andselfhood, such as self-abusivebehaviors, headbanging, recklessdisregard of safety, negative self-image;

Attention deficit disorder; and

Post-traumatic stress disorder,adjustment disorders and otherspecific situational reactions thatsignificantly impair functioning andinterfere with development.

Development of aService Delivery System

The service delivery system forinfants, toddlers, and their families inMaine functions through sixteen PreschoolCoordination Sites. There is one site ineach of the sixteen counties in Maine.The responsibilities of the sites includecoordinating existing programs andservices to identify previously unservedchildren and to identify and plan forunmet program needs.

There has been a comprehensiveChild Find system in Maine for childrenbirth to age five since 1984. Localcoordination sites have done considerableoutreach and have interacted extensivelywith other agencies that have contactwith young children and their families.The coordination sites stress severalfeatures: visibility within thecommunity; the ability to acceptreferrals and inquiries for all infant andpreschool children so that families neednot continually search for the particularprogram needs of their child;consolidation of services to reducefragmentation and duplication; and acommitment to networking with amultiplicity of agencies, often by sharingfacilities and office space.

Individualized Family Service Plans,including case management services, havebeen in use in Maine on a statewide basis

for the past two years. They were usedprior to that time in selected parts of thestate at the Pilot Preschool CoordinationSites.

Components of the Maine IFSPinclude some elements commonly held byother states:

Major handicaps or risk factors indecreasing order of severity

Child/family strengths

Child/family needs

Special equipment/requiredtransportation

Team members and bases ofevaluation

Statement concerning evaluationprocedures

Statement concerning placementrecommendations

Parental participation

Program service recommendations

Narrative comments/transitionplanning

Appropriate team member andparental signatures

In many instances, the case managerselected is the individual who is mostlikely to have long-term contact with thefamily or the individual who currently hasrapport with the family. The closeworking relationship between theprofessional at the PreschoolCoordination Site facilitates decisionmaking in this area. Parents are involvedin the IFSP process and can select aprimary contact person. Because of thelimited population, the very rural natureof Maine, and the limited number ofprofessionals, information related tofamilies is shared with relative ease whilemaintaining confidentiality.

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Each Preschool Coordination Site'sprogram has been governed by a LocalCoordinating Committee (LCC) thatconsists of physicians, therapists, otherservice providers, parents, state agencyworkers, etc. The LCCs have beenresponsible for monitoring theexpenditure of Preschool CoordinationSite funds, for hiring and supervising thePreschool Site Coordinator and forproviding policy and operational directionto its area's program. The focus ofintervention has been on the coordinationand efficient delivery of existing servicesrather than on the creation of a new andseparate tier of early childhood/specialeducation school-oriented services. Thisfocus was essentially due to the absenceof a strong state tradition of preschoolservices for non-handicapped children, anemphasis on "local control" of educationalprogramming, a commitment tointegration of handicapped children, thelogistical difficulty of creating highlyspecialized services in a rural state, theabsence of qualified professionals, and arecognition of limited state fiscalresources.

Ongoing networking among therelatively small number of professionalsinvolved with infants has enabled localinnovations to become readily knownthroughout the state. An existing,grassroots setting for early interventionin mental health/prevention wasfrequently cited as ideal: a husband/wifeprivate pediatric practice located inWinthrop, Maine. The husband engages intraditional, well child care. The wife, anurse trair.d in Trout/Greenspanprinciples, pi uvides preventive mentalhealth consultation to all families whoseek pediatric services. In anotherpediatrician's office in Lewiston, Maine,a medical social worker is employed on apart-time basis to provide preventivemental health services. This kind offront line medical/mental health

collaboration acknowledges that a child'ssocial/emotional needs are an integralcomponent of overall development andgood health.

The system establishes the idea ofthe inclusion of mental health services asan expected component of normalpediatric care. It was continuallyemphasized by service planners andproviders statewide that V .; ultimategoal is the development of amedical/mental health framework inwhich the stages of 5ocial/emotionaldevelopment would be accorded the samelevel of attention that such areas asphysical and cognitive development havetraditionally received. Mental healthservices have been basically viewed as anequal partner with all other pediatricservices as well as a virtual entitlementto all children and families.

Programs A Closer Look

Project AIMS. Clearly, the mostelaborate and far-reaching expression ofthis goal of entitlement has been thedevelopment of Project AIMS(Attachment, Interaction, Mastery,Support). Funded as a specialfederal/state venture between the U.S.Depai tment of Health and HumanServices and the major state agencies inMaine, the project's primary purpose isto have a positive impact on the waysphysicians, nurses, educat-ars, mentalhealth providers, day care providers andothers identify young children at risk foror presenting emotional problems, assessthe nature of the children's and families'strengths and difficulties, and providethem with appropriate treatment andsupport.

A major focus of Project VAS is thedevelopment of a screening tool thatfocuses on emotional development andthat can be easily integrated into

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standard physician office consultations.As written by Dr. Stephen Bauer in thefirst issue of the AIMS newsletter(September 1987, Volume 1, Number 1),

What is needed is a tool that willallow the practitioner to assessthe emotional status of the childand family, the functioning of thefamily, the stresses present inthe family situation, and how thefamily is adapting to thosestresses. The tool should providesome insight into problem areasas well as give clues tofunctional strengths... It shouldhelp to raise the consciousness ofboth providers and families as tothe importance and legitimacy ofincluding those sorts of concernsin the medical setting.

Dr. Bauer also relates,Our goal with the AIMS tool is toaccomplish in the areas ofemotional and familydevelopment somethingcomparable to what the DDST[Denver Development ScreeningTest] has achieved in its ownsectors of development.

The AIMS tool is keyed to achronological age progression andprovides opportunities for clinician-specific questions and Likert-type scalefor parents. Clinician questions are bothgeneral and focused. Under the formercategory parents may be queried aboutadjustment and coping, basic care, andrelationship issues. Focused questionsappear under the headings, "Attachment,""Interaction," "Mastery," and "Support,"and can be used when concerns haveemerged from the general questions. Adiscussion of strategies and ideas is thenpresented so that the clinician can offerhelpful, nonthreatening input that isdesigned to encourage the family to

dei.ermine its own system for contendingwith the identified issues.

There are two other central functionsof the AIMS endeavor. The first is theprovision of training to medical andhuman service clinicians in the fieldtesting of the tool as well as in thegeneral principles and applications ofinfant mental health theory. This is nowoccurring through a telecourse, trainingfor protective service workers, mentalhealth forums, and technical assistance tothe Preschool Coordination Sites. Thesecond is the continuing advocacy for anddevelopment of treatment services sothat a comprehensive network can be inplace for families whose needs extendbeyond the screening and preventionefforts of the front lire hea:th careprovider.

The AIMS staff continuallyemphasized that their system is driven bythe desire to provide family supportrather than by the need to providepsychiatrically oriented, diagnosticclassifications to families and children.

Rockland and Norway Sites. Thisspirit of family-centered, preventivemental health services is evident in themanner in which services are delivered atthe Preschool Coordination Sites.Examples are described here from theRockland and Norway sites.

The Rockland site was among theoriginal preschool coordination projects.Begun in 1978, there was an immediaterecognitien of inadequate regionalresources as well as a fragmentedrelationship among agencies anddisciplines. It was decided by the staffand the LCC that direct service providersfrom the various agencies should behoused in the same building whilecontinuing to report to their respectiveagencies. Staff members now includechild development workers, assessors,teachers, social workers, community

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health nurses, speech pathologists,occupational therapists, and a contractualpsychologist with a private practice inthe community. One of the therapistshas received intensive training fromMr. Trout and serves as trainer/clinicalsupervisor to other staff.

The program is targeted at familieswith children who have establishedhandicaps as well as those at risk formental health difficulties. Services caninclude home visitation, play groups,parent groups, a parent-to-parentprogram, dissemination of a newsletter,and parent/staff larticipation on avariety of committees.

Referrals come principally fromphysicians and parents. Assessments areconducted for children in the age rangeof birth to three and in the age range ofthree to five. Most of the more than onehundred referred children receive fairlytraditional, multidisciplinary evaluationswith an emphasis on family adjustmentand mental health issues. For childrenwho are likely to have highly specializedneeds and with major psychosocial issues,there is opportunity for extensive "arenastyle" evaluations. Based on the infantmental health orientation developedthrough Project OPTIMUS (a handicappedchildren's early education programformerly located in Brighton, MA), thisthree-and-a-half-hour transdisciplinaryassessment could include all relevantdisciplines in addition to an in-depthanalysis of social/emotional developmentand functioning.

The program is particularly pleasedwith its Parent-to-Parent Project. Thisproject targets at-risk families and has achief goal of modeling appropriateparenting skills to families that areexperiencing stressful parent-childrelationships. Parent helpers receiveextensive initial and ongoing training.Their role is to provide informal,nonthreatening assistance to client

families and demonstrate alternativeparenting strategies. They may providein-home or group experiences and helpcoordinate respite care or other services.

The Norway Preschool CoordinationSite has a variety of special services thatare specifically oriented to the at-riskand high-risk populations. Home-basedmental health services are a main featureof zhe system with 3upplemental center-based services that include both atherapeutic preschool as well as a ParentPlace. The therapeutic preschool has apreponderant enrollment of children whohave been victims of physical abuse,sexual abuse, or whose parents arealcoholics. Components of the programinclude the BABES program which focuseson drug/alcohol abuse prevention and asexual abuse prevention program entitled,"Talking About Touch." The Parent Placehouses parenting groups, drop-incounseling, information, and informalsupport.

Personnel Development andStandards for Training

The ICCPHC has four goals directlyrelated to personnel development. Skillsand information relating to infant mentalhealth/emotional development areaccorded equal status and attention withthose relating to disabilities affecting)ther areas of development. The goalsare:

1. To formalize the training sub-committee of ICCPHC, supportmeetings at least on a quarterlybasis, provide a forum forinformation exchange, technicalassistance and resource sharing,and maximize the trainingresources available.

2. To provide continued support forthe maintenance mid ongoingoperation of the mail-bag library,

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film resources, and materialsexchange for parents andprofessionals, focusing on infantsand young children, ages 0-5, whoare at-risk or developmentallydelayed.

3. To facilitate the identification,design, and development of inter-departmental, transdisciplinary,training opportunities focusingspecifically on the 0-5 populationand parenting/family issues.

4. To ensure interdepartmentalleadership in the identification ofeffective strategies for therecruitment and retention of avariety of professionalsthroughout the state of Maine towork with families, young infantsand children, ages 0 to 5.

SERWCE DELIVERY SYSTEM:STRENGTHS AND CHALLENGES

Strengths. Maine's interagency,multidisciplinary approach to infantmental health provides "Everybody Wins"alternatives. As one example, when theZero-to-Three Committee was formed,the Maternal and Child Healthrepresentative was partially motivated byhis past experience as chief medicalofficer for a neonatal intensive care unitand his desire to maintain (during thebirth-to-three period) the high newborn-survival rates Maine had achieved. ThePublic Health Nursing representative wasmotivated, in part, by her desire toenhance the role and self-image of publichealth nurses throughout the state and toprovide them with opportunities topractice primary prevention. The SpecialEducation representative was meeting acommitment in Maine's originalP.L. 94-142 State Plan to extend service

.=1.11downward to birth, and the children'smental health representative wasmotivated by a need to become proactivein the face of ever-increasing referrals ofseverely emotionally disturbed childrenand adolescents. Finally, theDevelopmental Disabilities Councilrepresentative was excited at theopportunity for non-categorical delaysand disabilities to achieve attention equalto that afforded commonly understoodhandicapping conditions.

Challenges. Like most states, Maineis faced with a generally static ordecreasing resource base together withincreasing human needs and cempetitionfor these resources from a growingvariety of social programs. To develupeffective constituencies forrepresentation to legislators and otherdecision makers, it becomes necessary toincrease consumer expectations fasterthan service delivery capacities. Thisprocess inevitably produces stress,impatience and frustration on the part ofconsumer and administrator alike.

NEXT STEPS

Service Agency Representatives andregional coordinators' staff indicated thatthere is significant community supportfor infant mental health services,however, lack of trained personnel andinadequate fiscal resources are barriersto service provision. There is anincreasing emphasis on the promotion ofan efficient transition system to thepublic schools for children who havereceived infant and preschool mentalhealth services so that support can beprovided without the requirement fordiagnosis and determination of ahandicapping condition.

There have been several strategiesadvanced to contend with the problem ofpersonnel shortages. These include:

1. Development of an earlychildhood/special educationgraduate program through theUniversity of Maine. This wouldbe the first program of its kindin the state; the focus would behighly transdisciplinary with astrong mental health orientation.Fducators would be part of thetransdisciplinary earlyintervention team rather thanserving only in more traditionalclassroom teacher roles.

2. Development of an extensivecadre of paraprofessionals whowork under the supervision ofprofessionals. This has beenoccurring with speech andlanguage pathologists. Theshortage of master's level speechand language pathologists hasprompted the emergence ofIIspeech aides" who are trained atthe bachelor's level and workunder the supervision of master's-level, trained speech pathologists.

3. Specialized supplemental trainingin infant mental health for thosealready in contact with infantsand their families -- hospital,office, community and publichealth nurses; day care providers;early intervention specialists;child protective workers; and out-patient staff members of mentalhealth centers. This approach isseen as more advantageous thanany attempt to develop a newspecialty or sub-specialty in atime of expanding needs anddiminishing resources.

4. Movement to raise salaries,particularly in the southern endof the state, to assist recruitmentand retention efforts. Neighbor-

ing states, particularlyMassachusetts, presently offersubstantially high,..:r salaries toindividuals seeking professionalpositions in school and clinicalsettings.

The lack of fiscal resources is arecurrent problem in Maine as the stateattempts to contend with a variety ofsocial/educational issues. There are twostrategies here: an endorsement of theexpectation that more federal monies areneeded to assist in the provision ofservices to children under P.L. 99-457and growing support at the state andlocal level for early intervention as itsefficacy is demonstrated.

Discussions with planners andproviders revealed a pride in theemphasis that has been placed onprevention and early mental healthintervention. There was also concernthat the system may not be able toabsorb continued referral demands andthat the family issues being brought tothe attention of service providers areincreasingly complex. While theinteragency expectations of P.I 99-457were greeted as congruent v., theexisting assumptions of collaborativeendeavors in Maine, there was greatconcern that dividing the service systemin two (birth to three and three to five)could threaten the foundation of theII seamless" preschool system that hasbeen a decade-long goal of serviceproviders. There was also recognitionthat what works well in a relativelyhomogenous, non-urban state may nottransfer well to states that aredemographically heterogeneous and havehistories of interdepartmentaldisharmony. While health care resourcescan still be targeted to the at-riskpopulation, there was fear, particularlyin the relatively urbanized, southern endof the state, that the emergingpopulation of chronically ill, extremely

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premature babies could force areallocation of resources away from apreventive system that features aphilosophy of "greatest good for thegreatest number," to a system thatprovides intensive services to childrenwith ongoing, life-threatening conditions.This could have a particularly profoundeffect on the future utilization of nursingservices.

RECOMMENDATIONSFOR OTHER STATES

Ed Hinckley, Chief OperationsManager of the Bureau of Children withSpecial Needs, and an ardent advocate ofinfant mental health services in Mainestated that "interagency collaboration isan unnatural act." But he also suggestedpractical guidelines to enhance thelikelihood of interagency success and tocreate excitement about the possibilitiesof infant intervention. These include:

Disabuse people of the notion thatmental health is the domain of anyone agency or discipline.

Remember that it takes time tobuild trust, develop a commonmission and devise a commondirection.

Begin with pilot sites. There isgreater likelihood of eventualadoption of a new state-levelpolicy if there is proven success atthe local level.

Provide opportunity for policymakers to conclude thatintervention is necessary ratherthan impose mandates for thecreation of intervention systems.Success is then more likely.

Provide coordination initially in thedevelopment of programs andsystems and resist the idea of the

immediate provisicn of new, directservices. A planning process isimperative.

Include the universities in theprovision of training in thebeginning of the process andcreate a university partnership.

RESOURCES AVMLABLETO OTHER STATES

A forty-five hour introductory courseon infant mental health has beendeveloped by the Maine Association forInfant Mental Health, Inc. (a chapter ofthe International Association for InfantMental Health) assisted by the Bureau ofChildren with Special Needs, DMHMR.Included in this course are ten half-hourvideo tapes, produced by Michael Trout,and related print materials; it has beenawarded three graduate credits by theUniversity of Southern Maine and will bean elective in the University of Maine'sgraduate MSW program. Moreinformation may be obtained bycontacting Edward Hinckley, at theaddress below.

Representatives of the associationand the various agencies involved inzero-to-five mental health programmingand service delivery are available toconduct workshops within the restrictionsof personal scheduling. Seminars,conferences, "train the trainer" classes,and technical assistance can be offeredto administrators and clinicians.

Contact Person:

Edward HinckleyChief Operations Manager

Bureau of Children with Special NeedsDepartment of MH/MR

State House Station #40Augusta, ME 04333

(207) 289-4250

NORTH CAROLINA

byEmily Schrag Fenichel

Site Visit Team: Emily Schrag Fenichel, M.S.W., Associate Director, NationalCenter for Clinical Infant Programs, Washington, D.C.; Judith Katz-Leavy, M.Ed.,Assistant Chief, Child and Family Support Branch, National Institute of MentalHealth, Washington, D.C.; John Hornstein, M.Ed., Director, Infant DevelopmentCenter, South Portland, Maine.

"Aintributors From North Carolina: We would like to thank the following peoplerom North Carolina's Department of Human 14ources, Division of Mental

Health, Mental Retardation and Substance Abuse Services, Raleigh, NorthCarolina: Lenore I3ehar, Special Assistant for Child and Family Support Services,for her support of North Carolina's involvement in this study. Paula Clarke,former CASSP Director and current Chief of Child and Adolescent Services,shared her expertise in the area of child psychology as well as her understandingof mental health service delivery issuer; and challenges. She was most helpful inher review of the initial draft of the North Carolina profile. Elaine Marcus,Training Specialist, Child Mental Health Training Unit, wnrked with Paula to planand coordinate the schedule of site visits. In addition, Elaine's knowledge andunderstanding of the personnel training issues confronting states related to theimplementation of P.L. 99-457 was extremely valuable. Both Elairie and Paulaalso deserve special thanks for chauffeuring the team between sites and showingus superb southern hospitality. Susan Robinson, current CASSP Director andformer Director of the Parent and Child Together (PACT) Program, Orange-Person-Chatham Mental Health Center in Chapel Hill, one of the sites we visited,did a marvelous job of assuming roject responsibilities following Paula'sdeparture.

From North Carolina's Department of Human Resources, DevelopmentalDisabilities Services Section, Raleigh, North Carolina: Duncan Munn, Chief ofDay Services, demonstrated on-going interest in this project and providedtechnical assistance in revising the draft manuscript. We also want toacknowledge the contributions of the many members of North Carolina'sInteragency Coordinating Council (ICC).

Site visits provided us with valuable insights into North Carolina's Part Himplementation model. We wouid like to thank the following individuals as wellas the members of their staffs: Mark Everson, Clinical Instructor, Departmentof Psychiatry, School of Medicine, University of North Carolina at Chapel Hill;Linda Foxworth, Assistant Director, KidSCope, Orange-Person-Chatham MentalHealth Center, Chapel Hill, North Carolina; Melissa Johnson, Pediatric ClinicalPsychologist, Neonatal Intensive Care Unit, Special Infant Care Clinic (SICC),Wake Hospital, Raleigh, North Carolina; Charles Kronberg, Assistant Director, andthe staff of Project Enlightenment, Wake County, North Ci alina; Joyce Moore,Nurse Consultant, Pediatric/Child Mental Health Evaluation Program, School ofMedicine, University of North Carolina at Chapel H111, Karen O'Donnell, AssistantProfessor, Division of Medical Psychology, Department of Pediatrics, DukeUniversity Medical Center, Durham, North Carolina; and J. Kenneth Whitt,Associate Professor, Department of Psychiatry and Pediatrics, School of Medicine,University of North Carolina at Chapel Hill.

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North Carolina has the second largestpopulation and the smallest geographicarea of the three states surveyed. It ischaracterized by moderate-size cities andextreme rural areas. As with many otherstates, there seems to be a concentrationof services in the most populated areas.In North Carolina there is a clearcommitment on the part of many stateagency leaders to develop a servicedelivery system that is family-centeredand that addresses infant-parent mentalhealth needs.

North Carolina's efforts to addressthe mental health of very young childrengrow out of a tradition of policydevelopment and direct service at leasttwenty years old. Twc major strands canbe identified in this tradition: 1) a desireto provide compr&ensive, skilleddiagnostic and treatment services tochildren with serious emotionaldisturbances; and 2) a conviction that asupportive, non-categorical approach tothe health and well-being of infants,toddlers, and their families must includeattention to psychosocial issues andemotional development. North Carol,aais the source of many innovative ideaswithin the areas of funding for mentalhealth services, service delivery models,and training early intervention personnelin mental health sensitivities and skills.


The creation of a framework forattending to the emotional developmentand mental health of North Carolina'sinfants, toddlers, and their families hasinvolved the efforts of the statelegislature, major state agencies,professional organizations, universities,service providers, community groups, and

4. di viduals with special expertise. WithLar, exception of departments of publicinstruction, all of the relevant stateagencies for preschool services arecomponents within the Department ofHuman Resources. These include theDivision of Health Services; the Divisionof Mental Health, Mental Retardation andSubstance Abuse Services (MH/MR/SAS,the Part H lead agency for P.L. 99-457);the Division of Social Services; the DayCare Section of the Division of FacilityServices; and the Division of MedicalAssistance. In addition, North Carolinahas tapped national resources byparticipating in a multistate initiativedesigned to improve services to disabledand high-risk infants, toddlers, and theirfamilies and by successfully competingfor discretionary funding from twofederal agencies in order to mountdemonstration programs related to infantmental health.

A few examples of collaborativeefforts illustrate the ways in whichfruitful partnerships have emerged and inwhich the achievements of one group'seffort provide fuel for another group'swork.

Initial Efforts

In 1974, a committee began toconsider the needs of infants at risk fordevelopmental delay. Chaired by staff ofthe Maternal and Child Section of theDivision of Health Services, it includedrepresentatives of the child mental healthand mental retardation sections of theDivision of MH/MR/SAS, as well as otherDepartment of Human Resourcesagencies. In July 1979, in conjunctionwith local health departments, hospitals,and the North Carolina Chapter of theAmerican Academy of Pediatrics, theDivision of Health Services instituted theprocedures that became known as the

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High Priority Infant Program (HPIP). In1984, North Carolina was selected as oneof ten states participating in Project Zeroto Three. The state's Zero-to-ThreeCommittee shared its experiences intracking and providing services to high-risk infants and toddlers with otherstates. Subsequently, in 1987, a set ofrisk indicators developed through thenational Project Zero to Three wereadopted as part of North Carolina'srevised HPIP procedures.

In 1986, the Mental Health StudyCommission, a body established by theNorth Carolina General Assembly,appointed a Child Mental Health TaskForce to provide long-range needsassessment and planning for acomprehensive child mental healthsystem. All relevant agencies at stateand local levels provided input, and publichearings were held across the state. TheDivision of MH/MR/SAS, in turn,responded to the plan with an analysis ofadministrative activities necessary tosupport further system developmentand/or improvement. As a specialoutgrowth of the task force'srecommendations, the 1987 GeneralAssembly appropriated two million dollarsin new resources to expand child mentalhealth services and made a commitmentto continued expansion over the next tenyears. Preschool children are one ofthree population groups given highpriority in the plan.

In the spring of 1986, theComprehensive Interagency PreschoolPlanning Committee (now the InteragencyCoordination Council) was established bythe Departments of Public Instruction andHuman Resources, through the Division ofExceptional Children of the former andthe MH/MR/SAS and Health Services ofthe latter. It served as the singleplanning and advisory forum consideringthe service needs of infants, toddlers, andpreschool children (birth through five)

with developmental difficulties.Membership on this committee includedstaff with management and direct serviceresponsibility from principal governmentalagencies as well as representatives ofadvocacy groups and professional andconsumer organizations. Task forceswere formed to address issues of serviceimplementation, training, eligibility,needs assessment, and transition.

Programs A Closer Look

Project Enlightenment. An exampleof a pre-P.L. 99-457 program in the earlyintervention network -- unique because ofthe many services offered -- is ProjectEnlightenment, a cluster of mental healthservices for young children and theirfamilies that operates within the WakeCounty Public School system; it is alsoaffiliated with the area mental healthagency for Wake County. Begun with aPart F Grant (Community Mental HealthCenter Act) in 1969, at a time when nomental health services existed in the areafor children under six, the project isdesigned to serve children from birththrough the completion of kindergarten.By its own description, ProjectEnlightenment operates from theassumption that "since children cannotalways have access to trained, specializedmental health personnel, it is importantthat the adults in a child's life gainsupport and skills which will enable themto help the child realize his or her fullestpotential... the approach does notemphasize problems, diagnostic labels andweaknesses, but focuses on accentuatingthe existing strengths in the home andschool."

The project offers teacher/parentconsultation, short-term parentcounseling, parent education, workshops,a telephone service for families, teachertraining, a resource center, and a range

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-of publications. A demonstration pre-school serves an average of twentychildren ages three to five, ten of whomhave emotional-social and/or learningproblems. First Years Together is aspecial demonstration project withinProject Enlightenment for Wake Countyfamilies whose babies have spent time inthe Neonatal Intensive Care Unit or arebeing followed through Wake MedicalCenter's Special Infant Care Clinic. FirstYears Together offers horr e and centervisits, assessments, a resource center,and a parents' group during the first twoyears of life. Its aim is preventive -- tooffer a continuum of services to parentswhose infants have had a worrisome start.

Th Family, Infant and PreschoolProgram. The Family, Infant andPreschool Program (FIPP) located at astate institution, Western CarolinaCenter, in Morganton, North Carolina, isa model demonstration program for youngchildren with disabilities and theirfamilies that approaches mental healthconcerns from a social systems, familysupport perspective. In their 1988 book,Enabling and Empowering Families:Principles and Guidelines for Practice,FIPP staff members Carl Dunst, CarolTrivette, Angela Deal and theircolleagues articulate a familyintervention approach based on theconviction "that the best way to be ofhelp is to support and strengthen familyfunctioning." This approach emphasizesa helping process which promotespositive, competent, family activityengaged in meeting the needs of allfamily members using resources withinand outside the family.

In the presentations they makefrequently to national audiences of earlyintervention practitioners, family supportprograms, and policy makers, FIPP staffand parents stress the evolution of theprogram from a child and disability-

focused treatment effort to a family-oriented, proactive approach. Thisevolution has built upon recent socialscience thinking about children, families,and would-be helpers but has also beengrounded in the experience of developingand field-testing various versions of anassessment and intervention model.Again, the program has received bothstate and federal support: the work ofthe FIPP has been funded in part bygrants from the North Carolina Divisionof MH/MR/SAS, Research and EvaluationSection; the North Carolina State Boardof Education; the Children's Trust Fund;the North Carolina Council onDevelopmental Disabilities; the NationalInstitute of Mental Health, PreventionResearch Branch, the U.S. Department ofHealth and Human ServicesAdministration on DevelopmentalDisabilities; and the U.S. Department ofEducation, Office of Special EducationPrograms.

MENTAL HEALTH SERVICESPOST-P.L. 99-457

The enactment of P.L. 99-457 andrelated state initiatives have providednew opportunities for collaboration onbehalf of young children and theirfamilies both within the Division ofMH/MR/SAS and among other state andlocal service providers.

Because of its high level of activityand visibility, the Preschool PlanningCommitcee was designated by theGovernor in March 1987 to be the officialInteragency Coordinating Council underP.L. 99-457. In the fall of that year, aState Implementation Team, includingmanagement staff from the threedivisions chairing the Preschool PlanningCommittee, was formed to accomplish

the day-to-day coordination necessarybetween the divisions and to developstrategies for carrying outrecommendations of the committee.

Before the Division of MH/MR/SASwas designated as the lead agency forcoordination of services for disabled andhigh-risk infants and toddlers, staff in thesections of Mental Health and of MentalRetardation were more likely to beinvolved in joint projects with staff ofthe Division of Health Services or theDepartment of Public Instruction thanwith each other. Emotionally troubledyoung children began to be considered asa subcategory of developmentally disabledyoung children by the InteragencyPreschool Planning Committee.Simultaneously, non-categorical,comprehensive services to young childrenand families began to receive increasingsupport. Reflecting these trends, theSpecial Assistant for Child and FamilyMental Health Services and the DeputyDirector for Mental Retardation andDevelopmental Disabilities (MR/DD)Services recommended a jointly-fundeddemonstration program to serveemotionally troubled infants, toddlers,preschoolers, and their families.

Proposed in 1987, the plan entailedusing the existing MR/DD earlyintervention network as a "service home"for these children with close involvementand support from local child mentalhealth units. At one existing earlyintervention program in each of fourregions, one mental health professionalhas been added to the staff. New supportactivities for mental health are toinclude, but are not limited to, suchactivities as child and family screeningand assessment, staff training,participation in case staffing, andprovision of clinical supervision for earlyintervention staff. A full-time projectcoordinator, a half-time trainer and abroadly representative advisory group

direct and integrate the work of the fourregional sites.

This approach was supported by theDivision of MH/MR/SAS. Categoricalresources from the Child and FamilyServices and Mental Retardation Sectionswere supplemented by a grant from thefederal Child arid Adolescent ServiceSystem Program (CASSP) of the NationalInstitute of Mental Health; servicedelivery began in January 1988.

One division within the Departmentof Human Resources that has yet tobecome fully involved in the developmentof integrated policy and service deliveryto emotionally troubled infants, toddlers,and their families is the Division ofSocial Services. It has been determinedthat over nine percent of the caseloadsfor early intervention in mentalretardation are protective services clientsof the Division of Social Services. Thedesignation of substantiated physicalabuse, sexual abuse, or other worrisomeenvironmental factors as criteria forinclusion in the atypical deveiopmentpopulation recognizes the developmentaleffects of abuse, neglect, and poorcaregiving. Given this framework, onewould anticipate an increase ininteraction between the Division of SocialServices and other agencies or groupsthat work with young clients and theirfamilies.


North Carolina's definition ofeligibility for services under P.L. 99-457recognizes both the extent and thelimitations of current understanding ofemotional development and mental healthdisturbances during the earliest years oflife. According to North Carolina'sdefinition, children from birth throughfive years of age ere eligible for early

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intervention services if they are:1) developmentally delayed; 2) demon-strate atypical development; or 3) are athigh risk for developmental delay oratypical development.

"Developmentally delayed_ children"means those whose development is delay-ed in one or more of the following areas:cognitive development, physical develop-ment, language/speech, and sclf help.The specific level of delay must be:

(a) Children from birth to thirty-sixmonths of age: documented byscores 1 1/2 standard deviationsbelow the mean on standardizedtests in at least one of theabove-mentioned areas ofdevelopment; or by a twentypercent delay on assessmentinstruments that yield scores inmonths.

(b) Children from thirty-six to sixtymonths of age: documented bytest performance 2 standardizeddeviations below the mean onstandardized tests in one area ofdevelopment; or by performancethat is 1 standard deviation belowthe norm in two areas ofdevelopment; or it may bedocumented by a twenty-fivepercent delay in two areas ofassessment instruments that yieldscores in months.

Careful assessment is necessary todetermine developmental delay and mustbe performed by appropriatelycredentialed professionals whose trainingqualifies them to assess children in thedevelopmental area of concern.Standardized tests, rating scales,developmental profiles, and otherinstruments and procedures that meetacceptable professional standards shall beused to document the nature and severityof' the problems necessitatingintervention.

"Atypical development" in childrenmeans those from birth to sixty monthsof age who demonstrate significantlyatypical behavioral, socioemotional,motor, or sensory development asmanifest by:

(a) Diagnosed hyperactivity, attentiondeficit disorder, or otherbehavioral disorders; or

(b) identified emotional/behavioraldisorders such as:

(1) delay or abnormality inachieving expected emotionalmilestones, for example,pleasurable interest in adultsand peers; ability tocommunicate emotional needs;and ability to toleratefrustration.

(2) persistent failure to initiate orrespond to most sodainteractions.

(3) fearfulness or other distressthat does not respond tocomforting by caregivers.

(4) indiscriminate sociability, e.g.,excessive familiarity withrelative strangers.

(5) self-injurious or unusuallyaggressive behavior.

(c) Substantiated physical abuse,sexual abnse, or otherenvironmental situations thatraise significant concernregarding the child's emotionalwell-being.

"High-risk children" means those frombirth to thirty-six months of age who:

(a) Have a diagnosed physical ormental condition which has a highwobability of resulting indevelopmental delay or atypicaldevelopment; or

(b) Have significantly atypicalpatterns of development(perceptual, sensory, physical,behavioral, motor anomalies) thathave a high probability ofresulting in developmental delayor atypical development; or

(c) Have responded well tointervention efforts, but forwhom there is evidence that theircontinued developmental progresscannot be assured withoutcontinued intervention.

Careful assessment is necessary todetermine high-risk status and must beperformed by appropriately credentialedprofessionals whose training qualifiesthem to assess children in thedevelopmental area of concern.Standardized tests, rating scales,developmental profiles, and otherinstruments and procedures that meetacceptalle professional standards shall beused to document the nature and severityof the problems necessitatingintervention.

The emotional development of infantsand toddlers in all three eligibility groupsis, of course, of concern, but it is theatypical development and the high-riskgroups that reflect North Carolina'sstrong mental health focus. Since so fewstates have adopted eligibility criteriaunder P.L. 99-457 that are as nearly non-categorical as North Carolina's, it maybe useful to describe the context in whichits definition of eligibility was developed.

North Carolina's definition ofeligibility represents an achievement ofcollaboration as well asconceptualization. The result of morethan a year of deliberations by theComprehensive Interagency PreschoolPlanning Committee, the definition wasdeveloped and synchronized with majorefforts in the Division of Health Servicesand in the Division of MH/MR/SAS.

The experience of the Division ofHealth Services in trying to identify andserve a high-risk population of infants andtoddlers may have made the interagencycommittee more comfortable with adefinition of eligibility that includedthese children. As early as 1979, theHigh Priority Infant Program of theDivision of Health Services began toidentify infants who had indicatorsassociated with later developmentaldelay; to enroll, track and assess thedevelopment of these infants; and tooffer support services, chiefly of publichealth nurses, to assist families andprimary care providers. In 1988, severalmajor revisions in the program becameeffective. A single set of risk indicators,including parental/family conditions,mental conditions, and post-neonatalconditions replaced a prior system withthree risk categories. Moreover, infantscould be identified and enrolled in theprogram any time within the first year oflife.

The high-risk children who can beserved under P.L. 99-457 may also be thebeneficiaries of North Carolina's tradidonof preventive services to disadvantagedyoung children and families. Therecognition that continued interventionmay be necessary to maintain thedevelopmental progress of young childrenwho have responded well to interventionreflects the findings of a number ofdemonstration projects that have focusedon psychosocial development.

Members of the Eligibility Sub-committee of the ICC developed broad,comprehensive criteria for a category of"atypical development" based on aphilosophy that eligibility for preschoolservices should allow a response to needsthat are diverse and that sometimes arenot easily diagnosed. As this non-categorical approach was being translatedinto the language of eligibility criteria,major changes were also being made in

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state statutes. After fifteen years ofdeliberation, the North Carolina GeneralAssembly enacted legislation in 1987which made those services previouslyavailable only to people with mentalretardation now available to anyonemeeting the current federal definition ofdevelopmental disabilities.Developmental delay and atypicaldevelopment were cited as additionalcategories to determine the eligibility ofinfants, toddlers, and preschoolers.Effective April 1988, accounting rules inthe Division of MH/MR/SAS were alsomodified to allow young childrenexperiencing atypical development to beserved with existing early interventionMR/DD funds.

The Preschool Planning Committeeestimates that seven percent of thegeneral population of preschoolers (zeroto five) are at risk for or do exhibitatypical development. Infants andchildren with established DSM III-R(American Psychiatric Association)diagnoses are considered part of thisgroup. So are young children who haveexperienced substantiated physical abuse,sexual abuse, or other worrisomeenvironmental situations: these are seenas occasions to provide developmentalservices to the child and family, notsimply as a matter for the judicial orfoster care system. It is worth notingthat, while careful assessment by anappropriately trained professional isemphasized in the description of atypicaldevelopment, examples ofemotional/behavioral disorders arepresented in non-technical language.


North Carolina envisions identifying,assessing and providing mental healthtreatment services to atypically

developing and high-risk infants andtoddlers within a non-categorical systemof early intervention services. Since thefour demonstration projects beingsponsored by Child Mental Health-MIVDDbuild on or are connected to servicecomponents that are availabie statewide,the successes they achieve may berelatively easy to replicate. State agencyplanners are also aware of the importanceof maintaining and learning fromexcellent community- and university-based mental health services.

Identification and Assessment ofInfants and Toddlers in Need ofMental Health Services

Because very young children enterthe human services network primarilythrough the health, social services, orday-care systems, service providers atthese entry points need to be aware ofmental health issues affecting infants andfamilies. North Carolina's planners haverecognized this need and are helpingservice providers become prepared tooffer appropriate assistance and/orreferral.

The High Priority Infant Programinvolves close cooperation among localhealth departments, private physicians,developmental evaluation centers,neonatal intensive care follow-up clinics,early intervention programs, hospitalsserving each county, and, of course,families. Infants may be enrolled in theprogram throughout the first year of life,if they meet any one of thirty riskconditions; those likely to be associatedwith mental health concerns includeparental mental illness, difficulty inparental/infant bonding, lack of familialand social support, failure to thrivn, andsignificant parental concerns.

The 1988 revisions to the HighPriority Infant Program emphasize actual

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family support services, rather than"paper" tracking. All infants -- includingprivate patients enrolled in theprogram receive the same supportservices protocol, which includes a homevisit by a HPIP (public health) nurse twoweeks after discharge from the hospital,and face-to-face contacts in the home orclinic at four, twelve, eighteen 'And thirtyto thirty-six months of chronologic age.All HPIP support services are provided inconjunction with the infant's primarycare provider. Through appropriationsgranted by the North Carolina GeneralAssembly, services included in the HPIPprotocol (identification, enrollment,tracking, support services, andintermediate assessments) are provided atno cost to families.

The support services protocolemphasizes the emotional well-being ofthe infant and the parent, in addition tothe parent-child relationship. Nursesobserve and assess the family'sadjustment to the infant and the homeenvironment, share information aboutcognitive and social development as wellas health states, and are alert to parents'use of or need for social support.

More extensive, multidisciplinaryevaluations of young children withsuspected developmental problems havebeen provided by nineteen DevelopmentalEvaluation Centers (DEC) throughoutNorth Carolina. Some 26,000 children areseen annually, with the focus increasinglyshifting to the zero-to-five population. Anew Intermediate Assessment, morethorough than a developmental screeningbut less intense than a multidisciplinaryevaluation, is now being provided tochildren enrolled in the High PriorityInfant Program on two occasions: thefirst, between fifteen and eighteenmonths of age; the second, betweenthirty and thirty-six months of age. TheIntermediate Assessment includes a fullDenver Developmental Screening Test

plus a special developmental checklistadministered by DEC staff. Theexpertise of North Carolina'sDevelopmental Evaluation Centers hashistorically rested in areas other thanmental health; if the primary cause forconcern about an infant or toddlerinvolved emotional development, the childand family might be referred elsewhere.Recruiting staff with infant mentalhealth expertise and/or providingappropriate training to current staff aremajor challenges for the centers.

A more specialized, but strictlycircumscribed, mental health evaluationresource is the Child Mental HealthEvaluation Program, a network ofpsychiatrists and licensed practicingpsychologists coordinated by theUniversity of North Carolina-Chapel HillMedical School faculty under directcontract with the state's Division ofSocial Services. The program providesextended psychiatric/psychologicale:Paluations for children suspected ofbeing abused or neglected; referrals arcmade primarily for complicatedsituations. Approximately thirty-five percent of these evaluations are forchildren under six. Case conferencestake place after most evaluations in orderto present results, to discuss the SocialServices plan for the child and family,and, where needed, to discussrecommendations for long-term treatmentof the child and family; however, theprogram does not provide direct links tofollow-up services.

To improve identification of infantsand toddlers in need of mental healthservices in their areas, the four ChildMental Health/MR/DD demonstrationprojects work closely with local HighPriority Infant Programs. They are alsomaking themselves known to primaryhealth care providers, day care providers,practitioners with adult mental healthand substance abuse caseloads, and other

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sources of potential referrals of infantsand toddlers experiencing atypicaldevelopment or at high risk for emotionalproblems. North Carolina has also usedPart H funds to establish an interagencydemonstration team for infant assessmentin one county. With staff from threeagencies -- the High Priority InfantProgram, the Developmental EvaluationCenter, and the Early InterventionTeam -- this "single portal" unit willconduct developmental assessments,coordinate service delivery, writeIndividualized Family Service Plans(IFSP), and assign case managementresponsibility. This first demonstration isseen as an opportunity to learn how useof the atypical development definiticr. foreligibility works in practice. Thepossibility of common forms andprocedures across agencies will beexplored; additional providers might alsobe included in the team.

Treatment Services

State-funded early childhoodintervention services for infants andtoddlers with developmental delays,atypical development, or at high risk fordevelopmental problems are offered underthe aegis of the Division of MH/MR/SAS,primarily through a network of home-based services that began in 1968.Multidisciplinary PACT (Parent and ChildTogether) teams provide comprehensiveassessment and prescriptivedevelopmental programming for child.enfrom birth to age three. These teamsmay include educational specialists, earlychildhood ethacators, psychologists, socialworkers, and speech, physical andoccupational therapists. Families areprovided with training, support andinformation on childrearing skills andmanagement, and on other resources andservices available to them. In 1986-87,

1,479 children and families were referredto Early Childhood Intervention Servicesstatewide; of these, 762 children werelater accepted into the program. Thetotal enrollment for 1986-87 was 1,659children. In January 1988, 200 childrenand families were on a waiting list.North Carolina has used Part H funds toextend Early Childhood InterventionServices to all counties in the state,beginning in 1988.

Seventy-nine Developmental DayPrograms, also sponsored by the Divisionof MH/MR/SAS in seventy-six of NorthCarolina's one hundred counties, servechildren who tend to have substantialimpairments. Almost nineteen percent(351 children) of those being served onMay 1, 1987, were under three years ofage. An almost equal number (334) ofchildren from zero to three were waitingfor services as of that date; lack ofclassroom space and insufficient fundswere the chief reasons for delays. Agrowing demand for center-based servicesfor infants is seen.

All PACT teams and DevelopmentalDay Program staff have already beenserving some children who evidenceatypical development or are at high riskfor emotional problems. Some tenpercent of children served are referred byProtective Services alone. The four newChild Mental Health/MR/DCdemonstration programs will be lookingfor better ways to address mental healthissues within the PACT model of home-based direct services, day careconsultation, and case managementservices, using the new, full-time mentalhealth specialist added to the staff withdemonstration grant funds.

The mental health specialist isexpected to work directly with familieson the parent-infant relationship, using afocus-on-the-child technique as a way tooffer emotional support to parentscomfortably. With particularly difficult

families, establishing a workingrelationship is itself a substantial goal.Helping families to find and use socialsupport and counseling for relationshipswith other children or spouses is anotherimportant feature. Making appropriatereferrals for more intensive therapy maybe indicated. The mental healthspecialist at each demonstration site isalso involved in clinical supervision ofstaff whose backgrounds are in otherdisciplines. As staff become moreexperienced in identifying and engagingmental health issues and az referralscome from a range nf sources, includingthe Division of Social Services, theprojects are likely to be increasingly ableto address the mental health needs ofdevelopmentally disabled, atypicallydeveloping, and high-risk infants andtoddlers.

A special word is in order aboutlinkages between early childhoodintervention and day care services. Daycare providers are seen as excellentpotential referral sources for youngchildren needing HPIP follow-up as wellas more specialized mental healthassessment. At the same time, familyday care homes and mainstreamed daycare centers can offer a communitysetting where an early intervention teamcan help providers and families meet theemotional needs of young children. Asmall number of atypically developingyoung children have been placed in familyday care with fees paid through Title XXCommunity Living Services. There arethirty-nine Early Childhood Intervention(ECI) programs in the state which provideinformation, referral and linkages. Oneof these is KidSCope, a project funded byone Community Mental Health Center toprovide on-site consultation and supportto mainstream day care centers servingemotionally troubled three- to "ive-yearolds and could be extended in time towork with younger children and withfamily day care providers.

Personnel Development andStandards for. Training

Training Plan for CASSPDemonstration Projects. As NorthCarolina's planners noted in theirapplication to CASSP, "a new servicedelivery system with new service modelswhich address the needs of a new targetpopulation requires a staff withbackground and skill levels to match theservice needs." Those service needs maycome from young victims of abuse andneglect; infants and toddlers whoseprecarious health status may haveovershadowed their emotionaldevelopment; and children whosetroubling behavior represents acomplicated, poorly understoodinteraction among physical, cognitive, andemotional factors. In addition, multiplystressed families whose members may ormay not have been coping with their ownemotional problems before the birth of avulnerable child may require service; theskills required for appropriate response tosuich diversity are high indeed. Moreover,as North Carolina's planners are aware,the field of infant/parent mental healthdiffers in its approach from some othermental health specialties, with anemphasis on strengthening positiveparent-child relationships rather than afocus on individual psychopathology. Asresearch and rflactice in the field evolve,in-service and continuing education are asessential as appropriate pre-servicetraining.

In keeping with the collaborativeapproach to administration and servicedelivery that characterizes NorthCarolina's four demonstration earlyintervention projects, trainingresponsibilities are shared by the ChildMental Health Training Unit (representingMH/MR/SAS), and the TechnicalAssistance Program-Intervention Network(TAP-IN) (representing the MR/DDSection). The two training agencies

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administer a wide range of trainingfunctions for the four demonstrationprojects; interagency collaboration hasmade possible expansion of trainingresources and elimination of duplfcativeefforts.

Training design efforts began with acomprehensive needs assessment. Resultsfrom the needs assessment plus trainingrequirements stipulated in the grantbecame the guidelines for the trainingplan. The plan is still evolving and willundoubtedly be modified throughout thegrant period to reflect changing needs ofstaff and to take advantage ofunidentified training opportunities. Thefollowing are the components of the firstdraft of the plan: annual statewideconference, case studies, workshops,resource library, curricula and trainingmaterials, and liaison with the stateinteragency council.

One feature of the training plan thatdeserves special recognition is thatcompetencies and a certification processfor infant mental health specialists havebeen developed. Meanwhile, staff of thefour demonstration projects who do nothave mental health degreel orcertification can become "QualifiedMental Health Professionals" (in NorthCarolina Medicaid parlance) by increasingtheir skills through group review of casestudies aad through clinical supervision oftheir work with children and families bya mental health professional. Once staffbecome thus "privileged" to provideclinical services, their work with eligiblechildren and families can he reimbursedby Medicaid. This arrangement providesservice programs with a financial as wellas a programmatic incentive to offerintegrated, sequenced in-service training.

Nursing Child Assessment SatelliteTraining. Training in awareness of infantmental health issues and in the skillsinvolved in strengthening fragile infant-parent relationships has been provided toNorth Carolina's HPIP personnel andother health professionals throughadaptation of the Nursing Child

Assessment Satellite Training (NCAST)originally developed at the University ofWashington, Seattle. The North CarolinaNCAST Project is sponsored by theDivision of Health Services and ofMH/MR/SAS within the Department ofHuman Resources, and by the School ofNursing Continuing Education Programand the Center for Development andLearning at the University of NorthCarolina at Chapel Hill.

Since the NCAST Project began inNorth Carolina in 1983, individuals in avariety of agencies around the state havebeen trained in NCAST's methods ofdetecting parent and infant interactionalproblems and using assessmentinformation to improve interventionplanning. NCAST includes scales forassessing infant sleep patterns, behaviors,interactions with caregivers, as well asthe caregiving environment. The NorthCarolina NCAST faculty have developeda videotape and other materials todemonstrate the application of NCAET tointervention with high-risk andhandicapped children and their families.

Professional organizations in NorthCarolina also play a role in expandingmental health awareness and skills ofpractitioners working with infants,toddlers and families. The publicationsand conferences of the North CarolinaPerinatal Association and the NorthCarolina Association for Infants andFamilies (an affiliate of the InternationalAssociation for Infant Mental Health) arevaluable resources for the professionalcommunity.

SERVICE DELIVERY SYSTEM:STRENGTHS AND CHALLENGES

Strengths:

Existing ICC (Interagency Co-ordinating Council) and legis-lative/gubernatorial support.

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Designated, active and cooperativeagencies for the implementationof P.L. 99-457.

Designated target population.

An evolving framework for inter-agency collaboration in place atalmost all system levels.

A ten-year mental health plan inwhich the infant, toddler andpreschool populations areprioritized for funding andidentified to receive servicedelivery.

An existing and very experiencedstatewide Early InterventionNetwork (20+ years).

Cross-disciplinary EarlyIntervention Teams.

An established and supportedstatewide training plan for earlyintervention staff.

An innovative and receptivesystem that is open to modeldesign and later replication.

A strong evaluation and researchcomponent which is an integralpart of the system.

An existing database of earlyintervention services, populations,and personnel for comparativecollaboration.

Both sections of MR/MH gatheredunder the umbrella of DHR in thissystem.

Autonomy of forty-one individualarea MH/MR/SAS programs.

Cross-section (MR/MH) and cross-disciplinary supervision establishedfor cross-categorical service earlyintervention staff.

A mandate for DHR which supportsand encourages intra-agencycollaboration.

Challenges:

A wide representation of verydiverse disciplines and philosophies,which creates a challenge inproviding unified services tocommunities and in maintainingcommunication lines among alllevels and disciplines of thesystem.

Limiting the impact that theDivision of MH/MR/SAS can haveon program development/changedue to local program autonomy,although autonomy is alsoconsidered a strength.

Lack of match between servicesand geographic populations/needs.

Wide variation of servicesavailableWide variation of geographicpopulations:- extreme rural- middle urban

Competition among age groups formental !,lealth funds.

Insufficient money to provideservices for increasing numbers ofeligible children identified throughimproved referral and diagnosismechanisms.

Establishing continuation andsupport funds for serving thispopulation (although Medicaidwaivers do exist).

Insufficient capacity at state levelto train/consult with earlyintervention programs other thanthe four model sites, although sitereplication plans are underway.

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NEXT STEPS

As its agency administrators pointout, North Carolina's new definitions ofP.L. 99-457 eligibility, with their non-categorical perspective and awareness ofmental health issues, are applicablestatewide. New state resources toimplement infant and toddler mentalhealth services are, however, currentlyavailable only at the four CASSPdemonstration project sites. Theimmediate challenge for the state is to:

1. Realize fully -- through staffdevelopment and continuedpractice in interagencycollaboration -- the potential ofthis model to identify, assess, andintervene appropriately withemotionally troubled infants,toddlers, and their families.Competencies and a certificationprocess for infant specialists havebeen developed. A specific goalis to review them in light of theneeds of the atypicaldevelopment population.

2. Develop new patterns ofinteragency collaboration on theneeds of atypically developingchildren, particularly with socialservice and assessment agencies.

3. Communicate what is learnedfrom the four demonstrationprojects to other PACT sites andto other state and privateagencies serving this population.

4. Investigate additional models ofservice delivery beyond thecurrent home-based system --consultation to child careproviders and to other communityagencies is one possibility.


North Carolina planners andadministrators offer two guidingprinciples to states eager to improvetheir mental health services to veryyoung children and their families.

First, involve all potential actorsfrom the start. Key referral sources(such as health, day care, and socialservice agencies), as well as likelyproviders of direct services should beincluded in brainstorming and planning.Representatives of dif ferent levels withinlarge service delivery systems should beinvolved; they may not be accustomed toworking together. Those who will becollecting data and evaluating a systemcan also be extremely helpful as needsare assessed and services designed. Theinclusion of many perspectives is likelyto yield new, useful ways of framingissues and developing strategies.

Scicond, establish formal mechanismsand allocate funding for public educationand staff training. The development ofmental health skills among program staffinvolves both preparation of curriculumand materials and clinical teachingthrough supervision and group review ofcases. Equally important are publiceducation about emotional developmentin the early years of life and specifictraining approaches for parents ofatypically developing children.

The following are other more specificrecommendations stemming from NorthCarolina's experience over the last fewyears:

Build on an existing servicesystem. This allowed NorthCarolina to capitalize on a trained,experienced staff of specialeducators with wide localcommunity acceptance. Witli the

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funding provided by P.L. 99-457,home-based services were madeavailable in all one hundredcounties in the state.

Develop funding mechanisms.Limited resources forced NorthCarolina to start small. It fundedfour demonstration sites in eachof the mental health regions tobegin to provide services throughthe PACT programs to theatypical 0-2 population. Therewas enough money to fund onlyfour positions, one in each of foursites, with joint federalP.L. 99-457 and state child mentalhealth monies. It was the task ofthese four sites to convert whatwas formerly a home-based,parent-focused, cognitive trainingprogram to one that had thecapacity to meet the mentalhealth needs of the traditionalMR/DD population as well as thenewly designed high-risk andatypical populations.

Other funding strategies that arevery important include:

Seeking new funding throughMedicaid and other third partyreimbursement. Casemanagement is an approvedreimbursement option in NorthCarolina. Broader Medicaidplans have been submittedwhich would cover servicesincluded in early interventionfor all categories of eligibility.Plans to expand EPSDT funclinginclude: adding psychologicalscreening to existing protocol;informing screeningprofessionals of diagnostic andtreatment options; and havingmental health professionalsparticipate.

Providing training to PACTstaff so that their services canbe reimbursable through

Medicaid. In North Carolina, aclinical privileging systempermits individual staff whoprovide clinical services tobecome what Is called a "GroupMental Health Program"(GMHP). Through a carefullydesigned supervision system,MR/DD PACT staff will becomeMedicaid reimbursable asGMHPs.

Seeking new funds throughlegislative increases to existingentities. North Carolina has aten-year child mental healthplan, ratified by the legislature,as the framework for increases.One of the priority popularnnsfor service development ischildren of birth through fiveyears of age.Seeking new grant funds.Recently, two crisis nurseryprograms were funded whichwere housed within thedemonstration sites. These arevoluntary, parent-requestedservices with multiple sites infamily day care homes andregular day care centers. Theywill be tied into the provision ofhome-based services later onwhen needed.

Develop a theoretical frameworkfor services. North Carolina haslargely relied on the structural/developmental frameworkarticulated by Stanley Greenspan.This has, as its basis, the premisethat development proceeds in amulti-linear fashion and thatdevelopmental delays in one areainfluence other developmentsystems.

Staff has been asked to considersix stages of development in thefirst four years of life, to evaluatethe capability of the child'smvironment to support stage-

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specific development, and topropose intervention, primarilyparent-focused, to facilitatespecific developmental tasks.

Develop a training plan to ensurethat all agencies involved inproviding care know how torecognize an atypical child frombirth through age two. Thetraining plan has been responsiveto needs articulated by staff ofthe four demonstration projects.It is insufficient, on a local level,to confine information aboutinfant emotional development andearly identification to one agency.People in this field are keenlyaware of the facilitative effect ofmulti-agency, multi-professional,joint publicprivate training. Aneffort is being made to share thisknowledge with other providersincluding private and public healthservices, social services, privatemental health providers, andeducation agencies.

Expand inter- and intra-agencycoordination. One of the mostbeneficial aspects of providingmental health services throughP.L. 99-457 has been the intra-agency coordination it hasstimu' -med. The single-systemapproi ;n to providing mentalhealth and other services topreschoolers provides challengesfor serving other populations, suchas the dually diagnosed.

At the state level, P.L. 99-457 hasforced agency staff to examinethe points at which their policiesinterfere with service delivery andcost-effective treatment. Jointfunding requests are in themaking.

RESOURCES AVAILABLETO OTHER STATES

Existing and available to others:

Early Childhood InterventionOrientation ManualEarly Childhood InterventionMainstreaming ManualEligibility Criteria (definitions)infant Specialists Credentialingand ProceduresFamily Support NetworkInformationICC-IAC AgreementP.L. 99-457 Governor's Report (AllOur Children)Case Management Agreement

Soon to be available:

Assessment Battery--After Year 2(on a limited basis)Parent Materials--After Year 2 (ona limited basis)IFSP ManualAssessment/Eligibility ManualCase Management ManualStaff Development CurriculumModel Site Visitation--AfterYear 3

Contact Person:

Susan E. RobinsonCASSP Director

North Carolina Departmentof Human Resources

Division of Mental Health,Mental Retardation and Substance Abuse

325 North Salisbury StreetRaleigh, North Carolina 27611

(919) 733-0598

OHIO

byJan Martner and Gary Delago

Site Visit Team: Roxane Kaufmann, Director of Special Projects, GeorgetownUniversity Child Development Center, Washington, D.C.; Jan Martner, M.S.W.,Project Coordinator, Georgetown University Child Development Center,Washington, D.C.

Contributors From Ohio: Patrick Kanary, Chief, Bureau of Children's Services,Ohio Department of Mental Health, Columbus, Ohio, is owed thanks for hissupport of Ohio's participation in this study. Susan Ignelzi, former CASSPDirector, Ohio Department of Mental Health, Bureau of Children's Services,Columbus, Ohio, planned and coordinated the site visits and graciouslytransported team members during their visit. Susan lent her energy andenthusiasm to us when we needed it. Her vast skills in the area of childpsychology and her clear vision of infant and toddler mental health needsprovided us with many useful insights. Her contributions also included readingand editing the many drafts of the Ohio profile, always providing additionalclarity. Cindy Hirschfeld, Administrator, Early Intervention Unit, Division ofMaternal and Child Health, Ohio Department of Health, Columbus, Ohio. In herrole as Part H Coordinator, Cindy provided in-depth, clear explanations of Ohio'sstructure of interagency coordination and offered important insights intolegislative initiatives. Along with Susan, Cindy generously spent many hours inthe revision process.

Others who contributed to the Ohio visit included: Laurie Albright, ProgramCoordinator/School Psychologist, and the staff of the Positive EducationProgram, Early Intervention Center-East, Lyndhurst, Ohio; Nan Borkowski,Assistant Superintendent/Principal and Director of the Early InterventionProject, and Penny Monroe, Infant Stimulation Instructor, as well as other staffof Beacon School, Athens, Ohio; Dee Dee Dransfield, Early ChildhoodCoordinator, and Mary Ann Fink, Early Childhood Service Coordinator, CHEERS,Southeast Ohio Special Education Regional Resources Center (SERRC), Athens,Ohio; Lois Jarvi, Developmental Disabilities Director, Tri-County Mental Healthand Counseling Services, Athens, Ohio; Paul Lilly, Coordinator of Children'sServices, Four County Mental Health Board, Defiance, Ohio; Members of theEarly Intervention Councils; Ricco Pal lotto, Executive Director, PositiveEducation Program (PEP), Cleveland, Ohio; Kathy Peppe, Assistant Chief,Division of Maternal and Child Health, Ohio Department of Health, Columbus,Ohio; and David Shearer, Project Director, Ohio Curriculum Project, Columbus,Ohio.

The state of Ohio, the largest of thethree states in the study, is characterizedby a large population, geographic andcultural diversity, and a complex servicedelivery system. In contrast to sr ne

other states, Ohio's service deliverysystem is very strongly county-based.The Ohio Department of Mental Health(ODMH), for exami.:e, provides leadershipand incentives to expand community-

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OM

based services, and is represented onstate and local planning groups to helpassure that the mental health needs ofinfants, toddlers, and families are met.However, ultimately, administrative andservice delivery responsibility for mentalhealth services in all 88 counties in Ohiorests with 53 Community Mental HealthBoards.

Ohio has chosen to build on existingservice systems rather than develop aseparate system for infant mental health.Interagency collaboration andcoordination has been the vehicle forimproving services for infants andtoddlers. The description that followsillustrates how the entire system benefitswhen state and local agencies, andfamilies of children who are in need ofservices and supports, work together toplan, implement, and evaluate services.Several successful collaborative effortshave been established in Ohio, somerelated to the passage of P.L. 99-457 andsome as a direct result of state andfederal initiatives in mental health.


In 1982, the Child DevelopmentCommittee of the Ohio DevelopmentalDisabilities Planning Council establishedan Early Intervention Task Force toexamine the status of early interventionin the state and to recommend change.The task force had representatives fromthe four existing systems mentionedabove, and ODMH, local agencies servingthe birth-to-three population, parents,advocates, pediatricians, and universitypersonnel.

Ohio's Philosophy Statement forEarly Intervention originated with theEarly Intervention Task Force in 1982. It

was later adopted by the OhioInteragency Early Intervention Council,which was appointed by the Governor inresponse to P.L. 99-457. A key sectionreads:

Early child development is bestenhanced by integrated programswhich offer long-term contactbetween normally developingyoung children and young childrenwith or at risk for developingdelays. Since no one agency orindividual can provide all servicesand support necessary to meetthe needs of familh 3 and childrenwho can benefit from early inter-vention, a collaborative inter-agency approach is essential.

Ohio's early intervention system hasa primarily interagency focus and isbased upon the following principles:

The right to optimum develop-ment -- Every child has a right tocare that facilitates his/her devel-opment.

The rights of families Thefamily is usually the mostconstant factor in the child's lifeand, as such, is the primaryintervenor for the child.

The right to a facilitativeenvironment -- Every child has theright to a nurturing environmentin which to use and elaborate allof his/her capacities.

According to the Ohio earlyintervention philosophy, eleven essentialcomponents form the framework forcollaborative early intervention services.These are as follows: philosophy, ChildFind, interdisciplinary assessment anddiagnosis, Follow-Along, family support,consumer involvement, comprehensiveservices, program evaluation, individualfamily service plan, service coordination,

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and a comprehensive system of persoaneldevelopment. In all of these components,services should be based upon currentlyaccepted standards of best practice andmust be carried out by qualified staff.

The resulting service model withthese eleven essential components wasdefined for use in Ohio on a voluntarybasis to be implemented by localcollaborative groups throughout the state.These eleven components later becamethe basis of the Ohio Curriculum.

Networking Projects

Also in 1982, Ohio participated in afederal outreach project on InteragencyCollaboration in Early InterventionServices headed by Phyllis Magrab ofGeorgetown University. Three countiespiloted the rridject, participated in thetraining, and then developed networkingprojects on their own.

Franklin County developed a centralpoint of intake and referral for earlychildhood programs aal gained thecooperation of thirty-two agencies toaccomplish the task. Today this projectincludes all child mental health agenciesin the county. Hamilton Countycoordinated funding resources acrossagencies.

Athens County coordinated tencounties in southeastern Ohio(Appalachian Region) to develop acooperative system of case coordinationfor children birth to six. This system wascalled the Community Health and EarlyEducation Resources Service (CHEERS).All major case-finding agencies andservice providers in each county wererepresented in CHEERS. Their activitiesincluded a needs assessment on eachfamily, provision of public awareness andparent advocacy materials, Child Findactivities, a central point of intake andreferral, and a computerized tracking

system. The process of CHEERS beganwhen a referral was presented at amonthly meeting. Members developed anaction plan based on the Service Model.A case manager, frequently from amental health agency, was identifiedfrom the membership to work with thefamily. The family was presented withall the service options available and wasasked to choose those that best met itsneeds. In addition to case management,mental health se rvices included diagnosis,family therapy, and family support.CHEERS has continued in operation and isdiscussed further in "Mental HealthServices Post-P.L. 99-457."

Child and Adolescent ServiceSystem Program (CASSP)

In 1984, the Ohio Department ofMental Health received a five-yearCASSP grant to augment state and localclusters of child-serving agencies; tocoordinate interagency services; and topromote blended funding for multi-need,seriously emotionally disturbed childrenand adolescents requiring long-termintervention by multiple human serviceagencies. Other goals were to improvethe capacity of the mental health systemfor children and adolescents, toencourage the involvement of families inthe delivery of these services, and tomake them culturally appropriate for thefamily. As a result of the CASSP grant,local clusters, involving representativesof the major child-serving agencies,attempted to meet the needs of theseyouth in their communities; the statebecame involved only if needed serviceswere not available or could not beprovided by local agencies.

The Ohio Interdepartmental StateCluster for Services to Youth includesrepresentatives from the Departments ofMental Retardation and Developmental

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Disabilities (MR/DD), Youth Services,Health, Human Services, Education,Mental Health, and later theRehabilitation Service; Commission. Atthe state level there is a liaison from theState Cluster for Services to Youth tothe Interagency Coordinating Council forEarly Int.ci vention. There may be twoplanning groups at the local level: one,the cluster overseeing planning servicesfor multi-need youth from birth toeighteen years of age; the other, an earlyintervention planning group developingstrategies for systems change specific tothe birth-to-three population. TheCommunity Mental Health Boards haverepresentation on each group. Inpractice, the two planning groups oftenhave overlapping functions and themembership may, in fact, be comprisedof the same people.

The CASSP initiative has allowedODMH to increase the number of staffwithin the Bureau of Children's Services.These staff members have co-sponsoredconferences on mental health services foryoung children and their families, andhave worked with the fifty-threeCommunity Mental Health Boards,encouraging them to develop new servicesfor infants, toddlers and their families incooperation with other agencies.

Special Projects of Regional andNational Significance (SPRANS)

Project Zero to Three. Additionally,Ohio was one of fifteen states invited toparticipate in Project Zero to Three,sponsored by the National Center forClinical Infant Programs. The purposewas to inform participating states of theexisting early intervention services andto develop a technical assistance/self-help system to facilitate the developmentof their programs.

The "Essential Components" ServiceModel. In 1985, the Departments ofHealth and MR/DD received a U.S.

Department of Health and HumanServices SPRANS (Special Projects ofRegional and National Significance) grant.This provided an opportunity to pilot theService Model in Richland and AthensCounties, using the interagencycollaborative approach. The projectproposed to: develop a locallyadministered interagency program forcomprehensive early identification andintervention services; improve the ChildFind efforts for children from birth toage three in need of early interventionservices; provide a comprehensive arrayof services; coordinate services acrossagencies; maximize benefits of earlyintervention through an extensive parentinvolvement component; assure continuityof care through Follow-Along; developtransition services as the child matures;and develop training materials to assistin replicating the project throughout thestate.

A few accomplishments of thisinteragency SPRANS grant were:

A network of mental health,medical, educational, and socialservice providers specially trainedto identify children birth to threefor early intervention services;

A centralized/standardized intakeand referral system whicheliminated duplication of servicesacross agencies;

Funding and services of a socialworker provided by the CountyBoard of Mental Health to conductspecial classes for parents ofchildren enrolled in the earlyintervention program.

An additional benefit was the OhioCurriculum, developed by consultantsfunded through the SPRANS grant. Thegoal of the Ohio Curriculum was toimprove early intervention servicedelivery by developing a cooperative

network of professionals (including mentalhealth service providers) and consumerstrained in the Service Model and itsimplementation through interagencycollaboration. The Service Model wasbased on the previousl7 mentioned elevenessential components. The curriculumproject is now funded by the OhioDevelopmental Disabilities Council tooffer training in all eighty-eight counties.Nearly all of these counties have receivedtraining or technical assistance.

State Incentive Grant Projects

Three incentive grant projectsfollowed the SPRANS grant. One,sponsored by the Ohio DevelopmentalDisabilities Planning Council (ODDPC),made grants available to a variety of leadagencies at the county level, many ofthem Mental Health Boards, to developlocal collaborative Early InterventionPlanning Groups. More than thirty-fivewere funded. The first of two incentivegrants by the Ohio Department ofEducation was for grants to counties thatelected to develop InteragencyCollaborative Groups for local earlyintervention service planning. The secondprogram provided grants to each of thesixteen Special Education RegionalResource Centers (SERRC) to add anearly childhood "contact" person to assistfamilies in receiving necessary servicesand making appropriate linkages with thecommunity. The roles and function ofthis person vary from one SFRRC toanother.

Also during this time, the OhioDevelopmental Disabilities PlanningCouncil funded two projects. One wasthe development of a videotape by agroup including mental healthprofessionals to be shown to new mothersstill in the hospital. The videotapeemphasiz Id normal physical and

emotional growth and developmentalmilestones, then described what to do ifa problem was suspected. The videotape,entitled An tiij_cg_21e,g___)rvntion, iscurrently in use in approximately 120hospitals in Ohio.

The second project was a parenteducation and support curriculum,entitled Family First, written by the OhioAssociation of Retarded Citizens. Theproject is a parent-to-parent programoffering information and support. It helpsparents, especially of young children,become more effective representatives oftheir children. It brings parents togetherto share support, encouragement anddreams. Family First works a bitdifferently in every community because itis parent-owned and operated. Acompanion curriculum for professionalswas developed to improve sensitivitytoward the concerns of parents.

Ohio's acceptance of federalopportunities prior to P.L. 99-457demonstrated a commitment to creatingthe necessary structure which wouldprovide services to children andadolescents. This structure allowedservices to be delivered to children frombirth to age three in a comprehensive,coordinated, interagency fashion. The1982-1983 federal outreach projects,USDHHS and NIMH grants assisted Ohioin developing and disseminating theService Model. Networking projectswithin and between counties producedcase coordination (CHEERS), a systemuniting a central point of intake,multidisciplinary evaluation, Child Find,and IFSP, which could be replicatedstatewide. The Service Model, pilotedthrough the SPRANS grant using the OhioCurriculum, made comprehensive trainingin the early intervention componentsavailable to all counties. This trainingof a network of professionals andconsumers helped improve the delivery ofmental health services. The CASSP grant

provided for a full spectrum of state andlocal cluster mental health servicesthrough child-serving agencies. Thiscomprehensive structure served as a solidfoundation on which mental healthcomponents specified in P.L. 99-457 couldbe built.

Since the passage of P.L. 99-457, theDepartment of Mental Health made thedecision not to create another localservice agency to further confusefamilies trying to access earlyintervention services, but to developservices in collaboration with the existingservice providers. Currently, there arefour existing systems providing servicesto infants and toddlers: the health,education, mental retardation anddevelopmental disabilities, and childwelfare systems. The philosophy of theDepartment of Mental Health is that thedepartment needs to develop and deliverearly intervention services within theseexisting systems. Mental health servicesavailable for this population prior toP.L. 99-457 included diagnosis andassessment, family therapy/family supportactivities, and case management. Allnew mental health programs beingdeveloped for young children and theirfamilies in Ohio must demonstrate acollaborative effort reflecting thisphilosophy.

MENTAL HEALTH SERVICESPOSr-P.L. 99-457

To implement Part H of P.L. 99-457,Governor Richard F. Celeste, byExecutive Order, appointed a fifteen-member Ohio Interagency EarlyIntervention Council with the OhioDepartment of Health as lead agency.The former Early latervention Task Forceestablished in 1982 was absorbed by the

new council. Former task forcemembers, including ODMH personnel,were invited to participate oncommittees focusing on legislationstandards, target population, servicecoordination, the Individualized FamilyService Plan (IFSP), transition services,and Child Find.

These are active committees, manyof which have mental healthrepresentation, and they continue to workout the numerous and ever-changingdetails within each of these major areas.


Ohio's definition of "developmentallydelayed" was drafted by the OhioInteragency Early Intervention Council.The Target Population Committeeconsidered several different approachesto defining developmental delay. To helpinfants, toddlers and their familiesreceive needed services, the committeewanted a definition which wasinclusionary and non-labeling. The broaddefinition adopted by the EarlyIntervention Council reflected thisphilosophy and the intent of P.L. 99-457.

The council approved the followingdefinition to be used to determineeligibility for early intervention services:

The child has not reached de-velopmental milestones expectedfor his/her chronological age, asmeasured by qualified profes-sionals using appropriate diag-nostic instruments and/or pro-cedures, in one or more of thefollowing developmental domains:cognitive, physical, language andspeech, psychosocial, self-helpskills. (Ohio Interagency EarlyIntervention Council,March 8, 1988)

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"At-Risk Children." Ohio's definitionof "at-risk" clearly demonstrates thedesire to include a broad range ofvariables that may impact on children andtheir families. "At-risk" is described as:

. . a situation or combinationof factors/conditions whichmake the child more likely fora disability, a secondary dis-ability or delay in development.No single factor necessarilyleads to a developmental delay/disability in the child, but thepresence of a factor means thatit is important for those pro-fessionals and parents involvedto consider the benefits of earlyintervention services for thefamily and child. When morethan one factor is present, thereis a multiplicative effect, caus-ing that child and family to beat significantly greater risk fordevelopmental delay/disabilitythan would be the case withonly one factor. (Ohio Inter-agency Early InterventionCouncil, November 10, 1987)

Risk factors have been organizedaccording to three categories:

Established Risk: High likelihoodof early, aberrant developmentrelated to diagnosedgenetic/medical disorders.

Biological Risk: History rfprenatal, perinatal or neonatal andearly development eventssuggestive of biological insult(s) tothe developing nervous systemwhich may lead to delayeddevelopment.

Environmental Risk: Limitingearly environmental experienceswhich may lead to delayeddevelopment. Some specificparental factors are: parentalsubstance abuse; parental

psychiatri:: disorder; inability toprovide basic parenting functionsdue to impairments inpsychological or interpersonalfunctioning.

Further, within the three categories,the assessment process takes intoaccount the point in time when the riskfactor may have been first apparent: theprenatal period, birth to hospitaldischarge, or infancy through age two.

It is assumed that anyone (health,social service, education, and mentalhealth agency personnel, privateproviders, and consumers) involved withthe child and family could use the riskinformation to identify those in need ofearly intervention services; to locateappropriate services; and to refer thechild/family to them. It is important tonote that mental health personnel arespecifically mentioned as users of thisidentification system. The CommunityMental Health Boards work with theircontract agencies, encouraging them tomake referrals of at-risk children.


According to Ohio's Service Model, alocal collaborative early interventionsystem for infants and toddlers wouldinclude:

A single interagency planninggroup addressing issues andstrategies for improving thedelivery of early interventionservices. This group wouldinteract with other planninggroups and would include parentsand advocates. The resultingsystem would be flexible andunique to the needs andexperiences of each community.A variety of home-based andcenter-based services would be

43

available in integrated settings(i.e., in settings where childrenwithout developmental delays ordisabilities would ordinarily befound).

A coordinated system ofinformation, intake and referralso that families and serviceproviders would be able tocontact a single, central point forassist r.nce. A family servicedatabase would be available forresource and financialinformation.

A coordinated mechanism forevaluation (to determineeligibility for early interventionand related services). A qualifiedearly intervention public healthnurse would be available to makehome visits and do Child Findactivities, including initialevaluation.

A system for service coordination(case management). A qualifiedearly intervention servicecoordinator would be available atthe central contact point toprovide interim Follow-Along andassistance for families inaccessing services until the infantand family were enrolled in aprogram.

CHEERS collaborative groups,described in the section "NetworkingProjects," are based on the idealessential components. A family residingin the region of a well functioningCHEERS would be able LA) contact theCHEERS coordinator -- a neutral point --and activate the available providers andsupport systems. The systems would beresponsive and flexible.

The implications for mental healthin this model are great. At the time ofreferral to local collaborative groups,many of the mental health needs of

families are typically being met byprivate providers such as physicians,psychologists, and social workers. Thepublic sector is making an effort to bringthese private providers into the system,especially to get them to notify thecentral point of intake (CHEERS) of afamily in need and to briefly describethose needs. CHEERS would thencoordinate all services with directionfrom the family. Mechanisms forpromoting private providers' awareness ofthe purpose and scope of CHEERS includeprofessional newsletters, communitymeetings, membership in CHEERS anddirect mailing.

Comrrehensive Child FindSystem

In Ohio, Child Find has been definedas a "coordinated, ongoing mechanism toidentify children and families who canbenefit from early intervention services."Mental health service providers play animportant role in the case-findingcomponent of Child Find, as well as inthe evaluation and assessment portions ofthis process. At this time, theCommunity Mental Health Boards arebecoming more involved in communityscreening efforts and are providingtraining for staff so that they canappropriately refer children and familiesto early intervention services. Mentalhealth professionals also may needadditional training in the evaluation andassessment of infants and young children.

The Ohio Department of Health andthe Ohio Department of MR/DD arecollaborating on the development,implementation and evaluation of alinked, computerized referral andtracking system for children birth-to-sixyears of age who are developmentallydisabled or at risk for developmentaldelays. The MATCH II project has

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developed a computer linkage betweenthe existing, statewide client informationsystem of the Ohio Department ofMR/DD and the client information filesof the Child and Family Health Services(CFHS) programs throughout the state.The confidentiality of client records ismaintained in accordance with the OhioPrivacy Act. The merged databasebetween th,.. two programs has resulted inimproved Find, case management,Follow-Aiung and program evaluation.

The Ohio Department of MentalHealth is a member nf the MATCH IIAdvisory Committee. ODMH sharesconcern for linking data between agenciesat the state level to allow for morecoordinated services to populations aidedby multiple agencies. The departmentuses Match II to identify the number ofat-risk children which helps in planningfor new service development.

Many things need to be accomplishedprior to the full implementation of thiscomprehensive information managementsystem. It is expected to be fullyoperative within the next five to tenyears.

IFSP and Case Management Services

In response to families' objections tothe term "case management," Ohio usesthe term "service coordination" todescribe the process of assisting familiesand children throughout all phases ofearly intervention services. This processinvolves coordination among multipleservice providers, including mental healthproviders; maximizes the use of existingresources; and is tailored to meet theunique circumstances of each individualchild and family. Individuals who arefunctioning as service coordinators areresponsible for providing service linkages,coordination of services, advocacy, andmonitoring of services within theIndividualized Family Service Plan.

Personnel Development andStandards for Training

Narsing Child Assessment SatelliteTraining (NCAST), described in NorthCarolina, is currently used throughoutOhio. NCAST has a strong social/emotional health focus and has been usedwith registered nurses working in the areaof maternal-child health, social workers,child abuse team members, mental healthprofessionals, day care personnel,pediatricians, and early childhoodeducators. Ohio current!), has fourteencertified NCAST trainers, who havetrained more than 500 professionals in thelast five years. The majority of thosehave been trained with Part H funds sincethe passage of P.L. 99-457.

The Ohio Curriculum, as discussedpreviously, continues to be an ongoingeffort to improve early interventionservice delivery.

Two additional statewide trainingprograms are receiving Part H funds.One, entitled Building Family Strengths,is to prepare parents (and professionals)to develop IFSPs. The other project is toprovide training, again to pareats andprofessionals together, in the area ofservice coordination. Both of theseprograms place a strong emphasis on thesocial and emotional well-being ofchildren and their families.

Office of Education and Training,ODMH, is giving support to the Universityof Akron Faculty for Early CLildhoodEducation to develop an interdisciplinarycertification for individuals working inintensive home-based service programs.Social workers, psychologists, nurses, andeducators have participated in thistraining, which reflects Ohio's philosophyof interagency collaboration. Individualsreceiving interdisciplinary trainingthrough this project are working inprograms for young children and theirfamilies throughout the state.

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SERVICE DELIVERY SYSTEM:STRENGTHS AND CHALLENGES

Strengths:

Focus of the service deliverysystem is on improvinginteragency collaboration andcoordination.

Local level planning is supportedat the state level through themandated "Interagency Cluster forMulti-Needs Youth" and throughvoluntary interagency earlyintervention planning groups.

Local-level planning is promotedthrough the availability oftraining, technical assistance, andgrants from several state agenciesincluding the Ohio Departments ofMental Health (CASSP Program),Human Services (InteragencyCluster for Multi-Needs Youth),and Health (P.L. 99-457, Part H,Early Intervention Program).

Mental health services areincluded as part of thecomprehensive service deliverysystem in proposed earlyintervention legislation.

Challenges:

The uneven amount of fundingacross counties due to heavyreliance on local levies.

Shortages of properly trainedpersonnel.

Competing priorities within theDepartment of Mental Health toserve multiple populations(including the chronically mentallyill, children and adolescents whoare severely emotionally

disturbed, and at-risk youngchildren).

Lack of awareness of indicators ofearly mental health disturbance onthe part of professionals,paraprofessionals, and parents.

Since the early 1980s and the passageof P.L. 99-457, Ohio has sharpened itsfocus so that the capability forcoordinating services, including mentalhealth services, for young children andtheir families became available in everycounty. This sharpened focus was due to:1) initiatives and state level support;2) enhanced financial support; 3) mentalhealth representation on ninety-onepercent of the Local InteragencyCollaborative groups; and 4) increasingwillingness of agencies to look at theissues and engage in comprehensiveplanning at the local level throughCASSP Clusters and local collaborativegroups.

The substantial activity focused onearly intervention, both before and afterthe passage of P.L. 99-457, reflectsOhio's commitment to interagencycoordination and collaboration, and to thedevelopment of new mental healthservices within existing agencies servingchildren from birth to age three.However, of the Departments of Health,MR/DD, and Mental Health, theDepartment of Mental Health has thelowest funding for this age group.Funding is available for families, but isnot based on the child's age.

The Community Mental HealthBoards are funded with state, federal andlocal levy money. Because the levy isbased on property taxes, the resources ofmental health boards vary greatly. Thisinequity creates differing levels ofavailable services; lack of acomprehensive system of services is mostevident in rural areas of Ohio.

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NEXT STEPS

Key informants of this studyindicated that the next steps for Ohioappear to be:

1. A legislative mandate forcoordinating early interventionservices and the development ofadministrative rules. Specifically,the Ohio Department of Health,as Part H lead agency, requiresstatutes and rules assuring dueprocess/procedural safeguards.This is one of the important,required components in Part H ofP.L. 99-457. The Department ofMental Health is suppoi tinglegislation being submitted by thislead agency.

2. Personnel development andstandards of training. Continuingeducation of human serviceprofessionals working in earlyintervention programs is necessaryto further develop theirsensitivities to the overall -eedsof the birth-to-three populationand their families. Training is apriority in order to assure thatprofessionals have the skills tomeet certification criteria alreadyestablished by the Department ofEducation and the Department ofMR/TX .

As the need for certified staffcontinues to increase, support forNCAST training will be continued.

The training on the OhioCurriculum will be ongoing. Thedevelopment of cooperativenetworks through continued stafftraining on the Ohio Curriculumwill further develop and refinecoordinated service delivery.

3. Increased parent participation inlocal collaborative. groups. It isthe position of the state of Ohiothat both providers and consumers

can learn to collaborate for thebenefit of children and thatfamilies will be included inplanning, advising, and advocacyroles in even greater numbers.


Many of the individuals interviewedin Ohio offered suggestions to otherstates.

"Blow away the stigma" aboutwhat mental health is in relationto very young children and educateprofessionals, including those inmental health fields, as well as thegeneral public, especially parentsof young children.

Involve the right people andagencies in the process anddiscussions from the beginning.Even if there are no mental healthservices currently available to thispopulation, the local mental healthagency needs to be a part of theplanning group(s).

Seek knowledgeable persons atstate and local levels who knowthe "intent" of P.L. 99-457.

Find individuals at state and locallevels who have excellent skills ingroup process and committeework.

Find out what services andresources are in and whatthe existing gaps are in an idealcontinuum of care.

Find out what the role of mentalhealth currently is in the availableservices.

Ask providers and parents, "If youcould add to your system, whatwould you add in order of

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priority?" Don't presume aknowledge of what infants,toddlers and their parents need.

Ask the question of all providers,"How might you provide servicesnon-categorically?" This requiresan excellent job of coordinatingand there may be a need fortechnical assistance with acollaborative process.

Approach the needs of thispopulation holistically. Avoidbeing department-, discipline-, orfacility-focused.

RESOURCES AVAILABLETO OTHER STATES

An Ounce of Prevention: EarlyIntervention and Your BabyVideotape, approximately 22minutes in length; color. Coversgeneral child development issuesfrom birth to age four years andgive clear instructions to parentson what to do q they have aconcern about their child'sdevelopment. Accompanyingbrochure lists developmentalmilestones and expected ageranges.

Linking Mental Health (MH) andMental Retardation/ Develop-mental Disability (MR/DD)Systems -- This project reportdescribes how one project, fundedthrough P.L. 99-457, Part H,successfully created a linkbetween local MH and MR/DDservice systems in a rural countyin Ohio.

Positive Education Program(PEP) -- This report provides anoverview of a collaborativeprogram between a CommunityMental Health Board in a large,

urban area, and the County Boardof Education serving families andchildren, birth through age six,who exhibit a wide variety ofmental health needs.

r in th m. . enti 1Components of a ComprehensiveEarlv Intervention System --Videotape, approximately 28minutes in length; color.Describes collaboration andpartnership between pubt:c andprivate agencies and parents ofyoung children to develop acomprehensive service system.Accompanying trainer's guide andparticipant's guide.

The Ohio Curriculum--EssentialComponents of a ComprehensiveModel _Collaborative EarlyIntervention Svstem -- Thistraining resource contains adescription of each of the essentialcomponents of a comprehensiveearly intervention system.

A Guide to Action Plaming -- Thisworkbook includes sampleagreements, forms, evaluationtools, and planning formats forlocal interagency groups.

Contact Persons:

Cindy HirschfeldPart H Coordinator

Administrator, Early Intervention UnitOhio Department of Mental Health131 North High Street - Suite 411,

Columbus, Ohio 43215(614) 644-8389

Patrick KanaryChief, Bureau of Children's ServicesOhio Department of Mental Health

30 E. Broad Street - llth FloorColumbus, Ohio 43215

(614) 466-1984

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SUMMARY OF STATE PROFILES

As the teams interviewed informantsin Maine, North Carolina and Ohio, theyfound that the pre-existing dynamicsamong state, county and local entitiesprofoundly influenced the mental healthservices in all three states. Invariably,issues related to mental health servicesfor infants, toddlers, and their familieshad roots in the individual state's history.Modifications to their mental healthservices after the passage of P.L. 99-457reflected the requirements imposed bythe law: the designation of a leadagency, the establishment of aninteragency coordinating council, thedevelopment of a definition for"developmentally delayed," and the designand implementation of statewide servicesto the birth-to-three population.Furthermore, modifications arose fromthe ingenuity of policy makers, dedicatedprofessionals and concerned consumers inaddressing the constraints imposed bylimited resources.

MAINE

Maine has an extensive tradition ofinteragency collaboration as a mechanismfor coping with limited fiscal resources;limited professional resources; and a vs,..),rural, widely dispersed population. As aresult, Maine has a strong, state-drivensystem of service delivery for youngchildren. Service initiatives originate atthe state level and are carried out by thestate-supported, local service provisionsites known as Preschool CoordinationSites. Therefore, there is structuralconsistency of mission, goals, interventionmodels, and strategies across the state.

This statewide consistency helps familiesin their attempt to negotiate the servicedelivery system and assists serviceproviders in their efforts to link familiesand available services. While this doesnot mean that all services are availablein all parts of the state, it does meanthat the structure is consistentthroughout the state and that there existsa single point of contact and planning forall families. More importF.ntly, a mentalhealth perspective is integrated into theavailable services.

Maine has placed great emphasis onidentifying children in need of servicethrough its network of public healthnurses and its home-visiting system forall newborns. The development oftraining curricula including both printmaterials and videotapes has helped toincrease the awareness and skill level ofall professionals and paraprofessionalswho might be able to identify and referinfants and families in need of mentalhealth services.

NORTH CAROLINA

North Carolina has a long history ofusing federal and state resources todevelop innovative programs for youngchildren and their families. P.L. 99-457has been the occasion for various statedepartments to go further in the processof collaborative planning.

One of the major features of NorthCarolina's response to P.L. 99-457 hasbeen a definition of "high-risk children"which includes the concept of atypicaldevelopment. This concept refers tochildren from birth to sixty months of

49r°,

age who demonstrate significantlyatypical behavioral, socioemotional,motor, or sensory development andincludes detailed assessment criteria.While the definition applies statewide,North Carolina will actually be assessingthe importance of adopting such aninclusive definition in its fourdemonstration sites which have receivedadditional funding for PACT coordinators.While North Carolina is similar to Mainein the rural nature of much of the state,it does differ rather significantly inavailable resources, particularly trainedprofessional and support personnel, aswell as in the existence of a number ofoutstanding university-based hospitals andhealth care centers providing ongoingtertiary and follow-up care. NorthCarolina has also moved quickly todevelop standards for certification forearly intervention workers with specifiedstate training requirements.

OHIO

Ohio's system of local control ofhuman services is of long standing. Thestate has also chosen to build onCHEERS, a pre-existing system foridentification, evaluation, and referral, asa mechanism for service coordination foryoung children and their families. Ohio'ssystem differs from those of NorthCarolina and Maine as its effectiveness isdependent, to a high degree, upon thesupport of local county commissioners. In

addition, both Maine and North Carolinahad legislation providing for mentalhealth services to young children beforethe passage of P.L. 99-457. However,Ohio has had a strong, recent history ofinteragency collaboration to serve multi-problem children. Ohio was able to buildon this cooperative, multidisciplinaryapproach (originating in the state andlocal cluster system) by extending theconcept to early intervention andspecifically to the birth-to-threepopulation. One of the majorcontributions of Ohio is the developmentof its model of placing earlyintervention/mental health providers inother appropriate agencies (such asmental retardation/developmentaldisability agencies, day care centers) sothat mental health services quicklybecome integrated into the overallservice delivery plan. In other parts ofthe country this concept is sometimesreferred to as "outplacing" and has beenfound to be most effective in promotingintegration and reducing barriers toservice.

Once the patterns of these threestates have been reviewed carefuliy, itbecomes possible for other states todetermine which of these patterns, orblend of patterns, would assist them inbuilding a responsive service deliverysystem. A system can then be tailored toa state's needs and its pre-existingstructure, one which is rooted in its ownhistory.

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LEARNING FROM EXPERIENCE: A THREE-STATE PERSPECTIVE

Participants in this study fromMaine, North Carolina and Ohio haveoffered guidance to other states workingto meet the challenging mental healthneeds of infants, toddlers, and theirfamilies. Many of the recommendationsare common to all three states.

First -- Involve as many individualsand agencies with a stake in the mentalhealth of infants, toddlers, and theirfamilies as possible from the beginning.Regardless of its present or past role inservice provision to very young children,mental health must be a part of theplanning process for service delivery tovery young children and their families. Ifa state department of mental health isunable to identify a representative withinfant mental health expertise, considerincluding a provider with this specialty onthe Interagency Coordinating Council orits committees.

Second -- Accept the possibility thatrepresentatives from state and localagencies, private practitioners, andconsumers may not be accustomed toworking together in a collaborativemanner. Collaboration requires that agreat deal of effort be made to maintainas much consistency of membership oncommittees and planning groups aspossible. Troia and a common vision arecritical elements of successful planningefforts. There may be a need forprofessional technical assistance in thearea of grimp process and maintenance ofeffort.

Third -- Begin with pilot sites forinnovative ideas. This strategy allows fora process of evaluation and modificationwhich will facilitate a higher overallsuccess rate. All three states studiedhave experience with pilot projects thathave, building on their success on a smallscale, evolved into statewide structures,policies, programs, and have often led tothe enactment of supportive legislationand fiscal resources.

Fourth -- From the very beginningwork closely with the Department ofEducation, the designated lead agencyunder P.L. 99-457 for the preschool (agethree through five) population, to plan forappropriate transitions when childrenreach age three. In the three statesstudied, the Department of Education wasnot selected as the lead agency for theirinfant and toddler programs. All thesestates expressed serious concerns overtransition issues as these children reachage three and emphasized the need tobegin planning now for coordination ofservices.

In considering the experiences andrecommendations offered here, readersneed to remember that most states havebeen unable to keep up with an increasingdemand for mental health services amongall age groups in the population. Theprovision of mental health services toinfants, toddlers and their families hastypically been ranked low in priority bystate health and human services agencies.However, the emotional vulnerability ofdrug-exposed infants, of medically fragileor technologically dependent children, andof children subject to a variety ofenvironmental risks is commandingincreased attention among policymakers.

States -- including those in thisstudy -- are just beginning to explore thepossibilities offered by P.L. 99-457 toprovide mental health preventive,assessment, and treatment services tovery young children and their families aspart of comprehensive, integrated,statewide systems of care. It is hopedthat this three-state study will allowplanners to benefit from the experienceof others as they work to incorporate amental health perspective into the goalsetting, planning, and implementizionprocesses in their own states.

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59

APPENDIX A

MENTAL HEALTH SERVICES FOR INFANTS,TODDLERS, AND THEIR FAMILIES:

A Three-State Perspective

SURVEY INSTRUMENT

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SURVEY INSTRUMENT

The survey instrument utilized in this study is included here to provide guidance forother states in their own assessment process. The instrument was designed for the use ofthe site team members during their key informant interviews. Informants were not askedthe questions directly from the survey tool, rather team members utilized it to ensurethey had asked all the pertinent questions and to organize the responses.

Data collected from each of the team members was collai ed, analyzed andsubsequently massaged into the form of the three state profiles in the text. The profileswere reviewed for accuracy several times in the writing and analysis phases of the studyby the contact person (see the end of each profile) and other key informants in eachstate.

STATE BACKGROUND INFORMATION

STATE: AGENCY:CONTACT PERSON: PHONE: ( )

Please assemble original documents and/or copies of theitems listed below. It would be very helpful if you could writebrief summary statements for each indicating specifics thatrelate to the delivery of mental health services to infants andtoddlers and their families.

Please check off information you have been able to provide.Check:

1. Description of state:

Geographic characteristicsDemographics:- population of state- minority populations- population breakdown by ageEconomic baseUrban - Rural

2. Legislation relative to the provision of mentalhealth services to infants, toddlers, and theirfamilies.

3. State Plans:

Copies of state plans that include mental healthservices. For example: State Education Plan, StateDepartment of Social Service Plan, and State Planfor 99-457.

4. List of state agencies that provide mental healthservices to children from birth through age threeand their families.

5. State resources that provide training in the areaof infant mental health. For example:

UniversitiesOutreach demonstration grantsResearch and training institutesPrivate practitioners who train studentsAgencies that have a student intern componentEtc.

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Check:

STATE BACKGROUND INFORMATION (Cont.)

6. Funding options available in the state/local arer 3used to provide mental health services to infants,toddlers, and their families.

Medicaid, i.e. waivers, case management, Early andPeriodic Screening, Diagnosis and Treatment (EPSDT)Third party insuranceSliding scale optionsFederal money (which programs)State agency moneyLocal fundingFee for servicesPhilanthropic organizations that focus on mentalhealth issues and/or business involvementOther

7. What interagency working/coordinating groupsexist on the state level related to birth throughage two mental health service delivery?

What groups/agencies are represented on each?What is the structure of each?What is the role of each in the service deliveryprocess?How do the groups interrelate?

8. Other:

Any additional information and/or documents youfeel would be relevant to this study?

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STATE QUESTIONNAIRE


1. What are you working towards in the provision of specificmental health services for children birth through age two ona statewide basis?

What services are included in the continuum?What services de you currently have in pine? How are theyaccessed?What is prohibiting you from implementing the remaining services?What local communities in your state do you find are providing afull range of services? What accounts for the difference betweencommunities?Given that your state is moving in a specific direction, do you havea proposed ideal continuum of services?

2. What systems do you have in place to facilitate theprovision of mental health services to children birth throughage two and their families?

What is your Child Find approach?How do you identify needs of child and family?What is the IFSP process?How do you assure care/case management?How do you pay for services? What services are included for eachpayment source?How do you evaluate service quality?Is there a statewide data collection system?How do you convey this system/process to local communities?

- training?- technical assistance?

Is there a method for monitoring the implementation of the statesystem at the local level?

3. Since the passage of P.L. 99-4579 what process has the statedeveloped to help it move towards providing and integratingmental health services into programs that already supportdisabled infants, toddlers, and their families?

Are there any changes since P.L. 99-457? If yes, what are they?What factors have facilitated this process?What barriers have there been in this process?

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STATE QUESTIONNAIRE (Cont.)

4. Do you participate in any working/coordinating groups on thestate level related to birth through age two mental healthservice delivery?

What is your role?What is the focus of the group in the area of infant mental health?

5. How are children with mental health needs being treated thesame/differently as children with other special needswithin the scope of P.L. 99-457 and the service deliverysystem?

Is mental health an equal partner in the ICC?What role is mental health playing -- is it equal or auxiliary?How are other systems supporting what mental health is doing?

6. How are families involved in mental health service deliveryfor infants and toddlers?

How are families involved in determining the IFSP goals andobjectives?How are families involved with the selection of servicesthey/their children receive?How are families involved in the assessment and diagnosticprocesses?How are families involved in the evaluation of the seNices theyreceive?

7. What specific advocacy services are available to childrenand their families?

What agencies/organizations/individuals provide these services?What role does your agency/group play in providing supportservices to families?What specific legislation/policy/mandates exist that includeadvocacy?

STATE QUESTIONNAIRE (Cont.)

8. What are the next steps that the state is planning?

9. If you were going to offer three (3) recommendations toanother state setting up mental health services for infantsand toddlers and their families, what would they be?

10. In Summary:

What is your impression of how your state arrived at its currentlevel of operation in the area of infant and toddler mental health?

How do you see infant mental health fitting into other existingstate systems?

What systems/structures exist in your state that can be buildingblocks for the further development of infant mental healthservices?

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LOCAL QUESTIONNAIRE

CITY/STATE: AGENCY:CONTACT PERSON: PHONE: ( )

1. Is the system established by the state providing you thenecessary structure to implement mental health services tochildren?

2. How is the state communicating its plans and scope ofsupport to you?

3. What kind of support do you receive from the state?

Training?Technical assistance?Accessibility to state officials?Financial support?

4. How effective is this support?

5. What interagency working/coordinating groups exist on thelocal level for infants and toddlers and their families?

What is your role?What groups'agencies are represented on each?What is the structure of each?What is the role of each in the service delivery process?

6. How are children with mental health needs being treated thesame/differently as children with other special needs?

Is mental health an equal partner in the local service deliverynetwork?What role is mental health playing -- is it equal or auxiliary?How are other systems supporting what mental health is doing?

7. How are families involved in mental health service deliveryto infants and toddlers?

How are families involved in determining the IFSP goals andobjectives?How are families involved with the selection of servicesthey/their children receive?

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LOCAL QUESTIONNAIRE (Cont.)

How are families involved ir the assessment and diagnosticprocesses?How are families involved in the evaluation of the services theyreceive?

8. What specific advocacy services are available to childrenand their families?

What agencies/organizations/individuals provide these services?What role does your agency/croup play in providing advocacyservices to families?What specific legislation/policy/mandates exist that includeadvocacy?

9. How is your community moving toward an ideal continuum ofcare?

What is the ideal?What elements are in place?What barriers exist that prevent the completion of the ideal?

10. What mental health services for children birth through agetwo and their families currently exist in your community?

What specific services are available?What local agencies provide mental health services to children?What critical elements make these services effective?

11. What are the next steps being planned in your community inthe provision of mental health services to children birththrough age two and their families?

12. What three recommendations would you suggest to otherstates establishing mental health services for infants andtoddlers and their families?

INIrliDUAL PROGRAM QUESTIONNAIRE


BACKGROUND INFORMATION

1. Description of community:

Geographic characteristicsDemographics:- population of state- minority populations- population breakdown by ageEconomic baseUrban - Rural

2. Description of the organization in the community of themental health service system for infants and toddlers andtheir familios.

Roles of: health agencies (public health, hospitals, andphysicians); mental health agencies; child welfare/social serviceagencies; private/not-for-profit agencies; private practitioners.Community-wide mechanisms for interagency collaboration.

3. Which of the following describes your agency?

PublicPrivate not-tor-profitPrivate for-profitOther

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INDIVIDUAL PROGRAM QUESTIONNAIRE (Cont.)

PROGRAM PROFILE

I. Client population:

Target populationTypes of clients served (socio-economic status, race, sex, age,nature of diagnosis)Needs assessment dataReferral sourcesCriteria for acceptance

2. Descriptions of specific programs/services provided:

CapacityDescription of clients servedTreatment philosophyServices providedDuration/intensity of treatmentFunding

3. Description of intra- and interagency mechanisms forcoordination:

Systems-level:- key structures/mechanisms used- purpose of each- effectiveness- problem areas- strengths- gaps

Client-level:- key stuctures/mechanisms used- purpose of each- effectiveness

problem areas- strengths- gaps

4. Case examples.

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INDIVIDUAL PROGRAM QUESTIONNAIRE (Cont.)5. Case management:

How is it provided?Which agencies are involved?Who is responsible?What does the role of case manager encompass?Training and background of case managers.Fund;crg for case management.

6. Family involvement:

How are families involved in determining the IFSP goals andobjectives?How are families involved with the selection of servicesthey/their children receive?How are families involved in the assessment and diagnosticprocesses?How are families involved in the evaluation of the services theyreceive?

7. Evaluation:

Effectiveness of linkages/services.Outcomes (expected and achieved).Problem areas (barriera to effective linkages).Agencies not participating.What works, and why?Recommendations for designing/implementing a working system.What system of accountability exists?How is it monitored?

8. Advocacy:

What specific services does your agency provide tofamilies/children in the area of advocacy?What involvement does your agency have in local advocacyefforts, i.e., legislation, policy making, public awareness?

9. What are the critical elements, as you see them, inproviding mental health services to infants and toddlersand their families?

10. Summary comments.

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APPENDIX B

CASE VIGNETTES:MAINE, NORTH CAROLINA AND OHIO

CASE VIGNETTES

The following vignettes illustrate the experiences of three families with young cHldrenwho are in need of supportive mental health services. They provide examples of thediversity of service models available and the necessity for collaboration between agencies.They clearly indicate how effective mental health early Intervention services can be inameliorating complex family problems.

These vignettes are based upon real experiences shared by the states participating inthis study.

CASE WGNETTE:MAINE

The following is an anecdotalsummary of a case presented to aCommunity Health Nurse working in apediatric office; the nurse interviews andcounsels parents before they see thedoctor. All names have been changed tomaintain confidentiality.

Presenting Problem. During BabyMary's six-week check-up, Mother Patsy,age eighteen, was hovering over Mary tothe point that Patsy could not have anyeye contact with me. Patsy's affect wasflat and hostile, and her main complaintwas that Mary was "too fat." Visually,Mary was not a "fat" baby. In fact,Doctor. Gardner had already made areferral to Home Health Services afterMary's two-week check-up, requesting anursing visit because she was not gainingweight.

When I asked Patsy about herstatement that the baby was "too fat,"bhe replied that she (Patsy) had gainedover 110 pounds during her pregnancy andthat she didn't want her baby to be likeher. She also told me that she kept Maryin bed with her at night because the babyliked to be up at night. Later Patsy toldme that the nights were long and lonelyfor her, especially since Mary's fatherhad deserted her during pregnancy.

When Dr. Gardner came in, Patsybecame much more hostile and curt,telling him that she had refused to havethe Home Health Nurse visit. She haddecided not to feed the baby as much asthe doctor wanted, since Mary was toofat. She also stated that too manypeople were bothering her; that she wastired of all the interfering. Sometimesshe felt like "ending it all." (Althoughshe denied suicidal ideation on directquestioning, this was a concern of ours;because she was projecting her distortedbody image onto Mary, we were worriedabout the possibility of Patsy hurting her

baby if her own emotional stateworsened.)

Patsy become more and more guardedas the appointment ended, and left theoffice threatening not to return.

Interagency Coordination. Afterconsultation with Dr. Gardner, I made areferral to the intake worker at the ChildProtective Services, Department ofHuman Services. I also contacted thestaff at the residential facility wherePatsy has been living since Mary's birthto outline concerns about Patsy. Thestaff and the Community Health Nursehad noted Patsy's distancing andwithdrawing behaviors. Patsy tended toisolate herself and her baby from boththe staff and the other residents. Toaddress all of these concerns, I suggesteda network meeting since a discussion ofthe problems at a systems level seemedan appropriate direct intervention. Allthe service providers and Patsy were ableto meet the next day.

Intervention. We met at the facilityand outlined our concerns to Patsy, whoattended clutching her baby -- she wasworried that the baby would be removedfrom her care after the meeting. Wediscussed our goal of meeting her needsin ways that would be more helpful forboth herself and Mary. We were veryclear that we wanted to help her be agood parent, yet we also needed to behonest about our concerns for Mary'ssafety, especially her nutrition. Patsyagree0. to work with all of us. Shesubsequently scheduled and keptappointments with a psychiatrist to assessand monitor her depression. Shecontinued to meet wizh the CommunityHealth Nurse who reported that Patsywas able to make and maintain eyecontact with her during the biweeklyvisits. The facility's staff reported that,shortly after the network meeting, Patsybegan to interact more frequently withthe other residents. She also participatedmore actively in the facility's group

activities. Mary maintained a healthyweight gain; Patsy did not threaten tostop feeding her again.

I stayed in phone contact with Patsyfor several weeks. During theseconversations, Patsy told me more abouther own history which included parentalabandonment, long-term foster care, andrecovery from chemical dependency. Shealso talked with the facility staff abouther longing to find Mary's father, perhapsa projection of her unresolved issues withher own parents. Although night-timecontinued to be difficult for her, Patsywas able to let Mary sleep alone in hercrib.

During Mary's routine well-babycheck-ups, Patsy interacted much moreeffectively with the doctor and myself,usually coming prepared with a list ofquestions. She had very few acute-carevisits, which, in my opinion, was anindication that Patsy was meeting herown needs and no longer needed herdaughter to be the "ticket of admission"into the health care system. Mary wasachieving age-appropriate landmarks.

After Patsy moved from the facilitywhen Mary was about six months old, shecontinued to have the Community HealthNurse visit weekly for ongoing supportand information. When Patsy moved to acommunity about 100 miles away, sherequested a referral to the communityhealth nursing service in that area. Thismove occurred when Mary was just undera year old.

CASE VIGNETM:NORTH CAROLINA

This vignette illustrates theintegration of a mental healthperspective into North Carolina's trackingsystem, referral processes, interventionapproaches, and case managemprocedures with very young children andtheir families. This is an actual case.The names have been changed to maintainconfidentiality.

History. Peter was the first-bornchild of parents who had been known tothe Department of Social Services fromchildhood. Both parents had been raisedin physically abusive families with ahistory of alcoholism and had physical,cognitive, and emotional disabilities.Peter's father was an alcoholic andphysically abusive to his mother; hismother suffered from a degenerativedisease and was mildly limited in herphysical functioning.

Peter was the result of a plannedconception and normal pregnancy,according to hie mother. He was bornwith a cleft lip arl palate and had a fiftypercent chance of developing his mother'sdegenerative disease.

In early infancy, Peter's developmentwas followed by several clinics at thehospital where he was born. The LocalHome Health Agency and a registerednurse from the Health Departmentprovided in-home nursing support. Thefamily was enrolled in the WIC programand received AFDC and SSI benefits.

At three months of age, the HighPriority Infant Clinic found Peterdeveloping well, as measured by theBayley Scales of Infant Development, andobserved that the baby initiatedinteractions and responded to bothmother and father. His cues were clear,and his mother stated that she could tellwhat F. wanted by his cries and facialexpres, dns.

At twelve months of age, Peterreceived a comprehensive evaluation atthe hospital clinic as part of its HighPriority Infant Protocol. AlthoughPeter's test scores were within normallimits, examiners did not see thespontaneity expected from toddlers hisage. The examiners and others involvedin ongoing contact with the family wereconcerned by an observed lack ofaffectionate responsiveness in Peter'smother; Peter's diminishing persistence ininteractions with people; a lack ofappropriate caution or distress inresponse to pain; and fl possible tendencytoward self-injurious behavior.

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Presenting Problem. When Peter wasfourteen months old, his parents'caseworker from the Department ofSocial Services (DSS) and a registerednurse from the High Priority InfantProgram at the county health departmentreferred the family to the PACT programbecause of high-risk factors fordevelopmental de!ay and atypicaldevelopment.

Intervention and InteragencyCoordination. The PACT therapist withDSS and Health Department staff madereferral and screening visits. The familywillingly participated in the screening,which included administration of theDenver Developmental Screening Test,the HOME instrument, and NCASTmeasures. After the family reviewedworrisome findings iir language andpersonal/social development with thecaseworker and the nurse, theyconsidered the services available throughPACT, and decided to request them.

After further assessments, alsoreviewed by the family, an IndividualFamily Service Plan (IFSP) was developedwith the family and in those individualsworking with the family. In the PACTsystem, the IFSP is a working documentthat is reviewed at least quarterly,amended as needed/requested by thefamily, and updated annually.

PACT, the Health Department, DSS,Vocational Re.habilitation, theDepartment of Mental Health/SubstanceAbuse Services, and a sheltered workshopwere all involved in working with Peterand his family. Interagency casemanagement meetings were held monthlyto facilitate and coordinate services.

Because both parents worked and thepaternal grandmother and aunt who hadbeen caring for Peter had histories ofneglect and abuse, family day careseemed to the interagency team anoptimal way to provide the specialnurturing environment Peter needed.However, Peter's family perceived daycare in a family setting as a potentialprecursor to involuntary foster

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placement. They were more comfortablewith the idea of center-based child care;after visiting and asking questions ofstaff at a mainstreamed child carecenter, they agreed to Peter'senrollment.

The rAcr therapist visits Peter's daycare cent .?i or biweekly to reviewIFSP goaln and activities with his teacher.Home visits are set to meet the family'sschedule. They include Peter, hisparents, and the extended family andmake use of books, toys and othermaterials.

To facilitate a smooth transition toother programs as Peter's needs change,consultation and support will be dferedto the family as well as service providersby the PACT team. In addition, thePACT therapist will contact the family atleast twice during the first year after thedate of discharge.

CASE VIGNME:OHIO

This vignette illustrates the positiveimpact on a family of early interventionservices with an integrated mental healthperspective. The referring source of thisfamily to an early intervention programwas a physician, a direct reflection ofOhio's efforts to bring private providersinto their referral, public awareness andcase management systems. This is anactual case, the names have been changedto maintain confidentiality.

Pr ssenting Problem. David is thenewly adopted two-year-old son ofMr. and Mrs. Thomas. The Thomases alsohave a six-year-old, natural borndaughter, Jessie. Mrs. Thomas wasreferred to the program by herpediatrician because they were bothconcerned about the difficulties she wasexperiencing in developing a positiveparent-child relationship with her son.

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David's presenting problems included:severe temper tantrums, screaming, shortattention span and high activity level.Mrs. Thomas expressed serious concernsabout continuing the adoption processbecause of David's out-of-controlbehavior.

David was assessed by the multi-disciplinary team that included a speechand language pathologist, psychologist,pediatrician and motor specialist. Davidwas diagnosed as having expressive andreceptive language delays as well asdeficits in adaptive and social skillfunctioning. The array of services thatcould be offered Mr. and Mrs. Thomasand David were described as behaviormanagement, modeling a interventiontechniques, parent support groups, parent-training seminars, home visits,observatior and mediation of parent-childinteractions, and speech and languagetherapy.

Intervention. Mrs. Thomas,occasionally accompanied by her husband,was involved in the program for sixmonths. While Mr. Thomas was notextensively involved with the program, hewas interested and supportive. Heattended initial meetings and multi-disciplinary assessments and alwaysfollowed through when asked to as,-Jst invarious intervention strategies.

Mrs. Thomas cane to the centerthree mornings per week for three hours.On each occasion, one hour was spent ina therapeutic setting with David, apsychologist, and the parent of anotherchild in the program. The purpose ofthese sessions was to help Mrs. Thomasrespond to David in a more thoughtfuland structured way within a variety offamily and social situations. The sesslom.-.were also designed to blend with David'sintervention plan helping him to improvehis language and social skills.

Mrs. Thomas spent the remaining twohours helping program staff work withother children at the center. This timeprovided her with an opportunity toobserve others' interaction with children

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and a chance to practice the skills thatshe was learning in the private sessionswith David. In addition, she couldparticipate in a one-hour parentingseminar which allowed for discussion ofconcerns among parents. Seminar topicsincluded stress management, positivereinforcement, self-esteem developmentin children, and developmentallyappropriate play activities.

After a short time in the program,Mrs. Thomas indicated that she was alsoexperiencing similar problems with hersix-year-old daughter. At her request,the multidisciplinary team observed Mrs.Thomas and Jessie together. In addition,Jessie was evaluated in physical, motor,social and emotional, and languagedevelopment areas. Jessie was found tobe within the normal range in alldomains. The observations of Jessie andMrs. Thomas led the examiners to offerMrs. Thomas assistance in her parentingapproach to Jessie, which she readilyaccepted. Many of these approacheswere similar to those that she waspracticing with David and other childrenin the program.

Over the span of her six-monthinvolvement in the program, Mrs. Thomasappeared to be gain in self- assurance asshe developed various positive mci.hi4s ofinteracting with David and Jessie. A. :thebegan to read their cues more accuratelyand gain a clearer understanding of eachof their personalities and temperaments,she grew more confident in her skills asa parent. Her relationship with eachchild gradually improved. The supportthat she received from other parents inthe program helped her to feel she had anetwork to sustain her if and when sheneeded it.

David is currently being integratedinto a regular preschool program. TheEarly Intervention Center providesregular consultation to the preschoolprogram and consultation is available toMrs. Thomas upon request. David is nowusing sentences of three or four wordsand, most importantly, is a contributingmember of his family. Mrs. Thomas hashappily completed the adoption process.

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