Cómo aprovechar al máximo su consulta de salud mental

(En inglés)

Making the Most of Your Infant and Early Childhood
Mental Health Consultation

Steve Shuman: So, now we're going to begin. Again, today's topic is “Making the Most of Your Infant and Early Childhood Mental Health Consultation.” And we are so lucky because we have not only one of our newer staff members – partners on the National Center, but really, a woman who is known as the godmother, really one of the founders of mental health consultation. Let me introduce Kadija Johnston. Kadija?

Kadija Johnston: Thank you so much, Steve. Godmother, grandmother, both or either, I'm not sure which, but I'm of the age at this point where the seasoned experience is welcome. It's so exciting to see and continue to watch the breadth of people who are joining. I feel honored. I wish we had a map where there was a little light that went on for every place that you all are joining us from. And I come for the last 33 or so years from having worked in the field of infant and early childhood mental health almost for decades now. And within the field of Infant and early childhood mental health, really spending a lot of my emphasis and energies thinking about mental health consultation, particularly mental health consultation in early care and education settings, but also in home visiting and other settings where very young children and their families either reside or cared for. And having done that for about four decades through – with the University of California, San Francisco at the Infant-Parent program, I recently, as Steve said, have left that position to be able to join the faculty at Georgetown University. And in that capacity, to be part of the National Center on Behavioral Health and Safety.

It's from that position that I come to you today to talk about early childhood mental health consultation, and how it can be most effectively implemented in Head Start settings. Let's talk a little bit about the terrain that will traverse over the next hour together. To ensure that we have a shared understanding of this mental health service, I'm going to begin by offering a definition, “What is infant and early childhood mental health consultation?” And then, I'm going to describe some conceptual pathways by which it can be employed and be of benefit in the Head Start settings in which you all are involved. And moving then from the theoretical to the practical, I'm going to describe the types of mental health consultation services and the range of activities in which a consultant can usefully be involved. And then we'll end with talking a little bit about who provides mental health consultation, what it can do, and at the very end, talking about what are the benefits of mental health consultation.

From the beginning, right now and along the way, I want to acknowledge the impact of the pandemic and associated exposure of and increases in inequities, not just in how early childhood mental health consultation is being delivered, but also, what the service is being called to respond to. I'll talk along the way about some of the adaptations that we all are, hopefully, making to mental health consultation to continue to have it to be a responsive service. And I will leave time at the end for questions and hopefully, a bit of conversation.

Let's begin with a definition. What is infant and early childhood mental health consultation? And it is first of all, a multi-level mental health strategy that I think elegantly spans the care continuum from promotion to prevention to intervention. It is an indirect service, meaning that the mental health professional does not work directly, typically, with the family or the child. But it's an indirect service that pairs a mental health professional with other providers who are the people who care for offer services to infants, young children, and their families. It is a capacity-building endeavor that's aimed at increasing the social-emotional awareness and knowledge and enhancing the reflective confidence and competence of the adults that support young children, primarily providers and parents. By collaborating with the primary people in children's lives, infant and early childhood mental health consultation supports – or where needed – strengthens caregiving practices. Thereby, promoting optimal development for all children in a setting or service system. While mental health consultation is directed at preserving the social and emotional well-being and relational health of all of the above constituents, which includes the well-being of the providers of care. And also, mental health consultation also serves a prevention and intervention function for those families and children at risk or exhibiting mental health difficulties.

And I want to acknowledge that, really, Head Start has been a pioneer in recognizing that mental health supports, like consultation, are an essential component of effective early childhood programming. Since its inception, which most of you probably know, Head Start required programs to prioritize services that acknowledge the importance of social-emotional domain of development for all children, and the need to offer supports in situations where an individual child's mental health is in jeopardy. And the more recent – the current performance standards as seen on the slide actually have strengthened, I think, the breadth and clarity of the previous requirements by instructing programs to use mental health consultants on a  – quote –  schedule of sufficient and consistent frequency. And while that might be multiply interpreted, we'll talk a little bit during this time about what goes into the – what constitutes sufficient and consistent frequency. And then, the current standards also acknowledge the special supports needed for children who've experienced trauma associated with homelessness or foster care. The well-being of the adults in children's lives is importantly and equally recognized. Addressing teachers and parents and home visitors’ mental health needs is articulated as a goal of the standards. What I want to say, though, is that even with these rigorous and I think righteous guidelines, it can be challenging to operationalize these standards, and to effectively integrate mental health services in Head Start settings. What I'd like to do next is to highlight and describe in more detail some parts of that definition that I just gave as a way of illustrating why early childhood mental health consultation is proving to be a powerful mental health support. And how it can be implemented in your settings most effectively.

First, let's look at the part of the definition that talked about it being a multi-level service, from promotion to prevention to intervention. I think that often mental health consultation is seen as an employed most extensively at that kind of prevention intervention end of the service spectrum, which is valuable. A mental health professional is often engaged by a program around a specific child whose score on an ASQ:SE or their behavior in the classroom is a concern or a puzzle to their caregivers and teachers.

Well, of course, tending to the maladies of an individual child is an important part of early childhood mental health consultation. Decades of practice, in my case. And more recent research confirms the benefit of a more upstream approach. Seen as a service that can promote the mental health of all children in a setting. Early childhood mental health consultation has the potential, I think of making the greatest impact when we think about and employ it in relation to promotion. By aiming the intervention at the providers of care and at the broader system and setting, early childhood mental health consultation is building capacity to foster the social and emotional well-being of all children and families served in a program. And not just those currently being served, but when you build capacity in providers, then also, future families and cohorts of children also benefit. For early childhood mental health consultation to effectively function as a promotion service, though, the consultant needs to have knowledge of the overall program and the opportunity to establish ongoing relationships with all staff at different levels in the hierarchy, which, of course, occurs only over time with a consistent presence and person. This to me speaks to that idea of what is sufficient and consistent frequency.

Expanding early childhood mental health consultations purview to include promotion, I think, sometimes causes people to feel confused or a bit of consternation. Why is it confusing? Well, I think on a practical level, that programs may want to reserve their resources for extreme kind of situations or acute mental health needs. And not see the value of cultivating a relationship with a mental health provider prior to a crisis situation of extreme needs of a few families. And yet, I'm suggesting that if there's already established relationship between your mental health consultant and the program, that it's far more efficient and effective even when those extreme or crisis situations arise because there's already mutual trust and knowledge. I think also that the way that mental health – the word, the term – is viewed also interferes with us thinking about mental health consultation as a promotion strategy.

Think about how we use the words “mental health.” The term usually – actually stands in for its opposite. We usually are referring to mental illness. Mental health services are rarely aimed at preserving a positive state. And even those of us who are mental health professionals are often limited to intervening when concerns – pretty serious concerns – are already evident. And it's really been mostly in that context when there are serious worries about a particular child that mental health consultation has traditionally entered the picture. What I'm suggesting is this is not a necessary nor do I think the most effective point of entry. What I'm suggesting is that the usefulness of mental health consultation is not limited to acute situations. I like to use the analogy that we don't become concerned about the nutritional needs of children only at the point at which we identify signs of malnutrition or starvation in a child. Similarly, it seems to me that we should not limit our sense of the importance of the mental health support to the individual child with a diagonalizable difficulty. Mental health consultation can take a proactive approach to create an atmosphere in which the mental health of all children, families, and staff in a particular program is protected and supported. How though does mental health consultation do that?

And this is where we turn to another part of the definition because as one of the founders of early – excuse me – of Head Start said, Ed Zigler said, "We make a difference by directing our efforts not only of the children, but at the adults in children's lives, providers and parents." We know what our grandmothers and probably their grandmothers before them knew, but what neuroimaging has convinced us of, and that is this that the early relational experiences between very young children and their primary caregivers is what contributes to – for good or for ill –their overall development. It's really that we want to support the adult’s capacity to be in those relationships with children by supporting and strengthening the provider's capacity and well-being. By aiming the service at the teacher or home visitor, and creating internal change in the adults in children's lives. The effort of early childhood mental health consultation influences not only that particular provider but consequently, it influences positively her interactions with all children and families, both those currently in care and in the future. When we have then, I think, we have to ask ourselves, what does it take to build provider capacity and well-being? And I want us to think about, what capacities are crucial to supporting young children's mental health? Learning, I would say, learning for any of us. Building capacity is not as we often think of it solely – or maybe even primarily – dependent on just gaining new information or knowledge. When are you most likely to learn or want to be excited about learning?

I think that a precursor to learning is that we have to feel that what we are learning about –what we do – matters. That we have to have enough sense of our own efficacy, enough energy and interest and attention to grow, to want to learn new things, and to be supported in doing so. And early childhood mental health consultation addresses these areas in adults. What I mean by that is this that we now have research and studies to support what anecdotal evidence was already there: That mental health consultation supports staff's well-being, first, by promoting provider well-being through addressing stress. And that is, in my opinion and should be, an explicit intention of mental health consultation. Lucky for me, my opinion is being backed by research. We know that the work of caring, especially for groups of young children or very vulnerable families, is extremely stressful. Often job stress is exacerbated by financial, familial, and societal strains on providers. And of course, these pressures have doubled during the pandemic. Whether because of stress caused by COVID or tensions that preceded it, those in child caring, family caring professions have – even before this pandemic – have among the highest rates of physical and mental health concerns of any profession. Even compared to others in the same income bracket. We are also sensitive to – and studies substantiate the powerful impact on children – of adults’ emotional well-being. Adults’ attitudes – their ability to attend and ability to regulate their own emotions – matters mightily to how they can care for and help children to learn.

Teachers who reported the greatest depression and job stress tend also to report greater levels of problem behavior in the children they care for. The correlation is no coincidence. And it's also true that those providers are more likely to ask that the children – those children who they perceive as challenging because they often don't have the bandwidth – not just the knowledge – to care for those children. Those are the children and providers who often are asked to be removed or expelled. Conversely, teachers who participate in early childhood mental health consultation describe decrease stress and are less likely to rely on expulsion or suspension, or harsh disciplinary practices as a way of remedying their tensions. And also, mental health consultation impacts self-efficacy. When you're stressed or depressed, it's hard to feel like anything you do matters. Many teachers describe feeling ineffective, especially in addressing challenging behavior. And early childhood mental health consultation has been shown to boost efficacy. I would suggest that it's necessary precursor to changing behavior. If you don't feel like what you do with children matters, why would you be interested in expanding or exploring, or changing what you understand and do? Increased self-efficacy seems extremely important. Feeling like, as a provider, you have an impact, I think is the precursor to changing one's perspective and eventually behaviors.

And early childhood mental health consultation recognizes that how we perceive behaviors is how we decide to respond to them. If you see a child's behavior as threatening or a danger, you probably respond in a way that doesn't necessarily support the child's growth but protects one's self. Consequently, mental health consultation aims to broaden possibilities of what the meaning of behavior can be, and when need be, to amend teachers’ attitudes, perceptions, and ways of treating children. Teachers, especially those who are overtaxed, attribute their stress to specific children, or maybe shift the blame, we've learned, to parents. Early childhood mental health consultation helps to recast the ways teachers appraise the source and the meaning of challenging behavior. Assisting providers in holding multiple rather than rigid perspectives increases their capacity to reflect and respond sensitively, which benefits all children. And studies are showing that targeting these areas – targeting the increase in reflection and empathy – is particularly relevant in reducing racial and gender biases that are contributing to the racial disproportionalities in suspensions expulsion and hard discipline. Research is also confirming that it's the quality of the relationship that the mental health consultant creates with her consultees that is the most powerful instrument of change.

Focusing on the characteristics of mental health consultation that correlate with effectiveness, studies found that the quality of the consultant staff relationship was the single most salient predictor of effective mental health consultation services. Frequency also boosts the positive impact. A positive consultant-consultee relationship is especially impactful when the child who is the focus of consultation is a child of color. What recent studies by Annie Davis and either Marie Shriver and Deb Perry found was that a positive relationship with a mental health consultant was the most beneficial predictor of changing – of changing providers perceptions, negative perceptions of African-American and Latinx boys, especially when the mental health consultant from their own description said that they had studied, that they had expertise in, that they addressed equity, diversity, and racism. And also, when the teacher and the early childhood mental health consultant were racially and/or ethnically matched, it added to the positive effect of their relationship, particularly for boys of color. Appreciating the power of that relationship – of the consultant consultee relationship – in terms of changing minds, and in turn, improving child and family outcomes. I think we then have to ask ourselves, so what are the factors? What are the factors that influence the formation of that positive relationship? As program administrators or as mental health consultants – and I imagine, we have many of both on this call – I'm going to ask us to think about – ask you each to think about from your position, what do you consider as you engage in the process of infant and early childhood mental health consultation? And I've provided here a fairly extensive, but not exhaustive list. Let's explore a few of these factors that I hope will help you consider how mental health consultation and mental health consultants can be engaged in your Head Start program.

First, talking about positioning. And what I mean by positioning, it refers to the consultant's location. Are they inside or employed outside of their organization? And there are benefits and limitations to each. Employed by the Head Start program – the consultant usually possesses a deeper knowledge of a program’s policies and philosophy and culture and procedures and day-to-day operation. That's typically a benefit. And maybe might be more accessible because they're embedded. Conversely, standing outside of a systems hierarchy and free of the constraints of your being an employee, an outside early childhood mental health consultant can assess and address influences at all levels and throughout the system, a freedom that I think is particularly beneficial to the service. And early childhood mental health consultant contracted from outside may then either be an individual mental health provider – that's what I'm talking about is independent, like someone in private practice – or one affiliated with likely a mental health agency. And here again, there can be pluses and minuses to each arrangement. Typically, however, agency affiliation ensures that the assigned early childhood mental health consultant, one, has been trained and receives ongoing supervision specific to the mental health specialty of consultation. And probably has more experience with very young children and the settings in which they reside or cared for. Especially during this time of remote service delivery and the need for kind of perpetual pivoting and flexibility, a mental health agency may have more resources to respond to the changing landscape, and may provide a broader array of services or afford more back up than an individual provider. I think also that the COVID-affected climate has impacted what entry –this next point – the entry process looks like. Yet many characteristics that promote a positive beginning are consistent regardless of services being delivered remotely or on site.

I think that often what happens is that when a mental health consultant is first engaged, it can be tempting because of eagerness or the urgency of needs to want a consultant to jump right into the work. However, like any worthwhile relationship, what I'm suggesting is time is taken in the beginning for the consultant to get to know the program and vice versa. Learning about Head Start's procedures, policies, philosophy, a particular program’s culture, the roles and responsibilities held by providers, and figuring out together what the focus and goals of consultation should be, creates conditions of mutual trust and clear and shared expectations. This process – this entry process described, usually in sometimes of more or less formal partner agreement, is what promotes positive outcomes. What gets articulated is what each partner agrees to do and what they will contribute, and what they can expect from one another, how available will the consultant be, or what meeting times are put aside for mental health consultation meetings with providers, are outlined from the beginning and then usually lead to more clarity and efficacy of the endeavor. When engaging early childhood mental health consultation, program administrators should ask about, I feel, both the mental health consultants approach and their model, as I've looked at as you can see on the slide. To differentiate, I identify and approach as the theories, the beliefs, the concepts upon which the model is based. And the model includes characteristics, like how frequently will the mental health consultant be engaged? And doing what activities and for how long. Which outcomes are going to be targeted? And it also includes – the model includes what skills, competencies, and credentials the mental health consultant possesses. Let's look a little more closely at those.

But before we do, I just want to say that several years ago, Georgetown University, through the Center of Child and Human Development, did a study that focused on identifying the essential components of effective mental health consultation programs. It looked at six programs at the time – some of the few programs across the country that had evidence of positive outcomes – and looked at what did they have in common. And the report that came out of that study – that's called the “What Works Report” – indicated that effective programs had all of the characteristics I just described. A clearly articulated model design. A strong service initiation process. Consultation was provided consistently, not just in crisis or around acute mental health needs. And it was provided by consultants with the following kind of characteristics. Effective mental health consultation in that study, and in other subsequent studies, hinges on the quality and characteristics of primarily of the person providing the service. The best service outcomes are associated with consultants who possess a master's degree or higher in a mental health discipline, and have at least two years of experience working in their discipline. But who also have training and ongoing reflective and clinical supervision support that is specific to infant and early childhood mental health, to equity, and to consultation. That this is a sub-specialty of mental health. That most mental health providers don't necessarily have or get as part of their academic training. Cultural congruence and ethnic or racial matching between consultants and consultees has also been shown to be of particular benefit, especially in addressing perceptions and hard disciplinary actions toward children of color, as I mentioned momentarily ago. I want to acknowledge this is – granted, this is a tall order and very difficult to find, but important, I feel to be aware of the characteristics correlated to efficacy, and for all of us to strive for there being a greater pipeline and pool of mental health consultants with these capacities.

So, then let's turn to, what do these mental health consultants do? And typically, there are three types of consultation offered in group care settings, and they are referred to as programmatic classroom and child or family focused. The first two types, programmatic and classroom, are of course, aimed at supporting, or where need be, enhancing a program and a provider's ability to engage in relationships with one another and with all of the children and families that promote – as I talked about in the beginning – social and emotional health and well-being throughout a Head Start community, be that center or home based. These promotional types of consultation are becoming more prevalent. The third type, family or child focused consultation, focuses on concerns in one or more of these individuals in the child, the family, or occasionally in a particular provider. Consultation centers on concerns about the caregiver-child relationship as it threatens to imperil a particular child's development. Although these types of consultations that I've just listed are distinct, they are often provided simultaneously and by one, the same consultant.

How does early childhood mental health consultation support the well-being of all, while simultaneously, through child and family specific, attend to children and families where there are concerns or questions about their social and emotional well-being. The central activity and the crux of change is the meetings. The consultation meetings with providers. Predictable, even if periodic, consultation meetings are essential. Carving out protected time for these discussions is often arduous because especially in group care, providers are often always engaged. And so it is … Creating these meetings is typically a goal, not a given, but it is a goal of a partnership agreement with mental health consultation. These consultative conversations are, of course, informed by the consultant's observation. The frequency and timing of observations are – of either a particular classroom or an individual child – are based on many factors, of course. Observations of a child are undertaken, though, only with parental permission. And optimally, I feel like, preceded by the mental health consultant having actually introduced herself and talked about the services to the child's family and caregivers from the very beginning, so that the family is a vital part of the consultation and feels themselves properly included.

Of course, observations can offer valuable information, but only if the purpose of the observation is clear and mutually agreed upon by the provider and the mental health consultant. What is one observing for and how will it be useful? Even then, observations are only one avenue of understanding. To develop a really complete picture of a program a child or a family, relies on the mental health consultants ability to elicit and integrate. The more in-depth and long standing perspective of a provider and parents necessary to being able to usefully understand and co-create strategies, particularly around an individual child. When you use your observations in tandem with the information you acquire from all the participants, then the mental health consultant can add their own expertise in early development and infant and early childhood mental health. And combining these sources of knowledge and understanding, then the consultant helps to generate and assist providers and parents to co-create strategies. The consultant also helps to translate the mutually held understanding of a child’s families or providers needs then into responsive action. The consultant has to though, I think, invite and be eager to be reminded of what a console team feels will work and what will not when we might, as mental health consultants, get overly enthusiastic in deciding about or constructing an intervention plan. It's only if the provider who is going to implement that intervention plan believes in it and feels like it will be useful that it can work. In instances where a child or family's needs exceed the interventions that are developed for and implemented in the classroom or in home visits, then a mental health consultant can, and I think should, assist in securing appropriate resources. And with parental permission, can continue to act as a liaison between those outside service providers, and the center or home visiting staff, the family advocate, the managers in Head Start to ensure continuity and coherence. Last but definitely not least, the mental health consultant meets with program administrators, site supervisors, and managers. Meeting with people at all levels in the system is aimed at promoting practices that support systemic health, as well as individual well-being. I hope that it has been clear all along – my talking this morning – that mental health consultation should from my perspective attend to the emotional needs of staff, as well as of children and parents.

The pandemic and associated racial reckoning, I think, have amplified the need and accentuated the importance of doing so. We all have struggled over this time with uncertainty. We've harbored fears about our own and our loved ones safety, and we've all had depths of depression and spikes of anxiety. Some among us have experienced excruciating loss. Early educators and home visitors have endured particular hardships, and some have faced the untenable choice between physical and economic safety. Mental health consultation services have hopefully – and hopefully will continue to – adapt to these trying circumstances. Adding individual and group remote staff gatherings to share and support some of the strain has in my experience proven useful. Offering similar forums for parents, again, individual or group has also in many programs been successfully instituted during this time. As circumstances continue to evolve, it will be essential for program administrators and mental health consultants to continue to connect closely, collaborate deeply, and continue to adapt.

I hope that the program administrators and leaders tuning in today will call on and benefit from – also yourselves – partnering around the pressures and sharing the strains with your mental health consultant as you continue to face into incredibly challenging and tumultuous times. In conclusion, I want to offer some – very briefly – some of the evidence of effectiveness of this comprehensive, multi-level approach to mental health consultation. And at the level of children and families, studies are indicating that the presence of a mental health consultant is correlated to, as you probably all know, fewer expulsions and suspensions and accounts for positive shifts in teachers' perceptions of children's challenging behavior, especially for African-American boys. Conversely, the practice is correlated to perceived gains in pro-social behavior, including teachers seeing children who previously they thought or felt were of concern and challenge and had developmental difficulties. Feeling that there had been gains after a mental health consultation in self-control, in coping skills, in social and emotional functioning, in ability to play, and interpersonal skills. One study showed that parents were able to maintain work because they were not regularly called because of concerns about or the need to pick up their child or of care. And then at the broader level, at the provider and program level, mental health consultation has been shown to contribute to improved communication among staff and between providers and families.

And I think that it is the relationships among adults that greatly impact children's development. While the child may be the hub of the wheel and the relationship that the child has with each of the adults in their lives – providers and parents, for the wheel of development to turn smoothly, that exterior rim of adult relationships must be interconnected. So, valuing the enhanced parent provider and inter staff relationships created or supported through mental health consultation. Other studies suggest that the practice of mental health consultation enhances program quality by reducing – as I referred to earlier – staff stress, improving teacher efficacy, and enhancing teacher capacity or caregiver capacity. Home visitor capacity for reflection, sensitivity, and improves skills in classroom management. And the finding that is for me most important and excites me the most, is that mental health consultation leads to the bettering of provider-child relationships. Yes, between provider and the child who might have been the focus of concern or exacerbation or alarm, but among providers and all children in their care. Positive relationships, whether between young children and those who care and teach them or between a mental health consultant and the consultee or really among any of us. Relationships are the place where meaning is made and growth and healing takes place.

I hope that the ideas I've offered, and this time together, affords some ideas about how to make the most of the relationships that those of you who are program leaders, administrators, and providers develop with those of you who provide mental health consultation. May those partnerships be truly transformative offering healing as needed and promoting promise and growth as desired. Now, before we turn to the questions, I want to draw your attention to the next couple of slides that Steve will introduce for us.

Steve: Oh, Kadija, thank you so much. You had so much richness and treasures in what you were saying. I'm going to call you the fairy godmother of mental health in profession.

Kadija: [Laughs] Thank you.

Steve: You're welcome.

Kadija: I had never received that moniker, and I take it as an honor, and I will get my wings very, very soon.

Steve: You will get your wings. I'm sending you a wand.

Kadija: Thank you.

Steve: A lot of people asked about the references, and anything that was able to be linked is in your one-page handout as a resource sheet. If you're looking for something specific, I'd like you to write to health@ecetta.info, and Libby will put that right in the chat. That's our address for the entire center, and we will be able to do our best to respond to you. Next slide, Kadija. Everything on this slide is available right there – the same links on your resource handout. That handout also has evaluation and links to the certificate and a copy of today's slides, where these are also linked. Next slide. Now, I'm going to turn it over to my colleague Kelli, who's going to help facilitate some of the many questions that came in. Kelli?

Kelli McDermott: Thank you, Steve. There was so much that you said that resonated, Kadija, with our audience if you just flip through the [Inaudible], you see that people gave this really amazing feedback already. We have lots of questions that have rolled in through the Q&A, and unfortunately, we won't have time to get all of them. There are a couple I think we can lump together as themes. Some people are asking about issues around attending case consultations and case conferences within the Head Start programs and wondering, especially if they're not directly employed by the Head Start program that are coming in as an independent person or a representative of another agency, and bumping into some issues around confidentiality and not being included in meetings. I'm wondering if you have any thoughts on ways that you address that in your practice, or you've seen others?

Kadija: I want to make sure I understand this strand of questioning. Is this from mental health consultants who have felt as if that they were not able to participate in ways that might be fulsome and useful because of confidentiality? And maybe others of you on the panel are in a better position, as representatives of Head Start, to speak to this from Head Start procedures and policies. In my experience with Head Start working as a mental health consultant and the head of a mental health consultant agency, that Head Start asked for and received permission from all families in a center’s care from the beginning of enrollment for a child, which gave permission for and spoke to the availability of a mental health consultant in their child's site. Now, whether that general permission that's given at admission – what level that allows –would be something that I'm not – from the Head Start side, particularly – well positioned to respond to. But what I would think about is that from the mental health agency side, I always think that it behooves us to have our own ways of seeking permission and directly being involved with parents of any child about whom we are going to be providing consultation around. I want the parent to know of my presence, and I want to have been able to have conversation beyond permission, so that that addresses the concerns about confidentiality. So that I'm one who thinks about actually having more – both from the Head Start and the mental health consultation site side – that having kind of double permission about involvement, because I think being involved in those case conferences is a vital positioning for a mental health consultant to contribute the synthesis of, hopefully, their understanding of a child and their particular mental health expertise.

I don't know that that answers the specific question about how to gain access, but I do think it's very worthwhile for systems to try to work together to figure out how to include the mental health consultants in those very rich and valuable case conference meetings, which I think would benefit all involved.

Kelli: And I think that speaks to something that was threaded throughout your presentation. This idea that mental health consultation is not something that should be happening once people are concerned or were noticing challenging behaviors or made aware of particular stressors that a family is experiencing, but it should be a universal practice. OK. Some other questions that came up are around what frequency is really most effective. Several people wrote in that they are responsible for the mental health consultation caseload of well over 1,000 children, for example. And so, how do you balance this need for a consistent connection with realistic time issues?

Kadija: And I appreciate that currently, I think that it is often the case that mental health consultation is spread incredibly thin. And although, I referenced it maybe only in a sentence or two. But this idea that these practical constraints related to how much resources available for mental health consultation often is what does shift the emphasis to the more acute or crisis situations, and doesn't allow for the level of consistency and frequency that would permit a mental health provider to have the more leisurely getting to know, and the most frequent contact that would be of most benefit. While I don't want to either shy away from or prescribe a particular frequency, what I do think is that the more that we can acknowledge the benefit of mental health consultation as a promotion or intervention, not just prevention and/or intervention around concern, the more will recognize that additional resources not just within Head Start, but also from mental health agencies that we develop and get additional resources so that more time can be spent for mental health consultants. Because when we think about it benefiting all children, and we spread then kind of the monetary benefit across not just a mental health consultant's involvement with one child who is of concern, but rather the way in which mental health consultation can promote and prevent difficulties, we see how economical it is and that we then try to promote the frequency and consistency. On a very pragmatic basis, I would say that one of the things that I think is necessary at the heart of it is that there be a consistent and predictable meeting between providers in a program – including managers, home, family advocates, administrators – at least on a monthly basis. In the program that I was associated with and with many that I've worked with across the country, it is far more frequent than that, so that the mental health consultant is at every site or involved with all of the providers in a mental health consultation meeting on a weekly to every other week basis.

But again, the crux of the activity is, to me, those meetings. And the meetings – if those can be prioritized, take a little bit less time, then if someone is trying to spend hours observing or being at a site without the prearranged idea of having meetings with the providers.

Steve: Kelli, I'm afraid that's all the time we have for questions today. And I know we could spend another hour just responding to incredible questions, too. I'm going to encourage people to write their questions to health@ecetta.info or post them on MyPeers. We have a wonderfully vibrant mental health community on MyPeers and that's a great opportunity for you to share ideas with your colleagues. Kadija, could you move us to the next slide? I want to show people the link to the evaluation.

Kadija: Yes, Steve.

Steve: There you go. And it's now there on your slide. It is in the handout, and it is now in the chat. After you submit the evaluation, a new link will appear that will allow you to access their certificate. Please follow that link to the evaluation. You can grab it in the chat. It will be on your slides if you downloaded the handout, it's right there as well.

Next slide, please, Kadija. I want to thank everybody, both back at the house – you saw Kelly, but we also had Livia and Kate and just incredible thank you to Kadija Johnston. We're so lucky to have you as part of our center, and we look forward to so much more. Next slide and the last slide. And once again, all of our material, including the many of the mental health resources, are there on ECLKC. They are linked on your handout, but they're always there on ECLKC. And you can write to us at health@ecetta.info. We're going to keep things up for just a few more seconds. And when the webinar platform goes down, the link to the evaluation will pop up. So don't go away. I'm going to put the link to the evaluation back into the chat in case you missed it. And there you go. And Kate, we're just going to wait a few more seconds. Again, thank you, Kadija. Thank you, Kelli. Thank you, Livia.

Kadija: Thank you, everyone.

Steve: Indeed. Great session.

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