Children's support services: providing a system of care for urban preschoolers with significant behavioral challenges.

Research showing the critical importance of school readiness highlights the need for early intervention with children who are exhibiting significant behavior problems. Young children who are perceived as socially competent and well-adjusted have a higher probability of school success, while preschoolers who experience serious emotional difficulty are at greater risk for early school difficulty (Raver, 2002).

The No Child Left Behind legislation acknowledges the importance of school readiness for children entering kindergarten. At the White House Summit on Early Childhood Cognitive Development in 2001, G. Reid Lyon, Chief, Child Development and Behavior Branch, National Institutes of Health, reported that the Bush administration has "charged us with developing and implementing a seamless, evidence-based early childhood educational program that builds and links critical cognitive, physical, social, and emotional abilities across transitions in ages, environments and classrooms to ensure school readiness and school success." One critical aspect of school readiness is healthy social and emotional development. In order to successfully navigate the kindergarten routine, young children need to be able to follow directions, participate in group activities, express their needs and ideas, conform to classroom rules, and interact appropriately with adults and peers. Preschoolers who demonstrate chronically disruptive or destructive behaviors in early childhood settings are at greater risk for academic failure (Arnold et al., 1999; McLelland, Morrison, & Holmes, 2000).

Urban areas often have a high percentage of families living below the poverty line. The concomitant incidence of young children in those neighborhoods with emotional and behavioral difficulties presents a continuous challenge for classroom teachers (Conduct Problems Prevention Research Group, 1999). As a result, the interventions that are implemented should not only stabilize and safeguard the classroom climate, but also support the child's positive social/emotional development. Research indicates that altering challenging behaviors in young children necessitates systemic intervention (Kazdin, 1987; Wahler & Dumas, 1986).

One of the additional challenges to providing services to the preschool-age population in an urban environment is the issue of access. Children between the ages of 3 and 5 typically are found at home, in family child care, at child care centers, at Head Start, or in parochial or public schools, and so it follows that preschoolers with behavioral difficulties can be found in all of these settings. An effective and efficient special education system must be in place to address the needs of all preschoolers with emotional disabilities who meet the eligibility criteria established by IDEA (the Individuals With Disabilities Education Act). There is, however, no complementary system of coordination institutionalized to serve young children who are not classified as emotionally disturbed, but who have significant behavior problems and are seriously at-risk for school failure. In From Neurons to Neighborhoods, the National Research Council concluded that the current delivery of health and mental health services to young children in the United States is highly fragmented and leaves the most vulnerable and poor members of the population underserved (National Research Council, 2000). That report stressed the need for establishing an infrastructure with a single point of entry that provides early education activities as well as parent-child strengthening interventions.

One Intervention Framework

The city of Lowell, Massachusetts, is an urban community of approximately 104,000 residents. Over 56 percent of the population are members of linguistic minority groups and over 60 percent of public school students are eligible for free or reduced lunch. The community has a long history of being the initial entry point for many immigrants, with Cambodian, Hispanic, and Portuguese populations constituting the largest ethnic groups.

There are approximately 4,000 preschool-age children in the city, many of whom are uninsured, live in poverty, and/or are members of immigrant families. The impact of multiple psychosocial stressors results in many children exhibiting signs of emotional distress at an early age. In order to address the mental health needs of these young children, the early childhood coordinator of the Lowell public school system chairs the Children's Support Services (CSS) project, which is an interagency, multidisciplinary (mental health, child development) program that:

* Coordinates the screening and case management of preschool children with mental health needs

* Provides consultation and support staff to early childhood programs (Head Start, family child care, center-based child care, and public school) to address the needs of young children who exhibit mental health concerns

* Provides information to parents and child care programs about community social service, health, and mental health resources

* Monitors preschool-age children who are receiving mental health and/or behavioral support services

* Maintains up-to-date information about the availability, accessibility, and affordability of mental health and family support services in the community.

The CSS project was begun in September 2000 with funding from a state department of education Community Partnership for Children grant. Originally, CSS addressed the needs of preschool-age children who exhibited significant behavioral difficulties and thus were asked to leave early childhood programs. Approximately 1,200 children, ages 3 to 5, are enrolled in some type of out-of-home care.

The program has since expanded to serve the following categories of children:

* Children who exhibit social/emotional/behavioral difficulties that interfere with their participation in program activities or that negatively affect the child's development

* Children who are considered environmentally at risk and in need of additional mental health and family support services from outside agencies

* Children/families who are involved with multiple agencies and, as a result, may need more intensive case monitoring and coordination.

CSS Components

CSS sponsors bimonthly case management meetings to examine the performance and needs of young children with significant behavioral concerns. From September 2000 to March 2005, 175 preschoolers with mental health issues have been referred, supported, and monitored by the CSS team. Child care directors, teachers, and/or health or social service professionals, upon approval of the parent, make referrals to the early childhood department of the child's public school. Team meetings, facilitated by the early childhood coordinator, are scheduled to elicit insight and input from a community-based social worker, as well as from a behavioral specialist, to develop, with the staff of the referring agency, individualized interventions for children considered at risk for mental health problems. In some cases, the child's social welfare agency case worker or another key service provider is invited to the team meeting. Written parental consent is obtained to permit communication among the child's primary care physician, the mental health clinicians, and the CSS child development staff. CSS also offers seed money to help early childhood programs develop partnerships with local mental health agencies. Mental health clinicians from the Massachusetts Society to Prevent Cruelty to Children (MSPCC) and from the early intervention field observe children, consult with teaching staff, offer workshops, and meet with parents.

The Behavioral Resource and Training Team is the third component of CSS. It is made up of a behavioral specialist and a team of paraprofessional behavioral assistants, all employees of a local mental health program. The behavioral specialist observes children, develops behavioral plans, and consults with staff and parents. If a child's behavior represents a serious safety issue, a behavioral teaching assistant is assigned to the child to provide an opportunity for more enhanced supervision and to assist the teaching team in implementing a behavioral program.

For preschoolers who are unable to function successfully in a large-group setting, the community pre-K classroom provides an alternative education program with reduced class size (usually less than 8 students), a higher staff to student ratio (2:8), a supplemental social skills curriculum, bi-monthly parent meetings, and ongoing case management review.

When children transition into the public school, follow-up to CSS services is provided by the school's early childhood department, a team of three elementary behavioral specialists, and Title I social workers. CSS is considered a family support project. The staff develop partnerships with parents, include them in team decisions, and refer them to appropriate resources.

CSS Program Goals

CSS has three primary goals:

* Early identification of young children who exhibit significant behavioral disorders 

* Ensuring continuity of programming for young children with challenging behaviors

* Enhancing the ability of early childhood programs to address the needs of young children with behavioral difficulties by providing

--Case management of children at risk

--Behavioral assessment and interventions for children

--Counseling, home visiting, resource/referral, and support services to families

--Consultation, mentoring, and training for early childhood staff.

Also, CSS encourages early care and education programs to foster partnerships with parents, communicate with them regularly, and seek their input in planning individualized interventions for their young children.

Project Outcomes

The early childhood department of Lowell Public Schools (Tewhey, 2005) maintains a database of all referrals to the CSS project, all interventions and services provided by CSS, and the current placements of all children who have received CSS services. Data revealed measurable positive outcomes in all three primary goal areas. The following summarizes the impact of the CSS project on the Lowell early childhood community.

Early Identification: Since 2000, 175 preschoolers have been referred to the CSS project. The vast majority of the children referred were currently enrolled in an early care/education program and were at risk of being terminated from service because of their problematic behavior. Annually, approximately 5 percent of all children attending a preschool program are identified as needing a comprehensive mental health intervention and are case-managed by the CSS Team.

Continuity of Programming: Table 1 details the placement options implemented for the preschool-age children receiving CSS services. Approximately 93 percent of all referred children were retained in some type of early childhood program. Seven percent of children referred to CSS were voluntarily withdrawn from the preschool or relocated to another community.

Enhance Capacity of Local Programs To Provide Mental Health Services/Supports: Table 2 summarizes the CSS services that were accessed by early care/education programs (Head Start, family child care systems, center-based child care, public school) that used the CSS collaborative project to supplement their mental health resources. The total preschool enrollment in the city is approximately 1,200 children.

In addition to enhancing the quality and comprehensiveness of services provided to children, families, and staff, the CSS project has resulted in a 70 percent reduction of special education referrals for children with significant behavioral difficulties attending a community-based child care program.

Summary

The CSS project in Lowell is a community-wide initiative that provides young children and their families a range of child development, mental health, and family support services. CSS services are available to any preschool-age child, regardless of where s/he is enrolled. The project has reduced fragmentation significantly in local systems and enhanced coordination of local resources. By centralizing the intake process within the early childhood department of the local public school system, CSS staff are able to promote earlier identification of children with behavioral problems, foster networking between public and community entities, be actively involved with transitioning children to kindergarten, and monitor students as they move through elementary school.

The CSS model has proven to be an effective and efficient system of mental health care for urban preschoolers with behavioral challenges who are at risk for academic failure. With access to the same primary components, other urban communities would be able to replicate the CSS model.

References

Arnold, D. H., Ortiz, C., Curry, J. C., Stowe, R. M., Goldstein, N. E., Fisher, P. H., Zeljo, A., & Yershova, K. (1999). Promoting academic success and preventing disruptive behavior disorders through community partnership. Journal of Community Psychology, 27(5), 589-598.

Conduct Problems Prevention Research Group. (1999). Initial impact of the Fast Track prevention trial for conduct problems: II. Classroom effects. Journal of Consulting and Clinical Psychology, 67(5), 648-657.

Kazdin, A. E. (1987). Treatment of antisocial behavior in children: Current status and future directions. Psychological Bulletin, 102, 187-203.

McLelland, M. M., Morrison, F. J., & Holmes, D.H. (2000). Children at risk for early academic problems: The role of learning-related social skills. Early Childhood Research Quarterly, 15, 307-29.

National Research Council and Institute of Medicine, Board on Children, Youth, and Families, Commission on Behavioral and Social Sciences and Education; Shonkoff, J. P. & Philips, D. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.

Raver, C. C. (2002). Emotions matter: Making the case for the role of young children's emotional development for school readiness. Social Policy Report, 16(3), 3-18.

Tewhey, K. (2005). CSS database. Unpublished.

Wahler, R., & Dumas, J. E. (1986). "A chip off the old block": Some interpersonal characteristics of coercive children across generations. In P. Strain, M. Guralnick, & H. M. Walker (Eds.), Children's social behavior: Development, assessment, and modification (pp. 49-91). Orlando, FL: Academic Press.

White House Summit on Early Childhood Cognitive Development. (2001, July). Address by G. Reid Lyon, the Chief of the Child Development and Behavior Branch, National Institutes of Health.

Karen Tewhey is Associate Commissioner, Massachusetts Department of Early Education and Care, and former Early Childhood Coordinator, Lowell Public Schools.

Table 1

Placements of Preschoolers Upon Receiving CSS Services

Continued to attend current program            47.5%
(Head Start, public school, child care)
with CSS supports

Transitioned into an inclusive public school     35%
classroom from a community-based program.

Enrolled in a special education classroom.      4.6%
(These children were primarily preschoolers
who were subsequently identified as having
autism or pervasive developmental disorder.)

Enrolled in the community pre-K social          5.5%
skills classroom.

Table 2

Annual Usage of Supplemental CSS Services

Percentage of early education/care programs     90%
in the city using CSS services.

Percentage of preschoolers in the city           5%
receiving CSS case management services.

Percentage of CSS preschoolers receiving        53%
additional classroom support from a CSS
behavioral teaching assistant.

Percentage of all referred children/families
who received on-site mental health              46%
support/counseling.

Percentage of program staff who had access     100%
to subsidized college courses (child
development/special needs) and inservice
training on mental health/behavioral issues.

Percentage of CSS families who received         20%
home visiting support.