Advancing Infant and Early Childhood Mental Health Policy in States: Stories From the Field, Part Two

Julie Cohen, ZERO TO THREE Policy Center, Washington, DC
Deborah Roderick Stark, Deborah Roderick Stark and Associates, Harwood, Maryland

Abstract

This article describes some of the extraordinary accomplishments of the second cohort of states to participate in the Infant and Early Childhood Mental Health Financing Policy Project (IECMH-FPP). The purpose of the IECMH-FPP is to support states’ advancement of IECMH assessment, diagnosis, and treatment policies that will contribute to the healthy development of young children. The policy stories are meant to inspire and offer lessons learned for other states interested in advancing IECMH policy. And they demonstrate that state leaders working across early childhood systems can drive meaningful change.

In 2016, ZERO TO THREE (with support from the Robert Wood Johnson Foundation, the Irving Harris Foundation, the Alliance for Early Success, and the University of Minnesota) launched the Infant and Early Childhood Mental Health Financing Policy Project (IECMH-FPP) with the goal of supporting states’ advancement of IECMH assessment, diagnosis, and treatment policies. The first cohort of states participating in the IECMH-FPP included Alaska, Colorado, Illinois, Indiana, Louisiana, Massachusetts, North Carolina, Oklahoma, Oregon, and Virginia. The second cohort was launched in May 2018. States participating included Alabama, the District of Columbia, Maryland, Nevada, New Hampshire, New Mexico, New York, South Carolina, Tennessee, and Washington. Some states entered the collaborative with a strong foundation and energy to build on, while others were in the early stages of building public awareness and political will related to the critical importance of IECMH.

In isolation, a new policy idea in one state may represent a small gain. However, when shared among a national network of professionals, workshopped with health policy and clinical experts, and considered in various policy contexts, these ideas can be brought to larger scale and adapted to influence mental health access for thousands of infants and toddlers. This vision is playing out across 20 states in real time, with innovations spreading. The policy stories included in this article illustrate just a few of the remarkable accomplishments of the Cohort 2 states that participated in the IECMH-FPP.

Stories of IECMH Policy Action

Alabama, New Mexico, South Carolina, Tennessee, and Washington, DC, are just a sample of the IECMH-FPP Cohort 2 states that have designed and successfully advanced IECMH policy. Their work took on many dimensions. Some states focused on just one aspect of IECMH; others took on multiple issues and objectives. While each state effort differs, their stories share common practices related to financing, workforce development, leadership, and collaboration. Each story highlights key practices and important lessons for states that have an interest in advancing IECMH policy. For more detailed information on the policy stories, please see the Learn More box.

State leaders harnessed every opportunity to expand critical components of the IECMH system of care.

The Innovation

Without delay, state and local leaders in Alabama are working both inside and outside government to develop the state’s IECMH system of care. Leaders across multiple state agencies and nongovernmental organizations are raising awareness, building capacity, capitalizing on like efforts, and bringing forth policy changes to support reimbursement of evidence-based assessment and treatment. No stone is left unturned, and no challenge is viewed as insurmountable.

The Process

Transformation started to occur in Alabama beginning in 2014. For example:

• Alabama received a Project LAUNCH Grant. The Alabama Department of Mental Health (ADMH) was awarded a 5-year cooperative agreement grant by the Substance Abuse and Mental Health Services Administration. The collaborative efforts to focus on Linking Actions for Unmet Needs in Children’s Health (LAUNCH) led the state’s leaders to quickly identify the lack of resources for IECMH. Funds from this grant helped to begin to build the foundation for what was to come.
• IECMH consultation was piloted. Project LAUNCH local services were established in Tuscaloosa County in partnership with the University of Alabama Child Development Resource Center and involved five core strategies including addressing IECMH in early care settings and the integration of behavioral health into primary care. To this end, two full-time IECMH consultants were hired by the university to work with early childhood providers and a pediatric practice. This effort is now being replicated across the state through funding from the Alabama Department of Human Resources (the Alabama agency that provides child care licensing and oversight) and in partnership with First 5 Alabama with six additional IECMH consultants working with licensed child care providers. By early 2020, eight more consultants will be added through state funds acquired by the ADMH. These consultants will work with early intervention personnel, Alabama First Class Pre-K teachers, and women affected by substance use disorder during pregnancy. In addition, workforce development and IECMH consultation is also included in the state’s federal Preschool Development Grant Birth Through Five.
• A full-time IECMH coordinator position was created and funded. This position is supported by the Alabama Department of Early Childhood Education (ADECE) and the ADMH, representing an ongoing interagency commitment.
• First 5 Alabama was launched. The state’s IECMH association, an affiliate of the Alliance for the Advancement of Infant Mental Health, was launched in 2017 to help build workforce capacity. Within a year, First 5 Alabama had more than 200 members. The association supports professionals in earning the Endorsement for Culturally Sensitive Relationship-Focused Practice Promoting Infant and Early Childhood Mental Health®. In addition to supporting the Endorsement® process, First 5 Alabama helps to ensure everyone working with infants, young children, and their families knows how to support social and emotional development through regular and intensive training, professional development, and other learning opportunities (e.g., virtual, in-person, with national experts).
• Support was provided to Alabama First Class Pre-K and infant/toddler coaches. More than 65 coaches support 1,200 Alabama First Class Pre-K classrooms across the state through ADECE. More than 25 infant/toddler specialists support licensed child care centers and Early Head Start classrooms as part of a collaboration between ADECE and the Department of Human Resources. IECMH state coordinator Dallas Rabig supports the ADECE professional development director and the director of early childhood development and professional support to establish best practices in reflective supervision. She has also worked to support state agency and nonprofit professionals in IECMH-informed practice and in application for endorsement through First 5 Alabama.
• Changes to Medicaid billing were approved. Licensed mental health clinicians can now enroll directly with Medicaid and do not have to work under a Medicaid-enrolled psychiatrist when treating Medicaid recipients under 21 years old. Medicaid is also working toward developing reimbursement codes that will be available only to those who have the IECMH Endorsement.
• Implementation is under way for the next iteration of Medicaid care coordination that will look at the whole family unit. The primary goal of the new Alabama Coordinated Health Networks, managed by Alabama Medicaid, is to move away from silos and toward comprehensive care coordination that will follow women through pregnancy and children’s early years.

Important Lessons

Alabama shared key lessons learned:

• Every barrier is an opportunity for change and growth. Don’t let yourself be overwhelmed by what people think you can’t do; instead, direct your energy toward advancing reform.
• You can’t do it alone. Partnership across agencies is essential. There is strength in collaboration.
• Have patience and persevere. Sometimes a back door or different messenger is needed to bring about the changes you seek.

A steady drumbeat provided a perfect overture to advance IECMH.

The Innovation

The New Mexico Children, Youth and Families Department (CYFD) leads a collaborative effort including multiple state departments and the University of New Mexico to promote the use of a common language to accurately assess the social, emotional, and developmental needs of infants and young children. Together, state leaders set goals to develop a continuum of behavioral and emotional health services that are connected through referrals and patient information, and to incorporate use of the DC:0–5TM: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–5TM; ZERO TO THREE, 2016) into the continuum by all types of providers.

The Process

Since 2012, Soledad Martinez of CYFD has been working to raise awareness in the state about IECMH. This effort required a steady drumbeat. That is now paying off, with significant markers of progress that have built on each other. These include participation in the ZERO TO THREE IECMH-FPP convening in Minnesota in 2018, followed by participation in the Harris Professional Development Network and the establishment of an official infant mental health unit within CYFD in 2019, and, most recently, a $1 million investment in IECMH by the state for FY2020.

Following the Minnesota meeting, the New Mexico team developed overall goals and subcommittees to work on a statewide IECMH agenda. Subcommittees examine policy and practice related to a) promotion; b) prevention; c) assessment, diagnosis, and treatment; d) regulations and reimbursement; and e) finance. A multiagency steering committee guides all the work.

For example, goals of the promotion subcommittee are to develop:

• a map of all current services;
• a story using statistics to demonstrate the need for social and emotional health education, attachment theory, and a common language across all pertinent providers by using the DC:0–5; and
• an informal campaign for parents through collaboration with the Preschool Development Grant Birth Through Five, early learning organizations, and the New Mexico Association for Infant Mental Health.

Forming these carefully defined subcommittees and ensuring cross-agency representation on each was strategic. In addition to leading this cross-agency work, Martinez’s work within CYFD is bringing about change in that department. In an important change, in 2019, the new cabinet secretary integrated language about infants and young children into the department’s strategic planning process. “Awareness in the department of babies and young children is heightened,” said Martinez. However, it is still a work in progress. For example, there have been challenges in implementing IECMH-informed practice within child protective services, where sometimes the focus on safety competes with the IECMH relational and science-based approach that prioritizes baby-centered transitions. This work is front and center as the state is implementing the Family First Prevention Services Act. With influence from the Tulane model for Infant Mental Health Teams, the state has been providing clinical services to babies in foster care. Because these infants have experienced many traumatic events, the CYFD Infant and Early Childhood Section has provided the trauma-informed, evidence-based clinical protocol of Child–Parent Psychotherapy (CPP).

Leaders in the state realize that workforce development is essential for IECMH practice to reach new heights. The close relationship between CYFD and Marcia Moriarta at the University of New Mexico has been key.

Soledad and I have been working together for 10 or 12 years. Representing the state government and flagship university, we continuously looked for ways to get the two bureaucracies to work together and provide the infrastructure for training. Over this time, we moved into new positions where we could provide more visibility to the issues and have a greater impact. (M. Moriarta, personal communication, September 11, 2019)

Together, they have created opportunities aimed at enhancing clinical competence with the goal to ensure all those working with babies across systems are competent in IECMH, and CPP in particular. With funding from the state, the University of New Mexico offers Infant Mental Health Theory to Practice courses. Currently, there are 40 people from across 10 agencies and two Indigenous communities participating in this training. World-renowned IECMH expert Alicia Lieberman is providing training for a fourth cohort in CPP. Dr. Lieberman also supports the New Mexico Infant Mental Health Community of Practice of approximately 75 clinicians who are engaged in trauma-informed clinical practice. The University also started a clinical psychology internship and a postdoctoral track, both focused on IECMH. This inside-outside government partnership between CYFD and the University of New Mexico has been key in advancing the workforce development efforts.

Important Lessons

New Mexico shared key lessons learned:

• Build and maintain relationships with allies, especially during times of challenge. Focus on the benevolence of the relationship and keep the goal of healthy baby outcomes in mind.
• Sometimes you need to slow the work down so that all can see the connections and the role they can play in advancing IECMH.
• Make sure decisions are driven by data. And use that data to tell stories about the difference made when IECMH practices and policies are in place.

South Carolina in Brief

Workforce awareness and development are necessary first steps toward growing IECMH services.

The Innovation

Leaders in South Carolina recognized the importance of increasing the awareness and capacity of the workforce to support the social and emotional well-being of young children. Both the Department of Mental Health and the Department of Social Services identified IECMH workforce goals such as building IECMH expertise among child welfare staff and ensuring at least one person at each community mental health center will have specialized training in serving children under 5 years old. The South Carolina Infant Mental Health Association (SCIMHA) supports these goals and continuously looks for other opportunities that can contribute to strengthening the knowledge, skills, and capacities of the workforce.

The Process

The South Carolina IECMH-FPP team identified the need to strengthen the workforce, from clinicians to teachers, so that all professionals who serve young children and families are aware of IECMH practices along the continuum of promotion to prevention and treatment. With equal amounts of nudging and technical support from SCIMHA, leaders across agencies set out to increase awareness and capacity of those serving infants and toddlers. Where possible, they tapped workforce development set-asides in existing programs (e.g., the Child Care and Development Fund) and situated the issue within new applications for funding, whether through private philanthropy (e.g., Pritzker Children’s Initiative) or public competitions (e.g., Project LAUNCH).

For example, they are using the infant–toddler set-aside in the Child Care and Development Fund to support the infant mental health promotion practice of relationship building between child care teachers and children. The Preschool Development Grant Birth Through Five is being used to create a mental health consultation model. The Pritzker planning grant provided the state an opportunity to plan for how they would expand high-quality services by 25% for low-income infants and toddlers by 2023, and 50% by 2025. SCIMHA, in partnership with leaders in state agencies serving young children, continues to target funding opportunities that would allow for staff at local mental health centers to be trained in CPP, expand IECMH consultation, and bring the Safe Babies Court Teams model to the state, among other IECMH-focused efforts.

Recognizing that change starts from the top, Ann-Marie Dwyer, director of Behavioral Health at the South Carolina Department of Health and Human Services organized a training on adverse childhood experiences for the executive leadership in the department. “It was not easy to manage schedules and get key deputies in a room,” said Dwyer, but she did, and she believes the training will play an important role in making evidence-based policy decisions related to IECMH.

Signals from new leadership at the Department of Social Services bode well for increased attention on IECMH within that department as well. Still, the first step is to raise awareness. According to Gwynne Goodlett, director of Child Health and Well-Being at the Department of Social Services, “Child welfare is still very much in the raising awareness phase. We are working to build internal capacity and may have a training track on IECMH in the future.” SCIMHA is working hand-in-hand with the Department to support this effort with a long-term goal of reaching all ranks of child welfare workers and foster parents as well.

Important Lessons

South Carolina shared key lessons learned:

• External experts can make an important impression. Invite colleagues in other states to share their experiences so your team can hear their stories and envision a path forward.
• Patience is important, and doggedness is important, too! It can take time for partners to move from brainstorming promising ideas to taking meaningful funded action. Sometimes it is best to weave this work into other initiatives and reform efforts so that it does not become just another unconnected thing to move along.
• Do not be overwhelmed and intimidated by Medicaid. Build relationships with Medicaid staff and ensure that they understand the critical role IECMH plays in healthy development. Supporters of IECMH need to learn how interventions are covered under Medicaid and find ways to partner. Understand that Medicaid agencies are like very large ships and cannot turn quickly.

Tennessee in Brief

Dozens of stakeholders work together to bring attention to IECMH financing.

The Innovation

Leaders in Tennessee, led by the newly formed Association of Infant Mental Health in Tennessee (AIMHTN) and TennCare (the state’s Medicaid program), organized more than three dozen people, representing 30 different state and community agencies and organizations, to engage in a set of activities that will move the state toward a comprehensive financing system to support the mental health assessment and treatment of infants and young children. Although Medicaid is an important payer, the leaders agreed from the start that there would be a commitment to diversifying funding sources to not overburden the state system.

The Process

The Tennessee State Plan outlined four goals that together aim to enhance the assessment and treatment of infants and young children. Action teams with shared leadership gathered to work on the goals. Each action team developed clear steps and monitored their progress.

Goal 1: Identify and utilize current mechanisms in place (Medicaid and alternatives) to finance IECMH services.
Led by: The Department of Health and AIMHTN
Select accomplishments:

• Sustained engagement and participation from cross-agency leaders including representatives from AIMHTN, managed care organizations (MCO) partners, IECMH experts, Tennessee Association of Mental Health Organizations (TAMHO), Tennessee Chapter of the American Academy of Pediatrics, Centers of Excellence for Children in State Custody (COE), Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS), the Tennessee Department of Health (TDH), and the Tennessee Department of Education (DOE).
• Designed a resource mapping project and secured funding through the Child Care and Development Block Grant to support the work.

Goal 2: Identify core IECMH services not currently reimbursable and explore options to finance those services.
Led by: TennCare
Select accomplishments:

• Sustained engagement and participation from cross-agency leaders including MCO partners, AIMHTN, IECMH experts, TAMHO, Tennessee Chapter of the American Academy of Pediatrics, COE, TDMHSAS, and DOE.
• Drafted a program description for a billing code to address barriers to best practices for infant mental health assessments.
• Finalized a program and provider qualifications description for IECMH assessment that will be operationalized and disseminated by MCOs.

In collaboration with a project of Allied Behavioral Health Solutions, created a DC:0–5 crosswalk.¹

¹ A crosswalk provides a means of connecting diagnostic codes between different classification systems to facilitate billing. In many states, the crosswalk has been an important tool for IECMH providers to bill for treatment services under existing adult, adolescent, and child codes while making appropriate diagnostic assessments of young children.

Goal 3: Expand the IECMH workforce and develop IECMH messaging for use with families and stakeholders.
Led By: Tennessee Commission on Children and Youth and AIMHTN
Select accomplishments:

• Sustained engagement and participation from cross-agency leaders including representatives from: Tennessee Council on Children and Youth, AIMHTN, IECMH experts, TAMHO, TennCare, COE, TDMHSAS, DOE, and TDH.
• Undertook an environmental scan of in-service professional development activities.
• Initiated scan of marketing and promotion materials used by other states to inform IECMH messaging.

Goal 4: Hold a “summit” for stakeholders to learn more about the efforts to expand financing and access to IECMH services.
Led By: AIMHTN and TDH
Select accomplishments:

• Sustained engagement and participation from cross-agency leaders including representatives from: TN Council on Children and Youth, IECMH experts, TAMHO, TennCare, COE, TDMHSAS, TN Department of Children’s Services, and TDH.
• Hosted the “Little Brain Builders: Investing in Infant and Early Childhood Mental Health for a Strong Tennessee” summit on June 27, 2019. More than 100 participants attended, including high-level state policy administrators and state policymakers.

Important Lessons

Tennessee shared key lessons learned:

• Engage Medicaid and the MCOs from the start so that they can understand the complexities of IECMH service delivery, the importance of assessment, and the benefits of early treatment. Although the ultimate goal is to ensure that the continuum of IECMH assessment, diagnosis, and treatment is reimbursable, start with assessment. Once that program description is agreed on, then consider the others.
• Relationships are everything. Learn the language, approaches, and needs of individual stakeholders. Some may approach the work with personal connection and passion, while others may be focused on meeting deadlines and sticking with decisions. Trusting relationships will help people step out of their silos and collaborate successfully.
• The reflective process may be new to some partners. Assure them that slowing down and reassessing to make sure there is agreement may take time, but that the end product will be more effective as a result.

Washington, DC, in Brief

A methodological approach to assessing opportunities and gaps provides a baseline for next steps.

The Innovation

Public and private sector leaders in Washington, DC, took a methodological approach to assessing opportunities and gaps in the financing of IECMH promotion, prevention, assessment, diagnosis, and treatment. In addition, they wanted to ensure that cross-sector provider communities (e.g., pediatricians, mental health professionals, child care/early learning providers and programs) understood the current landscape, including financing policy. The DC team created: (a) an asset map that outlines the IECMH service and workforce continuum from promotion and prevention through diagnosis, treatment, and recovery during the preconception/perinatal period through age 5; and (b) a draft financing primer of all early childhood programs and services with aligned Medicaid codes where applicable. It was important that the spreadsheet, which was developed as part of the financing primer, also served the purpose of highlighting where there are not billable codes for IECMH services.

The Process

When the DC team returned from ZERO TO THREE’s IECMH-FPP convening in May 2018, they took four important steps that contributed to their success. First, they decided to include more perspectives to ensure broader representation from cross-sector stakeholders. Second, they established a regular monthly meeting date and time and stuck to it. Third, they actively sought feedback for the tools that were being developed. Finally, they ardently looked for ways to plug IECMH into conversation happening throughout the District, whether it involves behavioral health reforms or other opportunities in early childhood development initiatives.

Including more perspectives. The team that attended the Minnesota meeting included representatives from the Office of the State Superintendent of Education, the DC Department of Health Care Finance (Medicaid), the DC Department of Behavioral Health, Children’s National, and the Early Childhood Innovation Network. The initial team determined it would be beneficial to gather additional perspectives and solicited input from representatives from children’s advocacy, the DC Behavioral Health Association, private service agencies, and others. This larger group was not only helpful in affirming that the map and funding tools would be useful, but it also helped to expand the understanding of what is available in the community before and after treatment.

Seeking feedback on core tools. Development of the asset map was iterative. As a core group, they drafted the map with input from all team members. They then revised the map, and each member of the team shared it with their respective departments or organizations for input. They sought feedback with other early childhood stakeholders too, again gathering comments and reworking the map. Most recently, families and community organizations provided feedback at the 2019 Mayor’s 2nd Annual Maternal and Infant Summit and the 2019 DC Early Childhood Summit. “The map transformed over the year with input from many stakeholders” said Leandra Godoy, assistant professor of pediatrics, Children’s National (personal communication, September 27, 2019). Meghan Sullivan, project director of DC Social Emotional and Early Development Project in the Department of Behavioral Health added, “People were excited about having it all on one page. It doesn’t dive into the specifics of each program but rather presents the information in a way that people can understand and talk about the whole continuum of IECMH” (personal communication, September 27, 2019).

Embedding the work in multiple efforts. Members of the DC IECMH team sit at many tables and have been intentional in seeking opportunities to weave IECMH into related efforts. For example, they are bringing IECMH concepts into discussions and planning for the Pritzker Children’s Initiative as well as the development of the District’s Early Childhood Strategic Plan. This work will help inform the conversations about changes to the behavioral health system through the District of Columbia Section 1115 Medicaid Behavioral Health Transformation Demonstration (1115 Waiver Initiative), illuminating how IECMH fits into the behavioral health system. They also organized a breakout at the Mayor’s 2019 Maternal and Infant Summit and DC’s Early Childhood Summit in order to reach service providers and residents who might not have the foundational understanding of IECMH.

Important Lessons

Washington, DC, shared key lessons learned:

• Be mindful of your partners’ time, and consider whether you might need to bring more people onto the team to accomplish your goals.
• The work is important and urgent, but change will not happen quickly. Maintain a sense of urgency and set short-term goals that will move you toward your ultimate vision.
• Find ways to tie the work into other projects to solicit feedback and to influence the other agendas.
• Consider how you can center the voice of parents and community members in the work.

Next Steps: The Continuation of the IECMH-FPP Learning Collaborative

We have recently announced plans for the continuation of the IECMH-FPP Learning Collaborative. Most of the Cohort 1 teams and all Cohort 2 teams have decided to remain active. State teams will be participating in webinars, topical “campfire chats,” and other peer-to-peer learning opportunities. Topics of interest for 2020 include: (a) how states are working with MCOs as well as private insurance providers, (b) how states have secured financial buy-in from different agencies to finance big IECMH initiatives, © how states have funded and increased access to IECMH consultation services, and (d) which funding streams states are using to expand access to evidence-based home visiting. Both within the IECMH-FPP and in our broader work, ZERO TO THREE looks forward to continuing to create opportunities for cross-state learning, collaboration, and innovation in the IECMH financing space in the future.

Conclusion

The IECMH-FPP is unique. It has given state policymakers an opportunity to be part of a cross-state collaborative where peer-to-peer sharing and problem solving happens in-person, on webinars/calls, and through a virtual collaboration platform (see Box 1). The project is driven by and responsive to the needs of individual state-level policymakers who are responsible for holding the vision of an IECMH system and driving progress forward. In some cases, there may be only one or a few people in a state who are responsible for holding this vision. Many have shared that their isolation limits their ability to engage in collaborative problem solving and challenges momentum and enthusiasm for their work. While the total number of these individuals may be small, they are experienced, passionate, and dedicated. And they need to be connected and supported in their collaboration in order to leverage the discoveries and innovation each makes in their own policy context.

Advancing IECMH policy spans a continuum from promotion to prevention, to developmentally appropriate assessment and diagnosis, to treatment. Now, more than ever, there is an urgent need to support state policymakers in understanding the critical value of IECMH and to ensure that the individuals making policy decisions are connected through a robust and supportive network. The policy stories included in this article illustrate just a few of the remarkable accomplishments of the Cohort 2 states that have participated in the IECMH-FPP. They are meant to inspire and offer lessons learned for other states interested in advancing IECMH policy. These stories demonstrate that state leaders working across early childhood systems can drive meaningful change. There are always opportunities to take action to increase access to high-quality mental health services for pregnant women, young children, and families.

Author Bios

Julie Cohen, MSW, is associate director of the ZERO TO THREE Policy Center. During her 20-year career at ZERO TO THREE, Ms. Cohen has worked on a wide range of policy issues impacting infants and toddlers including infant and early childhood mental health.

Deborah Roderick Stark, MSW, is a nationally recognized consultant focusing on child and family programs, research, and policy. She has more than 25 years of experience working with foundations, public agencies, the nonprofit community, and federal legislators.

Suggested Citaiton

Cohen, J., & Stark, D. R. (2020). Advancing infant and early childhood mental health policy in states: Stories from the field, Part two. ZERO TO THREE Journal, 40(5), 73–80.

Reference

ZERO TO THREE. (2016). DC:0–5TM: Diagnostic classification of mental health and developmental disorders of infancy and early childhood. Washington, DC: Author.