A Shared Lens for Working With Families: Can the city's fragmented early childhood system find common ground? 

By Kendra Hurley

The main office of Adelphi University’s Institute for Parenting in Nassau County looks unremarkable save for the image of a playroom flickering, almost constantly, across a computer monitor. Parents and foster parents tote babies and toddlers to that room where they play as part of a therapy that uses video to strengthen the bonds between young kids and their caretakers. 

One recent afternoon, a woman with tight jeans spills over the sides of a tot-sized chair. She looks on as two toddlers—both her foster children—take charge of the room. One kids leaps atop a chair. The other pounds at a play kitchen. Back in the Institute’s office, a therapist with short, choppy hair listens and watches them on the screen.

Soon the mother and therapist will review the video together. The therapist will point out positive moments of connection. She will also pay attention to the times when the children seem upset, uncertain or in need of assurance. Always, she will encourage the mother to puzzle over the kids’ internal worlds: What was one of the toddlers thinking when he turned away from her? What about when he moved in close?

To see behavior through a trauma lens changes how you think about dealing with the discipline or behavior. You think more about connecting.

A growing body of research suggests that such “relational” or “dyadic” therapies that work with caretaker and child together can be highly effective for children who have experienced trauma, or to life with whose parents are depressed, traumatized or under extreme stress. Their goal is simple: Support child development by increasing a caretaker’s ability to relate and respond to children.

But these therapies are time-consuming, expensive and depend on the skill of highly trained clinicians. They are also demanding, often asking already-overtaxed parents to bring young kids to offices over a series of weeks or months, and to work on parenting skills with clinicians who typically come from very different backgrounds from their own.

Today, though poverty and trauma are all too common in New York City, it is the rare city toddler who benefits from the know-how incubated at places like the Institute for Parenting.

Over the past few years, a number of infant mental health experts have been working to change that. They want to reach more children who could benefit from intensive treatment while also spreading their understanding of the very urgent and particular needs of young kids throughout the wider world of early childhood services.

“We want to introduce the idea of relationships, and how important relationships are to supporting the social emotional growth, the cognitive development and the school readiness” of young children, explains Candida Cucharo, the infant mental health planning specialist at the Institute for Parenting.

Cucharo and her colleagues are heading up one of a handful of statewide initiatives that some hope will, taken together, end the fragmentation that plagues early childhood development work and make professionals more responsive to the potential effects of poverty, violence and other social traumas.  The goal is to establish a framework for infusing the early childhood research and best practices fostered at universities, clinics and community settings into the early childhood workforce.

It is a heady, ambitious and formidable plan. Despite a recent surge in government-backed programs and initiatives for young kids, early childhood services remain notoriously disjointed, comprising what some in the field refer to as “pockets of support” that work in isolation from each other.  Bringing them all into focus with what Janice Im, chief program officer at Zero to Three National Center for Infants, Toddlers and Families, describes as “a shared lens of how to work with families” would be something entirely new in New York. 

Bob Frawley, co-chair of the state Early Childhood Advisory Committee (ECAC) and former TK deputy director of the New York State Council on Children and Families, says the state’s nascent plan contains the seeds for “a comprehensive system of support” for young children. 

 “The hope is to establish a system that does a better job of social-emotional development” for young children, says Frawley. “It’s a multi-pronged approach. It’s not just doing one thing, it’s doing several things.”

A Siloed System—and Its Cure

Talk to people in the city’s early childhood sector and you will hear stories of silos, of early childhood professionals and paraprofessionals working in isolation from one another, without a common way of thinking about their work: the pediatrician who does not consider a mom’s post-partum depression relevant to his work; the veteran child care worker who loves the kids in her class but can’t be bothered with their parents; the Family Court judge who allows a baby to bounce between foster homes.   

In some cases, the result is a mere missed opportunity to, say, help a new mom feel less isolated or learn an effective way of getting a 2-year-old to listen. In others, advocates and researchers say it can mean missing the chance to change the life trajectory of a traumatized child early on or, perhaps, prevent serious neglect or abuse.

This lack of a comprehensive system for young children is not for want of a vision. In fact, early childhood advocates and researchers are in surprising consensus regarding what a system that supports the social emotional development of young kids would look like.

Its goals—outlined in a plethora of white papers, PowerPoint presentations and call-to-action reports—are straightforward: promote the healthy development of all babies, toddlers and preschoolers; prevent problems from festering among those who are especially vulnerable; and identify kids who need services at the earliest point possible and connect them with help.

This means finding ways to provide babies and toddlers with routine developmental screenings and making a wide spectrum of supports available to families—both “lighter touch” services such as evidence-based parenting classes as well as intensive dyadic therapies for traumatized parents and kids.

Advocates are also in overwhelming agreement that supports and services should be placed not just in clinics, but where families with young children can easily access and use them. They should be “co-located” in child care centers, pediatric clinics, homeless shelters, Family Courts, foster homes, libraries, ob-gyn offices and home visiting services like Nurse Family Partnership. “It makes access easier. It decreases stigma. It feels more developmentally appropriate to parents,” says Susan Chinitz, the former director of the Early Childhood Center at Albert Einstein College of Medicine.

But advocates and researchers contend that it’s nearly impossible to bring the full range of child-serving systems on board without first laying the foundation for a comprehensive early childhood system that has a shared understanding of how to work with families.  They say that workers and organizations that touch the lives of babies and toddlers need to grasp the importance of attachment and ongoing relationships in young children’s development and embrace the value of addressing trauma early.

It’s going to be a lifelong effort to continually move in a direction of systems that impact children and families. We’re trying to change everything.

“In the medical model…[of treatment] it’s an individual model. The child needs to heal or the person needs to change,” explains Mary McHugh, the director of strategic clinical solutions at the New York State Office of Mental Health. “To see behavior through a trauma lens changes how you think about dealing with the discipline or behavior. You think more about connecting.”

The need for a workforce knowledgeable about the often-overlooked social and emotional needs of young children is a common thread running through infant mental health policy and advocacy literature. The National Center for Children in Poverty, for example, identified child welfare workers’ failure to recognize developmental problems as the main barrier to getting babies and toddlers in foster care the help they need.

And a report by Adelphi University’s Institute for Parenting released last summer outlined how the Early Intervention system—the nation’s most comprehensive health program for screening and treating children under 3—was failing to address social-emotional issues of young children, in large part because Early Intervention specialists lacked knowledge in this area.  Nationwide, the Institute for Parenting reported, more than 30 percent of parents with children receiving Early Intervention services said they had problems managing their children’s behavior, and more than 25 percent  believed their children to have such social-emotional issues as anxiety or depression. Yet only 4 percent of children nationwide receiving Early Intervention services were identified by providers as having social and emotional problems.

“Without well-trained professionals, the entire delivery system for 0-5 year olds with developmental and psychosocial disabilities and their families falters,” the report concluded.

Frawley of the state’s ECAC agrees. “There really aren’t a lot of professionals out there to address the needs of kids and their families who are struggling with social emotional development,” he says.

The Seeds of Change?

In June – as New York City’s mayor and City Council finalized a budget earmarking millions of new dollars for an array of initiatives promoting the social and emotional health of kids under 5 – Mary McHugh, the State OMH director of strategic clinical solutions, circulated a succinct PowerPoint presentation that one person in the field described as “groundbreaking.”  The reason:  It proposes to bring order, at the State level, to the kind of well-intentioned but loose patchwork of programs and policies exemplified by the City’s actions.

The PowerPoint, “Policy and Possibilities to Advancing Infant-Early Childhood Mental Health in NYS,” spent no time discussing the research around how trauma derails young kids’ development. Nor did it go into detail about what a comprehensive early childhood mental health system should look like. It didn’t need to; its recipients, many long-time players in the infant mental health field, were already converts. 

Instead, it outlined how the state could lay the foundation for such a system by training and educating an early childhood workforce. Most significant: it contained no pie in the sky wish list. Using the image of three meshing gears, it linked three separate, statewide initiatives already in the works. Taken collectively, some say, they provide the seeds for creating a statewide early childhood workforce responsive to social-emotional issues.  “It’s the framework for systemic change,” says Cucharo of the Institute for Parenting. “It’s new conceptually.”

The first initiative outlined in McHugh’s PowerPoint is being spearheaded by the ECAC.  It provides early childhood centers with targeted trainings and technical support on early childhood behavioral issues. Its ultimate goal is to help all child-serving systems better address young kids’ mental health needs.

To this end, ECAC has a small grant to bring the Pyramid Model for Supporting the Social-Emotional Competence in Infants and Young Children to New York. (Learn more about this project here.) Think of the Pyramid Model as a curriculum for redesigning early childhood programs. ECAC plans to create a cadre of instructors throughout the state providing organizations with training and technical support using this model.

The second initiative is headed up by Cucharo of Adelphi University’s Institute for Parenting and a committee composed of New York State advocates and experts. It would encourage anyone who works with young children to earn a credential certifying their knowledge of infant mental health.  (Learn more about where that project is at here.)

In line with that, Adelphi’s Institute for Parenting has taken the first steps to bring to New York what’s called the Michigan Association for Mental Health Endorsement System – one already adopted in about 20 other states.

In some states, the system has helped participating clinicians secure Medicaid reimbursement for infant mental health treatment; a small number of endorsed professionals in Colorado have reported other benefits of being accredited. (Learn more here.)

The program’s impact has, however, been limited.  As of August 2014, it had endorsed only about 1000 individuals nationwide, with about 900 more in the process of getting certification, according to an Adelphi University report.

Nor has the program been formally evaluated, which some researchers find problematic.

The third gear in McHugh’s PowerPoint symbolizes what may be the most ambitious undertaking: Revamping New York’s Early Intervention system so it can better address trauma and behavioral problems in young kids.

Early Intervention is the state’s largest, most comprehensive program for treating kids under the age of 3. In theory, it can work with children whose only issues are social-emotional. In practice, the program largely focuses on addressing developmental delays and disabilities, typically missing opportunities to help young kids struggling with trauma or stress. By creating a document of best practices and policies, the state hopes to  sensitize  Early Intervention Program providers to social-emotional issues and guide their responses. (Read more about that initiative here.)

All three initiatives are in very fledgling stages of coming to New York.

The most likely scenario is that participation in the endorsement system or in the Pyramid Model will be voluntary; it will be up to a program or to individuals to decide that it’s worth their while. For notoriously overworked and underpaid early childhood workers, this could be a tough sell.

Nevertheless, even before any of these projects has fully launched, many in the field find the careful thought and attention they’re receiving from the state significant and promising. In a year when so many city agencies have put forward early childhood development initiatives, they say that this big picture thinking represents a first step toward harnessing now-disjointed energy and enthusiasm for systemic change.

“I can't tell you how much further ahead we are then we were before,” says Frawley.

McHugh at the Office of Mental Health agrees, adding that though there’s still a long road ahead, she’s encouraged. “It’s going to be a lifelong effort to continually move in a direction of systems that impact children and families,” she says. “We’re trying to change everything.”