Implementación de consultas de salud mental de alta calidad

(En inglés)

Implementing High-quality Mental Health Consultation

Steve Shuman: Let me introduce today's speaker, someone we're very lucky to have as part of the National Center and is one of the godmothers of mental health consultation, Kadija Johnston. Kadija?

Kadija Johnston: Thank you, Steve. Thank you for that introduction. As you said, it's a pleasure for me to be part of Georgetown Center of Child and Human Development, and in that capacity, to have the opportunity to be involved in this national center. What also I hope positions me perfectly to be talking about mental health consultation implementation today is what I have been doing prior to being part of this center and the Georgetown family, and that is about three decades of my career, which was devoted to developing, implementing, disseminating, writing, and doing infant and early childhood mental health consultation. That's what we're going to spend our time today talking about.

Let me run us through, very briefly, an orienting agenda. We're going to talk about ways of implementing infant and early childhood mental health consultation to enhance and ensure that the highest-quality services are received by Early Head Start and Head Start programs, staff, and families. I'm going to begin by orienting us by offering a definition of early childhood mental health consultation and then spend the most of our time together describing what we are learning, from experience and research, are the best practices in early childhood mental health consultation and how those practices can be effectively integrated into both program planning and service delivery. I'm going to leave what I hope will feel like a fair amount or an ample amount of time at the end for wonderings and remarks.

Starting with the definition: Early childhood mental health consultation is a multilevel mental health strategy – multilevel meaning that it spans the care continuum of mental health services – from promotion to prevention to intervention, and it is an indirect service. By indirect, what we mean is that a mental health consultant does not typically intervene directly with children or families. But it's an indirect service that pairs a mental health professional with other providers who care for or offer services to young children and their families. It's a capacity-building endeavor aimed at really increasing the social and emotional awareness and knowledge and enhancing the reflective confidence and competence of the adults, primarily staff, who support very young children.

By collaborating with the primary people in young children's lives, mental health consultation supports or where needed, strengthens teaching or home-visiting practices, thereby promoting what we hope will be the optimal development for all children in a study. While the effort is directed at promoting the social and emotional well-being and relational health of all the involved constituents – by that I mean, children and adults – supporting the mental health and the alleviation of stress, which is so heightened at this time for staff. Infant and early childhood mental health consultation simultaneously serves as a prevention and an intervention for those children at risk for or already exhibiting mental health difficulties.

With that definition, I want to start by acknowledging that Head Start actually has, since its inception, been really a pioneer in recognizing that mental health supports, like consultation, are an essential component of an effective early childhood program and programming. As you all probably know better than I, since its inception, Head Start required programs to prioritize services that acknowledge the importance of the social-emotional domain of development for all children and the need to offer specific support in situations where a particular child or family's mental health is in jeopardy. Many … At last count, close to 40 of the performance standards actually reference social and emotional and mental health.

The link at the bottom of this slide and in your handouts is the specific Performance Standard that talks about child mental health and social-emotional well-being. I think that one of the things – although it's been long-standing, these performance standards – the current set of performance standards really strengthens the breadth and gives clarity to previous requirements by, from my perspective, emphasizing wellness promotion and instructing programs to use mental health consultants on … and I quote, "to use mental health consultants on a, schedule of sufficient and consistent frequency to ensure a mental health consultant is available to partner with staff and families in a timely and effective manner."

The standards acknowledge also, the special needs and the supports for those needs of children who have experienced trauma associated with homelessness or foster care and says that programs should ensure that their mental health consultants assist in addressing children's mental health concerns, including both internalizing, which we often don't pay as much attention to, but internalizing as well as externalizing problems. Also, what is very important – again, especially now, but always, from my estimation – is that the standards prioritize the well-being of the adults in children's lives. Addressing teachers, home visitors, and parents' mental health needs is articulated in the standards.

First, let's look at how – the principles and practices that have been explicitly and inclusively articulated by the Head Start Performance Standards – how they can actually be implemented. Because even with these inclusive standards, it can be challenging to operationalize them and effectively implement mental health services. I want to look at the principles and practices that provide the greatest possibility of implementing effective early childhood mental health consultation.

First, I think the way that we do that is by recognizing that early childhood mental health consultation really derives its powerfulness, its effectiveness, from being this broad-based service. What do we mean by a broad-based service? I mean that it doesn't restrict itself, mental health consultation, to the narrowness that we often think about with mental health services. Often, mental health services are seen as and employed most extensively only on the intervention end of the spectrum, around a specific child whose maybe score on an ASQ or behavior in the classroom, is deemed as challenging or very concerning. Of course, tending to the difficulties of an individual child or family is an important part of what consultation does. But what decades of practice and research confirm is the benefit of what I think of as a more upstream approach.

Early childhood mental health consultation can promote the mental health of all children in a study. By really aiming the intervention at the teachers and the home visitors and the families and the broader setting of Early Head Start, mental health consultation is building capacity in those adults to foster the social and emotional well-being of the children in their care. For early childhood mental health consultation to effectively function as this promotion service, then it requires that a consultant does have that frequency and knowledge – frequency and availability – to get to know the program and all the participants in it.

The mental health consultant needs to create relationships with all of the folks in a center and have a knowledge of the overall program and what the staff's needs are, which of course occurs only over time and with a consistent mental health consultant. This really speaks to that standard of sufficient and consistent frequency that I cited earlier. Expanding early childhood mental health consultations' purview to include promotion, though, can sometimes be a little disconcerting or confusing to people – including those of us – or maybe especially for those of us, in the positions of being mental health consultants. I think that mental health professionals often don't get the opportunity to work at the promotion end of the spectrum.

On a practical level, Head Start programs can want to maybe preserve the seemingly limited resources that they have for those extreme situations and so not see the value of really cultivating over time and before a crisis, a relationship with a mental health consultant. I think that the way that mental health, in general, is viewed in our society and in many societies also interferes with it being called on as a promotion strategy. I mean, think about when do we use the word or the term "mental health?" Usually, we use it when we're talking about its opposite: mental illness.

Rarely are mental health services aimed at preserving positive states of well-being. I'm suggesting that's how I hope we can think about these services. Because it is not the necessary point of entry only at a crisis with an adult in the center or a child. What I'm suggesting is that the usefulness of mental health consultation is not limited to these acute situations. I often use the analogy that we don't – in Head Start or other early childhood settings – become concerned about the nutritional needs of children only at the point at which we see signs of starvation in one child.

Similarly, what I'm suggesting is we shouldn't limit our sense of the importance of mental health supports only when there are mental health difficulties. Mental health consultation can take a proactive approach to create an atmosphere in which the mental health of all children, families, and staff is protected.

How? How does mental health consultation do this? I think actually … Ed Zigler, who all of you know as one of the early founders of Head Start, said it perfectly. I think that we make the most difference through mental health consultation by directing our efforts not only at the children, but to the adults in children's lives – their providers and parents – by aiming the service at the teachers or home visitors and creating internal change. Then the efforts, the mental health consultation efforts, not only have an immediate, but a long-lasting impact.

Then, we have to ask ourselves, what does it take to promote well-being in staff? What does it take to build staff capacity? I would also say, we want to ask ourselves, which capacities are we trying to build or support through mental health consultation?

No doubt, providing information, knowledge to staff and families about mental health is important and is a part of the mental health consultant's role. I'm asking us that we think about, what does it take for any of us to actually regulate ourselves, calm ourselves enough, to change our perspectives, to make change, to take in new information and perspectives? This is where I think promoting staff well-being and addressing stress – staff stress and family stress – is an important focus of early childhood mental health consultation.

We know that teaching and home visiting is stressful. Of course, the pressure has been doubled and then redoubled again during the pandemic and its impacts. Whether stress because or caused by COVID or tensions that preceded it, those in the teaching and caregiving professions have among the highest rates of physical and mental health concerns, even compared to others in the same income bracket. Teachers who report greater depression and job stress also report, not surprisingly, greater levels of problem behaviors in the children they care for. Those teachers who are stressed are the more likely ones to ask that children who they experience as challenging are removed or expelled or to promote harsh discipline practices with.

Conversely, teachers who participate in early childhood mental health consultation describe decreased stress and are less likely to rely on harsh discipline as ways of remedying their tensions. Of course, when any of us are stressed or depressed, it's hard to also feel that anything we do matters. Stressed teachers often describe themselves as not thinking they have much of an impact on the children or families in their care. If you don't feel like what you do matters, why would you be interested in thinking about new ways to approach children?

That what I would posit, that feeling like your actions do have an impact is a necessary precursor to changing your behavior or taking in new knowledge related to the children in your charge. This has been shown that many teachers who describe themselves as having children with challenging behavior felt like, when they had more efficacy, due to mental health consultation, that they felt more able to attend to children with challenging behavior who are in their charge. Therefore, attending to staff experiences on the job and beyond is a central tenet of mental health consultation.

The pandemic and the inequities it has exposed confirm, I think, the importance of and call us to redouble our emphasis on attending to staff mental health – mental well-being – by inviting, listening deeply, and leaning into staffs' and families' distress and being able to engage in difficult and often conflictual conversations. Mental health consultants help providers and parents recognize, regulate, and channel troubling experiences that otherwise, would likely be passed along to children or obstruct staff's ability to respond well to the children and families in their charge.

If you don't believe me, research is confirming that these qualities attending to staff stress – empathy for the staff, for providers' subjective experience, both on the job and at home – help with staff to reflect and regulate, without judgment – these characteristics of the relationship that a mental health consultant creates with her consultees – is what makes a difference for children. In a national study of mental health consultation and Head Start programs, researchers found that the single most important factor related to positive consultation outcomes for families and children was the quality as rated by the staff of teachers, the quality of the relationship between mental health consultant, staff, and families. These relationships between staff and mental health consultants were even more important, when the focus of the mental health consultation was a child of color.

A positive consultant-consultee relationship was seen by the folks in Arizona in their statewide early childhood mental health consultation program. The research done by my colleagues, Eva Shivers and Annie Davis looked at, looked at what the power of the relationship was to impact teachers' perceptions and treatment of particularly boys of color, African-American and Latinx boys. Data was collected on children who teachers initially saw as and described as lacking self-control, who they didn't feel close or attached to, who they felt were at higher risk for expulsion, or they felt they had conflict around.

These negative views of boys of color decreased more strongly over the course of six months of mental health consultation such that Black children's outcomes in the eyes of their teachers surpassed those of their White peers. The positive change lasted over the 12-month period that they were studied. These positive outcomes of the consultant-consultee relationship depended, though, on two additional factors. One was that it was the consultants' level of confidence in their capacities – their capacities related to feeling like they could understand, address – gave prominence to issues of culture, equity, and diversity, or when the consultant and the consultee were racially and ethnically matched. Those were the situations where the most positive outcomes were accrued for children who were the focus of mental health consultation, that were children of color.

Effective mental health consultation in these studies and in many others, of course, hinges on several factors. One study that I want to talk to you about actually started to identify, what are the factors that make a program, a mental health consultation program, effective? In a study called What Works: A Study of Effective Early Childhood Mental Health Consultation Programs – that's the title, done by folks at Georgetown – looked at six early childhood mental health consultation programs across the country that had positive outcomes. It looked at what did they have in common? What they had in common are the three broad characteristics you see here. They all had solid program infrastructure, highly qualified mental health consultants, and high-quality services. I want to delve a little deeper into each of these.

What do we mean by solid program infrastructure? That refers to the characteristics of the organization that employs the mental health consultant, whether that's Head Start, a mental health clinic, or any other type of agency. What the study found was that the best outcomes of consultation were associated with organizations that, one, had very stable and strong leaders. Its successful early childhood mental health consultation programs also were programs that had a really well-articulated philosophy and model of mental health consultation and where there was a clarity about what the role of the mental health consultant was.

Think about that in terms of our implementation. In Head Start, this clarity would involve, of course, everyone in the program understanding how they can engage and the parameters of what their work will be like with the mental health consultant. In addition to clarity about what collaboration will look like, it's also important that the role of the mental health consultant be distinguished from those in other very essential but different roles, like the health or the mental health or the disabilities manager. What's important is to articulate how those roles are different but also how those people in those distinct roles will collaborate with one another. People in those positions, in those managerial positions and in other administrative and leadership roles in Head Start, need to very closely identify how they will work with and collaborate with mental health consultants.

In addition to this internal to the program collaboration, another solid infrastructure characteristic is cross-systems collaboration. What does that mean? That means engaging partners outside of Head Start, typically like early intervention, special education, child welfare, and other mental health agencies or maybe the mental health agencies that employ the consultant. These external partners serve as one, referral sources, when needed, and can be very positive collaborators in service delivery.

Mental health consultation of effectiveness in the What Works Study and in my experience is enhanced by the employing agency providing ongoing support to the mental health consultant. This is typically provided in the form of reflective clinical supervision and training. That brings us to, of course, how you maintain, train, and sustain a highly qualified workforce, the second characteristic of effective mental health consultation programs.

What we have found, in every efficacious research analysis of mental health consultation, is that the consultant characteristics associated with the best service outcomes for families and children are those who, one – mental health consultants who, one, possess a master's degree or higher in a mental health discipline – by a mental health discipline, meaning social work, psychology, marriage and family counseling; and that they've had experience, at least two or more years of experience, in their discipline; and that they have training in not only their discipline, but in the things that seem to matter in terms of critical skills related to infant and early childhood mental health and development and cultural sensitivity and equity, as I just mentioned; and that they have ongoing support through mental health or reflective supervision.

The third … Now, let's turn to the third and final set of factors that are associated with effective mental health consultation. These have to do with components of service delivery. I'm not going to articulate all of them in depth, but I'll highlight a few. I'll speak a little bit later about the array of activities but speaking a little bit to the idea of frequency and duration.

Right now, there are not mutually agreed upon best practices in terms of, what's the necessary duration or frequency? The What Work Study and subsequent research, though, I think offer really valuable information in this area. In terms of duration, what we can take as good news is this that research has shown effectiveness of models regardless of duration, that sometimes six-month models or ongoing models have had good outcomes.

I think what's important to ask ourselves is, what kind of outcomes? It's important to note that shorter duration models are showing positive outcomes in terms of immediate changes in teachers' perceptions of target children's behavior, meaning that teachers especially, think that there has been less acting-out behavior after a short amount of mental health consultation. However, if we want to think about the capacity-building, the changes for adults, the support for adults, that we all know that internal and long-lasting change in provider capacity, teacher stress levels and job satisfaction and in program climate, would take longer to achieve.

In terms of duration, we need to think about, what outcomes are we wanting to achieve? In terms of frequency, what we can say from the What Work Study and others is that most mental health consultants report meeting weekly or every other week with staff. Of course, there is some variability. For example, consultants serving really rural areas often make less frequent visits because it takes longer to get there. Greater frequency in the What Works Study and in others has shown also to yield better outcomes. I think, while we all have anecdotal experiences and evidence, I think the remote delivery of mental health consultation service that has become more widespread and I think acceptable due to the pandemic's related restrictions appears also to be effective and could permit greater frequency and more access to previously harder to reach areas.

Let me talk just a minute about the strong service initiation process. I want to point out a few practices that help get consultation services off to a good start. First is the mental health consultant setting the right tone and approaching consultees in a way that invites collaboration and honors the expertise of the staff and program with whom the consultant is working, while clearly being able to communicate what we as mental health consultants can and will provide. Really, I advocate a series of introductory conversations between administrator, staff, and the mental health consultant and families that culminate in partnership agreements that describe what each partner – the consultant and the consultees – studying what we can expect from one another.

The introductory process really sets the foundation for a collaborative relationship and for a strong consultative alliance, the importance of which I spoke about earlier, that relationship that seems so connected to positive child outcomes. What we can take relief in is this: that consultation is an inherently collaborative process. As an indirect service, its usefulness relies on the other adults in children's lives – the providers and the parents – to act on the understanding and implement the strategies that are co-created with the consultant. The relationship between us is essential.

Engagement and collaboration with families is essential if consultation is to be effective. When a particular child is the focus of consultation, the family of the child, from my perspective, must be involved from the beginning. That might mean that the consultant initially merely thinks with program staff about what's the most useful way to introduce the consultation services to the family? But specific information about a child should be shared only with the parents' knowledge and consent.

More importantly, because parents know their children best and can provide invaluable insight into a child's behavior, as well as the circumstances that might be contributing to that behavior, what needs to be conveyed from the beginning is the desire that the parents, the family is a vital part of our consultation efforts. Inherent in all the exchanges between the family – whose child might be the focus of consultation, the staff, and the mental health consultant – is the sense given to the family that the parent possesses information, a perspective, that is essential to any of us understanding or assisting their child.

Throughout the exploratory endeavor with the parents of the child around whom consultation is focused, the mental health consultant and staff want to make explicit why we're inquiring about a child or a family's past, linking it to the fact that, with the parent's permission, we can share some of what has influenced perhaps the child's experience and how that might be showing up in the Head Start program. While acknowledging the usefulness of hearing about a child – for example, this is a hypothetical example – let's say that a mental health consultant meets with the family and hears from the parents that a child sibling was lost to SIDS, that [Inaudible] able, and that that has invoked for these parents, a fear about this child's falling asleep. She sleeps with them and they wake her regularly.

Also, they're worried about separation from her. Knowing that, and with the parents' permission, being able to convey that to staff helps us to understand that child's problems at nap time or why she doesn't separate easily. It is really by creating this bridge of continuity between parents and staff and gaining an understanding of the influences affecting a child's behavior or progress in a program that are the primary purposes of quality consultation with families.

With both families and staff, the cultural and linguistic sensitivity, and when possible, matching proves to be beneficial, as we saw in the outcomes of the Arizona study around African-American and Latinx boys. As mental health consultants, we begin with and regularly also want to return to critical self-reflection about our assumptions. We want to endeavor to understand the culture of our consultees, the organizational culture, as well as the individual and collective cultures of the families that we work with. When possible, we should strive also, I think, to match the ethnicity and language capacities of the consultant with families and providers.

Those are all a bit about the qualities that make for effective mental health consultation and how we might implement them. Let's turn for a moment to what mental health consultants do. Typically, there are three types of consultation. They're referred to as programmatic; in this case of group care programs, as classroom; and for home visiting, as well as group care programs, for child or family-focused.

The first two types are aimed at supporting or, where need be, enhancing the program and staff's ability to engage, one, in relationships with one another because what we know is adult relationships importantly influence how children can feel about themselves and their behavior. Program and classroom consultation also seeks to promote quality relationships between all the children and the staff in a program. The third type, child-specific consultation, focuses on an individual child whose development is perplexing or whose behavior is concerning to the provider.

Although these types of consultation are distinct, they are typically provided, one, simultaneously, and two, by the same person. Although structured differently in home visiting, program and family-specific consultation are typically offered. Let's look at, regardless of type, what are the activities that a mental health consultant can be involved in? This is where reference to … It was having this array, the full spectrum of activities, integrated with one another that led to the greatest or the most positive results.

I want to just emphasize that regardless of type of consultation, the central activity of a mental health consultant and where the crux of change occurs is the meetings that the consultant has with teachers, home visitors, managers, family advocates. Predictable, even if periodic, consultation meetings are essential. That's where the collaboration, the co-creation of meaning and strategies occur.

I know that carving out protected time for these discussions is often a goal, not a given. It's not easy to do in a very hectic work environment, but it is essential part of the partnership. Consultation groups are configured based on the teams that work together – a group of home visitors or classroom staff or staff that are interacting around a particular child and family. Group meetings are, of course, at times, hard to come together, but again, very important to figure out how to carve out.

Group meetings are often supplemented with individual meetings with staff. Individual meetings with staff might be specific to the needs of a particular staff member who is struggling or in crisis or is having a particularly challenging time with a particular child and therefore, might be time-limited. Also, individual but consistent meetings with site supervisors and managers to ensure program-wide coherence and a communication feedback loop … Those meetings are essential. In addition to the consultative meetings, observations may happen, and they may be of a classroom or a child.

Child observation, as we talked about, is only undertaken with parental permission and preferably preceded by the consultant having been actually introduced and met with the child's parents to introduce what the service is and to give a description and to make sure that the family feels properly included in the endeavor. Child observations are, of course, of most benefit only when the purpose is clearly articulated and agreed upon in advance by the important people in a child's life. So what are we observing and why? What do we hope the outcomes will be?

Consideration of the staff and the parents' wishes and perspective about when we observe is paramount. I'm also suggesting that rather than being routine, classroom observation should be purposely planned … The goal of the observation collaboratively determined between staff and consultant … What is the staff hoping that the consultant will see and be able, through the luxury of being uninvolved in the fray of activity … What is the hope of what the consultant's eyes can contribute?

We also want to recognize that observation aren't only one avenue to gaining information. Developing a complete picture of a program, a classroom, or a child relies on the mental health consultant's ability to meet with and integrate the more in-depth and longstanding perspective of the staff and in child-specific consultation of the parents. It's the consultant's observations in tandem with the information that she acquires from all the participants. Then she adds her own expertise: her expertise in mental health, her expertise in early childhood development, her expertise in trauma ... Combining these sources of knowledge, the consultant generates and then assists teachers and home visitors in developing hypotheses about the meaning of children's behavior.

Remember I talked about the little one, the hypothetical little one, who was having difficulty napping and separating, and that we learned from the parents about some of what might be contributing to that. That's the kind of information that gets synthesized. Then, the consultant can help translate a mutually-held understanding of a child's, family's, or teacher's needs into responsive action.

Continuing with my example, that you probably all thought about, when you learned about the hypothetical situation where the sibling had died of SIDS, and the parents were panicked about sleep and separation, you might have thought about ways that a staff in a Head Start program could support that child's needs and fears. The consultant might work with the parents and providers to set aside a few minutes each morning for a conversation so the child could witness the trust between them.

Others of you might have imagined strategically placing pictures of the child's parents, which she could be directed to look at and would be accompanied by staff providing reassuring words about when they would return. Some of you might have thought that special attention to and anticipation of transitions would be important. As sleep for this child has come to signify the most frightening separation, we might think about a provider who could be her primary helper to rest without requiring slumber. When a child has to close their eyes and sleep, that's the biggest moment of loss of control and separation.

These ideas would all be the kind of translations that a mental health consultant could and likely would suggest, but they would have been developed in concert with the consultees. Obviously, not all situations with a particular child or family are able to be addressed and remedied through consultation. In instances where a child's or family's needs exceed the interventions better developed for and implemented in the classroom or home visiting, a mental health consultant does assist in securing appropriate resources and with permission of the family and in concert with the Head Start managers, acts as a liaison between these outside service providers and the school, the Head Start program to ensure continuity and coherence.

In conclusion, let's review the arc of successfully implementing early childhood mental health consultation in Head Start. Success begins in the beginning with having a vision of what mental health services within Head Start or Early Head Start program can be. This starts with, I think, the program administrators and is contributed to by all staff and families within a setting. A program's vision will reflect its unique culture and the community that surrounds it.

It's premised on what I talked about earlier: a proactive view of mental health, a vision of how we can support the social-emotional well-being and relational health of everyone throughout the Head Start community … enhancing, not focusing slowly, or solely, or even primarily, on dysfunction or difficulty. That vision that is created by and within a program needs to be concretized, concretized perhaps in a written plan, but concretized in a plan that is developed and agreed upon by families, staff, and administrators.

If we truly embrace mental health from a proactive perspective, then the well-being of all has to be prioritized. Then, mental health principles will be imbued not just in one limited part of the program or only held by the mental health consultant, but mental health principles will be embedded in all aspects – throughout the education, the health, the disability, the nutrition, and social service components – of Head Start and Early Head Start. The vision will be upheld and the plan implemented by everyone, regardless of role.

As we know, for any vision to actually be applied or actualized, it also has to be responsive to the needs of the particular program. One way to assess the mental health needs in a program – and to keep tabs on if and how those mental health needs are being met – is for staff to complete an Early Childhood Mental Health Consultation Program Assessment Survey, which is available on the Center of Early Childhood Mental Health Consultation website. We're going to put that resource in the chat shortly, and it's going to be at the end of today's talk and in your handout.

This needs assessment is an online survey that asks questions about your program's current approach to mental health services provided by the early childhood mental health consultant and generally about mental health services in the program. Each individual staff, administrators who complete the survey then get a printout that shows how the rating of your program's mental health services and consultation compare to some of the best practices that I've been talking about. The report also offers resources for learning a little bit more about how to strengthen our mental health component in a Head Start program.

Another and additional idea about how we actually actualize a mental health plan would be to create a mental health workgroup that included staff, families, and the mental health consultant, that would meet periodically, but regularly, to assess how the vision and goals of the service are being experienced and enacted. Creating such a group also exemplifies, illustrates, and instills, I think, an atmosphere of collaboration. Collaboration is created, and relationships between mental health consultants, staff, and families is nurtured when we as mental health consultants demonstrate and program administrators convey messages that destigmatize mental health and that promote egalitarian relationships between the mental health consultant and the consultees.

How? By emphasizing things like that the consultant is here to support staff as well as children and families. We are not bringing in a mental health consultant to evaluate or because something is going wrong, but rather that the mental health consultant is part of the team, helping to make sure the program services best meet the needs of all children and families. They're not called in to fix a particular child or problematic staff, but to partner with staff to ensure the best possible care.

This trusting, collaborative relationship is nurtured through regular communication, reevaluation, and recalibration of how services are going. By returning to looking at how services are going, we can be called on to cooperatively enter relationships of companionship and nurturing what I call the nest of relationships that surround our children. We can preserve that perfect state of mental health that all of us enter the world with and I think heal the emotional wounds that are inflicted sometimes early on, ensuring that the mental health of Head Start community members – young and old, present and future – is sustained and supported.

So now, before we turn to questions, I just want to draw attention to one more slide. That's the link to the resources, a few of which I mentioned, one of which has just – thank you, Livia – been put in the chat. The one that has been put in the chat is the one I referenced most recently around the program assessment related to mental health. But all of these resources talk about implementing highest quality early childhood mental health consultation. These resources and more are in the handout that you will receive.

Now, I think we have a few minutes – well, very few minutes, fewer than I had imagined – my apologies. But I think we still have three minutes, according to my watch, to turn to a few questions. Is that accurate, Amy?

Amy Hunter: Yes, we can certainly take the three minutes. Hello, everyone. My name is Amy Hunter, and I neglect to introduce myself sometimes. I am a colleague of Kadija's at the National Center on Health, Behavioral Health, and Safety. Without further ado, we have amazing questions.

[Crosstalk]

Kadija: Oh, I'm sorry I didn't leave more time.

Amy: [Inaudible] rich questions. I don't know where to go … Such pressure with a couple of minutes. But one thing I think I've heard you talk about before, and we have a couple of questions about it, so I think this would be a good question: Is the pros and cons of having an internal versus external mental health consultant? I know in the field of infant early childhood mental health consultation, there's certainly strong opinions about that one way or another. I wonder if you could just share a little bit about that.

Kadija: Yeah, I think this question of what I call positioning is very important. I like to take it outside of the terms of negative and positive or pros and cons and really think about for each, not that there is one way that is better than the other, but what are the benefits of each? What I would suggest is that obviously, or maybe not so obviously, but the benefits to me of an internal consultant is that they typically have more familiarity with not only the specific culture of a center or centers or home visiting programs or Early Head Start programs, but they often have more knowledge and familiarity with the culture of Head Start, which is of course an asset.

Knowing the standards and the rules and regulations, as well as the promising practices, is an advantage. Also, it often tends to correlate to greater frequency and availability, which can, as we talked about, construct more trusting, efficacious relationships. On the flip side, I think that the advantage of being outside the system is that one is not limited to the pulls that might be part of being part of the hierarchy of any system, that you might feel less able – as a mental health consultant, to give your full perspective – if you were employed by the same agency that you are giving your perspective to.

Outside positioning also often allows a mental health consultant to have a perspective that can hold more hope and contribute to an ability to regulate themselves. Because they have opportunities to regularly step outside, both literally and figuratively, the environment in which they're consulting. What I would suggest is that, if you all can see me, is we don't all see things best from this office close. Sometimes having the pulled-back perspective of an outside mental health consultant provides a broader perspective and a more open stance of communication. Amy, I think you're still on mute, though.

Amy: I am. I’m not now. Thank you so much, Kadija--as always, very rich. I apologize to those other folks who had other questions. We will explore possibilities of ways to answer them outside of this live venue. They were very thoughtful questions. Thank you so much, Kadija.

Kadija: Thank you so much. I'm seeing that we're getting a message from Steve about the evaluation.

Steve: Right. Thank you, Kadija. Thank you, Amy and everybody, for sticking with us. Kadija, would you mind going two slides forward? It'll take us to the evaluation slide. There you go. The evaluation is on your handout. It will pop up when the webinar ends. Don't close the Zoom platform yourself. It will pop up. It is also on the slides, as you can see here. Next slide, please.

We want to thank you, all, for this incredibly interactive. There's so many wonderful chats in the chat, helping each other. We do have a mailing list. If you want to get on it, it is also linked on your handout. It was in the chat earlier.

The final slide … I know that we had a lot of questions that we didn't get to answer. But we always answer the questions that come to health@ecetta.info. There's a link on your handout for that. There's a link on your handout for MyPeers where we have a wonderfully vibrant mental health community, where you can have these conversations and questions. We encourage you to stay involved in this incredible topic. Kadija, wonderful, wonderful, of course, passionate information. I wanted to say amen because it felt like it was inspirational today. Thank you, Amy. Yes. Thank you, Amy. Thank you, Livia and Kate and Martine who hang out –  and Nydia – all behind the scenes making it work. In just a few seconds, the webinar is going to end, and the evaluation will pop up. If you have a problem, just write to us. Thank you, all.

Kadija: Thank you, all.

Amy: Thank you.

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