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1 Report March 2006 BUILDING SYSTEM CAPACITY: IMPROVING INFANT AND EARLY CHILDHOOD MENTAL HEALTH IN PHILADELPHIA Across the United States, a growing number of states and communities are taking action to help ensure that children have the opportunity to build strong social and emotional skills such as confidence, curiosity, self-control, the capacity to communicate, and cooperativeness. The science of early childhood development emphasizes that supporting these skills fosters ready children who are equipped to succeed in school and lead productive lives. However, not all children acquire these critical skills. Some need additional services to help support their healthy social and emotional development. This report documents Philadelphia s efforts over the last two years to build a comprehensive, coordinated infant and early childhood mental health service system. To get started, Philadelphia first examined the following questions: How can we support the social and emotional development of young children birth to five? What kinds of services and supports already exist in Philadelphia? Are these services coordinated and comprehensive? What gaps exist in current service delivery systems? How can we equip the many early childhood professionals to support young children s mental health? How can we support families? In order to answer these questions, ZERO TO THREE: National Center for Infants, Toddlers, and Families (ZTT) worked with Philadelphia s Citizens for Children and Youth (PCCY) and the Delaware Valley Group of the Pennsylvania Chapter of the World Association for Infant Mental Health (DVG-WAIMH) to take on the following activities described in this report: 1. convene a community symposium on infant and early childhood mental health to address the infant mental health system in Philadelphia; 2. assist in the creation of a local World Association for Infant Mental Health (WAIMH) chapter to promote the education, research, and study of social, and emotional development during infancy; and 3. document the strategic planning process in order to provide other communities and states around the country with a perspective about how to build infant and early childhood mental health system capacity.

2 Strengthening Social and Emotional Health: the Building Blocks of a Comprehensive System No one system provides mental health services for young children. The existence of multiple programs and funding streams - such as Part C Early Intervention, child care, and pediatric health care - has made it difficult for Philadelphia s families to locate the appropriate services and supports to help their children. The term systems building refers to weaving infant and early childhood mental health services into existing early childhood serving systems. Young children can acquire optimal social and emotional skills when early childhood services and supports are multidisciplinary, flexible, and coordinated. However, creating a comprehensive system is a multi-faceted task. In strategizing about how to build such a system, Philadelphia examined the following building blocks: Professional Development - a skilled and trained workforce of early childhood and mental health professionals; Service Delivery/Practice - the various early childhood systems that offer mental health services: promotion of mental wellness, prevention of potential problems in children growing up in risky environments, and treatment of children that are actually exhibiting mental health problems; Policy - the laws, regulations, provisions, and financing governing prenatal and early childhood services that respond to the unique developmental needs of infants, toddlers, preschoolers, and their families; Public Awareness - the awareness of the general public about young children s mental health, the relevance of the issue, and the ways that the public can support it; and Systems Collaboration- the ability of existing early childhood services systems to collaborate and work together to address structural, administrative barriers that have historically made it difficult for young children and families to receive the full range of mental health services and supports. Background of the Philadelphia Infant and Early Childhood Mental Health Initiative The strategic efforts of the Philadelphia Infant and Early Childhood Mental Health Initiative began with the William Penn Foundation s interest in meeting emerging infant and early childhood mental health issues. In 2004, the Foundation funded ZTT to carry out a year-long capacity building initiative aimed at improving infant and early childhood mental health in Philadelphia. The Initiative involved convening early childhood leaders in Philadelphia to examine current mental health services for young children with the goal of developing strategies for improvement. In order to develop strategies for improvement, Philadelphia had to examine the building blocks of a comprehensive mental health system, including: policy, public awareness, professional development and service delivery. The grant focused on Philadelphia because budding activities already taking place in the city showed great promise. For example, ZTT discovered that a professor at a local university was working on developing an infant mental health graduate program. On another front, an Early Intervention service professional was exploring how to start and connect an Early Head Start program to its Early Intervention program that would enhance infant mental health services for low-income toddlers with developmental delays and disabilities. In addition, prior to the start of the project, PCCY had started examining and working to build mental health capacity in child care. PCCY: conducted a needs assessment study to document child care provider needs; trained over 300 child care providers on infant mental health awareness and classroom behavior management; developed a resource guide that showed professionals how to access support; and scanned the behavioral health system to assess the capacity of providers that both accepted Medicaid and served children birth to five years of age.

3 Infant mental health capacity building activities were also taking place at the state level. When ZTT reached out to Pennsylvania s Department of Public Welfare (DPW), the Secretary of the agency informed ZTT that the timing of the initiative was just right. The state had already begun thinking about how to infuse building blocks like public awareness across child care, mental health, education/special education, and DPW programs such as behavioral health, welfare, and Medicaid. In addition, ZTT identified a small group of early childhood professionals in the Philadelphia area that had already begun working to create a local Philadelphia chapter of the World Association for Infant Mental Health (WAIMH). The professionals intended to use the creation of the new WAIMH as an opportunity to bring early childhood professionals and the broader Philadelphia community together in support of young children s social and emotional development. Across the nation, state chapters of WAIMH have offered professionals training and consultation in infant mental health practices, networking opportunities, and current knowledge related to research, practice, and policy. The Philadelphia group had already drafted bylaws and was seeking technical assistance in defining objectives, developing a mission statement, and incorporating into the WAIMH organization. ZTT informed the group of professionals about the Philadelphia Infant Mental Health Initiative and offered to assist in helping the group establish a local WAIMH chapter. This group later became the Delaware Valley Group-World Association for Infant Mental Health (DVG-WAIMH) and served as a collaborator of the initiative. Philadelphia Infant Mental Health Initiative: A Collaborative Effort ZTT was charged to help strengthen Philadelphia s capacity to serve young children and families by bringing the momentum of the work in Philadelphia and expertise of these stakeholders together through the Philadelphia Infant Mental Health Initiative. Collaboration was a key ingredient to successfully rolling out this Initiative. ZTT approached the Philadelphia Infant Mental Health Initiative with a collaborative spirit that drew on the strong existing relationships it already had in Philadelphia. Each of the partners, described below, brought a unique and critical perspective to the project. ZERO TO THREE: National Center for Infants, Toddlers, and Families (ZTT) ZTT is a national leader on the first three years of life. ZTT promotes the healthy development of our nation's infants and toddlers by supporting and strengthening families, communities, and those who work on their behalf. For over 27 years, the national non-profit has been dedicated to advancing current knowledge; promoting beneficial policies and practices; communicating research and best practices to a wide variety of audiences; and providing training, technical assistance and leadership development. Delaware Valley Group-World Association for Infant Mental Health (DVG-WAIMH) ZTT contacted Chiara Nuzzo, PhD, a practicing child psychologist, early childhood mental health consultant in Philadelphia, and also (2001) graduate fellow of ZTT s Leadership Development Initiative, to participate in the initiative. Outside of her private practice, Dr. Nuzzo had already been working with a small group of multidisciplinary early childhood mental health professionals from the Delaware Valley/Philadelphia metropolitan region - including Philadelphia and suburbs of Delaware and New Jersey - to form DVG-WAIMH. The major focus of this WAIMH chapter was to provide networking, education, and advocacy activities for practitioners, administrators, educators, and researchers that work on behalf of local families with infants, toddlers, and preschool children. The mental health expertise of Dr. Nuzzo and this group of mental health professionals brought the early childhood practitioners voices to the project.

4 Philadelphia Citizens for Children and Youth (PCCY) ZTT also invited PCCY, a strong champion and advocate of children s issues in Philadelphia and also a grantee of ZTT s Better Baby Care Initiative 1, to partner on the new mental health initiative. PCCY had just published a white paper, The mental health system for low-income children: The Philadelphia story, which examined the state of the mental health system for Medicaid children. While it focused on older children and adolescents, the document provided useful information about the inner workings of Philadelphia s mental health service system for children, including the system's philosophy, strengths, gaps, and barriers. Roles of Each Organization ZTT, PCCY, and DVG-WAIMH worked together to convene the symposium planning meetings. ZTT took the lead on providing content materials needed to plan the symposium, identifying speakers, and drafting this report. ZTT worked closely with PCCY and DVG-WAIMH to build on the skills and resources of both organizations. Both served as critical liaisons on the status of infant mental health services in Philadelphia. PCCY had already implemented several important mental health awareness activities in the city and offered advocacy strategies to help organize the meeting. Likewise, DVG- WAIMH brought the expertise of its mental health professionals to help inform the content and planning of the symposium. Activities of the Philadelphia Infant and Early Childhood Mental Health Initiative There are a variety of ways to build an infant and early childhood mental health system. Some states and communities have focused on policy. Others have used public awareness efforts to help decision makers and the general public understand how to support young children s social and emotional development. Across the country, states have employed training programs to assure that mental health practitioners can provide high-quality infant mental health assessments, consultation, and intervention. State and community efforts to improve mental health have also targeted service delivery - improving the range (promotion, prevention, and intervention/treatment) and quality of early childhood mental health services provided to children and families. The Philadelphia Infant and Early Childhood Mental Health Initiative considered each building block of a system and settled on the following activities: Activity One: Convening a community symposium ZTT, PCCY, and DVG-WAIMH met together for the first time in October 2004 to begin planning the symposium. The Initiative partners involved early childhood stakeholders early on to ensure buy-in from the community and encourage a shared vision for the symposium. The symposium planning committee was essential to the planning of the Philadelphia Infant Mental Health Symposium. Committee members shared their comprehensive perspective and brought the voice of Philadelphia s families to the symposium planning discussion. Symposium Planning Meetings ZTT, PCCY, and DVG-WAIMH led three face-to-face meetings with the symposium planning committee members. The meetings accomplished several goals. The first meeting allowed committee members to articulate the needs of Philadelphia s young children and families and emphasize the needs 1 ZERO TO THREE manages a pass-through grant project to support state- and community-based organizations that are raising awareness and advancing policy change for the healthy development of infants and toddlers. This project, called the Better Baby Care Grant Project, currently supports 10 organizations in 9 states across the country.

5 of underserved or hard-to-reach populations (e.g. young children of teenage parents, gay/lesbian parents, and those living in low-income, impoverished families). This information was used during the second and third meetings to craft the content and structure of the symposium. The committee decided that the symposium should include a: keynote address; case presentation by another community about its successful capacity building strategy; presentation on Pennsylvania s new infant toddler agenda; breakout group session to engage symposium participants and encourage peer-to-peer learning; and panel consisting of a state and city government leader, parent, and service provider that would react to the information shared during the symposium and share their recommendations for Philadelphia s next steps. Philadelphia Infant and Early Childhood Mental Health Symposium The Philadelphia Infant Mental Health Symposium was held on October 5 th, It was attended by more than 140 people, including parents, social workers, physicians, psychologists and psychiatrists, child care providers, and state and city government officials. In the morning, the symposium featured a keynote address by Dr. Charles Zeanah, Professor of Psychiatry and Pediatrics and Director of Child and Adolescent Psychiatry at Tulane University. Dr. Zeanah brought a wealth of knowledge to this topic. Dr. Zeanah offered his wisdom about the critical components of service delivery and presented compelling case studies. Following the keynote, Karen Freel, Ph.D., Vice President of Public Affairs at the Ounce of Prevention Fund, shared successful systems building strategies that Illinois used to coordinate infant and early childhood services. Harriet Dichter, Policy Director of Pennsylvania s Department of Education and the Deputy Secretary in the Office of Child Development in Pennsylvania s Department of Public Welfare, discussed Pennsylvania's new infant and toddler policy agenda and the state s plans to address the mental health needs of young children. In the afternoon, participants had an opportunity to join one of three breakout groups: enhancing public awareness, improving early identification of social and emotional problems, and increasing service delivery capacity through professional development. At the end of the breakout session, facilitators reported back to the entire symposium and shared action steps identified by the breakout groups (outlined below). The afternoon breakout sessions were followed by a panel discussion that featured Alicia Oglesby, parent of a toddler; Mary Graham, Executive Director of The Children s Village Child Care center; Ijeoma Achara-Abrahams, Director of Strategic Planning for the Philadelphia Department of Behavioral Health; Harris Rabinovich, Physician Advisor to the Philadelphia Department of Behavioral Health; and Estelle Richman, Secretary of Public Welfare for the Commonwealth of Pennsylvania. Each panel member reacted to the information presented throughout the day and offered suggestions of next steps that Philadelphia might consider in moving forward. Anecdotal feedback indicated that the symposium was very well-received. Participants made the following remarks: really well done professional good speakers very exciting for Philadelphia wow, things are happening here Overall, participants were enthused about the city s focus on infant and early childhood mental health and repeatedly asked when the workgroups would be meeting again. At the conclusion of the

6 symposium meeting, 39 participants signed up to participate in post-symposium workgroups to focus on the action steps outlined below. Enhancing Public Awareness The enhancing public awareness group discussed: 1. What do we need in Philadelphia to make the public aware of infant and early childhood mental health? 2. Who are the target audiences for infant and early childhood mental health public awareness efforts? 3. How do you reach and engage these groups? 4. What are the effective key messages to use? 5. Who are the messengers? Recommended Action Steps: Create a movement, using the symposium as the starting group. Develop tiered messages for mental health professionals, the public, and parents. Engage religious, cultural, and ethnic organizations to help craft and move the message. Get media coverage that positively frames mental health as wellness rather than illness. Improving Early Identification The improving early identification of social and emotional problems group discussed: 1. What structures and services does Philadelphia need to have in place to ensure promotion, prevention, and early identification services? 2. Who are the key partners needed to improve promotion, prevention, and early identification? 3. How can we improve access to preventive services for children birth to age five? 4. How can we improve promotion, prevention, and early identification services through financing (e.g. maximizing EPSDT and addressing barriers to provider reimbursement)? 5. How can we enhance the capacity of caregivers (professionals and/or parents) to recognize problems early on? Recommended Action Steps: Educate health care professionals about providing mental health screening and referral. Educate early childhood providers about developmental wellness, warning signs, and community resources. Engage providers and funders of early childhood initiatives to include social- emotional well-being program components. Partner with cultural groups to promote social and emotional wellness throughout the community. Blend funding to allow service delivery in multiple locations. Increasing Service Delivery through Professional Development The increasing service delivery capacity through professional development group discussed: 1. What do we need in Philadelphia to have good mental health treatment for the early childhood population? 2. What is the current capacity of the service system? 3. How is the system and its services financed? 4. How should practitioners be trained? 5. What quality of services do young children need? Recommended Action Steps: Review child care mental health consultation programs to develop one for Philadelphia. Increase systems collaboration between existing early childhood programs to improve access of mental health services for children birth to five. Develop a training program for existing mental health professionals to become IMH practitioners.

7 Activity Two: Assist in the creation of the local WAIMH chapter While symposium planning was underway, ZTT simultaneously supported Dr. Nuzzo s efforts to establish a local World Association of Infant Mental Health (WAIMH) chapter. Dr. Nuzzo and her group of early childhood professionals in the Philadelphia area had already started working towards creating a local chapter of WAIMH. ZTT assisted the group s efforts by reviewing drafts of the group s objectives and mission statement documents. ZTT worked with the group to incorporate into the WAIMH organization and the group became officially recognized as the Delaware Valley Group World Association for Infant Mental Health (DVG-WAIMH). ZTT also worked with DVG-WAIMH to obtain its non-profit 501c (3) status. Activity Three: Document activities of the Philadelphia Infant Mental Health Initiative ZTT documented the Philadelphia Infant Mental Health Initiative activities (the function of this report) from the start to reflect the entire process, from the stakeholder meetings through the post-symposium meetings. It was important to document the challenges, promising practices and useful strategies of the project to serve as a reference for Philadelphia and a tool for other communities and states across the country that are working to build or strengthen a mental health system. Post-symposium Activities A post-symposium workgroup meeting took place Dec. 19 th, 2005 to discuss the best way to make progress on the symposium recommendations. Participants enthusiastically added onto the recommendation list developed at the symposium. However, there was strong consensus that the group should start somewhere by picking one focus area. The group settled on working towards developing an infant mental health training program that would both train existing mental health professionals to be infant mental health specialists and also educate emerging professionals coming into the field. Currently, the group is considering the tasks trained professionals should be able to perform, the early childhood professionals that should be trained, and appropriate curricula. Workgroups are currently meeting and will continue over the next year to design an infant mental health training program. Lessons Learned Although this project is still underway, several lessons have already emerged that may be useful to other communities with similar goals of infant mental health capacity building. 1. Identify a multidisciplinary group of stakeholders. Initiative partners involved the community right from the start by organizing a symposium planning committee made up of a multidisciplinary group of early childhood stakeholders in Philadelphia. This group was essential to the planning of the symposium as they shared their comprehensive perspectives and brought the voice of Philadelphia s families to the symposium planning discussion. To organize the group, the initiative partners developed a matrix of professionals that intimately understood the strengths and gaps of the current mental health system in Philadelphia, had diverse early childhood backgrounds, and could bring a variety of perspectives to the discussions. Over 50 stakeholders were identified from a variety of disciplines health care, child care, preschool, Early Head Start, early childhood university graduate programs, maternal and child health, state and local government, Part C Early Intervention, and mental health. The initiative partners selected several stakeholders from this group and also members from the mental health coalition group that PCCY regularly convened. Altogether, 25 participants joined the stakeholder symposium planning committee. Such an open, collaborative approach fostered trust among all of the participating entities involved in the project.

8 2. Understand the history of the community. To cultivate trust and buy-in from Philadelphia stakeholders, it was important to understand the history of the community. It was helpful for initiative partners to know that previous strategic planning efforts in the city had left stakeholders with mixed impressions. One of those impressions was that strategic planning activities were often useful, well-thought out processes but sometimes ended at the planning stage and did not result in concrete, measurable outcomes for the city. Since initiative partners were aware of this view, they could anticipate certain concerns about the strategic planning process. The partners used this as an opportunity to demonstrate clearly how strategic planning would yield concrete outcomes in Philadelphia. One small but important step initiative partners took was renaming the strategic planning workgroups to symposium planning meetings to help convey the action that was to take place. 3. Focus on the goals not the process. At the symposium, Dr. Freel shared her wisdom that she has learned from her systems building work in Illinois. She told symposium participants that Capacity building is like a marathon; progress is made during a stretch of time. This advice has affirmed that systems change does not happen overnight, or after a single meeting. She informed symposium participants that the Illinois maternal mental health screening initiative took over four years to develop and enact. Stakeholders devoted to improving systems are encouraged to remain focused on the capacity building goals, even when progress seems slow. 4. Start small and build from there. Several recommendations emerged from the symposium breakout workgroups. Even after the symposium at the December 19 th meeting, postsymposium participants thought of new recommendations that were equally as pressing to consider. At the same time, the resources and time of even the most dedicated stakeholders of the infant and early childhood mental health systems- building cause are limited. This combination can frustrate the motivation of stakeholders. Philadelphia understood very early that building a comprehensive system does not mean building everything all at once, but instead starting in one place and building from there. Conclusion Infant and early childhood mental health system building is multifaceted. It requires the energy of all the adults that touch the lives of very young children parents, child care providers, psychiatrists, home visitors, policymakers, community leaders, etc. The contribution of each adult will vary but everyone has a role to play. Philadelphia has set an example for other communities that are interested in working to build a comprehensive infant and early childhood mental health system. Communities that have not already kicked off a planning process are encouraged to consider the Philadelphia model and start by engaging community stakeholders to explore the roles that each member might play in supporting young children s mental health. Making this modest time investment will also enable communities to organize their services and resources to help ensure that young children are equipped with the strong social and emotional skills essential for success in school and life.

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