Columbia University Mailman School of Public Health

Arkansas

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Strategies

IECMH Consultation in Early Care and Education Programs and for Vulnerable Children

In 2004, the Arkansas Department of Human Services/Division of Child Care and Early Childhood Education (DHS/DCCECE) funded a series of pilot projects to facilitate collaboration between Community Mental Health Centers (CMHCs) and early childcare programs. Building on these early pilot programs, Arkansas’ IECMH consultation program for early care and education (ECE) programs, Project PLAY (Positive Learning for Arkansas’ Youngest), was launched in July 2011.

From 2011 to 2016 Project PLAY primarily provided IECMH consultation designed to build supports for social-emotional development in ECE programs and raise overall quality, with a priority focus on centers where foster children were naturally clustering. Beginning in 2016, Project PLAY was refocused to provide support to Arkansas’ new BehaviorHelp (BH) system, launched to address the problem of suspension and expulsion from ECE settings. BH is Arkansas’ single point of entry system for ECE teachers who need assistance to address children’s challenging behavior. The system was developed to support the state’s policy requiring prior approval by DHS/DCCECE for the expulsion of children from state-funded prekindergarten programs and early care and education providers who accept child care subsidies or vouchers.

Project PLAY services are now accessed through the BH system. Teachers, center directors, parents, child welfare caseworkers, and others can submit requests to BH with an on-line request form. State BH support specialists located within DHS/DCCECE review requests for assistance, conduct a phone interview with the person making the request, and determine the most appropriate type of assistance to provide to the teacher or other person contacting BH. Three types of assistance are offered, depending on the circumstances. Tier 1 services are for situations where the concerning behaviors are developmentally normal and teacher frustration is not high. In these cases, the state BH support specialist can share information and provide resources to the concerned adults involved in care of the child. Tier 2 services, provided when the concerning behaviors are more serious and/or teacher frustration is high, consist of technical assistance (TA) provided by Arkansas State University (A-State). This TA includes an initial observational visit, two to 10 additional classroom visits, and identification of additional professional development opportunities. A-State classroom visits focus on helping the teacher use effective strategies to improve the classroom environment, promote children’s social-emotional learning, and address challenging behavior. Tier 3 services are for situations in which concerning behaviors are extremely severe and/or there is a history of trauma or multisystem involvement, such as involvement in foster care. These more intensive IECMHC services are provided through Project PLAY IECMH consultants.

For these Tier 3 cases, Project PLAY offers child-focused consultation services once a week for three months. Services include observations of the child and classroom; child developmental and social-emotional screening; assisting teachers in developing a plan and implementing strategies to address challenging behaviors and strengthen social and emotional supports in the classroom; coordinating with special education or other professionals involved in the case; partnering with teachers and parents to support consistency between school and home; providing support for teacher wellness; and making referrals for the family to community resources and further assessment and treatment, as needed. Consultants may also provide training topics such as childhood trauma and managing disruptive behavior. Because of the volume of requests that meet Tier 3 criteria, Project PLAY staff are rarely deployed outside of the BH system.

The Project PLAY leadership team is housed at the University of Arkansas for Medical Sciences (UAMS). Consultation services are staffed primarily through contracts with Community Mental Health Centers around the state. The Project PLAY team includes 11 consultants who provide services throughout the state. Consultants are licensed (or licensed-eligible) mental health professionals who receive extensive additional training and support to achieve DHS/DCCECE certification as an Early Childhood Mental Health Consultant to Child Care. Preparation for this certification involves web-based training and required reading, completion of five days of in-person training provided by the Project PLAY leadership team, shadowing experienced consultants, working with an assigned mentor, and development of a portfolio of work. Ongoing support is provided through monthly group and individual reflective supervision as well as administrative supervision and case-specific support provided by the Project PLAY leadership team.

Project PLAY has a long-standing partnership with Arkansas’ child welfare system and continues to provide training and supports to encourage placement of children in foster care in high quality ECE settings and promote collaboration between ECE providers and child welfare staff for the benefit of children in foster care. Educational materials and a partnership toolkit developed to support this partnership are available online.

Financing

Funding for Project PLAY and other BH supports come primarily from the state’s CCDF quality improvement set-aside funds. Additional one-time funding for Project PLAY consultant trainings has come from a federal SAMHSA Project LAUNCH grant.

Monitoring and Evaluation

The BH system collects extensive data on providers who use BH, initial behavior concerns, steps the teacher has taken to address the problem, level of the teacher’s frustration as perceived by the BH support specialist, and circumstances of the child’s family that might be related to classroom behavior. This information is captured in the Request Form callers use to ask for assistance and in the Interview Form used by the BH support specialist to record information gathered during the interview conducted with the provider or teacher. Data are also collected on services provided and expulsion outcomes. Additional data about children’s symptoms of emotional and behavioral concerns are gathered from teachers receiving Project PLAY services.

The following are key findings reported in the BehaviorHelp 2018 Update:

  • Center directors made referrals for almost half the children; others who referred were teachers, parents, and mental health professionals.
  • On average, children were reported to demonstrate five challenging behaviors; the most frequently reported were “hurts others” and “trouble following routine.” Others include destroys property, frequent crying, hurts self, and does not interact with children or staff.
  • Sixty-eight percent of teachers were perceived to have high levels of frustration.
  • Almost half of children had experienced grief or another traumatic event, and many children were also reported to live in families with other adverse circumstances such as parent drug abuse or mental illness.
  • From July 2016 to 2018, BH served 644 children, with 66 percent receiving Tier 2 services, 31 percent receiving Tier 3 Project PLAY IECMHC services, and 3 percent receiving both. Of the 602 cases that were closed, only 17 children were expelled.
  • Teachers and providers expressed positive views of BH: for example, 90 percent reported that they received help soon after making a request and 86 percent said they would recommend BH to another teacher.
  • Both TA providers and Project PLAY consultants use the short-form of the TPOT (Teaching Pyramid Observation Tool) in preschool classroom observations. The results help them identify both strengths in the classroom and opportunities to strengthen classroom practices that support social-emotional growth and reduce challenging behavior.

Key additional findings from the Project PLAY annual evaluation update for 2018-2019, which is forthcoming and will be available here, include the following:

  • One-fifth of the children served by Project PLAY had a history of foster care.
  • Teachers were asked to complete two standardized measures of children’s emotions and behavior pre-and post-consultation: the Sutter-Eyberg Student Behavior Inventory (SESBI)—Revised and the Strengths and Difficulties Questionnaire (SDQ).
    • Average scores on the rating scales exceeded the clinical cut-off at the pre-assessment, indicating the behavior concerns were serious in nature.
    • The frequency of children’s disruptive behaviors significantly decreased (as measured by the SESBI) over the course of consultation.
    • Scores reflecting degree to which children’s disruptive behaviors were rated as problematic for the teacher also decreased significantly over the course of consultation (as measured by the SESBI).

Total SDQ scores also improved significantly over the course of consultation, with significant decreases specifically in scales related to conduct problems and hyperactivity and increases in the scale related to prosocial behavior.

Dyadic Treatment and Workforce Development

Arkansas has recently engaged in several efforts to increase the use of evidence-based treatment for children under the age of four in its publicly-funded mental health system. The state Department of Human Services/Division of Aging, Adult, & Behavioral Health Services convened an Infant and Early Childhood Mental Health Standards Workgroup to develop an approval process for clinicians providing services for children ages 0-47 months under Medicaid. To meet these standards, clinicians must complete training in the DC:0-5 (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood) and have completed (or be actively participating in) training for an approved evidence-based dyadic treatment model appropriate for children 0-47 months of age. The state maintains a list of approved models, which must meet standards set by the California Evidence-Based Clearing House (a rating of 1 or 2) or the National Registry of Evidence-Based Programs and Practices (a rating of “effective”). State mental health agency staff review the credentials and training of clinicians who work with young children, and approve those who meet the requirements. The approval process went into effect in 2018, and 190 providers have been approved to provide infant-early childhood mental health services under Medicaid.

In Arkansas, Medicaid-covered dyadic treatment for children 0-47 months is commonly provided through Parent-Child Interaction Therapy (PCIT) and Child-Parent Psychotherapy (CPP) (see research summary on dyadic treatment), though other treatments are allowed as well. PCIT is designed for use with young children with disruptive behaviors, including those with a history of trauma. CPP is designed to help young children and their caregivers heal after stressful experiences and strengthen the parent-child relationship.

A list of providers who can deliver CPP and PCIT and other trauma treatments is available on the website of Arkansas Building Effective Services for Trauma (ARBEST), a state-funded program at the University of Arkansas for Medical Sciences (UAMS). The ARBEST team has trained more than 10,000 medical professionals, school personnel, parents and other caregivers, child welfare professionals, and others, about trauma, its impact on children, effective treatments, and how to find providers using the roster. Outreach efforts occur through webinars and frequent presentations at conferences and other community events. Treatment providers conduct additional outreach in their own communities. For children in foster care, the UAMS Project for Adolescent and Child Evaluations provides the multidisciplinary Comprehensive Health Assessment (CHA) in outreach clinics to all children placed in foster care within 60 days of entering custody. This includes a behavioral/emotional assessment; the team providing the assessment makes recommendations for evidence-based trauma assessment and treatment, as indicated.

Workforce Development

Efforts to expand PCIT, CPP, and other trauma treatments in Arkansas has required a deliberate process. Given the size of the investment to train providers in PCIT and CPP, Arkansas has recruited participants in its training cohorts from underserved areas and has supported agencies to meet infrastructure requirements for providing CPP and PCIT. ARBEST has partnered with national experts to train cohorts of providers, while building the capacity of ARBEST faculty to achieve approved trainer status in order to enhance sustainability of the training efforts. For PCIT and CPP, training is now available in several parts of the state through UAMS/ARBEST local trainers. For PCIT, there is a small but growing group outside of UAMS able to provide training within their own clinics through a co-therapy model in which trainers work directly with trainees during live sessions.

Financing

Clinicians can receive PCIT, CPP, and training in other trauma treatments free of charge through ARBEST, which receives support through a state legislative appropriation. Additional financial support for training cohorts and infrastructure mini-grants to treatment providers has been made available through the Department of Human Services as part of various federal grant initiatives such as the System of Care initiative and Project Launch.

Medicaid covers dyadic treatment in Arkansas, but only approved providers (those meeting the Infant Mental Health Standards) can bill for it using codes reserved for these providers. Evidence-based dyadic treatment delivered by these providers is reimbursed at a 10 percent higher rate.

Monitoring and Evaluation

All clinicians approved to serve children 0-47 months must be trained in an evidence-based treatment or be actively in training (which allows them to obtain provisional approval) prior to providing services. The Department of Human services cannot provide information on the specific evidence-based treatment provided to each child, but all services provided must use one of the evidence-based treatments. This is monitored through DHS retrospective reviews of services provided to ensure compliance with Medicaid regulations.

Special thanks to Nikki Edge, Professor and Associate Director, Research and Evaluation Division, Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, and staff at the Arkansas Department of Human Services for providing information for and reviewing this profile.