A seminal publication in 2000 From Neurons to Neighborhoods, The Science of Early Childhood Development has established the importance of early childhood experiences on lifelong well-being (JP Shonkoff & DA Phillips, Eds., 2000). Ongoing research continues to demonstrate that the early years in life are a critical period for physical and emotional development and health. Young children’s cognitive, language, motor, and social-emotional development are greatly shaped by environmental influences as well as their relationships with parents and caregivers. Infants and toddlers learn to express and manage emotions, explore the environment, and gain knowledge by having close and secure attachments with parents and caregivers (Zero to Three, 2012). Growing evidence shows that negative early experiences impact brain development and can lead to biological adaptations with lasting ill effects. These disruptions to development, if not met with nurturing adult support can persist into adolescence and adulthood, and research shows, can cause both physical and mental health impairments later in life. Therefore, promoting positive early childhood mental health and psychological well-being creates a foundation to support children to be successful in school, social relationships, and as adults in work, family life, and society.
Early experiences impact the developing brain and the stress response and immune system (SB Johnson, et al., 2013). Young children exposed to challenging circumstances such as poverty, domestic violence or abuse are likely to have an activated biological stress response system. Research indicates that if this stress is not matched by buffered protection with support from invested adults, then the child’s stress-response system is not restored to baseline, and this can lead to disruption to the brain architecture, which adversely affects other organs, and contributes to an increased risk for persistence of problems into adulthood (JP Shonkoff, 2010). This prolonged stress resulting from intense adversities has been called toxic stress.
Further, there is extensive evidence from research on adults and over time, that childhood adversities and trauma are linked to adult disease and illness. The Adverse Childhood Experiences (ACE) study has found associations between childhood trauma such as abuse, neglect or family dysfunction and later health and well-being including risky behaviors, depression, suicide attempts, illicit drug use, alcoholism, and health conditions such as lung, liver and heart disease throughout the lifespan (ACE Study, CDC, www.cdc.gov/ace/index.htm). The more types of adversity and individual experiences in childhood, the greater the likelihood that he/she will develop one of these conditions in adulthood.
Making early investments in children’s well-being has long-term health, mental health and social benefits for individuals, communities and society. Cost-benefit studies show that there are positive returns on high quality early childhood programs for at risk children. The Center on the Developing Child at Harvard University reports that “Three of the most rigorous long-term studies found a range of returns between $4 and $9 for every dollar invested in early learning programs for low-income children. Program participants followed into adulthood benefited from increased earnings while the public saw returns in the form of reduced special education, welfare, and crime costs, and increased tax revenues from program participants later in life” (Five Numbers to Remember About Early Childhood Development, 2007). Ensuring children have positive experiences before they reach school is likely to lead to better outcomes in adolescence and adulthood, generating a worthwhile return on investment.
The NYC Department of Health and Mental Hygiene (DOHMH), has the opportunity to focus on early childhood mental health through NYC Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health), a five-year project funded by the Substance Abuse and Mental Health Services Administration. NYC Project LAUNCH promotes social and emotional development and provides services in two high-need neighborhoods, East Harlem in Manhattan and Hunts Point in the Bronx, for children from birth through eight years and their families.
Because the parent-child relationship is critical to child’s social and emotional development, NYC Project LAUNCH provides parenting classes that promotes attachment. Using the evidence-informed Circle of Security® Parenting Program, Family Advocates from Family Resource Centers provide an eight-week model focused on teaching parents with young children (ages 0-5 years of age) to recognize their own strengths and challenges around parenting and to improve their responsiveness to their children’s needs. Group sessions involve participants responding to videos of parent-child interactions and examples of healthy caregiving with reflective dialogue, story sharing, and interactive exercises.
It is also important to support providers and systems that serve children and families such as in primary care and early care and educations settings. Providing mental health services in primary care settings can increase early identification, access to services and normalize and de-stigmatize behavioral health care. Young children routinely go to their primary care provider for well-child visits, and social and emotional development (mental health) is an important domain to be integrated into this care. A recent report by the SAMHSA-HRSA Center for Integrated Health Solutions says, “Most children and youth with mental health conditions that result in functional problems are more likely to be seen in their primary care setting than in the specialty mental health system” (Integrating Behavioral Health and Primary Care for Children and Youth, 2013). Through NYC Project LAUNCH, we are providing mental health screening, consultation, evaluation, short term treatment, and referrals for young children within pediatric clinics at a municipal hospital and at a Federally Qualified Health Center by co-locating mental health clinicians in these settings. Social and emotional development screening is conducted by using standardized measures (Ages and Stages Questionnaire: Social-Emotional and Pediatric Symptom Checklist). When there is a positive screen or other concern, the mental health consultant provides consultation to staff and families, and when indicated makes referrals to resources that may include mental health, Early Intervention or the Committee on Preschool Special Education.
Mental health consultation in early care and education settings, such as preschools and childcare, is another approach that can offset challenges to social and emotional development and provide the education workforce and families with tools to promote psychological well-being in young children. NYC Project LAUNCH also provides mental health consultation in select childcare sites that offers overall consultation to school staff to improve classroom management, communication with families, and provide an educational environment that supports children’s social and emotional health. The mental health clinician also works with school staff when a child is exhibiting emotional or behavioral concerns by conducting screening with standardized tools, consulting to staff and families regarding specific concerns, and making referrals in collaboration with school staff to other services such as mental health or the Committee on Preschool Special Education. This model works by providing training and support to school staff so that over time they can become better informed about mental health and competent in providing quality childcare that address social and emotional development once the consultant leaves the school setting.
In addition, at childcare settings, NYC Project LAUNCH trains teachers by using an evidence-based curriculum, Incredible Years, to acquire skills that promote positive interactions among children, and develop a culture that promotes positive behaviors and builds self-esteem and confidence in children. “Research studies show positive outcomes related to [Early Childhood Mental Health Consultation] ECMHC services, including a decrease in parental and teacher stress and an increase in the competence among childcare and preschool staff to recognize and address challenging behavior, reduce young children’s expulsions and reduce children’s externalizing behaviors such as aggression” (Project LAUNCH Technical Assistance Series, Brief 1: Early Childhood Mental Health Consultation).
As part of the NYC Project LAUNCH program evaluation, we are tracking outcomes to assess the impact of these interventions and services. For example, we are measuring the impact of the mental health consultation and teacher training on students in the childcare settings by examining improvements in children’s behavior such as self-control, attention, and ability to form positive relationships. We are also measuring the impact of the parenting classes on parent participants’ parent-childhood relationship and parent stress. These results will help us identify strategies and interventions that produce improved outcomes and will benefit from ongoing support.
The sustainability of this initiative will be critical to the success of NYC Project LAUNCH. One strategy is leveraging existing resources to build capacity for mental health clinicians to treat young children in evidence-based treatment models. Additionally, New York State Medicaid Redesign presents an opportunity for us to advocate for policies in Medicaid managed care that will promote and reimburse collaborative care models that integrate mental health services into pediatric primary care settings. We are advocating for services such as mental health consultation, and evidence-based treatment for the youngest children. We are also working to continue our partnerships with colleagues who serve young children in other systems to improve services to these children and their families in a more coordinated way.
NYC DOHMH recognizes the importance of ensuring the youngest children with mental health needs are able to get their needs met as early as possible. As the body of science grows and there is increasing awareness of the mental health needs of young children and their families, we are continuously striving to meet the needs of the youngest New Yorkers and their families.